Table of Contents

December 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

抑肽酶和氨甲环酸在心脏手术中的危险性: 一项 1188 例连续的病人随访一年的研究

裘毅敏译,马皓琳 李士通校

The Risks of Aprotinin and Tranexamic Acid in Cardiac Surgery: A One-Year Follow-Up of 1188 Consecutive Patients

Klaus Martin, Gunther Wiesner, Tamás Breuer, Rüdiger Lange, and Peter Tassani

Anesth Analg 2008 107: 1783-1790.

冠脉术前环氧合酶-1抑制剂的评估与患者自己报告服用阿司匹林血小板聚集度测定的比较

胡艳译   薛张刚校

An Evaluation of Cyclooxygenase-1 Inhibition Before Coronary Artery Surgery: Aggregometry Versus Patient Self-Reporting

Niels Rahe-Meyer, Michael Winterhalter, Julia Hartmann, Albert Pattison, Hartmut Hecker, Andreas Calatzis, and Cristina Solomon

Anesth Analg 2008 107: 1791-1797.

即时全血阻抗凝集测定与经典光照凝集测定用于观测阿司匹林和氯吡格雷的比较:初步研究结果

朱紫瑜 陈杰

Point-of-Care Whole Blood Impedance Aggregometry Versus Classical Light Transmission Aggregometry for Detecting Aspirin and Clopidogrel: The Results of a Pilot Study

Corinna Velik-Salchner, Stephan Maier, Petra Innerhofer, Werner Streif, Anton Klingler, Christian Kolbitsch, and Dietmar Fries

Anesth Analg 2008 107: 1798-1806.

氙引起体内延迟性心脏预处理:环氧合酶2的作用?

黄施伟 译,马皓琳 李士通

Xenon Induces Late Cardiac Preconditioning In Vivo: A Role for Cyclooxygenase 2?

Nina C. Weber, Jan Fräβdorf, Christoph Ratajczak, Yvonne Grueber, Wolfgang Schlack, Markus W. Hollmann, and Benedikt Preckel

Anesth Analg 2008 107: 1807-1813.

预防性使用地塞米松可减少双腔管拔管后咽喉痛和声嘶的发生率

黄凝译  薛张纲校

Prophylactic Dexamethasone Decreases the Incidence of Sore Throat and Hoarseness After Tracheal Extubation with a Double-Lumen Endobronchial Tube

Sang-Hyun Park, Sung-Hee Han, Sang-Hwan Do, Jung-Won Kim, Ka-young Rhee, and Jin-Hee Kim

Anesth Analg 2008 107: 1814-1818.

PEDIATRIC ANESTHESIOLOGY:

右旋美托咪啶联合咪达唑仑与丙泊酚用于接受磁共振成像检查患儿麻醉维持的比较

周姝婧 陈杰

A Comparison of Dexmedetomidine-Midazolam with Propofol for Maintenance of Anesthesia in Children Undergoing Magnetic Resonance Imaging

Christopher Heard, Frederick Burrows, Kristin Johnson, Prashant Joshi, James Houck, and Jerrold Lerman

Anesth Analg 2008 107: 1832-1839.

儿童心脏手术术前重要的电解质紊乱与心脏药物并无关联

慧译 马皓琳 李士通校

Cardiac Medications Are Not Associated with Clinically Important Preoperative Electrolyte Disturbances in Children Presenting for Cardiac Surgery

Laura A. Hastings, John C. Wood, Bryan Harris, Sabine Von Busse, Ana Drachenberg, Frederick Dorey, and Gerald A. Bushman

Anesth Analg 2008 107: 1840-1847.

先天性主动脉瓣上狭窄与麻醉相关性猝死原因是什么?

蒋宗明译  薛张纲校

Congenital Supravalvular Aortic Stenosis and Sudden Death Associated with Anesthesia: What’s the Mystery? (Special Article)

Thomas M. Burch, Francis X. McGowan, Jr, Barry D. Kussman, Andrew J. Powell, and James A. DiNardo

Anesth Analg 2008 107: 1848-1854.

AMBULATORY ANESTHESIOLOGY:

ProSealTM喉罩在2114例成人中应用的前瞻性研究

赵嫣红 陈杰

Use of ProSealTM Laryngeal Mask Airway in 2114 Adult Patients: A Prospective Study

Kai Goldmann, Carolin Hechtfischer, Amena Malik, Andrea Kussin, and Christian Freisburger

Anesth Analg 2008 107: 1856-1861.

ANESTHETIC PHARMACOLOGY:

肥胖会适当地影响人吸入麻醉剂的动力学特性

姜旭晖译,马皓琳,李士通校

Obesity Modestly Affects Inhaled Anesthetic Kinetics in Humans

Hendrikus J. M. Lemmens, Lawrence J. Saidman, Edmond I. Eger, II, and Michael J. Laster

Anesth Analg 2008 107: 1864-1870.

右旋美托咪啶作为全麻辅助药在下腹部手术病人中的苏醒研究

刘沁译 薛张纲校

Recovery Profiles from Dexmedetomidine as a General Anesthetic Adjuvant in Patients Undergoing Lower Abdominal Surgery

Norimasa Ohtani, Kotaro Kida, Kazuhiro Shoji, Yutaka Yasui, and Eiji Masaki

Anesth Analg 2008 107: 1871-1874.

一个跨膜残基对丙泊酚与士的宁敏感的甘氨酸α1 α1β受体相互关系的影响

怀晓蓉 陈杰

A Transmembrane Residue Influences the Interaction of Propofol with the Strychnine-Sensitive Glycine {alpha}1 and {alpha}1β Receptor

Jörg Ahrens, Martin Leuwer, Sina Stachura, Klaus Krampfl, Delia Belelli, Jeremy J. Lambert, and Gertrud Haeseler

Anesth Analg 2008 107: 1875-1883.

丙泊酚预处理大鼠可减少神经酰胺产量及肠道缺血再灌注所致肠粘膜细胞凋亡

江继宏   马皓琳 李士通

Propofol Pretreatment Reduces Ceramide Production and Attenuates Intestinal Mucosal Apoptosis Induced by Intestinal Ischemia/Reperfusion in Rats

Ke-Xuan Liu, Shu-Qing Chen, Wen-Qi Huang, Yun-Sheng Li, Michael G. Irwin, and Zhengyuan Xia

Anesth Analg 2008 107: 1884-1891.

尼可地尔-三磷酸腺苷敏感的钾离子通道开放剂能阻断毒蕈碱乙酰胆碱受体介导的PC12细胞细胞外信号调节激酶的激活

刘婷洁译 薛张纲校

Nicorandil, an Adenosine Triphosphate-Sensitive Potassium Channel Opener, Inhibits Muscarinic Acetylcholine Receptor-Mediated Activation of Extracellular Signal-Regulated Kinases in PC12 Cells

Kazumi Niinomi, Yoshiko Banno, Hiroki Iida, and Shuji Dohi

Anesth Analg 2008 107: 1892-1898.

组胺和蕈毒碱受体参与了致敏的兔注射肌肉松弛药而导致的支气管收缩

王鹏 陈杰

The Involvement of Histaminic and Muscarinic Receptors in the Bronchoconstriction Induced by Myorelaxant Administration in Sensitized Rabbits

Walid Habre, Ágnes Adamicza, Enikõ Lele, Tímea Novák, Peter D. Sly, and Ferenc Petak

Anesth Analg 2008 107: 1899-1906.

TECHNOLOGY, COMPUTING, AND SIMULATION:

田野麻醉机中气动控制呼吸机的氧耗

唐李隽 译 马皓琳 李士通 校 

Oxygen Consumption of a Pneumatically Controlled Ventilator in a Field Anesthesia Machine

Dale F. Szpisjak, Elizabeth N. Javernick, Richard R. Kyle, and Paul N. Austin

Anesth Analg 2008 107: 1907-1911.

PATIENT SAFETY:

肥胖患者置喉镜与气管插管时头高位的随机可控等价试验

秦敏菊译 薛张纲校

Laryngoscopy and Tracheal Intubation in the Head-Elevated Position in Obese Patients: A Randomized, Controlled, Equivalence Trial

Srikantha L. Rao, Allen R. Kunselman, H. Gregg Schuler, and Susan DesHarnais

Anesth Analg 2008 107: 1912-1918.

伸展位Mallampati评分和糖尿病是病态肥胖病人困难喉镜的预测因子

丁俊云 陈杰

The Extended Mallampati Score and a Diagnosis of Diabetes Mellitus Are Predictors of Difficult Laryngoscopy in the Morbidly Obese

George A. Mashour, Sachin Kheterpal, Vishnu Vanaharam, Amy Shanks, Luke Y.-J. Wang, Warren S. Sandberg, and Kevin K. Tremper

Anesth Analg 2008 107: 1919-1923.

退伍军人事务局医院手术当天病人意外死亡的相关因素分析

吴进   马皓琳 李士通

Factors Associated with Unanticipated Day of Surgery Deaths in Department of Veterans Affairs Hospitals

Michael J. Bishop, Jennifer E. Souders, Cecilia M. Peterson, William G. Henderson, and Karen B. Domino

Anesth Analg 2008 107: 1924-1935

剖腹手术增加术中氧化应激反应:能被预防吗?

舒慧刚 陈杰

Open Abdominal Surgery Increases Intraoperative Oxidative Stress: Can It Be Prevented?

Masahiko Tsuchiya, Eisuke F. Sato, Masayasu Inoue, and Akira Asada

Anesth Analg 2008 107: 1946-1952.

CRITICAL CARE AND TRAUMA:

严重脓毒症对日常健康相关的生活质量的影响:一项长期随访研究

唐亮   马皓琳 李士通

The Impact of Severe Sepsis on Health-Related Quality of Life: A Long-Term Follow-Up Study

José G. M. Hofhuis, Peter E. Spronk, Henk F. van Stel, Augustinus J. P. Schrijvers, Johannes H. Rommes, and Jan Bakker

Anesth Analg 2008 107: 1957-1964.

OBSTETRIC ANESTHESIOLOGY:

比较三组病人自控硬膜外镇痛的随机试验

孙鹏飞译  薛张纲校

A Randomized Controlled Trial of Three Patient-Controlled Epidural Analgesia Regimens for Labor

Yvonne Lim, Cecilia E. Ocampo, Mia Supandji, Wendy H. L. Teoh, and Alex T. Sia

Anesth Analg 2008 107: 1968-1972.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

用于教学和研究的数字化脑血管模拟模型的设计

叶乐 陈杰

The Design of a Digital Cerebrovascular Simulation Model for Teaching and Research

Massimo Giannessi, Mauro Ursino, and W. Bosseau Murray

Anesth Analg 2008 107: 1997-2008.

丙泊酚预处理减弱大鼠短暂的局部脑缺血再灌注后水通道蛋白-4过度表达并减轻脑水肿

王宏 马皓琳 李士通校

Propofol Pretreatment Attenuates Aquaporin-4 Over-Expression and Alleviates Cerebral Edema After Transient Focal Brain Ischemia Reperfusion in Rats

Yue-Ying Zheng, Yun-Ping Lan, Hui-Fang Tang, and Sheng-Mei Zhu

Anesth Analg 2008 107: 2009-2016.

ANALGESIA:

一种新型的经鼻吗啡合剂、快速释放口服吗啡、静脉用吗啡和安慰剂用于术后牙痛模型中的镇痛效果和安全性比较

夏俊明译 薛张纲校

The Analgesic Efficacy and Safety of a Novel Intranasal Morphine Formulation (Morphine plus Chitosan), Immediate Release Oral Morphine, Intravenous Morphine, and Placebo in a Postsurgical Dental Pain Model

Kyle S. Christensen, Amy E. Cohen, Fred H. Mermelstein, Douglas A. Hamilton, Ewan McNicol, Najib Babul, and Daniel B. Carr

Anesth Analg 2008 107: 2018-2024.

鼻腔内应用酮咯酸在术后疼痛治疗中的安全性和镇痛效应

张磊 陈杰

The Safety and Analgesic Efficacy of Intranasal Ketorolac in Patients with Postoperative Pain

John E. Moodie, Colin R. Brown, Eileen J. Bisley, Hans U. Weber, and Lincoln Bynum

Anesth Analg 2008 107: 2025-2031.

氯胺酮和氯诺昔康用于预防芬太尼引起的术后吗啡用量增加

黄佳佳译,马皓琳 李士通校

Ketamine and Lornoxicam for Preventing a Fentanyl-Induced Increase in Postoperative Morphine Requirement

Yu Xuerong, Huang Yuguang, Ju Xia, and Wang Hailan

Anesth Analg 2008 107: 2032-2037.

慢性头痛的针灸治疗:系统综述

宣丽真译 薛张纲校

Acupuncture for the Management of Chronic Headache: A Systematic Review

Yanxia Sun and Tong J. Gan

Anesth Analg 2008 107: 2038-2047.

单剂量Tapentadol在牙科手术后镇痛效果 :一个随机,双盲,安慰剂对照研究

刘世文 陈杰

Single Dose Analgesic Efficacy of Tapentadol in Postsurgical Dental Pain: The Results of a Randomized, Double-Blind, Placebo-Controlled Study

Regina Kleinert, Claudia Lange, Achim Steup, Peter Black, Jutta Goldberg, and Paul Desjardins

Anesth Analg 2008 107: 2048-2055.

腹横肌平面阻滞为行腹式全子宫切除术的病人提供有效的术后镇痛

黄丽娜 马皓琳 李士通

The Transversus Abdominis Plane Block Provides Effective Postoperative Analgesia in Patients Undergoing Total Abdominal Hysterectomy

John Carney, John G. McDonnell, Alan Ochana, Raj Bhinder, and John G. Laffey

Anesth Analg 2008 107: 2056-2060.

给绵羊鞘内注射酮基布洛芬和氯胺酮预防N -甲基- D -天门冬氨酸引起的机械痛

章一静译 薛张纲校

Prevention of N-Methyl-d-Aspartate-Induced Mechanical Nociception by Intrathecal Administration of Ketoprofen and Ketamine in Sheep

Ignacio Lizarraga, J. Paul Chambers, and Craig B. Johnson

Anesth Analg 2008 107: 2061-2067.

筋膜上和筋膜下输注布比卡因用于腹式子宫切除术后的镇痛治疗

陈伟 陈杰

Bupivacaine Infusion Above or Below the Fascia for Postoperative Pain Treatment After Abdominal Hysterectomy

Meltem Cakmak Hafizoglu, Kaan Katircioglu, Murat Y. Ozkalkanli, and Serdar Savaci

Anesth Analg 2008 107: 2068-2072.

利多卡因和苏芬太尼用于脊麻对下尿道功能的影响

彭中美 马皓琳 李士通

The Effects of Spinal Anesthesia with Lidocaine and Sufentanil on Lower Urinary Tract Functions

Ed T. Kamphuis, Peter W. Kuipers, Ger E. van Venrooij, and Cor J. Kalkman

Anesth Analg 2008 107: 2073-2078.

弹性输注泵用于术后区域麻醉的可靠性:一项对430件设备的调查

陈珺珺译 薛张纲校

Elastomeric Pump Reliability in Postoperative Regional Anesthesia: A Survey of 430 Consecutive Devices

Francis Remerand, Anne Sophie Vuitton, Michel Palud, Sylvie Buchet, Xavier Pourrat, Annick Baud, Marc Laffon, and Jacques Fusciardi

Anesth Analg 2008 107: 2079-2084.

低容量高浓度的比高容量低浓度局麻药用于Labat's坐骨神经阻滞更有效:一项前瞻性、随机、对照试验

潘钱玲 陈杰

Low Volume and High Concentration of Local Anesthetic Is More Efficacious than High Volume and Low Concentration in Labat's Sciatic Nerve Block: A Prospective, Randomized Comparison
Manuel Taboada Muñiz, Jaime Rodríguez, María Bermúdez, Cristina Valiño, Noemi Blanco, Marcos Amor, Pilar Aguirre, Ana Masid, Joaquin Cortes, Julián Álvarez, and Peter G. Atanassoff

Anesth Analg 2008 107: 2085-2088.

 

 

即时全血阻抗凝集测定与经典光照凝集测定用于观测阿司匹林和氯吡格雷的比较:初步研究结果

Point-of-Care Whole Blood Impedance Aggregometry Versus Classical Light Transmission Aggregometry for Detecting Aspirin and Clopidogrel: The Results of a Pilot Study

Corinna Velik-Salchner, MD*, Stephan Maier, MD*, Petra Innerhofer, MD*, Werner Streif, MD{dagger}, Anton Klingler, PhD{ddagger}, Christian Kolbitsch, MD*, and Dietmar Fries, MD§

From the Departments of *Anesthesiology and Intensive Care Medicine, {dagger}Pediatrics, {ddagger}General, Thoracic and Transplantation Surgery, Experimental Surgery Laboratory, and §General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2008 107: 1798-1806.

 

背景:作者研究以确认Multiplate®全血阻抗凝集测定用于观察抗血小板药物作用是否具有与经典光照凝集测定(LTA)或者血小板功能分析PFA-100相同的可靠度。

方法:Multiplate®试验(M),测量单位时间内电阻变化作为凝聚单位(AU*min);LTA试验由胶原(COL)、二磷酸腺苷(ADP)或者花生四烯酸(AA)诱导;PFA-100试验,使用肾上腺(PEA100-EPI)或者ADPPEA100-ADP)元件;对连续70名选择性冠状动脉搭桥术病人的麻醉前动脉血样本进行同步全血阻抗凝集测定、LTAPEA。组A的患者(n=48)为对照组,组B的患者(n=11)接受阿司匹林100mg/d,组Cn=11)接受阿司匹林100mg/d和氯吡格雷75mg/d直至术前。

结果:对照组患者的M-COLAU*min阻抗变化的中位数(第一,第三四分位数)(374[231-469])明显高于接受阿司匹林的患者(164[86-211]P=0.0009),也高于接受阿司匹林和氯吡格雷的患者(118[101-244]P=0.004)。对照组的M-ADP值为258158-389),阿司匹林组为261159-393),阿司匹林和氯吡格雷组的则为8848-231P=0.054)。对于M-AA值,阿司匹林组(45[28-60]P=0.0004)或者阿司匹林和氯吡格雷组(44[26-221]P=0.0085)明显低于对照组(200[86-345])。接受者操作特性曲线(ROC曲线)下的面积代表使用全血阻抗凝集测定或者经典LTACOLAA试验对于区分患者有无接受阿司匹林的能力是相似的(M-COL0.84[P=0.001]LTA-COL0.85[P=<0.001]M-AA0.84[P=<0.001]LTA-AA0.87[P=<0.001]),但是对于PFA-100-EPI则只有0.74P=0.03)。同样,对于鉴别患者接受抗血小板药物还是接受氯吡格雷和阿司匹林,ROC曲线下的面积在两种凝集测定中也相似,M-COL0.77(P=0.006)LTA-COL0.78(P=0.004)M-ADP0.74(P=0.015)LTA-ADP0.73(P=0.018)

结论:对于选择性心脏手术病人术前阿司匹林和氯吡格雷的功效观测,床边Multiplate®试验的结果同经典凝集测定无差异。

(朱紫瑜 陈杰 校)

BACKGROUND: We determined whether whole blood impedance aggregometry using the Multiplate® detects the effects of antiplatelet drugs as reliably as does classical light transmission aggregometry (LTA) or the platelet function analyzer PFA-100®.

METHODS: Multiplate (M) assays, measuring changes in electrical resistance as aggregation units over time (AU*min), and LTA assays induced by collagen (COL), adenosine diphosphate (ADP) or arachidonic acid (AA) and PFA-100 testing, using epinephrine (PFA100-EPI) or ADP (PFA100-ADP) cartridges, were performed simultaneously using arterial blood samples obtained before induction of anesthesia in 70 consecutive patients scheduled for elective coronary artery bypass grafting. Patients in group A (n = 48) served as controls, patients in group B (n = 11) received aspirin 100 mg/d and those in group C (n = 11) aspirin 100 mg/d and clopidogrel 75 mg/d until the day before surgery.

RESULTS: In controls the median (1st, 3rd quartiles) change in impedance AU*min for M-COL (374 [231–469]) was significantly greater than in patients receiving aspirin (164 [86–211], P = 0.0009) or receiving aspirin and clopidogrel (118 [101–244], P = 0.004). M-ADP values in controls were 258 (158–389), in patients receiving aspirin 261 (159–393), and in patients receiving aspirin and clopidogrel 88 (48–231, P = 0.054). M-AA values were significantly lower in patients receiving aspirin alone (45 [28–60], P = 0.0004) or aspirin and clopidogrel (44 [26–221], P = 0.008) than in controls (200 [86–345]).

The areas under the receiver operating characteristic curves indicating the ability to discriminate patients taking aspirin from those not taking aspirin were comparable for COL and AA assays using whole blood impedance aggregometry or classical LTA (M-COL 0.84 [P = 0.001], LTA-COL 0.85 [P = < .001], M-AA 0.84 [P = < .001] and LTA-AA 0.87 [P = < .001]), but only 0.74 for PFA-100-EPI (P = 0.03). Similarly, for discrimination of patients not taking antiplatelet drugs from patients taking clopidogrel and aspirin the areas under the receiver operating characteristic curve were also comparable for both aggregometry methods M-COL 0.77 (P = 0.006), LTA-COL 0.78 (P = 0.004), M-ADP 0.74 (P = 0.015), LTA-ADP 0.73 (P = 0.018).

CONCLUSION: Results achieved with the bedside Multiplate assays were not different than those obtained with classical aggregometry for detecting the effects of aspirin and clopidogrel in preoperative patients scheduled for elective cardiac surgery.



右旋美托咪啶联合咪达唑仑与丙泊酚用于接受磁共振成像检查患儿麻醉维持的比较

A Comparison of Dexmedetomidine-Midazolam with Propofol for Maintenance of Anesthesia in Children Undergoing Magnetic Resonance Imaging

Christopher Heard, MBChB, FRCA*, Frederick Burrows, MD{dagger}, Kristin Johnson, PharmD{ddagger}, Prashant Joshi, MD§, James Houck, MD||, and Jerrold Lerman, MD, FRCPC, FANZCA¶#

From the *Department of Anesthesiology and Division of Pediatric Critical Care, State University of New York at Buffalo, Women and Children’s Hospital of Buffalo, Buffalo, New York; {dagger}Department of Anesthesiology, State University of New York at Buffalo, Women and Children’s Hospital of Buffalo, Buffalo, New York; {ddagger}Department of Pharmacy, Women and Children’s Hospital of Buffalo, Buffalo, New York; §Division of Pediatric Critical Care, State University of New York at Buffalo, Women and Children’s Hospital of Buffalo, Buffalo, New York; ||Department of Anesthesiology, Women and Children’s Hospital of Buffalo, Buffalo, New York; ¶State University of New York at Buffalo and University of Rochester, Rochester, New York; and #Department of Anesthesiology, Women and Children’s Hospital of Buffalo, Buffalo and Strong Memorial Hospital, Rochester, New York.

Anesth Analg 2008 107: 1832-1839.

 

背景:右旋美托咪啶是α2受体激动剂,作者在接受磁共振成像(MRI)、并以七氟醚进行麻醉诱导的患儿中比较了右旋美托咪啶联合咪达唑仑与丙泊酚的药代动力学效应,以研究它是否适用于小儿麻醉。

方法401-10岁、ASA分级III级的患儿随机分为2组,在向其给予七氟醚作麻醉诱导后,一组给予右旋美托咪啶联合咪达唑仑,一组给予丙泊酚作麻醉维持,其后患儿接受MRI检查。给药方式为先给予右旋美托咪啶负荷量(1μg/kg),再追加持续量(0.5μg/kg/min);在持续输注开始时,给予咪达唑仑(0.1mg/kg)。丙泊酚则以持续输注的方式(250-300μg/kg/min)给予。然后由一位对实验目的不知情的护士记录患儿的复苏时间。

结果:接受右旋美托咪啶联合咪达唑仑维持的患儿其完全复苏、并从门诊离开的时间明显长于接受丙泊酚维持的患儿(15min)。变量分析显示,右旋美托咪啶组的患儿的心率低于、而收缩压高于丙泊酚组的患儿。两组的呼吸指数相似。复苏期间,两组患儿的血流动力学反应相似。麻醉和复苏期间,患儿的心脏呼吸指数维持在该年龄段儿童的正常范围内。没有发生不良反应。

结论:与丙泊酚相比,尽管复苏时间有所延长,右旋美托咪啶联合咪达唑仑能够为接受MRI检查的患儿提供充分的麻醉深度,且后者能够提供较慢的心率和较高的收缩压。两种治疗方式的呼吸指数相似。

(周姝婧 陈杰 校)

BACKGROUND: Dexmedetomidine is an {alpha}2 agonist that is currently being investigated for its suitability to provide anesthesia for children. We compared the pharmacodynamic responses to dexmedetomidine-midazolam and propofol in children anesthetized with sevoflurane undergoing magnetic resonance imaging (MRI).

METHODS: Forty ASA 1 or 2 children, 1–10 yr of age, were randomized to receive either dexmedetomidine-midazolam or propofol for maintenance of anesthesia for MRI after a sevoflurane induction. Dexmedetomidine was administered as an initial loading dose (1 µg/kg) followed by a continuous infusion (0.5 µg · kg–1 · h–1). Midazolam (0.1 mg/kg) was administered IV when the infusion commenced. Propofol was administered as a continuous infusion (250–300 µg · kg–1 · min–1). Recovery times and hemodynamic responses were recorded by one nurse who was blinded to the treatments.

RESULTS: We found that the times to fully recover and to discharge from the ambulatory unit after dexmedetomidine administration were significantly greater (by 15 min) than those after propofol. Analysis of variance demonstrated that heart rate was slower and systolic blood pressure was greater with dexmedetomidine than propofol. Respiratory indices for the two treatments were similar. During recovery, hemodynamic responses were similar. Cardiorespiratory indices during anesthesia and recovery remained within normal limits for the children’s ages. No adverse events were recorded.

CONCLUSION: Dexmedetomidine-midazolam provides adequate anesthesia for MRI although recovery is prolonged when compared with propofol. Heart rate was slower and systolic blood pressure was greater with dexmedetomidine when compared with propofol. Respiratory indices were similar for the two treatments.

 

 ProSealTM喉罩在2114例成人中应用的前瞻性研究

Use of ProSealTM Laryngeal Mask Airway in 2114 Adult Patients: A Prospective Study

Kai Goldmann, MD, PhD, DEAA*{dagger}, Carolin Hechtfischer*, Amena Malik*, Andrea Kussin, MD*, and Christian Freisburger, MD*

From the *Department of Anaesthesia and Intensive Care Therapy, Philipps University Marburg, Germany; {dagger}Department of Anaesthesia, Dubai Hospital, Dubai Health Authority, UAE.

Anesth Analg 2008 107: 1856-1861.

 

背景:虽然已有较多有关ProSealTM喉罩(PLMA)的研究,但其中只有少部分为大规模临床研究。本实验旨在采集关于ProSealTM喉罩的特性,有效性,安全性等方面的综合信息进行分析。信息采集由教学中心的专业麻醉医师完成。

方法:使用标准化采集方式进行信息采集。临床资料的收集范围包括使用者的特性,患者病情特征,类型及手术时程,气道管理,麻醉方法,有无不良事件发生及患者术后情况。

结果:81位麻醉医师(57%为实习医师,43%为执业医师)对2114例患者实施应用ProSealTM喉罩(PLMA)。置入喉罩的成功率为99%(最多三次尝试内)。平均气道漏气压为2811-40cmH2O3.2%的病例放弃使用ProSealTM喉罩而改用气管内插管。98%的病例进行控制通气。3.3%病例有临床相关不良事件,其中0.6%被列为严重不良事件。所有病例中没有产生长期的不良后遗症。12例有明显胃液返流的病例中,在使用ProSealTM喉罩引流管后无一发生误吸。5例困难通气及16例困难插管患者成功有效使用了ProSealTM喉罩。

结论:这项研究证实使用ProSealTM喉罩(PLMA)进行气道管理在临床应用中是安全并且有效的。实验结果也支持将ProSealTM喉罩置入正确位置可以有效防止胃液返流引起的误吸,且对困难气道同样有效。

(赵嫣红 陈杰

BACKGROUND: There have been numerous studies published on the ProSealTM laryngeal mask airway (PLMA). However, few have investigated its utility in a large practice setting. We sought to gather comprehensive data about the characteristics, efficacy, and safety of its use by a representative group of anesthesiologists working at a teaching center.

METHODS: Information was collected on a standardized data collection form. Clinical information obtained included user characteristics, patient characteristics, type and duration of operation, details of airway management and anesthetic technique, details of adverse events, and postoperative status of the patient.

RESULTS: Use of the PLMA was documented in 2114 patients by 81 anesthesiologists (57% trainee, 43% staff grade). The insertion success rate was 99% within a maximum of 3 attempts. Mean airway leak pressure was 28 (11–40) cm H2O. In 3.2% of cases, the PLMA was abandoned in favor of the endotracheal tube. Ventilation was controlled in 98%. Clinically "relevant" adverse events were recorded in 3.3% of all cases, of which 0.6% were classified as "serious." No long-term adverse sequelae resulted. No signs of aspiration were found in 12 patients with apparent regurgitation of gastric fluid through the drain tube of the PLMA. Five cases of difficult ventilation and 16 cases of difficult endotracheal intubation were successfully managed by the use of the PLMA.

CONCLUSION: This study demonstrates that airway management using the PLMA is safe and effective in a general practice setting. The results support the assumption that a correctly positioned PLMA can protect from pulmonary aspiration of regurgitate gastric fluid. The data also support use of the PLMA for the management of the difficult airway.

 

一个跨膜残基对丙泊酚与士的宁敏感的甘氨酸α1 α1β受体相互关系的影响

A Transmembrane Residue Influences the Interaction of Propofol with the Strychnine-Sensitive Glycine {alpha}1 and {alpha}1β Receptor

Jörg Ahrens, MD*, Martin Leuwer, MD{dagger}, Sina Stachura, MD*, Klaus Krampfl, MD{ddagger}, Delia Belelli, MD§, Jeremy J. Lambert, MD§, and Gertrud Haeseler, MD*

From the *Department of Anesthesiology, Hannover Medical School, Hannover, Germany; {dagger}Division of Clinical Sciences, The University of Liverpool, Liverpool, UK; {ddagger}Department of Neurology and Neurophysiology, Hannover Medical School, Hannover, Germany; and §Neurosciences Institute, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.

Anesth Analg 2008 107: 1875-1883.

 

背景:丙泊酚,以它的麻醉效应而知名,作为一个正的α1-氨基丁酸AGABAA)受体的变构调节剂作用,同时也增强甘氨酸受体的功能。丙泊酚GABA的调节效应受GABAA受体β亚单位的一个位于第二跨膜区(TM2)内的氨基酸残基的影响。在甘氨酸亚单位α1,相应的残基(丝氨酸267)影响醇和烷类麻醉剂的甘氨酸调节剂的作用。本研究中作者研究了这个残基在丙泊酚与甘氨酸α1 α1β受体相互关系中的作用。

方法:应用细胞膜片钳技术研究丙泊酚对于表达在人类胚肾293细胞的野生型和突变型(α1S267Mα1S267Iα1S267Mβα1S267Iβ)甘氨酸受体的作用。

结果:无论异亮氨酸或者甲硫氨酸α1单位TM2的丝氨酸残基的突变都降低了对甘氨酸的受体的敏感性,并且阻止了丙泊酚对甘氨酸受体的直接激活作用。此外,甲硫氨酸和独特的异亮氨酸突变型减少了丙泊酚的甘氨酸增强作用。

结论:野生型甘氨酸α1单位TM2残基(267)影响了丙泊酚的甘氨酸作用和受体的直接激活。这种变异导致丙泊酚与甘氨酸和GABA A受体作用发生变化,有助于更好地理解丙泊酚对相关受体的决定子,并且可能有助于发展选择性甘氨酸受体调节剂。

(怀晓蓉 陈杰

BACKGROUND: Propofol, well known for its anesthetic effects, acts as a positive allosteric modulator of the {alpha}-aminobutyric acid type A (GABAA) receptor but also enhances the function of the glycine receptor. The GABA modulatory effects of propofol are influenced by an amino acid residue located within the second transmembrane domain (TM2) of the GABAA receptor β subunit. In glycine {alpha}1 subunits, the homologous residue (serine 267) affects the glycine modulatory actions of alcohols and alkane anesthetics. In the present study we investigated the role of this residue on the interaction of propofol with the glycine {alpha}1 and {alpha}1β receptor.

METHODS: The influence of propofol on wild type and mutant ({alpha}1S267M, {alpha}1S267I, {alpha}1S267Mβ, {alpha}1S267Iβ) glycine receptors expressed in human embryonic kidney 293 cells was investigated by using the whole-cell clamp technique.

RESULTS: Mutation of the {alpha}1 subunit TM2 serine residue to either isoleucine or methionine decreased the sensitivity of the receptor to glycine, and abolished the direct activation of the glycine receptor by propofol. Additionally, the methionine and particularly the isoleucine mutation decreased the glycine-enhancing actions of propofol.

CONCLUSIONS: The nature of the TM2 residue (267) of the glycine {alpha}1 subunit influences the glycine modulatory effect of propofol and direct activation of the receptor by this anesthetic. A comparison of the impact of such complementary mutations on the interaction of propofol with glycine and GABAA receptors should permit a better understanding of the molecular determinants of action of propofol on these structurally related receptors and may aid in the development of selective glycine receptor modulators.

 

组胺和蕈毒碱受体参与了致敏的兔注射肌肉松弛药而导致的支气管收缩

The Involvement of Histaminic and Muscarinic Receptors in the Bronchoconstriction Induced by Myorelaxant Administration in Sensitized Rabbits

Walid Habre, MD, PhD*, Ágnes Adamicza, PhD{dagger}, Enikõ Lele, MD{ddagger}, Tímea Novák{dagger}{ddagger}, Peter D. Sly, MBBS, MD, DSc, FRACP§, and Ferenc Petak, MSc, PhD{ddagger}

From the *Pediatric Anesthesia Unit, Geneva Children's Hospital, Switzerland; {dagger}Institute of Experimental Surgery, University of Szeged, Hungary; {ddagger}Department of Medical Informatics and Engineering, University of Szeged, Hungary; and §Telethon Institute for Child Health Research and Centre for Child Health Research, University of Western Australia, Perth, Australia.

Anesth Analg 2008 107: 1899-1906.

 

背景:肌肉松弛药通过引起组胺的释放和/或由于作用于毒蕈碱样受体引起支气管痉挛;作者试图探究这些通路在支气管高反应性动物中各自的重要性。

方法:卵清蛋白致敏的兔子模型随机分组:组C为未处理组;在其他的三组中,组M123,使用H1H2组胺受体阻断剂,保留M1M2M3毒蕈碱受体的功能;组M12中,H1H2组胺受体阻断,M3毒蕈碱受体阻断,保留M1M2毒蕈碱受体功能;组M3中,切断迷走神经。静脉给予司可林,美维库铵或阿曲库铵后每90秒测量呼吸系统的阻力。检测两秒时间窗内肺部力学的变化,检测呼吸系统的阻力、组织阻尼及弹回率。

结果:气道阻力的峰值在组C中使用司可林(79%±17%)和美维库铵(75%±12%)的升高的最明显,而使用阿曲库铵(40%±11%)的升高较少。在同时行组胺和毒蕈碱受体阻断中这些变化显著的减少,同样的处理在M3中使用司可林(14%±5.2%)和组M123中使用美维库铵(5.1%±9.1%)和阿曲库铵(7.8%±4.0%)中阻力减少的最多。

结论:尽管支气管痉挛主要是由使用肌松药后组胺释放引起的气道过敏引起的,但司可林对M1M2M3受体,阿曲库铵对M1M2受体,美维库铵对M3受体影响可能也起一定作用。

(王鹏 陈杰

BACKGROUND: Muscle relaxants cause bronchospasm via histamine release and/or by acting on the muscarinic receptors; we sought to characterize the respective importance of these pathways in the presence of bronchial hyperreactivity.

METHODS: Ovalbumin-sensitized rabbits were randomly assigned to several protocol groups: Group C comprised untreated animals; in the other three groups, either H1 and H2 histaminic receptor blockade was performed, leaving the M1, M2, and M3 muscarinic receptors functional (Group M123), or combining this treatment with M3 muscarinic receptor blockade (Group M12), or with vagotomy (Group M3). Respiratory system impedance was measured over a 90-s period, during which succinylcholine, mivacurium or atracurium was administered. To monitor the changes in lung mechanics, respiratory system impedance was averaged in a 2-s time window and fitted by a model featuring airway resistance and inertance and tissue damping and elastance.

RESULTS: The peak increases in airway resistance in Group C were greatest with succinylcholine (79 ± 17[SE]%) and mivacurium administration (75% ± 12%), whereas they were lower after attracurium (40% ± 11%). These changes were markedly attenuated by both histamine and muscarinic receptor blockade with the largest reduction in Group M3 for succinylcholine (14% ± 5.2%), and in Group M123 for mivacurium (5.1% ± 9.1%) and attracurium (7.8% ± 4.0%).

DISCUSSION: Although the bronchospasm developing in the allergic airways after muscle relaxants is mediated primarily by the histaminic pathway, the interactions of succinylcholine on the M1, M2, and M3 receptors, those of atracurium on the M1 and M2 receptors, and those of mivacurium on the M3 receptors may also play a role.

 

伸展位Mallampati评分和糖尿病是病态肥胖病人困难喉镜的预测因子

The Extended Mallampati Score and a Diagnosis of Diabetes Mellitus Are Predictors of Difficult Laryngoscopy in the Morbidly Obese

George A. Mashour, MD, PhD*, Sachin Kheterpal, MD, MBA*, Vishnu Vanaharam, MD{dagger}, Amy Shanks, MS*, Luke Y.-J. Wang, MD*, Warren S. Sandberg, MD, PhD{dagger}, and Kevin K. Tremper, MD, PhD*

From the *Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; and {dagger}Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2008 107: 1919-1923.

 

背景: 修正Mallampati分级(MMP)为评估口咽结构预测困难喉镜的标准方法。先前的研究显示头颈关节伸展位(Extended Mallampati Score, EMS)较中位的MMP评分预测价值更有意义。本研究,作者对比了MMPEMS在病态肥胖病人中的预测价值。

方法:作者设计了一项超过12个月的前瞻性研究,比较了体重指数(BMI ≥40的成人MMPEMS 。比较MMPEMS和其他常用的方法预测困难喉镜的能力, Cormack-Lehane 分级34级定义为困难喉镜。位置调整及直接喉镜检查技术不作为标准。比较BMI ≥<40困难喉镜、困难插管的发生率。

结果:346 BMI ≥40的病人接受了喉镜检查并用MMPEMS进行评分。头颈后仰减低了MMP等级(P < 0.0001),相对于MMPEMS保持稳定的灵敏度的同时提高了特异性和预测价值。相对于MMP和其他测试,在病态肥胖病人中EMS评分34分并诊断为糖尿病可准确预测为困难喉镜。在BMI <40的病态肥胖病人中困难喉镜插管的发生率没有显著差别。

结论:在病态肥胖病人中预测困难插管EMS优于MMP。这一人群中诊断为糖尿病也是困难喉镜的预测因子。最后,这项研究支持先前的发现:病态肥胖症本身并不能作为困难喉镜和困难插管的预测因子。

(丁俊云 陈杰 校)

BACKGROUND: The modified Mallampati (MMP) classification is a standard method of oropharyngeal evaluation for predicting difficult laryngoscopy. Previous studies have demonstrated that the predictive value of the MMP is improved when the patient's craniocervical junction is extended rather than neutral (Extended Mallampati Score, EMS). In the present study, we compared the predictive value of the MMP and EMS in the morbidly obese.

METHODS: We performed a prospective study of adult patients with a Body Mass Index (BMI) ≥40 over a 12-mo period comparing the MMP and EMS. The performance of the MMP, EMS, and other commonly used tests was compared for the ability to predict difficult laryngoscopy, defined as a Cormack-Lehane grade of 3 or 4. Positioning and direct laryngoscopic techniques were not standardized. The incidence of difficult laryngoscopy and difficult intubation was compared in patients with BMI ≥or <40.

RESULTS: Three-hundred-forty-six patients with a BMI ≥40 were evaluated with both the MMP and EMS and received direct laryngoscopy. On average, craniocervical extension decreased the MMP class (P < 0.0001). Compared to the MMP, the EMS improved specificity and predictive value while maintaining sensitivity. Compared to the MMP and other tests, an EMS class of 3 or 4 and a diagnosis of diabetes mellitus were the only statistically significant predictors of difficult laryngoscopy in the morbidly obese. There was no difference in the incidence of difficult laryngoscopy or intubation in the morbidly obese compared to patients with a BMI <40.

CONCLUSIONS: The EMS was superior to the MMP in the prediction of difficult laryngoscopy in the morbidly obese population. A diagnosis of diabetes mellitus also warrants further investigation as a predictor of difficult laryngoscopy in this population. Finally, this study supports previous findings that morbid obesity is not itself a predictor of difficult laryngoscopy or intubation.

 

剖腹手术增加术中氧化应激反应:能被预防吗?

Open Abdominal Surgery Increases Intraoperative Oxidative Stress: Can It Be Prevented?

Masahiko Tsuchiya, MD, PhD*, Eisuke F. Sato, PhD{dagger}, Masayasu Inoue, MD, PhD{dagger}, and Akira Asada, MD, PhD*

From the Departments of *Anesthesiology, and {dagger}Biochemistry and Molecular Pathology, Osaka City University Medical School, Abeno-Ku, Osaka, Japan.

Anesth Analg 2008 107: 1946-1952.

 

背景:活性氧物质被高度怀疑参与了手术应激和损伤的发展,但未被证实。医学上没有方法处理这种类型的氧化应激。

方法:在四种不同麻醉方法下乙状结肠切除术中,测定血液中的过氧化氢水平作为细胞氧化损伤的指标,以及血浆铁还原能力作为总抗氧化潜力的指标:七氟醚麻醉开腹乙状结肠切除术,七氟醚麻醉腹腔镜下乙状结肠切除术,异丙酚麻醉开腹乙状结肠切除术,异丙酚麻醉腹腔镜下乙状结肠切除术。

结果:七氟醚麻醉开腹乙结肠切除手术中铁还原能力显著减弱,减幅387 ± 153 mmol/L,尽管过氧化氢水平没有改变,这表明手术增加了氧化应激。然而其毒性并没有高至造成细胞损伤,因为细胞氧化的典型产物过氧化氢并未增加。七氟醚麻醉腹腔镜下乙结肠切除术中过氧化氢水平和铁还原能力没有改变,这表明腹腔镜手术不会增加手术的氧化应激反应。异丙酚麻醉开腹和腹腔镜乙结肠切除术中过氧化氢显著减少,减幅分别为120 ± 73144 ± 107 Ucarr1 Ucarr对应0.8 mg/L H2O2)

结论:剖腹肠道手术增加了氧化应激。腹腔镜手术与氧化应激并无相关,而异丙酚作为抗氧化剂明显减少氧化应激。

(舒慧刚 陈杰 校)

BACKGROUND: The involvement of reactive oxygen species early in the development of surgical stress and injury is highly suspected but has not been confirmed. Medical approaches to manage this type of oxidative stress are unknown.

METHODS: We measured levels of blood hydroperoxides as an index of oxidative injury of cellular components, as well as plasma ferric-reducing ability as an index of total antioxidant potential, during sigmoidectomy under four conditions: open sigmoidectomy with sevoflurane anesthesia, laparoscopic sigmoidectomy with sevoflurane anesthesia, open sigmoidectomy with propofol anesthesia, and laparoscopic sigmoidectomy with propofol anesthesia.

RESULTS: Ferric-reducing ability decreased significantly during surgery for the open sigmoidectomy with sevoflurane anesthesia, by 387 ± 153 mmol/L, though the hydroperoxides level did not change, showing that oxidative stress increases in surgical patients. However, its toxicity may not be high enough to injure cellular components, since hydroperoxides, which are typical oxidized products of cellular components, did not increase. There were no changes in the hydroperoxides level or the ferric-reducing ability for the laparoscopic sigmoidectomy with sevoflurane anesthesia, indicating that this procedure does not increase surgical oxidative stress. Only hydroperoxides decreased significantly at the end of surgery for the open sigmoidectomy with propofol anesthesia and laparoscopic sigmoidectomy with propofol anesthesia, by 120 ± 73 and 144 ± 107 UCarr (1 UCarr corresponds to 0.8 mg/L H2O2), respectively.

CONCLUSIONS: It seems certain that open abdominal surgery of the intestinal tract increases intraoperative oxidative stress. A laparoscopic procedure was not associated with oxidative stress, and propofol anesthesia reduced it by apparently functioning as an antioxidant.


用于教学和研究的数字化脑血管模拟模型的设计

The Design of a Digital Cerebrovascular Simulation Model for Teaching and Research

Massimo Giannessi, MSc*, Mauro Ursino, PhD*, and W. Bosseau Murray, MD{dagger}

From the *Department of Electronics, Computer Science and Systems, University of Bologna, Cesena, Italy; and {dagger}Simulation Development and Cognitive Science Laboratory, Pennsylvania State University College of Medicine, Pennsylvania.

Anesth Analg 2008 107: 1997-2008.

 

背景:作者开发了一项综合脑血流和颅内压模型模拟并研究多重因素同时变化时引起的脑血液动力学复杂的相互影响,包括脑自动调节正常和异常功能状态。

方法来自先前动物和人类研究得出的方程是通过复杂的模拟程序得出。包括在正常生理模型,脑血流量,动脉血压,以及二氧化碳(CO2  )分压。作者还增加外部和病理干扰,如头高位和颅内出血。

结果:该模型的临床实际参数来自临床医生收集的创伤病人和其病历。医生很容易理解搏动性输出的图形。模拟方法包括变化的基础生理参数(例如,动脉血压,中心静脉压,二氧化碳张力,头的位置,和呼吸对血管压力的影响) ,以及病理参数(例如,急性颅内出血,脑脊液引流梗阻)

结论:根据调查结果,作者认为该模型对于复杂脑血流动力学的互相关系和临床一些问题研究有一定价值,如优化头部位置的影响,颅内出血的脑血流动力学变化,以及最适二氧化碳浓度,以达到最佳颅内压和灌注的平衡。基于对模型复杂性的区别能力,作者认为该模型将有助于初学者和有经验者。该模型也适用于临床(输入必要临床操作带来的影响,然后运行该模型来测试最佳的组合治疗方法)。

(叶乐 陈杰 校)

BACKGROUND: We developed a comprehensive cerebral blood flow and intracranial pressure model to simulate and study the complex interactions in cerebrovascular dynamics caused by multiple simultaneous alterations, including normal and abnormal functional states of autoregulation of the brain.

METHODS: Individual published equations (derived from prior animal and human studies) were implemented into a comprehensive simulation program. Included in the normal physiological modeling was cerebral blood flow, arterial blood pressure, and carbon dioxide (CO2) partial pressure. We also added external and pathological perturbations, such as head-up position and intracranial hemorrhage.

RESULTS: The model performed clinically realistically given inputs of published traumatized patients and cases encountered by clinicians. The pulsatile nature of the output graphics was easy for clinicians to interpret. The maneuvers simulated include changes of basic physiological inputs (e.g., arterial blood pressure, central venous pressure, CO2 tension, head-up position, and respiratory effects on vascular pressures) as well as pathological inputs (e.g., acute intracranial bleeding, and obstruction of cerebrospinal outflow).

CONCLUSIONS: Based on the results, we believe the model would be useful to teach complex relationships of brain hemodynamics and study clinical research questions such as the optimal head-up position, the effects of intracranial hemorrhage on cerebral hemodynamics, as well as the best CO2 concentration, to reach the optimal compromise between intracranial pressure and perfusion. With the ability to vary the model’s complexity, we believe it would be useful for both beginners and advanced learners. The model could also be used by practicing clinicians to model individual patients (entering the effects of needed clinical manipulations and then running the model to test for optimal combinations of therapeutic maneuvers).

 

鼻腔内应用酮咯酸在术后疼痛治疗中的安全性和镇痛效应

 

The Safety and Analgesic Efficacy of Intranasal Ketorolac in Patients with Postoperative Pain

John E. Moodie, MB, ChB, FRCA, FANZCA*, Colin R. Brown, BSc, MBBS, FANZCA*, Eileen J. Bisley, BN, G Dip BusS*, Hans U. Weber, PhD{dagger}, and Lincoln Bynum, MD{ddagger}

From the *Department of Anaesthesia, Waikato Clinical Research, Waikato Hospital, Hamilton, New Zealand; {dagger}Palo Alto, California; and {ddagger}ICON Clinical Research, Redwood City, California.

Anesth Analg 2008 107: 2025-2031.

 

背景:作者评估了多种剂量鼻腔应用内酮咯酸氨丁三醇(酮咯酸)的术后镇痛的安全性和有效性。

方法:在这一双盲、安慰剂对照的研究中,施行大手术的患者术后随机接受每8小时一次的鼻腔内应用酮咯酸10毫克或30毫克或安慰剂共40小时。记录用药后30分钟和1 2 3 4 5 6 8 12 16 20 24 28 32 36 40 4448 h时镇痛情况,疼痛强度至少维持在100mm视觉模尺的40mm以内。患者自控应用吗啡作辅助镇痛。

结果 127名患者,第一个24小时内30毫克酮咯酸组患者吗啡用量( 37.8毫克)低于安慰剂组( 56.5毫克)和10毫克酮咯酸组( 54.3毫克)。48小时内,30毫克酮咯酸组吗啡使用量比安慰剂组大大减少。30毫克酮咯酸组术后46 h疼痛强度与其它组相比有显著差异。酮咯酸30毫克组发热和心动过速发生率较安慰剂组显著降低。其他不良反应事件发生率率组间无差异,且大部分被认为与治疗无关。

结论 鼻腔内应用30毫克酮咯酸较10毫克酮咯酸和安慰剂相比,具有显著的镇痛效应。

(张磊 陈杰 校)

BACKGROUND: We evaluated the safety and efficacy of multiple doses of intranasal ketorolac tromethamine (ketorolac) for postoperative pain.

METHODS: This was a double-blind, placebo-controlled study in patients undergoing major surgery who were randomized to receive intranasal ketorolac, 10 mg or 30 mg, or placebo every 8 h for 40 h. After surgery, patients with pain intensity of at least 40 on a 100-mm visual analog scale were assessed at 30 min and at 1, 2, 3, 4, 5, 6, 8, 12, 16, 20, 24, 28, 32, 36, 40, 44, and 48 h after receiving the study drug. Patient-controlled IV morphine provided supplemental analgesia.

RESULTS: Among 127 patients enrolled, morphine use during the first 24 h was significantly less in patients receiving 30 mg of ketorolac (37.8 mg) than in the placebo group (56.5 mg) and in the 10-mg ketorolac group (54.3 mg). Over 48 h, the 30-mg ketorolac group used significantly less morphine than the placebo group. Summed pain intensity differences at 4 and 6 h significantly favored the 30-mg ketorolac group over the other groups. The rates of pyrexia and tachycardia were significantly lower in the ketorolac 30-mg group than in the placebo group. Other adverse events were reported with similar frequency in all treatment groups and most were considered unrelated to treatment.

CONCLUSION: Thirty milligrams of intranasal ketorolac demonstrated significant analgesic efficacy compared to 10 mg of intranasal ketorolac and placebo.

 

单剂量Tapentadol在牙科手术后镇痛效果 :一个随机,双盲,安慰剂对照研究

Single Dose Analgesic Efficacy of Tapentadol in Postsurgical Dental Pain: The Results of a Randomized, Double-Blind, Placebo-Controlled Study

Regina Kleinert, MSc*, Claudia Lange, MD, MSc*, Achim Steup, Dipl Stat*, Peter Black, MS{dagger}, Jutta Goldberg, PhD*, and Paul Desjardins, DMD, PhD{dagger}

From the *Grünenthal GmbH, Aachen, Germany; and {dagger}Scirex Corporation, Austin, Texas.

Anesth Analg 2008 107: 2048-2055.

 

背景Tapentadol是一种新型的中枢作用镇痛药,具有两种镇痛途径,一种为µ受体激动剂,另一种抑制去甲肾上腺素再摄取。作者研究了tapentadol与标准剂量的吗啡及与安慰剂在中度至重度术后牙齿疼痛的疗效和耐受性。

方法:下颌第三磨牙拔除术后经历中度至重度疼痛的患者随机接受单剂量盐酸tapentadol剂量 25 50 75 100 ,或200毫克) ,硫酸吗啡( 60毫克) ,布洛芬( 400毫克;用来建立模型的敏感性),或安慰剂。平均总缓解疼痛超过8小时( TOTPAR - 8 )为主要终点。第二次终结点包括平均总缓解疼痛超过4小时( TOTPAR - 4 )和镇痛的开始,使用Fisher 精确检验法研究药物与安慰剂作用差异,并记录不良事件。

结果: 400名患者随机接受治疗,并完成了研究。与安慰剂相比,盐酸tapentadol 50毫克( P0.041 75毫克( P0.001 100毫克( P “ 0.001 200毫克( P ” 0.001 ),硫酸吗啡60毫克(P < 0.001)和布洛芬400毫克(P < 0.001)TOTPAR – 8显着延长。布洛芬组TOTPAR - 8评分显着高于安慰剂组。相对于硫酸吗啡60毫克来说平均TOTPAR – 4在盐酸tapentadol200毫克似乎更加迅速快速,高效。硫酸吗啡60毫克疼痛缓解分数介于盐酸tapentadol 100毫克和200毫克之间。各种剂量盐酸tapentadol比硫酸吗啡60毫克的恶心,呕吐发生率低,但没有统计学意义。

结论:单剂量口服75毫克tapentadol相对吗啡来说能呈剂量相关的方式更有效地减少中度至重度牙科术后疼痛并且有良好的耐受性。这些数据表明tapentadol是一种副作用更少、起效更迅速的中枢作用的镇痛药。

(刘世文 陈杰 校)

BACKGROUND: Tapentadol is a novel, centrally acting analgesic with two modes of action, combining mu-opioid agonism and norepinephrine reuptake inhibition in a single molecule. We compared the efficacy and tolerability of tapentadol and a standard dose of morphine with placebo in a model of moderate-to-severe postoperative dental pain.

METHODS: Patients undergoing mandibular third molar extraction and experiencing moderate-to-severe pain postsurgery were randomized to receive single, oral doses of tapentadol HCl (25, 50, 75, 100, or 200 mg), morphine sulfate (60 mg), ibuprofen (400 mg; used to establish model sensitivity), or placebo. Mean total pain relief over 8 h (TOTPAR-8) was the primary end point. Secondary end points included mean total pain relief over 4 h (TOTPAR-4) and onset of analgesia. Pairwise comparisons of study drug to placebo were assessed using the Fisher least significant difference test. Adverse events were recorded.

RESULTS: Four hundred patients were randomized to treatment and completed the study. Compared with placebo, mean TOTPAR-8 was significantly greater for tapentadol HCl 50 mg (P = 0.041), 75 mg (P = 0.001), 100 mg (P < 0.001), and 200 mg (P < 0.001); morphine sulfate 60 mg (P < 0.001); and ibuprofen 400 mg (P < 0.001) in a nonparametric analysis of the primary end point. The significantly higher TOTPAR-8 score for ibuprofen compared with placebo established the sensitivity of the model. Mean TOTPAR-4 was higher and onset of action appeared more rapid for tapentadol HCl 200 mg than morphine sulfate 60 mg. Pain relief scores with morphine sulfate 60 mg were between those of tapentadol HCl 100 and 200 mg. The incidence of nausea and vomiting appeared to be lower with all doses of tapentadol HCl coMpared with morphine sulfate 60 mg, but was not statistically significant.

CONCLUSION: Single oral doses of tapentadol 75 mg or higher effectively reduced moderate-to-severe postoperative dental pain in a dose-related fashion and were well-tolerated relative to morphine. These data suggest that tapentadol is a highly effective, centrally acting analgesic with a favorable side effect profile and rapid onset of action.

 

筋膜上和筋膜下输注布比卡因用于腹式子宫切除术后的镇痛治疗
Bupivacaine Infusion Above or Below the Fascia for Postoperative Pain Treatment After Abdominal Hysterectomy

Meltem Cakmak Hafizoglu, MD, Kaan Katircioglu, MD, Murat Y. Ozkalkanli, MD, and Serdar Savaci, MD

From the Izmir Ataturk Training and Research Hospital, Department of Anesthesiology and Reanimation, Izmir, Turkey.

Anesth Analg 2008 107: 2068-2072.

 

背景:作者评估了腹式子宫切除术后筋膜上或筋膜下输注布比卡因的镇痛效果。
方法 62ASAIII级接受腹式子宫和双侧输卵管卵巢切除术患者列入这一随机双盲研究。给予统一标准的麻醉管理。在术毕时,多孔20号硬膜外导管放置于筋膜上( 筋膜上组29例)和筋膜下(筋膜下组 31例),通过病人自控镇痛装置给予0.25 %布比卡因,设定为锁定间隔60分钟输注9.0毫升持续24小时。在术后第一个6小时,追加注射芬太尼( 25微克)实现视觉模拟评分<4 cm。比较总布比卡因用量,总芬太尼追加量,疼痛分数(在休息,咳嗽,和直腿抬高状态)以及两组满意度。
结果24小时内总布比卡因用量在筋膜上组明显低于组筋膜下组(90 ± 26 mL vs 104 ± 28 mL, respectively, P < 0.05)。芬太尼的总用量在术后第一个6小时在筋膜上组和筋膜下组分别为109 ± 59 µg166 ± 70µg(P < 0.01) 。筋膜上组疼痛评分在前5 h内休息和咳嗽时和12小时内直腿抬高时较低(所有测量中P < 0.05 在筋膜上组有13例( 68 )的镇痛满意度极好,而在筋膜下组只有6例( 32 )的满意度极佳( P0.034
结论:经腹子宫切除术后的12小时内筋膜上比筋膜下输注布比卡因提供了更好术后镇痛。

(陈伟 陈杰 校)

BACKGROUND: We evaluated in which anatomic layer (above the fascia [AF] or below the fascia [BF]) wound infusion of bupivacaine has the best effect on postoperative pain after abdominal hysterectomy.

METHODS: Sixty-two ASA physical status I and II patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy were enrolled into this prospective randomized, double-blind study. A standard general anesthetic was administered. On completion of the operation, a multiorifice 20-gauge epidural catheter was placed above (group AF, n = 29) or below (group BF, n = 31) the superficial abdominal fascia and 0.25% bupivacaine was administered via a patient-controlled analgesia device, programmed to deliver 9.0 mL with a 60-min lockout interval for 24 h. During the first 6 h after surgery, rescue IV fentanyl (25 µg) was administered to achieve a visual analog scale score of <4 cm. Total bupivacaine consumption, total rescue fentanyl consumption, pain scores (with resting, coughing, and leg raising), and patient satisfaction scores were compared in both groups.

RESULTS: Total bupivacaine consumption over 24 h was significantly lower in group AF rather than group BF (90 ± 26 mL vs 104 ± 28 mL, respectively, P < 0.05). The total fentanyl consumption during the first 6 h after surgery was 109 ± 59 µg in group AF and 166 ± 70 µg in group BF (P < 0.01). Pain scores were lower in group AF at rest and coughing for the first 5 h and for the first 12 h with leg raise (P < 0.05 for all measurements). Thirteen patients (68%) in group AF defined their satisfaction as excellent whereas six patients (32%) in group BF defined their satisfaction as excellent (P = 0.034).

CONCLUSION: We conclude that bupivacaine wound infusion AF provides better postoperative analgesia compared with infusion BF in the first 12 h after abdominal hysterectomy.

 

低容量高浓度的比高容量低浓度局麻药用于Labat's坐骨神经阻滞更有效:一项前瞻性、随机、对照试验

Low Volume and High Concentration of Local Anesthetic Is More Efficacious than High Volume and Low Concentration in Labat's Sciatic Nerve Block: A Prospective, Randomized Comparison

Manuel Taboada Muñiz, MD, PhD*, Jaime Rodríguez, MD, PhD*, María Bermúdez, MD*, Cristina Valiño, MD{dagger}, Noemi Blanco, MD*, Marcos Amor, MD*, Pilar Aguirre, MD*, Ana Masid, MD*, Joaquin Cortes, MD, PhD*, Julián Álvarez, MD, PhD*, and Peter G. Atanassoff, MD{ddagger}

From the *Department of Anesthesiology, University of Santiago de Compostela, Hospital Clínico Universitario de Santiago, Spain; {dagger}Department of Anesthesiology, Hospital Meixoeiro, CHUVI, Vigo, Spain; and {ddagger}Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut.

Anesth Analg 2008 107: 2085-2088.

 

背景:各种各样的因素能显著影响周围神经阻滞的起效时间和成功率。这项前瞻性、随机、双盲研究旨在比较300mg甲哌卡因稀释于20ml30ml用于后路坐骨神经阻滞时其效果的差异。

方法 90名行足部手术患者随机接受1.5%的甲哌卡因20mln=45)或1%的甲哌卡因30mln=45)坐骨神经阻滞。所有的阻滞均采用神经刺激仪(刺激频率为2Hz;强度为1.4-0.5mA)。在这两组中, <0.5mA神经刺激引出足部的拓屈反应。记录知觉起效及在胫、腓神经分布区域运动阻滞的时间。一个成功的阻滞定义为在坐骨神经分布区域对针刺觉的完全消失及无力完成足部的拓屈及背屈反射。

结果1.5%的甲哌卡因20ml组阻滞成功率(96.6%)较1%的甲哌卡因30ml组(68.9%)更高(P<0.05)。1.5%甲哌卡因20ml组知觉完全消失及运动阻滞的时间分别为11±6min13±7min,比1%的甲哌卡因30ml组(分别为17±8min19±8min)更短。

结论Labat's坐骨神经阻滞时给予低容量高浓度的局麻药(1.5%的甲哌卡因)比高容量低浓度的局麻药(1%的甲哌卡因)成功率更高,起效时间更短。

(潘钱玲 陈杰

BACKGROUND: Various factors markedly affect the onset time and success rate, of peripheral nerve blockade. This prospective, randomized, double-blind study, compared a dose of mepivacaine 300 mg, in a 20 or 30 mL injection volume for sciatic nerve blockade using Labat's posterior approach.

METHODS: A total of 90 patients undergoing foot surgery were randomly allocated to receive sciatic nerve block with 20 mL of 1.5% mepivacaine (n = 45) or 30 mL of 1% mepivacaine (n = 45). All blocks were performed with the use of a nerve stimulator (stimulation frequency 2 Hz; intensity 1.5–0.5 mA). In the two groups, appropriate nerve stimulation was elicited at <0.5 mA and the targeted evoked motor response was plantar flexion of the foot. Time required for onset of sensory and motor block in the distribution of the tibial and common peroneal nerves were recorded. A successful block was defined as a complete loss of pinprick sensation in the sciatic nerve distribution with concomitant inability to perform plantar or dorsal flexion of the foot.

RESULTS: A greater success rate was observed with 20 mL of 1.5% mepivacaine (96.6%) than with 30 mL of 1% mepivacaine (68.9%; P < 0.05). Time to onset of complete sensory and motor block was shorter after injection of 20 mL of 1.5% mepivacaine (11 ± 6 min and 13 ± 7 min, respectively) than after 30 mL of 1% mepivacaine (17 ± 8 min and 19 ± 8 min, respectively, P < 0.05).

CONCLUSION: In Labat's sciatic nerve blockade, administering a low volume and a high concentration of local anesthetic (1.5% mepivacaine) is associated with a higher success rate and a shorter onset time than a high volume and a low concentration of solution (1% mepivacaine).

 

冠脉术前环氧合酶-1抑制剂的评估与患者自己报告服用阿司匹林血小板聚集度测定的比较

An Evaluation of Cyclooxygenase-1 Inhibition Before Coronary Artery Surgery: Aggregometry Versus Patient Self-Reporting

Niels Rahe-Meyer, Michael Winterhalter, Julia Hartmann, Albert Pattison, Hartmut Hecker, Andreas Calatzis, and Cristina Solomon

Department of Anesthesiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.

Anesth Analg 2008 107: 1791-1797.

 

背景:抗血小板治疗引起的血小板功能障碍会引起围手术期出血。在术前五天内用阿司匹林的几个试验调查显示,输血的需求对阿司匹林的使用者没有增加或者说没有显著差异。 我们的目的在于比较评价自己报告服用阿司匹林的患者和测定血小板功能的患者对输血的需求。

方法:在一个前瞻性的试验中,对100名在冠脉搭桥术前5天内服用阿司匹林的患者进行标准问卷调查。用多种血小板功能分析研究花生四烯酸对全血小板聚集的触发作用。

结果:23名术前服用阿司匹林的患者中,11人有异常聚集的现象。77名未在术前服用阿司匹林的患者中,9人有异常的聚集反应。术后24小时内胸管引流量及输注红细胞在服用和未服用阿司匹林的患者间无显著差异。正常和异常聚集反应的患者的术后24小时胸管引流量无显著差异。有异常聚集反应(<51U)的患者比正常聚集的患者(1.1U 对比0.3U,P=0.01)需要更多的血小板输注。

结论:我们的结果显示花生四烯酸介导的全血聚集检测比患者自己报告阿司匹林服用能更好的预测血小板相关的凝血障碍和血小板输注需要。

(胡艳译   薛张刚校)

BACKGROUND: Platelet dysfunction due to antiplatelet therapy contributes to perioperative bleeding. Several trials investigating the influence of aspirin intake within the 5 days before surgery reported that transfusion requirements were either increased or not significantly affected by aspirin intake. Our objective was to compare the assessment of aspirin intake by patient self-reporting and by measurement of platelet function with regard to transfusion requirements.

METHODS: In a prospective trial, a standardized questionnaire was used in 100 patients for aspirin intake within the 5 days immediately before coronary artery bypass grafting. Whole blood platelet aggregation triggered by arachidonic acid was investigated using the Multiplate platelet function analyzer.

RESULTS: Eleven of 23 patients with aspirin intake within the 5 days before the intervention showed an abnormal aggregation response. Nine of 77 patients who reported no aspirin intake before surgery had an abnormal aggregation response. There were no significant differences in chest tube drainage and red blood cell transfusion over the first 24 h postoperatively between patients with and without reported aspirin intake. There was no significant difference in chest tube drainage over the first 24 h postoperatively between patients showing normal or abnormal aggregation response. Patients with abnormal aggregation before intervention (<51 U) received significantly more platelet transfusion than patients with normal aggregation (1.1 U compared to 0.3 U, P = 0.001).

CONCLUSIONS: Our results suggest that arachidonic acid-induced aggregation in whole blood may be a better predictor of platelet-related coagulopathy and platelet transfusion than the assessment of aspirin intake by patient self-reporting.

                                                     

 

预防性使用地塞米松可减少双腔管拔管后咽喉痛和声嘶的发生率

Prophylactic Dexamethasone Decreases the Incidence of Sore Throat and Hoarseness After Tracheal Extubation with a Double-Lumen Endobronchial Tube

Sang-Hyun Park, Sung-Hee Han, Sang-Hwan Do, Jung-Won Kim, Ka-young Rhee, and Jin-Hee Kim

Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam City, Kyeonggi-do, Korea.

Anesth Analg 2008 107: 1814-1818.

 

背景:术后咽喉痛和声嘶是气管插管后的常见并发症,尤其是使用双腔管(DLT)后。此项前瞻性,随机化,双盲,安慰剂对照研究旨在评价预防性使用地塞米松对减少术后咽喉痛和声嘶发生率和严重程度的有效性。

方法166名预计使用双腔管行胸外科手术患者(年龄1875)进入此项研究。全麻诱导前经静脉给予0.1 mg/kg地塞米松(D1), 0.2 mg/kg地塞米松(D2), 或安慰剂(P),分组采用双盲,前瞻性,随机化方式。以CormackLehane评分法确定声门暴露情况,并记录插入双腔管的阻力,尝试插管的次数,完成插管的时间和气管插管的持续时间。气管插管后1小时和24小时,使用直观类比标度法(VAS 0分=不痛,100分=可想象的最痛)评估患者咽喉痛和声嘶的程度。

结果:气管拔管后1小时,DI(分别为31%, P = 0.021; 11%, P = 0.003; VAS 12.4, P < 0.001)D2(分别为11%, P = 0.001; 4%, P = 0.001; VAS 6.6, P < 0.001)术后咽喉痛和声嘶的发生率以及咽喉痛严重程度均较P(分别为53%, 36%,VAS 30.9)低。气管拔管后24小时,D2(分别为27%, P = 0.002; 15%, P = 0.001; VAS 29.9, P < 0.002)D1(分别为47%, 31%, VAS 43.9)P(分别为57%, 45%, VAS 51.3)术后咽喉痛和声嘶的发生率以及咽喉痛严重程度显著降低。未出现与使用地塞米松相关的并发症。

结论:预防性使用0.2 mg/kg地塞米松可显著降低双腔管拔管后1小时和24小时咽喉痛和声嘶的发生率以及咽喉痛的严重程度。

(黄凝译  薛张纲校)

BACKGROUND: Postoperative sore throat and hoarseness are common complications after tracheal intubation, particularly after using a double-lumen endobronchial tube (DLT). We conducted a prospective, randomized, double-blind, placebo-controlled study to evaluate the efficacy of dexamethasone for reducing the incidence and severity of postoperative sore throat and hoarseness.

METHODS: One hundred sixty-six patients (aged 18-75 yr) scheduled for thoracic surgery with a DLT were enrolled. Before induction of general anesthesia, 0.1 mg/kg dexamethasone (Group D1), 0.2 mg/kg dexamethasone (Group D2), or a placebo (Group P) were infused IV in a double-blind and prospectively randomized manner. Glottic exposure as defined by Cormack and Lehane score, resistance to DLT insertion, number of intubation attempts, time to achieve intubation, and the duration of tracheal intubation were recorded. At 1 h and 24 h after tracheal extubation, the patients were evaluated for sore throat and hoarseness using a visual analog scale (VAS; where 0 = no pain and 100 = worst pain imaginable).

RESULTS: One hour after tracheal extubation, the incidence of postoperative sore throat and hoarseness, along with the severity of sore throat were lower in Group D1 (31%, P = 0.021; 11%, P = 0.003; and VAS 12.4, P < 0.001, respectively) and D2 (11%, P = 0.001; 4%, P = 0.001; and VAS 6.6, P < 0.001, respectively) compared with Group P (53%, 36% and VAS 30.9, respectively). Twenty-four hours after tracheal extubation, the incidence of postoperative sore throat, hoarseness, and the severity of sore throat were significantly lower in Group D2 (27%, P = 0.002; 15%, P = 0.001; and VAS 29.9, P < 0.002, respectively) compared with Group D1 (47%, 31%, and VAS = 43.9, respectively) and Group P (57%, 45%, and VAS = 51.3, respectively). There was no complication associated with the dexamethasone administration.

CONCLUSION: The prophylactic use of 0.2 mg/kg of dexamethasone significantly decreases the incidence and severity of sore throat and hoarseness 1 h and 24 h after tracheal extubation of a DLT.

 

 

先天性主动脉瓣上狭窄与麻醉相关性猝死原因是什么?

Congenital Supravalvular Aortic Stenosis and Sudden Death Associated with Anesthesia: What’s the Mystery?

Burch TM,McGowan FX,Kussman BD,Powell AJ,DiNardo JA

.From the *Division of Cardiac Anaesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, and {dagger}Department of Pediatrics, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2008;107:1848 –1854

摘要:

主动脉瓣上狭窄合并外周肺动脉狭窄的病人中绝大多数有Williams-Beuren综合征,这类病人有其固有的心肌缺血的危险因素,在手术镇静和麻醉的情况下尤其如此。这些病变会引起双心室肥大进而增加心肌氧耗和损害心肌氧供。此外,这类病人常有直接多因素的冠状动脉血流减少。本文将分析主动脉瓣上狭窄的病理生理和复习镇静与麻醉相关性猝死的文献,并在已获得资料基础上提供一些术前评估与处理的建议。

(蒋宗明译  薛张纲校)

Patients with congenital supravalvular aortic stenosis and associated peripheral

pulmonary artery stenoses, the majority of whom have Williams-Beuren syndrome,

are inherently at risk for development of myocardial ischemia. This is particularly

true in the setting of procedural sedation and anesthesia. The biventricular

hypertrophy that accompanies these lesions increases myocardial oxygen consumption

and compromises oxygen delivery. In addition, these patients often have

direct, multifactorial compromise of coronary blood flow. In this article, we review

both the pathophysiology of congenital supravalvular aortic stenosis and the

literature regarding sudden death in association with sedation and anesthesia.

Recommendations as to preoperative assessment and management of these patients

are made based on the best available evidence.

 

 

右旋美托咪啶作为全麻辅助药在下腹部手术病人中的苏醒研究

Recovery Profiles from Dexmedetomidine as a General Anesthetic Adjuvant in Patients Undergoing Lower Abdominal Surgery

Norimasa Ohtani, Kotaro Kida, Kazuhiro Shoji, Yutaka Yasui, and Eiji Masaki

From the Departments of Anesthesiology, *Tohoku University Hospital, Sendai; and {dagger}Jikei University School of Medicine, Tokyo, Japan.

Anesth Analg 2008 107: 1871-1874.

 

背景:右旋美托咪啶可减少拔管期间的血流动力学变化,顾这种药物对需要平稳苏醒的全麻病人可能会有帮助。我们已知当七氟醚和异丙酚在单独使用时都能提供一个安全且快速的苏醒,因此我们旨在明确当七氟醚或异丙酚麻醉在合用右旋美托咪啶时对苏醒的影响作用。

方法60名行下腹部手术的病人根据所用的麻醉药物被随机的分配到四组,分别以七氟醚(S组),异丙酚(P组),七氟醚+右旋美托咪啶(SD组),或异丙酚+右旋美托咪啶(PD组)来维持麻醉。在诱导后麻醉的维持S组为0.6%–1.5%的七氟醚,P组为2–5 mg/kg/hSD组为七氟醚加右旋美托咪啶(10分钟的剂量为1 µg/kg ,后以 0.4 µg/kg/h直至手术结束)PD组为异丙酚加右旋美托咪啶,且所有组均复合持续硬膜外输注。在所有组,BIS值以调整七氟醚浓度或异丙酚输注速率的方式维持在45 ± 5之间。记录下从中止使用麻醉维持药物到病人睁眼的时间。手术后的认知功能是以短时定向记忆注意集中测试来评价的。

结果:将S组的睁眼时间(8.5 ± 2.5 min, mean ± sd; n = 15)SD组的睁眼时间(12.0 ± 3.3 min)作比较,PD(21.7 ± 7.1 min)P(11.0 ± 4.4 min)的睁眼时间延长,且PD组的睁眼时间比其他三组都明显延长(P < 0.001)。在S组及P组间的短时定向记忆注意集中测试评分相近,且并不受是否合用右旋美托咪啶的影响。

结论:当合用右旋美托咪啶时,七氟醚比异丙酚显示了更短的睁眼时间,且术后认知功能并不受右旋美托咪啶的影响。这些结果表明当右旋美托咪啶作为异丙酚全静脉麻醉的辅助用药时,可能会延迟苏醒时间。

(刘沁译 薛张纲校)

BACKGROUND: Dexmedetomidine induces less change in hemodynamic values during the extubation period. This drug may be useful in anesthetic management requiring smooth emergence from anesthesia. We sought to determine the effects of co-administration of dexmedetomidine on the recovery profiles from sevoflurane and propofol, which usually provide safe and rapid recovery when administered alone.

METHODS: Sixty patients undergoing lower abdominal surgery were randomly divided into four groups according to the anesthetic to be administered; namely, sevoflurane (group S), propofol (group P), both sevoflurane and dexmedetomidine (group SD), or propofol and dexmedetomidine (group PD) as maintenance general anesthetics. After induction, anesthesia was maintained with sevoflurane (0.6%–1.5%) in group S, propofol (2–5 mg/kg/h) in group P, sevoflurane and dexmedetomidine (1 µg/kg over 10 min followed by 0.4 µg/kg/h until the end of surgery) in group SD, and propofol and dexmedetomidine in group PD with continuous epidural infusion. Bispectral Index values were maintained within 45 ± 5 by changing the concentration of sevoflurane or the infusion rate of propofol in all groups. The time between the interruption of maintenance general anesthetics and eye opening was measured. Postoperative cognitive function was evaluated using the Short Orientation Memory Concentration Test.

RESULTS: The time to eye opening of groups S (8.5 ± 2.5 min, mean ± sd; n = 15) and SD (12.0 ± 3.3 min) were comparable, whereas that of group PD (21.7 ± 7.1 min) was longer than that of group P (11.0 ± 4.4 min). The time to eye opening of group PD was significantly (P < 0.001) longer than those of the other three groups. The scores of Short Orientation Memory Concentration Test between groups S and P were similar and were not changed by co-administration of dexmedetomidine.

CONCLUSION: When co-administered with dexmedetomidine, sevoflurane produced a shorter time to eye opening than propofol. Postoperative cognitive function was not affected by dexmedetomidine administration. These results suggest dexmedetomidine may delay recovery when given as an adjuvant to propofol during total IV anesthesia.

 

 

尼可地尔-三磷酸腺苷敏感的钾离子通道开放剂能阻断毒蕈碱乙酰胆碱受体介导的PC12细胞细胞外信号调节激酶的激活

Nicorandil, an adenosine triphosphate-sensitive potassium channel opener, inhibits muscarinic acetylcholine receptor-mediated activation of extracellular signal-regulated kinases in PC12 cells.

Niinomi K, Banno Y, Iida H, Dohi S.

Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 501-1194, Japan.

Anesth Analg 2008 107: 1892-1898.

 

背景尼可地尔-三磷酸腺苷敏感的钾离子通道开放剂被报道能通过使钾离子通道超极化产生抗伤害性刺激效应。细胞外信号调节激酶的激活-有丝分裂原(细胞分裂剂)激活蛋白中的一族在背根神经节的突触可塑性以及伤害性刺激中扮演一个重要的角色。有报道世纪神经元诱发了这种激活。为了理解尼可地尔的这种生物机制,我们检测它在毒蕈碱乙酰胆碱受体介导的一个神经元细胞(大鼠嗜铬细胞瘤PC12细胞)中细胞外信号调节激酶的激活效应。

方法:用蛋白质印迹分析检测PC12细胞在有或无尼可地尔时对乙酰胆碱的刺激反应及细胞外信号调节激酶的磷酸化。我们还检测尼可地尔在由4beta-phorbol 12-myristate 13-acetate(一种蛋白激酶C)或伊屋诺霉素(一种该离子载体)诱导下细胞外信号调节激酶的激活效应。PC12细胞内钙离子的增加可用荧光标记后用荧光显微镜观察。

结果尼可地尔阻滞乙酰胆碱诱导的细胞外信号调节激酶的激活并具有浓度依赖性。这种阻滞可被格列本脲(一种对三磷酸腺苷敏感的钾通道阻滞剂)消除。尼可地尔抑制细胞外信号调节激酶的激活是由伊屋诺霉素诱导的而非4beta-phorbol 12-myristate 13-acetatePC12细胞用尼可地尔预处理通过乙酰胆碱的刺激减少细胞内钙离子浓度。

结论尼可地尔通过减少细胞内钙离子浓度能阻断毒蕈碱细胞外信号调节激酶信号路径的激活。

(刘婷洁译 薛张纲校)

BACKGROUND: Nicorandil, an adenosine triphosphate-sensitive potassium channel opener, is reported to have an antinociceptive effect by hyperpolarization through the K(+) channel. The activation of extracellular signal-regulated kinase (ERK), a family of mitogen-activated protein kinases, plays an important role in synaptic plasticity and noxious stimulation in the dorsal root ganglion, and spinal neurons have been reported to induce its activation. To understand the biological mechanisms of nicorandil, we examined the effects of nicorandil on muscarinic acetylcholine (ACh) receptor-mediated activation of ERK in a neuronal model cell, rat pheochromocytoma PC12 cells.

METHODS: PC12 cells were stimulated with ACh in the presence or absence of nicorandil, and phosphorylation of ERK was examined by a Western blot analysis. We also examined the effects of nicorandil on the ERK activation induced by 4beta-phorbol 12-myristate 13-acetate, an activator of protein kinase C, or ionomycin, a calcium ionophore. Intracellular Ca(2+) increase was visualized in fluo-3-loaded PC12 cells using fluorescence microscopy.

RESULTS: Nicorandil inhibited ACh-induced ERK activation in a concentration-dependent manner. The inhibition was abolished by glibenclamide, an adenosine triphosphate-sensitive potassium channel blocker. Nicorandil suppressed the ERK activation induced by ionomycin but not 4beta-phorbol 12-myristate 13-acetate. Pretreatment of PC12 cells with nicorandil reduced the intracellular Ca(2+) concentration stimulated by ACh.

CONCLUSIONS: Nicorandil inhibits muscarinic activation of the ERK signaling pathway by reducing the intracellular Ca(2+) concentration.

 

 

肥胖患者置喉镜与气管插管时头高位的随机可控等价试验

Laryngoscopy and Tracheal Intubation in the Head-Elevated Position in Obese Patients: A Randomized, Controlled, Equivalence Trial

Srikantha L. Rao, Allen R. Kunselman, H. Gregg Schuler, and Susan DesHarnais.

From the *Department of Anesthesiology, {dagger}Office of the Vice Dean for Research and Graduate Studies, and {ddagger}Department of Public Health Sciences, Pennsylvania State University, College of Medicine, M.S. Hershey Medical Center, Pennsylvania.

Anesth Analg 2008 107: 1912-1918.

 

背景:患者的正确摆体位是直接喉镜以及气管插管成功的关键因素。在肥胖患者中,行气管插管时,25º的垫背位或头高位都要优于平卧位。这种体位通常通过在患者的头部及肩部放置摆位毛毯或者其他装置来实现。这种体位也可以通过操纵常用的手术床来做到:屈曲纵线力臂以及抬高手术床靠背部分(手术床斜面)。这种利用手术床来摆位的方法可以省去额外摆位装置的费用,而且可以避免患者及摆位者在插管后移除这些装置时可能受到的伤害。本次研究就是想要知道通过手术床来摆体位,是否与使用摆位装置一样有效,即两者花费的插管时间是否相同。

方法85个择期手术BMI30kg/m2的患者同意参加这个前瞻、随机的等价研究。本研究在一个教学医院进行,随机化通过使用随机表格来决定,即将受试者平等分布在随机表格中,来决定其使用体位毯方式或手术床方式。本次试验的观察终点是达到头高位,即患者的外耳道线与胸骨切迹位于同一水平线。虽然所有患者的摆位都是由同一个麻醉医生完成,但置喉镜和气管插管是由不同经验程度的学习者来完成的。本试验所使用的是标准的静脉诱导以及气管插管技术。从患者失去意识的时点开始记录直到气管插管成功EtCO2被检测到为终点。同时也要记录面罩通气的有效性以及喉镜暴露的质量。

结果:使用毛毯组的插管平均时间是175秒钟,标准差为66秒钟。手术床组的插管平均时间是163秒钟,标准差为71秒钟。假定等价边界为-55.55秒,当检验的显著性水平为0.05时,我们使用了两种单侧检验的方法计算出95%的可信区间为-36.22秒和13.52秒。两组置喉镜的次数并无差别(p=0.21),保持气道安全性的气管插管也无区别(p=0.76)。

结论:麻醉诱导前,肥胖患者要在手术床上放置为一个头部高于肩部的体位,这可以通过在患者的肩背部放置一个摆位毛毯或者通过摇动手术床斜面来达到。对于置直接喉镜和行气管插管来说,这两种方法的效果等价。

(秦敏菊译 薛张纲校)

BACKGROUND: The proper positioning of patients before direct laryngoscopy is a key step that facilitates tracheal intubation. In obese patients, the 25 degree back-up or head-elevated laryngoscopic position, which is better than the supine position for tracheal intubation, is usually achieved by placing blankets or other devices under the patient’s head and shoulders. This position can also be achieved by reconfiguring the normally flat operating room (OR) table by flexing the table at the trunk-thigh hinge and raising the back (trunk) portion of the table (OR table ramp). This table-ramp method can be used without the added expense of positioning devices, and it reduces the possibility of injury to the patient or providers that can occur during removal of such devices once tracheal intubation is achieved. In this study, we sought to determine if the table-ramp method of patient positioning was equivalent to the blanket method with regard to the time required for tracheal intubation.

METHODS: Eighty-five adults with a Body Mass Index 30 kg/m2, scheduled for elective surgery, consented to participate in this prospective randomized equivalence study conducted in a teaching hospital. The randomization scheme used permuted blocks with subjects equally allocated to be positioned using either the blanket method or the table-ramp method. The end-point in either case was to achieve a head-elevated position, where the patient’s external auditory meatus and sternal notch were in the same horizontal plane. Although all patients were positioned by the same anesthesiologist, laryngoscopy and tracheal intubation were performed by trainees with various levels of expertise. Standard IV induction and tracheal intubation techniques were used. The time from loss of consciousness to the time after tracheal intubation when end-tidal CO2 was detected was recorded. The effectiveness of mask ventilation and quality of laryngeal exposure were also noted.

RESULTS: The mean time (sd) to tracheal intubation was 175 (66) s in the blanket group, as compared to 163 (71) s in the table-ramp group. Assuming the bounds for equivalence are-55,55 s, our study found a 95% confidence interval of -36.22, 13.52 s using two one-sided tests for equivalence corresponding to a significance level of 0.05. There was no difference in the number of attempts at laryngoscopy (P = 0.21) and tracheal intubation (P = 0.76) required to secure the airway between the two groups.

CONCLUSIONS: Before induction of anesthesia, obese patients can be positioned with their head elevated above their shoulders on the operating table, on a ramp created by placing blankets under their upper body or by reconfiguring the OR table. For the purpose of direct laryngoscopy and tracheal intubation, these two methods are equivalent.

 

 

比较三组病人自控硬膜外镇痛的随机试验

A Randomized Controlled Trial of Three Patient-Controlled Epidural Analgesia Regimens for Labor

Yvonne Lim, MMED, Cecilia E. Ocampo, MD, Mia Supandji, MD, Wendy H. L. Teoh, FANZCA, and Alex T. Sia, MMED

From the Department of Woman Anesthesia, KK Women's and Children's Hospital, Singapore.

Anesth Analg 2008; 107:1968-1972

 

背景:病人自控硬膜外镇痛(PCEA)是安全有效的人工镇痛方法,但是何为理想的镇痛模式则有争议。

方法:在该前瞻性,随机,双盲研究中,我们比较追加量镇痛和有背景剂量镇痛的止痛效果。研究对象为300名未孕者。首先以罗派卡因2mg和芬太尼15ug开始镇痛,以硬膜外0.1%罗哌卡因和2 µg/mL芬太尼维持。病人分为3组。0组:无背景剂量,追加量5ml,锁定时间15分钟,5组:背景剂量5mL/h,追加量5ml,锁定时间12分钟,10组:背景剂量10mL/h,追加量5ml,锁定时间10分钟。所有组最大剂量为20 mL/h。第一项结果是剧烈疼痛的发生率,第二项结果包括分娩期疼痛评分,神经阻滞特征,副作用,罗哌卡因总量和小时用量,新生儿和产科结果。

结果0组的剧烈疼痛发生率和疼痛评分显著高于5组和10组。10组无痛期更长于0组,罗哌卡因用量更高,和更晚使用第二次追加剂量有关。

结论:和有背景剂量镇痛相比,只有追加剂量的镇痛所用麻醉药更少,但疼痛发生率高,疼痛评分高,有效无痛期短,母亲满意度低。

(孙鹏飞译  薛张纲校)

BACKGROUND: Patient-controlled epidural analgesia (PCEA) is a safe and effective mode of maintaining labor analgesia; however, the ideal PCEA regimen is controversial.

METHODS: In this prospective, randomized, double-blind study, we examined the analgesic efficacy of demand-only PCEA and PCEA with background infusion. We recruited 300 nulliparous parturients. Analgesia was initiated with intrathecal ropivacaine 2 mg and fentanyl 15 µg and maintained with epidural ropivacaine 0.1% with fentanyl 2 µg/mL. Parturients were randomized to one of three groups. Group 0: demand-only PCEA, bolus of 5 mL, lockout interval of 15 min. Group 5: background infusion of 5 mL/h, bolus of 5 mL, lockout interval of 12 min. Group 10: background infusion of 10 mL/h, bolus of 5 mL, lockout interval of 10 min. The maximum dose of all groups was 20 mL/h. The primary outcome was incidence of breakthrough pain. Secondary outcomes included intrapartum pain scores, neuraxial blockade characteristics, side effects, the total and hourly volume of ropivacaine, neonatal outcomes, and obstetric outcomes.

RESULTS: The incidence of breakthrough pain and the maximum visual analog scale (0–100 mm scale) pain scores were higher in Group 0 versus Groups 5 and 10 (43% vs 17% and 11%, P < 0.001 and 37 ± 28 vs 22 ± 26 and 16 ± 25 [mean ± sd], P < 0.001), respectively. Group 10 had a longer duration of effective analgesia compared with Group 0 (mean 895 min, 95% CI 823–966 vs 565 min, 95% CI 454–677, P < 0.001) and increased ropivacaine consumption, and was associated with a longer duration of the second stage of labor.

CONCLUSION: Demand-only PCEA (5-mL bolus, 15-min lockout interval) resulted in less local anesthetic consumption but an increased incidence of breakthrough pain, higher pain scores, shorter duration of effective analgesia, and lower maternal satisfaction, when compared with PCEA with background infusion (5-mL bolus, 10–12-min lockout interval, and 5–10 mL/h infusion).

 

 

一种新型的经鼻吗啡合剂、快速释放口服吗啡、静脉用吗啡和安慰剂用于术后牙痛模型中的镇痛效果和安全性比较

The Analgesic Efficacy and Safety of a Novel Intranasal Morphine Formulation (Morphine plus Chitosan), Immediate Release Oral Morphine, Intravenous Morphine, and Placebo in a Postsurgical Dental Pain Model

Kyle S. Christensen, DDS*, Amy E. Cohen, MS{dagger}, Fred H. Mermelstein, PhD{ddagger}, Douglas A. Hamilton, MBA§, Ewan McNicol, MS||, Najib Babul, PharmD, and Daniel B. Carr, MD#{ddagger}

From the *Jean Brown Associates, Salt Lake City, Utah; {dagger}Clinical Operations, {ddagger}Javelin Pharmaceuticals, Cambridge, Massachusetts; §New Biology Ventures, San Francisco, California; ||Analgesic Trial Design, Charlestown, Massachusetts; ¶TheraQuest Biosciences Inc., Blue Bell, Pennsylvania; and #Tufts Medical Center, Boston, Massachusetts.

Anesth Analg 2008 107: 2018-2024.

 

背景:阿片类药物是用于术后镇痛的标准药物。本研究中,我们对比了经鼻吗啡合剂、静脉用吗啡、口服吗啡以及安慰剂的功效和安全性。

方法225位拔除第三磨牙后患有中到重度疼痛的患者随机分为四组,分别接受次剂量经鼻吗啡合剂7.5 mg 15 mg, 静脉用吗啡7.5 mg, 口服吗啡60 mg以及安慰剂。疼痛程度评定采用VAS评分法,疼痛减轻采用直接评分。结果包括总体疼痛减轻状况,疼痛程度差异,总计疼痛程度差异,止痛效果起效时间,要求进一步药物支持的时间以及患者对治疗的总体评价。安全评估包括副作用记录以及鼻部检查。

结果:参考了多种评价结果,两种经鼻吗啡合剂使用剂量与后两者(静脉及口服吗啡)相比统计学结果相近,四种用药途径的吗啡治疗都显著有效于安慰剂。经鼻吗啡合剂15mg与静脉用吗啡7.5mg的效用相近,两种治疗起效都相当迅速,并且在6小时评估时间内效果都持久稳定。低剂量经鼻吗啡合剂,7.5mg,与其它治疗方法在2小时和6小时的效果统计学结果相近,与安慰剂治疗效果在4小时统计学结果相近。治疗研究总体上能够被接受,没有因为副作用或者其它安全因素而退组的情况,没有严重的副作用记录。频繁发生的副作用事件都是典型的阿片类药物的全身性副作用。

结论:相对静脉用吗啡而言,经鼻吗啡合剂为术后镇痛提供了一种无创用药途径。 

(夏俊明译 薛张纲校)

BACKGROUND: Opioids are standard treatment for postoperative pain. In this study, we compared the safety and efficacy of intranasal (IN) morphine to IV and oral morphine and placebo.

METHODS: Two-hundred-twenty-five patients with moderate-to-severe pain after third molar extraction were randomized to receive a single dose of IN morphine 7.5 mg or 15 mg, IV morphine 7.5 mg, oral morphine 60 mg or placebo. Pain intensity was assessed using visual analog and categorical scales, and pain relief using a categorical scale. Outcomes included total pain relief, pain intensity difference, summed pain intensity difference, time to analgesic onset, time to requesting rescue medication, and patients’ global evaluation of their treatment. Safety assessments included adverse event recording and nasal examinations.

RESULTS: Across the various efficacy outcomes, both IN morphine doses were statistically similar to the positive comparators (IV and oral morphine), and all four morphine treatments were statistically superior to placebo. Overall, IN morphine 15 mg presented an efficacy profile similar to IV morphine 7.5 mg; both treatments demonstrated rapid onset of efficacy, generally persistent throughout the 6-h assessment period. The lower dose of IN morphine, 7.5 mg, was statistically similar to the other active treatments at 2 h and 6 h and similar to placebo at 4 h. Study medications were generally well tolerated, with no withdrawals due to adverse events or other safety concerns, and no serious adverse events reported. The most frequently reported adverse events were typical systemic opioid effects.

CONCLUSIONS: IN morphine offers a noninvasive alternative to IV morphine for postoperative analgesia.

 

 

慢性头痛的针灸治疗:系统综述

Acupuncture for the Management of Chronic Headache: A Systematic Review

Sun, Yanxia MD; Gan, Tong J. MB, FRCA

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

Anesth Analg 2008 107: 2038-2047.

 

目的:这篇综述的目的是评价慢性疼痛的针灸治疗的疗效。

方法:我们搜索了Medline1966-2007),CINAHLThe Cochrane Central Register of Controlled Trials (2006)Scopus等数据库中关于慢性头痛针灸治疗的随机对照实验。实验包括成人慢性疼痛(包括偏头痛或紧张性头痛或两者都有),随机接受针刺治疗,对照组包括假的针灸治疗,药物治疗和其他非药物治疗。我们引用头痛强度,头痛频率和早期和晚期随访的应答率等数据。

结果:这篇综述包括31项研究。大部分比较了真假针灸治疗的研究支持针灸疗法。针灸治疗组的组合应答率显著高于假针灸治疗组,不论是在随访早期(RR1.19, 95%CI1.08, 1.30)或随访晚期(RR1.22, 95%CI1.04, 1.43)。组合数据同样表明针灸治疗优于药物治疗:头痛强度(加权平均数:-8.54 mm, 95% CI: -15.52, -1.57),头痛频率(标准差: -0.70, 95% CI: -1.38, -0.02),躯体功能(加权平均数: 4.16, 95% CI: 1.33, 6.98),应答率(RR: 1.49, 95% CI: 1.02, 2.17).

结论:在改善头痛强度,头痛频率和应答率方面针灸治疗优于假针灸治疗和药物治疗。

(宣丽真译 薛张纲校)

OBJECTIVE: The objective of this review was to evaluate the efficacy of acupuncture for treatment of chronic headache.

METHODS: We searched the databases of Medline (1966–2007), CINAHL, The Cochrane Central Register of Controlled Trials (2006), and Scopus for randomized controlled trials investigating the use of acupuncture for chronic headache. Studies were included in which adults with chronic headache, including migraine, tension-type headache or both, were randomized to receive needling acupuncture treatment or control consisting of sham acupuncture, medication therapy, and other nonpharmacological treatments. We extracted the data on headache intensity, headache frequency, and response rate assessed at early and late follow-up periods.

RESULTS: Thirty-one studies were included in this review. The majority of included trials comparing true acupuncture and sham acupuncture showed a trend in favor of acupuncture. The combined response rate in the acupuncture group was significantly higher compared with sham acupuncture either at the early follow-up period (risk ratio [RR]: 1.19, 95% confidence interval [CI]: 1.08, 1.30) or late follow-up period (RR: 1.22, 95% CI: 1.04, 1.43). Combined data also showed acupuncture was superior to medication therapy for headache intensity (weighted mean difference: -8.54 mm, 95% CI: -15.52, -1.57), headache frequency (standard mean difference: -0.70, 95% CI: -1.38, -0.02), physical function (weighted mean difference: 4.16, 95% CI: 1.33, 6.98), and response rate (RR: 1.49, 95% CI: 1.02, 2.17).

CONCLUSION: Needling acupuncture is superior to sham acupuncture and medication therapy in improving headache intensity, frequency, and response rate.

 

 

给绵羊鞘内注射酮基布洛芬和氯胺酮预防N -甲基- D -天门冬氨酸引起的机械痛

Prevention of N-Methyl-d-Aspartate-Induced Mechanical Nociception by Intrathecal Administration of Ketoprofen and Ketamine in Sheep

Ignacio Lizarraga, MVZ, MVSc, PhD*, J. Paul Chambers, BVSc, DVA(RCVS), DipECVA, PhD

From the *Facultad de Medicina Veterinaria y Zootecnia, Universidad Nacional Autónoma de México, México D.F, México; and {dagger}IVABS, Massey University, Palmerston North, New Zealand.

Anesth Analg 2008 107: 2061-2067

 

背景:非甾体抗炎药和N -甲基- D -天冬氨酸( NMDA )受体拮抗剂通过鞘内注射减轻疼痛敏感性。但他们的联合影响几乎未被研究。我们估计了非类固醇消炎药酮丙酸的作用和NMDA感受器官渠道阻碍ketamine单独给出和在组合,在绵羊的机械痛感的门限被种入的与存在的子宫颈i.t.导尿管

方法给予绵羊,它导管,酮基布洛芬( 200-3200微米; 100 μL )及氯胺酮( 25-400微米; 100 μL )单独或联合( 837.95-3350.78微米; 100 μL ; 0.955:0.045的比例) 。他们还收到了NMDA受体( 2毫米; 100 μL )之前,最集中的酮洛芬和氯胺酮单独或联合。生理盐水( 0.9 ; 100 μL )和二甲苯胺噻嗪( 1.95毫米; 100 μL )被用来作为阴性和阳性对照。

结果二甲苯胺噻嗪显着增加该地区的感受阈值随时间的曲线值(曲线) 30 60 ,和180分钟前后。酮基布洛芬和氯胺酮,单独和组合,产生任何重大影响的AUC值。 NMDA受体仅减少了哥伦比亚联合自卫军值为30分钟前后。这种疼痛被阻止过敏的preadministering酮基布洛芬和氯胺酮单独和组合。

结论: 在绵羊,酮丙酸的i.t.管理和ketamine,单独或一起,没有生产hypoalgesia; 然而,他们防止了NMDA导致的机械过敏症。 酮丙酸和ketamine也许有在情况的治疗潜力与坚持痛苦相关。

章一静译 薛张纲校

Abstract

BACKGROUND: Nonsteroidal antiinflammatory drugs and N-methyl-d-aspartate (NMDA) receptor antagonists reduce pain hypersensitivity when given by the intrathecal (i.t.) route, but their combined effects have hardly been studied. We assessed the effects of the nonsteroidal antiinflammatory drug ketoprofen and the NMDA receptor channel blocker ketamine, given alone and in combination, on mechanical nociceptive thresholds in sheep implanted with indwelling cervical i.t. catheters.

METHODS: Sheep were given, by i.t. catheter, ketoprofen (200–3200 µM; 100 µL) and ketamine (25–400 µM; 100 µL) alone or in combination (837.95–3350.78 µM; 100 µL; 0.955:0.045 proportion). They also received NMDA (2 mM; 100 µL) preceded by the highest concentration of ketoprofen and ketamine alone or in combination. Saline solution (0.9%; 100 µL) and xylazine (1.95 mM; 100 µL) were used as negative and positive controls, respectively.

RESULTS: Xylazine significantly increased the area under the nociceptive threshold versus time curve values (AUC) for 30, 60, and 180 min posttreatment. Ketoprofen and ketamine, alone and in combination, produced no significant effect on AUC values. NMDA alone decreased the AUC value for 30 min posttreatment. This pain hypersensitivity was prevented by preadministering ketoprofen and ketamine alone and in combination.

CONCLUSIONS: In sheep, i.t. administration of ketoprofen and ketamine, alone or together, produced no hypoalgesia; however, they prevented NMDA-induced mechanical hypersensitivity. Ketoprofen and ketamine may have therapeutic potential in conditions associated with persistent pain.


弹性输注泵用于术后区域麻醉的可靠性:一项对430件设备的调查

Postoperative Regional Anesthesia: A Survey of 430 Consecutive Devices

Francis Remerand, MD, Anne Sophie Vuitton, MD, Michel Palud, MD, Sylvie Buchet, MD, Xavier Pourrat, PharmD, Annick Baud, MD, Marc Laffon, MD, PhD, and Jacques Fusciardi, MD

From the Groupement dAnesthésie Réanimation, Hôpital Trousseau, CHU Tours, Université François Rabelais, 37041 Tours cedex 1, France.

Anesth Analg 2008 107: 2079-2084.

 

背景:相比于与术后全身镇痛,持续神经周围输注局麻药效果更好。相比于电子模型,弹性输注泵更受病人欢迎。在离体试验中,按既定的输注速率,会剩下10%的预输液。我们选择了行矫形手术的病人,评估在体使用弹性输注泵的输注速率。

方法:所有关于持续使用弹性输注泵的都是在10个月内的回顾性研究。术前在神经周围留置导管,术后与装有0.2%罗派卡因的弹性输注泵相连。在输注前,弹性输注泵和罗派卡因在室温下保存。随机使用两种型号的泵:InfusorTM LV5 (Baxter, France) EasypumpTM (Braun, Germany),都设为5 mL/h。护士在床旁使用便携式电子称对输注泵称重,直到导管被拿走。按时间测定重量可以用来判断输注泵体积缩小量的准确性和计算输注速率。重量不变提示导管阻塞或输注泵失效。

结果:连接导管后,88个设备没有缩小(300 Easypump中有80个,130 Infusor中占8, P < 0.0001)。一个Easypump即使不连接导管也不能缩小。有两例导管阻塞。在21例中,导管在1172小时没有开放即被拔除。24例泵在经导管很顺利在加了负荷剂量后缩小。剩下的40例装置在连接后643小时后自行缩小。这88个弹性输注泵术后第一天的最大直观类比刻度高于装置连接后可显示的缩小量(34 ± 21 mm vs 26 ± 19 mm, P = 0.006)。分别在平均使用周期54 ± 18 h (Easypump)49 ± 19 h (Infusor)测定流速。 流速为5 mL/h ± 15%EasypumpInfusord分别占47% 34% (P = 0.01)

结论:弹性泵在活体的可靠性和离体的不同。术后使用周围神经镇痛早期,弹性输注泵不缩小应引起重视。我们建议在开始24h内内每三个小时对镇痛泵称重。

(陈珺珺译 薛张纲校)

BACKGROUND: Postoperative analgesia via continuous perineural infusion of local anesthetics compares favorably with systemic analgesia. Elastomeric pumps increase patient satisfaction compared with electronic models. In in vitro investigations, infusions remained within 15% of their designated set rates. We assessed in vivo the infusion rate of elastomeric pumps in regional analgesia after orthopedic surgery.

METHODS: All consecutive elastomeric pumps were retrospectively studied during a 10-mo period. Perineural catheters were inserted preoperatively and connected postoperatively to elastomeric pumps filled with ropivacaine 0.2%. Before infusion, elastomeric pumps and ropivacaine were stored at room temperature. Two models of pumps were randomly used: InfusorTM LV5 (Baxter, France) or EasypumpTM (Braun, Germany), both set at 5 mL/h. Nurses weighed the devices at the bedside using a portable electronic scale several times a day until catheter removal. Weights over time allowed accurate deflation profile assessment and flow rate calculation. An unchanged weight over time indicated either an obstructed catheter or an ineffective device.

RESULTS: After connection to the catheter, 88 devices did not deflate (80 Easypump of 300 and 8 Infusor of 130, P < 0.0001). One Easypump was impossible to deflate, even after disconnection from its catheter. In two cases, catheters were obstructed. In 21 cases, catheters were removed 11 to 72 h later without being tested for patency. In 24 cases, pumps correctly deflated after catheters were injected without difficulty with a local anesthetic bolus. The remaining 40 devices spontaneously started to deflate 6 to 43 h after their connection. These 88 elastomeric pumps were associated with higher maximal visual analog scale scores during the first postoperative night than devices showing immediate deflation after connection (34 ± 21 mm vs 26 ± 19 mm, P = 0.006). Flow rates were calculated over a mean period of 54 ± 18 h (Easypump) and 49 ± 19 h (Infusor). The flow rates differed from those set by manufacturers (5 mL/h ± 15%) in 47% of Easypump and in 34% of Infusor devices (P = 0.01).

CONCLUSIONS: In vivo reliability of elastomeric pumps is different than in vitro. In the event of early insufficient postoperative perineural analgesia, an absence of deflation of the elastomeric pump must be considered. We recommend weighing these devices every 3 h during the first 24 h of infusion.


抑肽酶和氨甲环酸在心脏手术中的危险性: 一项 1188 例连续的病人随访一年的研究

The Risks of Aprotinin and Tranexamic Acid in Cardiac Surgery: A One-Year Follow-Up of 1188 Consecutive Patients

Klaus Martin, MD*, Gunther Wiesner, MD*, Tamás Breuer, MD*{dagger}, Rüdiger Lange, MD{ddagger}, and Peter Tassani, MD*

From the *Institute of Anesthesiology, German Heart Centre Munich, Munich, Germany; {dagger}Department of Cardiology, Semmelweis University, Budapest, Hungary; and {ddagger}Department of Cardiovascular Surgery, German Heart Centre Munich, Munich, Germany.

Anesth Analg 2008; 107:1783-1790

背景: 我们的目标是在非选择性、连续的人群中调查比较使用抑肽酶及氨甲环酸的术后并发症及病死率。

方法: 2005 年九月和 2006 年六月之间,前瞻性地收集一家大学附属医院的连续行心脏手术病人的围术期数据(n=1188)。在最初 5 个月期间, 596位病人接受抑肽酶(A);在后续的5个月中, 592位病人接受氨甲环酸治疗(T) 。除了抗纤溶治疗以外、麻醉和手术的方案保持不变。

结果:术前和术中参数两个治疗组相似。术后T组惊厥的发生率明显较高(4.6% 相对 1.2%, P<0.001)。这个差异在第一次换瓣手术和高危手术亚组中也是很明显的(分别为7.9% 相对 1.2%, P=0.003; 7.3% 相对 2.4%, P=0.035)。在第一次换瓣手术亚组中持续的房颤(7.9% 相对 2.3%, P=0.020)和肾衰(9.7% 相对 1.7%, P=0.002)也是在T组更常见。相反,对于第一次冠状动脉搭桥手术病人,A组病人急性心肌梗塞和肾功能障碍更多见(分别为5.8% 相对 2.0%, P=0.027; 22.5% 相对 15.2%, P=0.036)。在高危手术组接受抑肽酶治疗之后一年的病死率明显较高(17.7% 相对 9.8%, P=0.034)

结论: 抗纤溶及抑肽酶产生的副作用依赖于心脏手术的类型。使用抑肽酶应该避免冠状动脉搭桥和高度危险病人, 氨甲环酸不推荐在瓣膜手术中使用。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: Our aim was to investigate postoperative complications and mortality after administration of aprotinin compared to tranexamic acid in an unselected, consecutive cohort.

METHODS: Perioperative data from consecutive cardiac surgery patients were prospectively collected between September 2005 and June 2006 in a university-affiliated clinic (n = 1188). During the first 5 mo, 596 patients received aprotinin (Group A); in the next 5 mo, 592 patients were treated with tranexamic acid (Group T). Except for antifibrinolytic therapy, the anesthetic and surgical protocols remained unchanged.

RESULTS: The pre- and intraoperative variables were comparable between the treatment groups. Postoperatively, a significantly higher incidence of seizures was found in Group T (4.6% vs 1.2%, P < 0.001). This difference was also significant in the primary valve surgery and the high risk surgery subgroups (7.9% vs 1.2%, P = 0.003; 7.3% vs 2.4%, P = 0.035, respectively). Persistent atrial fibrillation (7.9% vs 2.3%, P = 0.020) and renal failure (9.7% vs 1.7%, P = 0.002) were also more common in Group T, in the primary valve surgery subgroup. On the contrary, among primary coronary artery bypass surgery patients, there were more acute myocardial infarctions and renal dysfunction in Group A (5.8% vs 2.0%, P = 0.027; 22.5% vs 15.2%, P = 0.036, respectively). The 1-yr mortality was significantly higher after aprotinin treatment in the high risk surgery group (17.7% vs 9.8%, P = 0.034).

CONCLUSION: Both antifibrinolytic drugs bear the risk of adverse outcome depending on the type of cardiac surgery. Administration of aprotinin should be avoided in coronary artery bypass graft and high risk patients, whereas administration of tranexamic acid is not recommended in valve surgery.



氙引起体内延迟性心脏预处理:环氧合酶2的作用?

Xenon Induces Late Cardiac Preconditioning In Vivo: A Role for Cyclooxygenase 2?

Nina C. Weber, PhD*, Jan Fräβdorf, MD*, Christoph Ratajczak, CAND, MED{dagger}, Yvonne Grueber, BSc{dagger}, Wolfgang Schlack, MD, DEAA*, Markus W. Hollmann, MD, PhD, DEAA*, and Benedikt Preckel, MD, MA, DEAA*

From the *Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center (A.M.C.), University of Amsterdam, Amsterdam, The Netherlands; and {dagger}Department of Anesthesiology, University Hospital, Düsseldorf, Germany.

Anesth Analg 2008; 107:1807-1813

背景:氙引起大鼠体内早期心肌预处理,但是否能引起延迟性心肌保护尚属未知。已有研究显示环氧合酶2COX-2)是心肌缺血延迟性预处理(i-LPC)的信号传导中一个重要的介质。我们探讨氙是否引起延迟性预处理(Xe-LPC)以及COX-2的活性和/表达是否与此介导作用有关。

方法:雄性Wistar大鼠麻醉后置入冠状动脉封堵器。经过7天恢复后,大鼠被随机分为5组,每组8只。i-LPC组接受5min的冠脉阻断引起i-LPC。通过给予氙(70v%15min进行Xe-LPC。其它大鼠用COX-2抑制剂NS-398 (5 mg kg–1 体重i.p.)加和不加Xe-LPC。一组只进行手术而不行i-LPC Xe-LPC作为对照(Con)。24h之后,所有大鼠麻醉后接受25min由收紧冠脉封堵器造成的心肌缺血,之后予2h再灌注。用氯三苯四唑染色评定心肌梗死面积。在另外的实验中,分别于预处理后不同时点采集心脏标本,通过聚合酶链反应和红外蛋白质印迹分别测定COX-2mRNA和蛋白表达。

结果:Con相比,i-LPC Xe-LPC均减少了心肌梗死面积(占受危区域的%)(i-LPC 29 ± 7%Xe-LPC 31 ± 8%,均P < 0.05 vs Con 64 ± 6%)。COX-2mRNA和蛋白表达仅在i-LPC组中增加,而未见于Xe-LPC组。

结论:氙引起延迟性的心肌预处理,此作用被COX-2活性的功能性阻断所取消。与i-LPC相反,Xe-LPC不引起COX-2mRNA和蛋白表达的增加。这些资料提示在i-LPC Xe-LPC COX-2的调节是不同的。

(黄施伟 译,马皓琳 李士通 校)

 

BACKGROUND: Xenon induces early myocardial preconditioning of the rat heart in vivo, but whether xenon induces late cardioprotection is not known. Cyclooxygenase-2 (COX-2) has been shown to be an important mediator in the signal transduction of myocardial ischemic late preconditioning (i-LPC). We investigated whether xenon induces late preconditioning (Xe-LPC) and whether COX-2 activity and/or expression are involved in mediating this effect.

METHODS: Anesthetized male Wistar rats were instrumented with a coronary artery occluder. After 7 d of recovery, animals were randomized to 1 of 5 groups each containing 8 animals. The i-LPC group underwent 5 min of coronary occlusion to induce i-LPC. Xe-LPC was achieved by administration of xenon (70 volume%) for 15 min. Additional rats were pretreated with the COX-2 inhibitor NS-398 (5 mg kg–1 body weight i.p.) with and without Xe-LPC. A group of sham operated animals not undergoing i-LPC or Xe-LPC served as controls (Con). After 24 h, all animals were anesthetized and underwent 25 min of myocardial ischemia induced by tightening of the coronary artery occluder followed by 2 h of reperfusion. Myocardial infarct size was assessed by triphenyltetrazolium chloride staining. In additional experiments, hearts were excised at different time points after preconditioning to investigate COX-2 mRNA and protein expression by polymerase chain reaction and infrared Western blot, respectively.

RESULTS: Both i-LPC and Xe-LPC reduced myocardial infarct size (% of the area at risk) compared with Con (i-LPC: 29 ± 7%; Xe-LPC 31 ± 8%, both P < 0.05 vs Con 64 ± 6%). NS-398 abolished the cardioprotective effect of Xe-LPC (61 ± 6%, P < 0.05 vs Xe-LPC). COX-2 mRNA and protein expression was only increased in the i-LPC group, but not in the Xe-LPC group.

CONCLUSION: Xenon induces late myocardial preconditioning that is abolished by functional blockade of COX-2 activity. In contrast to i-LPC, Xe-LPC did not lead to an increased expression of COX-2 mRNA and protein. These data suggest differences in COX-2 regulation in i-LPC and Xe-LPC.



儿童心脏手术术前重要的电解质紊乱与心脏药物并无关联

Cardiac Medications Are Not Associated with Clinically Important Preoperative Electrolyte Disturbances in Children Presenting for Cardiac Surgery

Laura A. Hastings, MD*{dagger}, John C. Wood, MD, PhD{dagger}, Bryan Harris, MD*, Sabine Von Busse, MD*, Ana Drachenberg, MD*, Frederick Dorey, PhD{dagger}, and Gerald A. Bushman, MD*

From the *Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Los Angeles; and {dagger}Department of Pediatrics, University of Southern CA, Keck School of Medicine, Los Angeles, California.

Anesth Analg 2008; 107:1840-1847

背景:择期手术患者术前实验室检查几十年来都是常规进行的。尽管有大量文献提到对成年患者适当的术前评估,但是与儿童相关的文献并没有详细的说明。患有心脏疾病的儿童及年轻成人是在进行大量术前实验室检查的人群中特别容易受刺激的群体。我们检查患有心脏疾病行门诊手术的儿童血清中的化学成分。研究的目的是说明在儿童和年轻成人这个人群中术前电解质测定的效果。

方法:200111日到2003131日期间所有经门诊入院接受三级护理,在独立的儿童医院进行择期心脏手术的儿童患者进行回顾性病历回顾。核对所有入选日期和心脏手术日期相符的患者的病历。如果术前实验室检查不在我们的设备上完成,或没有进行术前实验室检查,或患者是被转送到我们医院的,这些患者将被排除在外。患者根据3种方法分组:心脏治疗的数目(04),心脏药物治疗,无心脏药物治疗和无药物治疗。在应用不同药理作用的心脏药物的情况下检查有无电解质紊乱。主要的评测结果是服用不同心脏药物的儿童中实验室检查异常的发生率。

结果:找到933个初始的病历,其中774个符合观察标准的被纳入分析。尽管用或不用心脏药物与术前电解质相关是有统计学差异的,但其中的相关性并无临床价值。数据表明整个研究人群中低钾和低镁血症的发生率很低。

结论:儿童和年轻成人做心脏手术前电解质紊乱是很少见的。在成人中服用心脏药物所顾及的低钾或低镁血症在儿童中并不确定。这些数据不支持在服用心脏药物的儿童中常规需要进行术前电解质评估。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Preoperative laboratory examination of patients undergoing elective surgical procedures has been routinely performed for decades. Although there is a large body of literature concerning the appropriate preoperative assessment of adult patients, corresponding literature for the pediatric population is not as well defined. Children and young adults with cardiac disease are a particularly vulnerable subset of patients who often undergo an extensive battery of preoperative laboratory testing. We examined the serum chemistry profiles for children with cardiac disease presenting for outpatient surgery. The investigation aims to define the effectiveness of preoperative electrolyte determination in this population of children and young adults.

METHODS: A retrospective chart review of all children presenting as outpatients to a tertiary care, freestanding children’s hospital for elective cardiac surgery between January 1, 2000 and January 31, 2003 was performed. All patient charts in which the admission date matched the cardiac surgical date were examined. Patients were excluded if the preoperative laboratory evaluation was performed outside of our facility, preoperative laboratory investigation was not performed, or the patient was transported by medical transport to our hospital. Patients were grouped according to three methods: the number of cardiac medications (none to four), and cardiac medications, noncardiac medications, and no medications. The presence of electrolyte abnormalities was also examined in the context of cardiac medications with various pharmacologic effects. The primary outcome measure was the incidence of abnormal laboratory values for children taking various cardiac medications.

RESULTS: Of the 933 initial entries found, 774 met the investigational criteria and were included in the analysis. Although statistically significant differences in preoperative electrolytes were associated with the use of cardiac and noncardiac medication, there was no clinical value to this correlation. The data demonstrate a very low incidence of hypokalemia and hypomagnesemia in the entire study population.

CONCLUSION: Preoperative electrolyte disturbances in children and young adults presenting for cardiac surgery are uncommon. The concern of hypokalemia or hypomagnesemia important in the adult population taking cardiac medications was not identified in the pediatric population. These data do not support the need for routine preoperative electrolyte evaluation in children taking cardiac medications.




肥胖会适当地影响人吸入麻醉剂的动力学特性

Obesity Modestly Affects Inhaled Anesthetic Kinetics in Humans

Hendrikus J. M. Lemmens, MD, PhD*, Lawrence J. Saidman, MD*, Edmond I. Eger, II, MD{dagger}, and Michael J. Laster, DVM{dagger}

From the *Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and {dagger}the Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Anesth Analg 2008; 107:1864-1870

背景:几乎没有研究已经证实了肥胖对吸入麻醉剂的药代动力学有影响。我们假设强效吸入麻醉剂在脂肪组织中的可溶性与肥胖患者的BMI指数增加两者之间起相互作用从而增加了吸入麻醉剂的摄入,降低了吸入麻醉剂传送(FD)和吸入(FI)浓度足以达到不变的维持肺泡浓度(呼气末或FA)的速度。这个假设提示了肥胖对可溶性较大的异氟醚的影响相较地氟醚而言更大。

方法: 107ASA分级为I-III级的病人,用丙泊酚麻醉诱导,用神经肌肉阻滞剂便于气管插管,用含50%的笑气的氧气控制呼吸使得呼气末二氧化碳浓度维持在35-45mmHg。在1L/min的流量中以FD浓度给予异氟醚或地氟醚,使得FA维持在0.6MAC(分别为0.7%3.7%)。开始给予强效吸入麻醉剂后51020406090120150180分钟我们测定FDFIFA

结果:59位病人接受了异氟醚,48位病人接受了地氟醚。BMI范围在18-63 kg/m2,两组病人的人口统计变异值没有差异。异氟醚的FD/FA FI/FA9/18个时点与BMI之间有微弱的(但显著的)相关性,而地氟醚的FD/FA FI/FA只在1个时点与BMI显著相关(P < 0.01)。将每组病人区分成肥胖(BMI30)和非肥胖病人(BMI<30)后,异氟醚在肥胖病人中有4个时点FD/FA FI/FA比较高,而地氟醚在两种病人中没有差别。接受异氟醚的病人在中止麻醉后需要更长时间来对命令做出反应,但是肥胖对接受异氟醚或地氟醚后的苏醒时间没有影响。用BMI标准化FI/FA FD/FA时,异氟醚的中位数值始终超过地氟醚的中位数值,系数范围从35,其值和它们的血/气分配系数(3.1)、肌肉/气分配系数(4.6)和脂肪/气分配系数(5.4)相当。

结论:BMI适当影响了FD/FAFI/FA,对于在所有组织中的可溶性都较大的麻醉剂其影响因素最明显。BMI的增大提高了麻醉剂的摄入,因此也提高了为了维持在一个恒定的肺泡麻醉剂浓度所需要传送的麻醉剂,对于可溶性比较大的麻醉剂而言尤其明显。但是体重增加时这种提高作用较小。

(姜旭晖译,马皓琳,李士通校)

BACKGOUND: Few studies have determined the effect of obesity on inhaled anesthetic pharmacokinetics. We hypothesized that the solubility of potent inhaled anesthetics in fat and increased body mass index (BMI) in obese patients interact to increase anesthetic uptake and decrease the rate at which the delivered (FD) and inspired (FI) concentrations of an inhaled anesthetic approach a constantly maintained alveolar concentration (end-tidal or FA). This hypothesis implies that the effect of obesity would be greater with a more soluble anesthetic such as isoflurane versus desflurane.

METHODS: In 107 ASA physical status I–III patients, anesthesia was induced with propofol, tracheal intubation facilitated with neuromuscular blockade, and ventilation controlled with 50% nitrous oxide in oxygen to maintain end-tidal carbon dioxide concentrations between 35 and 45 mm Hg. Isoflurane or desflurane was administered in a 1 L/min inflow rate at FD concentrations sufficient to maintain FA at 0.6 minimum alveolar anesthetic concentration (0.7% or 3.7%, respectively). FD, FI, and FA were measured 5, 10, 20, 40, 60, 90, 120,150, and 180 min after starting potent inhaled anesthetic delivery.

RESULTS: Fifty-nine patients received isoflurane and 48 received desflurane. BMI ranged between 18 and 63 kg/m2 and demographic variables did not differ between anesthetic groups. For isoflurane, FD/FA or FI/FA weakly (but significantly) correlated with BMI at 9/18 time points whereas for desflurane FD/FA or FI/FA correlated significantly with BMI at only one time point (P < 0.01). After dividing each group into nonobese (BMI < 30) and obese (BMI ≥30) patients, with isoflurane, FD/FA or FI/FA was higher in obese patients at four time points whereas there was no difference between nonobese and obese patients for desflurane. Patients receiving isoflurane took longer to respond to command after discontinuing anesthesia but obesity did not increase or decrease awakening time for either isoflurane or desflurane. When BMI was used to normalize FI/FA and FD/FA the median values for isoflurane consistently exceeded the median value for desflurane by factors ranging from 3 to 5, values comparable to the ratios of their blood/gas (3.1), muscle/gas (4.6), and fat/gas (5.4) partition coefficients.

CONCLUSION: BMI modestly affects FD/FA and FI/FA, and this effect is most apparent for an anesthetic having a greater solubility in all tissues. An increased BMI increases anesthetic uptake and, thus, the need for delivered anesthetic to sustain a constant alveolar anesthetic concentration, particularly with a more soluble anesthetic. However, the increase with an increased body mass is small.



丙泊酚预处理大鼠可减少神经酰胺产量及肠道缺血再灌注所致肠粘膜细胞凋亡

Propofol Pretreatment Reduces Ceramide Production and Attenuates Intestinal Mucosal Apoptosis Induced by Intestinal Ischemia/Reperfusion in Rats

Ke-Xuan Liu, PhD, MD*, Shu-Qing Chen, PhD, MD{dagger}, Wen-Qi Huang, MD*, Yun-Sheng Li, MD*, Michael G. Irwin, MD{ddagger}, and Zhengyuan Xia, PhD, MD{ddagger}

From the Departments of *Anesthesiology, {dagger}Gynecology and Obstetrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; and {ddagger}Department of Anesthesiology, University of Hong Kong, Hong Kong SAR, China.

Anesth Analg 2008; 107:1884-1891

背景: 研究表明,细胞凋亡是肠道缺血再灌注(II/R)所致肠上皮细胞死亡的一种主要方式。缺血再灌注往往与氧化性应激增加有关。有人提出神经酰胺是细胞凋亡信号调控中的一个信使。我们试图研究给予具有抗氧化性质的丙泊酚作预处理是否能降低神经酰胺的产量,因而减少II/R所致的肠上皮细胞凋亡。

方法:钳夹大鼠肠系膜上动脉1 h后再灌注3 h建立II/R损伤模型。30只大鼠随机分为对照组、损伤组(II/R)、丙泊酚(预处理)组(每组n = 10)。缺血前30min,丙泊酚组给予丙泊酚50 mg/kg腹腔注射,使得大鼠对疼痛刺激反射性反应消失而依然对切皮敏感。其他两组则给予等量的脂肪乳注射液腹腔注射。采用电子显微镜和TUNEL分析法检测肠粘膜上皮细胞凋亡水平,用比色分析法评估脂质氧化产物丙二醛及超氧化物歧化酶活性。分别采用高分产薄层层析法和逆转录聚合酶链反应(RT-PCR)测定肠粘膜神经酰胺产量和鞘磷酯酶mRNA表达水平。

结果:II/R诱导肠粘膜上皮细胞凋亡和神经酰胺过量产生,同时上调鞘磷酯酶mRNA的表达和增加脂质氧化(与对照组相比 P < 0.01 )。丙泊酚预处理则明显减少这些变化(丙泊酚组与损伤组相比,P < 0.01)。

结论:本研究表明,丙泊酚预处理能减少II/R所致肠上皮细胞凋亡,这可能与丙泊酚调节神经酰胺通路的抗氧化性质有关。

(江继宏   马皓琳 李士通 校)

BACKGROUND: Apoptosis has been shown to be a major mode of intestinal epithelial cell death caused by intestinal ischemia/reperfusion (II/R), a condition that is associated with increased oxidative stress. Ceramide has been proposed as a messenger of apoptosis. We investigated if pretreatment with propofol, an anesthetic with antioxidant properties, could reduce ceramide production, and consequently, mucosal epithelial apoptosis induced by II/R in rats.

METHODS: Rat II/R injury was produced by clamping the superior mesenteric artery for 1 h followed by 3 h of reperfusion. Thirty rats were randomly allocated into control, injury (II/R) and propofol (pretreatment) groups (n = 10 per group). In the propofol group, propofol 50 mg/kg, a dose that has been shown to cause the loss of reflex responses to a painful stimulus while remaining sensitive to skin incision in rats, was administered intraperitoneally 30 min before inducing intestinal ischemia, while animals in control and untreated injury groups received an equal volume of intralipid. Intestinal mucosal epithelial apoptosis was detected via electron microscopy and TUNEL analysis. Lipid oxidation product malondialdehyde and the activities of superoxide dismutase were assessed by colorimetric analyses. Ceramide generation and sphingomyelinase mRNA expression in intestinal mucosa were determined by high performance thin layer chromatography and reverse transcriptase polymerase chain reaction, respectively.

RESULTS: II/R caused intestinal mucosal epithelial apoptosis and over-production of ceramide accompanied by up-regulation of sphingomyelinase mRNA expression and increases in lipid oxidation (all P < 0.01 versus control). Propofol pretreatment significantly attenuated these changes (all P < 0.01, propofol versus injury).

CONCLUSION: The findings indicate that propofol pretreatment attenuates II/R-induced intestinal epithelial apoptosis, which might be attributable to its antioxidant property modulating the ceramide pathway.



田野麻醉机中气动控制呼吸机的氧耗

Oxygen Consumption of a Pneumatically Controlled Ventilator in a Field Anesthesia Machine

Dale F. Szpisjak, MD, MPH*, Elizabeth N. Javernick, MD{dagger}, Richard R. Kyle, MS{ddagger}, and Paul N. Austin, PhD, CRNA§

From the *Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; {dagger}Department of Anesthesiology, Walter Reed Army Medical Center, Washington, DC; {ddagger}Department of Anatomy, Physiology, and Genetics; and §Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Anesth Analg 2008; 107:1907-1911

背景:田野麻醉机(FAM)已被开发出用于压缩医用气体或电流的可靠供应缺乏的偏僻地方。在电流、气动控制呼吸机用压缩气体代替电流来为定时电路供能和开动气阀。我们试图测定一种FAM式气动控制呼吸机在高(HC)和低(LC)总胸廓顺应性的机械模式下的总氧耗和呼吸机气体的消耗(驱动气体 [DG] 加上气动控制气体[PC])。

方法:用理想气体定律和从E量筒测量的氧耗质量来计算带气动控制呼吸机的Magellan-2200 (Oceanic Medical Products, Atchison, 堪萨斯州) FAM的总氧耗量。用Wright Respirometer Mk 8 (Ferraris Respiratory Europe, Hertford, 英国)测定到达风箱罐装置的DG。用E量筒的总氧气量扣除DG和新鲜气流(FGF)计算PC气体消耗。用呼吸速度描记图(Hans Rudolph, KS City, 密苏里州) 测定传送的潮气量(VT)。用通气辅助训练测试肺模型(MI Instruments, Grand Rapids, 密执安州)测试两种肺模型(HC LC)时的三种不同的VT5007501000 mL)。呼吸变量包括:吸呼比1:2,新鲜气流 1 L/min,呼吸频率10 /min

结果:氧耗总量和潮气量呈正比,和顺应性呈反比。最小氧耗速度(包括 FGF)HC-500 模式下的9.3 ± 0.4 L/min,而最大则是 LC-1000 模式下的15.9 ± 0.5 L/min (P < 0.001)。平均PC电路消耗是3.9 ± 0.24 L/min或每次呼吸390 mL ± 24 mL

结论:考虑到中心DG供应的损耗,总胸廓顺应性低时估计量筒持续时间将提高患者的安全性。用从较小顺应性和最大潮气量模型(LC-1000)得到的数据,一个充满氧气的E 量筒会在<42 min内耗尽,而一个装满的H 量筒大约可持续433 min.

(唐李隽 译 马皓琳 李士通 校) 

 

BACKGROUND: Field anesthesia machines (FAM) have been developed for remote locations where reliable supplies of compressed medical gases or electricity may be absent. In place of electricity, pneumatically controlled ventilators use compressed gas to power timing circuitry and actuate valves. We sought to determine the total O2 consumption and ventilator gas consumption (drive gas [DG] plus pneumatic control [PC] gas) of a FAM's pneumatically controlled ventilator in mechanical models of high (HC) and low (LC) total thoracic compliance.

METHODS: The amount of total O2 consumed by the Magellan-2200 (Oceanic Medical Products, Atchison, KS) FAM with pneumatically controlled ventilator was calculated using the ideal gas law and the measured mass of O2 consumed from E cylinders. DG to the bellows canister assembly was measured with the Wright Respirometer Mk 8 (Ferraris Respiratory Europe, Hertford, UK). PC gas consumption was calculated by subtracting DG and fresh gas flow (FGF) from the total O2 consumed from the E cylinder. The delivered tidal volume (VT) was measured with a pneumotach (Hans Rudolph, KS City, MO). Three different VT were tested (500, 750, and 1000 mL) with two lung models (HC and LC) using the Vent Aid Training Test Lung (MI Instruments, Grand Rapids, MI). Respiratory variables included an I:E of 1:2, FGF of 1 L/min, and respiratory rate of 10 breaths/min.

RESULTS: Total O2 consumption was directly proportional to VT and inversely proportional to compliance. The smallest total O2 consumption rate (including FGF) was 9.3 ± 0.4 L/min in the HC-500 model and the largest was 15.9 ± 0.5 L/min in the LC-1000 model (P < 0.001). The mean PC circuitry consumption was 3.9 ± 0.24 L/min or 390 mL ± 24 mL/breath.

CONCLUSIONS: To prepare for loss of central DG supply, patient safety will be improved by estimating cylinder duration for low total thoracic compliance. Using data from the smaller compliance and greatest VT model (LC-1000), a full O2 E cylinder would be depleted in <42 min, whereas a full H cylinder would last approximately 433 min.



退伍军人事务局医院手术当天病人意外死亡的相关因素分析

Factors Associated with Unanticipated Day of Surgery Deaths in Department of Veterans Affairs Hospitals

Michael J. Bishop, MD*{dagger}||, Jennifer E. Souders, MD{dagger}, Cecilia M. Peterson, MSPH{ddagger}, William G. Henderson, PhD{ddagger}, and Karen B. Domino, MD, MPH||

From the *Department of Veterans Affairs Central Office Anesthesia Service, Washington, DC; {dagger}The Puget Sound Veterans Health Care System, Seattle, Washington; {ddagger}The Colorado Health Outcomes Program of the University of Colorado Health Sciences Center, Denver, Colorado; and ||The Department of Anesthesiology at the University of Washington School of Medicine, Seattle, Washington.

Anesth Analg 2008; 107:1924-1935

背景ASA分级为13级的病人进行择期手术,由于他们自身没有潜在的对生命构成持续威胁的疾病,因此手术当天他们死亡的风险不应当看得过高。

方法:我们回顾了美国退伍军人事务局全国外科质量提高计划数据库里的815,077ASA分级为13级的择期手术病人,以便找出手术当天死亡的病例。然后我们鉴别出可以预示意外死亡的因素以及我们在医疗中潜在的可以改进的地方。同时我们对其中一部分病例的麻醉记录单逐一回顾,以便可以找到麻醉管理中可以改进的地方。

结果:在调查的全部病人中,有0.08% 死于手术当天。多变量回归分析显示,最能预测手术当天死亡的因素是手术的类型,其中主动脉手术的优势比为13.67 (95% CI 9.76–19.17)。用同样的方法鉴别出其他因素,这些因素包括低蛋白血症、呼吸困难以及胆红素或者肌酐的升高。对死亡病例中的88例病历回顾发现其中13例的麻醉管理还可以有改进。我们估计有大约1/13,900的病例,如果改进麻醉,死亡本可以避免。心肌梗塞和出血是常见的可以鉴别出的因素。一个意料之外的因素是,许多死亡发生在从手术结束到把病人最终转送到复苏室之间的这段时间内。

结论:我们认为虽然手术当天绝大多数的死亡是由病人和手术因素所引起的,但是麻醉管理的改进对降低此类死亡的发生还是存有一定空间的。

(吴进   马皓琳 李士通 校)

BACKGROUND: Patients of ASA physical status 1, 2, and 3 undergoing elective surgery do not have underlying conditions that are a constant threat to life, and hence should not be expected to be at significant risk for death on the day of surgery.

METHODS: We analyzed 815,077 ASA physical status 1, 2, and 3 elective surgery patients in the Department of Veterans Affairs National Surgical Quality Improvement Program database to identify patients who died on the day of surgery. We then attempted to identify factors predictive of unexpected death and to identify potential areas for improvement in care. A subset of the cases underwent individual chart review as well to identify areas for improvement in anesthesia care.

RESULTS: Of the total patients, 0.08% died on the day of surgery. The strongest predictive factor by multiple variable regression was the type of surgery, with aortic surgery resulting in an odds ratio of 13.67, (95% CI 9.76–19.17). Other factors predictive of death were identified by multiple variable regressions and included low albumin, existence of dyspnea, and elevated bilirubin or creatinine. Chart reviews of 88 of the deaths found that opportunities for improved anesthesia care were present in 13 of the 88. We estimated that a death that might have been prevented by improved anesthesia care occurred in approximately 1/13,900 cases. Myocardial infarction and hemorrhage were frequently identified factors. An unexpected factor was that the period between the conclusion of surgery and the final transfer of care in recovery was a time when many of the deaths occurred.

CONCLUSIONS: We conclude that, although patient and surgical factors lead to the vast majority of deaths on the day of surgery, there are identifiable areas for reducing the incidence of such deaths by improvements in anesthesia care.



严重脓毒症对日常健康相关的生活质量的影响:一项长期随访研究

The Impact of Severe Sepsis on Health-Related Quality of Life: A Long-Term Follow-Up Study

José G. M. Hofhuis, MSc*{dagger}, Peter E. Spronk, MD, PhD*, Henk F. van Stel, PhD{ddagger}, Augustinus J. P. Schrijvers, PhD{ddagger}, Johannes H. Rommes, MD, PhD*, and Jan Bakker, MD, PhD{dagger}

From the *Department of Intensive Care, Gelre Hospital, Location Lukas, Apeldoorn, The Netherlands; {dagger}Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands; and {ddagger}Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht, The Netherlands.

Anesth Analg 2008; 107:1957-1964

背景:严重的脓毒症常常并发器官衰竭和伴随着高死亡率。从严重的脓毒症中幸免生存下来的患者的日常健康相关生活质量(HRQOL)受到影响。严重脓毒症存活患者的HRQOL在转出重症监护室(ICU)后和在普通病房中的变化时程还没有进行过研究。

方法:我们在内科-外科ICU中进行了长期的前瞻性研究。有严重的脓毒症并入住ICU>48小时的患者(n=170)被纳入此研究。我们使用简表36来评估严重脓毒症患者入ICU之前和住院前以及在转出ICU3个月和6个月时的HRQOL。此外,还进行对ICU收入后的结果和转出ICU6个月的结果与年龄相一致的普通荷兰人群的HRQOL结果的比较。

结果:在转出ICU6个月,95例患者不能评估(8例失去随访,67例死亡)。HRQOL显示出在ICU入住期间有多方面的减退,在转出ICU6个月中在社会功能、活力、角色-情绪和心理健康方面逐渐改善。然而,在出ICU6个月的躯体活动功能及角色-体格、一般健康方面仍然显著低于住院前的值。这段时间里面躯体和精神方面的分数有着显著的变化。特别是精神方面的分数在转出ICU时有一些下降,但迅速恢复,转出ICU6个月时恢复至接近正常值。另外,简表36得分在脓毒症患者中8方面中除了社会功能和身体疼痛以外的其他6个方面都低于对应的一般人群。有趣的是在存活下来的患者中,他们在入住ICU8个方面中就有3个(角色-体格、心理健康和活力)已经低于一般人群。

讨论:重度脓毒症患者在入住ICU期间HRQOL急剧下降,在转出ICU后的6个月中逐渐恢复。恢复从转出ICU到普通病房后开始。然而,去入住ICU前情况比较,在躯体活动功能及角色-体格、一般健康方面是恢复不完全的

(唐亮   马皓琳 李士通 校)

BACKGROUND: Severe sepsis is frequently complicated by organ failure and accompanied by high mortality. Patients surviving severe sepsis can have impaired health-related quality of life (HRQOL). The time course of changes in HRQOL in severe sepsis survivors after discharge from the intensive care unit (ICU) and during a general ward stay have not been studied.

METHODS: We performed a long-term prospective study in a medical-surgical ICU. Patients with severe sepsis (n = 170) admitted for >48 h were included in the study. We used the Short-form 36 to evaluate the HRQOL of severe sepsis patients before ICU and hospital stay and at 3 and 6 mo after ICU discharge. Furthermore, we compared the results for ICU admission and 6 mo after ICU discharge with those of an age-matched general Dutch population.

RESULTS: At 6 mo after ICU discharge, 95 patients could be evaluated (eight patients were lost to follow-up, 67 died). HRQOL showed a multidimensional decline during the ICU stay and gradual improvement over the 6 mo after ICU discharge for the social functioning, vitality, role-emotional, and mental health dimensions. However, 6 mo after ICU discharge, scores for the physical functioning, role-physical, and general health dimensions were still significantly lower than preadmission values. Physical and Mental Component Scores changed significantly over time. In particular, the Mental Component Score showed a small decline at ICU discharge but recovered rapidly, and at 6 mo after ICU discharge had improved to near normal values. In addition, Short-form 36 scores were lower than those in a matched general population in six of the eight dimensions, with the exception of social functioning and bodily pain. Interestingly, the preadmission HRQOL in surviving patients was already lower in three of the eight dimensions (role-physical, mental health, and vitality) when compared with the general population.

CONCLUSIONS: Severe sepsis patients demonstrate a sharp decline of HRQOL during ICU stay and a gradual improvement during the 6 mo after ICU discharge. Recovery begins after ICU discharge to the general ward. Nevertheless, recovery is incomplete in the physical functioning, role-physical, and general health dimensions at 6 mo after ICU discharge compared with preadmission status.



丙泊酚预处理减弱大鼠短暂的局部脑缺血再灌注后水通道蛋白-4过度表达并减轻脑水肿

Propofol Pretreatment Attenuates Aquaporin-4 Over-Expression and Alleviates Cerebral Edema After Transient Focal Brain Ischemia Reperfusion in Rats

Yue-Ying Zheng, MS*, Yun-Ping Lan, MS*, Hui-Fang Tang, PhD{dagger}, and Sheng-Mei Zhu, MD, PhD*

From the *Department of Anesthesiology, the First Affiliated Hospital, School of Medicine, Zhejiang University, People’s Republic of China; and {dagger}Department of Pharmacology, School of Medicine, Zhejiang University, Hang Zhou, People’s Republic of China.

Anesth Analg 2008; 107:2009-2016

背景:脑水肿对中风患者是主要的威胁。大多数研究关注丙泊酚对梗塞范围而不是脑水肿方面的神经保护活性。在各种神经损伤中,水通道蛋白-4(AQP4)在维持脑内水平衡起着重要作用。我们观察丙泊酚预处理对大鼠脑缺血再灌注模型脑水肿的效应,并评价AQP4的参与作用。

方法:为诱发脑缺血再灌注,我们把涂上硅胶的单丝尼龙缝线引到大脑中动脉起端,90分钟后退出缝线。治疗组(n=32)阻断前静脉输注丙泊酚(0.1mL·kg-1·min-1) 30分钟;溶媒组(n=32)和假手术组(n=28)在阻断前以同样的速度静脉输注英脱利匹特溶媒。我们使用2,3,5-三苯基四唑氯化物染色来评估脑梗塞范围;湿-干重比例是估算脑水肿的基础,并且使用免疫组化和蛋白质印迹方法来检测AQP4表达。

结果:湿-干重比例在溶媒组(n = 6)86.89% ± 0.71%,而在丙泊酚组(n = 6)减少到72.42% ± 0.74%,相应地平均减少16%。使用免疫组化半定量方法观察到,丙泊酚组较溶媒组显著减弱缺血边缘区AQP4过度表达:1.28 ± 0.03 vs 1.40 ± 0.05, n = 7, P < 0.05。来自蛋白质印迹定量的值,丙泊酚组与溶媒组相似地减少:20.85% ± 4.18% vs 31.67% ± 3.23%, n = 4, P < 0.05。然而,缺血后大鼠丙泊酚组梗塞范围和神经功能欠缺与溶媒组没有统计学差异。

结论:我们得出如下结论:中风前丙泊酚处理减少大鼠缺血后脑水肿,可能通过抑制缺血边缘区AQP4过度表达。

(王宏 马皓琳 李士通校)

BACKGROUND: Cerebral edema is a major threat for stroke victims. Most studies have focused on the neuroprotective activities of propofol, addressing infarct volume rather than cerebral edema. Aquaporin-4 (AQP4) plays an important role in maintaining brain water homeostasis under various neurological insults. We explored the effect of propofol pretreatment on cerebral edema in a rat model of brain ischemia reperfusion and assessed the involvement of AQP4.

METHODS: To induce brain ischemia reperfusion, we introduced a silicone-coated monofilament nylon suture into the origin of the middle cerebral artery, withdrawing it after 90 min. Treatment groups (n = 32), received propofol (0.1 mL · kg–1 · min–1) infusion for 30 min before occlusion; the vehicle group (n = 32) and the sham-operated group (n = 28), which received the intralipid vehicle at the same time and rate. To assess cerebral infarct volume, we used 2, 3, 5-triphenyl-tetrazolium chloride staining; wet–dry weight ratio was the basis for cerebral edema estimation, and we used immunohistochemistry and Western blot to detect AQP4 expression.

RESULTS: The wet–dry weight ratio decreased from 86.89% ± 0.71% in the vehicle group (n = 6) to 72.42% ± 0.74% in the propofol group (n = 6), corresponding to an average decrease of 16%. In parallel and based on immunohistochemical semi-quantification, the propofol group exhibited remarkable attenuation of AQP4 over-expression in the ischemic border zone compared with the vehicle group: 1.28 ± 0.03 vs 1.40 ± 0.05, n = 7, respectively; P < 0.05. Values derived from Western blot quantification were similarly decreased in the propofol group compared to the vehicle group: 20.85% ± 4.18% vs 31.67% ± 3.23%, n = 4, respectively; P < 0.05. However, infarct volume and neurologic deficit in postischemic rats in the propofol group were not statistically different from values in the vehicle group.

CONCLUSIONS: We conclude that prestroke treatment with propofol reduces postischemic cerebral edema in rats, possibly through inhibiting AQP4 over-expression in the boundary zone of ischemia.



氯胺酮和氯诺昔康用于预防芬太尼引起的术后吗啡用量增加

Ketamine and Lornoxicam for Preventing a Fentanyl-Induced Increase in Postoperative Morphine Requirement

Yu Xuerong, MD*, Huang Yuguang, MD*, Ju Xia, MD{dagger}, and Wang Hailan, MD{ddagger}

From the *Department of Anesthesiology, Peking Union Medical College Hospital, China; {dagger}Department of Anesthesiology, Anqing Hospital, Anhui Province, China; and {ddagger}Department of Anesthesiology, The 4th People’s Hospital of Hengshui, Hebei Province, China.

Anesth Analg 2008; 107:2032-2037

背景:N-甲基-d-天门冬氨酸受体拮抗剂和非甾体类抗炎药被认为可以预防阿片类诱导的痛觉过敏和/或急性阿片类耐受,后者可以导致术后阿片药物需要量的增加。在这项随机、双盲、安慰剂对照的试验中,我们研究了氯胺酮或氯诺昔康与芬太尼合用是否可以预防由单纯芬太尼引起的术后吗啡需要量的增加。

方法:90位在脊麻下行腹式全子宫切除术的女性患者随机分为六组,分别为:安慰剂组(生理盐水,C),芬太尼组(注射三次,每次1 µg·kg1F),氯胺酮组(15 µg·kg1·min1持续输注,K),氯胺酮复合芬太尼组(15 µg·kg1·min1 氯胺酮持续输注,同时注射三次芬太尼,每次1 µg·kg1FK),氯诺昔康组(单次注射8mgL),氯诺昔康复合芬太尼组(单次注射8mg氯诺昔康,同时注射三次芬太尼,每次1 µg·kg1FL)。记录术后136122448 h吗啡总用量、疼痛评分和副作用。

结果:术后3612h F组吗啡用量比C组显著增加(P < 0.05)。术后吗啡用量在CKFKLFL组之间基本相同,各组间术后疼痛评分也无显著性差异。与C组相比,K组和FK组中有更多的患者在术中和/或术后存在幻觉(P < 0.05)

结论:我们的数据显示,术中应用芬太尼所引起的术后吗啡用量增加可以被氯胺酮或氯诺昔康所预防。

(黄佳佳译,马皓琳 李士通校)

BACKGROUND: N-methyl-d-aspartate receptor antagonists and nonsteroidal anti-inflammatory drugs are believed to prevent opioid-induced hyperalgesia and/or acute opioid tolerance, which could cause an increase in postoperative opioid requirement. In this randomized, double-blind, placebo-controlled study, we investigated whether co-administration of ketamine or lornoxicam and fentanyl could prevent the increase of postoperative morphine requirement induced by fentanyl alone.

METHODS: Ninety females undergoing total abdominal hysterectomy with spinal anesthesia were randomly assigned to six groups consisting of placebo (normal saline, C), fentanyl (three bolus of 1 µg · kg–1, F), ketamine (infusion of 15 µg · kg–1 · min–1, K), ketamine and fentanyl (infusion of 15 µg · kg–1 · min–1 ketamine plus three bolus of 1 µg · kg–1 fentanyl, FK), lornoxicam (one bolus of 8 mg, L), and lornoxicam and fentanyl (one bolus of 8 mg lornoxicam plus three bolus of 1 µg · kg–1 fentanyl, FL). Cumulative morphine consumption, pain score, and adverse effects were recorded at 1, 3, 6, 12, 24, and 48 h postoperatively.

RESULTS: Cumulative morphine consumption in Group F was significantly more than that in Group C at 3, 6, and 12 h postoperatively (P < 0.05). Postoperative cumulative morphine consumption was similar in Groups C, K, FK, L, and FL. No differences in postoperative pain scores were observed among groups. More patients in Groups K and FK had hallucinations during and/or after surgery than those in Group C (P < 0.05).

CONCLUSIONS: Our data suggest that the increase of postoperative morphine requirements induced by intraoperative administration of fentanyl could be prevented by ketamine or lornoxicam.



腹横肌平面阻滞为行腹式全子宫切除术的病人提供有效的术后镇痛

The Transversus Abdominis Plane Block Provides Effective Postoperative Analgesia in Patients Undergoing Total Abdominal Hysterectomy

John Carney, MB*{dagger}, John G. McDonnell, MB, FCARCSI*{dagger}{ddagger}, Alan Ochana, MB{dagger}, Raj Bhinder, MB{dagger}, and John G. Laffey, MD, MA, BSc, FCARCSI*{dagger}{ddagger}

From the *Department of Anaesthesia, Clinical Sciences Institute, National University of Ireland, Galway; {dagger}Department of Anaesthesia and Intensive Care Medicine, and {ddagger}Clinical Research Facility, Galway University Hospitals, Galway, Ireland.

Anesth Analg 2008; 107:2056-2060

背景:行腹式全子宫切除术的病人术后有明显的疼痛。腹横肌平面阻滞近来被描述为前腹壁提供镇痛的一个途径。我们在一个随机、对照、双盲的临床试验中,评价了经由下腹壁横切口行腹式全子宫切除术的病人腹横肌平面阻滞的镇痛效能。

方法:50名行择期腹式全子宫切除术的女性病人随机分入两组。一组为用罗哌卡因行腹横肌平面阻滞组(n=24),一组为安慰剂组(n=26)。另外,病人还行标准的术后镇痛,包括病人自控静脉输注吗啡镇痛及常规的双氯芬酸和扑热息痛镇痛。所有的病人均行全身麻醉,并且在切皮前,用1.5mg/kg的罗哌卡因(最大剂量为150mg)行双侧的腹横肌平面阻滞或在每一侧注入生理盐水。每一名患者分别在麻醉后恢复室和术后24612243648小时由一名不知分组的观察者评价术后疼痛程度。

结果:与安慰剂组相比,罗哌卡因腹横肌平面阻滞降低术后VAS疼痛评分。在术后第一个48小时内,平均的吗啡需要量也减少(55 ± 17 mg27 ± 20 mg, P < 0.001)。镇静的发生率也明显降低。腹横肌平面阻滞没有相关的并发症。

结论:腹横肌平面阻滞,作为多模式术后镇痛的一个组成部分,与安慰剂阻滞相比,在手术后48小时里为行择期腹式全子宫切除术的病人提供了良好的镇痛。

(黄丽娜 马皓琳 李士通 校)

BACKGROUND: Patients undergoing total abdominal hysterectomy suffer significant postoperative pain. The transversus abdominis plane (TAP) block is a recently described approach to providing analgesia to the anterior abdominal wall. We evaluated the analgesic efficacy of the TAP block in patients undergoing total abdominal hysterectomy via a transverse lower abdominal wall incision, in a randomized, controlled, double-blind clinical trial.

METHODS: Fifty females undergoing elective total abdominal hysterectomy were randomized to undergo TAP block with ropivacaine (n = 24) versus placebo (n = 26) in addition to standard postoperative analgesia comprising patient-controlled IV morphine analgesia and regular diclofenac and acetaminophen. All patients received a general anesthetic and, before surgical incision, a bilateral TAP block was performed using 1.5 mg/kg ropivacaine (to a maximal dose of 150 mg) or saline on each side. Each patient was assessed postoperatively by a blinded investigator in the postanesthesia care unit and at 2, 4, 6, 12, 24, 36, 48 h postoperatively.

RESULTS: The TAP block with ropivacaine reduced postoperative visual analog scale pain scores compared to placebo block. Mean (±sd) total morphine requirements in the first 48 postoperative hours were also reduced (55 ± 17 mg vs 27 ± 20 mg, P < 0.001). The incidence of sedation was reduced in patients undergoing TAP blockade. There were no complications attributable to the TAP block.

CONCLUSIONS: The TAP block, as a component of a multimodal analgesic regimen, provided superior analgesia when compared to placebo block up to 48 postoperative hours after elective total abdominal hysterectomy.



利多卡因和苏芬太尼用于脊麻对下尿道功能的影响

The Effects of Spinal Anesthesia with Lidocaine and Sufentanil on Lower Urinary Tract Functions

Ed T. Kamphuis, MD, PhD*, Peter W. Kuipers, MD{dagger}, Ger E. van Venrooij, PhD{ddagger}, and Cor J. Kalkman, MD, PhD§

From the *Department of Anesthesiology, Rijnstate Ziekenhuis, Arnhem; {dagger}Department of Anesthesiology, Gelre Ziekenhuizen, Apeldoorn; Departments of {ddagger}Urology (GE van Vanrooij former fellow); and §Anesthesiology, University Medical Center, Utrecht, The Netherlands.

Anesth Analg 2008; 107:2073-2078

背景:脊麻干扰排尿反射;膀胱功能维持受损直到感觉阻滞消退到S3节段。鞘内注射阿片类会引起剂量依赖性的逼尿肌收缩抑制。我们研究利多卡因和苏芬太尼联合用于脊麻对于下尿道功能的影响。

方法:对10例行择期下肢整形外科手术的健康年轻男性患者进行充盈性膀胱测压。记录基础数据后,每个患者接受脊麻,用重比重利多卡因100 mg20 µg苏芬太尼。在术后阶段,记录感觉和运动阻滞的消退,持续测定尿动力直到患者能自行排空,而无残余尿。

结果:脊麻后尿意恢复的平均时间是 240 (37)分钟,但没有患者能在那时排空。6例患者当感觉阻滞消退到S2节段时,能在膀胱容量达到最大时有尿意,其他4例患者感觉阻滞消退到S3。尽管有尿意,但没有逼尿肌收缩。在脊麻后332 (52)  min患者能完全排空膀胱。恢复尿意和膀胱正常排空的平均间隔时间90分钟。

结论:当重比重利多卡因和苏芬太尼联合用于脊麻,膀胱收缩恢复远远晚于S3节段感觉功能的恢复。

(彭中美 马皓琳 李士通 校)

BACKGROUND: Spinal local anesthetics interrupt the micturition reflex; bladder function remains impaired until sensory block had regressed to the S3 segment. Intrathecal opioids cause dose-dependent suppression of detrusor contractility. We studied the effects of spinal anesthesia with a combination of lidocaine and sufentanil on lower urinary tract function.

METHODS: Filling cystometry was performed in 10 healthy young male patients undergoing elective lower limb orthopedic surgery. After baseline recordings, each patient received spinal anesthesia with 100 mg hyperbaric lidocaine combined with 20 µg sufentanil. In the postoperative phase, regressions of sensory and motor block were recorded and urodynamic measurements continued until the patient could void spontaneously without residual volume in the bladder.

RESULTS: The mean (sd) time to recovery of urge was 240 (37) min after spinal injection, but no patient was able to void at that time. Six patients experienced urge at the previously observed maximum bladder capacity when the sensory block had regressed to the second sacral segment (S2), in four patients to S3. Despite this urge, no detrusor contraction was recorded. The patients were able to completely empty the bladder 332 (52) min after spinal injection. The average time difference between recovery of urge and return of normal bladder emptying was 90 min.

CONCLUSION: Bladder contractility returns much later than recovery of sensory function in sacral dermatomes (S3) when hyperbaric lidocaine combined with sufentanil is used for spinal anesthesia.