Table of Contents

December 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

抑肽酶和氨甲環酸在心臟手術中的危險性: 一項 1188 例連續的病人隨訪一年的研究

裘毅敏譯,馬皓琳 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.

冠脈術前環氧合酶-1抑制劑的評估與患者自己報告服用阿司匹林血小板聚集度測定的比較

胡豔譯   薛張剛校

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.

即時全血阻抗凝集測定與經典光照凝集測定用於觀測阿司匹林和氯吡格雷的比較:初步研究結果

朱紫瑜 陳傑

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.

氙引起體內延遲性心臟預處理:環氧合酶2的作用?

黃施偉 譯,馬皓琳 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.

預防性使用地塞米松可減少雙腔管拔管後咽喉痛和聲嘶的發生率

黃凝譯  薛張綱校

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:

右旋美托咪啶聯合咪達唑侖與丙泊酚用於接受磁共振成像檢查患兒麻醉維持的比較

周姝婧 陳傑

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.

兒童心臟手術術前重要的電解質紊亂與心臟藥物並無關聯

慧譯 馬皓琳 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.

先天性主動脈瓣上狹窄與麻醉相關性猝死原因是什麼?

蔣宗明譯  薛張綱校

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例成人中應用的前瞻性研究

趙嫣紅 陳傑

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:

肥胖會適當地影響人吸入麻醉劑的動力學特性

姜旭暉譯,馬皓琳,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.

右旋美托咪啶作為全麻輔助藥在下腹部手術病人中的蘇醒研究

劉沁譯 薛張綱校

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.

一個跨膜殘基對丙泊酚與士的甯敏感的甘氨酸α1 α1β受體相互關係的影響

懷曉蓉 陳傑

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.

丙泊酚預處理大鼠可減少神經酰胺產量及腸道缺血再灌注所致腸粘膜細胞凋亡

江繼宏   馬皓琳 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.

尼可地爾-三磷酸腺苷敏感的鉀離子通道開放劑能阻斷毒蕈堿乙酰膽鹼受體介導的PC12細胞細胞外信號調節激酶的啟動

劉婷潔譯 薛張綱校

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.

組胺和蕈毒堿受體參與了致敏的兔注射肌肉鬆弛藥而導致的支氣管收縮

王鵬 陳傑

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:

田野麻醉機中氣動控制呼吸機的氧耗

唐李雋 譯 馬皓琳 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:

肥胖患者置喉鏡與氣管插管時頭高位的隨機可控等價試驗

秦敏菊譯 薛張綱校

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評分和糖尿病是病態肥胖病人困難喉鏡的預測因數

丁俊雲 陳傑

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.

退伍軍人事務局醫院手術當天病人意外死亡的相關因素分析

吳進   馬皓琳 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

剖腹手術增加術中氧化應激反應:能被預防嗎?

舒慧剛 陳傑

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:

嚴重膿毒症對日常健康相關的生活質量的影響:一項長期隨訪研究

唐亮   馬皓琳 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:

比較三組病人自控硬膜外鎮痛的隨機試驗

孫鵬飛譯  薛張綱校

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:

用於教學和研究的數位化腦血管類比模型的設計

葉樂 陳傑

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.

丙泊酚預處理減弱大鼠短暫的局部腦缺血再灌注後水通道蛋白-4過度表達並減輕腦水腫

王宏 馬皓琳 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:

一種新型的經鼻嗎啡合劑、快速釋放口服嗎啡、靜脈用嗎啡和安慰劑用於術後牙痛模型中的鎮痛效果和安全性比較

夏俊明譯 薛張綱校

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.

鼻腔內應用酮咯酸在術後疼痛治療中的安全性和鎮痛效應

張磊 陳傑

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.

氯胺酮和氯諾昔康用於預防芬太尼引起的術後嗎啡用量增加

黃佳佳譯,馬皓琳 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.

慢性頭痛的針灸治療:系統綜述

宣麗真譯 薛張綱校

Acupuncture for the Management of Chronic Headache: A Systematic Review

Yanxia Sun and Tong J. Gan

Anesth Analg 2008 107: 2038-2047.

單劑量Tapentadol在牙科手術後鎮痛效果 :一個隨機,雙盲,安慰劑對照研究

劉世文 陳傑

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.

腹橫肌平面阻滯為行腹式全子宮切除術的病人提供有效的術後鎮痛

黃麗娜 馬皓琳 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.

給綿羊鞘內注射酮基布洛芬和氯胺酮預防N -甲基- D -天門冬氨酸引起的機械痛

章一靜譯 薛張綱校

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.

筋膜上和筋膜下輸注布比卡因用於腹式子宮切除術後的鎮痛治療

陳偉 陳傑

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.

利多卡因和蘇芬太尼用於脊麻對下尿道功能的影響

彭中美 馬皓琳 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.

彈性輸注泵用於術後區域麻醉的可靠性:一項對430件設備的調查

陳珺珺譯 薛張綱校

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.

低容量高濃度的比高容量低濃度局麻藥用於Labat's坐骨神經阻滯更有效:一項前瞻性、隨機、對照試驗

潘錢玲 陳傑

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.

 

 

即時全血阻抗凝集測定與經典光照凝集測定用於觀測阿司匹林和氯吡格雷的比較:初步研究結果

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:作者研究以確認Multiplate®全血阻抗凝集測定用於觀察抗血小板藥物作用是否具有與經典光照凝集測定(LTA)或者血小板功能分析PFA-100相同的可靠度。

方法:Multiplate®試驗(M),測量單位時間內電阻變化作為凝聚單位(AU*min);LTA試驗由膠原(COL)、二磷酸腺苷(ADP)或者花生四烯酸(AA)誘導;PFA-100試驗,使用腎上腺(PEA100-EPI)或者ADPPEA100-ADP)元件;對連續70名選擇性冠狀動脈搭橋術病人的麻醉前動脈血樣本進行同步全血阻抗凝集測定、LTAPEA。組A的患者(n=48)為對照組,組B的患者(n=11)接受阿司匹林100mg/d,組Cn=11)接受阿司匹林100mg/d和氯吡格雷75mg/d直至術前。

結果:對照組患者的M-COLAU*min阻抗變化的中位數(第一,第三四分位數)(374[231-469])明顯高於接受阿司匹林的患者(164[86-211]P=0.0009),也高於接受阿司匹林和氯吡格雷的患者(118[101-244]P=0.004)。對照組的M-ADP值為258158-389),阿司匹林組為261159-393),阿司匹林和氯吡格雷組的則為8848-231P=0.054)。對於M-AA值,阿司匹林組(45[28-60]P=0.0004)或者阿司匹林和氯吡格雷組(44[26-221]P=0.0085)明顯低於對照組(200[86-345])。接受者操作特性曲線(ROC曲線)下的面積代表使用全血阻抗凝集測定或者經典LTACOLAA試驗對於區分患者有無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]),但是對於PFA-100-EPI則只有0.74P=0.03)。同樣,對於鑒別患者接受抗血小板藥物還是接受氯吡格雷和阿司匹林,ROC曲線下的面積在兩種凝集測定中也相似,M-COL0.77(P=0.006)LTA-COL0.78(P=0.004)M-ADP0.74(P=0.015)LTA-ADP0.73(P=0.018)

結論:對於選擇性心臟手術病人術前阿司匹林和氯吡格雷的功效觀測,床邊Multiplate®試驗的結果同經典凝集測定無差異。

(朱紫瑜 陳傑 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.



右旋美托咪啶聯合咪達唑侖與丙泊酚用於接受磁共振成像檢查患兒麻醉維持的比較

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受體激動劑,作者在接受磁共振成像(MRI)、並以七氟醚進行麻醉誘導的患兒中比較了右旋美托咪啶聯合咪達唑侖與丙泊酚的藥代動力學效應,以研究它是否適用于小兒麻醉。

方法401-10歲、ASA分級III級的患兒隨機分為2組,在向其給予七氟醚作麻醉誘導後,一組給予右旋美托咪啶聯合咪達唑侖,一組給予丙泊酚作麻醉維持,其後患兒接受MRI檢查。給藥方式為先給予右旋美托咪啶負荷量(1μg/kg),再追加持續量(0.5μg/kg/min);在持續輸注開始時,給予咪達唑侖(0.1mg/kg)。丙泊酚則以持續輸注的方式(250-300μg/kg/min)給予。然後由一位元對實驗目的不知情的護士記錄患兒的復蘇時間。

結果:接受右旋美托咪啶聯合咪達唑侖維持的患兒其完全復蘇、並從門診離開的時間明顯長於接受丙泊酚維持的患兒(15min)。變數分析顯示,右旋美托咪啶組的患兒的心率低於、而收縮壓高於丙泊酚組的患兒。兩組的呼吸指數相似。復蘇期間,兩組患兒的血流動力學反應相似。麻醉和復蘇期間,患兒的心臟呼吸指數維持在該年齡段兒童的正常範圍內。沒有發生不良反應。

結論:與丙泊酚相比,儘管復蘇時間有所延長,右旋美托咪啶聯合咪達唑侖能夠為接受MRI檢查的患兒提供充分的麻醉深度,且後者能夠提供較慢的心率和較高的收縮壓。兩種治療方式的呼吸指數相似。

(周姝婧 陳傑 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例成人中應用的前瞻性研究

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:雖然已有較多有關ProSealTM喉罩(PLMA)的研究,但其中只有少部分為大規模臨床研究。本實驗旨在採集關於ProSealTM喉罩的特性,有效性,安全性等方面的綜合資訊進行分析。資訊採集由教學中心的專業麻醉醫師完成。

方法:使用標準化採集方式進行資訊採集。臨床資料的收集範圍包括使用者的特性,患者病情特徵,類型及手術時程,氣道管理,麻醉方法,有無不良事件發生及患者術後情況。

結果:81位麻醉醫師(57%為實習醫師,43%為執業醫師)對2114例患者實施應用ProSealTM喉罩(PLMA)。置入喉罩的成功率為99%(最多三次嘗試內)。平均氣道漏氣壓為2811-40cmH2O3.2%的病例放棄使用ProSealTM喉罩而改用氣管內插管。98%的病例進行控制通氣。3.3%病例有臨床相關不良事件,其中0.6%被列為嚴重不良事件。所有病例中沒有產生長期的不良後遺症。12例有明顯胃液返流的病例中,在使用ProSealTM喉罩引流管後無一發生誤吸。5例困難通氣及16例困難插管患者成功有效使用了ProSealTM喉罩。

結論:這項研究證實使用ProSealTM喉罩(PLMA)進行氣道管理在臨床應用中是安全並且有效的。實驗結果也支持將ProSealTM喉罩置入正確位置可以有效防止胃液返流引起的誤吸,且對困難氣道同樣有效。

(趙嫣紅 陳傑

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.

 

一個跨膜殘基對丙泊酚與士的甯敏感的甘氨酸α1 α1β受體相互關係的影響

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,以它的麻醉效應而知名,作為一個正的α1-氨基丁酸AGABAA)受體的變構調節劑作用,同時也增強甘氨酸受體的功能。丙泊酚GABA的調節效應受GABAA受體β亞單位的一個位於第二跨膜區(TM2)內的氨基酸殘基的影響。在甘氨酸亞單位α1,相應的殘基(絲氨酸267)影響醇和烷類麻醉劑的甘氨酸調節劑的作用。本研究中作者研究了這個殘基在丙泊酚與甘氨酸α1 α1β受體相互關係中的作用。

方法:應用細胞膜片鉗技術研究丙泊酚對於表達在人類胚腎293細胞的野生型和突變型(α1S267Mα1S267Iα1S267Mβα1S267Iβ)甘氨酸受體的作用。

結果:無論異亮氨酸或者甲硫氨酸α1單位TM2的絲氨酸殘基的突變都降低了對甘氨酸的受體的敏感性,並且阻止了丙泊酚對甘氨酸受體的直接啟動作用。此外,甲硫氨酸和獨特的異亮氨酸突變型減少了丙泊酚的甘氨酸增強作用。

結論:野生型甘氨酸α1單位TM2殘基(267)影響了丙泊酚的甘氨酸作用和受體的直接啟動。這種變異導致丙泊酚與甘氨酸和GABA A受體作用發生變化,有助於更好地理解丙泊酚對相關受體的決定子,並且可能有助於發展選擇性甘氨酸受體調節劑。

(懷曉蓉 陳傑

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.

 

組胺和蕈毒堿受體參與了致敏的兔注射肌肉鬆弛藥而導致的支氣管收縮

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:肌肉鬆弛藥通過引起組胺的釋放和/或由於作用於毒蕈堿樣受體引起支氣管痙攣;作者試圖探究這些通路在支氣管高反應性動物中各自的重要性。

方法:卵清蛋白致敏的兔子模型隨機分組:組C為未處理組;在其他的三組中,組M123,使用H1H2組胺受體阻斷劑,保留M1M2M3毒蕈堿受體的功能;組M12中,H1H2組胺受體阻斷,M3毒蕈堿受體阻斷,保留M1M2毒蕈堿受體功能;組M3中,切斷迷走神經。靜脈給予司可林,美維庫銨或阿曲庫銨後每90秒測量呼吸系統的阻力。檢測兩秒時間窗內肺部力學的變化,檢測呼吸系統的阻力、組織阻尼及彈回率。

結果:氣道阻力的峰值在組C中使用司可林(79%±17%)和美維庫銨(75%±12%)的升高的最明顯,而使用阿曲庫銨(40%±11%)的升高較少。在同時行組胺和毒蕈堿受體阻斷中這些變化顯著的減少,同樣的處理在M3中使用司可林(14%±5.2%)和組M123中使用美維庫銨(5.1%±9.1%)和阿曲庫銨(7.8%±4.0%)中阻力減少的最多。

結論:儘管支氣管痙攣主要是由使用肌松藥後組胺釋放引起的氣道過敏引起的,但司可林對M1M2M3受體,阿曲庫銨對M1M2受體,美維庫銨對M3受體影響可能也起一定作用。

(王鵬 陳傑

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評分和糖尿病是病態肥胖病人困難喉鏡的預測因數

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分級(MMP)為評估口咽結構預測困難喉鏡的標準方法。先前的研究顯示頭頸關節伸展位元(Extended Mallampati Score, EMS)較中位的MMP評分預測價值更有意義。本研究,作者對比了MMPEMS在病態肥胖病人中的預測價值。

方法:作者設計了一項超過12個月的前瞻性研究,比較了體重指數(BMI ≥40的成人MMPEMS 。比較MMPEMS和其他常用的方法預測困難喉鏡的能力, Cormack-Lehane 分級34級定義為困難喉鏡。位置調整及直接喉鏡檢查技術不作為標準。比較BMI ≥<40困難喉鏡、困難插管的發生率。

結果:346 BMI ≥40的病人接受了喉鏡檢查並用MMPEMS進行評分。頭頸後仰減低了MMP等級(P < 0.0001),相對於MMPEMS保持穩定的靈敏度的同時提高了特異性和預測價值。相對於MMP和其他測試,在病態肥胖病人中EMS評分34分並診斷為糖尿病可準確預測為困難喉鏡。在BMI <40的病態肥胖病人中困難喉鏡插管的發生率沒有顯著差別。

結論:在病態肥胖病人中預測困難插管EMS優於MMP。這一人群中診斷為糖尿病也是困難喉鏡的預測因數。最後,這項研究支持先前的發現:病態肥胖症本身並不能作為困難喉鏡和困難插管的預測因數。

(丁俊雲 陳傑 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.

 

剖腹手術增加術中氧化應激反應:能被預防嗎?

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:活性氧物質被高度懷疑參與了手術應激和損傷的發展,但未被證實。醫學上沒有方法處理這種類型的氧化應激。

方法:在四種不同麻醉方法下乙狀結腸切除術中,測定血液中的過氧化氫水平作為細胞氧化損傷的指標,以及血漿鐵還原能力作為總抗氧化潛力的指標:七氟醚麻醉開腹乙狀結腸切除術,七氟醚麻醉腹腔鏡下乙狀結腸切除術,異丙酚麻醉開腹乙狀結腸切除術,異丙酚麻醉腹腔鏡下乙狀結腸切除術。

結果:七氟醚麻醉開腹乙結腸切除手術中鐵還原能力顯著減弱,減幅387 ± 153 mmol/L,儘管過氧化氫水平沒有改變,這表明手術增加了氧化應激。然而其毒性並沒有高至造成細胞損傷,因為細胞氧化的典型產物過氧化氫並未增加。七氟醚麻醉腹腔鏡下乙結腸切除術中過氧化氫水平和鐵還原能力沒有改變,這表明腹腔鏡手術不會增加手術的氧化應激反應。異丙酚麻醉開腹和腹腔鏡乙結腸切除術中過氧化氫顯著減少,減幅分別為120 ± 73144 ± 107 Ucarr1 Ucarr對應0.8 mg/L H2O2)

結論:剖腹腸道手術增加了氧化應激。腹腔鏡手術與氧化應激並無相關,而異丙酚作為抗氧化劑明顯減少氧化應激。

(舒慧剛 陳傑 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.


用於教學和研究的數位化腦血管類比模型的設計

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:作者開發了一項綜合腦血流和顱內壓模型類比並研究多重因素同時變化時引起的腦血液動力學複雜的相互影響,包括腦自動調節正常和異常功能狀態。

方法來自先前動物和人類研究得出的方程是通過複雜的類比程式得出。包括在正常生理模型,腦血流量,動脈血壓,以及二氧化碳(CO2  )分壓。作者還增加外部和病理干擾,如頭高位和顱內出血。

結果:該模型的臨床實際參數來自臨床醫生收集的創傷病人和其病歷。醫生很容易理解搏動性輸出的圖形。模擬方法包括變化的基礎生理參數(例如,動脈血壓,中心靜脈壓,二氧化碳張力,頭的位置,和呼吸對血管壓力的影響) ,以及病理參數(例如,急性顱內出血,腦脊液引流梗阻)

結論:根據調查結果,作者認為該模型對於複雜腦血流動力學的互相關係和臨床一些問題研究有一定價值,如優化頭部位置的影響,顱內出血的腦血流動力學變化,以及最適二氧化碳濃度,以達到最佳顱內壓和灌注的平衡。基於對模型複雜性的區別能力,作者認為該模型將有助於初學者和有經驗者。該模型也適用於臨床(輸入必要臨床操作帶來的影響,然後運行該模型來測試最佳的組合治療方法)。

(葉樂 陳傑 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).

 

鼻腔內應用酮咯酸在術後疼痛治療中的安全性和鎮痛效應

 

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:作者評估了多種劑量鼻腔應用內酮咯酸氨丁三醇(酮咯酸)的術後鎮痛的安全性和有效性。

方法:在這一雙盲、安慰劑對照的研究中,施行大手術的患者術後隨機接受每8小時一次的鼻腔內應用酮咯酸10毫克或30毫克或安慰劑共40小時。記錄用藥後30分鐘和1 2 3 4 5 6 8 12 16 20 24 28 32 36 40 4448 h時鎮痛情況,疼痛強度至少維持在100mm視覺模尺的40mm以內。患者自控應用嗎啡作輔助鎮痛。

結果 127名患者,第一個24小時內30毫克酮咯酸組患者嗎啡用量( 37.8毫克)低於安慰劑組( 56.5毫克)和10毫克酮咯酸組( 54.3毫克)。48小時內,30毫克酮咯酸組嗎啡使用量比安慰劑組大大減少。30毫克酮咯酸組術後46 h疼痛強度與其他組相比有顯著差異。酮咯酸30毫克組發熱和心動過速發生率較安慰劑組顯著降低。其他不良反應事件發生率率組間無差異,且大部分被認為與治療無關。

結論 鼻腔內應用30毫克酮咯酸較10毫克酮咯酸和安慰劑相比,具有顯著的鎮痛效應。

(張磊 陳傑 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.

 

單劑量Tapentadol在牙科手術後鎮痛效果 :一個隨機,雙盲,安慰劑對照研究

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是一種新型的中樞作用鎮痛藥,具有兩種鎮痛途徑,一種為µ受體激動劑,另一種抑制去甲腎上腺素再攝取。作者研究了tapentadol與標準劑量的嗎啡及與安慰劑在中度至重度術後牙齒疼痛的療效和耐受性。

方法:下頜第三磨牙拔除術後經歷中度至重度疼痛的患者隨機接受單劑量鹽酸tapentadol劑量 25 50 75 100 ,或200毫克) ,硫酸嗎啡( 60毫克) ,布洛芬( 400毫克;用來建立模型的敏感性),或安慰劑。平均總緩解疼痛超過8小時( TOTPAR - 8 )為主要終點。第二次終結點包括平均總緩解疼痛超過4小時( TOTPAR - 4 )和鎮痛的開始,使用Fisher 精確檢驗法研究藥物與安慰劑作用差異,並記錄不良事件。

結果: 400名患者隨機接受治療,並完成了研究。與安慰劑相比,鹽酸tapentadol 50毫克( P0.041 75毫克( P0.001 100毫克( P “ 0.001 200毫克( P ” 0.001 ),硫酸嗎啡60毫克(P < 0.001)和布洛芬400毫克(P < 0.001)TOTPAR – 8顯著延長。布洛芬組TOTPAR - 8評分顯著高於安慰劑組。相對於硫酸嗎啡60毫克來說平均TOTPAR – 4在鹽酸tapentadol200毫克似乎更加迅速快速,高效。硫酸嗎啡60毫克疼痛緩解分數介於鹽酸tapentadol 100毫克和200毫克之間。各種劑量鹽酸tapentadol比硫酸嗎啡60毫克的噁心,嘔吐發生率低,但沒有統計學意義。

結論:單劑量口服75毫克tapentadol相對嗎啡來說能呈劑量相關的方式更有效地減少中度至重度牙科術後疼痛並且有良好的耐受性。這些資料表明tapentadol是一種副作用更少、起效更迅速的中樞作用的鎮痛藥。

(劉世文 陳傑 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.

 

筋膜上和筋膜下輸注布比卡因用於腹式子宮切除術後的鎮痛治療
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:作者評估了腹式子宮切除術後筋膜上或筋膜下輸注布比卡因的鎮痛效果。
方法 62ASAIII級接受腹式子宮和雙側輸卵管卵巢切除術患者列入這一隨機雙盲研究。給予統一標準的麻醉管理。在術畢時,多孔20號硬膜外導管放置於筋膜上( 筋膜上組29例)和筋膜下(筋膜下組 31例),通過病人自控鎮痛裝置給予0.25 %布比卡因,設定為鎖定間隔60分鐘輸注9.0毫升持續24小時。在術後第一個6小時,追加注射芬太尼( 25微克)實現視覺類比評分<4 cm。比較總布比卡因用量,總芬太尼追加量,疼痛分數(在休息,咳嗽,和直腿抬高狀態)以及兩組滿意度。
結果24小時內總布比卡因用量在筋膜上組明顯低於組筋膜下組(90 ± 26 mL vs 104 ± 28 mL, respectively, P < 0.05)。芬太尼的總用量在術後第一個6小時在筋膜上組和筋膜下組分別為109 ± 59 µg166 ± 70µg(P < 0.01) 。筋膜上組疼痛評分在前5 h內休息和咳嗽時和12小時內直腿抬高時較低(所有測量中P < 0.05 在筋膜上組有13例( 68 )的鎮痛滿意度極好,而在筋膜下組只有6例( 32 )的滿意度極佳( P0.034
結論:經腹子宮切除術後的12小時內筋膜上比筋膜下輸注布比卡因提供了更好術後鎮痛。

(陳偉 陳傑 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.

 

低容量高濃度的比高容量低濃度局麻藥用於Labat's坐骨神經阻滯更有效:一項前瞻性、隨機、對照試驗

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:各種各樣的因素能顯著影響周圍神經阻滯的起效時間和成功率。這項前瞻性、隨機、雙盲研究旨在比較300mg甲呱卡因稀釋於20ml30ml用於後路坐骨神經阻滯時其效果的差異。

方法 90名行足部手術患者隨機接受1.5%的甲呱卡因20mln=45)或1%的甲呱卡因30mln=45)坐骨神經阻滯。所有的阻滯均採用神經刺激儀(刺激頻率為2Hz;強度為1.4-0.5mA)。在這兩組中, <0.5mA神經刺激引出足部的拓屈反應。記錄知覺起效及在脛、腓神經分佈區域運動阻滯的時間。一個成功的阻滯定義為在坐骨神經分佈區域對針刺覺的完全消失及無力完成足部的拓屈及背屈反射。

結果1.5%的甲呱卡因20ml組阻滯成功率(96.6%)較1%的甲呱卡因30ml組(68.9%)更高(P<0.05)。1.5%甲呱卡因20ml組知覺完全消失及運動阻滯的時間分別為11±6min13±7min,比1%的甲呱卡因30ml組(分別為17±8min19±8min)更短。

結論Labat's坐骨神經阻滯時給予低容量高濃度的局麻藥(1.5%的甲呱卡因)比高容量低濃度的局麻藥(1%的甲呱卡因)成功率更高,起效時間更短。

(潘錢玲 陳傑

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).

 

冠脈術前環氧合酶-1抑制劑的評估與患者自己報告服用阿司匹林血小板聚集度測定的比較

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:抗血小板治療引起的血小板功能障礙會引起圍手術期出血。在術前五天內用阿司匹林的幾個試驗調查顯示,輸血的需求對阿司匹林的使用者沒有增加或者說沒有顯著差異。 我們的目的在於比較評價自己報告服用阿司匹林的患者和測定血小板功能的患者對輸血的需求。

方法:在一個前瞻性的試驗中,對100名在冠脈搭橋術前5天內服用阿司匹林的患者進行標準問卷調查。用多種血小板功能分析研究花生四烯酸對全血小板聚集的觸發作用。

結果:23名術前服用阿司匹林的患者中,11人有異常聚集的現象。77名未在術前服用阿司匹林的患者中,9人有異常的聚集反應。術後24小時內胸管引流量及輸注紅細胞在服用和未服用阿司匹林的患者間無顯著差異。正常和異常聚集反應的患者的術後24小時胸管引流量無顯著差異。有異常聚集反應(<51U)的患者比正常聚集的患者(1.1U 對比0.3U,P=0.01)需要更多的血小板輸注。

結論:我們的結果顯示花生四烯酸介導的全血聚集檢測比患者自己報告阿司匹林服用能更好的預測血小板相關的凝血障礙和血小板輸注需要。

(胡豔譯   薛張剛校)

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.

                                                     

 

預防性使用地塞米松可減少雙腔管拔管後咽喉痛和聲嘶的發生率

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:術後咽喉痛和聲嘶是氣管插管後的常見併發症,尤其是使用雙腔管(DLT)後。此項前瞻性,隨機化,雙盲,安慰劑對照研究旨在評價預防性使用地塞米松對減少術後咽喉痛和聲嘶發生率和嚴重程度的有效性。

方法166名預計使用雙腔管行胸外科手術患者(年齡1875)進入此項研究。全麻誘導前經靜脈給予0.1 mg/kg地塞米松(D1), 0.2 mg/kg地塞米松(D2), 或安慰劑(P),分組採用雙盲,前瞻性,隨機化方式。以CormackLehane評分法確定聲門暴露情況,並記錄插入雙腔管的阻力,嘗試插管的次數,完成插管的時間和氣管插管的持續時間。氣管插管後1小時和24小時,使用直觀類比標度法(VAS 0分=不痛,100分=可想像的最痛)評估患者咽喉痛和聲嘶的程度。

結果:氣管拔管後1小時,DI(分別為31%, P = 0.021; 11%, P = 0.003; VAS 12.4, P < 0.001)D2(分別為11%, P = 0.001; 4%, P = 0.001; VAS 6.6, P < 0.001)術後咽喉痛和聲嘶的發生率以及咽喉痛嚴重程度均較P(分別為53%, 36%,VAS 30.9)低。氣管拔管後24小時,D2(分別為27%, P = 0.002; 15%, P = 0.001; VAS 29.9, P < 0.002)D1(分別為47%, 31%, VAS 43.9)P(分別為57%, 45%, VAS 51.3)術後咽喉痛和聲嘶的發生率以及咽喉痛嚴重程度顯著降低。未出現與使用地塞米松相關的併發症。

結論:預防性使用0.2 mg/kg地塞米松可顯著降低雙腔管拔管後1小時和24小時咽喉痛和聲嘶的發生率以及咽喉痛的嚴重程度。

(黃凝譯  薛張綱校)

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.

 

 

先天性主動脈瓣上狹窄與麻醉相關性猝死原因是什麼?

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:

主動脈瓣上狹窄合併外周肺動脈狹窄的病人中絕大多數有Williams-Beuren綜合征,這類病人有其固有的心肌缺血的危險因素,在手術鎮靜和麻醉的情況下尤其如此。這些病變會引起雙心室肥大進而增加心肌氧耗和損害心肌氧供。此外,這類病人常有直接多因素的冠狀動脈血流減少。本文將分析主動脈瓣上狹窄的病理生理和復習鎮靜與麻醉相關性猝死的文獻,並在已獲得資料基礎上提供一些術前評估與處理的建議。

(蔣宗明譯  薛張綱校)

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.

 

 

右旋美托咪啶作為全麻輔助藥在下腹部手術病人中的蘇醒研究

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:右旋美托咪啶可減少拔管期間的血流動力學變化,顧這種藥物對需要平穩蘇醒的全麻病人可能會有幫助。我們已知當七氟醚和異丙酚在單獨使用時都能提供一個安全且快速的蘇醒,因此我們旨在明確當七氟醚或異丙酚麻醉在合用右旋美托咪啶時對蘇醒的影響作用。

方法60名行下腹部手術的病人根據所用的麻醉藥物被隨機的分配到四組,分別以七氟醚(S組),異丙酚(P組),七氟醚+右旋美托咪啶(SD組),或異丙酚+右旋美托咪啶(PD組)來維持麻醉。在誘導後麻醉的維持S組為0.6%–1.5%的七氟醚,P組為2–5 mg/kg/hSD組為七氟醚加右旋美托咪啶(10分鐘的劑量為1 µg/kg ,後以 0.4 µg/kg/h直至手術結束)PD組為異丙酚加右旋美托咪啶,且所有組均複合持續硬膜外輸注。在所有組,BIS值以調整七氟醚濃度或異丙酚輸注速率的方式維持在45 ± 5之間。記錄下從中止使用麻醉維持藥物到病人睜眼的時間。手術後的認知功能是以短時定向記憶注意集中測試來評價的。

結果:將S組的睜眼時間(8.5 ± 2.5 min, mean ± sd; n = 15)SD組的睜眼時間(12.0 ± 3.3 min)作比較,PD(21.7 ± 7.1 min)P(11.0 ± 4.4 min)的睜眼時間延長,且PD組的睜眼時間比其他三組都明顯延長(P < 0.001)。在S組及P組間的短時定向記憶注意集中測試評分相近,且並不受是否合用右旋美托咪啶的影響。

結論:當合用右旋美托咪啶時,七氟醚比異丙酚顯示了更短的睜眼時間,且術後認知功能並不受右旋美托咪啶的影響。這些結果表明當右旋美托咪啶作為異丙酚全靜脈麻醉的輔助用藥時,可能會延遲蘇醒時間。

(劉沁譯 薛張綱校)

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.

 

 

尼可地爾-三磷酸腺苷敏感的鉀離子通道開放劑能阻斷毒蕈堿乙酰膽鹼受體介導的PC12細胞細胞外信號調節激酶的啟動

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.

 

背景尼可地爾-三磷酸腺苷敏感的鉀離子通道開放劑被報導能通過使鉀離子通道超極化產生抗傷害性刺激效應。細胞外信號調節激酶的啟動-有絲分裂原(細胞分裂劑)啟動蛋白中的一族在背根神經節的突觸可塑性以及傷害性刺激中扮演一個重要的角色。有報導世紀神經元誘發了這種啟動。為了理解尼可地爾的這種生物機制,我們檢測它在毒蕈堿乙酰膽鹼受體介導的一個神經元細胞(大鼠嗜鉻細胞瘤PC12細胞)中細胞外信號調節激酶的啟動效應。

方法:用蛋白質印跡分析檢測PC12細胞在有或無尼可地爾時對乙酰膽鹼的刺激反應及細胞外信號調節激酶的磷酸化。我們還檢測尼可地爾在由4beta-phorbol 12-myristate 13-acetate(一種蛋白激酶C)或伊屋諾黴素(一種該離子載體)誘導下細胞外信號調節激酶的啟動效應。PC12細胞內鈣離子的增加可用螢光標記後用螢光顯微鏡觀察。

結果尼可地爾阻滯乙酰膽鹼誘導的細胞外信號調節激酶的啟動並具有濃度依賴性。這種阻滯可被格列本脲(一種對三磷酸腺苷敏感的鉀通道阻滯劑)消除。尼可地爾抑制細胞外信號調節激酶的啟動是由伊屋諾黴素誘導的而非4beta-phorbol 12-myristate 13-acetatePC12細胞用尼可地爾預處理通過乙酰膽鹼的刺激減少細胞內鈣離子濃度。

結論尼可地爾通過減少細胞內鈣離子濃度能阻斷毒蕈堿細胞外信號調節激酶信號路徑的啟動。

(劉婷潔譯 薛張綱校)

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.

 

 

肥胖患者置喉鏡與氣管插管時頭高位的隨機可控等價試驗

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:患者的正確擺體位是直接喉鏡以及氣管插管成功的關鍵因素。在肥胖患者中,行氣管插管時,25º的墊背位元或頭高位都要優於平臥位元。這種體位通常通過在患者的頭部及肩部放置擺位元毛毯或者其他裝置來實現。這種體位也可以通過操縱常用的手術床來做到:屈曲縱線力臂以及抬高手術床靠背部分(手術床斜面)。這種利用手術床來擺位的方法可以省去額外擺位元裝置的費用,而且可以避免患者及擺位者在插管後移除這些裝置時可能受到的傷害。本次研究就是想要知道通過手術床來擺體位,是否與使用擺位元裝置一樣有效,即兩者花費的插管時間是否相同。

方法85個擇期手術BMI30kg/m2的患者同意參加這個前瞻、隨機的等價研究。本研究在一個教學醫院進行,隨機化通過使用隨機表格來決定,即將受試者平等分佈在隨機表格中,來決定其使用體位元毯方式或手術床方式。本次試驗的觀察終點是達到頭高位,即患者的外耳道線與胸骨切跡位於同一水平線。雖然所有患者的擺位都是由同一個麻醉醫生完成,但置喉鏡和氣管插管是由不同經驗程度的學習者來完成的。本試驗所使用的是標準的靜脈誘導以及氣管插管技術。從患者失去意識的時點開始記錄直到氣管插管成功EtCO2被檢測到為終點。同時也要記錄面罩通氣的有效性以及喉鏡暴露的質量。

結果:使用毛毯組的插管平均時間是175秒鐘,標準差為66秒鐘。手術床組的插管平均時間是163秒鐘,標準差為71秒鐘。假定等價邊界為-55.55秒,當檢驗的顯著性水平為0.05時,我們使用了兩種單側檢驗的方法計算出95%的可信區間為-36.22秒和13.52秒。兩組置喉鏡的次數並無差別(p=0.21),保持氣道安全性的氣管插管也無區別(p=0.76)。

結論:麻醉誘導前,肥胖患者要在手術床上放置為一個頭部高於肩部的體位,這可以通過在患者的肩背部放置一個擺位毛毯或者通過搖動手術床斜面來達到。對於置直接喉鏡和行氣管插管來說,這兩種方法的效果等價。

(秦敏菊譯 薛張綱校)

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.

 

 

比較三組病人自控硬膜外鎮痛的隨機試驗

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:病人自控硬膜外鎮痛(PCEA)是安全有效的人工鎮痛方法,但是何為理想的鎮痛模式則有爭議。

方法:在該前瞻性,隨機,雙盲研究中,我們比較追加量鎮痛和有背景劑量鎮痛的止痛效果。研究物件為300名未孕者。首先以羅派卡因2mg和芬太尼15ug開始鎮痛,以硬膜外0.1%羅呱卡因和2 µg/mL芬太尼維持。病人分為3組。0組:無背景劑量,追加量5ml,鎖定時間15分鐘,5組:背景劑量5mL/h,追加量5ml,鎖定時間12分鐘,10組:背景劑量10mL/h,追加量5ml,鎖定時間10分鐘。所有組最大劑量為20 mL/h。第一項結果是劇烈疼痛的發生率,第二項結果包括分娩期疼痛評分,神經阻滯特徵,副作用,羅呱卡因總量和小時用量,新生兒和產科結果。

結果0組的劇烈疼痛發生率和疼痛評分顯著高於5組和10組。10組無痛期更長於0組,羅呱卡因用量更高,和更晚使用第二次追加劑量有關。

結論:和有背景劑量鎮痛相比,只有追加劑量的鎮痛所用麻醉藥更少,但疼痛發生率高,疼痛評分高,有效無痛期短,母親滿意度低。

(孫鵬飛譯  薛張綱校)

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).

 

 

一種新型的經鼻嗎啡合劑、快速釋放口服嗎啡、靜脈用嗎啡和安慰劑用於術後牙痛模型中的鎮痛效果和安全性比較

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:阿片類藥物是用於術後鎮痛的標準藥物。本研究中,我們對比了經鼻嗎啡合劑、靜脈用嗎啡、口服嗎啡以及安慰劑的功效和安全性。

方法225位拔除第三磨牙後患有中到重度疼痛的患者隨機分為四組,分別接受次劑量經鼻嗎啡合劑7.5 mg 15 mg, 靜脈用嗎啡7.5 mg, 口服嗎啡60 mg以及安慰劑。疼痛程度評定採用VAS評分法,疼痛減輕採用直接評分。結果包括總體疼痛減輕狀況,疼痛程度差異,總計疼痛程度差異,止痛效果起效時間,要求進一步藥物支持的時間以及患者對治療的總體評價。安全評估包括副作用記錄以及鼻部檢查。

結果:參考了多種評價結果,兩種經鼻嗎啡合劑使用劑量與後兩者(靜脈及口服嗎啡)相比統計學結果相近,四種用藥途徑的嗎啡治療都顯著有效於安慰劑。經鼻嗎啡合劑15mg與靜脈用嗎啡7.5mg的效用相近,兩種治療起效都相當迅速,並且在6小時評估時間內效果都持久穩定。低劑量經鼻嗎啡合劑,7.5mg,與其他治療方法在2小時和6小時的效果統計學結果相近,與安慰劑治療效果在4小時統計學結果相近。治療研究總體上能夠被接受,沒有因為副作用或者其他安全因素而退組的情況,沒有嚴重的副作用記錄。頻繁發生的副作用事件都是典型的阿片類藥物的全身性副作用。

結論:相對靜脈用嗎啡而言,經鼻嗎啡合劑為術後鎮痛提供了一種無創用藥途徑。 

(夏俊明譯 薛張綱校)

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.

 

 

慢性頭痛的針灸治療:系統綜述

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:這篇綜述的目的是評價慢性疼痛的針灸治療的療效。

方法:我們搜索了Medline1966-2007),CINAHLThe Cochrane Central Register of Controlled Trials (2006)Scopus等資料庫中關於慢性頭痛針灸治療的隨機對照實驗。實驗包括成人慢性疼痛(包括偏頭痛或緊張性頭痛或兩者都有),隨機接受針刺治療,對照組包括假的針灸治療,藥物治療和其他非藥物治療。我們引用頭痛強度,頭痛頻率和早期和晚期隨訪的應答率等數據。

結果:這篇綜述包括31項研究。大部分比較了真假針灸治療的研究支持針灸療法。針灸治療組的組合應答率顯著高於假針灸治療組,不論是在隨訪早期(RR1.19, 95%CI1.08, 1.30)或隨訪晚期(RR1.22, 95%CI1.04, 1.43)。組合資料同樣表明針灸治療優於藥物治療:頭痛強度(加權平均數:-8.54 mm, 95% CI: -15.52, -1.57),頭痛頻率(標準差: -0.70, 95% CI: -1.38, -0.02),軀體功能(加權平均數: 4.16, 95% CI: 1.33, 6.98),應答率(RR: 1.49, 95% CI: 1.02, 2.17).

結論:在改善頭痛強度,頭痛頻率和應答率方面針灸治療優於假針灸治療和藥物治療。

(宣麗真譯 薛張綱校)

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.

 

 

給綿羊鞘內注射酮基布洛芬和氯胺酮預防N -甲基- D -天門冬氨酸引起的機械痛

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:非甾體抗炎藥和N -甲基- D -天冬氨酸( NMDA )受體拮抗劑通過鞘內注射減輕疼痛敏感性。但他們的聯合影響幾乎未被研究。我們估計了非類固醇消炎藥酮丙酸的作用和NMDA感受器官渠道阻礙ketamine單獨給出和在組合,在綿羊的機械痛感的門限被種入的與存在的子宮頸i.t.導尿管

方法給予綿羊,它導管,酮基布洛芬( 200-3200微米; 100 μL )及氯胺酮( 25-400微米; 100 μL )單獨或聯合( 837.95-3350.78微米; 100 μL ; 0.955:0.045的比例) 。他們還收到了NMDA受體( 2毫米; 100 μL )之前,最集中的酮洛芬和氯胺酮單獨或聯合。生理鹽水( 0.9 ; 100 μL )和二甲苯胺噻嗪( 1.95毫米; 100 μL )被用來作為陰性和陽性對照。

結果二甲苯胺噻嗪顯著增加該地區的感受閾值隨時間的曲線值(曲線) 30 60 ,和180分鐘前後。酮基布洛芬和氯胺酮,單獨和組合,產生任何重大影響的AUC值。 NMDA受體僅減少了哥倫比亞聯合自衛軍值為30分鐘前後。這種疼痛被阻止過敏的preadministering酮基布洛芬和氯胺酮單獨和組合。

結論: 在綿羊,酮丙酸的i.t.管理和ketamine,單獨或一起,沒有生產hypoalgesia; 然而,他們防止了NMDA導致的機械過敏症。 酮丙酸和ketamine也許有在情況的治療潛力與堅持痛苦相關。

章一靜譯 薛張綱校

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.


彈性輸注泵用於術後區域麻醉的可靠性:一項對430件設備的調查

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:相比於與術後全身鎮痛,持續神經周圍輸注局麻藥效果更好。相比於電子模型,彈性輸注泵更受病人歡迎。在離體試驗中,按既定的輸注速率,會剩下10%的預輸液。我們選擇了行矯形手術的病人,評估在體使用彈性輸注泵的輸注速率。

方法:所有關於持續使用彈性輸注泵的都是在10個月內的回顧性研究。術前在神經周圍留置導管,術後與裝有0.2%羅派卡因的彈性輸注泵相連。在輸注前,彈性輸注泵和羅派卡因在室溫下保存。隨機使用兩種型號的泵:InfusorTM LV5 (Baxter, France) EasypumpTM (Braun, Germany),都設為5 mL/h。護士在床旁使用攜帶型電子稱對輸注泵稱重,直到導管被拿走。按時間測定重量可以用來判斷輸注泵體積縮小量的準確性和計算輸注速率。重量不變提示導管阻塞或輸注泵失效。

結果:連接導管後,88個設備沒有縮小(300 Easypump中有80個,130 Infusor中占8, P < 0.0001)。一個Easypump即使不連接導管也不能縮小。有兩例導管阻塞。在21例中,導管在1172小時沒有開放即被拔除。24例泵在經導管很順利在加了負荷劑量後縮小。剩下的40例裝置在連接後643小時後自行縮小。這88個彈性輸注泵術後第一天的最大直觀類比刻度高於裝置連接後可顯示的縮小量(34 ± 21 mm vs 26 ± 19 mm, P = 0.006)。分別在平均使用週期54 ± 18 h (Easypump)49 ± 19 h (Infusor)測定流速。 流速為5 mL/h ± 15%EasypumpInfusord分別占47% 34% (P = 0.01)

結論:彈性泵在活體的可靠性和離體的不同。術後使用周圍神經鎮痛早期,彈性輸注泵不縮小應引起重視。我們建議在開始24h內內每三個小時對鎮痛泵稱重。

(陳珺珺譯 薛張綱校)

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.


抑肽酶和氨甲環酸在心臟手術中的危險性: 一項 1188 例連續的病人隨訪一年的研究

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: 我們的目標是在非選擇性、連續的人群中調查比較使用抑肽酶及氨甲環酸的術後併發症及病死率。

方法: 2005 年九月和 2006 年六月之間,前瞻性地收集一家大學附屬醫院的連續行心臟手術病人的圍術期資料(n=1188)。在最初 5 個月期間, 596位病人接受抑肽酶(A);在後續的5個月中, 592位病人接受氨甲環酸治療(T) 。除了抗纖溶治療以外、麻醉和手術的方案保持不變。

結果:術前和術中參數兩個治療組相似。術後T組驚厥的發生率明顯較高(4.6% 相對 1.2%, P<0.001)。這個差異在第一次換瓣手術和高危手術亞組中也是很明顯的(分別為7.9% 相對 1.2%, P=0.003; 7.3% 相對 2.4%, P=0.035)。在第一次換瓣手術亞組中持續的房顫(7.9% 相對 2.3%, P=0.020)和腎衰(9.7% 相對 1.7%, P=0.002)也是在T組更常見。相反,對於第一次冠狀動脈搭橋手術病人,A組病人急性心肌梗塞和腎功能障礙更多見(分別為5.8% 相對 2.0%, P=0.027; 22.5% 相對 15.2%, P=0.036)。在高危手術組接受抑肽酶治療之後一年的病死率明顯較高(17.7% 相對 9.8%, P=0.034)

結論: 抗纖溶及抑肽酶產生的副作用依賴於心臟手術的類型。使用抑肽酶應該避免冠狀動脈搭橋和高度危險病人, 氨甲環酸不推薦在瓣膜手術中使用。

(裘毅敏譯,馬皓琳 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.



氙引起體內延遲性心臟預處理:環氧合酶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:氙引起大鼠體內早期心肌預處理,但是否能引起延遲性心肌保護尚屬未知。已有研究顯示環氧合酶2COX-2)是心肌缺血延遲性預處理(i-LPC)的信號傳導中一個重要的介質。我們探討氙是否引起延遲性預處理(Xe-LPC)以及COX-2的活性和/表達是否與此介導作用有關。

方法:雄性Wistar大鼠麻醉後置入冠狀動脈封堵器。經過7天恢復後,大鼠被隨機分為5組,每組8只。i-LPC組接受5min的冠脈阻斷引起i-LPC。通過給予氙(70v%15min進行Xe-LPC。其他大鼠用COX-2抑制劑NS-398 (5 mg kg–1 體重i.p.)加和不加Xe-LPC。一組只進行手術而不行i-LPC Xe-LPC作為對照(Con)。24h之後,所有大鼠麻醉後接受25min由收緊冠脈封堵器造成的心肌缺血,之後予2h再灌注。用氯三苯四唑染色評定心肌梗死面積。在另外的實驗中,分別於預處理後不同時點採集心臟標本,通過聚合酶鏈反應和紅外蛋白質印跡分別測定COX-2mRNA和蛋白表達。

結果:Con相比,i-LPC Xe-LPC均減少了心肌梗死面積(占受危區域的%)(i-LPC 29 ± 7%Xe-LPC 31 ± 8%,均P < 0.05 vs Con 64 ± 6%)。COX-2mRNA和蛋白表達僅在i-LPC組中增加,而未見於Xe-LPC組。

結論:氙引起延遲性的心肌預處理,此作用被COX-2活性的功能性阻斷所取消。與i-LPC相反,Xe-LPC不引起COX-2mRNA和蛋白表達的增加。這些資料提示在i-LPC Xe-LPC COX-2的調節是不同的。

(黃施偉 譯,馬皓琳 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.



兒童心臟手術術前重要的電解質紊亂與心臟藥物並無關聯

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:擇期手術患者術前實驗室檢查幾十年來都是常規進行的。儘管有大量文獻提到對成年患者適當的術前評估,但是與兒童相關的文獻並沒有詳細的說明。患有心臟疾病的兒童及年輕成人是在進行大量術前實驗室檢查的人群中特別容易受刺激的群體。我們檢查患有心臟疾病行門診手術的兒童血清中的化學成分。研究的目的是說明在兒童和年輕成人這個人群中術前電解質測定的效果。

方法:200111日到2003131日期間所有經門診入院接受三級護理,在獨立的兒童醫院進行擇期心臟手術的兒童患者進行回顧性病歷回顧。核對所有入選日期和心臟手術日期相符的患者的病歷。如果術前實驗室檢查不在我們的設備上完成,或沒有進行術前實驗室檢查,或患者是被轉送到我們醫院的,這些患者將被排除在外。患者根據3種方法分組:心臟治療的數目(04),心臟藥物治療,無心臟藥物治療和無藥物治療。在應用不同藥理作用的心臟藥物的情況下檢查有無電解質紊亂。主要的評測結果是服用不同心臟藥物的兒童中實驗室檢查異常的發生率。

結果:找到933個初始的病歷,其中774個符合觀察標準的被納入分析。儘管用或不用心臟藥物與術前電解質相關是有統計學差異的,但其中的相關性並無臨床價值。資料表明整個研究人群中低鉀和低鎂血症的發生率很低。

結論:兒童和年輕成人做心臟手術前電解質紊亂是很少見的。在成人中服用心臟藥物所顧及的低鉀或低鎂血症在兒童中並不確定。這些資料不支援在服用心臟藥物的兒童中常規需要進行術前電解質評估。

(朱 慧譯 馬皓琳 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.




肥胖會適當地影響人吸入麻醉劑的動力學特性

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:幾乎沒有研究已經證實了肥胖對吸入麻醉劑的藥代動力學有影響。我們假設強效吸入麻醉劑在脂肪組織中的可溶性與肥胖患者的BMI指數增加兩者之間起相互作用從而增加了吸入麻醉劑的攝入,降低了吸入麻醉劑傳送(FD)和吸入(FI)濃度足以達到不變的維持肺泡濃度(呼氣末或FA)的速度。這個假設提示了肥胖對可溶性較大的異氟醚的影響相較地氟醚而言更大。

方法: 107ASA分級為I-III級的病人,用丙泊酚麻醉誘導,用神經肌肉阻滯劑便於氣管插管,用含50%的笑氣的氧氣控制呼吸使得呼氣末二氧化碳濃度維持在35-45mmHg。在1L/min的流量中以FD濃度給予異氟醚或地氟醚,使得FA維持在0.6MAC(分別為0.7%3.7%)。開始給予強效吸入麻醉劑後51020406090120150180分鐘我們測定FDFIFA

結果:59位病人接受了異氟醚,48位病人接受了地氟醚。BMI範圍在18-63 kg/m2,兩組病人的人口統計變異值沒有差異。異氟醚的FD/FA FI/FA9/18個時點與BMI之間有微弱的(但顯著的)相關性,而地氟醚的FD/FA FI/FA只在1個時點與BMI顯著相關(P < 0.01)。將每組病人區分成肥胖(BMI30)和非肥胖病人(BMI<30)後,異氟醚在肥胖病人中有4個時點FD/FA FI/FA比較高,而地氟醚在兩種病人中沒有差別。接受異氟醚的病人在中止麻醉後需要更長時間來對命令做出反應,但是肥胖對接受異氟醚或地氟醚後的蘇醒時間沒有影響。用BMI標準化FI/FA FD/FA時,異氟醚的中位數值始終超過地氟醚的中位數值,係數範圍從35,其值和它們的血/氣分配係數(3.1)、肌肉/氣分配係數(4.6)和脂肪/氣分配係數(5.4)相當。

結論:BMI適當影響了FD/FAFI/FA,對於在所有組織中的可溶性都較大的麻醉劑其影響因素最明顯。BMI的增大提高了麻醉劑的攝入,因此也提高了為了維持在一個恒定的肺泡麻醉劑濃度所需要傳送的麻醉劑,對於可溶性比較大的麻醉劑而言尤其明顯。但是體重增加時這種提高作用較小。

(姜旭暉譯,馬皓琳,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.



丙泊酚預處理大鼠可減少神經酰胺產量及腸道缺血再灌注所致腸粘膜細胞凋亡

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,細胞凋亡是腸道缺血再灌注(II/R)所致腸上皮細胞死亡的一種主要方式。缺血再灌注往往與氧化性應激增加有關。有人提出神經酰胺是細胞凋亡信號調控中的一個信使。我們試圖研究給予具有抗氧化性質的丙泊酚作預處理是否能降低神經酰胺的產量,因而減少II/R所致的腸上皮細胞凋亡。

方法:鉗夾大鼠腸系膜上動脈1 h後再灌注3 h建立II/R損傷模型。30只大鼠隨機分為對照組、損傷組(II/R)、丙泊酚(預處理)組(每組n = 10)。缺血前30min,丙泊酚組給予丙泊酚50 mg/kg腹腔注射,使得大鼠對疼痛刺激反射性反應消失而依然對切皮敏感。其他兩組則給予等量的脂肪乳注射液腹腔注射。採用電子顯微鏡和TUNEL分析法檢測腸粘膜上皮細胞凋亡水平,用比色分析法評估脂質氧化產物丙二醛及超氧化物歧化酶活性。分別採用高分產薄層層析法和逆轉錄聚合酶鏈反應(RT-PCR)測定腸粘膜神經酰胺產量和鞘磷酯酶mRNA表達水平。

結果:II/R誘導腸粘膜上皮細胞凋亡和神經酰胺過量產生,同時上調鞘磷酯酶mRNA的表達和增加脂質氧化(與對照組相比 P < 0.01 )。丙泊酚預處理則明顯減少這些變化(丙泊酚組與損傷組相比,P < 0.01)。

結論:本研究表明,丙泊酚預處理能減少II/R所致腸上皮細胞凋亡,這可能與丙泊酚調節神經酰胺通路的抗氧化性質有關。

(江繼宏   馬皓琳 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.



田野麻醉機中氣動控制呼吸機的氧耗

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:田野麻醉機(FAM)已被開發出用於壓縮醫用氣體或電流的可靠供應缺乏的偏僻地方。在電流、氣動控制呼吸機用壓縮氣體代替電流來為定時電路供能和開動氣閥。我們試圖測定一種FAM式氣動控制呼吸機在高(HC)和低(LC)總胸廓順應性的機械模式下的總氧耗和呼吸機氣體的消耗(驅動氣體 [DG] 加上氣動控制氣體[PC])。

方法:用理想氣體定律和從E量筒測量的氧耗質量來計算帶氣動控制呼吸機的Magellan-2200 (Oceanic Medical Products, Atchison, 堪薩斯州) FAM的總氧耗量。用Wright Respirometer Mk 8 (Ferraris Respiratory Europe, Hertford, 英國)測定到達風箱罐裝置的DG。用E量筒的總氧氣量扣除DG和新鮮氣流(FGF)計算PC氣體消耗。用呼吸速度描記圖(Hans Rudolph, KS City, 密蘇里州) 測定傳送的潮氣量(VT)。用通氣輔助訓練測試肺模型(MI Instruments, Grand Rapids, 密西根州)測試兩種肺模型(HC LC)時的三種不同的VT5007501000 mL)。呼吸變數包括:吸呼比1:2,新鮮氣流 1 L/min,呼吸頻率10 /min

結果:氧耗總量和潮氣量呈正比,和順應性呈反比。最小氧耗速度(包括 FGF)HC-500 模式下的9.3 ± 0.4 L/min,而最大則是 LC-1000 模式下的15.9 ± 0.5 L/min (P < 0.001)。平均PC電路消耗是3.9 ± 0.24 L/min或每次呼吸390 mL ± 24 mL

結論:考慮到中心DG供應的損耗,總胸廓順應性低時估計量筒持續時間將提高患者的安全性。用從較小順應性和最大潮氣量模型(LC-1000)得到的資料,一個充滿氧氣的E 量筒會在<42 min內耗盡,而一個裝滿的H 量筒大約可持續433 min.

(唐李雋 譯 馬皓琳 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.



退伍軍人事務局醫院手術當天病人意外死亡的相關因素分析

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分級為13級的病人進行擇期手術,由於他們自身沒有潛在的對生命構成持續威脅的疾病,因此手術當天他們死亡的風險不應當看得過高。

方法:我們回顧了美國退伍軍人事務局全國外科質量提高計畫資料庫裏的815,077ASA分級為13級的擇期手術病人,以便找出手術當天死亡的病例。然後我們鑒別出可以預示意外死亡的因素以及我們在醫療中潛在的可以改進的地方。同時我們對其中一部分病例的麻醉記錄單逐一回顧,以便可以找到麻醉管理中可以改進的地方。

結果:在調查的全部病人中,有0.08% 死於手術當天。多變數回歸分析顯示,最能預測手術當天死亡的因素是手術的類型,其中主動脈手術的優勢比為13.67 (95% CI 9.76–19.17)。用同樣的方法鑒別出其他因素,這些因素包括低蛋白血症、呼吸困難以及膽紅素或者肌酐的升高。對死亡病例中的88例病歷回顧發現其中13例的麻醉管理還可以有改進。我們估計有大約1/13,900的病例,如果改進麻醉,死亡本可以避免。心肌梗塞和出血是常見的可以鑒別出的因素。一個意料之外的因素是,許多死亡發生在從手術結束到把病人最終轉送到復蘇室之間的這段時間內。

結論:我們認為雖然手術當天絕大多數的死亡是由病人和手術因素所引起的,但是麻醉管理的改進對降低此類死亡的發生還是存有一定空間的。

(吳進   馬皓琳 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.



嚴重膿毒症對日常健康相關的生活質量的影響:一項長期隨訪研究

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:嚴重的膿毒症常常併發器官衰竭和伴隨著高死亡率。從嚴重的膿毒症中倖免生存下來的患者的日常健康相關生活質量(HRQOL)受到影響。嚴重膿毒症存活患者的HRQOL在轉出重症監護室(ICU)後和在普通病房中的變化時程還沒有進行過研究。

方法:我們在內科-外科ICU中進行了長期的前瞻性研究。有嚴重的膿毒症併入住ICU>48小時的患者(n=170)被納入此研究。我們使用簡表36來評估嚴重膿毒症患者入ICU之前和住院前以及在轉出ICU3個月和6個月時的HRQOL。此外,還進行對ICU收入後的結果和轉出ICU6個月的結果與年齡相一致的普通荷蘭人群的HRQOL結果的比較。

結果:在轉出ICU6個月,95例患者不能評估(8例失去隨訪,67例死亡)。HRQOL顯示出在ICU入住期間有多方面的減退,在轉出ICU6個月中在社會功能、活力、角色-情緒和心理健康方面逐漸改善。然而,在出ICU6個月的軀體活動功能及角色-體格、一般健康方面仍然顯著低於住院前的值。這段時間裏面軀體和精神方面的分數有著顯著的變化。特別是精神方面的分數在轉出ICU時有一些下降,但迅速恢復,轉出ICU6個月時恢復至接近正常值。另外,簡表36得分在膿毒症患者中8方面中除了社會功能和身體疼痛以外的其他6個方面都低於對應的一般人群。有趣的是在存活下來的患者中,他們在入住ICU8個方面中就有3個(角色-體格、心理健康和活力)已經低於一般人群。

討論:重度膿毒症患者在入住ICU期間HRQOL急劇下降,在轉出ICU後的6個月中逐漸恢復。恢復從轉出ICU到普通病房後開始。然而,去入住ICU前情況比較,在軀體活動功能及角色-體格、一般健康方面是恢復不完全的

(唐亮   馬皓琳 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.



丙泊酚預處理減弱大鼠短暫的局部腦缺血再灌注後水通道蛋白-4過度表達並減輕腦水腫

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:腦水腫對中風患者是主要的威脅。大多數研究關注丙泊酚對梗塞範圍而不是腦水腫方面的神經保護活性。在各種神經損傷中,水通道蛋白-4(AQP4)在維持腦內水平衡起著重要作用。我們觀察丙泊酚預處理對大鼠腦缺血再灌注模型腦水腫的效應,並評價AQP4的參與作用。

方法:為誘發腦缺血再灌注,我們把塗上矽膠的單絲尼龍縫線引到大腦中動脈起端,90分鐘後退出縫線。治療組(n=32)阻斷前靜脈輸注丙泊酚(0.1mL·kg-1·min-1) 30分鐘;溶媒組(n=32)和假手術組(n=28)在阻斷前以同樣的速度靜脈輸注英脫利匹特溶媒。我們使用2,3,5-三苯基四唑氯化物染色來評估腦梗塞範圍;濕-幹重比例是估算腦水腫的基礎,並且使用免疫組化和蛋白質印跡方法來檢測AQP4表達。

結果:濕-幹重比例在溶媒組(n = 6)86.89% ± 0.71%,而在丙泊酚組(n = 6)減少到72.42% ± 0.74%,相應地平均減少16%。使用免疫組化半定量方法觀察到,丙泊酚組較溶媒組顯著減弱缺血邊緣區AQP4過度表達:1.28 ± 0.03 vs 1.40 ± 0.05, n = 7, P < 0.05。來自蛋白質印跡定量的值,丙泊酚組與溶媒組相似地減少:20.85% ± 4.18% vs 31.67% ± 3.23%, n = 4, P < 0.05。然而,缺血後大鼠丙泊酚組梗塞範圍和神經功能欠缺與溶媒組沒有統計學差異。

結論:我們得出如下結論:中風前丙泊酚處理減少大鼠缺血後腦水腫,可能通過抑制缺血邊緣區AQP4過度表達。

(王宏 馬皓琳 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.



氯胺酮和氯諾昔康用於預防芬太尼引起的術後嗎啡用量增加

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-天門冬氨酸受體拮抗劑和非甾體類抗炎藥被認為可以預防阿片類誘導的痛覺過敏和/或急性阿片類耐受,後者可以導致術後阿片藥物需要量的增加。在這項隨機、雙盲、安慰劑對照的試驗中,我們研究了氯胺酮或氯諾昔康與芬太尼合用是否可以預防由單純芬太尼引起的術後嗎啡需要量的增加。

方法:90位在脊麻下行腹式全子宮切除術的女性患者隨機分為六組,分別為:安慰劑組(生理鹽水,C),芬太尼組(注射三次,每次1 µg·kg1F),氯胺酮組(15 µg·kg1·min1持續輸注,K),氯胺酮複合芬太尼組(15 µg·kg1·min1 氯胺酮持續輸注,同時注射三次芬太尼,每次1 µg·kg1FK),氯諾昔康組(單次注射8mgL),氯諾昔康複合芬太尼組(單次注射8mg氯諾昔康,同時注射三次芬太尼,每次1 µg·kg1FL)。記錄術後136122448 h嗎啡總用量、疼痛評分和副作用。

結果:術後3612h F組嗎啡用量比C組顯著增加(P < 0.05)。術後嗎啡用量在CKFKLFL組之間基本相同,各組間術後疼痛評分也無顯著性差異。與C組相比,K組和FK組中有更多的患者在術中和/或術後存在幻覺(P < 0.05)

結論:我們的資料顯示,術中應用芬太尼所引起的術後嗎啡用量增加可以被氯胺酮或氯諾昔康所預防。

(黃佳佳譯,馬皓琳 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.



腹橫肌平面阻滯為行腹式全子宮切除術的病人提供有效的術後鎮痛

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:行腹式全子宮切除術的病人術後有明顯的疼痛。腹橫肌平面阻滯近來被描述為前腹壁提供鎮痛的一個途徑。我們在一個隨機、對照、雙盲的臨床試驗中,評價了經由下腹壁橫切口行腹式全子宮切除術的病人腹橫肌平面阻滯的鎮痛效能。

方法:50名行擇期腹式全子宮切除術的女性病人隨機分入兩組。一組為用羅呱卡因行腹橫肌平面阻滯組(n=24),一組為安慰劑組(n=26)。另外,病人還行標準的術後鎮痛,包括病人自控靜脈輸注嗎啡鎮痛及常規的雙氯芬酸和撲熱息痛鎮痛。所有的病人均行全身麻醉,並且在切皮前,用1.5mg/kg的羅呱卡因(最大劑量為150mg)行雙側的腹橫肌平面阻滯或在每一側注入生理鹽水。每一名患者分別在麻醉後恢復室和術後24612243648小時由一名不知分組的觀察者評價術後疼痛程度。

結果:與安慰劑組相比,羅呱卡因腹橫肌平面阻滯降低術後VAS疼痛評分。在術後第一個48小時內,平均的嗎啡需要量也減少(55 ± 17 mg27 ± 20 mg, P < 0.001)。鎮靜的發生率也明顯降低。腹橫肌平面阻滯沒有相關的併發症。

結論:腹橫肌平面阻滯,作為多模式術後鎮痛的一個組成部分,與安慰劑阻滯相比,在手術後48小時裏為行擇期腹式全子宮切除術的病人提供了良好的鎮痛。

(黃麗娜 馬皓琳 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.



利多卡因和蘇芬太尼用於脊麻對下尿道功能的影響

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:脊麻干擾排尿反射;膀胱功能維持受損直到感覺阻滯消退到S3節段。鞘內注射阿片類會引起劑量依賴性的逼尿肌收縮抑制。我們研究利多卡因和蘇芬太尼聯合用於脊麻對於下尿道功能的影響。

方法:對10例行擇期下肢整形外科手術的健康年輕男性患者進行充盈性膀胱測壓。記錄基礎資料後,每個患者接受脊麻,用重比重利多卡因100 mg20 µg蘇芬太尼。在術後階段,記錄感覺和運動阻滯的消退,持續測定尿動力直到患者能自行排空,而無殘餘尿。

結果:脊麻後尿意恢復的平均時間是 240 (37)分鐘,但沒有患者能在那時排空。6例患者當感覺阻滯消退到S2節段時,能在膀胱容量達到最大時有尿意,其他4例患者感覺阻滯消退到S3。儘管有尿意,但沒有逼尿肌收縮。在脊麻後332 (52)  min患者能完全排空膀胱。恢復尿意和膀胱正常排空的平均間隔時間90分鐘。

結論:當重比重利多卡因和蘇芬太尼聯合用於脊麻,膀胱收縮恢復遠遠晚於S3節段感覺功能的恢復。

(彭中美 馬皓琳 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.