Anesthesia & Analgesia

January 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

经心外超声心动图使用连续性方程监测主动脉瓣区的可行性

裘毅敏译,马皓琳 李士通校

The Feasibility of Epicardial Echocardiography for Measuring Aortic Valve Area by the Continuity Equation

Jan N. Hilberath, Stanton K. Shernan, Scott Segal, Brian Smith, and Holger K. Eltzschig

Anesth Analg 2009 108: 17-22.

在兔子鞘膜内进行吗啡预处理可以通过激活δκμ阿片类受体产生心脏保护

胡艳译  薛张纲校

Intrathecal Morphine Preconditioning Induces Cardioprotection via Activation of Delta, Kappa, and Mu Opioid Receptors in Rats

Rui Li, Gordon T. C. Wong, Tak Ming Wong, Ye Zhang, Zhengyuan Xia, and Michael G. Irwin

Anesth Analg 2009 108: 23-29. itioning. This finding might have implications for when neuroaxial analgesia is planned perioperatively for patients with coronary artery disease.

迅速降解的羟乙基淀粉溶液损害心脏手术后的凝血功能:一项前瞻性随机试验
陈伟 译 陈杰 校
Rapidly Degradable Hydroxyethyl Starch Solutions Impair Blood Coagulation After Cardiac Surgery: A Prospective Randomized Trial

Alexey A. Schramko, Raili T. Suojaranta-Ylinen, Anne H. Kuitunen, Sinikka I. Kukkonen, and Tomi T. Niemi

Anesth Analg 2009 108: 30-36.

术中多普勒组织成像对心脏麻醉医师的医疗设备而言是一项有价值的补充:一项核心回顾

唐李隽 译  马皓琳  李士通 校

Intraoperative Doppler Tissue Imaging Is a Valuable Addition to Cardiac Anesthesiologists’ Armamentarium: A Core Review (Review Article)

Nikolaos Skubas

Anesth Analg 2009 108: 48-66.

PEDIATRIC ANESTHESIOLOGY:

外伤性脑损伤儿童围术期高血糖发生率及危险因子

黄凝译  薛张纲校

Incidence and Risk Factors for Perioperative Hyperglycemia in Children with Traumatic Brain Injury

Deepak Sharma, Jill Jelacic, Rohini Chennuri, Onuma Chaiwat, Wayne Chandler, and Monica S. Vavilala

Anesth Analg 2009 108: 81-89.

新生期接触异氟醚对小鼠脑细胞生存、成年后行为、学习和记忆的影响

周雅春 马皓琳 李士通

The Effects of Neonatal Isoflurane Exposure in Mice on Brain Cell Viability, Adult Behavior, Learning, and Memory

新生小鼠接触异氟谜对脑细胞成活力、成年期行为、学习和记忆的影响

张燕 陈杰

Andreas W. Loepke, George K. Istaphanous, John J. McAuliffe, III, Lili Miles, Elizabeth A. Hughes, John C. McCann, Kathryn E. Harlow, C. Dean Kurth, Michael T. Williams, Charles V. Vorhees, and Steve C. Danzer

Anesth Analg 2009 108: 90-104.

 

亚专业影响因子:儿科麻醉与疼痛文献的贡献

蒋宗明译  薛张纲校

Subspecialty Impact Factors: The Contribution of Pediatric Anesthesia and Pain Articles

Robert Ramsdell, Jerrold Lerman, Donald Pickhardt, Doron Feldman, James Foster, and Timothy T. Houle

Anesth Analg 2009 108: 105-110.

AMBULATORY ANESTHESIOLOGY:

三个声门上气道装置应用中头颈位置对口咽漏气压力和套囊位置的影响

王腾 译 陈杰 校

The Influence of Head and Neck Position on the Oropharyngeal Leak Pressure and Cuff Position of Three Supraglottic Airway Devices

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

Anesth Analg 2009 108: 112-117. ition use of the laryngeal tube section and Cobra perilaryngeal airway resulted in an increased incidence of gastric insufflation and difficulty in ventilation.

ANESTHETIC PHARMACOLOGY:

减脂手术中肺泡复原和动脉地氟烷浓度

张曦 译,马皓琳 李士通 校

Alveolar Recruitment and Arterial Desflurane Concentration During Bariatric Surgery

Juraj Sprung, Francis X. Whalen, Thomas Comfere, Zeljko J. Bosnjak, Zeljko Bajzer, Ognjen Gajic, Michael G. Sarr, Darrell R. Schroeder, Lavonne M. Liedl, Chetan P. Offord, and David O. Warner

Anesth Analg 2009 108: 120-127.

在动静脉中乳酸林格氏液血浆稀释及分布动力学的差异

刘婷洁译 薛张纲校

Arteriovenous Differences in Plasma Dilution and the Distribution Kinetics of Lactated Ringer's Solution

乳酸林格式液在血浆中稀释度的动静脉差别及分布动力学

刘沁译 薛张纲校

Arteriovenous Differences in Plasma Dilution and the Distribution Kinetics of Lactated Ringer's Solution

Christer H. Svensen, Peter M. Rodhe, Joel Olsson, Elisabet Børsheim, Asle Aarsland, and Robert G. Hahn

Anesth Analg 2009 108: 128-133.

烟碱受体部分介导了吸入麻醉药异氟醚诱发的脑干自主神经失功

刘世文 译 陈杰 校

Nicotinic Receptors Partly Mediate Brainstem Autonomic Dysfunction Evoked by the Inhaled Anesthetic Isoflurane

Xin Wang

Anesth Analg 2009 108: 134-141. nic receptors. These mechanisms may contribute to cardiorespiratory homeostatic autonomic regulation impairment induced by isoflurane.

丙泊酚和异氟烷增强疑核心脏迷走神经元张力型γ-氨基丁酸A型电流

黄施伟 译,马皓琳 李士通 校

Propofol and Isoflurane Enhancement of Tonic Gamma-Aminobutyric Acid Type A Current in Cardiac Vagal Neurons in the Nucleus Ambiguus

Xin Wang

Anesth Analg 2009 108: 142-148.

依托咪酯作用于下丘脑-皮质系统GABA能神经的模型

叶乐 译 陈杰 校

Modeling the Gabaergic Action of Etomidate on the Thalamocortical System

Jason A. Talavera, Steven K. Esser, Florin Amzica, Sean Hill, and Joseph F. Antognini

Anesth Analg 2009 108: 160-167.

挥发性芳香族麻醉剂对N-甲基-d-天冬氨酸受体的抑制和制动作用的分子基础的比较

颜涛 译, 马皓琳 李士通 校

A Comparison of the Molecular Bases for N-Methyl-d-Aspartate-Receptor Inhibition Versus Immobilizing Activities of Volatile Aromatic Anesthetics

Jason C. Sewell, Douglas E. Raines, Edmond I. Eger, II, Michael J. Laster, and John W. Sear

Anesth Analg 2009 108: 168-175.

异氟醚耐受不发生于发育中的光滑爪蟾蝌蚪

秦敏菊译 薛张纲校

Tolerance to Isoflurane Does Not Occur in Developing Xenopus laevis Tadpoles

Pavle S. Milutinovic, Jing Zhao, and James M. Sonner

Anesth Analg 2009 108: 176-180.

TECHNOLOGY, COMPUTING, AND SIMULATION:

术中磁共振成像设备的电噪声

王宏译,马皓琳、李士通校

Electrical Noise in the Intraoperative Magnetic Resonance Imaging Setting

Roger Dzwonczyk, Jeffrey T. Fujii, Orlando Simonetti, Ricardo Nieves-Ramos, and Sergio D. Bergese

Anesth Analg 2009 108: 181-186.

可视喉镜插管对上切牙的作用力评估

施颖译  薛张纲校

Forces Applied to the Maxillary Incisors During Video-Assisted Intubation

Ruben A. Lee, André A. J. van Zundert, Ralph L. J. G. Maassen, Remi J. Willems, Leon P. Beeke, Jan N. Schaaper, Johan van Dobbelsteen, and Peter A. Wieringa

Anesth Analg 2009 108: 187-191.

如何评定充气式保温系统疗效?模拟人上半身应用的评价

张磊 译 陈杰 校

What Determines the Efficacy of Forced-Air Warming Systems? A Manikin Evaluation with Upper Body Blankets

Anselm Bräuer, Henning Bovenschulte, Thorsten Perl, Wolfgang Zink, Michael John Murray English, and Michael Quintel

Anesth Analg 2009 108: 192-198.

PATIENT SAFETY:

引介先进术中方案的新颖程序:一种减轻危害和促进病人安全的多学科规范

江继宏 译  马皓琳 李士通 校

A Novel Process for Introducing a New Intraoperative Program: A Multidisciplinary Paradigm for Mitigating Hazards and Improving Patient Safety (Special Article)

Jose M. Rodriguez-Paz, Lynette J. Mark, Kurt R. Herzer, James D. Michelson, Kelly L. Grogan, Joseph Herman, David Hunt, Linda Wardlow, Elwood P. Armour, and Peter J. Pronovost

Anesth Analg 2009 108: 202-210..

新的FDA药品说明书:旨在患者安全和临床护理

孙鹏飞译 薛张刚校

The New Food and Drug Administration Drug Package Insert: Implications for Patient Safety and Clinical Care (Review Article)

Kelley Teed Watson and Paul G. Barash

Anesth Analg 2009 108: 211-218.

CRITICAL CARE AND TRAUMA:

内皮素-1对大鼠肺泡液体清除率和肺水肿形成的影响

丁俊云 译 陈杰 校

The Effect of Endothelin-1 on Alveolar Fluid Clearance and Pulmonary Edema Formation in the Rat

Marc Moritz Berger, C. Sjula Rozendal, Carolin Schieber, Martin Dehler, Stefanie Zügel, Hubert J. Bardenheuer, Peter Bärtsch, and Heimo Mairbäurl Anesth

Analg 2009 108: 225-231. aed, e.g., in acute respiratory distress syndrome and at high-altitude.

急性间质性肺炎(Hamman-Rich综合征)的临床表现和诊断治疗

朱 慧译 马皓琳 李士通校

Acute Interstitial Pneumonia–Hamman-Rich Syndrome: Clinical Characteristics and Diagnostic and Therapeutic Considerations

Lone S. Avnon, Oleg Pikovsky, Neta Sion-Vardy, and Yaniv Almog

Anesth Analg 2009 108: 232-237.

OBSTETRIC ANESTHESIOLOGY:

剖宫产手术中比较单次注射腰麻和腰硬联合麻醉技术向头端感觉阻滞的最大程度的一项随机试验

宣丽真译 薛张纲校

A Randomized Trial of Maximum Cephalad Sensory Blockade with Single-Shot Spinal Compared with Combined Spinal-Epidural Techniques for Cesarean Delivery

Damian J. Horstman, Edward T. Riley, and Brendan Carvalho

Anesth Analg 2009 108: 240-245.

一项关于腰-硬联合和硬膜外用于经产妇分娩镇痛的随机研究

舒慧刚 陈杰

A Randomized Trial of Breakthrough Pain During Combined Spinal-Epidural Versus Epidural Labor Analgesia in Parous Women

Stephanie R. Goodman, Richard M. Smiley, Maria A. Negron, Paula A. Freedman, and Ruth Landau

Anesth Analg 2009 108: 246-251.

分娩硬膜外镇痛用于产时剖宫产失败:一项回顾性研究

黄佳佳译,马皓琳 李士通校

Failure of Augmentation of Labor Epidural Analgesia for Intrapartum Cesarean Delivery: A Retrospective Review (Brief Report)

Shuying Lee, Eileen Lew, Yvonne Lim, and Alex T. Sia

Anesth Analg 2009 108: 252-254.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

用于模拟困难气道气管插管的气道镜和探针镜

夏俊明译 薛张纲校

Airway Scope and StyletScope for Tracheal Intubation in a Simulated Difficult Airway

Ryu Komatsu, Kotoe Kamata, Keiko Hamada, Daniel I. Sessler, and Makoto Ozaki

Anesth Analg 2009 108: 273-279.

体内缺乏β2-肾上腺素能受体的小鼠脑缺血后脑损伤减少

赵嫣红 译 陈杰 校

Postischemic Brain Injury Is Attenuated in Mice Lacking the β2-Adrenergic Receptor

Ru-Quan Han, Yi-Bing Ouyang, Lijun Xu, Rani Agrawal, Andrew J. Patterson, and Rona G. Giffard

Anesth Analg 2009 108: 280-287.

β肾上腺素受体拮抗剂对大鼠蛛网膜下腔出血后促炎细胞因子浓度的影响

张莹译  马皓琳 李士通校

The Effects of β-Adrenoceptor Antagonists on Proinflammatory Cytokine Concentrations After Subarachnoid Hemorrhage in Rats

Haruto Kato, Masahiko Kawaguchi, Satoki Inoue, Katsuji Hirai, and Hitoshi Furuya

Anesth Analg 2009 108: 288-295.

ANALGESIA:

环氧化酶-2选择性抑制剂帕瑞考昔和伐地考昔应用于术后,在心血管方面的安全性:整合数据的分析

章一静译 薛张纲校

Cardiovascular Safety of the Cyclooxygenase-2 Selective Inhibitors Parecoxib and Valdecoxib in the Postoperative Setting: An Analysis of Integrated Data

Stephan A. Schug, Girish P. Joshi, Frederic Camu, Sharon Pan, and Raymond Cheung

Anesth Analg 2009 108: 299-307.

吸烟状态对于慢性疼痛患者戒除阿片类药物的影响

周姝婧 译 陈杰 校

The Effects of Smoking Status on Opioid Tapering Among Patients with Chronic Pain

W. Michael Hooten, Cynthia O. Townsend, Barbara K. Bruce, and David O. Warner

Anesth Analg 2009 108: 308-315.

髂腹股沟-髂腹下神经和肋间神经联合阻滞对肾移植受体术后缓解疼痛的效果

唐亮 译  马皓琳 李士通 校

The Efficacy of Ilioinguinal-Iliohypogastric and Intercostal Nerve Co-Blockade for Postoperative Pain Relief in Kidney Recipients (Brief Report)

Gita Shoeibi, Babak Babakhani, and Sussan Soltani Mohammadi

Anesth Analg 2009 108: 330-333.

静脉注射利多卡因后,分别在脊髓前脚给予无害和急性伤害刺激后大脑的激活作用:在试验鼠上的功能核磁共振成像研究

陈珺珺译 薛张纲校

The Effect of Intravenous Lidocaine on Brain Activation During Non-Noxious and Acute Noxious Stimulation of the Forepaw: A Functional Magnetic Resonance Imaging Study in the Rat

Zhongchi Luo, Mei Yu, S. David Smith, Mary Kritzer, Congwu Du, Yu Ma, Nora D. Volkow, Peter S. Glass, and Helene Benveniste

Anesth Analg 2009 108: 334-344.

局麻药浓度和剂量对持续锁骨下神经阻滞效果的影响:一项多中心、随机、隐蔽观察、对照研究

怀晓蓉 陈杰

The Effects of Local Anesthetic Concentration and Dose on Continuous Infraclavicular Nerve Blocks: A Multicenter, Randomized, Observer-Masked, Controlled Study

Brian M. Ilfeld, Linda T. Le, Joanne Ramjohn, Vanessa J. Loland, Anupama N. Wadhwa, J. C. Gerancher, Elizabeth M. Renehan, Daniel I. Sessler, Jonathan J. Shuster, Douglas W. Theriaque, Rosalita C. Maldonado, Edward R. Mariano, For the PAINfRETM Investigators, and Terese T. Horlocker

Anesth Analg 2009 108: 345-350.

通过对成人手术病人行硬膜外神经刺激联合持续硬膜外镇痛评价硬膜外导管的位置

黄丽娜 译 马皓琳 李士通 校

An Evaluation of the Epidural Catheter Position by Epidural Nerve Stimulation in Conjunction with Continuous Epidural Analgesia in Adult Surgical Patients

Johannes G. Förster, Tomi T. Niemi, Markku T. Salmenperä, Saana Ikonen, and Per H. Rosenberg

Anesth Analg 2009 108: 351-358.

比较改良肌腱内给药和经典腘窝坐骨神经阻滞一项随机研究:

陈珺珺译 薛张纲校

A Randomized Comparison of a Modified Intertendinous and Classic Posterior Approach to Popliteal Sciatic Nerve Block (Brief Report)

Antoun Nader, Mark C. Kendall, Kenneth D. Candido, Hubert Benzon, and Robert J. McCarthy

Anesth Analg 2009 108: 359-363.

手臂外展对锁骨下臂丛神经解剖关系的影响:一项超声研究

朱紫瑜 陈杰

The Influence of Arm Abduction on the Anatomic Relations of Infraclavicular Brachial Plexus: An Ultrasound Study (Brief Report)

Ana Ruíz, Xavier Sala, Xavier Bargalló, Paola Hurtado, Maria Jose Arguis, and Ana Carrera

Anesth Analg 2009 108: 364-366.

曲马多应用于利多卡因腋路法臂丛神经阻滞的辅助用药

姜旭晖 译  马皓琳 李士通 校

Tramadol as an Adjuvant to Lidocaine for Axillary Brachial Plexus Block (Brief Report)

Olfa Kaabachi, Rami Ouezini, Walid Koubaa, Badii Ghrab, Amin Zargouni, and Ahmed Ben Abdelaziz

Anesth Analg 2009 108: 367-370.

 

迅速降解的羟乙基淀粉溶液损害心脏手术后的凝血功能:一项前瞻性随机试验
Rapidly Degradable Hydroxyethyl Starch Solutions Impair Blood Coagulation After Cardiac Surgery: A Prospective Randomized Trial

Alexey A. Schramko, MD, Raili T. Suojaranta-Ylinen, MD, PhD, Anne H. Kuitunen, MD, PhD, Sinikka I. Kukkonen, MD, PhD, and Tomi T. Niemi, MD, PhD

From the Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Meilahti Hospital, Helsinki, Finland.

Anesth Analg 2009 108: 30-36.

背景:羟乙基淀粉溶液(HES)对凝血功能的影响一直受到关注。迅速降解的羟乙基淀粉溶液对血块硬度已显示有较大的影响。由于心脏手术后出血的风险增加,因此作者研究了心脏手术后给予这些类型的羟乙基淀粉是否产生凝血功能变化。
方法:本研究在45例择期接受心脏手术的患者中比较了给予两种新型的迅速降解的羟乙基淀粉溶液与人血白蛋白对凝血功能的影响。入住心脏外科重症监护病房(CICU)后,患者随机接受短时( 70-240分钟)输液羟乙基淀粉溶液15ml/kg6 HES200/0.56 HES130/0.4 )或4 %的人血白蛋白溶液。
结果:在输注两种羟乙基淀粉溶液组的血栓形成描记中,血块生成时间延长且最大血块硬度降低,这种损害在完成研究性输液2小时后血栓形成描记中部分可恢复(使用InTEM ®ExTEM ®凝血激活),血小板对血块最大硬度的影响在所有的研究组中未体现。羟乙基淀粉溶液不会引起纤维蛋白溶解。输注人血白蛋白组在血栓形成描记中无显著变化。研究中胸管引流具有可比性。
结论
:在心脏手术后短时间内输注迅速降解的羟乙基淀粉溶液对纤维蛋白生成和血栓形成描记中血块硬度有削弱作用。在此临床环境中,人血白蛋白不损害止血功能。

(陈伟 译 陈杰 校)

BACKGROUND: There is continuing concern about the effect of hydroxyethyl starch (HES) solutions on blood coagulation. Rapidly degradable HES solutions with more favorable effects on clot strength have therefore been developed. Because the risk of bleeding is increased after cardiopulmonary bypass, we examined whether these types of HES solutions could be administered after cardiac surgery without an alteration of coagulation.

METHODS: Two new rapidly degradable HES solutions were compared with human albumin in 45 patients scheduled for elective primary cardiac surgery. After admission to the cardiac surgical intensive care unit, the patients were allocated in random order to receive either 15 mL/kg of HES solution with low molecular weight and low molar substitution (either 6% HES200/0.5 or 6% HES130/0.4) or 4% human albumin solution as a short-time (70–240 min) infusion.

RESULTS: Clot formation time was prolonged and maximum clot firmness was decreased in thromboelastometry tracings after infusion of both HES solutions. This impairment in thromboelastometry tracings partly recovered (using InTEM® and ExTEM® coagulation activators) at 2 h after the completion of the study infusion. Platelet contribution to maximum clot firmness remained unaffected in all of the study groups. HES did not induce fibrinolysis. No changes in thromboelastometry tracings were observed after human albumin infusion. Chest tube drainage was comparable in the study groups.

CONCLUSIONS: We conclude that a short-time infusion of rapidly degradable HES solutions after cardiac surgery produces impairment in fibrin formation and clot strength in thromboelastometry tracings. In this clinical setting, human albumin does not impair hemostasis.

 

新生小鼠接触异氟谜对脑细胞成活力、成年期行为、学习和记忆的影响

The Effects of Neonatal Isoflurane Exposure in Mice on Brain Cell Viability, Adult Behavior, Learning, and Memory

Andreas W. Loepke, MD, PhD, FAAP*, George K. Istaphanous, MD*, John J. McAuliffe, III, MD, MBA, FAAP*, Lili Miles, MD{dagger}, Elizabeth A. Hughes, BS{ddagger}, John C. McCann, BS{ddagger}, Kathryn E. Harlow, BS{ddagger}, C. Dean Kurth, MD, FAAP*, Michael T. Williams, PhD§, Charles V. Vorhees, PhD§, and Steve C. Danzer, PhD*

From the *Departments of Anesthesia, {dagger}Pathology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio; {ddagger}Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; §Department of Pediatrics, Division of Neurology, Cincinnati Children’s Research Foundation and University of Cincinnati College of Medicine, Cincinnati, Ohio.

Anesth Analg 2009 108: 90-104.

背景:挥发性麻醉剂,如异氟醚,广泛用于婴儿和新生儿。新生大鼠接受异氟醚、咪唑安定,和一氧化二氮之后出现神经退行性变和神经损伤,提高了关于小儿麻醉安全性的关注。新生小鼠,长时接受异氟醚可触发低血糖症,这可能与认知功能受损有关。作者研究了新生小鼠接受异氟醚对血糖,自发活动,以及空间学习和记忆的影响。 
方法: 7日龄小鼠,随机分组接受6小时的1.5 %异氟醚或6小时的室内空气同时注射或不注射葡萄糖或生理盐水。测定动脉血气及血糖。2小时, 18小时,或11周后,用脑切片(用
Fluoro-Jade B, caspase 3, NeuN染色)评估细胞存活率。九周后,用隐藏和简化的平台试验的Morris水迷宫法,评估自发活动能力,空间学习和记忆力。 
结果:与没有麻醉比较,接受异氟醚后早期大脑几个区域凋亡细胞增加。尽管麻醉组有细胞凋亡,成年期麻醉与非麻醉鼠间大脑区域神经元密度无差异。无论新生期是否接受异氟醚,成年期,群体间自主运动及空间学习和记忆力相似。新生小鼠接受异氟醚导致18 %的死亡,以及
动脉血二氧化碳分压和乳酸瞬时增加,碱缺失,血糖水平降低。然而,低血糖症似乎与神经退行性病变无关,因为补充葡萄糖未能阻止神经元的损失。 
结论:新生小鼠长时接受异氟烷导致脑细胞变性增加。但到成人期,未见神经元密度显著减少,自主运动、空间学习及记忆功能也无显著缺失。

(张燕 译 陈杰 校)

BACKGROUND: Volatile anesthetics, such as isoflurane, are widely used in infants and neonates. Neurodegeneration and neurocognitive impairment after exposure to isoflurane, midazolam, and nitrous oxide in neonatal rats have raised concerns regarding the safety of pediatric anesthesia. In neonatal mice, prolonged isoflurane exposure triggers hypoglycemia, which could be responsible for the neurocognitive impairment. We examined the effects of neonatal isoflurane exposure and blood glucose on brain cell viability, spontaneous locomotor activity, as well as spatial learning and memory in mice.

METHODS: Seven-day-old mice were randomly assigned to 6 h of 1.5% isoflurane with or without injections of dextrose or normal saline, or to 6 h of room air without injections (no anesthesia). Arterial blood gases and glucose were measured. After 2 h, 18 h, or 11 wk postexposure, cellular viability was assessed in brain sections stained with Fluoro-Jade B, caspase 3, or NeuN. Nine weeks postexposure, spontaneous locomotor activity was assessed, and spatial learning and memory were evaluated in the Morris water maze using hidden and reduced platform trials.

RESULTS: Apoptotic cellular degeneration increased in several brain regions early after isoflurane exposure, compared with no anesthesia. Despite neonatal cell loss, however, adult neuronal density was unaltered in two brain regions significantly affected by the neonatal degeneration. In adulthood, spontaneous locomotor activity and spatial learning and memory performance were similar in all groups, regardless of neonatal isoflurane exposure. Neonatal isoflurane exposure led to an 18% mortality, and transiently increased Paco2, lactate, and base deficit, and decreased blood glucose levels. However, hypoglycemia did not seem responsible for the neurodegeneration, as dextrose supplementation failed to prevent neuronal loss.

CONCLUSIONS: Prolonged isoflurane exposure in neonatal mice led to increased immediate brain cell degeneration, however, no significant reductions in adult neuronal density or deficits in spontaneous locomotion, spatial learning, or memory function were observed.


 三个声门上气道装置应用中头颈位置对口咽漏气压力和套囊位置的影响

The Influence of Head and Neck Position on the Oropharyngeal Leak Pressure and Cuff Position of Three Supraglottic Airway Devices

Sang-Hyun Park, MD*, Sung-Hee Han, MD, PhD*, Sang-Hwan Do, MD, PhD*, Jung-Won Kim, MD, PhD{dagger}, and Jin-Hee Kim, MD, PhD*

From the *Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam City, Kyeonggi-do, Korea; and {dagger}Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang City, Kyeonggi-do, Korea.

Anesth Analg 2009 108: 112-117.

背景:在使用声门上气道装置时,例如: 喉管吸引(LTS),胃管引流型喉罩(PLMA),Cobra喉周通气道(CobraPLA),口咽漏气压力和套囊位置会随着头颈位置的变化而变化。本研究作者测试了使用上述三种装置时头颈位置改变时口咽漏气压力和套囊位置的变化。

方法:139名择期小型手术患者随机接受使用三种声门上气道装置中的一种。测量以下四种头颈部位置下口咽泄漏压力和套囊位置:自然,前屈45度,后仰45度,右偏45度。同时检测不良反应(如通气困难和胃胀气)。

结果:胃管引流型喉罩(PLMA)漏气压力最低。在头颈后仰体位时为18.5 cm H2O,而喉管(LTS)和喉周通气管(CobraPLA)分别为23.9 cm H2O26.8 cm H2O;(P<0.001)。头颈偏转时胃管引流型喉罩(PLMA)为25.0 cm H2O,喉管(LTS)和喉周通气管(CobraPLA)分别为29.4 cm H2O28.5 cm H2OP<0.005)。使用喉周通气管(CobraPLA)时,45名病人中有37名在口咽装置漏气之前出现胃胀气。在使用喉管(LTS)的病人中有7名颈前屈的病人出现了通气困难,以至于需要使用气管插管。

结论:在头颈位置为后仰和偏转时,使用胃管引流型喉罩(PLMA)比使用口咽泄漏压力喉管(LTS)和喉周通气管(CobraPLA)能显著降低口咽泄漏压力。在使用喉管(LTS)和喉周通气管(CobraPLA)时一定要注意头颈位置,可能会发生通气困难。

(王腾 译 陈杰 校)

BACKGROUND: With supraglottic airway devices, such as the laryngeal tube suction (LTS), ProSeal laryngeal mask airway (PLMA) and Cobra perilaryngeal airway (CobraPLA), oropharyngeal leak pressure or cuff position may vary according to changes in the position of the head and neck. We evaluated oropharyngeal leak pressure and cuff pressure of the PLMA, LTS, and CobraPLA in different head and neck positions.

METHODS: One-hundred-thirty-nine patients (aged 18-70 yr) scheduled for minor surgical procedures were randomly allocated to one of the supraglottic airway devices. Oropharyngeal leak pressure and cuff pressure were evaluated in four head and neck positions: neutral, 45° of flexion, 45° of extension, and 45° of right rotation. Adverse events (i.e., difficulty in ventilation or gastric insufflation) were assessed during the study.

RESULTS: Leak pressures of the PLMA were lowest in the extension (18.5 vs 23.9 and 26.8 cm H2O of LTS and CobraPLA, respectively; P < 0.001) and in the rotation position (25.0 vs 29.4 and 28.5 cm H2O of LTS and CobraPLA, respectively; P < 0.005). With the CobraPLA, gastric insufflations occurred before the oropharyngeal leak in 37 of 45 patients. There were ventilatory difficulties in seven patients with LTS after neck flexion, which required tracheal intubation.

CONCLUSIONS: The PLMA showed significantly lower oropharyngeal leak pressures than did the LTS or CobraPLA in the neck extension and rotation positions. Caution is warranted when changing the position of the head and neck when using the Cobra-PLA or LTS as gastric insufflation or ventilatory difficulty may occur.

烟碱受体部分介导了吸入麻醉药异氟醚诱发的脑干自主神经失功

Nicotinic Receptors Partly Mediate Brainstem Autonomic Dysfunction Evoked by the Inhaled Anesthetic Isoflurane

Xin Wang, PhD, MD

From the Departments of Pharmacology and Physiology, and Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC.

Anesth Analg 2009 108: 134-141.

背景:异氟醚是最常用的吸入麻醉药之一,然而其心肺抑制的机制知之甚少。本研究作者检测了异氟醚对副交感心脏迷走神经元突触后GABA受体的调节作用和在GABA能突触前末梢烟碱乙酰胆碱受体靶向作用导致的GABA能作用的变化

方法从舌下神经根800微米髓节记录与吸气节律相关活动。CVNs通过逆行荧光标记确定,使用膜片钳技术检查GABA能神经到CVNs的传递。

结果:异氟醚浓度大于50 µM时明显抑制吸气频率,振幅和持续时间。异氟醚呈剂量依赖性地降低了频率,增加了在CVNs GABA能抑制性突触后电流( IPSCs )自发衰减的时间。为了测试GABA能对CVNs活力抑制是否通过突触前烟碱受体介导,应用浓度为3µM{alpha}4β2-选择性烟碱拮抗剂二氢-β刺桐碱。二氢-β刺桐碱阻止异氟醚诱发的GABAIPSC频率的抑制,但异氟醚仍然可以增加IPSC的衰减时间。

结论:临床相关浓度的异氟醚抑制脑干呼吸节律的发生,在CVNs延长GABA能抑制后电流和减少GABA的活动。GABAIPSCs频率的减少取决于突触前{alpha}4β2烟碱受体的抑制。

(刘世文 译 陈杰 校)

BACKGROUND: Isoflurane is one of the most commonly used volatile anesthetics, yet the cardiorespiratory depression that occurs with its use remains poorly understood. In this study, the author examined isoflurane modulation of postsynaptic {gamma}-aminobutyric acid (GABA) receptors in parasympathetic cardiac vagal neurons (CVNs) and alterations of GABAergic function by targeting nicotinic acetylcholine receptors on GABAergic presynaptic terminals.

METHODS: Rhythmic inspiratory-related activity was recorded from the hypoglossal rootlet of 800 µm medullary sections. CVNs were identified by retrograde fluorescent labeling, and GABAergic neurotransmission to CVNs were examined using patch-clamp electrophysiological techniques.

RESULTS: Isoflurane at concentrations of >50 µM significantly suppressed inspiratory bursting frequency, amplitude, and duration. Isoflurane dose-dependently decreased the frequency and increased the decay time of spontaneous GABAergic inhibitory postsynaptic currents (IPSCs) in CVNs. To test whether the inhibition of GABAergic activity to CVNs was mediated by presynaptic nicotinic receptors, the nicotinic antagonist, dihydro-β-erythroidine in an {alpha}4β2-selective concentration (3 µM), was used. Dihydro-β-erythroidine (3 µM) prevented the isoflurane-evoked depression of spontaneous GABAergic IPSC frequency, yet isoflurane still increased the IPSC decay time.

CONCLUSIONS: These results suggest clinically relevant concentrations of isoflurane inhibit brainstem respiratory rhythmogenesis, prolong inhibitory GABAergic postsynaptic currents and reduce GABA activity in CVNs. The decrease of GABAergic IPSCs frequency is dependent upon inhibition of presynaptic {alpha}4β2 nicotinic receptors.

 依托咪酯作用于下丘脑-皮质系统GABA能神经的模型

Modeling the Gabaergic Action of Etomidate on the Thalamocortical System

Jason A. Talavera, BS, Steven K. Esser, BS, Florin Amzica, PhD, Sean Hill, PhD, and Joseph F. Antognini, MD

From the Department of Anesthesiology and Pain Medicine, University of California, Davis; University of Montreal; Neuroscience Training Program, University of Wisconsin; and the Brain Mind Institute, Ecole Polytechnique Fédérale de Lausanne.

Anesth Analg 2009 108: 160-167.

背景:作者曾使用丘脑皮质系统的计算模型来测定相关类麻醉药物对皮层和丘脑GABA能神经元功能的影响。本研究作者检测了麻醉药的相性和紧张性抑制,以及对丘脑和皮层相对重要区域的影响。

方法:通过模型来产生GABA相关的相性抑制,所需依托咪酯的浓度在0.25-0.5UM,而引起意识消失的浓度范围在0.25-0.5UM,另外单独模拟紧张性抑制,然后同时模拟相性抑制和紧张性抑制。同时将两种抑制分别引入丘脑和皮层,来考察此结构区域对麻醉性抑制作用重要性。

结果:当依托米酯浓度0.25-0.5UM时,相性抑制可降低皮层神经元代谢的11-18%,当达到2UM时可以降低38%。紧张性抑制产生类似的抑制,在0.25-0.5UM时可降低皮层神经元代谢的11-21%,但在2UM时,却可降低65%。两者同时作用可以产生最大的抑制(在2UM时,却可降低代谢率65%)。当丘脑和皮层分别接受相性抑制和紧张性抑制时,相较于皮层丘脑同时接受抑制时的代谢率,单独皮层代谢率下降较小。在0.25-0.5UM的范围里,依托米酯只作用在丘脑时,皮层代谢率受到的影响最小。

结论:丘脑皮层系统的计算模型显示紧张性抑制似乎比相性抑制更为重要(特别在较高依托米酯浓度的时候),尽管两者同时作用将产生最大的皮层代谢率。此外,就依托米酯其本身在丘脑的作用,似乎很难解释其诱导意识丧失的作用。

(叶乐 译 陈杰 校)

BACKGROUND: We have used a computational model of the thalamocortical system to investigate the effects of a GABAergic anesthetic (etomidate) on cerebral cortical and thalamic neuronal function. We examined the effects of phasic and tonic inhibition, as well as the relative importance of anesthetic action in the thalamus and cortex.

METHODS: The amount of phasic GABAergic inhibition was adjusted in the model to simulate etomidate concentrations of between 0.25 and 2 µM, with the concentration range producing unconsciousness assumed to be between 0.25 and 0.5 µM. In addition, we modeled tonic inhibition separately, and then phasic and tonic inhibition together. We also introduced phasic and tonic inhibition into the cerebral cortex and thalamus separately to determine the relative importance of each of these structures to anesthetic-induced depression of the thalamocortical system.

RESULTS: Phasic inhibition decreased cortical neuronal firing by 11%–18% in the 0.25–0.5 µM range and by 38% at 2 µM. Tonic inhibition produced similar depression (11%–21%) in the 0.25–0.5 µM range but 65% depression at 2 µM; phasic and tonic inhibition combined produced the most inhibition (76% depression at 2 µM). When the thalamus and cortex were separately subjected to phasic and tonic inhibition, cortical firing rates decreased less compared to when both structures were targeted. In the 0.25–0.5 µM range, cortical firing rate was minimally affected when etomidate action was simulated in the thalamus only.

CONCLUSIONS: This computational model of the thalamocortical system indicated that tonic GABAergic inhibition seems to be more important than phasic GABAergic inhibition (especially at larger etomidate concentrations), although both combined had the most effect on cerebral cortical firing rates. Furthermore, etomidate action in the thalamus, by itself, does not likely explain etomidate-induced unconsciousness.

 

如何评定充气式保温系统疗效?模拟人上半身应用的评价

What Determines the Efficacy of Forced-Air Warming Systems? A Manikin Evaluation with Upper Body Blankets

Anselm Bräuer, MD, PhD, DEAA*, Henning Bovenschulte, MD{dagger}, Thorsten Perl, MD*, Wolfgang Zink, MD, PhD, DEAA*, Michael John Murray English, FRCA{ddagger}, and Michael Quintel, MD, PhD*

From the *Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany; {dagger}Department of Radiology, University of Colonge, Colonge, Germany; and {ddagger}Department of Anesthesia, Montreal General Hospital and McGill University, Montreal, Canada.

Anesth Analg 2009 108: 192-198.

背景:充气式保温系统为防止围术期低温已被接受。然而,对空气流动和空气温度在喷嘴的影响和这些系统在保温毯热分布的疗效的影响知之甚少。

方法:作者在模拟人上采用5充气式保温系统研究热交流,以确定影响热量从保温毯传到模拟人上的因素。

结果:在动力装置喷嘴处的空气温度和热传递没有任何关系。同样,动力装置的气流和由此产生的热传递也没有关系。保温毯产生最佳疗效时空气流速在19/秒以上。保温毯和模拟人之间的热交换系数,平均温度梯度与所产生的热传导呈正相关,最小和最大毯温度之间的差异与所产生的热传递呈负相关。

结论充气式保温系统疗效主要决定于保温毯。现代电力单位能提供足够的热能以最大限度的为病人取暖。保温毯的优化设计是让毯和人之间(或任何其他表面)存在优化平均温度梯度,使其存在一个非常均匀的温度分布,这将促使制造商开发出更好的保温系统。

(张磊 译 陈杰 校)

BACKGROUND: Forced-air warming has gained acceptance as an effective means to prevent perioperative hypothermia. However, little is known about the influence of air flow and air temperature at the nozzle and the influence of heat distribution in the blankets on the efficacy of these systems.

METHODS: We conducted a manikin study with heat flux transducers using five forced-air warming systems to determine the factors that are responsible for heat transfer from the blanket to the manikin.

RESULTS: There was no relation between air temperature at the nozzle of the power unit and the resulting heat transfer. There was also no relation between the air flow at the nozzle of the power unit and the resulting heat transfer. However, all blankets performed best at high air flows above 19 L/s. The heat exchange coefficient, the mean temperature gradient between the blanket and the manikin correlated positively with the resulting heat transfer and the difference between the minimal and maximal blanket temperature correlated negatively with the resulting heat transfer.

CONCLUSIONS: The efficacy of forced-air warming systems is primarily determined by the blanket. Modern power units provide sufficient heat energy to maximize the ability of the blanket to warm the patient. Optimizing blanket design by optimizing the mean temperature gradient between the blanket and the manikin (or any other surface) with a very homogeneous temperature distribution in the blanket will enable the manufacturers to develop better forced-air warming systems.

 

 

 内皮素-1对大鼠肺泡液体清除率和肺水肿形成的影响

The Effect of Endothelin-1 on Alveolar Fluid Clearance and Pulmonary Edema Formation in the Rat

Marc Moritz Berger, MD*{dagger}, C. Sjula Rozendal{dagger}, Carolin Schieber{dagger}, Martin Dehler, MD{dagger}, Stefanie Zügel{dagger}, Hubert J. Bardenheuer, MD*, Peter Bärtsch, MD{dagger}, and Heimo Mairbäurl, PhD{dagger}

From the *Department of Anesthesiology; and {dagger}Medical Clinic VII, Sports Medicine, University Hospital Heidelberg, Germany.

Anesth Analg 2009 108: 225-231.

背景:内皮素-1被认为在肺水肿形成中起着关键的作用,基本的机制仍然不明确,但可能包括毛细管压力与血管通透性的改变。没有调查研究是否内皮素-1也影响到肺泡液体清除率这一解决肺水肿的主要机制。因此,作者设计了这项研究,以阐明内皮素-1对大鼠肺泡重吸收和液体平衡的影响。

方法:肺泡液体清除率通过用或不用内皮素-1 10–7 M)和/或阿米洛利( 100µM)时在大鼠肺中灌注5 %白蛋白溶液来测定 。在有或没有的内皮素-1 0.8 nm )加入灌注液的情况下,在隔离、通风、恒压灌流的环境中测定大鼠肺泡液体达到平衡时间、水肿的形成时间、肺毛细血管压力和肺泡白蛋白渗透率。

结果:在被液体灌注的肺中,内皮素-1使肺泡液体清除率降低了约65 % ,它的作用与降低了阿米洛利敏感的Na +通道的转运有关( P< 0.001 ) 。内皮素-1的抑制作用是通过完全阻断内皮素B受体拮抗剂BQ788来实现的( P =0.006 ) ,而对内皮素A受体拮抗剂BQ123没有影响( P =0.663 ) 。在隔离、通风的条件下往大鼠肺组织灌注内皮素 -1的能造成的肺泡液体增加约20 % ( P<0.011 ,与对照组比较) ,而对照组大鼠肺组织清除约20 %的灌注液。 内皮素-1增加了肺泡毛细血管压(+9.4 cm H2O) ,减少了灌注流量( -81 % ) ,加快了肺重量的增加,降低了肺组织生存期( P < 0.001 ) 。内皮素-1对白蛋白渗透率无明显的影响( P0.24 ) 。

结论:内皮素-1通过抑制麻醉大鼠中阿米洛利敏感的上皮Na +通道来降低肺泡液体清除率。内皮素-1的抑制作用通过激活的内皮素B受体来体现。这些结果表明了内皮素-1的作用机制是增加毛细血管的压力、促进肺水肿的形成。

(丁俊云 译 陈杰 校)

BACKGROUND: Endothelin-1 (ET-1) is thought to play a pivotal role in pulmonary edema formation. The underlying mechanisms remain uncertain but may include alterations in capillary pressure and vascular permeability. There are no studies investigating whether ET-1 also affects alveolar fluid clearance which is the primary mechanism for the resolution of pulmonary edema. Therefore, we performed this study to clarify effects of ET-1 on alveolar reabsorption and fluid balance in the rat lung.

METHODS: Alveolar fluid clearance was measured in fluid instilled rat lungs using a 5% albumin solution with or without ET-1 (10–7 M) and/or amiloride (100 µM). Net alveolar fluid balance, time course of edema formation, pulmonary capillary pressure, and alveolar permeability to albumin were measured in the isolated, ventilated, constant pressure perfused rat lung with or without ET-1 (0.8 nM) added to the perfusate.

RESULTS: In the fluid-instilled lung, ET-1 reduced alveolar fluid clearance by about 65%, an effect that was related to a decrease in amiloride-sensitive transepithelial Na+ transport (P < 0.001). The ET-1-induced inhibition was completely prevented by the endothelin B receptor antagonist BQ788 (P = 0.006), whereas the endothelin A receptor antagonist BQ123 had no effect (P = 0.663). In the isolated, ventilated, perfused rat lung ET-1 caused a net accumulation of alveolar fluid by about 20% (P = 0.011 vs control), whereas lungs of control rats cleared about 20% of the instilled fluid. ET-1 increased pulmonary capillary pressure (+9.4 cm H2O), decreased perfusate flow (–81%), accelerated lung weight gain and reduced lung survival time (P < 0.001). Permeability to albumin was not significantly affected by ET-1 (P = 0.24).

CONCLUSION: ET-1 inhibitis alveolar fluid clearance of anesthetized rats by inhibition of amiloride-sensitive epithelial Na+ channels. The inhibitory effect of ET-1 results from activation of the endothelin B receptor. These findings suggest a mechanism by which ET-1, in addition to increasing capillary pressure, contributes to pulmonary edema formation.

一项关于腰-硬联合和硬膜外用于经产妇分娩镇痛的随机研究

A Randomized Trial of Breakthrough Pain During Combined Spinal-Epidural Versus Epidural Labor Analgesia in Parous Women

Stephanie R. Goodman, MD, Richard M. Smiley, MD, PhD, Maria A. Negron, MD, Paula A. Freedman, BA, and Ruth Landau, MD

From the Department of Anesthesiology, Columbia University, New York City, New York.

Anesth Analg 2009 108: 246-251.

背景:关于腰-硬联合(CSE)和硬膜外麻醉(EPID)用于分娩镇痛的益处与风险存在争议。作者推测相比于EPID,CSE可以减少患者追加剂量的需求。

方法: 100ASAIII级的分娩早期(宫颈扩张<5cm)的需要镇痛的产妇,随机双盲接受EPID(硬膜外给予2.5 mg/mL的布比卡因3ml,随后给予1.25 mg/mL的布比卡因10ml和芬太尼50ug)或CSE(鞘内给予布比卡因2.5mg和芬太尼25ug)。两组均以12ml/h的速度输注相同的布比卡因(浓度0.625 mg/mL)和芬太尼(浓度2 µg/mL)。

结果:两组中不管是要求追加剂量的患者的百分比(44% CSE51% EPID95%置信区间的差异–28% to +14%)还是要求多种药物追加剂量的比值(14% CSE vs 15% EPID)无明显差异。开始镇痛后10分钟[中位数0 cm (0, 0) 4 cm (1, 6) P < 0.001]30分钟[0 cm (0, 0) vs 0 cm (0, 1),  P = 0.03],CSE组视觉模拟量表评分比EPID组低。

结论: 经产妇CSEEPID两种方法中需求追加剂量方面无显著差异;但CSEEPID在镇痛最初的30分钟提供了更好的镇痛效果。

(舒慧刚 译 陈杰 校)

BACKGROUND: There is controversy regarding the benefits and risks of combined spinal-epidural compared with epidural analgesia (CSE, EPID) for labor analgesia. We hypothesized that CSE would result in fewer patient requests for top-up doses compared to EPID.

METHODS: One-hundred ASA physical status I or II parous women at term in early labor (<5 cm cervical dilation) requesting analgesia were randomized in double-blind fashion to the EPID group (epidural bupivacaine 2.5 mg/mL, 3 mL, followed by bupivacaine 1.25 mg/mL, 10 mL with fentanyl 50 µg) or the CSE group (intrathecal bupivacaine 2.5 mg with fentanyl 25 µg). Both groups received identical infusions of bupivacaine 0.625 mg/mL with fentanyl 2 µg/mL at 12 mL/h. The primary outcome variable was the number of top-up doses requested to treat breakthrough pain.

RESULTS: There was no significant difference between the two groups in the percentage of patients requesting top-up doses (44% CSE vs 51% EPID; 95% confidence interval of the difference –28% to +14%) nor in the need for multiple top-up doses (14% CSE vs 15% EPID). Visual analog scale scores were lower in the CSE group compared to the EPID group at 10 min after initiation of analgesia [median 0 cm (0, 0) vs 4 cm (1, 6) respectively, P < 0.001] and at 30 min [0 cm (0, 0) vs 0 cm (0, 1), respectively, P = 0.03].

CONCLUSIONS: We did not find a difference in the need for top-up doses in parous patients; however, CSE provided better analgesia in the first 30 min compared to EPID.

 

体内缺乏β2-肾上腺素能受体的小鼠脑缺血后脑损伤减少

Postischemic Brain Injury Is Attenuated in Mice Lacking the β2-Adrenergic Receptor

Ru-Quan Han, MD, PhD*{dagger}, Yi-Bing Ouyang, PhD*, Lijun Xu, MD*, Rani Agrawal, PhD*, Andrew J. Patterson, MD, PhD*, and Rona G. Giffard, MD, PhD*

From the *Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and {dagger}Department of Anesthesia, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

Anesth Analg 2009 108: 280-287.

背景:研究表明,β-肾上腺素能受体(BAR)阻滞剂对于脑缺血损伤具有神经保护作用。然而,克伦特罗——一种特殊的β2-肾上腺素能受体阻滞剂,通过增加神经生长因子的表达产生神经保护作用。作者选取β2-肾上腺素能受体敲除小鼠及选择性β2-肾上腺素能受体阻滞剂作为研究对象,研究β2-肾上腺素能受体缺乏对短暂性脑缺血灶的影响。

 

方法:本实验通过腔内缝合方法建立缺血模型,具体方法为大脑中动脉闭塞(MCAO60分钟后进行24小时的再灌注,并评分神经功能。梗死灶大小由甲酚紫染色或235-三苯基氯化四唑染色评定。大鼠分为两组,分别为β2-肾上腺素能受体缺乏小鼠及野生型同类系小鼠作为对照组,两组野生型小鼠在MCAO 30分钟前分别腹腔内随机注射选择性β2-肾上腺素能受体阻滞剂ICI1185510.2mg/kg)或0.9%生理盐水(每组n=10)。通过免疫组化及免疫印迹法对缺血后热休克蛋白Hsp72进行标记测定。

 

结果:60分钟的MCAO后进行24小时的再灌注之后,与野生鼠(对照组)相比,β2-肾上腺素能受体缺乏鼠的梗死范围减少了22.3%39.7±10.7mm351.07±11.4mm3,每组n=10P=0.034)。与对照组相比,进行预处理即注射选择性β2-肾上腺素能受体阻滞剂ICI118551的小鼠梗死范围也有显著减少25.1%32.8±11.9mm343.8±10.3mm3,每组n=10P=0.041)。β2-肾上腺素能受体缺乏鼠及进行ICI118551预处理的鼠在神经功能评分方面也有显著提高。脑缺血后,β2-肾上腺素能受体缺乏鼠体内的热休克蛋白Hsp72的总水平及热休克蛋白Hsp72的免疫阳性细胞也有所提高。

 

结论:在缺乏β2AR的小鼠及对进行选择性β2AR阻滞剂预处理后的小鼠体内,进行MCAO,其脑损伤及神经功能损伤都有所减少。这与脑缺血时β2AR活性从存活信号到凋亡信号的转变是一致的。这种保护机制与高水平的热休克蛋白Hsp72-一种抗凋亡蛋白有关。β2-肾上腺素能受体信号在脑缺血中的影响极为复杂,仍然需要进一步研究来证实。

(赵嫣红 译 陈杰 校)

BACKGROUND: Several β-adrenergic receptor (βAR) antagonists have been shown to have neuroprotective effects against cerebral ischemia. However, clenbuterol, a β2AR agonist, was shown to have neuroprotective activity by increasing nerve growth factor expression. We used β2AR knockout mice and a β2 selective antagonist to test the effect of loss of β2ARs on outcome from transient focal cerebral ischemia.

METHODS: Ischemia was induced by the intraluminal suture method, for 60 min of middle cerebral artery occlusion (MCAO) followed by 24 h reperfusion. Neurological score was determined at 24 h reperfusion and infarct size was determined by cresyl violet or 2,3,5-triphenyltetrazolium chloride staining. β2AR knockout mice and wild-type congenic FVB/N controls were studied, as well as 2 groups of wild type mice given either ICI 118,551 (0.2 mg/kg) or 0.9% saline intraperitoneally 30 min before MCAO (n = 10 per group). Changes in expression of heat shock protein (Hsp)72 after ischemia were examined by immunohistochemistry and western blots.

RESULTS: Compared with wild type littermates, infarct volume was decreased by 22.3% in β2AR knockout mice (39.7 ± 10.7 mm3 vs 51.0 ± 11.4 mm3, n = 10/group, P = 0.034) after 60 min of MCAO followed by 24 h reperfusion. Pretreatment with a β2AR selective antagonist, ICI 118,551, also decreased infarct size significantly, by 25.1%, compared with the saline control (32.8 ± 11.9 mm3 vs 43.8 ± 10.3 mm3, n = 10/group, P = 0.041). Neurological scores were also significantly improved in mice lacking the β2AR or pretreated with ICI 118,551. After cerebral ischemia, total levels of Hsp72 and the number of Hsp72 immunopositive cells were greater in mice lacking β2 AR.

CONCLUSION: Brain injury is reduced and neurological outcome improved after MCAO in mice lacking the β2AR, or in wild type mice pretreated with a selective β2AR antagonist. This is consistent with a shift away from prosurvival signaling to prodeath signaling in the presence of β2AR activation in cerebral ischemia. Protection is associated with higher levels of Hsp72, a known antideath protein. The effect of β2AR signaling in the setting of cerebral ischemia is complex and warrants further study.

吸烟状态对于慢性疼痛患者戒除阿片类药物的影响

The Effects of Smoking Status on Opioid Tapering Among Patients with Chronic Pain

W. Michael Hooten, MD*{dagger}, Cynthia O. Townsend, PhD{dagger}, Barbara K. Bruce, PhD{dagger}, and David O. Warner, MD*

From the Departments of *Anesthesiology, and {dagger}Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, Minnesota.

 

Anesth Analg 2009 108: 308-315.

目的:本次研究的主要目的是确定在一项为期3周的疼痛康复项目中,吸烟是否对慢性疼痛患者的阿片类药物减量过程有影响。次要目的包括研究吸烟状态、住院期间阿片类药物的使用,及疼痛的严重程度之间的关系。

 

方法:作者使用了回顾性、重复测试的试验设计以评估患者在治疗前后的一些指标。评估的对象是在20039月至20072月之间接受一项为期3周的门诊患者疼痛治疗项目的全部患者。评估指标包括阿片类药物的成功戒除率、多学科疼痛调查的疼痛程度量表和治疗项目完成情况。

 

结果:总共有1241位患者入选本次研究(女性928位);其中,313位(25%)是吸烟者,294位(24%)现已戒烟,其余634位(51%)未曾吸烟。入组时,相较于已戒烟者及不吸烟者,有更多的吸烟者使用阿片类药物(P<0.001)。类似的,吸烟者吗啡的平均等效剂量(P=0.013)和疼痛评分(P<0.001)明显高于已戒烟者和不吸烟者。阿片类药物的成功戒除率与患者是否吸烟无关,治疗项目结束时,各组患者的疼痛均有明显缓解(P<0.001)。但是,很大一部分吸烟者未能完成治疗(P<0.001)。

 

结论:大部分完成全部疼痛康复计划的患者能够戒除使用阿片类药物,这与患者是否吸烟无关。但值得注意的是,有更多的吸烟者未能完成该治疗项目,其中最常见的原因包括对治疗的期望值存在差异,突发急性疾病,以及心理社会的应激。

(周姝婧 译 陈杰 校)

OBJECTIVE: The primary aim of this study was to determine if smoking status affected the ability of patients with chronic pain to reduce opioid consumption during a 3-wk pain rehabilitation program. Secondary aims included determining the associations between smoking status, admission opioid use, and pain severity.

METHODS: We used a retrospective, repeated measures design to assess pre- and post-treatment outcomes in a consecutive series of patients admitted to a 3-wk, outpatient pain treatment program from September 2003 through February 2007. Outcome measures included the frequency of successful opioid tapering, pain severity subscale of the Multidisciplinary Pain Inventory, and program completion status.

RESULTS: The study cohort included 1241 patients (women 928); 313 (25%) smokers, 294 (24%) former smokers, and 634 (51%) never smokers. There were more smokers using opioids at admission (P < 0.001) compared to former and never smokers. Likewise, the mean morphine equivalent dose (P = 0.013) and pain severity scores (P < 0.001) of smokers were higher compared to former and never smokers. The success of opioid tapering did not depend on smoking status, and all groups experienced significant reductions in pain severity at program completion (P < 0.001). However, a higher proportion of smokers did not complete treatment (P < 0.001).

CONCLUSIONS: For patients completing a pain rehabilitation program, most were able to eliminate opioid use, regardless of smoking status. However, significantly more smokers did not complete treatment. The most frequent reasons for program noncompletion included discrepant expectations of treatment, acute illness, and psychosocial stressors.

局麻药浓度和剂量对持续锁骨下神经阻滞效果的影响:一项多中心、随机、隐蔽观察、对照研究

The Effects of Local Anesthetic Concentration and Dose on Continuous Infraclavicular Nerve Blocks: A Multicenter, Randomized, Observer-Masked, Controlled Study

Brian M. Ilfeld, MD, MS*, Linda T. Le, MD{dagger}, Joanne Ramjohn, MD{dagger}, Vanessa J. Loland, MD*, Anupama N. Wadhwa, MD{ddagger}, J. C. Gerancher, MD§, Elizabeth M. Renehan, MSc, MD||, Daniel I. Sessler, MD, Jonathan J. Shuster, PhD#**, Douglas W. Theriaque, MS**, Rosalita C. Maldonado, BS*, Edward R. Mariano, MD* For the PAINfRETM Investigators, Section Editor Terese T. Horlocker

From the *Department of Anesthesiology, University of California San Diego, San Diego, California; {dagger}Department of Anesthesiology, University of Florida, Gainesville, Florida; {ddagger}Department of Anesthesiology, University of Louisville, Louisville, Kentucky; §Department of Anesthesiology, Wake Forest Medical Center, Winston-Salem, North Carolina; ||Department of Anesthesiology, University of Ottawa, Ottawa, Ontario, Canada; ¶Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; #Department of Epidemiology and Health Policy Research, University of Florida, Gainesville, Florida; and **General Clinical Research Center, University of Florida, Gainesville, Florida.

Anesth Analg 2009 108: 345-350.

背景:周围神经阻滞效果的主要决定因子是局麻药浓度还是药物剂量目前还不清楚。曾有研究显示,持续的腘窝坐骨神经阻滞中,与小容量高浓度罗哌卡因相比,大容量低浓度罗哌卡因感觉阻滞更好。然而,仍不清楚这种关系是坐骨神经特有的还是仅取决于处在腘窝这个位置。本研究作者检验这一假说,比较了总剂量相等时不同浓度和容量的罗哌卡因用于持续的锁骨下臂丛神经阻滞的差异。

方法:肘远端整形外科手术患者,经喙突径路置入锁骨下导管。从术后第二天开始随机接受周围神经0.2%罗哌卡因(背景剂量8ml/h,单次剂量4ml),或者0.4%罗哌卡因(背景剂量4ml/L,单次剂量2ml),即接受罗哌卡因16mg/h,病人自控追加剂量8mg, 锁定时间为30min。主要的终点为24h期间肢体无感觉发生率。第二终点包括镇痛效果和病人的满意度。

结果 0.4%罗哌卡因组(n=27)肢体无感觉发生为1.8 ±1.6次,而0.2%罗哌卡因组(n=23);为0.6±0.9(差异为1.2 95%置信区间,0.5-1.9 p=0.001)。0.2%罗哌卡因组术后镇痛的满意度(范围0-1010=最高)为10.0 (中位数25th-75th%8.0–10.0)0.4%罗哌卡因组为7.05.3-8.9)(p=0.018)。组间镇痛效果相似。

结论:持续锁骨下神经阻滞,除了局麻药总量外,局麻药浓度和容量影响其阻滞效果。小容量高浓度罗哌卡因组发生肢体无感觉更常见。这与已报道的持续腘窝-坐骨神经阻滞相反。局麻药浓度和剂量之间的相互关系仍然是复杂的,且随导管位置的不同而改变。

(怀晓蓉 译 陈杰 校)

BACKGROUND: It remains unclear whether local anesthetic concentration or total drug dose is the primary determinant of continuous peripheral nerve block effects. The only previous investigation, involving continuous popliteal-sciatic nerve blocks, specifically addressing this issue reported that insensate limbs were far more common with higher volumes of relatively dilute ropivacaine compared with lower volumes of relatively concentrated ropivacaine. However, it remains unknown if this relationship is specific to the sciatic nerve in the popliteal fossa or whether it varies depending on anatomic location. We therefore tested the null hypothesis that providing ropivacaine at different concentrations and rates, but at an equal total basal dose, produces comparable effects when used in a continuous infraclavicular brachial plexus block.

METHODS: Preoperatively, an infraclavicular catheter was inserted using the coracoid approach in patients undergoing moderately painful orthopedic surgery distal to the elbow. Patients were randomly assigned to receive a postoperative perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Both groups, therefore, received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. Our primary end point was the incidence of an insensate limb during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction.

RESULTS: Patients given 0.4% ropivacaine (n = 27) experienced an insensate limb, a mean (sd) of 1.8 (1.6) times, compared with 0.6 (0.9) times for subjects receiving 0.2% ropivacaine (n = 23; estimated difference = 1.2 episodes, 95% confidence interval, 0.5–1.9 episodes; P = 0.001). Satisfaction with postoperative analgesia (scale 0–10, 10 = highest) was scored a median (25th–75th percentiles) of 10.0 (8.0–10.0) in Group 0.2% and 7.0 (5.3–8.9) in Group 0.4% (P = 0.018). Analgesia was similar in each group.

CONCLUSIONS: For continuous infraclavicular nerve blocks, local anesthetic concentration and volume influence perineural infusion effects in addition to the total mass of local anesthetic administered. Insensate limbs were far more common with smaller volumes of relatively concentrated ropivacaine. This is the opposite of the relationship previously reported for continuous popliteal-sciatic nerve blocks. The interaction between local anesthetic concentration and volume is thus complex and varies among catheter locations.

手臂外展对锁骨下臂丛神经解剖关系的影响:一项超声研究

The Influence of Arm Abduction on the Anatomic Relations of Infraclavicular Brachial Plexus: An Ultrasound Study

Ana Ruíz*, Xavier Sala*, Xavier Bargalló{dagger}, Paola Hurtado*, Maria Jose Arguis*, and Ana Carrera{ddagger}

From the Departments of *Anesthesiology, {dagger}Radiology, University of Barcelona, Hospital Clinic of Barcelona, Barcelona, Spain; {ddagger}Department of Human Anatomy, University of Barcelona, Barcelona, Spain.

Anesth Analg 2009 108: 364-366.

背景:臂丛至喙突以及胸膜的距离对于进行锁骨下阻滞是至关重要的。作者使用超声评价手臂外展时神经血管束相对于皮肤,喙突以及胸膜之间的位置。

方法:26名患者行锁骨下臂丛神经超声检查。测量并记录手臂外展(角度分别为45°90°)时腋动脉至皮肤,喙突和胸膜之间的距离,。在另外14名接受手部手术的患者上进行神经刺激下锁骨下臂丛阻滞。

结果:在超声检查下,腋动脉至皮肤的距离在手臂外展时明显减少(0°: 32 ± 7 mm, 45°: 29 ± 7 mm, 90°: 25 ± 5 mm, P < 0.05)。在内侧偏斜为18 ± 3度的情况下,皮肤至胸膜的距离为47 ± 5 mm,并且不受手臂位置的影响。使用神经刺激来确认臂丛,其距离皮肤的垂直深度为41 ± 7 mm

结论:手臂外展能够减少臂丛的深度但并不能改变腋动脉相对于喙突或者胸膜之间的位置。超声影像可能低估了臂丛的实际深度。

(朱紫瑜 译 陈杰 校)

BACKGROUND: Distances from brachial plexus to the coracoid process and the pleura are critical for performing infraclavicular block. We evaluated the influence of arm abduction on the position of the neurovascular bundle relative to the skin, to the coracoid process and to the pleura using ultrasonography.

METHODS: An ultrasound examination of the brachial plexus at the infraclavicular level was performed on 26 patients. Distances from the axillary artery to the skin, to the coracoid process and to the pleura were measured and noted with different degrees of arm abduction (0°, 45°, and 90°). Vertical infraclavicular brachial plexus block was then performed by means of nerve stimulation in 14 additional patients undergoing hand surgery.

RESULTS: Under ultrasound examination, the distance from the axillary artery to the skin was found to be significantly less with arm abduction (0°: 32 ± 7 mm, 45°: 29 ± 7 mm, 90°: 25 ± 5 mm, P < 0.05). The distance from the skin to the pleura was 47 ± 5 mm with a medial deviation of 18 ± 3 degrees and was not influenced by arm position. Brachial plexus was identified by nerve stimulation at a vertical depth of 41 ± 7 mm from the skin.

CONCLUSION: Abduction of the arm reduces the depth of the brachial plexus but does not change the position of the axillary artery relative to the coracoid process or the pleura. Ultrasonography may under-estimate the actual depth of the plexus.

经心外超声心动图使用连续性方程监测主动脉瓣区的可行性

The Feasibility of Epicardial Echocardiography for Measuring Aortic Valve Area by the Continuity Equation

Jan N. Hilberath, MD*, Stanton K. Shernan, MD*, Scott Segal, MD*, Brian Smith, MD*, and Holger K. Eltzschig, MD, PhD{dagger}{ddagger}

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; {dagger}Department of Anesthesiology and Perioperative Medicine, University of Colorado Health Science Center, Denver, Colorado; and {ddagger}Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany.

Anesth Analg 2009; 108:17-22

背景:测定主动脉瓣区(AVA)是行主动脉瓣手术的病人术中广泛的心外超声(EE)检查中的一个重要部分。心外心超(EE)代表了一种可行的替代经食道心超(TEE)的方法。但是与监测AVA的其他显像模式之间的一致性及相关性尚未系统性验证过。

方法:我们在85位行心脏手术的病人中经EE使用连续性方程监测AVAAVA-EE)。在同样的人群中将AVA-EE监测与术中用经食道超声心动图得到的AVA-TEE相比较。在患者亚组中,还将AVA-EE与其他AVA监测手段作比较:术前经胸壁超声心动图(AVA-TTE) (n = 65)或术前四周获得的心导管检查(AVA-Cath) (n = 35)

结果94%接受AVA-TEE100%接受AVA-EE的患者获得了经主动脉瓣的多普勒记录。AVA-EEAVA-TEE监测相比较显示出高度的一致性(平均差[偏差] ± 95%可信区间CI = –0.09 cm2 ± 0.18 cm2, r2 = 0.83, P < 0.0001)AVA-EE同样与AVA-Cath(平均差± 95% CI = –0.03 cm2 ± 0.12 cm2, r2 = 0.87, P < 0.0001) AVA-TTE (平均差± 95% CI = –0.06 cm2 ± 0.22 cm2, r2 = 0.81, P < 0.0001) 有很好的一致性。

结论:经EE使用连续性方程监测AVA与其他AVA评估技术相比显示出高度的一致性及相关性。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: Measuring the aortic valve area (AVA) remains an important component of a comprehensive intraoperative echocardiographic examination in patients undergoing aortic valve surgery. Epicardial echocardiography (EE) represents an accessible alternative to transesophageal echocardiography (TEE), however, its agreement and correlation with other imaging modalities for measuring AVA has not been systematically validated.

METHODS: EE was used in 85 patients undergoing cardiac surgery to measure AVA (AVA-EE) using the continuity equation. AVA-EE was compared to measurements obtained by intraoperative transesophageal echocardiography (AVA-TEE) in the same population. In a subset of patients, AVA-EE was also compared to AVA measurements from either preoperative transthoracic echocardiography (AVA-TTE) (n = 65) or cardiac catheterization (AVA-Cath) (n = 35) that were acquired within 4 wk before the date of surgery.

RESULTS: Adequate trans-AV Doppler recordings were obtained in 94% of patients for AVA-TEE and 100% of patients for AVA-EE. EE measurements of AVA showed close agreement with TEE measurements (mean difference [bias] ± 95% CI = –0.09 cm2 ± 0.18 cm2, r2 = 0.83, P < 0.0001). AVA-EE also agreed well with AVA-Cath (mean difference ± 95% CI = –0.03 cm2 ± 0.12 cm2, r2 = 0.87, P < 0.0001) and AVA-TTE (mean difference ± 95% CI = –0.06 cm2 ± 0.22 cm2, r2 = 0.81, P < 0.0001).

CONCLUSIONS: EE measurements of AVA by the continuity equation show high agreement and closely correlate with established techniques of AVA assessment.


术中多普勒组织成像对心脏麻醉医师的医疗设备而言是一项有价值的补充:一项核心回顾

Intraoperative Doppler Tissue Imaging Is a Valuable Addition to Cardiac Anesthesiologists’ Armamentarium: A Core Review

Nikolaos Skubas, MD, FASE

From the Department of Anesthesiology, Weill Cornell Medical College, New York, New York.

Anesth Analg 2009; 108:48-66

心动周期中心脏内部运动和表面/容量变化是用超声心动图的方法来评估局部(室壁运动分析)或整体(分段区域改变、心搏量和射血分数)心功能的。这些常规方法可能是主观的,和/或花费时间,并且依赖环境,致使麻醉医师的注意力可能从手术活动中转移。多普勒组织成像(DTI)是一种新奇的超声心动图技术,它可显示和测量心肌局部的收缩和舒张速度。DTI 操作简便且不依赖于足够的心内成像。数字信息(速度或时间间隔)可轻易获得和测量。局部(局部缺血的检出)和整体水平(射血分数、舒张期功能障碍的分级)的收缩和舒张功能的判定以及充盈压的评估可从DTI信号中获取并被任何工作中的心脏麻醉医师所用。本综述叙述了DTI的原理、成像方式和临床应用。
(唐李隽 译  马皓琳  李士通 校)

Endocardial motion and surface/volume changes during the cardiac cycle are echocardiographic methods for regional (analysis of wall motion) and global (fractional area change, stroke volume, and ejection fraction) evaluation of cardiac function. These conventional methods can be subjective, and/or time consuming and, depending upon circumstances, may divert the anesthesiologist’s attention from intraoperative activities. Doppler tissue imaging (DTI) is a novel echocardiographic technique, which displays and measures systolic and diastolic velocity from a myocardial region. DTI is simple to perform and independent of adequate endocardial imaging. The numeric information (velocity or time intervals) is easily obtained and measured. Assessment of systolic and diastolic function on regional (detection of ischemia) as well as global level (ejection fraction, grading of diastolic dysfunction) and evaluation of filling pressure can be derived from DTI signals and used by any practicing cardiac anesthesiologist. This review describes the principles, imaging modalities, and clinical applications of DTI.

 

 

 

新生期接触异氟醚对小鼠脑细胞生存、成年后行为、学习和记忆的影响

The Effects of Neonatal Isoflurane Exposure in Mice on Brain Cell Viability, Adult Behavior, Learning, and Memory

Andreas W. Loepke, MD, PhD, FAAP*, George K. Istaphanous, MD*, John J. McAuliffe, III, MD, MBA, FAAP*, Lili Miles, MD{dagger}, Elizabeth A. Hughes, BS{ddagger}, John C. McCann, BS{ddagger}, Kathryn E. Harlow, BS{ddagger}, C. Dean Kurth, MD, FAAP*, Michael T. Williams, PhD§, Charles V. Vorhees, PhD§, and Steve C. Danzer, PhD*

From the *Departments of Anesthesia, {dagger}Pathology, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio; {ddagger}Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; §Department of Pediatrics, Division of Neurology, Cincinnati Children’s Research Foundation and University of Cincinnati College of Medicine, Cincinnati, Ohio.

Anesth Analg 2009; 108:90-104

研究背景:吸入麻醉药,如异氟醚,现被广泛用于婴儿和新生儿。新生大鼠暴露于异氟醚、咪达唑仑和氧化亚氮后出现神经变性和神经认知功能损害已引起对于儿科麻醉安全的关注。新生小鼠长时间接触异氟醚可引起低血糖,而低血糖可能是神经认知功能损害的原因。本研究调查了新生期接触异氟醚和血糖水平对小鼠脑细胞生存、自发活动能力和空间学习记忆的影响。

研究方法:7日龄小鼠随机分组,分别吸入1.5%异氟醚6小时,注射或不注射葡萄糖或生理盐水,或暴露于室内空气且不注射任何药物(未接受麻醉组)。测定动脉血气和血糖。小鼠吸入异氟醚后2小时、18小时和11周用荧光绿B、细胞凋亡蛋白酶或NeuN染色的脑切片评估脑细胞活性。吸入异氟醚后9周评估自发活动能力,并通过Morris水迷宫隐藏和减少平台试验评估小鼠空间学习和记忆能力。

研究结果:与未接受麻醉组相比,小鼠吸入异氟醚后早期一些脑区凋亡性细胞变性增加。虽然有新生期细胞消亡,新生期神经变性显著影响的2个脑区在小鼠成年后其神经元细胞密度不变。所有组成年小鼠自发活动能力、空间学习和记忆能力相似,与新生期异氟醚接触无关。新生期接触异氟醚引起18%的死亡率并短暂增加Paco2、乳酸和碱不足,并降低血糖水平。然而,由于补糖并不能避免神经元消亡,低血糖似乎不是神经变性的原因。

结论:小鼠新生期长时间接触异氟醚可使急性脑细胞变性数量增加,但并未观察到成年期神经元密度显著减少或自发活动、空间学习或记忆功能的损害。

(周雅春 译 马皓琳 李士通 校)

BACKGROUND: Volatile anesthetics, such as isoflurane, are widely used in infants and neonates. Neurodegeneration and neurocognitive impairment after exposure to isoflurane, midazolam, and nitrous oxide in neonatal rats have raised concerns regarding the safety of pediatric anesthesia. In neonatal mice, prolonged isoflurane exposure triggers hypoglycemia, which could be responsible for the neurocognitive impairment. We examined the effects of neonatal isoflurane exposure and blood glucose on brain cell viability, spontaneous locomotor activity, as well as spatial learning and memory in mice.

METHODS: Seven-day-old mice were randomly assigned to 6 h of 1.5% isoflurane with or without injections of dextrose or normal saline, or to 6 h of room air without injections (no anesthesia). Arterial blood gases and glucose were measured. After 2 h, 18 h, or 11 wk postexposure, cellular viability was assessed in brain sections stained with Fluoro-Jade B, caspase 3, or NeuN. Nine weeks postexposure, spontaneous locomotor activity was assessed, and spatial learning and memory were evaluated in the Morris water maze using hidden and reduced platform trials.

RESULTS: Apoptotic cellular degeneration increased in several brain regions early after isoflurane exposure, compared with no anesthesia. Despite neonatal cell loss, however, adult neuronal density was unaltered in two brain regions significantly affected by the neonatal degeneration. In adulthood, spontaneous locomotor activity and spatial learning and memory performance were similar in all groups, regardless of neonatal isoflurane exposure. Neonatal isoflurane exposure led to an 18% mortality, and transiently increased Paco2, lactate, and base deficit, and decreased blood glucose levels. However, hypoglycemia did not seem responsible for the neurodegeneration, as dextrose supplementation failed to prevent neuronal loss.

CONCLUSIONS: Prolonged isoflurane exposure in neonatal mice led to increased immediate brain cell degeneration, however, no significant reductions in adult neuronal density or deficits in spontaneous locomotion, spatial learning, or memory function were observed.


减脂手术中肺泡复原和动脉地氟烷浓度

Alveolar Recruitment and Arterial Desflurane Concentration During Bariatric Surgery

Juraj Sprung, MD, PhD*, Francis X. Whalen, MD*, Thomas Comfere, MD*, Zeljko J. Bosnjak, PhD{dagger}, Zeljko Bajzer, PhD§, Ognjen Gajic, MD||, Michael G. Sarr, MD{ddagger}, Darrell R. Schroeder, MS, Lavonne M. Liedl, RT*, Chetan P. Offord, RT§, and David O. Warner, MD*

From the *Department of Anesthesiology, {ddagger}Department of Surgery, §Biomathematics Resource and Department of Biochemistry and Molecular Biology, ||Division of Pulmonary and Critical Care Medicine, ¶Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, Minnesota, and {dagger}Anesthesia Research Medical College of Wisconsin, Milwaukee, Wisconsin.

Anesth Analg 2009; 108:120-127

背景:我们研究减脂手术中用肺泡复原操作(RM)逆转术中肺不张是否会影响地氟烷的动脉浓度。

方法:麻醉诱导和维持用丙泊酚,病人随机接受(RM)或者不接受(对照组)间断RM。地氟烷以6%开始,测量两组肺泡地氟烷浓度增加速度(呼气末和吸气浓度比值,FA/FI)和地氟烷血液浓度。麻醉结束后也测量血液和呼气末地氟烷浓度。

结果:与对照组相比,RM组术中Pao2/Fio2较高(两者都P < 0.001)。在诱导过程中,两组地氟烷血液浓度上升速度都很快。在可进行比较的机械通气设置中,对照组和RM组,达到0.5 mM (3%)的中位数时间分别是2.11.59分钟(P = 0.09)。达到0.7 mM (4.2%)地氟烷的时间,对照组和RM组分别是15.99.3分钟(P = 0.08)。在RM组,地氟烷血液浓度在诱导后最初的30分钟趋于更高(P = 0.066)。在维持或苏醒过程中,对照组和RM组的血液地氟烷浓度没有差别。因此,两组间睁眼时间没有差别。

结论:尽管,在减脂手术中RM显示出一个有效改善术中氧合的方法,但是,它并不显著影响麻醉中血液地氟烷浓度以及苏醒过程中的消除。

(张曦 译,马皓琳 李士通 校)

BACKGROUND: We investigated whether reversal of intraoperative atelectasis with the lung recruitment maneuver (RM) affects desflurane arterial concentrations during bariatric surgery.

METHODS: After anesthetic induction and maintenance with propofol, patients were randomized to receive alveolar RM at intervals (RM group) or not (controls). Desflurane 6% was initiated, and rate of increase of alveolar desflurane concentration (ratio of end-expiratory to inspiratory concentrations, FA/FI) and desflurane blood concentrations were measured in both groups. Blood and end-tidal desflurane concentrations were also measured after the discontinuation of anesthesia.

RESULTS: The RM group had higher intraoperative Pao2/Fio2 compared with the control group (both, P < 0.001). During induction, the rate of increase in blood desflurane concentrations was rapid in both groups. At comparable mechanical ventilation settings, median times to achieve 0.5 mM (approximately 3%) were 2.1 and 1.59 min (P = 0.09) in the control and RM group, respectively. The times to achieve 0.7 mM (approximately 4.2%) desflurane were 15.9 and 9.3 min in the control and RM group, respectively (P = 0.08). Desflurane blood concentrations tended to be higher during the first 30 min after induction in the RM group (P = 0.066). During maintenance or emergence, the blood desflurane concentrations were not different between control and RM groups. Consequently, the time to eye opening did not differ between groups.

CONCLUSION: Although the RM during bariatric surgery represents an effective method for improving intraoperative oxygenation, it does not significantly affect the desflurane blood concentrations during anesthesia or its elimination during emergence.



丙泊酚和异氟烷增强疑核心脏迷走神经元张力型γ-氨基丁酸A型电流

Propofol and Isoflurane Enhancement of Tonic Gamma-Aminobutyric Acid Type A Current in Cardiac Vagal Neurons in the Nucleus Ambiguus

Xin Wang, PhD, MD

From the Department of Pharmacology and Physiology, and Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington DC.

Anesth Analg 2009; 108:142-148

 

背景:全麻使用丙泊酚和异氟烷引起心血管系统的变化,包括低血压和心率改变。神经节前心脏迷走神经元(CVNs)是控制心率和自主调节的主要核心部分。本研究中,我们检验了丙泊酚和异氟烷是否作用于相型或张力型γ-氨基丁酸A型(GABAA)受体介导的CVNs抑制。

方法:体外使用逆向荧光标记确定CVNs。使用全细胞膜片钳技术来测定CVNs上的相型和张力型GABA电流。

结果:丙泊酚(10 µM)增加膜维持电流63 ± 13%,并将GABA能抑制性微突触后电流(mIPSCs)的衰减时间从对照的42.3 ± 2.8 ms延长到61.8 ± 4.5 ms。异氟烷,在浓度为100300500µM时,分别降低mIPSCs的频率26.0 ± 16% 64.6 ± 10.4%70.5 ± 9.8%,将GABAmIPSCs的衰减时间从47.9 ± 7.3 分别延长至 64.5 ± 8.1 ms70.3 ± 10.4 ms66.8 ± 8.1 ms,并分别增加膜维持电流32.8 ± 12.8%42.7 ± 10%39.9 ± 3%GABA能拮抗剂gabazine(25 µM)可阻断由丙泊酚和异氟烷引起的GABAmIPSCs,却不能改变增强的维持电流。相反,GABAA受体的通道阻断剂印防己毒素(100 µM)逆转了由丙泊酚和异氟烷引起的膜维持电流增加。

结论:结果说明全麻药丙泊酚和异氟烷同时增强了相型和张力型GABAA受体介导的CVNs的抑制。

(黄施伟 译,马皓琳 李士通 校)

BACKGROUND: General anesthesia with propofol and isoflurane induces alterations of the cardiovascular system, including hypotension and changes in heart rate. The preganglionic cardiac vagal neurons (CVNs) are one of the major central components controlling heart rate and autonomic regulation. In this study, we examined whether propofol and isoflurane act on phasic or tonic {gamma}-aminobutyric acid type A (GABAA) receptor-mediated inhibition in CVNs.

METHODS: CVNs were identified in vitro by retrograde fluorescent labeling. Phasic and tonic GABA currents in CVNs were examined using the whole cell patch-clamp technique.

RESULTS: Propofol (10 µM) increased the membrane holding currents by 63 ± 13% and prolonged the decay time of GABAergic miniature inhibitory postsynaptic currents (mIPSCs) from 42.3 ± 2.8 ms in control to 61.8 ± 4.5 ms. Isoflurane, at concentrations of 100, 300, and 500 µM, decreased GABAergic mIPSCs frequency by 26.0 ± 16%, 64.6 ± 10.4%, and 70.5 ± 9.8%, prolonged the decay time of GABAergic mIPSCs from 47.9 ± 7.3 to 64.5 ± 8.1 ms, 70.3 ± 10.4 ms, and 66.8 ± 8.1 ms, and increased the membrane holding currents by 32.8 ± 12.8%, 42.7 ± 10%, and 39.9 ± 3%, respectively. The GABAergic antagonist gabazine (25 µM) blocked GABAergic mIPSCs, but failed to alter the enhanced holding potential induced by propofol and isoflurane. In contrast, the channel blocker of GABAA receptors, picrotoxin (100 µM), reversed the propofol and isoflurane-evoked increase in membrane holding current.

CONCLUSION: The results demonstrate that the general anesthetics propofol and isoflurane enhance both phasic and tonic GABAA receptor-mediated inhibition of CVNs.



挥发性芳香族麻醉剂对N-甲基-d-天冬氨酸受体的抑制和制动作用的分子基础的比较

A Comparison of the Molecular Bases for N-Methyl-d-Aspartate-Receptor Inhibition Versus Immobilizing Activities of Volatile Aromatic Anesthetics

Jason C. Sewell, PhD*, Douglas E. Raines, MD{dagger}{ddagger}, Edmond I. Eger, II, MD§, Michael J. Laster, DVM§, and John W. Sear, PhD, FFARCS*

From the *Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Headington, UK; {dagger}Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts; {ddagger}Department of Anesthesia, Harvard Medical School, Boston, Massachusetts; and §Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Anesth Analg 2009; 108:168-175

背景:芳香族麻醉剂显示出广泛的抑制N-甲基-d-天冬氨酸(NMDA)受体的作用和制动作用。我们试图使用比较分子场分析(CoMFA)方法确定其抑制NMDA受体的分子基础特征,并且与采用等效模型对其制动作用进行研究得到的结果进行了比较。

方法:14种已发表的效能资料加上另外两种药物的新资料。麻醉药被分成用于构成药效模型的训练组(n=12)和用于独立验证模型预测能力的实验组(n=4)。采用从头开始量子力学对麻醉药物的结构进行几何学优化,并用场匹配最小化来排列以提供分子的立体结构与静电场之间的最佳相关性以及一个或多个带头结构。保留能产生具有最佳预测能力(使用弃一法交叉核实来评估)的CoMFA模型的方向。

结果:用于抑制NR1/NR2B 受体的最终CoMFA模型能够解释所观察的12套训练组药物活性差异的99.3%(F2,9 = 661.5, P < 0.0001)。该模型有效预测了训练组(交叉核实的r2CV = 0.944)4套被排除的实验组药物(预测的r2Pred = 0.966)的抑制活性。用于对伤害性刺激的制动反应的等效模型能解释所观察到的训练组活性差异的98.0% (F2,9 = 219.2, P < 0.0001),且对训练组(r2CV = 0.872)和实验组(r2Pred = 0.926)显示出足够的预测能力。对药效团地图进行比较表明几个关键立体和静电区域共同存在于这两种活性模型中,但是观察到关于麻醉药两方面活性的关键区域的相对重要性有差别。

(颜涛 译, 马皓琳 李士通 校)

BACKGROUND: Aromatic anesthetics exhibit a wide range of N-methyl-d-aspartate (NMDA) receptor inhibitory potencies and immobilizing activities. We sought to characterize the molecular basis of NMDA receptor inhibition using comparative molecular field analysis (CoMFA), and compare the results to those from an equivalent model for immobilizing activity.

METHODS: Published potency data for 14 compounds were supplemented with new values for 2 additional agents. The anesthetics were divided into a training set (n = 12) used to formulate the activity models and a test set (n = 4) used to independently assess the models’ predictive capability. The anesthetic structures were geometry optimized using ab initio quantum mechanics and aligned by field-fit minimization to provide the best correlation between the steric and electrostatic fields of the molecules and one or more lead structures. Orientations that yielded CoMFA models with the greatest predictive capability (assessed by leave-one-out cross-validation) were retained.

RESULTS: The final CoMFA model for the inhibition of NR1/NR2B NMDA receptors explained 99.3% of the variance in the observed activities of the 12 training set agents (F2,9 = 661.5, P < 0.0001). The model effectively predicted inhibitory potency for the training set (cross-validated r2CV = 0.944) and 4 excluded test set compounds (predictive r2Pred = 0.966). The equivalent model for immobility in response to noxious stimuli explained 98.0% of the variance in the observed activities for the training set (F2,9 = 219.2, P < 0.0001) and exhibited adequate predictive capability for both the training set (r2CV = 0.872) and test set (r2Pred = 0.926) agents. Comparison of pharmacophoric maps showed that several key steric and electrostatic regions were common to both activity models, but differences were observed in the relative importance of these key regions with respect to the two aspects of anesthetic activity.

CONCLUSIONS: The similarities in the pharmacophoric maps are consistent with NMDA receptors contributing part of the immobilizing activity of volatile aromatic anesthetics.



术中磁共振成像设备的电噪声

Electrical Noise in the Intraoperative Magnetic Resonance Imaging Setting

Roger Dzwonczyk, MSBME*, Jeffrey T. Fujii, BS*, Orlando Simonetti, PhD{dagger}, Ricardo Nieves-Ramos, MD*, and Sergio D. Bergese, MD*

From the Departments of *Anesthesiology, and {dagger}Cardiovascular Medicine, The Ohio State University, Columbus, Ohio.

Anesth Analg 2009; 108:181-186

背景:现在术中磁共振成像(iMRI)是神经外科常用的工具。在这个手术室环境中安全可靠的患者监护依赖于这样的环境:电噪声(EN)没有干扰电子监护或成像设备的运作。在本调查中,我们评估了在本手术室中使用的iMRI系统和麻醉病人监护仪产生的EN对这两种设备性能的影响。

方法:我们衡量了我们的iMRI兼容麻醉病人监护仪产生的由我们的iMRI系统中EN分析公式检测到的EN。我们衡量了我们的iMRI系统在扫描中产生的由我们病人监护仪中的心电图(ECG)波形检测到的EN。我们分析了我们的iMRI兼容的麻醉病人监护仪提供的ECG噪声滤波器对EN减少和信号质量的影响

结果:通过iMRI EN分析公式检测到了我们的病人监护仪产生的EN,然而,这种干扰是在iMRI扫描时iMRI制造商可接受的限度内(超过背景系统水平噪声的<10%)。在临床病例分析中,iMRI产生的窄带低频(20Hz)相对高能量的EN干扰了我们的病人监护仪的ECG信号。这种ENiMRI系统扫描过程中产生的听觉噪声相关,并和iMRI系统射频(RF)和磁梯度脉动有关。在扫描时,ECG波形的完整性几乎完全丧失。ECG监护仪的滤波器减少但不能完全消除这种20Hz的干扰。我们发现滤波器改变了ECG信号的形态,这可能使我们分辨临床相关的ECG改变变得困难。

结论:我们的麻醉患者监护仪产生的ENiMRI系统可接受的限度内,但iMRI产生的EN却使大多数通常使用的滤波模式下的ECG无法读取。监护仪滤波器减少这种噪声,但也改变ECG波形的形态。麻醉学医师必须知道这些技术的弊端,并认识到在iMRI扫描时需要调节监护仪上的ECG滤波器以获得对病人监护有用的ECG信号,但是ECG的诊断价值将减少。

(王宏译,马皓琳、李士通校)

BACKGROUND: Intraoperative magnetic resonance imaging (iMRI) is a tool now commonly used in neurosurgery. Safe and reliable patient care in this (or any other) operating room setting depends on an environment, where electrical noise (EN) does not interfere with the operation of the electronic monitoring or imaging equipment. In this investigation, we evaluated the EN generated by the iMRI system and the anesthesia patient monitor used at this institution that impacts the performance of these two devices.

METHODS: We measured the EN generated by our iMRI-compatible anesthesia patient monitor as detected by the EN analysis algorithm in our iMRI system. We measured the EN generated by our iMRI system during scanning as detected in the electrocardiogram (ECG) waveform of our patient monitor. We analyzed the effects on EN reduction and signal quality of the ECG noise filters provided in our iMRI-compatible anesthesia patient monitor.

RESULTS: Our patient monitor generated EN that was detectable by the iMRI EN analysis algorithm; however, this interference was within the iMRI manufacturer’s acceptable limits for an iMRI scan (<10% more than background system-level noise). In the clinical case analyzed, the iMRI generated a narrow-band low-frequency (20 Hz) relatively high-energy EN that interfered with the ECG signal of our patient monitor during an iMRI scan. This EN was correlated with the acoustic noise from the iMRI system during the scan and was associated with the radio frequency (RF) and magnetic gradient pulsations of the iMRI system. The integrity of the ECG waveform was nearly entirely lost during a scan. The filters of the ECG monitor diminished but did not entirely eliminate this 20 Hz interference. We found that the filters alter the morphology of the ECG signal, which may make it difficult to identify clinically relevant ECG changes.

CONCLUSION: The EN generated by our anesthesia patient monitor is within acceptable limits for the iMRI system. The iMRI generates EN which renders the ECG unreadable in the most commonly used filter mode. The monitor’s filters diminish this noise but also alter the morphology of the ECG waveform. The anesthesiologist must be cognizant of these technical compromises and recognize that adjusting the ECG filters on the monitor is required to obtain a useful ECG signal for patient monitoring during the iMRI scan but that the diagnostic value of the ECG will be reduced.



引介先进术中方案的新颖程序:一种减轻危害和促进病人安全的多学科规范

A Novel Process for Introducing a New Intraoperative Program: A Multidisciplinary Paradigm for Mitigating Hazards and Improving Patient Safety

Jose M. Rodriguez-Paz, MD*, Lynette J. Mark, MD*, Kurt R. Herzer*, James D. Michelson, MD{dagger}, Kelly L. Grogan, MD*, Joseph Herman, MD, MSc{ddagger}, David Hunt, RN§, Linda Wardlow, RN§, Elwood P. Armour, PhD{ddagger}, and Peter J. Pronovost, MD, PhD*§

From the *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; {dagger}Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, Vermont; Departments of {ddagger}Radiation Oncology and Molecular Radiation Sciences, and §Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Anesth Analg 2009; 108:202-210

背景:自从医学会通报《To Err is Human》发表后,人们设计并应用了众多的措施去改正导致医疗差错和不良事件的医疗缺陷。无论如何,大多数努力在很大程度上还是有效的。人们把大部分目光投向安全性、沟通、团队表现、有效性等领域的同时,还特别注重新技术、方法和操作的引进。我们描述了在引进一种新技术――高剂量率术中放射治疗(HDR-IORT)前,我们医院用于鉴定和减少医疗危害的多学科程序。

方法:组建包括手术医生、麻醉医生、肿瘤放射治疗医生、物理学家、护士、医院风险管理者和设备专家在内的多学科小组,采用包括原位临床模拟的结构性程序来揭示医护人员之间的利害关系,并前瞻性地鉴定和减轻用HDR-IORT技术进行手术对病人产生的缺陷。

结果:在应用于真实病人之前,我们在模拟医疗病人监护程序中明确并改正了20 处缺陷。随后,8位病人接受HDR-IORT手术过程中再没有出现模拟法明确的或意料之外的缺陷。

结论:采用系统性程序引介HDR-IORT技术具有多重优点;换言之,治疗该特定患者群体的安全性和有效性是最佳化的,而且用于真实病人前,采用这种程序可以减少有害和不良事件的发生。需要进一步的研究,但是本文概括的程序可以广泛用于任何新技术、新疗法或新操作的引介。

(江继宏 译  马皓琳 李士通 校)

BACKGROUND: Since the Institute of Medicine’s report, To Err is Human, was published, numerous interventions have been designed and implemented to correct the defects that lead to medical errors and adverse events; however, most efforts were largely reactive. Safety, communication, team performance, and efficiency are areas of care that attract a great deal of attention, especially regarding the introduction of new technologies, techniques, and procedures. We describe a multidisciplinary process that was implemented at our hospital to identify and mitigate hazards before the introduction of a new technique: high-dose-rate intraoperative radiation therapy, (HDR-IORT).

METHODS: A multidisciplinary team of surgeons, anesthesiologists, radiation oncologists, physicists, nurses, hospital risk managers, and equipment specialists used a structured process that included in situ clinical simulation to uncover concerns among care providers and to prospectively identify and mitigate defects for patients who would undergo surgery using the HDR-IORT technique.

RESULTS: We identified and corrected 20 defects in the simulated patient care process before application to actual patients. Subsequently, eight patients underwent surgery using the HDR-IORT technique with no recurrence of simulation-identified or unanticipated defects.

CONCLUSION: Multiple benefits were derived from the use of this systematic process to introduce the HDR-IORT technique; namely, the safety and efficiency of care for this select patient population was optimized, and this process mitigated harmful or adverse events before the inclusion of actual patients. Further work is needed, but the process outlined in this paper can be universally applied to the introduction of any new technologies, treatments, or procedures.



急性间质性肺炎(Hamman-Rich综合征)的临床表现和诊断治疗

Acute Interstitial Pneumonia–Hamman-Rich Syndrome: Clinical Characteristics and Diagnostic and Therapeutic Considerations

Lone S. Avnon, MD*, Oleg Pikovsky, MD{dagger}, Neta Sion-Vardy, MD{ddagger}, and Yaniv Almog, MD§

From the *Division of Pulmonary Medicine, Departments of {dagger}Medicine, {ddagger}Pathology, and §Medical Intensive Care Unit, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel.

Anesth Analg 2009; 108:232-237

背景:急性间质性肺炎是一种快速进展的疾病,常导致呼吸衰竭和机械通气治疗。尽管努力地诊断和治疗,但预后仍很差。

方法:在这个回顾性群体调查中,选取了达到急性特发性间质性肺炎预定义标准的低氧血症性呼吸衰竭的患者。回顾患者的记录、放射学研究资料以及病理标本。所有数据记录在每个患者的研究文件中随后分析。

结果:此次回顾包括5位男性和4位女性患者,平均年龄69.4岁(55-80岁)。所有患者的胸片在12天后都进展为双侧弥漫性渗透表现。所有9位患者通过经支气管活检或开放式肺活检都发现与急性间质性肺炎相符的弥漫性肺泡损害的组织学证据。所有患者都需要收入内科重症监护室,并进行机械通气。死亡率100%,患者在进入重症监护室5-36天死亡。

结论:急性间质性肺炎(Hamman-Rich综合征)是一种特发性的、快速进展的且有时致命的肺间质疾病。经支气管活检是合理的第一步诊断方法,如果需要的话,接着可以进行开放的肺活检。在我们的研究中皮质类固醇效果很小。对常规治疗失败且有合适的供体的患者,可考虑肺移植作为另外一种选择。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Acute interstitial pneumonia is a rapidly progressive disease frequently leading to respiratory failure and mechanical ventilation. The prognosis is usually poor despite aggressive diagnostic and treatment efforts.

METHODS: In this retrospective cohort survey, we enrolled patients with hypoxemic respiratory failure who met predefined criteria of acute idiopathic interstitial pneumonia. Patients’ records, radiologic studies, and pathologic specimens were reviewed. All data were recorded in each patient’s study file and subsequently analyzed.

RESULTS: Our cohort consisted of 5 men and 4 women with a mean age of 69.4 yr (55–80 yr). The chest radiograph in all patients progressed to diffuse bilateral infiltrates over a 12-day course. All nine patients had histological proof of diffuse alveolar damage consistent with acute interstitial pneumonia, obtained by either transbronchial biopsy or open lung biopsy. All patients required admission to the medical intensive care unit and mechanical ventilation. The mortality rate was 100%, and patients died within 5–26 days of their admission to the unit.

CONCLUSIONS: Acute interstitial pneumonia (Hamman-Rich syndrome) is an idiopathic, rapidly progressive and, at times, fatal form of interstitial lung disease. A transbronchial biopsy is a logical first diagnostic step, to be followed by an open lung biopsy, if necessary. Response to corticosteroids in our series was minimal. In patients who fail to respond to conventional therapy and are otherwise appropriate candidates, lung transplantation may be considered as an additional alternative.



分娩硬膜外镇痛用于产时剖宫产失败:一项回顾性研究

Failure of Augmentation of Labor Epidural Analgesia for Intrapartum Cesarean Delivery: A Retrospective Review

Shuying Lee, MMed, Eileen Lew, MMed, Yvonne Lim, MMed, and Alex T. Sia, MMed

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

Anesth Analg 2009; 108:252-254

在这项研究中,我们的目的在于确定与分娩硬膜外镇痛用于剖宫产失败的发生率和预测因素。我们对18个月期间已接受硬膜外分娩镇痛但随后需要接受产时剖宫产的产妇进行回顾性分析。用单变量逻辑回归分析鉴定在硬膜外麻醉应该起效的足够时间里硬膜外镇痛平面弥散失败的预见因素。在1025名产妇中,1.7%硬膜外麻醉弥散失败。硬膜外麻醉失败的预测因素包括:仅用单纯硬膜外麻醉进行分娩镇痛(与腰硬联合麻醉相比)(P = 0.001),分娩期间经历了两阶段极其强烈的疼痛(P < 0.001),以及硬膜外分娩镇痛持续时间过长(P = 0.02)

(黄佳佳译,马皓琳 李士通校)

In this study, we aimed to identify the incidence and predictive factors associated with failed labor epidural augmentation for cesarean delivery. Data of parturients, who had received neuraxial labor analgesia and who subsequently required intrapartum cesarean delivery during an 18-mo period, were retrospectively studied. Predictors associated with failure of extension of epidural analgesia in the presence of adequate time for onset of epidural anesthesia were identified by univariate logistic regression. Of the 1025 parturients, 1.7% had failed epidural extension. Predictors of failed epidural anesthesia included initiation of labor analgesia with plain epidural technique (compared to combined spinal-epidural) (P = 0.001), ≥2 episodes of breakthrough pain during labor (P < 0.001) and prolonged duration of neuraxial labor analgesia (P = 0.02).


β肾上腺素受体拮抗剂对大鼠蛛网膜下腔出血后促炎细胞因子浓度的影响

The Effects of β-Adrenoceptor Antagonists on Proinflammatory Cytokine Concentrations After Subarachnoid Hemorrhage in Rats

Haruto Kato, MD, Masahiko Kawaguchi, MD, Satoki Inoue, MD, Katsuji Hirai, MD, and Hitoshi Furuya, MD

From the Department of Anesthesiology, Nara Medical University, Kashihara City, Nara, Japan.

Anesth Analg 2009; 108:288-295

背景:蛛网膜下腔出血(SAH)后脑脊液(CSF)中促炎细胞因子的浓度会升高。近来的研究提示β肾上腺素受体拮抗剂可能减少促炎细胞因子。我们的研究就是为了证明β肾上腺素受体拮抗剂是否能减少大鼠蛛网膜下腔出血后促炎细胞因子。

方法:实验1,为了观察白介素6(IL-6)和肿瘤坏死因子(TNF-{alpha})的时程,大鼠随机分组:蛛网膜下腔出血或伪实验后13612小时。在相同时点,抽取脑脊液和血样。实验2,为了研究β肾上腺素受体拮抗剂对IL-6TNF-{alpha}浓度的影响,大鼠随机分为以下几组:1) 对照组:蛛网膜下腔出血+生理盐水,2) 普萘洛尔组:蛛网膜下腔出血+普萘洛尔,3) 美托洛尔组:蛛网膜下腔出血+美托洛尔,4) 布托沙明组:蛛网膜下腔出血+布托沙明2肾上腺素受体拮抗剂)。在蛛网膜下腔出血后6小时抽取脑脊液和血样。检测样本中的IL-6TNF-{alpha}浓度。

结果:实验1中,大鼠蛛网膜下腔出血后脑脊液中IL-6浓度明显上升,在出血后6小时达到峰值,但TNF-{alpha}浓度一直保持较低水平。实验2中,与对照组相比,普萘洛尔组和布托沙明组脑脊液IL-6浓度明显较低(分别为P < 0.01 P < 0.05)。血浆IL-6、脑脊液TNF-{alpha}和血浆TNF-{alpha}4组比较无统计学差异。

结论:大鼠蛛网膜下腔出血急性期脑脊液IL-6浓度会明显升高,β肾上腺素受体拮抗剂或β2肾上腺素受体阻滞作用会抑制大鼠SAHIL-6浓度的升高。

(张莹译  马皓琳 李士通校)

BACKGROUND: Proinflammatory cytokines increase in cerebrospinal fluid (CSF) after subarachnoid hemorrhage (SAH). Recent evidence suggested that β-adrenoceptor antagonist could reduce proinflammatory cytokines. We conducted the present study to examine whether β-adrenoceptor antagonists would reduce proinflammatory cytokine concentrations after SAH in rats.

METHODS: In Experiment 1, to investigate the time course of interleukin-6 (IL-6) and tumor necrosis factor-{alpha} (TNF-{alpha}), rats were randomized into groups: 1, 3, 6, and 12 h after SAH or sham operation. CSF and blood samples were obtained at each time point. In Experiment 2, to investigate the effects of β-adrenoceptor antagonists on the IL-6 and TNF-{alpha} concentrations, rats were randomized into groups: 1) control group: SAH + normal saline, 2) propranolol group: SAH + propranolol, 3) metoprolol group: SAH + metoprolol, and 4) butoxamine group: SAH + butoxamine (β2-adrenoceptor antagonist). CSF and blood samples were obtained 6 h after SAH. IL-6 and TNF-{alpha} concentrations in samples were measured.

RESULTS: In Experiment 1, CSF IL-6 concentrations in the SAH groups increased markedly and peaked at 6 h after SAH, whereas CSF TNF-{alpha} concentrations in the SAH groups were consistently low. In Experiment 2, CSF IL-6 concentrations in the propranolol and butoxamine groups were significantly lower compared with those in the control group (P < 0.01 and P < 0.05 for each group). Plasma IL-6, CSF TNF-{alpha}, and plasma TNF-{alpha} concentrations were comparable in all four groups.

CONCLUSIONS: CSF IL-6 concentrations increased in the acute stage of SAH and β-adrenoceptor antagonists with a β2-adrenoceptor blocking action suppressed this elevation of IL-6 concentrations after SAH in rats.



髂腹股沟-髂腹下神经和肋间神经联合阻滞对肾移植受体术后缓解疼痛的效果

The Efficacy of Ilioinguinal-Iliohypogastric and Intercostal Nerve Co-Blockade for Postoperative Pain Relief in Kidney Recipients

Gita Shoeibi, MD, Babak Babakhani, MD, and Sussan Soltani Mohammadi, MD

From the Department of Anesthesia and Intensive Care Medicine, Dr. Shariati Hospital, Tehran University of Medical Sciences, Iran.

Anesth Analg 2009; 108:330-333

背景:肾移植患者术后疼痛是很剧烈的。全身性的镇痛会因为肾功能受损而产生严重的并发症。我们来研究是否低位肋间神经阻滞联合髂腹股沟-髂腹下(IG-IH)神经阻滞是否能改善镇痛的效果,从而减少术后24小时内吗啡的用量。

方法:42例行肾移植的患者随机平均分成两组,运用相同的麻醉方法。手术后在术侧用0.5%布比卡因进行髂腹股沟-髂腹下神经阻滞和T11T12肋间神经阻滞。对照组不进行阻滞。术后疼痛程度和吗啡的用量由一个不知道分组情况的人进行记录。

结果:在研究组的所有时间点上两组的直观类比标度评分(25th-75th)测量结果的中位数有显著性差异(P<0.05)24小时吗啡的用量,阻滞组12.7 ± 10.5 mg,对照组34.9 ± 5.9 mg,有显著性差异(P < 0.001)

讨论:肾移植术后运用髂腹股沟-髂腹下神经和低位肋间神经联合阻滞能显著缓解术后疼痛和减少阿片类药物用量。

(唐亮 译  马皓琳 李士通 校)

BACKGROUND: Postoperative pain is severe in patients undergoing renal transplantation. Systemic analgesia may produce complications as a result of impaired renal function. We investigated whether combined lower intercostal and Ilioinguinal-Iliohypogastric (IG-IH) nerve block might improve the quality of analgesia and reduce morphine consumption during the first 24 h after surgery.

METHODS: Forty-two patients, scheduled as kidney transplant recipients were randomized into two equal groups and were anesthetized with the same technique. After surgery IG-IH, T11 and T12 intercostal nerves on the side of surgery were blocked by bupivacaine 0.5%. The control group was not blocked. Postoperative pain and total amount of morphine consumption were recorded by a person who was blinded to the allocation.

RESULTS: There were significant differences in median visual analog scale scores (25th–75th) measurements at all time points in the study groups (P < 0.05). The total amount of morphine consumption during 24 h was 12.7 ± 10.5 mg in the blocked group compared with 34.9 ± 5.9 mg in the nonblocked group (P < 0.001).

CONCLUSIONS: Combined IG-IH and lower intercostal nerves blockade after renal transplantation significantly reduced postoperative pain and opioid consumption.



通过对成人手术病人行硬膜外神经刺激联合持续硬膜外镇痛评价硬膜外导管的位置

An Evaluation of the Epidural Catheter Position by Epidural Nerve Stimulation in Conjunction with Continuous Epidural Analgesia in Adult Surgical Patients

Johannes G. Förster, MD*, Tomi T. Niemi, MD, PhD*, Markku T. Salmenperä, MD, PhD*, Saana Ikonen, MD, PhD{dagger}, and Per H. Rosenberg, MD, PhD*

From the Departments of *Anesthesiology and Intensive Care Medicine, and {dagger}Radiology, Helsinki University Hospital, Helsinki, Finland.

Anesth Analg 2009; 108:351-358

背景:确定硬膜外导管位置的硬膜外刺激试验已经被描述为一种简单、快速、值得信赖的方法。我们评价了硬膜外刺激试验的可行性和其对有效的术后持续硬膜外镇痛的潜在性作用。

方法:进行大的腹部手术或开胸手术的30名成年病人(ASA I–III)术后在胸段水平接受持续的硬膜外镇痛。分别在导管置入后、局部麻醉药推注后、硬膜外镇痛过程中,对每位病人进行最多6次的硬膜外刺激试验。通过硬膜外造影术对病人的硬膜外导管的位置进行核实(在硬膜外镇痛开始前以及术后第二天再次进行核实)。

结果:一些技术问题(如为了使大于25%的测量结果中维持有足够的刺激,需要用盐水冲洗导管)和一些判断问题(如呼吸运动的干扰[n = 6])使在导管放置时以及硬膜外镇痛期间完成硬膜外刺激试验更加费时。在导管放置后的即刻(试验剂量前),硬膜外刺激试验并不能完全鉴别出脊椎管外的所有4根导管的位置。而且,最先的硬膜外刺激试验表明在25个正确放置在硬膜外腔的导管中,有3根可能位于鞘内或椎旁。在导管尖端位于硬膜外且硬膜外先前或同时注射局麻药的122个结果中,共有107个硬膜外刺激试验引出了运动反应(88%)。在所有的25名硬膜外造影术阳性的病人中,连续的硬膜外镇痛均提供了充分的疼痛缓解。

结论:硬膜外刺激试验通常与技术难题和判断困难相联系。在进行术后硬膜外连续镇痛的病人中,为了保证质量反复应用硬膜外刺激试验的作用仍未确定。

(黄丽娜 译 马皓琳 李士通 校)

BACKGROUND: The epidural stimulation test to confirm epidural catheter position has been described as being simple, fast, and reliable. We evaluated the feasibility of the epidural stimulation test and its potential in contributing to effective postoperative continuous epidural analgesia.

METHODS: Thirty adult patients (ASA I–III) undergoing major abdominal surgery or thoracotomy were to receive continuous epidural analgesia at a thoracic level postoperatively. The epidural stimulation test was performed after catheter placement, after local anesthetic boluses, and during epidural analgesia, up to six times in each patient. Catheter positions were verified by epidurography (before start of epidural analgesia and again on the second postoperative day).

RESULTS: Several technical issues (e.g., need to flush catheter with saline in order to maintain adequate stimulation during >25% of all measurements) and interpretation problems (e.g., interference of respiratory activity [n = 6]) made the implementation of the epidural stimulation test rather time consuming, both at the time of catheter placement and during epidural analgesia. Immediately after catheter placement (before test dose) the epidural stimulation test did not identify four of four catheters positioned outside the spinal canal. In addition, the initial epidural stimulation test indicated a possible intrathecal or paravertebral placement in 3 of 25 catheters correctly positioned in the epidural space. During 107 of 122 (88%) measurements with the catheter tip situated epidurally and with preceding or simultaneous administration of epidural local anesthetic, the epidural stimulation test elicited a motor response. Continuous epidural analgesia provided adequate pain relief in all 25 patients having positive epidurography.

CONCLUSIONS: The epidural stimulation test was often associated with technical difficulties and interpretation problems. The role of the repeated use of the epidural stimulation test for quality assurance in patients undergoing postoperative continuous epidural analgesia remains undetermined.



曲马多应用于利多卡因腋路法臂丛神经阻滞的辅助用药

Tramadol as an Adjuvant to Lidocaine for Axillary Brachial Plexus Block

Olfa Kaabachi, MD*, Rami Ouezini, MD*, Walid Koubaa, MD*, Badii Ghrab, MD*, Amin Zargouni, MD*, and Ahmed Ben Abdelaziz, MD{dagger}

From the *Department of Anesthesiology and Intensive Care Medicine, Kassab Orthopedic Institute, Ksar Said, Tunis, Tunisia; and {dagger}Department of Statistics, Sahloul Hospital, Sousse, Tunisia.

Anesth Analg 2009; 108:367-370

背景:在本次前瞻性随机研究中,我们研究了曲马多应用于腋路法臂丛神经阻滞的辅助用药的效果。

方法:我们选取了102位行择期手部手术采用腋路法臂丛神经阻滞麻醉的病人,神经阻滞时给予1.5%的利多卡因(加入1/200,000的肾上腺素),对照组再给予4mL盐水,TL组再给予100mg曲马多和2mL盐水,TH组再给予200mg曲马多。

结果:起效时间在TH组显著延长,16 ± 7 min (对照组是9 ± 3 min; P = 0.01)。感觉阻滞(TH265 ± 119 minTL190 ± 87 min,对照组126 ± 48 min; P = 0.018)和第一次需要镇痛的时间(TH734 ± 434 minTL573 ± 516 min,对照组375 ± 316 min; P = 0.02)TH组都比TL组和对照组显著延长。

结论:曲马多应用于利多卡因腋路法臂丛神经阻滞的辅助用药可以延长阻滞时间,但是有起效慢的局限性。

(姜旭晖 译  马皓琳 李士通 校)

BACKGROUND: In this prospective randomized study, we evaluated the effect of tramadol as an adjuvant to axillary block.

METHODS: We studied 102 patients scheduled for hand surgery under axillary block with lidocaine 1.5% (epinephrine 1/200,000) and the addition of either 4 mL saline (control group), 100 mg tramadol and 2 mL saline (TL group), or 200 mg tramadol (TH group).

RESULTS: Onset time was longer in the TH group, 16 ± 7 min (9 ± 3 min in control group; P = 0.01). Sensory block and time for first rescue analgesia were significantly prolonged in the TH group compared with both TL and control groups (265 ± 119 min vs 190 ± 87 min vs 126 ± 48 min; P = 0.018); (734 ± 434 min vs 573 ± 516 min vs 375 ± 316 min; P = 0.02).

CONCLUSIONS: The benefit of block prolongation associated with the addition of 200 mg tramadol to lidocaine during axillary block is limited by the slow onset of the block.

 

在兔子鞘膜内进行吗啡预处理可以通过激活δκμ阿片类受体产生心脏保护

Intrathecal Morphine Preconditioning Induces Cardioprotection via Activation of Delta, Kappa, and Mu Opioid Receptors in Rats

Rui Li, Gordon T. C. Wong, Tak Ming Wong, Ye Zhang, Zhengyuan Xia, and Michael G. Irwin

Department of Anesthesiology, University of Hong Kong, Hong Kong

Anesth Analg 2009 108: 23-29.

 

背景:鞘膜内小剂量的吗啡可以产生和静脉注射吗啡相似的心脏保护作用。但是,鞘膜内吗啡预处理(IT-MPC)的效果是否因缺血预处理引起是未知的。而且,IT-MPC是否通过由阿片类受体介导也是未知的。在此项研究中,我们比较IT-MPCIPC的心脏保护效果以及调查阿片类受体在其中所起的作用。

方法80只雄性的,在麻醉后行开胸手术的Sprague-Dawley兔子在成功气管插管后分为1-13组(n=6-7)。IPC组的兔子要进行5分钟的心肌缺血(通过阻断左冠状动脉主干),然后再灌注5分钟,重复3次。在IPC后,心肌的缺血再灌注损伤在左主干阻断半小时,再灌注2小时后出现。IT-MPC组中,在心肌缺血再灌注损伤前,兔子分别接受连续三次的鞘膜内注射吗啡(0.03,0.3,3.0,30.0微克/千克),每次间隔5分钟。在另外2组既没有300微克/千克静脉注射吗啡,也没有10微升鞘膜内注射的给与生理盐水。分别给与IT-MPC组的兔子选择性的δκμ受体拮抗剂(naltrindole, nor-binaltorphimine, and D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH2 (CTOP))来评价参与IT-MPC预处理的阿片类受体亚型。用2,3,5-triphenyltetrazolium染色法来确定心肌缺血的大小(IS)及缺血心肌所占百分比(AAR)。

结果:鞘膜内注射0.3-30微克/千克吗啡组和鞘膜内注射生理盐水组心肌IS比较。IS/AAR为:33%+/-10%0.3微克/千克),29%+/-10%3微克/千克),29%+/-16%30微克/千克),与对照组53%+/-8%比较,P<0.01IT-MPCIS/AAR减少与静脉注射吗啡(33%+/-6%P=0.84)和IPC组(22%+/-4%P=0.41)相似。IT-MPC联合应用阿片类受体拮抗剂的心肌预处理效果减弱(IT-MPC+naltrindole 50% +/- 9%, IT-MPC + nor binaltorphimine 43% +/- 6%, IT-MPC + CTOP 53% +/- 9%, P = 0.14)

结论IT-MPC产生与静脉注射吗啡和IPC相似的心肌保护。鞘膜内注射吗啡的心脏预处理与δκμ阿片类受体相关。

(胡艳译  薛张纲校)

BACKGROUND: Small doses of intrathecal morphine provide cardioprotection similar to that conferred by IV morphine. However, the extent of intrathecal morphine preconditioning (IT-MPC) relative to that resulting from ischemic preconditioning (IPC) is unknown. Further, it is uncertain whether IT-MPC is mediated by opioid receptor dependent pathways. In this study, we compared the extent of cardioprotection conferred by IT-MPC with IPC and investigated the role of opioid receptors in this effect.

METHODS: Eighty anesthetized, open-chest, male Sprague-Dawley rats were assigned to 1 of 13 groups (n = 6-7) after successful intrathecal catheter placement. Rats in the IPC group were subjected to three 5-min cycles of myocardial ischemia (induced by occlusion of the left main coronary artery) interspersed with 5 min of reperfusion. After IPC, myocardial ischemia and reperfusion injury was induced by 30 min of left main coronary artery occlusion followed by 2 h of reperfusion. In the IT-MPC groups, the rats were given 3 consecutive 5 min intrathecal morphine infusions (0.03, 0.3, 3.0, or 30.0 microg/kg, respectively) interspersed with 5 min infusion-free periods, before myocardial ischemia reperfusion injury. In 2 other groups either 300microg/kg of IV morphine or 10 microL of intrathecal normal saline were given. The selective delta, kappa, and mu opioid receptor antagonists naltrindole, nor-binaltorphimine, and D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH2 (CTOP), respectively, were given to groups of animals receiving IT-MPC to evaluate the relative role of the specific opioid receptor subtypes in IT-MPC preconditioning. Myocardial infarct size (IS), as a percentage of the area at risk (AAR), was determined by 2,3,5-triphenyltetrazolium staining.

RESULTS: Intrathecal morphine 0.3 to 30 microg/kg reduced myocardial IS compared with intrathecal normal saline control animals. The IS/AAR were 33% +/- 10% (0.3 microg/kg), 29% +/- 10% (3 microg/kg) and 29% +/- 16% (30 mug/kg), versus 53% +/- 8% for the control group (P < 0.01). The reduction in IS/AAR with IT-MPC was similar to that produced by IV morphine (33% +/- 6%, P = 0.84) and IPC (22% +/- 4%, P = 0.41). Myocardial preconditioning due to IT-MPC was attenuated by co-administration of any one of the opioid receptor antagonists (IT-MPC + naltrindole 50% +/- 9%, IT-MPC + nor binaltorphimine 43% +/- 6%, IT-MPC + CTOP 53% +/- 9%, P = 0.14).

CONCLUSIONS: IT-MPC produced comparable cardioprotection to myocardial IPC and IV morphine. Myocardial preconditioning from intrathecal morphine seems to involve delta, kappa, and mu opioid receptors.

 

 

外伤性脑损伤儿童围术期高血糖发生率及危险因子

Incidence and Risk Factors for Perioperative Hyperglycemia in Children with Traumatic Brain Injury

Deepak Sharma, Jill Jelacic, Rohini Chennuri, Onuma Chaiwat, Wayne Chandler, and Monica S. Vavilala

Department of Anesthesiology, Harborview Injury Prevention and Research Center, Departments of Laboratory Medicine, Pediatrics and Neurological Surgery, and Harborview Anesthesia Research Center, University of Washington, Seattle, Washington

Anesth Analg 2009 108: 81-89.

 

背景:外伤性脑损伤(TBI)后高血糖与不良预后相关。本研究验证了外伤性脑损伤儿童围术期高血糖发生率及危险因子。

方法:对1994年至2004年于Harborview医学中心(I级成人及儿科外伤中心)行紧急或急诊颅骨切开术且年龄<=13岁的儿童进行回顾性队列研究。回顾每位患者术前(急诊部至全麻开始),术中(全麻中)和术后即刻(术后24小时)的血糖值。确定高血糖(血糖>=200 mg/dL)和低血糖(血糖<60 mg/dL)的范围。持续性高血糖定义为2/3的研究时段(术前,术中和术后即刻)发生高血糖,而暂时性高血糖定义为仅一个研究时段发生高血糖。使用多因素logistic回归分析确定围术期高血糖的独立预测因子。数据以调整后的OR(AOR) (95% 可信区间)表示,P < 0.05表示有显著性差异。

结果:每个研究时段至少记录一个血糖值的情况如下:术前(86 [82%]),术中(94 [89%])和术后(101 [97%])64%的儿童麻醉中血糖记录每小时少于1次。47(45%)的儿童在至少一个研究时段中发生高血糖。29(28%)儿童发生暂时性高血糖,18(17%)儿童发生持续性高血糖。围术期高血糖的独立预测因子为年龄<4(AOR [95% CI]; 3.5 [1.2-10.6])Glasgow昏迷评分<=8 (AOR 95% CI; 7.2 [2.4-21.5])和存在包括硬脑膜下血肿在内的多发伤。六名儿童接受胰岛素治疗,两名儿童发生与胰岛素治疗无关的低血糖。

结论:围术期高血糖较常见,而术中低血糖亦非罕见,但术中血糖采样频率应更高才能更好的确定围术期低血糖和高血糖的发生率。年龄<4岁,严重TBI和存在包括硬膜下血肿在内的多发伤是围术期高血糖的危险因子。

(黄凝译  薛张纲校)

BACKGROUND: Hyperglycemia after traumatic brain injury (TBI) is associated with poor outcome. In this study, we examined the incidence and risk factors for perioperative hyperglycemia in children with TBI.

METHODS: A retrospective cohort study of children <=13 yr who underwent urgent or emergent craniotomy for TBI at Harborview Medical Center (level I Adult and Pediatric Trauma Center) between 1994 and 2004 was performed. Preoperative (emergency department to general anesthesia start), intraoperative (during general anesthesia), and immediate postoperative (first 24 h after surgery) glucose values for each patient were retrieved. The incidence of hyperglycemia (glucose >=200 mg/dL) and hypoglycemia (glucose <60 mg/dL) was determined. Persistent hyperglycemia was defined as hyperglycemia during any 2/3 (preoperative, intraoperative, and immediate postoperative) study periods, whereas transient hyperglycemia was defined as hyperglycemia during any one study period. Multivariate logistic regression analysis was used to determine the independent predictors of perioperative hyperglycemia. Data are presented as adjusted odds ratio (AOR) (95% CI) and P < 0.05 reflects significance.

RESULTS: At least one serum glucose value was recorded during each study period: preoperative (86 [82%]), intraoperative (94 [89%]), and postoperative (101 [97%]). Sixty-four percent of children had less than one glucose recorded per anesthetic hour. Forty-seven (45%) children had hyperglycemia during at least one study period. Transient hyperglycemia occurred in 29 (28%) and persistent hyperglycemia occurred in 18 (17%) children. Independent predictors of perioperative hyperglycemia were age <4 yr (AOR [95% CI]; 3.5 [1.2-10.6]), Glasgow Coma Scale <=8 (AOR 95% CI; 7.2 [2.4-21.5]) and the presence of multiple lesions including subdural hematoma (AOR 95% CI; 34.7 [2.3-525.5]). Six children were treated with insulin, and two children had hypoglycemia, unrelated to insulin treatment.

CONCLUSIONS: Perioperative hyperglycemia was common and intraoperative hypoglycemia was not rare, but more frequent intraoperative glucose sampling may be needed to better determine the incidence of hypo and hyperglycemia during the perioperative period. Age <4 yr, severe TBI and the presence of multiple lesions, including subdural hematoma, were risk factors for perioperative hyperglycemia.

 

 

亚专业影响因子:儿科麻醉与疼痛文献的贡献

Subspecialty Impact Factors: The Contribution of Pediatric Anesthesia and Pain Articles

Ramsdell R Lerman JPickhardt D Feldman D Foster J Houle T.

. From the *Department of Anesthesiology, Women and Children’s Hospital of Buffalo, SUNY at Buffalo, New York; {dagger}Department of Anesthesiology, Strong Memorial Hospital, University of Rochester, Rochester, New York; {ddagger}Department of Pediatrics, Women and Children’s Hospital of Buffalo, SUNY at Buffalo, New York; and §Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Anesth Analg 2009;108(1):105-110

 

背景:科学引文索引(杂志影响因子 JIF)广泛用于评价杂志的质量和声誉。麻醉专业的JIF每年都有报道,而这些杂志相关亚专业文献影响因子(IFs)尚无记载。因此,我们比较了两个时期四种麻醉杂志儿科麻醉文献(Ped IFs)和疼痛文献影响因子(Pain IFs)。

方法:通过人工逐篇检索1998199920032004年刊载在美国麻醉杂志、麻醉与镇痛、英国麻醉杂志和加拿大麻醉杂志上儿科麻醉和疼痛论文。采用ISI Web of Science数据库检索这些杂志上发表文章每年被引用的次数。对2000年和2005年相关杂志Ped Ifs Pain Ifs与儿科麻醉杂志进行比较。

结果2005年四种杂志Ped IFs超过其相应杂志2000IF,而Pain IFs保持不变。两者均对杂志IF有重要作用,其中Pain IFs作用比Ped IFs70%。

结论:除了2005年英国麻醉杂志外,Ped IFs一直低于其JIFPain IFs。儿科麻醉文章引用次数大于IF高的杂志同类文章被引用次数。这意味着亚专业IFs需要进一步关注。

(蒋宗明译  薛张纲校)

BACKGROUND: The Science Citation Index “Journal Impact Factor” (JIF) is widely used to assess journal quality and prestige. The JIFs for the specialty anesthesia are reported annually, however, the impact factors (IFs) for subspecialties in those journals have not been reported. Therefore, we compared the IFs of pediatric anesthesia (Ped IFs) and pain (Pain IFs) articles from four anesthesia journals for two epochs.

METHODS: An article-by-article manual search for “source” pediatric anesthesia and pain articles published in 1998, 1999, 2003, and 2004 in Anesthesiology, Anesthesia & Analgesia, British Journal of Anaesthesia, and Canadian Journal of Anesthesia was performed. The citations for each of these articles in each of the years were surveyed in the ISI Web of Science database. Ped IFs and Pain IFs for the 2000 and 2005 epochs were calculated and compared with the JIF from which they were derived and to those of the journal, Pediatric Anesthesia.

RESULTS: Ped IFs for the four journals in 2005 exceeded those in 2000, whereas the Pain IFs were unchanged. For both the Ped IFs and the Pain IFs, there was a significant effect of the journal. The Pain IFs were 70% greater than the Ped IFs.

CONCLUSIONS: Ped IFs were consistently less than the JIFs in which they were published and the Pain IFs, except for the British Journal of Anaesthesia 2005 in the latter case. The numbers of citations of pediatric anesthesia articles were greater in journals with greater IFs. The implications of subspecialty IFs warrant further consideration.

 

 

乳酸林格式液在血浆中稀释度的动静脉差别及分布动力学

Arteriovenous Differences in Plasma Dilution and the Distribution Kinetics of Lactated Ringer's Solution

Christer H. Svensen, Peter M. Rodhe, Joel Olsson, Elisabet Børsheim, Asle Aarsland, and Robert G. Hahn

From the *Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas; {dagger}Department of Clinical Science and Education, Karolinska institutet, Söder Hospital, Stockholm, Sweden; and {ddagger}Clinical Research Center, Södertälje, Sweden.

Anesth Analg 2009 108: 128-133.

 

背景: 传统观念认为输入的晶体液最先分布到血浆中,然后,因为毛细血管对液体的通透性非常高,这些晶体液几乎立刻便与细胞外的液体间隙达到了平衡。而我们则将以根据容量动力学分析所取得的发现来对这一观点提出挑战。

方法:我们让15名志愿者在10分钟内静注输入总量为15 mL/kg的乳酸林格式液,与此同时分别采取其动静脉血样并测量Hgb。得到在前臂的Hgb动静脉差后,再以一个适合的容量动力学模型来分析这一系列的动静脉Hgb浓度。

结果:乳酸林格式液分别在动、静脉中的血浆稀释度仅在输注时和之后的2.5 分钟内有差别,这代表着液体从血浆到组织的时间。动力学分析表明外周体液间隙的容量扩张是在输液结束后的14 分钟(动脉血) 20 分钟(静脉血)时开始下降的。乳酸林格式液在前臂的分布较之在全身显然迅速得多。因此,在前臂的动静脉差别并不能准确的反映出乳酸林格式液的分布或者其对全身血浆容积的改变量。

结论:乳酸林格式液在其输注期间和输注后的30 分钟内对血浆起到扩容作用的,对于它相对缓慢的全身分布,可能是由于毛细血管通透性和不同身体区域间的组织渗透性差异这两者的联合效应。

(刘沁译 薛张纲校)

BACKGROUND: Conventional concept suggests that infused crystalloid fluid is first distributed in the plasma volume and then, since the capillary permeability for fluid is very high, almost instantly equilibrates with the extracellular fluid space. We challenge whether this view is consistent with findings based on volume kinetic analysis.

METHODS: Fifteen volunteers received an IV infusion of 15 mL/kg of lactated Ringer’s solution during 10 min. Simultaneous arterial and venous blood hemoglobin (Hgb) samples were obtained and Hgb concentrations measured. The arteriovenous (AV) difference in Hgb dilution in the forearm was determined and a volume kinetic model was fitted to the series of Hgb concentrations in arterial and venous blood.

RESULTS: The AV difference in plasma dilution was only positive during the infusion and for 2.5 min thereafter, which represents the period of net flow of fluid from practolol plasma to tissue. Kinetic analysis showed that volume expansion of the peripheral fluid space began to decrease 14 min (arterial blood) and 20 min (venous blood) after the infusion ended. Distribution of lactated Ringer’s solution apparently occurs much faster in the forearm than in the body as a whole. Therefore, the AV difference in the arm does not accurately reflect the distribution of Ringer’s solutions or whole-body changes in plasma volume.

CONCLUSIONS: The relatively slow whole-body distribution of lactated Ringer’s solution, which boosts the plasma volume expansion during and for up to 30 min after an infusion, is probably governed by a joint effect of capillary permeability and differences in tissue perfusion between body regions.

 

 

在动静脉中乳酸林格氏液血浆稀释及分布动力学的差异

Arteriovenous differences in plasma dilution and the distribution kinetics of lactated ringer's solution.

Svensen CH, Rodhe PM, Olsson J, Børsheim E, Aarsland A, Hahn RG.

Clinical Research Center, Södertalje Hospital, Södertalje, Sweden.

Anesth Analg 2009 108: 149-159.

 

背景:一般我们认为输入晶体液在血容量中是一室分布的但因为的毛细血管通透对晶体液是很高的,所以晶体液在血管内与细胞外间隙立刻就会达到平衡。我们研究这种观点是否与容量动力学分析的结果相一致。

方法:十五位志愿者在十分钟内静脉输注乳酸林格氏液15 mL/kg。同时抽取动静脉血红蛋白样本进行血红蛋白浓度检测。这样就确定了前臂动静脉血红蛋白稀释的不同并建立一个在动静脉中一系列血红蛋白浓度变化的动态模型。

结果:动静脉中血浆稀释仅在输注时及之后2.5分钟内有效,在此之后是从血浆向组织的净输注期。动态分析显示在输注结束后动脉血14分钟后,静脉血20分钟后其扩容效果开始下降。乳酸林格氏液在前臂的分布速度显然要比在全身的分布快。因此,前臂动静脉中的差异不能准确反映乳酸林格氏液在整个身体中改变血浆容量的情况。

结论:相关显示乳酸林格氏液在注射后30分钟内在全身分布的血浆扩容效果可能由血管通透性及不同身体解剖区域组织灌注有关。

(刘婷洁译 薛张纲校)

BACKGROUND: Conventional concept suggests that infused crystalloid fluid is first distributed in the plasma volume and then, since the capillary permeability for fluid is very high, almost instantly equilibrates with the extracellular fluid space. We challenge whether this view is consistent with findings based on volume kinetic analysis.

METHODS: Fifteen volunteers received an IV infusion of 15 mL/kg of lactated Ringer's solution during 10 min. Simultaneous arterial and venous blood hemoglobin (Hgb) samples were obtained and Hgb concentrations measured. The arteriovenous (AV) difference in Hgb dilution in the forearm was determined and a volume kinetic model was fitted to the series of Hgb concentrations in arterial and venous blood.

RESULTS: The AV difference in plasma dilution was only positive during the infusion and for 2.5 min thereafter, which represents the period of net flow of fluid from plasma to tissue. Kinetic analysis showed that volume expansion of the peripheral fluid space began to decrease 14 min (arterial blood) and 20 min (venous blood) after the infusion ended. Distribution of lactated Ringer's solution apparently occurs much faster in the forearm than in the body as a whole. Therefore, the AV difference in the arm does not accurately reflect the distribution of Ringer's solutions or whole-body changes in plasma volume.

CONCLUSIONS: The relatively slow whole-body distribution of lactated Ringer's solution, which boosts the plasma volume expansion during and for up to 30 min after an infusion, is probably governed by a joint effect of capillary permeability and differences in tissue perfusion between body regions.

 

 

异氟醚耐受不发生于发育中的光滑爪蟾蝌蚪

Tolerance to Isoflurane Does Not Occur in Developing Xenopus laevis Tadpoles

Pavle S. Milutinovic, Jing Zhao, and James M. Sonner

From the *The University of Pittsburg School of Medicine, Pittsburgh, Pennsylvania; {dagger}Peking Union Medical College, Peking, China; and {ddagger}The Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Anesth Analg 2009 108: 176-180.

 

背景:研究已经发现,多种中枢神经系统抑制剂,包括作为麻醉剂的乙醇都有耐受现象。但对于氟烷类吸入麻醉药却还没有足够的相关证据来证明。耐受的证据缺乏可能是由于对麻醉剂的暴露不足所致。在本次研究中,我们将光滑爪蟾的蝌蚪暴露于外科手术麻醉浓度的异氟醚一周。

方法:光滑爪蟾的蝌蚪来源于体外受精,从受精开始即暴露于0.59%0.98%1.52%的异氟醚或者氧气下一周时间。

结果:试验发现麻醉药物的EC50变化微小,且变化方向并不一致。对照组动物的异氟醚EC500.549%±0.003%,暴露于1.52%异氟醚的光滑爪蟾蝌蚪EC50低于对照组(低16%);但在0.59%浓度及0.98%浓度下成长的光滑爪蟾EC50却高于对照组(分别为4.7%7.4%)。

结论:我们首次描述了暴露于外科手术麻醉气体浓度下一周的脊椎动物,亦是首次报道了发育中的脊椎动物。在光滑爪蟾蝌蚪中并没有发现异氟醚的耐受现象。综合其他生物体的试验报道,乙醇能产生耐受而异氟醚却未产生耐受,这可能说明这两种药物的共同机制并不是产生耐受的原因。

(秦敏菊译 薛张纲校)

INTRODUCTION: Tolerance is observed for a variety of central nervous system depressants including ethanol, which is an anesthetic, but has not been convincingly demonstrated for a potent halogenated volatile anesthetic. Failure to demonstrate tolerance to these agents may be the result of inadequate exposure to anesthetic. In this study, we exposed Xenopus laevis tadpoles to surgical anesthetic concentrations of isoflurane for 1 wk.

METHODS: Xenopus laevis tadpoles were produced by in vitro fertilization, and exposed to isoflurane (0.59%, 0.98%, 1.52%) or oxygen for 1 wk starting from the time of fertilization.

RESULTS: Changes in anesthetic EC50 were small and not in a consistent direction. Control animals had an anesthetic EC50 of 0.594% _ 0.003% isoflurane. Tadpoles exposed to 1.52% isoflurane had a lower EC50 than controls (by 16%), whereas tadpoles raised under 0.59% and 0.98% isoflurane had higher EC50s than control (by 4.7% and 7.4%, respectively).

CONCLUSION: We provide the first description of week-long exposures of vertebrates to surgical anesthetic concentrations of isoflurane, and the first report of such exposures in developing vertebrates. Tolerance to isoflurane does not occur in developing Xenopus laevis tadpoles. Taken together with studies in other organisms, the development of tolerance to ethanol but not isoflurane suggests that mechanisms shared by these drugs probably do not account for the development of tolerance.

 

 

可视喉镜插管对上切牙的作用力评估

Forces Applied to the Maxillary Incisors During Video-Assisted Intubation

Ruben A. Lee, BE(hons)*, André A. J. van Zundert, PhD, MD, FRCA, Ralph L. J. G. Maassen, MD, Remi J. Willems, MD, Leon P. Beeke, BSc*, Jan N. Schaaper, BSc*, Johan van Dobbelsteen, PhD*, and Peter A. Wieringa, PhD*

From the *Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands; {dagger}Department of Anesthesiology, Intensive Care, and Pain Therapy, Catharina Hospital–Brabant Medical School, Eindhoven, The Netherlands; and {ddagger}Department of Anesthesiology, University Ghent Hospital, Gent, Belgium.

Anesth Analg 2009 108: 187-191.

 

背景:由于可视喉镜的应用,声门暴露变得更为简单明了,从而使气管插管变得更为容易。在此,我们应用客观标准,将可视喉镜插管法与传统插管法对患者上切牙的作用力进行比较。

方法:麻醉师分别应用Macintosh喉镜与可视喉镜(均由德国Karl Storz制造)暴露患者声门至他或她所认为的最佳暴露,实际插管只用可视喉镜。应用传感器测量作用于病人上颌切牙的压力。在插管前及插管中分别对患者进行困难气道评估(如Mallampati试验及Cormack-Lehane评分)。

结果:所有列入研究的患者(女性24名, [ 50 ± 16] 20男性[ 56 ± 13] )应用传统插管法及可视喉镜插管法均获得成功。应用压力传感器记录得:Macintosh喉镜的作用力为0 87.4 n,中位数为15.3n,而可视喉镜作用力为0 45.2n,中位数为2.1n。喉镜类型是影响上切牙作用力的唯一可确定显著影响因素(P <0.01)。与传统插管法比较,可视喉镜可降低插管过程中对上切牙的作用力。

结论:考虑到困难气道插管中对上切牙的作用力,可视喉镜较传统插管法对患者更为有益。在这项研究中,我们不认为Mallampati试验及Cormack-Lehane评分可对作用力的大小进行预测。

(施颖译  薛张纲校)

BACKGROUND: Modern, video laryngoscopes provide an easier view of the glottis, possibly facilitating easier intubations. We describe an objective method for evaluating the benefits of video-assisted laryngoscopy, compared with standard techniques using force measurements.

METHOD: Macintosh and video laryngoscopes (both Karl Storz, Tuttlingen, Germany) were used on the patients until the anesthesiologist was convinced he or she had the best possible view of the glottis. Actual intubation was only performed with the second of the laryngoscopes. Sensors measured the forces directly applied to the patients’ maxillary incisors. Additionally, common subjective pre- (e.g., Mallampati) and intraintubation (e.g., Cormack-Lehane [C&L]) metrics of intubation difficulty were evaluated by the anesthesiologists.

RESULTS: All patients (24 female, [50 ± 16 yr], 20 male [56 ± 13 yr]) included in the study were successfully intubated with both the classic and video laryngoscopes. The forces recorded for the classic Macintosh blade ranged from 0 to 87.4 N with a median of 15.3 N, whereas the video laryngoscope forces ranged from 0 to 45.2 N, with a median of 2.1 N. The only factor determined to be significantly influential on the associated forces applied to the maxillary incisors was the laryngoscope type (P < 0.01). Video-assisted laryngoscopes reduced the applied forces over standard blades. Mallampati and C&L grade were not predictive of the forces applied.

CONCLUSIONS: Video-assisted laryngoscopes seem beneficial when considering forces applied to the maxillary incisors as an objective metric of intubation difficulty. In this study, we could not support that Mallampati and C&L grades predict the forces that are applied to the maxillary incisors.

 

 

新的FDA药品说明书:旨在患者安全和临床护理

The New Food and Drug Administration Drug Package Insert: Implications for Patient Safety and Clinical Care

Kelley Teed Watson, MD, and Paul G. Barash, MD

From the Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut.

Anesth Analg 2009; 108:211-218

 

摘要:美国FDA是科学性的调控性的公共健康机构,为联邦政府规范管理食物,药品,医疗设备,放射性设备以及化妆品等许多产品。其宗旨是保证在美国制造和销售的产品有效,安全和纯粹。药品说明书的目的是为消费者提供关于产品的详细信息,由产品制造者经FDA审核批准后编写而成。2006年,为使其更人性化,更加有效的为从业者服务,产品说明书的标准格式有了改动。据医疗机构提供的数据,每年院内药品不良反应发生400000例,造成35亿美元的额外损失。希望新的药品说明书改革能更快捷有效的提供关于药品的关键信息,降低医疗过错,促进患者安全。

(孙鹏飞译 薛张刚校)

The United States Food and Drug Administration (FDA) is the scientific, regulatory, and public health agency that regulates many products, including food products, drugs, medical devices, radiation emitting devices, and cosmetics for the federal government of the United States. The FDA’s mission is to assure that consumer products made and sold in the United States are safe, effective, and pure. The purpose of the package insert (also known as prescription drug product insert or professional labeling) is to provide detailed drug information compiled and distributed by the drug manufacturer, after FDA review and approval. In 2006, the standard format for the package insert was changed in an attempt to make it more user-friendly and a more efficient resource tool for practitioners. According to the Institute of Medicine, in-hospital adverse drug reactions occur at a rate of 400,000 per year and incur $3.5 billion of extra hospital expense. It is expected that the new package insert format will enhance rapid access to important pharmacologic information and improve patient safety by decreasing medication errors.

 

 

剖宫产手术中比较单次注射腰麻和腰硬联合麻醉技术向头端感觉阻滞的最大程度的一项随机试验

A Randomized Trial of Maximum Cephalad Sensory Blockade with Single-Shot Spinal Compared with Combined Spinal-Epidural Techniques for Cesarean Delivery

Horstman, Damian J. MD, PhD; Riley, Edward T. MD; Carvalho, Brendan MBBCh, FRCA

From the Department of Anesthesia, Stanford University School of Medicine, Stanford, California.

Anesth Analg 2009 108: 240-245.

 

背景:过去的研究表明在择期剖宫产女性使用腰硬联合(CSE)麻醉比单次注射腰麻(SSS)产生更广的向头端的感觉阻滞。这被假设是因为在腰硬联合麻醉时置入硬膜外注射针破坏了硬膜外间隙的负压,导致脑脊液压力相对升高,增加了鞘内局麻药的扩散。我们验证了腰硬联合麻醉比单次注射腰麻产生更广的向头端的感觉阻滞和在腰硬联合麻醉开始阻力消失时脑脊液压力比单次注射腰麻高这一假设。

方法:三十名安排行择期剖宫产手术的临产妇加入这项随机双盲试验。患者接受单次注射腰麻或腰硬联合麻醉,鞘内注射相等剂量的麻醉药(高比重布比卡因12mg,芬太尼10µg和吗啡200µg)。在鞘内注射前,用纤维光学压力传感器测定脑脊液压力。最高感觉平面用痛觉,温度觉和触觉来测量。记录使用的维持基线动脉血压的去氧肾上腺素的剂量。

结果SSS组和CSE组中位数痛觉阻滞平面高度[T4 (T4–2) vs T3 (T4–1)]或脑脊液压力[6 (4–12) vs 9 (8–12) mm Hg]无显著差异。脑脊液压力和阻滞高度或去氧肾上腺素总剂量无显著关联。

结论SSSCSE两种技术侧卧位进针产生相同的感觉阻滞范围和脑脊液压力。这些发现可能提示改变鞘内注射剂量是不必要的,CSE麻醉时硬膜外注射针最初置入硬膜外间隙引起任何鞘内压力的不同没有临床意义。

(宣丽真译 薛张纲校)

BACKGROUND: Previous studies have shown more extensive cephalad sensory blockade in women receiving combined spinal-epidural (CSE) anesthesia compared with single-shot spinal (SSS) anesthesia for elective cesarean delivery. It has been postulated that introduction of the epidural needle during CSE disturbs the negative pressure in the epidural space, resulting in relatively greater cerebrospinal fluid (CSF) pressure and increased spread of intrathecal local anesthetic. We tested the hypothesis that CSE results in more extensive cephalad sensory blockade than SSS anesthesia and that loss-of-resistance during initiation of CSE anesthesia increases CSF pressure compared with SSS.

METHODS: Thirty parturients scheduled for elective cesarean delivery were enrolled in this randomized, double-blind study. Patients received either SSS or CSE anesthesia with equal doses of intrathecal anesthetic (hyperbaric bupivacaine 12 mg, fentanyl 10 µg and morphine 200 µg). Before the intrathecal injection, the CSF pressure was measured with a fiberoptic pressure sensor. Maximum cephalad sensory blockade to pinprick, cold and touch was measured. The total dose of phenylephrine required to maintain baseline arterial blood pressure was also recorded.

RESULTS: There were no significant differences in the median (interquartile range) pinprick sensory block height [T4 (T4–2) vs T3 (T4–1)] or CSF pressures [6 (4–12) vs 9 (8–12) mm Hg] between the SSS and CSE groups. There were no significant correlations between CSF pressure and block height or total dose of phenylephrine.

CONCLUSION: The SSS and CSE techniques inserted in the lateral decubitus position resulted in similar extent of sensory blockade and CSF pressure. These findings suggest that altering the intrathecal dose is not necessary and that any difference in intrathecal pressure associated with initial placement of an epidural needle in the epidural space during CSE anesthesia is clinically inconsequential.

 

 

用于模拟困难气道气管插管的气道镜和探针镜

Airway Scope and StyletScope for Tracheal Intubation in a Simulated Difficult Airway

Ryu Komatsu, MD*, Kotoe Kamata, MD*, Keiko Hamada, MD*, Daniel I. Sessler, MD{dagger}, and Makoto Ozaki, MD{ddagger}

From the *Department of Anesthesia, Kosei Hospital, Japan; {dagger}Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio; and {ddagger}Department of Anesthesiology, Tokyo Women’s Medical University, Tokyo, Japan.

Anesth Analg 2009 108: 273-279.

 

背景:直接咽喉镜在颈椎被颈套固定的病人使用是困难的。气道镜和探针镜是被设计用来处理困难气道插管的咽喉镜。在这些病人二者都有高成功率,然而,气道镜更快而且较少引起误入食道。

方法:选取需行气管插管麻醉的成年患者为研究对象。麻醉诱导肌松后,患者的颈部行硬性颈套固定,并且随机分为两组,分别行气道镜(n50)和探针镜(n50)插管。记录插管成功率,所用时间,成功插管前尝试次数以及并发症。

结果:插管成功率气道镜为98%,探针镜为96%。气道镜插管时间(32[8];平均)相比探针镜(51[29] s)短19秒。两种设备插管成功的尝试次数相近,气道镜26/18/5 (一次/两次/三次尝试),探针镜为26/17/5。引起粘膜水肿和唇部损伤的次数相近,但是仅有探针镜插管误入食道(n6);无牙齿损伤或缺氧发生。

结论:气道镜和探针镜在处理颈套固定引起的困难气道插管中都有高成功率,然而,气道镜更快而且较少引起误入食道。

(夏俊明译 薛张纲校)

BACKGROUND: Direct laryngoscopy is difficult when the cervical spine is immobilized. The Airway Scope® and StyletScope® are new laryngoscopes designed to facilitate intubation under these circumstances. Thus, in patients wearing a rigid cervical collar to simulate a difficult airway, we tested the hypothesis that the intubation success rates of the Airway Scope and StyletScope are similar, but that intubation with Airway Scope is faster.

METHODS: Adult patients requiring tracheal intubation as part of anesthesia were enrolled. After anesthesia induction and muscle relaxation, patients’ necks were stabilized with a rigid Philadelphia collar and patients were randomly assigned to tracheal intubation with Airway Scope (n = 50) or StyletScope (n = 50). Overall intubation success rate, time required for intubation, the number of attempts required for successful intubation, and airway complications related to intubation were recorded.

RESULTS: Overall intubation success rates were 98% with Airway Scope and 96% with StyletScope. Intubation was 19 s faster with Airway Scope (32[8] s; mean) versus StyletScope (51[29] s). The number of required intubation attempts was similar with each device: 26/18/5 (first/second/third attempt) for Airway Scope versus 26/17/5 for StyletScope. The incidence of mucosal trauma and lip injury was similar, except esophageal intubation occurred only with StyletScope (n = 6); neither dental injury nor hypoxia occurred.

CONCLUSIONS: Both the Airway Scope and StyletScope offer high success rates in a simulated difficult airway achieved by a rigid collar. However, the Airway Scope is faster and less likely to cause esophageal intubation.


环氧化酶-2选择性抑制剂帕瑞考昔和伐地考昔应用于术后,在心血管方面的安全性:整合数据的分析

Cardiovascular Safety of the Cyclooxygenase-2 Selective Inhibitors Parecoxib and Valdecoxib in the Postoperative Setting: An Analysis of Integrated Data
Stephan A. Schug, MD, FANZCA, FFPMANZCA*
{dagger}, Girish P. Joshi, MBBS, MD, FFARCSI{ddagger}, Frederic Camu, MD, PhD§, Sharon Pan, PhD||, and Raymond Cheung, PhD

From the *Pharmacology and Anaesthesiology Unit, University of Western Australia Perth, Australia; {dagger}Department of Pain Medicine, Royal Perth Hospital, Perth, Australia; {ddagger}University of Texas Southwestern Medical Center, Dallas, Texas; §University of Brussels, Brussels, Belgium; and ||Pfizer Inc, New York, New York.

Anesth Analg 2009 108: 299-307.

 

背景:研究帕瑞考昔――环氧合酶-2选择性抑制剂和伐地考昔提供冠状动脉旁路移植手术后的镇痛作用,与安慰剂相比,可以增加心血管时间发生的风险的不良事件。我们进行这项研究,以解决是否帕瑞考昔和伐地考昔可以增加非心脏手术术后心血管事件的发生。
方法:集中分析使用的是2大数据: 17个关于帕瑞考昔非心脏手术的对照试验和32项研究,其中包括17个非心脏手术的帕瑞考昔的研究和15项伐地考昔的研究。32项研究数据提示,有95%的可能性相信,假定使用安慰剂心血管事件的发生率是1%,那么试验组该事件的发生率增加两倍(估计从先前的研究资料);如果安慰剂组的发病率是0.5%,那么有69%的可能性相信试验组该事件的发生率增加两倍。
结果17项帕瑞考昔的研究表明,使用帕瑞考昔心血管事件的发生率是0.44%(2966中有13例),而对照组的发生率是0.37%(1915中有7例)(P
> 0.20)32项研究分析,帕瑞考昔/伐地考昔心血管事件总的发生率是0.40%(5285中有21例),而安慰剂组该事件的发生率是0.50%(3226中有16例)(P > 0.20)。两组之间个心血管疾病的种类没有统计学差异。如果按病人心血管疾病危险因素的数量分层,帕瑞考昔/伐地考昔和安慰剂组之间心血管事件的发生没有统计学差异。
结论:大规模的分析显示,选择性环氧合酶抑制剂或非甾体抗炎药应用于疼痛管理,帕瑞考昔和伐地考昔并不会增加非心脏手术术后心血管事件的发生率。

章一静译 薛张纲校

BACKGROUND: Studies of parecoxib, the inactive prodrug of the cyclooxygenase-2 selective inhibitor valdecoxib, and valdecoxib for postoperative pain relief in patients undergoing coronary artery bypass graft surgery revealed an increased risk of cardiovascular (CV) adverse events compared with placebo. We conducted this study to address whether parecoxib and valdecoxib increased CV risk in noncardiac surgery patients.

METHODS: A pooled post hoc analysis was conducted using 2 large datasets: 17 controlled trials of parecoxib for noncardiac studies and 32 studies, including the 17 noncardiac parecoxib studies plus 15 studies of valdecoxib. The 32-study dataset provided 95% power to detect a twofold increase in the incidence of CV adverse events assuming a placebo group incidence of 1% (estimated from previous study data), and 69% power to detect a twofold increase from a 0.5% incidence.

RESULTS: The incidence of total CV events for the 17 parecoxib studies was 0.44% (13 of 2966) in patients who received parecoxib and 0.37% (7 of 1915) in those receiving placebo (P > 0.20). In the analysis of 32 studies, the incidence of total CV events was 0.40% (21 of 5285) in the parecoxib/valdecoxib group compared with 0.50% (16 of 3226) in the placebo group (P > 0.20). No significant differences in the incidence of total or any individual CV event category were observed between the parecoxib or parecoxib/valdecoxib and placebo groups in the two analyses. When patients were stratified by number of baseline CV risk factors, no significant difference in CV events was detected in parecoxib/valdecoxib patients compared with placebo.

CONCLUSIONS: In the largest analysis of the CV risk of cyclooxygenase selective inhibitors or nonsteroidal antiinflammatory drugs for perioperative pain management, parecoxib and valdecoxib were not found to increase the risk of CV adverse events after noncardiac surgery

 


静脉注射利多卡因后,分别在脊髓前脚给予无害和急性伤害刺激后大脑的激活作用:在试验鼠上的功能核磁共振成像研究

The Effect of Intravenous Lidocaine on Brain Activation During Non-Noxious and Acute Noxious Stimulation of the Forepaw: A Functional Magnetic Resonance Imaging Study in the Rat

Zhongchi Luo, MS*, Mei Yu, BS{dagger}, S. David Smith, PhD{ddagger}, Mary Kritzer, PhD§, Congwu Du, PhD{dagger}{ddagger}, Yu Ma, PhD{dagger}, Nora D. Volkow, MD||, Peter S. Glass, MD{dagger}, and Helene Benveniste, MD, PhD{dagger}{ddagger}

From the Departments of *Biomedical Engineering, {dagger}Anesthesiology, State University of New York at Stony Brook, Stony Brook, New York; {ddagger}Department of Medicine, Brookhaven National Laboratory, Upton, New York; §Department of Neurobiology and Behavior, State University of New York at Stony Brook, Stony Brook, New York; and ||National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland

Anesth Analg 2009 108: 334-344.

 

背景:在人类和实验动物上,低血药浓度的利多卡因就可以减缓急性和慢性疼痛。全身给药时,利多卡因的镇痛机制还不是很清楚,但是知道与外周神经传导阻滞无关。与利多卡因有关地镇痛作用与中枢的钠通道及其它受体位点有关,与外周神经系统无关。根据我们的认识,利多卡因作用于大脑的镇痛机制还不是很清楚。在这里,我们通过功能MRIfMRI)显像研究全身使用利多卡因后大脑对无害和急性有害刺激的反应。

方法:在全身静脉注射利多卡因前和后,通过fRMI分别测定α氯醛糖麻醉的小鼠大脑对前脚的无害和有害刺激的反应。

结果:前脚的无害刺激只能引起对侧皮层初级自体感觉区(S1)的激活。急性前脚的伤害性刺激可引起大脑皮层与痛觉相关区域的激活,包括:次级皮层自体感觉区(S2)、丘脑、岛叶和边缘区。分别静脉给予利多卡因1mg/kg4mg/kg10mg/kg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   不能消除或减弱大脑对无害或有害刺激的反应。事实上,4mg/kg10mg/kg的利多卡因可以增强S1S2对急性无害刺激的反应,增加50%~60%激活的大脑皮层的面积。

结论:全身给利多卡因的镇痛作用与阿片类的镇痛作用机制不一致,并非直接影响疼痛引起的大脑fMRI的改变。通过fMRI,利多卡因可以增强大脑皮层对急性疼痛的反应,这一现象与可卡因的作用相似。我们近来的研究表明,利多卡因和可卡因都可以增加大脑皮层细胞内钙离子的浓度,这揭示了机体对躯体感觉刺激敏感性增强与这一药理作用有关。因为我们的试验仅仅针对生理的急性疼痛,因此有必要进一步研究与此有相同作用通路的利多卡因在神经痛方面的作用,从而了解其镇痛机制。

(陈珺珺译 薛张纲校)

BACKGROUND: Lidocaine can alleviate acute as well as chronic neuropathic pain at very low plasma concentrations in humans and laboratory animals. The mechanism(s) underlying lidocaine’s analgesic effect when administered systemically is poorly understood but clearly not related to interruption of peripheral nerve conduction. Other targets for lidocaine’s analgesic action(s) have been suggested, including sodium channels and other receptor sites in the central rather than peripheral nervous system. To our knowledge, the effect of lidocaine on the brain’s functional response to pain has never been investigated. Here, we therefore characterized the effect of systemic lidocaine on the brain’s response to innocuous and acute noxious stimulation in the rat using functional magnetic resonance imaging (fMRI).

METHODS: Alpha-chloralose anesthetized rats underwent fMRI to quantify brain activation patterns in response to innocuous and noxious forepaw stimulation before and after IV administration of lidocaine.

RESULTS: Innocuous forepaw stimulation elicited brain activation only in the contralateral primary somatosensory (S1) cortex. Acute noxious forepaw stimulation induced activation in additional brain areas associated with pain perception, including the secondary somatosensory cortex (S2), thalamus, insula and limbic regions. Lidocaine administered at IV doses of either 1 mg/kg, 4 mg/kg or 10 mg/kg did not abolish or diminish brain activation in response to innocuous or noxious stimulation. In fact, IV doses of 4 mg/kg and 10 mg/kg lidocaine enhanced S1 and S2 responses to acute nociceptive stimulation, increasing the activated cortical volume by 50%–60%.

CONCLUSION: The analgesic action of systemic lidocaine in acute pain is not reflected in a straightforward interruption of pain-induced fMRI brain activation as has been observed with opioids. The enhancement of cortical fMRI responses to acute pain by lidocaine observed here has also been reported for cocaine. We recently showed that both lidocaine and cocaine increased intracellular calcium concentrations in cortex, suggesting that this pharmacological effect could account for the enhanced sensitivity to somatosensory stimulation. As our model only measured physiological acute pain, it will be important to also test the response of these same pathways to lidocaine in a model of neuropathic pain to further investigate lidocaine’s analgesic mechanism of action.


比较改良肌腱内给药和经典腘窝坐骨神经阻滞一项随机研究:

A Randomized Comparison of a Modified Intertendinous and Classic Posterior Approach to Popliteal Sciatic Nerve Block

Antoun Nader, MD, Mark C. Kendall, MD, Kenneth D. Candido, MD, Hubert Benzon, MD, and Robert J. McCarthy, PharmD

From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Anesth Analg 2009 108: 359-363.

 

序论:在这项前瞻性随机研究中,对于行踝和足部手术的患者,我们用两种方法:改良肌腱内单次给药和经典腘窝内坐骨神经阻滞,比较了他们的效果。

方法:神经刺激引导的阻滞可在腘窝上7–8 cm (经典)12–14 cm(改良的肌腱内)进行。0.625%左旋布比卡因加肾上腺素1300000(左旋布比卡因,Purdue Pharma, Stamford, CT)总共给予0.4ml/kg(即总量25–35 mL),分次给予5ml。进针后≤0.4 mA刺激即可以诱发同测肢体的跖屈、背屈、内翻、外翻发生,提示进针位置正确。给药后30分钟内,我们可以确定麻醉效果。

结果:在腘窝上进针的平均距离分别是:改良的肌腱内位置是14.0 cm (四分位数范围, 13.5–15 cm) 、经典的位置为7.5 cm (四分位数范围,7.0–8.0 cm) (P < 0.01)。改良的肌腱内注射后,55人中44人完全阻滞(占81.5%);经典的位置注射,54人中39人完全阻滞(占70.9%)(P = 0.26)。发生内翻的56名病人中有49人完全阻滞(占87.5%),发生跖屈的30名病人中有23人完全阻滞(占76.7%);频率高于发生背屈或外翻的23名病人中有11人完全阻滞(占47.8%),(P = 0.001)。对于改良肌腱内注射,通过诱发内翻运动反应而达到完全阻滞的平均时间为10分钟(0-22分钟),快于通过经典后路达到完全阻滞的30分钟(4-56分钟)(P = 0.04)

结论:相比于经典入路,改良方法的优点是加快坐骨神经阻滞的麻醉起效时间。

(陈珺珺译 薛张纲校)

INTRODUCTION: In this prospective randomized study, we compared a single-injection modified inter tendinous (n = 55) with the  classic posterior (n = 54) popliteal sciatic nerve block for patients undergoing ankle/foot surgery.

METHODS: Nerve stimulator-guided blocks were performed 7–8 cm (classic posterior) or 12–14 cm (modified inter tendinous) above the popliteal crease. Levobupivacaine 0.625% with epinephrine 1:300,000 (Chirocaine®, Purdue Pharma, Stamford, CT), was injected in 5 mL aliquots to a total volume of 0.4 mL/kg (range, 25–35 mL). The needle position was considered acceptable if an evoked motor response of plantar flexion, inversion, eversion  or a dorsiflexion of the ipsilateral foot was elicited at ≤0.4 mA. Complete block was defined as pinprick anesthesia and motor paralysis of the foot within 60 min.

RESULTS: The median distance from the popliteal crease to the modified intertendinous site was 14.0 cm (interquartile range, 13.5–15 cm) compared to 7.5 cm (interquartile range 7.0–8.0 cm) for the classic posterior site (P < 0.01). Complete block was achieved in 44 of 55 patients (81.5%) in the modified intertendinous compared to 39 of 54 patients (70.9%) in the classic posterior group (P = 0.26). Complete block frequency was greater with an evoked motor response of inversion 49 of 56 patients (87.5%) and plantar flexion 23 of 30 patients (76.7%) compared with  dorsiflexion/eversion 11 of 23 patients (47.8%) (P = 0.001). The median (95% CI ) time (min) to complete block with an evoked motor response of inversion was 10 (0–22 min) for the modified intertendinous compared to 30 (4–56 min) with the classic posterior approach (P = 0.04).

CONCLUSIONS: Potential advantages of the modified inter endinous  approach include more rapid onset of anesthesia with an evoked motor response of inversion compared to a classic posterior popliteal sciatic nerve block. 背屈