Anesthesia & Analgesia

January 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

經心外超聲心動圖使用連續性方程監測主動脈瓣區的可行性

裘毅敏譯,馬皓琳 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.

在兔子鞘膜內進行嗎啡預處理可以通過啟動δ、κ、μ阿片類受體產生心臟保護

胡豔譯  薛張綱校

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.

迅速降解的羥乙基澱粉溶液損害心臟手術後的凝血功能:一項前瞻性隨機試驗
陳偉 譯 陳傑 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.

術中多普勒組織成像對心臟麻醉醫師的醫療設備而言是一項有價值的補充:一項核心回顧

唐李雋 譯  馬皓琳  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:

外傷性腦損傷兒童圍術期高血糖發生率及危險因數

黃凝譯  薛張綱校

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.

新生期接觸異氟醚對小鼠腦細胞生存、成年後行為、學習和記憶的影響

周雅春 馬皓琳 李士通

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

新生小鼠接觸異氟謎對腦細胞成活力、成年期行為、學習和記憶的影響

張燕 陳傑

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.

 

亞專業影響因數:兒科麻醉與疼痛文獻的貢獻

蔣宗明譯  薛張綱校

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:

三個聲門上氣道裝置應用中頭頸位置對口咽漏氣壓力和套囊位置的影響

王騰 譯 陳傑 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:

減脂手術中肺泡復原和動脈地氟烷濃度

張曦 譯,馬皓琳 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.

在動靜脈中乳酸林格氏液血漿稀釋及分佈動力學的差異

劉婷潔譯 薛張綱校

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

乳酸林格式液在血漿中稀釋度的動靜脈差別及分佈動力學

劉沁譯 薛張綱校

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.

煙鹼受體部分介導了吸入麻醉藥異氟醚誘發的腦幹自主神經失功

劉世文 譯 陳傑 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.

丙泊酚和異氟烷增強疑核心臟迷走神經元張力型γ-氨基丁酸A型電流

黃施偉 譯,馬皓琳 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.

依託咪酯作用於下丘腦-皮質系統GABA能神經的模型

葉樂 譯 陳傑 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.

揮發性芳香族麻醉劑對N-甲基-d-天冬氨酸受體的抑制和制動作用的分子基礎的比較

顏濤 譯, 馬皓琳 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.

異氟醚耐受不發生於發育中的光滑爪蟾蝌蚪

秦敏菊譯 薛張綱校

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:

術中磁共振成像設備的電雜訊

王宏譯,馬皓琳、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.

可視喉鏡插管對上切牙的作用力評估

施穎譯  薛張綱校

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.

如何評定充氣式保溫系統療效?模擬人上半身應用的評價

張磊 譯 陳傑 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:

引介先進術中方案的新穎程式:一種減輕危害和促進病人安全的多學科規範

江繼宏 譯  馬皓琳 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藥品說明書:旨在患者安全和臨床護理

孫鵬飛譯 薛張剛校

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:

內皮素-1對大鼠肺泡液體清除率和肺水腫形成的影響

丁俊雲 譯 陳傑 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.

急性間質性肺炎(Hamman-Rich綜合征)的臨床表現和診斷治療

朱 慧譯 馬皓琳 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:

剖宮產手術中比較單次注射腰麻和腰硬聯合麻醉技術向頭端感覺阻滯的最大程度的一項隨機試驗

宣麗真譯 薛張綱校

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.

一項關於腰-硬聯合和硬膜外用於經產婦分娩鎮痛的隨機研究

舒慧剛 陳傑

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.

分娩硬膜外鎮痛用於產時剖宮產失敗:一項回顧性研究

黃佳佳譯,馬皓琳 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:

用於模擬困難氣道氣管插管的氣道鏡和探針鏡

夏俊明譯 薛張綱校

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.

體內缺乏β2-腎上腺素能受體的小鼠腦缺血後腦損傷減少

趙嫣紅 譯 陳傑 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腎上腺素受體拮抗劑對大鼠蛛網膜下腔出血後促炎細胞因數濃度的影響

張瑩譯  馬皓琳 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:

環氧化酶-2選擇性抑制劑帕瑞考昔和伐地考昔應用於術後,在心血管方面的安全性:整合資料的分析

章一靜譯 薛張綱校

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.

吸煙狀態對於慢性疼痛患者戒除阿片類藥物的影響

周姝婧 譯 陳傑 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.

髂腹股溝-髂腹下神經和肋間神經聯合阻滯對腎移植受體術後緩解疼痛的效果

唐亮 譯  馬皓琳 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.

靜脈注射利多卡因後,分別在脊髓前腳給予無害和急性傷害刺激後大腦的啟動作用:在試驗鼠上的功能核磁共振成像研究

陳珺珺譯 薛張綱校

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.

局麻藥濃度和劑量對持續鎖骨下神經阻滯效果的影響:一項多中心、隨機、隱蔽觀察、對照研究

懷曉蓉 陳傑

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.

通過對成人手術病人行硬膜外神經刺激聯合持續硬膜外鎮痛評價硬膜外導管的位置

黃麗娜 譯 馬皓琳 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.

比較改良肌腱內給藥和經典膕窩坐骨神經阻滯一項隨機研究:

陳珺珺譯 薛張綱校

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.

手臂外展對鎖骨下臂叢神經解剖關係的影響:一項超聲研究

朱紫瑜 陳傑

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.

曲馬多應用於利多卡因腋路法臂叢神經阻滯的輔助用藥

姜旭暉 譯  馬皓琳 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.

 

迅速降解的羥乙基澱粉溶液損害心臟手術後的凝血功能:一項前瞻性隨機試驗
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:羥乙基澱粉溶液(HES)對凝血功能的影響一直受到關注。迅速降解的羥乙基澱粉溶液對血塊硬度已顯示有較大的影響。由於心臟手術後出血的風險增加,因此作者研究了心臟手術後給予這些類型的羥乙基澱粉是否產生凝血功能變化。
方法:本研究在45例擇期接受心臟手術的患者中比較了給予兩種新型的迅速降解的羥乙基澱粉溶液與人血白蛋白對凝血功能的影響。入住心臟外科重症監護病房(CICU)後,患者隨機接受短時( 70-240分鐘)輸液羥乙基澱粉溶液15ml/kg6 HES200/0.56 HES130/0.4 )或4 %的人血白蛋白溶液。
結果:在輸注兩種羥乙基澱粉溶液組的血栓形成描記中,血塊生成時間延長且最大血塊硬度降低,這種損害在完成研究性輸液2小時後血栓形成描記中部分可恢復(使用InTEM ®ExTEM ®凝血啟動),血小板對血塊最大硬度的影響在所有的研究組中未體現。羥乙基澱粉溶液不會引起纖維蛋白溶解。輸注人血白蛋白組在血栓形成描記中無顯著變化。研究中胸管引流具有可比性。
結論:在心臟手術後短時間內輸注迅速降解的羥乙基澱粉溶液對纖維蛋白生成和血栓形成描記中血塊硬度有削弱作用。在此臨床環境中,人血白蛋白不損害止血功能。

(陳偉 譯 陳傑 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.

 

新生小鼠接觸異氟謎對腦細胞成活力、成年期行為、學習和記憶的影響

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:揮發性麻醉劑,如異氟醚,廣泛用於嬰兒和新生兒。新生大鼠接受異氟醚、咪唑安定,和一氧化二氮之後出現神經退行性變和神經損傷,提高了關於小兒麻醉安全性的關注。新生小鼠,長時接受異氟醚可觸發低血糖症,這可能與認知功能受損有關。作者研究了新生小鼠接受異氟醚對血糖,自發活動,以及空間學習和記憶的影響。 
方法: 7日齡小鼠,隨機分組接受6小時的1.5 %異氟醚或6小時的室內空氣同時注射或不注射葡萄糖或生理鹽水。測定動脈血氣及血糖。2小時, 18小時,或11周後,用腦切片(用Fluoro-Jade B, caspase 3, NeuN染色)評估細胞存活率。九周後,用隱藏和簡化的平臺試驗的Morris水迷宮法,評估自發活動能力,空間學習和記憶力。 
結果:與沒有麻醉比較,接受異氟醚後早期大腦幾個區域凋亡細胞增加。儘管麻醉組有細胞凋亡,成年期麻醉與非麻醉鼠間大腦區域神經元密度無差異。無論新生期是否接受異氟醚,成年期,群體間自主運動及空間學習和記憶力相似。新生小鼠接受異氟醚導致18 %的死亡,以及動脈血二氧化碳分壓和乳酸暫態增加,堿缺失,血糖水準降低。然而,低血糖症似乎與神經退行性病變無關,因為補充葡萄糖未能阻止神經元的損失。 
結論:新生小鼠長時接受異氟烷導致腦細胞變性增加。但到成人期,未見神經元密度顯著減少,自主運動、空間學習及記憶功能也無顯著缺失。

(張燕 譯 陳傑 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.


 三個聲門上氣道裝置應用中頭頸位置對口咽漏氣壓力和套囊位置的影響

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:在使用聲門上氣道裝置時,例如: 喉管吸引(LTS),胃管引流型喉罩(PLMA),Cobra喉周通氣道(CobraPLA),口咽漏氣壓力和套囊位置會隨著頭頸位置的變化而變化。本研究作者測試了使用上述三種裝置時頭頸位置改變時口咽漏氣壓力和套囊位置的變化。

方法:139名擇期小型手術患者隨機接受使用三種聲門上氣道裝置中的一種。測量以下四種頭頸部位置下口咽洩漏壓力和套囊位置:自然,前屈45度,後仰45度,右偏45度。同時檢測不良反應(如通氣困難和胃脹氣)。

結果:胃管引流型喉罩(PLMA)漏氣壓力最低。在頭頸後仰體位時為18.5 cm H2O,而喉管(LTS)和喉周通氣管(CobraPLA)分別為23.9 cm H2O26.8 cm H2O;(P<0.001)。頭頸偏轉時胃管引流型喉罩(PLMA)為25.0 cm H2O,喉管(LTS)和喉周通氣管(CobraPLA)分別為29.4 cm H2O28.5 cm H2OP<0.005)。使用喉周通氣管(CobraPLA)時,45名病人中有37名在口咽裝置漏氣之前出現胃脹氣。在使用喉管(LTS)的病人中有7名頸前屈的病人出現了通氣困難,以至於需要使用氣管插管。

結論:在頭頸位置為後仰和偏轉時,使用胃管引流型喉罩(PLMA)比使用口咽洩漏壓力喉管(LTS)和喉周通氣管(CobraPLA)能顯著降低口咽洩漏壓力。在使用喉管(LTS)和喉周通氣管(CobraPLA)時一定要注意頭頸位置,可能會發生通氣困難。

(王騰 譯 陳傑 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.

煙鹼受體部分介導了吸入麻醉藥異氟醚誘發的腦幹自主神經失功

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:異氟醚是最常用的吸入麻醉藥之一,然而其心肺抑制的機制知之甚少。本研究作者檢測了異氟醚對副交感心臟迷走神經元突觸後GABA受體的調節作用和在GABA能突觸前末梢煙鹼乙醯膽鹼受體靶向作用導致的GABA能作用的變化

方法從舌下神經根800微米髓節記錄與吸氣節律相關活動。CVNs通過逆行螢光標記確定,使用膜片鉗技術檢查GABA能神經到CVNs的傳遞。

結果:異氟醚濃度大於50 µM時明顯抑制吸氣頻率,振幅和持續時間。異氟醚呈劑量依賴性地降低了頻率,增加了在CVNs GABA能抑制性突觸後電流( IPSCs )自發衰減的時間。為了測試GABA能對CVNs活力抑制是否通過突觸前煙鹼受體介導,應用濃度為3µM{alpha}4β2-選擇性煙鹼拮抗劑二氫刺桐堿。二氫刺桐堿阻止異氟醚誘發的GABAIPSC頻率的抑制,但異氟醚仍然可以增加IPSC的衰減時間。

結論:臨床相關濃度的異氟醚抑制腦幹呼吸節律的發生,在CVNs延長GABA能抑制後電流和減少GABA的活動。GABAIPSCs頻率的減少取決於突觸前{alpha}4β2煙鹼受體的抑制。

(劉世文 譯 陳傑 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.

 依託咪酯作用於下丘腦-皮質系統GABA能神經的模型

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:作者曾使用丘腦皮質系統的計算模型來測定相關類麻醉藥物對皮層和丘腦GABA能神經元功能的影響。本研究作者檢測了麻醉藥的相性和緊張性抑制,以及對丘腦和皮層相對重要區域的影響。

方法:通過模型來產生GABA相關的相性抑制,所需依託咪酯的濃度在0.25-0.5UM,而引起意識消失的濃度範圍在0.25-0.5UM,另外單獨模擬緊張性抑制,然後同時模擬相性抑制和緊張性抑制。同時將兩種抑制分別引入丘腦和皮層,來考察此結構區域對麻醉性抑制作用重要性。

結果:當依託米酯濃度0.25-0.5UM時,相性抑制可降低皮層神經元代謝的11-18%,當達到2UM時可以降低38%。緊張性抑制產生類似的抑制,在0.25-0.5UM時可降低皮層神經元代謝的11-21%,但在2UM時,卻可降低65%。兩者同時作用可以產生最大的抑制(在2UM時,卻可降低代謝率65%)。當丘腦和皮層分別接受相性抑制和緊張性抑制時,相較於皮層丘腦同時接受抑制時的代謝率,單獨皮層代謝率下降較小。在0.25-0.5UM的範圍裏,依託米酯只作用在丘腦時,皮層代謝率受到的影響最小。

結論:丘腦皮層系統的計算模型顯示緊張性抑制似乎比相性抑制更為重要(特別在較高依託米酯濃度的時候),儘管兩者同時作用將產生最大的皮層代謝率。此外,就依託米酯其本身在丘腦的作用,似乎很難解釋其誘導意識喪失的作用。

(葉樂 譯 陳傑 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.

 

如何評定充氣式保溫系統療效?模擬人上半身應用的評價

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:充氣式保溫系統為防止圍術期低溫已被接受。然而,對空氣流動和空氣溫度在噴嘴的影響和這些系統在保溫毯熱分佈的療效的影響知之甚少。

方法:作者在模擬人上採用5充氣式保溫系統研究熱交流,以確定影響熱量從保溫毯傳到模擬人上的因素。

結果:在動力裝置噴嘴處的空氣溫度和熱傳遞沒有任何關係。同樣,動力裝置的氣流和由此產生的熱傳遞也沒有關係。保溫毯產生最佳療效時空氣流速在19/秒以上。保溫毯和模擬人之間的熱交換係數,平均溫度梯度與所產生的熱傳導呈正相關,最小和最大毯溫度之間的差異與所產生的熱傳遞呈負相關。

結論充氣式保溫系統療效主要決定於保溫毯。現代電力單位能提供足夠的熱能以最大限度的為病人取暖。保溫毯的優化設計是讓毯和人之間(或任何其他表面)存在優化平均溫度梯度,使其存在一個非常均勻的溫度分佈,這將促使製造商開發出更好的保溫系統。

(張磊 譯 陳傑 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.

 

 

 內皮素-1對大鼠肺泡液體清除率和肺水腫形成的影響

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:內皮素-1被認為在肺水腫形成中起著關鍵的作用,基本的機制仍然不明確,但可能包括毛細管壓力與血管通透性的改變。沒有調查研究是否內皮素-1也影響到肺泡液體清除率這一解決肺水腫的主要機制。因此,作者設計了這項研究,以闡明內皮素-1對大鼠肺泡重吸收和液體平衡的影響。

方法:肺泡液體清除率通過用或不用內皮素-1 10–7 M)和/或阿米洛利( 100µM)時在大鼠肺中灌注5 %白蛋白溶液來測定 。在有或沒有的內皮素-1 0.8 nm )加入灌注液的情況下,在隔離、通風、恒壓灌流的環境中測定大鼠肺泡液體達到平衡時間、水腫的形成時間、肺毛細血管壓力和肺泡白蛋白滲透率。

結果:在被液體灌注的肺中,內皮素-1使肺泡液體清除率降低了約65 % ,它的作用與降低了阿米洛利敏感的Na +通道的轉運有關( P< 0.001 ) 。內皮素-1的抑制作用是通過完全阻斷內皮素B受體拮抗劑BQ788來實現的( P =0.006 ) ,而對內皮素A受體拮抗劑BQ123沒有影響( P =0.663 ) 。在隔離、通風的條件下往大鼠肺組織灌注內皮素 -1的能造成的肺泡液體增加約20 % ( P<0.011 ,與對照組比較) ,而對照組大鼠肺組織清除約20 %的灌注液。 內皮素-1增加了肺泡毛細血管壓(+9.4 cm H2O) ,減少了灌注流量( -81 % ) ,加快了肺重量的增加,降低了肺組織生存期( P < 0.001 ) 。內皮素-1對白蛋白滲透率無明顯的影響( P0.24 ) 。

結論:內皮素-1通過抑制麻醉大鼠中阿米洛利敏感的上皮Na +通道來降低肺泡液體清除率。內皮素-1的抑制作用通過啟動的內皮素B受體來體現。這些結果表明了內皮素-1的作用機制是增加毛細血管的壓力、促進肺水腫的形成。

(丁俊雲 譯 陳傑 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.

一項關於腰-硬聯合和硬膜外用於經產婦分娩鎮痛的隨機研究

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:關於腰-硬聯合(CSE)和硬膜外麻醉(EPID)用於分娩鎮痛的益處與風險存在爭議。作者推測相比于EPIDCSE可以減少患者追加劑量的需求。

方法: 100ASAIII級的分娩早期(宮頸擴張<5cm)的需要鎮痛的產婦,隨機雙盲接受EPID(硬膜外給予2.5 mg/mL的布比卡因3ml,隨後給予1.25 mg/mL的布比卡因10ml和芬太尼50ug)或CSE(鞘內給予布比卡因2.5mg和芬太尼25ug)。兩組均以12ml/h的速度輸注相同的布比卡因(濃度0.625 mg/mL)和芬太尼(濃度2 µg/mL)。

結果:兩組中不管是要求追加劑量的患者的百分比(44% CSE51% EPID95%置信區間的差異–28% to +14%)還是要求多種藥物追加劑量的比值(14% CSE vs 15% EPID)無明顯差異。開始鎮痛後10分鐘[中位數0 cm (0, 0) 4 cm (1, 6) P < 0.001]30分鐘[0 cm (0, 0) vs 0 cm (0, 1),  P = 0.03],CSE組視覺類比量表評分比EPID組低。

結論: 經產婦CSEEPID兩種方法中需求追加劑量方面無顯著差異;但CSEEPID在鎮痛最初的30分鐘提供了更好的鎮痛效果。

(舒慧剛 譯 陳傑 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.

 

體內缺乏β2-腎上腺素能受體的小鼠腦缺血後腦損傷減少

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-腎上腺素能受體(BAR)阻滯劑對於腦缺血損傷具有神經保護作用。然而,克倫特羅——一種特殊的β2-腎上腺素能受體阻滯劑,通過增加神經生長因數的表達產生神經保護作用。作者選取β2-腎上腺素能受體敲除小鼠及選擇性β2-腎上腺素能受體阻滯劑作為研究物件,研究β2-腎上腺素能受體缺乏對短暫性腦缺血灶的影響。

 

方法:本實驗通過腔內縫合方法建立缺血模型,具體方法為大腦中動脈閉塞(MCAO60分鐘後進行24小時的再灌注,並評分神經功能。梗死灶大小由甲酚紫染色或235-三苯基氯化四唑染色評定。大鼠分為兩組,分別為β2-腎上腺素能受體缺乏小鼠及野生型同類系小鼠作為對照組,兩組野生型小鼠在MCAO 30分鐘前分別腹腔內隨機注射選擇性β2-腎上腺素能受體阻滯劑ICI1185510.2mg/kg)或0.9%生理鹽水(每組n=10)。通過免疫組化及免疫印跡法對缺血後熱休克蛋白Hsp72進行標記測定。

 

結果:60分鐘的MCAO後進行24小時的再灌注之後,與野生鼠(對照組)相比,β2-腎上腺素能受體缺乏鼠的梗死範圍減少了22.3%39.7±10.7mm351.07±11.4mm3,每組n=10P=0.034)。與對照組相比,進行預處理即注射選擇性β2-腎上腺素能受體阻滯劑ICI118551的小鼠梗死範圍也有顯著減少25.1%32.8±11.9mm343.8±10.3mm3,每組n=10P=0.041)。β2-腎上腺素能受體缺乏鼠及進行ICI118551預處理的鼠在神經功能評分方面也有顯著提高。腦缺血後,β2-腎上腺素能受體缺乏鼠體內的熱休克蛋白Hsp72的總水準及熱休克蛋白Hsp72的免疫陽性細胞也有所提高。

 

結論:在缺乏β2AR的小鼠及對進行選擇性β2AR阻滯劑預處理後的小鼠體內,進行MCAO,其腦損傷及神經功能損傷都有所減少。這與腦缺血時β2AR活性從存活信號到凋亡信號的轉變是一致的。這種保護機制與高水準的熱休克蛋白Hsp72-一種抗凋亡蛋白有關。β2-腎上腺素能受體信號在腦缺血中的影響極為複雜,仍然需要進一步研究來證實。

(趙嫣紅 譯 陳傑 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.

吸煙狀態對於慢性疼痛患者戒除阿片類藥物的影響

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確定在一項為期3周的疼痛康復專案中,吸煙是否對慢性疼痛患者的阿片類藥物減量過程有影響。次要目的包括研究吸煙狀態、住院期間阿片類藥物的使用,及疼痛的嚴重程度之間的關係。

 

方法:作者使用了回顧性、重複測試的試驗設計以評估患者在治療前後的一些指標。評估的物件是在20039月至20072月之間接受一項為期3周的門診患者疼痛治療專案的全部患者。評估指標包括阿片類藥物的成功戒除率、多學科疼痛調查的疼痛程度量表和治療專案完成情況。

 

結果:總共有1241位患者入選本次研究(女性928位);其中,313位(25%)是吸煙者,294位(24%)現已戒煙,其餘634位(51%)未曾吸煙。入組時,相較於已戒煙者及不吸煙者,有更多的吸煙者使用阿片類藥物(P<0.001)。類似的,吸煙者嗎啡的平均等效劑量(P=0.013)和疼痛評分(P<0.001)明顯高於已戒煙者和不吸煙者。阿片類藥物的成功戒除率與患者是否吸煙無關,治療專案結束時,各組患者的疼痛均有明顯緩解(P<0.001)。但是,很大一部分吸煙者未能完成治療(P<0.001)。

 

結論:大部分完成全部疼痛康復計畫的患者能夠戒除使用阿片類藥物,這與患者是否吸煙無關。但值得注意的是,有更多的吸煙者未能完成該治療專案,其中最常見的原因包括對治療的期望值存在差異,突發急性疾病,以及心理社會的應激。

(周姝婧 譯 陳傑 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.

局麻藥濃度和劑量對持續鎖骨下神經阻滯效果的影響:一項多中心、隨機、隱蔽觀察、對照研究

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:周圍神經阻滯效果的主要決定因數是局麻藥濃度還是藥物劑量目前還不清楚。曾有研究顯示,持續的膕窩坐骨神經阻滯中,與小容量高濃度羅呱卡因相比,大容量低濃度羅呱卡因感覺阻滯更好。然而,仍不清楚這種關係是坐骨神經特有的還是僅取決於處在膕窩這個位置。本研究作者檢驗這一假說,比較了總劑量相等時不同濃度和容量的羅呱卡因用於持續的鎖骨下臂叢神經阻滯的差異。

方法:肘遠端整形外科手術患者,經喙突徑路置入鎖骨下導管。從術後第二天開始隨機接受周圍神經0.2%羅呱卡因(背景劑量8ml/h,單次劑量4ml),或者0.4%羅呱卡因(背景劑量4ml/L,單次劑量2ml),即接受羅呱卡因16mg/h,病人自控追加劑量8mg, 鎖定時間為30min。主要的終點為24h期間肢體無感覺發生率。第二終點包括鎮痛效果和病人的滿意度。

結果 0.4%羅呱卡因組(n=27)肢體無感覺發生為1.8 ±1.6次,而0.2%羅呱卡因組(n=23);為0.6±0.9(差異為1.2 95%置信區間,0.5-1.9 p=0.001)。0.2%羅呱卡因組術後鎮痛的滿意度(範圍0-1010=最高)為10.0 (中位數25th-75th%8.0–10.0)0.4%羅呱卡因組為7.05.3-8.9)(p=0.018)。組間鎮痛效果相似。

結論:持續鎖骨下神經阻滯,除了局麻藥總量外,局麻藥濃度和容量影響其阻滯效果。小容量高濃度羅呱卡因組發生肢體無感覺更常見。這與已報導的持續膕窩-坐骨神經阻滯相反。局麻藥濃度和劑量之間的相互關係仍然是複雜的,且隨導管位置的不同而改變。

(懷曉蓉 譯 陳傑 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.

手臂外展對鎖骨下臂叢神經解剖關係的影響:一項超聲研究

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:臂叢至喙突以及胸膜的距離對於進行鎖骨下阻滯是至關重要的。作者使用超聲評價手臂外展時神經血管束相對於皮膚,喙突以及胸膜之間的位置。

方法:26名患者行鎖骨下臂叢神經超聲檢查。測量並記錄手臂外展(角度分別為45°90°)時腋動脈至皮膚,喙突和胸膜之間的距離,。在另外14名接受手部手術的患者上進行神經刺激下鎖骨下臂叢阻滯。

結果:在超聲檢查下,腋動脈至皮膚的距離在手臂外展時明顯減少(0°: 32 ± 7 mm, 45°: 29 ± 7 mm, 90°: 25 ± 5 mm, P < 0.05)。在內側偏斜為18 ± 3度的情況下,皮膚至胸膜的距離為47 ± 5 mm,並且不受手臂位置的影響。使用神經刺激來確認臂叢,其距離皮膚的垂直深度為41 ± 7 mm

結論:手臂外展能夠減少臂叢的深度但並不能改變腋動脈相對於喙突或者胸膜之間的位置。超聲影像可能低估了臂叢的實際深度。

(朱紫瑜 譯 陳傑 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.

經心外超聲心動圖使用連續性方程監測主動脈瓣區的可行性

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:測定主動脈瓣區(AVA)是行主動脈瓣手術的病人術中廣泛的心外超聲(EE)檢查中的一個重要部分。心外心超(EE)代表了一種可行的替代經食道心超(TEE)的方法。但是與監測AVA的其他顯像模式之間的一致性及相關性尚未系統性驗證過。

方法:我們在85位行心臟手術的病人中經EE使用連續性方程監測AVAAVA-EE)。在同樣的人群中將AVA-EE監測與術中用經食道超聲心動圖得到的AVA-TEE相比較。在患者亞組中,還將AVA-EE與其他AVA監測手段作比較:術前經胸壁超聲心動圖(AVA-TTE) (n = 65)或術前四周獲得的心導管檢查(AVA-Cath) (n = 35)

結果94%接受AVA-TEE100%接受AVA-EE的患者獲得了經主動脈瓣的多普勒記錄。AVA-EEAVA-TEE監測相比較顯示出高度的一致性(平均差[偏差] ± 95%可信區間CI = –0.09 cm2 ± 0.18 cm2, r2 = 0.83, P < 0.0001)AVA-EE同樣與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。

結論:經EE使用連續性方程監測AVA與其他AVA評估技術相比顯示出高度的一致性及相關性。

(裘毅敏譯,馬皓琳 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.


術中多普勒組織成像對心臟麻醉醫師的醫療設備而言是一項有價值的補充:一項核心回顧

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

心動週期中心臟內部運動和表面/容量變化是用超聲心動圖的方法來評估局部(室壁運動分析)或整體(分段區域改變、心搏量和射血分數)心功能的。這些常規方法可能是主觀的,和/或花費時間,並且依賴環境,致使麻醉醫師的注意力可能從手術活動中轉移。多普勒組織成像(DTI)是一種新奇的超聲心動圖技術,它可顯示和測量心肌局部的收縮和舒張速度。DTI 操作簡便且不依賴於足夠的心內成像。數位資訊(速度或時間間隔)可輕易獲得和測量。局部(局部缺血的檢出)和整體水準(射血分數、舒張期功能障礙的分級)的收縮和舒張功能的判定以及充盈壓的評估可從DTI信號中獲取並被任何工作中的心臟麻醉醫師所用。本綜述敍述了DTI的原理、成像方式和臨床應用。
(唐李雋 譯  馬皓琳  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.

 

 

 

新生期接觸異氟醚對小鼠腦細胞生存、成年後行為、學習和記憶的影響

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:吸入麻醉藥,如異氟醚,現被廣泛用於嬰兒和新生兒。新生大鼠暴露於異氟醚、咪達唑侖和氧化亞氮後出現神經變性和神經認知功能損害已引起對於兒科麻醉安全的關注。新生小鼠長時間接觸異氟醚可引起低血糖,而低血糖可能是神經認知功能損害的原因。本研究調查了新生期接觸異氟醚和血糖水準對小鼠腦細胞生存、自發活動能力和空間學習記憶的影響。

研究方法:7日齡小鼠隨機分組,分別吸入1.5%異氟醚6小時,注射或不注射葡萄糖或生理鹽水,或暴露於室內空氣且不注射任何藥物(未接受麻醉組)。測定動脈血氣和血糖。小鼠吸入異氟醚後2小時、18小時和11周用螢光綠B、細胞凋亡蛋白酶或NeuN染色的腦切片評估腦細胞活性。吸入異氟醚後9周評估自發活動能力,並通過Morris水迷宮隱藏和減少平臺試驗評估小鼠空間學習和記憶能力。

研究結果:與未接受麻醉組相比,小鼠吸入異氟醚後早期一些腦區凋亡性細胞變性增加。雖然有新生期細胞消亡,新生期神經變性顯著影響的2個腦區在小鼠成年後其神經元細胞密度不變。所有組成年小鼠自發活動能力、空間學習和記憶能力相似,與新生期異氟醚接觸無關。新生期接觸異氟醚引起18%的死亡率並短暫增加Paco2、乳酸和堿不足,並降低血糖水準。然而,由於補糖並不能避免神經元消亡,低血糖似乎不是神經變性的原因。

結論:小鼠新生期長時間接觸異氟醚可使急性腦細胞變性數量增加,但並未觀察到成年期神經元密度顯著減少或自發活動、空間學習或記憶功能的損害。

(周雅春 譯 馬皓琳 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.


減脂手術中肺泡復原和動脈地氟烷濃度

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:我們研究減脂手術中用肺泡復原操作(RM)逆轉術中肺不張是否會影響地氟烷的動脈濃度。

方法:麻醉誘導和維持用丙泊酚,病人隨機接受(RM)或者不接受(對照組)間斷RM。地氟烷以6%開始,測量兩組肺泡地氟烷濃度增加速度(呼氣末和吸氣濃度比值,FA/FI)和地氟烷血液濃度。麻醉結束後也測量血液和呼氣末地氟烷濃度。

結果:與對照組相比,RM組術中Pao2/Fio2較高(兩者都P < 0.001)。在誘導過程中,兩組地氟烷血液濃度上升速度都很快。在可進行比較的機械通氣設置中,對照組和RM組,達到0.5 mM (3%)的中位數時間分別是2.11.59分鐘(P = 0.09)。達到0.7 mM (4.2%)地氟烷的時間,對照組和RM組分別是15.99.3分鐘(P = 0.08)。在RM組,地氟烷血液濃度在誘導後最初的30分鐘趨於更高(P = 0.066)。在維持或蘇醒過程中,對照組和RM組的血液地氟烷濃度沒有差別。因此,兩組間睜眼時間沒有差別。

結論:儘管,在減脂手術中RM顯示出一個有效改善術中氧合的方法,但是,它並不顯著影響麻醉中血液地氟烷濃度以及蘇醒過程中的消除。

(張曦 譯,馬皓琳 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.



丙泊酚和異氟烷增強疑核心臟迷走神經元張力型γ-氨基丁酸A型電流

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:全麻使用丙泊酚和異氟烷引起心血管系統的變化,包括低血壓和心率改變。神經節前心臟迷走神經元(CVNs)是控制心率和自主調節的主要核心部分。本研究中,我們檢驗了丙泊酚和異氟烷是否作用於相型或張力型γ-氨基丁酸A型(GABAA)受體介導的CVNs抑制。

方法:體外使用逆向螢光標記確定CVNs。使用全細胞膜片鉗技術來測定CVNs上的相型和張力型GABA電流。

結果:丙泊酚(10 µM)增加膜維持電流63 ± 13%,並將GABA能抑制性微突觸後電流(mIPSCs)的衰減時間從對照的42.3 ± 2.8 ms延長到61.8 ± 4.5 ms。異氟烷,在濃度為100300500µM時,分別降低mIPSCs的頻率26.0 ± 16% 64.6 ± 10.4%70.5 ± 9.8%,將GABAmIPSCs的衰減時間從47.9 ± 7.3 分別延長至 64.5 ± 8.1 ms70.3 ± 10.4 ms66.8 ± 8.1 ms,並分別增加膜維持電流32.8 ± 12.8%42.7 ± 10%39.9 ± 3%GABA能拮抗劑gabazine(25 µM)可阻斷由丙泊酚和異氟烷引起的GABAmIPSCs,卻不能改變增強的維持電流。相反,GABAA受體的通道阻斷劑印防己毒素(100 µM)逆轉了由丙泊酚和異氟烷引起的膜維持電流增加。

結論:結果說明全麻藥丙泊酚和異氟烷同時增強了相型和張力型GABAA受體介導的CVNs的抑制。

(黃施偉 譯,馬皓琳 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.



揮發性芳香族麻醉劑對N-甲基-d-天冬氨酸受體的抑制和制動作用的分子基礎的比較

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:芳香族麻醉劑顯示出廣泛的抑制N-甲基-d-天冬氨酸(NMDA)受體的作用和制動作用。我們試圖使用比較分子場分析(CoMFA)方法確定其抑制NMDA受體的分子基礎特徵,並且與採用等效模型對其制動作用進行研究得到的結果進行了比較。

方法:14種已發表的效能資料加上另外兩種藥物的新資料。麻醉藥被分成用於構成藥效模型的訓練組(n=12)和用於獨立驗證模型預測能力的實驗組(n=4)。採用從頭開始量子力學對麻醉藥物的結構進行幾何學優化,並用場匹配最小化來排列以提供分子的立體結構與靜電場之間的最佳相關性以及一個或多個帶頭結構。保留能產生具有最佳預測能力(使用棄一法交叉核實來評估)的CoMFA模型的方向。

結果:用於抑制NR1/NR2B 受體的最終CoMFA模型能夠解釋所觀察的12套訓練組藥物活性差異的99.3%(F2,9 = 661.5, P < 0.0001)。該模型有效預測了訓練組(交叉核實的r2CV = 0.944)4套被排除的實驗組藥物(預測的r2Pred = 0.966)的抑制活性。用於對傷害性刺激的制動反應的等效模型能解釋所觀察到的訓練組活性差異的98.0% (F2,9 = 219.2, P < 0.0001),且對訓練組(r2CV = 0.872)和實驗組(r2Pred = 0.926)顯示出足夠的預測能力。對藥效團地圖進行比較表明幾個關鍵立體和靜電區域共同存在於這兩種活性模型中,但是觀察到關於麻醉藥兩方面活性的關鍵區域的相對重要性有差別。

(顏濤 譯, 馬皓琳 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.



術中磁共振成像設備的電雜訊

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:現在術中磁共振成像(iMRI)是神經外科常用的工具。在這個手術室環境中安全可靠的患者監護依賴于這樣的環境:電雜訊(EN)沒有干擾電子監護或成像設備的運作。在本調查中,我們評估了在本手術室中使用的iMRI系統和麻醉病人監護儀產生的EN對這兩種設備性能的影響。

方法:我們衡量了我們的iMRI相容麻醉病人監護儀產生的由我們的iMRI系統中EN分析公式檢測到的EN。我們衡量了我們的iMRI系統在掃描中產生的由我們病人監護儀中的心電圖(ECG)波形檢測到的EN。我們分析了我們的iMRI相容的麻醉病人監護儀提供的ECG雜訊濾波器對EN減少和信號品質的影響

結果:通過iMRI EN分析公式檢測到了我們的病人監護儀產生的EN,然而,這種干擾是在iMRI掃描時iMRI製造商可接受的限度內(超過背景系統水準雜訊的<10%)。在臨床病例分析中,iMRI產生的窄帶低頻(20Hz)相對高能量的EN干擾了我們的病人監護儀的ECG信號。這種ENiMRI系統掃描過程中產生的聽覺雜訊相關,並和iMRI系統射頻(RF)和磁梯度脈動有關。在掃描時,ECG波形的完整性幾乎完全喪失。ECG監護儀的濾波器減少但不能完全消除這種20Hz的干擾。我們發現濾波器改變了ECG信號的形態,這可能使我們分辨臨床相關的ECG改變變得困難。

結論:我們的麻醉患者監護儀產生的ENiMRI系統可接受的限度內,但iMRI產生的EN卻使大多數通常使用的濾波模式下的ECG無法讀取。監護儀濾波器減少這種雜訊,但也改變ECG波形的形態。麻醉學醫師必須知道這些技術的弊端,並認識到在iMRI掃描時需要調節監護儀上的ECG濾波器以獲得對病人監護有用的ECG信號,但是ECG的診斷價值將減少。

(王宏譯,馬皓琳、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.



引介先進術中方案的新穎程式:一種減輕危害和促進病人安全的多學科規範

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:自從醫學會通報《To Err is Human》發表後,人們設計並應用了眾多的措施去改正導致醫療差錯和不良事件的醫療缺陷。無論如何,大多數努力在很大程度上還是有效的。人們把大部分目光投向安全性、溝通、團隊表現、有效性等領域的同時,還特別注重新技術、方法和操作的引進。我們描述了在引進一種新技術――高劑量率術中放射治療(HDR-IORT)前,我們醫院用於鑒定和減少醫療危害的多學科程式。

方法:組建包括手術醫生、麻醉醫生、腫瘤放射治療醫生、物理學家、護士、醫院風險管理者和設備專家在內的多學科小組,採用包括原位臨床類比的結構性程式來揭示醫護人員之間的利害關係,並前瞻性地鑒定和減輕用HDR-IORT技術進行手術對病人產生的缺陷。

結果:在應用于真實病人之前,我們在類比醫療病人監護程式中明確並改正了20 處缺陷。隨後,8位病人接受HDR-IORT手術過程中再沒有出現模擬法明確的或意料之外的缺陷。

結論:採用系統性程式引介HDR-IORT技術具有多重優點;換言之,治療該特定患者群體的安全性和有效性是最佳化的,而且用於真實病人前,採用這種程式可以減少有害和不良事件的發生。需要進一步的研究,但是本文概括的程式可以廣泛用於任何新技術、新療法或新操作的引介。

(江繼宏 譯  馬皓琳 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.



急性間質性肺炎(Hamman-Rich綜合征)的臨床表現和診斷治療

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:急性間質性肺炎是一種快速進展的疾病,常導致呼吸衰竭和機械通氣治療。儘管努力地診斷和治療,但預後仍很差。

方法:在這個回顧性群體調查中,選取了達到急性特發性間質性肺炎預定義標準的低氧血症性呼吸衰竭的患者。回顧患者的記錄、放射學研究資料以及病理標本。所有資料記錄在每個患者的研究檔中隨後分析。

結果:此次回顧包括5位男性和4位女性患者,平均年齡69.4歲(55-80歲)。所有患者的胸片在12天后都進展為雙側彌漫性滲透表現。所有9位患者通過經支氣管活檢或開放式肺活檢都發現與急性間質性肺炎相符的彌漫性肺泡損害的組織學證據。所有患者都需要收入內科重症監護室,並進行機械通氣。死亡率100%,患者在進入重症監護室5-36天死亡。

結論:急性間質性肺炎(Hamman-Rich綜合征)是一種特發性的、快速進展的且有時致命的肺間質疾病。經支氣管活檢是合理的第一步診斷方法,如果需要的話,接著可以進行開放的肺活檢。在我們的研究中皮質類固醇效果很小。對常規治療失敗且有合適的供體的患者,可考慮肺移植作為另外一種選擇。

(朱 慧譯 馬皓琳 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.



分娩硬膜外鎮痛用於產時剖宮產失敗:一項回顧性研究

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

在這項研究中,我們的目的在於確定與分娩硬膜外鎮痛用於剖宮產失敗的發生率和預測因素。我們對18個月期間已接受硬膜外分娩鎮痛但隨後需要接受產時剖宮產的產婦進行回顧性分析。用單變數邏輯回歸分析鑒定在硬膜外麻醉應該起效的足夠時間裏硬膜外鎮痛平面彌散失敗的預見因素。在1025名產婦中,1.7%硬膜外麻醉彌散失敗。硬膜外麻醉失敗的預測因素包括:僅用單純硬膜外麻醉進行分娩鎮痛(與腰硬聯合麻醉相比)(P = 0.001),分娩期間經歷了兩階段極其強烈的疼痛(P < 0.001),以及硬膜外分娩鎮痛持續時間過長(P = 0.02)

(黃佳佳譯,馬皓琳 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腎上腺素受體拮抗劑對大鼠蛛網膜下腔出血後促炎細胞因數濃度的影響

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:蛛網膜下腔出血(SAH)後腦脊液(CSF)中促炎細胞因數的濃度會升高。近來的研究提示β腎上腺素受體拮抗劑可能減少促炎細胞因數。我們的研究就是為了證明β腎上腺素受體拮抗劑是否能減少大鼠蛛網膜下腔出血後促炎細胞因數。

方法:實驗1,為了觀察白介素6(IL-6)和腫瘤壞死因數(TNF-{alpha})的時程,大鼠隨機分組:蛛網膜下腔出血或偽實驗後13612小時。在相同時點,抽取腦脊液和血樣。實驗2,為了研究β腎上腺素受體拮抗劑對IL-6TNF-{alpha}濃度的影響,大鼠隨機分為以下幾組:1) 對照組:蛛網膜下腔出血+生理鹽水,2) 普萘洛爾組:蛛網膜下腔出血+普萘洛爾,3) 美托洛爾組:蛛網膜下腔出血+美托洛爾,4) 布托沙明組:蛛網膜下腔出血+布托沙明2腎上腺素受體拮抗劑)。在蛛網膜下腔出血後6小時抽取腦脊液和血樣。檢測樣本中的IL-6TNF-{alpha}濃度。

結果:實驗1中,大鼠蛛網膜下腔出血後腦脊液中IL-6濃度明顯上升,在出血後6小時達到峰值,但TNF-{alpha}濃度一直保持較低水準。實驗2中,與對照組相比,普萘洛爾組和布托沙明組腦脊液IL-6濃度明顯較低(分別為P < 0.01 P < 0.05)。血漿IL-6、腦脊液TNF-{alpha}和血漿TNF-{alpha}4組比較無統計學差異。

結論:大鼠蛛網膜下腔出血急性期腦脊液IL-6濃度會明顯升高,β腎上腺素受體拮抗劑或β2腎上腺素受體阻滯作用會抑制大鼠SAHIL-6濃度的升高。

(張瑩譯  馬皓琳 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.



髂腹股溝-髂腹下神經和肋間神經聯合阻滯對腎移植受體術後緩解疼痛的效果

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:腎移植患者術後疼痛是很劇烈的。全身性的鎮痛會因為腎功能受損而產生嚴重的併發症。我們來研究是否低位肋間神經阻滯聯合髂腹股溝-髂腹下(IG-IH)神經阻滯是否能改善鎮痛的效果,從而減少術後24小時內嗎啡的用量。

方法:42例行腎移植的患者隨機平均分成兩組,運用相同的麻醉方法。手術後在術側用0.5%布比卡因進行髂腹股溝-髂腹下神經阻滯和T11T12肋間神經阻滯。對照組不進行阻滯。術後疼痛程度和嗎啡的用量由一個不知道分組情況的人進行記錄。

結果:在研究組的所有時間點上兩組的直觀類比標度評分(25th-75th)測量結果的中位數有顯著性差異(P<0.05)24小時嗎啡的用量,阻滯組12.7 ± 10.5 mg,對照組34.9 ± 5.9 mg,有顯著性差異(P < 0.001)

討論:腎移植術後運用髂腹股溝-髂腹下神經和低位肋間神經聯合阻滯能顯著緩解術後疼痛和減少阿片類藥物用量。

(唐亮 譯  馬皓琳 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.



通過對成人手術病人行硬膜外神經刺激聯合持續硬膜外鎮痛評價硬膜外導管的位置

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:確定硬膜外導管位置的硬膜外刺激試驗已經被描述為一種簡單、快速、值得信賴的方法。我們評價了硬膜外刺激試驗的可行性和其對有效的術後持續硬膜外鎮痛的潛在性作用。

方法:進行大的腹部手術或開胸手術的30名成年病人(ASA I–III)術後在胸段水準接受持續的硬膜外鎮痛。分別在導管置入後、局部麻醉藥推注後、硬膜外鎮痛過程中,對每位病人進行最多6次的硬膜外刺激試驗。通過硬膜外造影術對病人的硬膜外導管的位置進行核實(在硬膜外鎮痛開始前以及術後第二天再次進行核實)。

結果:一些技術問題(如為了使大於25%的測量結果中維持有足夠的刺激,需要用鹽水沖洗導管)和一些判斷問題(如呼吸運動的干擾[n = 6])使在導管放置時以及硬膜外鎮痛期間完成硬膜外刺激試驗更加費時。在導管放置後的即刻(試驗劑量前),硬膜外刺激試驗並不能完全鑒別出脊椎管外的所有4根導管的位置。而且,最先的硬膜外刺激試驗表明在25個正確放置在硬膜外腔的導管中,有3根可能位於鞘內或椎旁。在導管尖端位於硬膜外且硬膜外先前或同時注射局麻藥的122個結果中,共有107個硬膜外刺激試驗引出了運動反應(88%)。在所有的25名硬膜外造影術陽性的病人中,連續的硬膜外鎮痛均提供了充分的疼痛緩解。

結論:硬膜外刺激試驗通常與技術難題和判斷困難相聯繫。在進行術後硬膜外連續鎮痛的病人中,為了保證品質反復應用硬膜外刺激試驗的作用仍未確定。

(黃麗娜 譯 馬皓琳 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.



曲馬多應用於利多卡因腋路法臂叢神經阻滯的輔助用藥

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:在本次前瞻性隨機研究中,我們研究了曲馬多應用于腋路法臂叢神經阻滯的輔助用藥的效果。

方法:我們選取了102位行擇期手部手術採用腋路法臂叢神經阻滯麻醉的病人,神經阻滯時給予1.5%的利多卡因(加入1/200,000的腎上腺素),對照組再給予4mL鹽水,TL組再給予100mg曲馬多和2mL鹽水,TH組再給予200mg曲馬多。

結果:起效時間在TH組顯著延長,16 ± 7 min (對照組是9 ± 3 min; P = 0.01)。感覺阻滯(TH265 ± 119 minTL190 ± 87 min,對照組126 ± 48 min; P = 0.018)和第一次需要鎮痛的時間(TH734 ± 434 minTL573 ± 516 min,對照組375 ± 316 min; P = 0.02)TH組都比TL組和對照組顯著延長。

結論:曲馬多應用於利多卡因腋路法臂叢神經阻滯的輔助用藥可以延長阻滯時間,但是有起效慢的局限性。

(薑旭暉 譯  馬皓琳 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.

 

在兔子鞘膜內進行嗎啡預處理可以通過啟動δ、κ、μ阿片類受體產生心臟保護

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:鞘膜內小劑量的嗎啡可以產生和靜脈注射嗎啡相似的心臟保護作用。但是,鞘膜內嗎啡預處理(IT-MPC)的效果是否因缺血預處理引起是未知的。而且,IT-MPC是否通過由阿片類受體介導也是未知的。在此項研究中,我們比較IT-MPCIPC的心臟保護效果以及調查阿片類受體在其中所起的作用。

方法80只雄性的,在麻醉後行開胸手術的Sprague-Dawley兔子在成功氣管插管後分為1-13組(n=6-7)。IPC組的兔子要進行5分鐘的心肌缺血(通過阻斷左冠狀動脈主幹),然後再灌注5分鐘,重複3次。在IPC後,心肌的缺血再灌注損傷在左主幹阻斷半小時,再灌注2小時後出現。IT-MPC組中,在心肌缺血再灌注損傷前,兔子分別接受連續三次的鞘膜內注射嗎啡(0.03,0.3,3.0,30.0微克/千克),每次間隔5分鐘。在另外2組既沒有300微克/千克靜脈注射嗎啡,也沒有10微升鞘膜內注射的給與生理鹽水。分別給與IT-MPC組的兔子選擇性的δ、κ、μ受體拮抗劑(naltrindole, nor-binaltorphimine, and D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH2 (CTOP))來評價參與IT-MPC預處理的阿片類受體亞型。用2,3,5-triphenyltetrazolium染色法來確定心肌缺血的大小(IS)及缺血心肌所占百分比(AAR)。

結果:鞘膜內注射0.3-30微克/千克嗎啡組和鞘膜內注射生理鹽水組心肌IS比較。IS/AAR為:33%+/-10%0.3微克/千克),29%+/-10%3微克/千克),29%+/-16%30微克/千克),與對照組53%+/-8%比較,P<0.01IT-MPCIS/AAR減少與靜脈注射嗎啡(33%+/-6%P=0.84)和IPC組(22%+/-4%P=0.41)相似。IT-MPC聯合應用阿片類受體拮抗劑的心肌預處理效果減弱(IT-MPC+naltrindole 50% +/- 9%, IT-MPC + nor binaltorphimine 43% +/- 6%, IT-MPC + CTOP 53% +/- 9%, P = 0.14)

結論IT-MPC產生與靜脈注射嗎啡和IPC相似的心肌保護。鞘膜內注射嗎啡的心臟預處理與δ、κ、μ阿片類受體相關。

(胡豔譯  薛張綱校)

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.

 

 

外傷性腦損傷兒童圍術期高血糖發生率及危險因數

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:外傷性腦損傷(TBI)後高血糖與不良預後相關。本研究驗證了外傷性腦損傷兒童圍術期高血糖發生率及危險因數。

方法:對1994年至2004年於Harborview醫學中心(I級成人及兒科外傷中心)行緊急或急診顱骨切開術且年齡<=13歲的兒童進行回顧性佇列研究。回顧每位患者術前(急診部至全麻開始),術中(全麻中)和術後即刻(術後24小時)的血糖值。確定高血糖(血糖>=200 mg/dL)和低血糖(血糖<60 mg/dL)的範圍。持續性高血糖定義為2/3的研究時段(術前,術中和術後即刻)發生高血糖,而暫時性高血糖定義為僅一個研究時段發生高血糖。使用多因素logistic回歸分析確定圍術期高血糖的獨立預測因數。資料以調整後的OR(AOR) (95% 可信區間)表示,P < 0.05表示有顯著性差異。

結果:每個研究時段至少記錄一個血糖值的情況如下:術前(86 [82%]),術中(94 [89%])和術後(101 [97%])64%的兒童麻醉中血糖記錄每小時少於1次。47(45%)的兒童在至少一個研究時段中發生高血糖。29(28%)兒童發生暫時性高血糖,18(17%)兒童發生持續性高血糖。圍術期高血糖的獨立預測因數為年齡<4(AOR [95% CI]; 3.5 [1.2-10.6])Glasgow昏迷評分<=8 (AOR 95% CI; 7.2 [2.4-21.5])和存在包括硬腦膜下血腫在內的多發傷。六名兒童接受胰島素治療,兩名兒童發生與胰島素治療無關的低血糖。

結論:圍術期高血糖較常見,而術中低血糖亦非罕見,但術中血糖採樣頻率應更高才能更好的確定圍術期低血糖和高血糖的發生率。年齡<4歲,嚴重TBI和存在包括硬膜下血腫在內的多發傷是圍術期高血糖的危險因數。

(黃凝譯  薛張綱校)

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.

 

 

亞專業影響因數:兒科麻醉與疼痛文獻的貢獻

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:科學引文索引(雜誌影響因數 JIF)廣泛用於評價雜誌的品質和聲譽。麻醉專業的JIF每年都有報導,而這些雜誌相關亞專業文獻影響因數(IFs)尚無記載。因此,我們比較了兩個時期四種麻醉雜誌兒科麻醉文獻(Ped IFs)和疼痛文獻影響因數(Pain IFs)。

方法:通過人工逐篇檢索1998199920032004年刊載在美國麻醉雜誌、麻醉與鎮痛、英國麻醉雜誌和加拿大麻醉雜誌上兒科麻醉和疼痛論文。採用ISI Web of Science資料庫檢索這些雜誌上發表文章每年被引用的次數。對2000年和2005年相關雜誌Ped Ifs Pain Ifs與兒科麻醉雜誌進行比較。

結果2005年四種雜誌Ped IFs超過其相應雜誌2000IF,而Pain IFs保持不變。兩者均對雜誌IF有重要作用,其中Pain IFs作用比Ped IFs70%。

結論:除了2005年英國麻醉雜誌外,Ped IFs一直低於其JIFPain IFs。兒科麻醉文章引用次數大於IF高的雜誌同類文章被引用次數。這意味著亞專業IFs需要進一步關注。

(蔣宗明譯  薛張綱校)

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.

 

 

乳酸林格式液在血漿中稀釋度的動靜脈差別及分佈動力學

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: 傳統觀念認為輸入的晶體液最先分佈到血漿中,然後,因為毛細血管對液體的通透性非常高,這些晶體液幾乎立刻便與細胞外的液體間隙達到了平衡。而我們則將以根據容量動力學分析所取得的發現來對這一觀點提出挑戰。

方法:我們讓15名志願者在10分鐘內靜注輸入總量為15 mL/kg的乳酸林格式液,與此同時分別採取其動靜脈血樣並測量Hgb。得到在前臂的Hgb動靜脈差後,再以一個適合的容量動力學模型來分析這一系列的動靜脈Hgb濃度。

結果:乳酸林格式液分別在動、靜脈中的血漿稀釋度僅在輸注時和之後的2.5 分鐘內有差別,這代表著液體從血漿到組織的時間。動力學分析表明外周體液間隙的容量擴張是在輸液結束後的14 分鐘(動脈血) 20 分鐘(靜脈血)時開始下降的。乳酸林格式液在前臂的分佈較之在全身顯然迅速得多。因此,在前臂的動靜脈差別並不能準確的反映出乳酸林格式液的分佈或者其對全身血漿容積的改變量。

結論:乳酸林格式液在其輸注期間和輸注後的30 分鐘內對血漿起到擴容作用的,對於它相對緩慢的全身分佈,可能是由於毛細血管通透性和不同身體區域間的組織滲透性差異這兩者的聯合效應。

(劉沁譯 薛張綱校)

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.

 

 

在動靜脈中乳酸林格氏液血漿稀釋及分佈動力學的差異

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:一般我們認為輸入晶體液在血容量中是一室分佈的但因為的毛細血管通透對晶體液是很高的,所以晶體液在血管內與細胞外間隙立刻就會達到平衡。我們研究這種觀點是否與容量動力學分析的結果相一致。

方法:十五位志願者在十分鐘內靜脈輸注乳酸林格氏液15 mL/kg。同時抽取動靜脈血紅蛋白樣本進行血紅蛋白濃度檢測。這樣就確定了前臂動靜脈血紅蛋白稀釋的不同並建立一個在動靜脈中一系列血紅蛋白濃度變化的動態模型。

結果:動靜脈中血漿稀釋僅在輸注時及之後2.5分鐘內有效,在此之後是從血漿向組織的淨輸注期。動態分析顯示在輸注結束後動脈血14分鐘後,靜脈血20分鐘後其擴容效果開始下降。乳酸林格氏液在前臂的分佈速度顯然要比在全身的分佈快。因此,前臂動靜脈中的差異不能準確反映乳酸林格氏液在整個身體中改變血漿容量的情況。

結論:相關顯示乳酸林格氏液在注射後30分鐘內在全身分佈的血漿擴容效果可能由血管通透性及不同身體解剖區域組織灌注有關。

(劉婷潔譯 薛張綱校)

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.

 

 

異氟醚耐受不發生於發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:研究已經發現,多種中樞神經系統抑制劑,包括作為麻醉劑的乙醇都有耐受現象。但對於氟烷類吸入麻醉藥卻還沒有足夠的相關證據來證明。耐受的證據缺乏可能是由於對麻醉劑的暴露不足所致。在本次研究中,我們將光滑爪蟾的蝌蚪暴露於外科手術麻醉濃度的異氟醚一周。

方法:光滑爪蟾的蝌蚪來源於體外受精,從受精開始即暴露於0.59%0.98%1.52%的異氟醚或者氧氣下一周時間。

結果:試驗發現麻醉藥物的EC50變化微小,且變化方向並不一致。對照組動物的異氟醚EC500.549%±0.003%,暴露於1.52%異氟醚的光滑爪蟾蝌蚪EC50低於對照組(低16%);但在0.59%濃度及0.98%濃度下成長的光滑爪蟾EC50卻高於對照組(分別為4.7%7.4%)。

結論:我們首次描述了暴露於外科手術麻醉氣體濃度下一周的脊椎動物,亦是首次報導了發育中的脊椎動物。在光滑爪蟾蝌蚪中並沒有發現異氟醚的耐受現象。綜合其他生物體的試驗報導,乙醇能產生耐受而異氟醚卻未產生耐受,這可能說明這兩種藥物的共同機制並不是產生耐受的原因。

(秦敏菊譯 薛張綱校)

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.

 

 

可視喉鏡插管對上切牙的作用力評估

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:由於可視喉鏡的應用,聲門暴露變得更為簡單明瞭,從而使氣管插管變得更為容易。在此,我們應用客觀標準,將可視喉鏡插管法與傳統插管法對患者上切牙的作用力進行比較。

方法:麻醉師分別應用Macintosh喉鏡與可視喉鏡(均由德國Karl Storz製造)暴露患者聲門至他或她所認為的最佳暴露,實際插管只用可視喉鏡。應用感測器測量作用于病人上頜切牙的壓力。在插管前及插管中分別對患者進行困難氣道評估(如Mallampati試驗及Cormack-Lehane評分)。

結果:所有列入研究的患者(女性24名, [ 50 ± 16] 20男性[ 56 ± 13] )應用傳統插管法及可視喉鏡插管法均獲得成功。應用壓力感測器記錄得:Macintosh喉鏡的作用力為0 87.4 n,中位數為15.3n,而可視喉鏡作用力為0 45.2n,中位數為2.1n。喉鏡類型是影響上切牙作用力的唯一可確定顯著影響因素(P <0.01)。與傳統插管法比較,可視喉鏡可降低插管過程中對上切牙的作用力。

結論:考慮到困難氣道插管中對上切牙的作用力,可視喉鏡較傳統插管法對患者更為有益。在這項研究中,我們不認為Mallampati試驗及Cormack-Lehane評分可對作用力的大小進行預測。

(施穎譯  薛張綱校)

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藥品說明書:旨在患者安全和臨床護理

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:美國FDA是科學性的調控性的公共健康機構,為聯邦政府規範管理食物,藥品,醫療設備,放射性設備以及化妝品等許多產品。其宗旨是保證在美國製造和銷售的產品有效,安全和純粹。藥品說明書的目的是為消費者提供關於產品的詳細資訊,由產品製造者經FDA審核批准後編寫而成。2006年,為使其更人性化,更加有效的為從業者服務,產品說明書的標準格式有了改動。據醫療機構提供的資料,每年院內藥品不良反應發生400000例,造成35億美元的額外損失。希望新的藥品說明書改革能更快捷有效的提供關於藥品的關鍵資訊,降低醫療過錯,促進患者安全。

(孫鵬飛譯 薛張剛校)

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.

 

 

剖宮產手術中比較單次注射腰麻和腰硬聯合麻醉技術向頭端感覺阻滯的最大程度的一項隨機試驗

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:過去的研究表明在擇期剖宮產女性使用腰硬聯合(CSE)麻醉比單次注射腰麻(SSS)產生更廣的向頭端的感覺阻滯。這被假設是因為在腰硬聯合麻醉時置入硬膜外注射針破壞了硬膜外間隙的負壓,導致腦脊液壓力相對升高,增加了鞘內局麻藥的擴散。我們驗證了腰硬聯合麻醉比單次注射腰麻產生更廣的向頭端的感覺阻滯和在腰硬聯合麻醉開始阻力消失時腦脊液壓力比單次注射腰麻高這一假設。

方法:三十名安排行擇期剖宮產手術的臨產婦加入這項隨機雙盲試驗。患者接受單次注射腰麻或腰硬聯合麻醉,鞘內注射相等劑量的麻醉藥(高比重布比卡因12mg,芬太尼10µg和嗎啡200µg)。在鞘內注射前,用纖維光學壓力感測器測定腦脊液壓力。最高感覺平面用痛覺,溫度覺和觸覺來測量。記錄使用的維持基線動脈血壓的去氧腎上腺素的劑量。

結果SSS組和CSE組中位數痛覺阻滯平面高度[T4 (T4–2) vs T3 (T4–1)]或腦脊液壓力[6 (4–12) vs 9 (8–12) mm Hg]無顯著差異。腦脊液壓力和阻滯高度或去氧腎上腺素總劑量無顯著關聯。

結論SSSCSE兩種技術側臥位進針產生相同的感覺阻滯範圍和腦脊液壓力。這些發現可能提示改變鞘內注射劑量是不必要的,CSE麻醉時硬膜外注射針最初置入硬膜外間隙引起任何鞘內壓力的不同沒有臨床意義。

(宣麗真譯 薛張綱校)

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.

 

 

用於模擬困難氣道氣管插管的氣道鏡和探針鏡

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:直接咽喉鏡在頸椎被頸套固定的病人使用是困難的。氣道鏡和探針鏡是被設計用來處理困難氣道插管的咽喉鏡。在這些病人二者都有高成功率,然而,氣道鏡更快而且較少引起誤入食道。

方法:選取需行氣管插管麻醉的成年患者為研究物件。麻醉誘導肌松後,患者的頸部行硬性頸套固定,並且隨機分為兩組,分別行氣道鏡(n50)和探針鏡(n50)插管。記錄插管成功率,所用時間,成功插管前嘗試次數以及併發症。

結果:插管成功率氣道鏡為98%,探針鏡為96%。氣道鏡插管時間(32[8];平均)相比探針鏡(51[29] s)短19秒。兩種設備插管成功的嘗試次數相近,氣道鏡26/18/5 (一次/兩次/三次嘗試),探針鏡為26/17/5。引起粘膜水腫和唇部損傷的次數相近,但是僅有探針鏡插管誤入食道(n6);無牙齒損傷或缺氧發生。

結論:氣道鏡和探針鏡在處理頸套固定引起的困難氣道插管中都有高成功率,然而,氣道鏡更快而且較少引起誤入食道。

(夏俊明譯 薛張綱校)

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.


環氧化酶-2選擇性抑制劑帕瑞考昔和伐地考昔應用於術後,在心血管方面的安全性:整合資料的分析

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――環氧合酶-2選擇性抑制劑和伐地考昔提供冠狀動脈旁路移植手術後的鎮痛作用,與安慰劑相比,可以增加心血管時間發生的風險的不良事件。我們進行這項研究,以解決是否帕瑞考昔和伐地考昔可以增加非心臟手術術後心血管事件的發生。
方法:集中分析使用的是2大資料: 17個關於帕瑞考昔非心臟手術的對照試驗和32項研究,其中包括17個非心臟手術的帕瑞考昔的研究和15項伐地考昔的研究。32項研究資料提示,有95%的可能性相信,假定使用安慰劑心血管事件的發生率是1%,那麼試驗組該事件的發生率增加兩倍(估計從先前的研究資料);如果安慰劑組的發病率是0.5%,那麼有69%的可能性相信試驗組該事件的發生率增加兩倍。
結果17項帕瑞考昔的研究表明,使用帕瑞考昔心血管事件的發生率是0.44%(2966中有13例),而對照組的發生率是0.37%(1915中有7例)(P > 0.20)32項研究分析,帕瑞考昔/伐地考昔心血管事件總的發生率是0.40%(5285中有21例),而安慰劑組該事件的發生率是0.50%(3226中有16例)(P > 0.20)。兩組之間個心血管疾病的種類沒有統計學差異。如果按病人心血管疾病危險因素的數量分層,帕瑞考昔/伐地考昔和安慰劑組之間心血管事件的發生沒有統計學差異。
結論:大規模的分析顯示,選擇性環氧合酶抑制劑或非甾體抗炎藥應用於疼痛管理,帕瑞考昔和伐地考昔並不會增加非心臟手術術後心血管事件的發生率。

章一靜譯 薛張綱校

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

 


靜脈注射利多卡因後,分別在脊髓前腳給予無害和急性傷害刺激後大腦的啟動作用:在試驗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:在人類和實驗動物上,低血藥濃度的利多卡因就可以減緩急性和慢性疼痛。全身給藥時,利多卡因的鎮痛機制還不是很清楚,但是知道與外周神經傳導阻滯無關。與利多卡因有關地鎮痛作用與中樞的鈉通道及其它受體位點有關,與外周神經系統無關。根據我們的認識,利多卡因作用於大腦的鎮痛機制還不是很清楚。在這裏,我們通過功能MRIfMRI)顯像研究全身使用利多卡因後大腦對無害和急性有害刺激的反應。

方法:在全身靜脈注射利多卡因前和後,通過fRMI分別測定α氯醛糖麻醉的小鼠大腦對前腳的無害和有害刺激的反應。

結果:前腳的無害刺激只能引起對側皮層初級自體感覺區(S1)的啟動。急性前腳的傷害性刺激可引起大腦皮層與痛覺相關區域的啟動,包括:次級皮層自體感覺區(S2)、丘腦、島葉和邊緣區。分別靜脈給予利多卡因1mg/kg4mg/kg10mg/kg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   不能消除或減弱大腦對無害或有害刺激的反應。事實上,4mg/kg10mg/kg的利多卡因可以增強S1S2對急性無害刺激的反應,增加50%~60%啟動的大腦皮層的面積。

結論:全身給利多卡因的鎮痛作用與阿片類的鎮痛作用機制不一致,並非直接影響疼痛引起的大腦fMRI的改變。通過fMRI,利多卡因可以增強大腦皮層對急性疼痛的反應,這一現象與可卡因的作用相似。我們近來的研究表明,利多卡因和可卡因都可以增加大腦皮層細胞內鈣離子的濃度,這揭示了機體對軀體感覺刺激敏感性增強與這一藥理作用有關。因為我們的試驗僅僅針對生理的急性疼痛,因此有必要進一步研究與此有相同作用通路的利多卡因在神經痛方面的作用,從而瞭解其鎮痛機制。

(陳珺珺譯 薛張綱校)

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.


比較改良肌腱內給藥和經典膕窩坐骨神經阻滯一項隨機研究:

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.

 

序論:在這項前瞻性隨機研究中,對於行踝和足部手術的患者,我們用兩種方法:改良肌腱內單次給藥和經典膕窩內坐骨神經阻滯,比較了他們的效果。

方法:神經刺激引導的阻滯可在膕窩上7–8 cm (經典)12–14 cm(改良的肌腱內)進行。0.625%左旋布比卡因加腎上腺素1300000(左旋布比卡因,Purdue Pharma, Stamford, CT)總共給予0.4ml/kg(即總量25–35 mL),分次給予5ml。進針後≤0.4 mA刺激即可以誘發同測肢體的蹠屈、背屈、內翻、外翻發生,提示進針位置正確。給藥後30分鐘內,我們可以確定麻醉效果。

結果:在膕窩上進針的平均距離分別是:改良的肌腱內位置是14.0 cm (四分位數範圍, 13.5–15 cm) 、經典的位置為7.5 cm (四分位數範圍,7.0–8.0 cm) (P < 0.01)。改良的肌腱內注射後,55人中44人完全阻滯(占81.5%);經典的位置注射,54人中39人完全阻滯(占70.9%)(P = 0.26)。發生內翻的56名病人中有49人完全阻滯(占87.5%),發生蹠屈的30名病人中有23人完全阻滯(占76.7%);頻率高於發生背屈或外翻的23名病人中有11人完全阻滯(占47.8%),(P = 0.001)。對於改良肌腱內注射,通過誘發內翻運動反應而達到完全阻滯的平均時間為10分鐘(0-22分鐘),快於通過經典後路達到完全阻滯的30分鐘(4-56分鐘)(P = 0.04)

結論:相比于經典入路,改良方法的優點是加快坐骨神經阻滯的麻醉起效時間。

(陳珺珺譯 薛張綱校)

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