Table of Contents

February 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

小鼠缺血再灌注后抑肽酶对左室收缩功能的剂量依赖性改变及细胞因子的释放

单嘉琪译 薛张纲校

Aprotinin Modifies Left Ventricular Contractility and Cytokine Release After Ischemia-Reperfusion in a Dose-Dependent Manner in a Murine Model

Matthew D. McEvoy, Michel J. Sabbagh, Anna Greta Taylor, Juozas A. Zavadzkas, Christine N. Koval, Robert E. Stroud, Rachael L. Ford, Julie E. McLean, Scott T. Reeves, Rupak Mukherjee, and Francis G. Spinale

Anesth Analg 2009 108: 399-406.

心脏手术中的右心室:围手术期的解剖、生理和评估

周姝婧 译 陈杰 校

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: I. Anatomy, Physiology, and Assessment (Review Article)

François Haddad, Pierre Couture, Claude Tousignant, and André Y. Denault

Anesth Analg 2009 108: 407-421.

心脏手术中的右心室,一个围术期角度:II. 病理生理学、临床重要性和管理

彭中美 译 马皓琳 李士通 校

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management (Review Article)

François Haddad, Pierre Couture, Claude Tousignant, and André Y. Denault

Anesth Analg 2009 108: 422-433.

PEDIATRIC ANESTHESIOLOGY:

抑肽酶对行体外循环的新生儿患者术后肾功能不全影响的回顾性分析

范羽译 薛张纲校

The Impact of Aprotinin on Postoperative Renal Dysfunction in Neonates Undergoing Cardiopulmonary Bypass: A Retrospective Analysis

Nina A. Guzzetta, Faye M. Evans, Eli S. Rosenberg, Tom M. Fazlollah, Michael J. Baker, Elizabeth C. Wilson, Anna M. Kaiser, Steven R. Tosone, and Bruce E. Miller

Anesth Analg 2009 108: 448-455.

芬太尼联合异丙酚麻醉延长阵发性室上性心动过速患儿的窦房结恢复时间

黄丹 译 陈杰 校

Fentanyl Added to Propofol Anesthesia Elongates Sinus Node Recovery Time in Pediatric Patients with Paroxysmal Supraventricular Tachycardia

Keisuke Fujii, Hiroshi Iranami, Yoshihide Nakamura, and Yoshio Hatano

Anesth Analg 2009 108: 456-460.

儿童的气道管理:气管插管即刻行超声检查?

黄丽娜 译  马皓琳 李士通 校

Airway Management in Children: Ultrasonography Assessment of Tracheal Intubation in Real Time?

Bruno Marciniak, Pierre Fayoux, Anne Hébrard, Renée Krivosic-Horber, Thomas Engelhardt, and Bruno Bissonnette

Anesth Analg 2009 108: 461-465.

AMBULATORY ANESTHESIOLOGY:

门诊手术病人术前检查项目的略过

黄剑译 薛张纲校

Elimination of Preoperative Testing in Ambulatory Surgery

Frances Chung, Hongbo Yuan, Ling Yin, Santhira Vairavanathan, and David T. Wong

Anesth Analg 2009 108: 467-475.

ANESTHETIC PHARMACOLOGY:

华人异丙酚-瑞芬太尼靶控输注时意识丧失和疼痛刺激无反应时的C50BIS值:一项多中心临床实验

赵嫣红 译 陈杰 校

C50 for Propofol-Remifentanil Target-Controlled Infusion and Bispectral Index at Loss of Consciousness and Response to Painful Stimulus in Chinese Patients: A Multicenter Clinical Trial

Zhipeng Xu, Fang Liu, Yun Yue, Tiehu Ye, Bingxi Zhang, Mingzhang Zuo, Mingjun Xu, Rongrong Hao, Yuan Xu, Ning Yang, and Xiangming Che

Anesth Analg 2009 108: 478-483.

麻醉药对海马CA1神经元持续性和位相性{gamma}-氨基丁酸受体的作用是有区别的

颜涛 译, 马皓琳 李士通 校

Anesthetics Discriminate Between Tonic and Phasic {gamma}-Aminobutyric Acid Receptors on Hippocampal CA1 Neurons

Mark C. Bieda, Henry Su, and M. Bruce MacIver

Anesth Analg 2009 108: 484-490.

促食素A缩短氯胺酮诱导鼠麻醉时间:与大脑去甲肾上腺素能神经元活性的相关性

李莹译 薛张纲校

Orexin A Decreases Ketamine-Induced Anesthesia Time in the Rat: The Relevance to Brain Noradrenergic Neuronal Activity

Ryuji Tose, Tetsuya Kushikata, Hitoshi Yoshida, Mihoko Kudo, Kenichi Furukawa, Shinya Ueno, and Kazuyoshi Hirota

Anesth Analg 2009 108: 491-495.

依托咪酯对大鼠肠系膜阻力动脉血管反应性直接作用的机制

朱紫瑜 译 陈杰 校

The Mechanisms of the Direct Action of Etomidate on Vascular Reactivity in Rat Mesenteric Resistance Arteries

Kazuhiro Shirozu, Takashi Akata, Jun Yoshino, Hidekazu Setoguchi, Keiko Morikawa, and Sumio Hoka

Anesth Analg 2009 108: 496-507.

TECHNOLOGY, COMPUTING, AND SIMULATION:

术后2年死亡率与术中脑电双频指数低和术前存在的恶性疾病间的关系

朱 慧译 马皓琳 李士通校

Mortality Within 2 Years After Surgery in Relation to Low Intraoperative Bispectral Index Values and Preexisting Malignant Disease

Maj-Lis Lindholm, Stefan Träff, Fredrik Granath, Scott D. Greenwald, Anders Ekbom, Claes Lennmarken, and Rolf H. Sandin

Anesth Analg 2009 108: 508-512.

一项通过Vigileo/FloTrac 系统获得的每搏量变异来预测机械通气患者对液体治疗反应性的研究

姚敏敏译 薛张纲校

The Ability of Stroke Volume Variations Obtained with Vigileo/FloTrac System to Monitor Fluid Responsiveness in Mechanically Ventilated Patients

Maxime Cannesson, Henri Musard, Olivier Desebbe, Cécile Boucau, Rémi Simon, Roland Hénaine, and Jean-Jacques Lehot

Anesth Analg 2009 108: 513-517.

多重输注线路延长对输注泵压力报警的影响

怀晓蓉 译 陈杰 校

The Effects of Multiple Infusion Line Extensions on Occlusion Alarm Function of an Infusion Pump (Technical Communication)

Diana Deckert, Christian Buerkle, Andreas Neurauter, Peter Hamm, Karl H. Lindner, and Volker Wenzel

Anesth Analg 2009 108: 518-520.

PATIENT SAFETY:

一项有方法学含义的关于术中知晓的回顾性研究

裘毅敏译,马皓琳 李士通校

A Retrospective Study of Intraoperative Awareness with Methodological Implications

George A. Mashour, Luke Y.-J. Wang, Christopher R. Turner, John C. Vandervest, Amy Shanks, and Kevin K. Tremper

Anesth Analg 2009 108: 521-526.

术中知晓:危险因素,诱因及后遗症:文献中报道病例的总结

俞佳译 薛张纲校

Awareness During Anesthesia: Risk Factors, Causes and Sequelae: A Review of Reported Cases in the Literature

Mohamed M. Ghoneim, Robert I. Block, Mary Haffarnan, and Maya J. Mathews

Anesth Analg 2009 108: 527-535.

困难气道患者喷雾式气道表面麻醉:2 %和4 %利多卡因的随机、双盲比较研究

张磊 译 陈杰 校

Spray-As-You-Go Airway Topical Anesthesia in Patients with a Difficult Airway: A Randomized, Double-Blind Comparison of 2% and 4% Lidocaine

Fu S. Xue, He P. Liu, Nong He, Ya C. Xu, Quan Y. Yang, Xu Liao, Xiu Z. Xu, Xin L. Guo, and Yan M. Zhang

Anesth Analg 2009 108: 536-543.

困难喉镜检查的诊断性预测指标:颏舌距离比

黄佳佳译,马皓琳 李士通 校

Diagnostic Predictor of Difficult Laryngoscopy: The Hyomental Distance Ratio

Jin Huh, Hwa-Yong Shin, Seong-Hyop Kim, Tae-Kyoon Yoon, and Duk-Kyung Kim

Anesth Analg 2009 108: 544-548.

灌注指数作为衡量成年异丙酚麻醉者血管内注射含肾上腺素的硬膜外试验剂量后变化的指标的有效性

张玥琪译 薛张纲校

The Efficacy of Perfusion Index as an Indicator for Intravascular Injection of Epinephrine-Containing Epidural Test Dose in Propofol-Anesthetized Adults

Hany A. Mowafi, Salah A. Ismail, Mohammed A. Shafi, and AbdulMohsin A. Al-Ghamdi

Anesth Analg 2009 108: 549-553.

CRITICAL CARE AND TRAUMA:

短期吸入高浓度氧在兔的体外模型呼吸机所致肺损伤中并不加重损伤

丁俊云 译 陈杰 校

Short-Term Administration of a High Oxygen Concentration Is Not Injurious in an Ex-Vivo Rabbit Model of Ventilator-Induced Lung Injury

Petros Kopterides, Theodoros Kapetanakis, Ilias I. Siempos, Christina Magkou, Aimilia Pelekanou, Thomas Tsaganos, Evangelos Giamarellos-Bourboulis, Charis Roussos, and Apostolos Armaganidis

Anesth Analg 2009 108: 556-564.

带有自适应辅助通气的脱机自动装置:一项应用于心胸外科手术病人的随机对照试验

姜旭晖译,马皓琳 李士通校

Weaning Automation with Adaptive Support Ventilation: A Randomized Controlled Trial in Cardiothoracic Surgery Patients

Dave A. Dongelmans, Denise P. Veelo, Frederique Paulus, Bas A. J. M. de Mol, Johanna C. Korevaar, Anna Kudoga, Pauline Middelhoek, Jan M. Binnekade, and Marcus J. Schultz

Anesth Analg 2009 108: 565-571.

OBSTETRIC ANESTHESIOLOGY:

妊娠期败血症和急性肾功能衰竭

张钊译 薛张纲校

Sepsis and Acute Renal Failure in Pregnancy (Review Article)

Samuel M. Galvagno, Jr. and William Camann

Anesth Analg 2009 108: 572-575.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

神经外科危重病人经皮气管切开术“ Percutwist ”期间颅内压的监测

刘世文 译 陈杰 校

Intracranial Pressure Monitoring During Percutaneous Tracheostomy "Percutwist" in Critically Ill Neurosurgery Patients

Carmela Imperiale, Giuseppina Magni, Roberto Favaro, and Giovanni Rosa

Anesth Analg 2009 108: 588-592.

氙气麻醉对于健康受试者的脑葡萄糖代谢与脑血流之间的关系的效应:正电子断层扫描研究

唐亮 译  马皓琳 李士通 校

The Effects of Xenon Anesthesia on the Relationship Between Cerebral Glucose Metabolism and Blood Flow in Healthy Subjects: A Positron Emission Tomography Study

Ruut M. Laitio, Jaakko W. Långsjö, Sargo Aalto, Kaike K. Kaisti, Elina Salmi, Anu Maksimow, Riku Aantaa, Vesa Oikonen, Tapio Viljanen, Riitta Parkkola, and Harry Scheinin

Anesth Analg 2009 108: 593-600.

七氟烷预处理对氧和葡萄糖缺乏的海马皮层的影响酪氨酸激酶与缺血期的作用

朱兰芳译 薛张纲较

The Preconditioning Effect of Sevoflurane on the Oxygen Glucose-Deprived Hippocampal Slice: The Role of Tyrosine Kinases and Duration of Ischemia

Stéphanie Sigaut, Virginie Jannier, Danielle Rouelle, Pierre Gressens, Jean Mantz, and Souhayl Dahmani

Anesth Analg 2009 108: 601-608.

GENERAL ARTICLES:

经腹和腹腔镜下手术期间在维持前负荷及心指数平时乳酸林格液需求量

叶乐 译 陈杰 校

The Volume of Lactated Ringer's Solution Required to Maintain Preload and Cardiac Index During Open and Laparoscopic Surgery

Mario R. Concha, Verónica F. Mertz, Luis I. Cortínez, Katya A. González, Jean M. Butte, Francisco López, George Pinedo, and Alvaro Zúñiga

Anesth Analg 2009 108: 616-622.

ANALGESIA:

围术期给予加巴喷丁、美洛昔康及其联合应用对门诊腹腔镜胆囊切除术后自发和运动诱发疼痛的影响的随机、双盲、对照实验

吴进 译  马皓琳 李士通 校

A Randomized, Double-Blind, Controlled Trial of Perioperative Administration of Gabapentin, Meloxicam and Their Combination for Spontaneous and Movement-Evoked Pain After Ambulatory Laparoscopic Cholecystectomy

Ian Gilron, Elizabeth Orr, Dongsheng Tu, C. Dale Mercer, and David Bond

Anesth Analg 2009 108: 623-630.

脊柱手术后硬膜外注射可乐定的镇痛作用:一项随机对照研究

陈珺珺译 薛张纲校

The Analgesic Effect of Epidural Clonidine After Spinal Surgery: A Randomized Placebo-Controlled Trial (Brief Report)

Andrew D. Farmery and James Wilson-MacDonald

Anesth Analg 2009 108: 631-634.

微循环对针刺刺激和光疗的反应

舒慧刚 译 陈杰 校

Microcirculatory Responses to Acupuncture Stimulation and Phototherapy

Makiko Komori, Katsumi Takada, Yasuko Tomizawa, Keiko Nishiyama, Izumi Kondo, Miwako Kawamata, and Makoto Ozaki

Anesth Analg 2009 108: 635-640.

布比卡因、罗哌卡因(含肾上腺素)及等容积复合利多卡因合剂用于股神经和坐骨神经阻滞的药效学和药动学的比较:一个双盲、随机化研究

江继宏 译  马皓琳 李士通 校

A Comparison of the Pharmacodynamics and Pharmacokinetics of Bupivacaine, Ropivacaine (with Epinephrine) and Their Equal Volume Mixtures with Lidocaine Used for Femoral and Sciatic Nerve Blocks: A Double-Blind Randomized Study

Philippe Cuvillon, Emmanuel Nouvellon, Jacques Ripart, Jean-Christophe Boyer, Laurence Dehour, Aba Mahamat, Joel L’Hermite, Christophe Boisson, Nathalie Vialles, Jean Yves Lefrant, and Jean Emmanuel de La Coussaye

Anesth Analg 2009 108: 641-649.

老年患者脊麻醉前晶体/胶体与晶体血管内容量治疗对心输出量和每搏输出量影响的比较

张燕 译 陈杰 校

Crystalloid/Colloid Versus Crystalloid Intravascular Volume Administration Before Spinal Anesthesia in Elderly Patients: The Influence on Cardiac Output and Stroke Volume

André Riesmeier, Alexander Schellhaass, Joachim Boldt, and Stefan Suttner

Anesth Analg 2009 108: 650-654.

脊髓麻醉后头低脚高体位乳酸林格氏液和6 %羟乙基淀粉溶液对心输出量的影响

王腾 译 陈杰 校

The Effect of Trendelenburg Position, Lactated Ringer’s Solution and 6% Hydroxyethyl Starch Solution on Cardiac Output After Spinal Anesthesia

Nusa Zorko, Mirt Kamenik, and Vito Starc

Anesth Analg 2009 108: 655-659.

超声引导前路坐骨神经阻滞:与后路阻滞比较

王宏 译 马皓琳、李士通 校

Ultrasound-Guided Anterior Approach to Sciatic Nerve Block: A Comparison with the Posterior Approach

Junichi Ota, Shinichi Sakura, Kaoru Hara, and Yoji Saito

Anesth Analg 2009 108: 660-665.

比较利多卡因/普鲁卡因(EMLA®)和基于酒精的消毒剂对未受损皮肤上菌群的抗菌作用

陈珺珺译 薛张纲校

A Comparison of the Antimicrobial Property of Lidocaine/Prilocaine Cream (EMLA®) and an Alcohol-Based Disinfectant on Intact Human Skin Flora (Brief Report)

Istvan Batai, Lajos Bogar, Vera Juhasz, Reka Batai, and Monika Kerenyi

Anesth Analg 2009 108: 666-668.

心脏手术中的右心室,一个围术期角度:II. 病理生理学、临床重要性和管理

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical Importance, and Management

François Haddad, MD*{dagger}, Pierre Couture, MD*, Claude Tousignant, MD{ddagger}, and André Y. Denault, MD*

From the *Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; {dagger}Division of Cardiovascular Medicine, Stanford University, Stanford, California; and {ddagger}Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2009; 108:422-433

对于右室功能在心血管疾病和心脏手术中重要性的认识已经有很多年了。已有研究显示心脏手术和心脏移植手术中右室功能障碍是重要的预后因素。这篇综述的第一部分复习了右室的解剖、生理和评估。在第二部分,我们回顾了心脏手术中右室衰竭的病理生理学、临床重要性和处理。

(彭中美 译 马皓琳 李士通 校)

The importance of right ventricular (RV) function in cardiovascular disease and cardiac surgery has been recognized for several years. RV dysfunction has been shown to be a significant prognostic factor in cardiac surgery and heart transplantation. In the first article of this review, key features of RV anatomy, physiology, and assessment were presented. In this second part, we review the pathophysiology, clinical importance, and management of RV failure in cardiac surgery.


儿童的气道管理:气管插管即刻行超声检查?

Airway Management in Children: Ultrasonography Assessment of Tracheal Intubation in Real Time?

Bruno Marciniak, MD*, Pierre Fayoux, MD{dagger}{ddagger}, Anne Hébrard, MD*, Renée Krivosic-Horber, MD*, Thomas Engelhardt, MD, PhD§, and Bruno Bissonnette, BSc, MD, FRCPC||

From the *Pôle d’Anesthésie Réanimation, Hôpital Jeanne de Flandre, CHRU, Rue Eugène Aviné, 59037 Lille Cedex France; {dagger}UPRES JE2490, Preclinical research group in perinatal medicine, Lille 2 University, Lille, France; {ddagger}U.F. d’ORL pédiatrique, Pôle d’ORL Hôpital Claude Huriez. CHRU Lille, France; §Royal Aberdeen Children’s Hospital, Foresterhill, Aberdeen, UK; and ||Department of Anesthesia, Hospital Sick Children, Toronto, Canada.

Anesth Analg 2009; 108:461-465

背景:儿科病人的插管需要足够的专业技能,对很多麻醉医生来说可能是一个挑战。证实正确的气管插管位置依赖于直接可视或间接措施,如听诊和二氧化碳波形图。这些方法在敏感性和特异性方面有差异,尤其对于婴儿和幼儿。超声检查是无创的,对于麻醉医生而言,变得越来越容易使用。在该项研究中,我们调查了气管内插管期间正常儿童呼吸道特征性的即刻超声检查结果,以及临床应用的适应性。

方法:研究了30名需要气管内插管的正常气道的儿童。深吸入麻醉下对气管插管的儿童气道进行超声检查,设备为Sonosite Titan® (Sonosite, Bothell, WA)扫描仪,在这一过程中记录了特征图像。正确的气管插管位置进一步通过听诊和满意的呼气末二氧化碳波形图证实。

结果:研究病人的平均(±标准差)年龄为48 ± 37 mo,体重为19.7. ± 8.6 kg,性别比(男/女)为1:2。成功的气管插管通过如下的标准证实:1)辨别气管和气管环,2)可见到声带,3)当气管导管置入时声门变宽,4)隆突上气管导管的位置以及手控通气时胸壁内脏壁胸膜界面的运动(如移动征象)。通过导管在左侧气管旁空间的显像,容易地发现了一例置入食管的病例。

结论:该研究描述了气管插管过程中儿童气道的特征性超声检查图像结果。提示我们超声检查可能会对儿童气道管理有用。

(黄丽娜 译  马皓琳 李士通 校)

BACKGROUND: Pediatric tracheal intubation requires considerable expertise and can represent a challenge to many anesthesiologists. Confirmation of correct tracheal tube position relies on direct visualization or indirect measures, such as auscultation and capnography. These methods have varying sensitivity and specificity, especially in the infant and young child. Ultrasonography is noninvasive and is becoming more readily available to the anesthesiologist. In this study, we investigated the characteristic real-time ultrasonographic findings of the normal pediatric airway during tracheal intubation and its suitability for clinical use.

METHODS: Thirty healthy children with normal airways requiring tracheal intubation were studied. Ultrasonographic measurements of the pediatric airway during tracheal intubation under deep inhaled anesthesia were performed using a Sonosite Titan® (Sonosite, Bothell, WA) scanner while recording characteristic images during this process. Correct tracheal tube placement was further confirmed using auscultation and satisfactory end-tidal capnography.

RESULTS: The mean (± sd) age of studied patients was 48 ± 37 mo, weight was 19.7. ± 8.6 kg and the sex ratio (m/f) was 1:2. Successful tracheal intubation was verified using the following criteria: 1) identification of the trachea and tracheal rings, 2) visualization of vocal cords, 3) widening of glottis as the tracheal tube passes through, and 4) tracheal tube position above carina and demonstration of movement of the chest wall visceroparietal pleural interface (i.e., sliding sign) after manual ventilation of the lungs. One esophageal intubation was readily recognized by visualization of the tube in the left paratracheal space.

CONCLUSION: This study describes characteristic ultrasonographic findings of the pediatric airway during tracheal intubation. It suggests that ultrasonography may be useful for airway management in children.



麻醉药对海马CA1神经元持续性和位相性{gamma}-氨基丁酸受体的作用是有区别的

Anesthetics Discriminate Between Tonic and Phasic {gamma}-Aminobutyric Acid Receptors on Hippocampal CA1 Neurons

Mark C. Bieda, PhD, Henry Su, BS, and M. Bruce MacIver, MSc, PhD

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

Anesth Analg 2009; 108:484-490

背景:麻醉是通过抑制中枢神经系统(CNS)信号而产生的;然而,这种抑制的作用机制仍然不明。近来的研究表明麻醉药能够通过增加细胞膜中持续性{gamma}-氨基丁酸(GABAA)受体门控的氯离子通道电流来加强CNS神经元的抑制。持续性抑制增强可能促进麻醉药产生的CNS抑制,但是麻醉药对这些受体的作用在多大程度上促进CNS抑制还有待研究。在本研究中,我们比较和对照了持续性和突触性GABAA受体在异氟烷和硫喷妥产生的CNS神经元功能性抑制中所起的作用。

方法:在大鼠海马脑片上采用全细胞膜片钳记录来研究麻醉药对CA1神经元自发兴奋性的作用;采用群峰电位记录来研究对突触诱发放电的作用。选择这些反应来检验麻醉药对GABA受体的作用是否改变单个神经元放电和/或环路层次上突触的功能。使用GABAA拮抗剂gabazine选择性阻断相位性(突触)GABA受体,采用氯离子通道阻断剂印防己毒素阻断持续性反应。

结果:临床应用范围的等效浓度硫喷妥和异氟烷抑制CA1神经元突触诱发的放电。使用gabazine(20 µM)阻断突触GABAA受体可部分逆转这种抑制效应。硫喷妥产生的抑制作用约60%可被逆转,但异氟烷产生的抑制作用仅约20%可被逆转。再添加100µM印防己毒素阻断持续性GABAA受体可使硫喷妥产生的抑制再多逆转40%,但对异氟烷产生的抑制没有进一步的逆转作用。硫喷妥抑制直流电直接注射引起的CA1神经元放电,并且增加膜电导。印防己毒素可逆转这两种作用,而gabazine无效。相反,异氟烷既不抑制电流诱发的放电,也不改变CA1神经元的膜电导。

结论:这些结果表明全麻药能辨别突触GABAA受体和持续性GABAA受体。对位相性受体和持续性受体的两种作用结合起来抑制硫喷妥钠产生的神经环路的反应;异氟烷仅对突触GABAA受体作用具有重要意义。结合这两种麻醉药其他抑制作用位点,我们的结果支持麻醉药作用机制是多位点的和具有药物差异性的。

(颜涛 译, 马皓琳 李士通 校)

BACKGROUND: Anesthesia is produced by a depression of neuronal signaling in the central nervous system (CNS); however, the mechanism(s) of action underlying this depression remain unclear. Recent studies have indicated that anesthetics can enhance inhibition of CNS neurons by increasing current flow through tonic {gamma}-aminobutyric acid (GABAA) receptor gated chloride channels in their membranes. Enhanced tonic inhibition would contribute to CNS depression produced by anesthetics, but it remains to be determined to what extent anesthetic actions at these receptors contribute to CNS depression. In the present study, we compared and contrasted the involvement of tonic versus synaptic GABAA receptors in the functional depression of CNS neurons produced by isoflurane and thiopental.

METHODS: In rat hippocampal slices, whole cell patch clamp recordings were used to study anesthetic effects on CA1 neuron intrinsic excitability, and population spike recordings were used to investigate effects on synaptically evoked discharge. These responses were chosen to test whether anesthetic effects on GABA receptors alter single neuron discharge and/or circuit level synaptic functioning. Phasic (synaptic) GABA receptors were selectively blocked using the GABAA antagonist gabazine and tonic responses were blocked using the chloride channel blocker picrotoxin.

RESULTS: Clinically relevant and equi-effective concentrations of thiopental and isoflurane depressed CA1 neuron synaptically evoked discharge. This depression was partially reversed by blocking synaptic GABAA receptors with gabazine (20 µM). The thiopental-induced depression was reversed by approximately 60%, but the isoflurane-induced depression was reversed by only approximately 20%. Blocking tonic GABAA receptors with the addition of 100 µM picrotoxin produced an additional 40% reversal of the thiopental-induced depression, but no additional reversal was seen for isoflurane-depressed responses. In response to direct DC current injection, CA1 neuron discharge was depressed by thiopental and membrane conductance was increased. Both of these effects were reversed by picrotoxin, but not by gabazine. Isoflurane, in contrast, neither depressed current-evoked discharge, nor altered the membrane conductance of CA1 neurons.

CONCLUSIONS: These results indicate that general anesthetics discriminate between synaptic and tonic GABAA receptors. Effects on both phasic and tonic receptors combined to depress circuit responses produced by thiopental, whereas only effects on synaptic GABA receptors appeared to play an important role for isoflurane. Together with the other known sites of action for these two anesthetics, our results support a multisite, agent-specific mechanism for anesthetic actions.


 

术后2年死亡率与术中脑电双频指数低和术前存在的恶性疾病间的关系

Mortality Within 2 Years After Surgery in Relation to Low Intraoperative Bispectral Index Values and Preexisting Malignant Disease

Maj-Lis Lindholm, PhD, RN*, Stefan Träff, MD{dagger}, Fredrik Granath, PhD{ddagger}, Scott D. Greenwald, PhD§, Anders Ekbom, MD, PhD{ddagger}, Claes Lennmarken, MD, PhD{dagger}, and Rolf H. Sandin, MD, PhD*

From the *Department of Physiology and Pharmacology, Section for Anesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden; {dagger}Department of Anesthesia and Intensive Care, University Hospital, Linköping, Sweden; {ddagger}Department of Medicine, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden; and §Aspect Medical Systems, Norwood, Massachusetts.

Anesth Analg 2009; 108:508-512

背景:深麻醉(定义为脑电双频指数(BIS)<45的时间;TBIS<45)与术后1年死亡间的关系曾被报道。为了确认或推翻这些发现,我们把TBIS<45作为术后1年和2年死亡的独立危险因子进行评估,同时评估的还有以前报导的主要死因恶性疾病的影响。

方法:对4087例监测BIS的患者记录其术后2年的死亡率、死亡原因和手术时发现的恶性疾病。确定对死亡率有统计学意义的单变量预测因子。为了考虑到对照先前的数据,接下来的多变量分析先不包括主要死因即事先存在的恶性疾病,再包括这些因素进行分析。

结果:1年内174例(4.3%)患者死亡,另92例在第二年死亡(2年中共6.5%)。当事先存在的恶性疾病不是协变因子时,TBIS <45是1年和2年死亡率的显著预测因子(危害比[HR]分别是1.13[1.01–1.27]和1.18[1.08–1.29])。进一步的研究显示在事先存在恶性疾病进行广泛手术,预后不良的患者中术后死亡率和TBIS<45有显著相关性。模型中2年死亡率的最强预测因子(包括事先存在恶性疾病)是ASA评分IV级(HR 19.3 [7.31–51.1]), 年龄>80 岁(HR 2.93 [1.79–4.79]),以及事先存在恶性疾病与不良预后有关(HR 9.30 [6.60–13.1])。当使用事先存在的恶性疾病状态作为模型中共同变量把最初的多元回归分析重复进行时,之前1年死亡率、2年死亡率和TBIS<45之间的显著相关性就没有统计学意义了。

结论:我们在先前的工作中使用一套相似的协同因子,证实了1年死亡率和TBIS<45间在统计学上有相关性,并且我们把这个观察结果延伸到了2年死亡率。然而,这个相关性对统计学模型中协同因子的选择很敏感,且需要一个随机化的研究来证明TBIS<45和术后死亡率确实有因果关系。如果是,其影响与用ASA评分、手术前存在的恶性疾病及年龄评估的协同发病率比较可能是很微弱的。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: A correlation between deep anesthesia (defined as time with Bispectral Index (BIS) <45; TBIS <45) and death within 1 yr after surgery has previously been reported. In order to confirm or refute these findings, we evaluated TBIS <45 as an independent risk factor for death within 1 and 2 yr after surgery and also the impact of malignancy, the predominant cause of death in the previous report.

METHODS: Mortality within 2 yr after surgery, causes of death and the occurrence of malignant disease at the time of surgery were identified in a cohort of 4087 BIS-monitored patients. Statistically significant univariate predictors of mortality were identified. In order to allow for comparison with previous data, the following multivariate analysis was first done without, and thereafter with, preexisting malignancy status, the predominant cause of death.

RESULTS: One-hundred-seventy-four (4.3%) patients died within 1 yr and another 92 during the second year (totaling 6.5% in 2 yr). TBIS <45 was a significant predictor of 1- and 2-yr mortality when preexisting malignant disease was not among the co-variates (hazard ratio [HR] 1.13 [1.01–1.27] and 1.18 [1.08–1.29], respectively). Further exploration confined the significant relation between postoperative mortality and TBIS <45 to patients with preexisting malignant diagnoses associated with extensive surgery and less favorable prognosis. The most powerful predictors of 2-yr mortality in the model, including preexisting malignancy, were ASA physical score class IV (HR 19.3 [7.31–51.1]), age >80 yr (HR 2.93 [1.79–4.79]), and preexisting malignancy associated with less favorable prognosis (HR 9.30 [6.60–13.1]).When the initial multivariate regression was repeated using preexisting malignancy status among the co-variates in the model, the previously significant relation between 1, and 2-yr mortality and TBIS <45 did not reach statistical significance.

CONCLUSION: Using a similar set of co-variates as in previous work, we confirmed the statistical relation between 1-yr mortality and TBIS <45, and we extended this observation to 2-yr mortality. However, this relation is sensitive to the selection of co-variates in the statistical model, and a randomized study is required to demonstrate that there really is a causal impact from and TBIS <45 on postoperative mortality and, if it does, the effect is probably very weak in comparison with co-morbidity as assessed by ASA physical score, the preexisting malignancy status at surgery and age.



一项有方法学含义的关于术中知晓的回顾性研究

A Retrospective Study of Intraoperative Awareness with Methodological Implications

George A. Mashour, MD, PhD, Luke Y.-J. Wang, MD, Christopher R. Turner, MD, PhD, MBA, John C. Vandervest, BS, Amy Shanks, MS, and Kevin K. Tremper, PhD, MD

From the Department of Anesthesiology, University of Michigan Medical School, Michigan.

Anesth Analg 2009; 108:521-526

背景:全麻中的知晓问题正日益受到医生和患者的关注。一项大的多中心研究确立了全麻知晓的可接受的发生率大约为每1000例中1-2例或0.15%。然而,最近更多的回顾性研究提出实际的发生率可能低至0.0068%。

方法:我们回顾了3年内行外科手术的成年患者,以评估本机构内知晓的发生率。我们从围术期信息系统中术后第一天的标准评估中获取术中知晓的信息。并不就知晓特别询问患者。

结果:我们回顾了116,478例病史;其中65,061个病例接受了全麻,另外51,417个病例接受了其他方式的麻醉。全麻中的44,006例有完整的术后资料。在此人群中被报道的不受欢迎的术中知晓发生率为10/44,006 (1/4401或 0.023%)。在其他方式的麻醉患者中,22,885例有完整的术后资料。在未接受全麻的患者中报道的不受欢迎的术中知晓发生率为7/22,885(1/3269 或 0.03%)。两组报道的术中知晓发生率无统计学差别(P = 0.54)。全麻与非全麻相比,术中知晓的相对危险为0.74,95%可信区间[0.28, 2.0]。

结论:使用回顾性方法学,全麻与非全麻术中知晓的发生率无统计学差别。这些结果提示,尽管回顾性资料能成功报导另外一些罕见的围术期事件,然而回顾性资料分析的分辨率可能太低了而不能用于研究术中知晓问题。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: Awareness during general anesthesia is a problem receiving increased attention from physicians and patients. Large multicentered studies have established an accepted incidence of awareness during general anesthesia as approximately 1–2 per 1000 cases or 0.15%. More recent retrospective data, however, suggest that the actual incidence may be as low as 0.0068%.

METHODS: To assess the incidence of awareness at our institution, we conducted a review of adult patients undergoing surgical procedures over a 3-year period. Information on awareness came from entries of "Intraoperative Awareness" captured during our standard evaluations on postoperative day one in our perioperative information system. Patients were not questioned specifically about awareness.

RESULTS: We reviewed 116,478 charts; 65,061 patients received general anesthesia and 51,417 received other types of anesthesia. Of the patients receiving general anesthesia, 44,006 had complete postoperative documentation. The reported incidence of undesired intraoperative awareness in this population was 10/44,006 (1/4401 or 0.023%). Of the patients who received other anesthetic modalities, 22,885 had complete postoperative documentation. Undesired intraoperative awareness was reported in 7/22,885 patients who did not receive general anesthesia (1/3269 or 0.03%). The reported incidence of intraoperative awareness was not statistically different between the two groups (P = 0.54). Relative risk of intraoperative awareness during a general anesthetic compared with a nongeneral anesthetic was 0.74, with 95% confidence interval [0.28, 2.0].

CONCLUSION: Using a retrospective methodology, reports of intraoperative awareness are not statistically different in patients who received general anesthesia compared with those who did not. These results suggest that, despite success with other rare perioperative events, the resolution of retrospective database analyses may be too low to study intraoperative awareness.



困难喉镜检查的诊断性预测指标:颏舌距离比

Diagnostic Predictor of Difficult Laryngoscopy: The Hyomental Distance Ratio

Jin Huh, MD*, Hwa-Yong Shin, MD{dagger}, Seong-Hyop Kim, MD{dagger}, Tae-Kyoon Yoon, MD{dagger}, and Duk-Kyung Kim, MD{dagger}

From the *Department of Anesthesiology, Seoul National University Borame Municipal Hospital; and {dagger}Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, South Korea.

Anesth Analg 2009; 108:544-548

背景:我们通过以下单一或混合的术前气道指标评估了颏舌距离(HMD)比(HMDR)在预测表面上正常的患者喉镜检查时发生困难视野(DVL)的可靠性:改良Mallampati 试验、头部中立位时的HMD、头部最大伸展位时HMD和甲颏距离以及HMDR。HMDR定义在为头部最大伸展位和中立位时HMD的比值。

方法:我们在术前评估了213位进行插管全麻患者的上述5项气道预测指标。一位有经验的麻醉医生参与了所有的直接喉镜检查,并且用改良的Cormack 和 Lehane评分进行视野可视度评级。这位医生不知道气道评估结果。可视度3级或4级均被定义为DVL。每一个试验的最佳终止点确定在受试者操作特征曲线下面积达到最大点时。在改良Mallampati试验中,预定义≥3级为DVL的一项预测指标。

结果:26位(12.2%)病人中喉镜视野困难。在单变量分析中,头部最大伸展位时的HMD和甲颏距离以及HMDR都与DVL之间显著相关。HMDR在最佳终止点为1.2时(曲线下面积0.782)比其他单一预测指标具有较大的诊断精确性 (P < 0.05),而且单纯这个指标就比其他任何试验组合具有更好的诊断有效性(敏感性88%,特异性60%)。

结论: HMDR的试验阈值为1.2是DVL的可靠临床预测指标。

(黄佳佳译,马皓琳 李士通 校)

BACKGROUND: We evaluated the usefulness of the hyomental distance (HMD) ratio (HMDR), defined as the ratio of the HMD at the extreme of head extension to that in the neutral position, in predicting difficult visualization of the larynx (DVL) in apparently normal patients, by examining the following preoperative airway predictors, alone and in combination: the modified Mallampati test, HMD in the neutral position, HMD and thyromental distance at the extreme of head extension and HMDR.

METHODS: Preoperatively, we assessed the five airway predictors in 213 adult patients undergoing general anesthesia with tracheal intubation. A single experienced anesthesiologist, blinded to the results of the airway evaluation, performed all of the direct laryngoscopies and graded the views using the modified Cormack and Lehane scale. DVL was defined as a Grade 3 or 4 view. The optimal cutoff points for each test were determined at the maximal point of the area under the curve in the receiver operating characteristic curve. For the modified Mallampati test, Class ≥3 was predefined as a predictor of DVL.

RESULTS: The larynx was difficult to visualize in 26 (12.2%) patients. In univariate analyses, the HMD and thyromental distance at the extreme of head extension and the HMDR were significantly related to DVL. The HMDR with the optimal cutoff point of 1.2 had greater diagnostic accuracy (area under the curve of 0.782), than other single predictors (P < 0.05), and it alone showed a greater diagnostic validity profile (sensitivity, 88%; specificity, 60%) than any test combinations.

CONCLUSIONS: The HMDR with a test threshold of 1.2 is a clinically reliable predictor of DVL.


带有自适应辅助通气的脱机自动装置:一项应用于心胸外科手术病人的随机对照试验

Weaning Automation with Adaptive Support Ventilation: A Randomized Controlled Trial in Cardiothoracic Surgery Patients

Dave A. Dongelmans, MD, MSc*, Denise P. Veelo, MD*{dagger}{ddagger}, Frederique Paulus, RN*, Bas A. J. M. de Mol, MD, PhD§, Johanna C. Korevaar, PhD||, Anna Kudoga, MS*, Pauline Middelhoek, RN*, Jan M. Binnekade, PhD*, and Marcus J. Schultz, MD, PhD*{ddagger}

From the Departments of *Intensive Care Medicine and {dagger}Anesthesiology, {ddagger}Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Departments of §Cardiothoracic Surgery and ||Clinical Epidemiology and Biostatistics, Academic Medical Centre, University of Amsterdam; and ¶HERMES Critical Care Group, Amsterdam, The Netherlands.

Anesth Analg 2009; 108:565-571

背景:自适应辅助通气(ASV)是一种微机控制模式的机械通气装置,它可自动地从控制通气切换到辅助通气,并且根据肺部机能选择适合的通气参数。

方法:在本次随机对照实验中,非快通道冠状动脉旁路搭桥的病人在手术中通过ASV或者压力控制/压力支持通气(对照)来进行肺部通气,从而来比较气管导管拔除的时间、控制通气和辅助通气持续时间的比例以及通气特征。

结果:128位连续的病人随机化入选实验。ASV组病人气管导管拔除时间为16.4hr(四分位范围12.5-20.8hr),对照组是16.3 (13.7–19.3) hr(P= 0.97)。病人辅助通气时间比例(辅助通气时间/总通气时间)ASV组是43% (28%–67%),对照组是52% (33%–75%)(P<0.05)。但是,ASV组病人发生从控制通气切换到辅助通气的病例数(43.0 [14.0–74.0])高于对照组(4.0 [2.0–9.0])(P < 0.001)。ASV组病人在控制通气过程中的平均潮气量(8.6 ± 0.8 mL/kg预计体重)显著大于对照组(7.1 ± 1.4 mL/kg预计体重)(P= 0.05),但是在辅助通气过程中两组潮气量没有差别。

结论:带有自适应辅助通气的脱机自动装置可行而且安全地应用于非快通道冠状动脉旁路搭桥的病人。ASV组病人气管导管拔除时间和标准脱机组病人相差不多,但是在手术中需要在控制通气和辅助通气间做频繁的(自动)切换。

(姜旭晖译,马皓琳 李士通校)

Background: Adaptive support ventilation (ASV) is a microprocessor-controlled mode of mechanical ventilation that switches automatically from controlled ventilation to assisted ventilation and selects ventilatory settings according to measured lung mechanics.

Methods: In a randomized controlled trial, non–fast-track coronary artery bypass grafting patients' lungs were ventilated with ASV or pressure-controlled/pressure-support ventilation (control) to compare time until tracheal extubation, duration of controlled ventilation versus assisted ventilation, and ventilation characteristics.

Results: One hundred twenty-eight consecutive patients were randomized. ASV patients had their tracheas extubated after median 16.4 and interquartile range 12.5–20.8 hr, and control patients after 16.3 (13.7–19.3) hr, respectively (P = 0.97). The percentage of time patients were on assisted ventilation (expressed as the median percentage of total duration of ventilation) was 43% (28%–67%) in the ASV group and 52% (33%–75%) in the control group (P < 0.05). However, the number of switches from controlled to assisted ventilation was higher in the ASV group (43.0 [14.0–74.0]) than in the control group (4.0 [2.0–9.0]) (P < 0.001). In ASV patients, mean tidal volumes were significantly larger during controlled ventilation than in control patients (8.6 ± 0.8 mL/kg predicted body weight vs 7.1 ± 1.4 mL/kg predicted body weight; P = 0.05), and no differences in tidal volumes were found during assisted ventilation.

Conclusion: Weaning automation with ASV is feasible and safe in non–fast-track coronary artery bypass grafting patients. Time until tracheal extubation with ASV equals time until tracheal extubation with standard weaning and allows for frequent (automatic) switches between controlled and assisted ventilation.



氙气麻醉对于健康受试者的脑葡萄糖代谢与脑血流之间的关系的效应:正电子断层扫描研究

The Effects of Xenon Anesthesia on the Relationship Between Cerebral Glucose Metabolism and Blood Flow in Healthy Subjects: A Positron Emission Tomography Study

Ruut M. Laitio, MD*{dagger}, Jaakko W. Långsjö, MD*{dagger}, Sargo Aalto, MSc*{ddagger}, Kaike K. Kaisti, MD*{dagger}, Elina Salmi, MD*§, Anu Maksimow, MD*{dagger}, Riku Aantaa, MD{dagger}, Vesa Oikonen, MSc*, Tapio Viljanen, MSc*, Riitta Parkkola, MD||, and Harry Scheinin, MD*

From the *Turku PET Centre, University of Turku; {dagger}Departments of Anesthesiology and Intensive Care, §Otorhinolaryngology, and ||Radiology, Turku University Hospital; and {ddagger}Department of Psychology, Åbo Akademi University, Turku, Finland.

Anesth Analg 2009; 108:593-600

背景:全麻可以改变局部脑葡萄糖代谢(rCMRglc)和脑血流(rCBF).之间的关系。在这个正电子断层扫描的研究中,我们的目的是评估同一个体在氙气麻醉时的rCMRglc和rCBF。

方法:18F标记的氟脱氧葡萄糖和15O标记的水分别来测定5名健康男性志愿者处于基线水平(清醒)和1个最小肺泡麻醉浓度(MAC)的氙气麻醉中的rCMRglc和rCBF。麻醉中只使用氙气。rCMRglc和rCBF变化用感兴趣区域和基于三维像素的分析来量化。

结果:氙气麻醉中的浓度平均值(标准差)是67.2 (0.8)%。氙气麻醉导致所有人的rCMRglc下降,而rCBF在13个脑区域中有7个下降。脑灰质的rCMRglc和rCBF分别平均减少32.4 (4.0)% (P < 0.001) 和14.8 (5.9)% (P = 0.007)。脑白质的rCMRglc减少10.9 (6.4)% (P = 0.030),而rCBF增加9.2 (7.3)% (P = 0.049)。rCBF/rCMRglc比在间脑、前后回和躯体感觉皮质增加得特别明显。

结论:总体来说,在1MAC的氙气麻醉下rCMRglc减少程度超过rCBF的降低,因此rCBF和rCMRglc比例有所升高。有趣的是,氙气所导致的脑代谢和脑血流的改变和挥发性吸入麻醉药所致的改变相似。

(唐亮 译  马皓琳 李士通 校)      

BACKGROUND: General anesthetics can alter the relationship between regional cerebral glucose metabolism (rCMRglc) and blood flow (rCBF). In this positron emission tomography study, our aim was to assess both rCMRglc and rCBF in the same individuals during xenon anesthesia.

METHODS: 18F-labeled fluorodeoxyglucose and 15O-labeled water were used to determine rCMRglc and rCBF, respectively, in five healthy male subjects at baseline (awake) and during 1 minimum alveolar anesthetic concentration of xenon. Anesthesia was based solely on xenon. Changes in rCMRglc and rCBF were quantified using region-of-interest and voxel-based analyses.

RESULTS: The mean (sd) xenon concentration during anesthesia was 67.2 (0.8)%. Xenon anesthesia induced a uniform reduction in rCMRglc, whereas rCBF decreased in 7 of 13 brain regions. The mean decreases in the gray matter were 32.4 (4.0)% (P < 0.001) and 14.8 (5.9)% (P = 0.007) for rCMRglc and rCBF, respectively. rCMRglc decreased by 10.9 (6.4)% in the white matter (P = 0.030), whereas rCBF increased by 9.2 (7.3)% (P = 0.049). The rCBF/rCMRglc ratio was especially increased in the insula, anterior and posterior cingulate, and in the somatosensory cortex.

CONCLUSIONS: In general, the magnitude of the decreases in rCMRglc during 1 minimum alveolar anesthetic concentration xenon anesthesia exceeded the reductions in rCBF. As a result, the ratio between rCMRglc and rCBF was shifted to a higher level. Interestingly, xenon-induced changes in cerebral metabolism and blood flow resemble those induced by volatile anesthetics.

 

 

 

围术期给予加巴喷丁、美洛昔康及其联合应用对门诊腹腔镜胆囊切除术后自发和运动诱发疼痛的影响的随机、双盲、对照实验

A Randomized, Double-Blind, Controlled Trial of Perioperative Administration of Gabapentin, Meloxicam and Their Combination for Spontaneous and Movement-Evoked Pain After Ambulatory Laparoscopic Cholecystectomy

Ian Gilron, MD, MSc, FRCPC*{dagger}, Elizabeth Orr, RN*, Dongsheng Tu, PhD{ddagger}, C. Dale Mercer, MD, FRCSC§, and David Bond, MB, BChir, MA, MSc, CCFP, FRCPC||

From the *Department of Anesthesiology, Kingston General Hospital, and the Departments of {dagger}Pharmacology and Toxicology, {ddagger}Mathematics and Statistics, and §Surgery, Queen's University, Kingston, Ontario, Canada; and ||Department of Anesthesiology, University of British Columbia, Vancouver, British Columbia, Canada.

Anesth Analg 2009; 108:623-630

背景住院子宫切除和脊柱手术实验提示环氧酶-2 抑制剂和加巴喷丁/普加巴林之间在术后1-2天有良好的相互作用。我们进行了把美洛昔康-加巴喷丁联合应用于门诊腹腔镜胆囊切除术后的初次试验。

方法:本实验为随机、双盲实验,比较术前1h开始到术后2天每天口服1)美洛昔康15mg、2)加巴喷丁1200-1600mg以及3)联合口服这两种药物的不同作用。主要的观察指标包括手术当天自发和运动所诱发的疼痛。其次的观察指标包括术后1、2和30天的疼痛、不良反应、阿片类药物的需求、呼吸量测定、疼痛相关的干扰、出院时间、恢复工作时间以及病人的满意度。

结果:手术当天,单独口服加巴喷丁的60分钟静息疼痛评分(2.0 ± 1.6)(0-10数字分级评分±标准差)明显比单独口服美洛昔康(3.6 ± 2.1)低(P < 0.05)。联合口服两种药物(2.9 ± 2.1)与单独口服加巴喷丁之间所观察到的疼痛差别非常小(P > 0.05),且这种差别对单独口服加巴喷丁有利。二次分析表明,联合口服两种药物术后恶心的发生率(24%)明显比单独口服美洛昔康(57%)低。

结论:虽然联合口服美洛昔康和加巴喷丁可以减少术后恶心,但是本实验不能或几乎不能支持联合用药用于缓解手术当天的疼痛。这表明围术期给予多种镇痛药并不总是必要或者恰当的。

(吴进 译  马皓琳 李士通 校)

BACKGROUND: Hysterectomy and spinal surgery inpatient trials suggest favorable interactions between cyclooxgenase-2 inhibitors and gabapentin/pregabalin on postoperative days 1–2. We present the first trial of meloxicam-gabapentin combination after outpatient laparoscopic cholecystectomy.

METHODS: This was a randomized, double-blind trial comparing daily oral administration of 1) meloxicam 15 mg, 2) gabapentin 1200–1600 mg, and 3) a combination of the two starting 1 h before until 2 days after surgery. Primary outcomes included day of surgery spontaneous and movement-evoked pain. Secondary outcomes included pain on Days 1, 2, and 30, adverse effects, opioid consumption, spirometry, pain-related interference, hospital discharge time, return to work time, and patient satisfaction.

RESULTS: On the day of surgery, 60-min rest pain (0–10 numerical rating scale ± sd) was significantly lower (P < 0.05) with gabapentin alone (2.0 ± 1.6) versus meloxicam alone (3.6 ± 2.1). Observed pain differences between the combination (2.9 ± 2.1) and gabapentin alone were fairly small in favor of gabapentin alone (P > 0.05). Secondary analyses indicated that nausea was significantly less frequent with the combination (24%) versus the single-drug meloxicam (57%) only.

CONCLUSION: Although nausea was reduced with combination therapy, this trial provides little or no support for the combined use of meloxicam and gabapentin for pain relief on the day of surgery. This suggests that perioperative analgesic polypharmacy may not always be necessary or appropriate.



布比卡因、罗哌卡因(含肾上腺素)及等容积复合利多卡因合剂用于股神经和坐骨神经阻滞的药效学和药动学的比较:一个双盲、随机化研究

A Comparison of the Pharmacodynamics and Pharmacokinetics of Bupivacaine, Ropivacaine (with Epinephrine) and Their Equal Volume Mixtures with Lidocaine Used for Femoral and Sciatic Nerve Blocks: A Double-Blind Randomized Study

Philippe Cuvillon, MD, MSc*, Emmanuel Nouvellon, MD, MSc*, Jacques Ripart, MD, PhD*, Jean-Christophe Boyer, MD{dagger}, Laurence Dehour, MD*, Aba Mahamat, MD{ddagger}, Joel L’Hermite, MD*, Christophe Boisson, MD*, Nathalie Vialles, MD*, Jean Yves Lefrant, MD, PhD*, and Jean Emmanuel de La Coussaye, MD, PhD*

From the *Division of the Department of Anesthesiology and Pain Management, University Groupe Caremeau Hospital, France and University of Montpellier 1, France; {dagger}Laboratoire de Biochimie, University Groupe Caremeau Hospital, Place Professeur Debré, 30029 Nîmes, France; and {ddagger}Laboratoire d’épidémiologie et de Biostatistiques, Institut Universitaire de Recherche Clinique, Montpellier, France and Département Informatique Médicale, CHU Nîmes, France.

Anesth Analg 2009; 108:641-649

背景:长效局麻药复合利多卡因合剂常用于外周神经阻滞。目前关注局麻药合剂安全性、有效性和药代动力学的研究数据很少。我们的研究比较了0.5%布比卡因、0.75%罗哌卡因、等容量0.5%布比卡因复合2%利多卡因合剂以及等容量0.75%罗哌卡因复合2%利多卡因合剂用于股神经-坐骨神经阻滞后手术的效能。本研究主要终点指标是起效时间。

方法:82名接受股神经(20 mL)和坐骨神经(20 mL)阻滞的下肢手术成年病人,随机、双盲地给予0.5%布比卡因(200 mg)、0.5%布比卡因20 mL (100 mg)复合2% 利多卡因 (400 mg)合剂、0.75%罗哌卡因(300 mg)或0.75%罗哌卡因20 mL(150mg)复合2%利多卡因 (400 mg)合剂。每一种阻滞液中均含有1:200,000肾上腺素。我们比较了实施阻滞的时间、起效(注射结束至感觉及运动完全阻滞)时间、感觉及运动阻滞的持续时间、病人静脉自控镇痛的吗啡用量。神经阻滞后0、5、15、30、45、60和90 min分别静脉采血5mL用于测定血药浓度。

结果:四组病人一般情况和手术持续时间相似。利多卡因复合长效局麻药缩短坐骨神经阻滞起效时间(感觉和运动阻滞)。与单独应用布比卡因组(28 ± 12 min)相比,布比卡因复合利多卡因组起效时间为16 ± 9 min;与单独应用罗哌卡因组(23 ± 12 min)相比,罗哌卡因复合利多卡因组起效时间为16 ± 12 min。与单独应用布比卡因组(60 min)相比,布比卡因复合利多卡因组所有病人在40min内感觉完全阻滞;与单独应用罗哌卡因组(40 min)相比,罗哌卡因复合利多卡因组所有病人在30 min内感觉完全阻滞(P < 0.05)。合剂组的感觉和运动觉阻滞持续时间明显较短。除单独应用布比卡因组吗啡用量中位数(9 mg)少于布比卡因复合利多卡因组(15 mg)(P < 0.01)外,各组术后48 h内疼痛视觉模拟评分和吗啡使用量没有差别。各组之间不良事件的发生率无差异。与长效局麻药复合利多卡因组相比,单独应用长效局麻药组的病人血浆布比卡因和罗哌卡因浓度较高且持续升高时间较长(P < 0.01)。

结论:长效局麻药复合利多卡因合剂起效快,持续时间短。我们还不清楚长效局麻药复合利多卡因是否具有安全性这一优点,因为血浆长效局麻药浓度降低的益处可能被存在显著增高的血浆利多卡因浓度所抵消。

(江继宏 译  马皓琳 李士通 校)

BACKGROUND: Mixtures of lidocaine with a long-acting local anesthetic are commonly used for peripheral nerve block. Few data are available regarding the safety, efficacy, or pharmacokinetics of mixtures of local anesthetics. In the current study, we compared the effects of bupivacaine 0.5% or ropivacaine 0.75% alone or in a mixed solution of equal volumes of bupivacaine 0.5% and lidocaine 2% or ropivacaine 0.75% and lidocaine 2% for surgery after femoral-sciatic peripheral nerve block. The primary end point was onset time.

METHODS: In a double-blind, randomized study, 82 adults scheduled for lower limb surgery received a sciatic (20 mL) and femoral (20 mL) peripheral nerve block with 0.5% bupivacaine (200 mg), a mixture of 0.5% bupivacaine 20 mL (100 mg) with 2% lidocaine (400 mg), 0.75% ropivacaine (300 mg) or a mixture of 0.75% ropivacaine 20 mL (150 mg) with 2% lidocaine (400 mg). Each solution contained epinephrine 1:200,000. Times to perform blocks, onset times (end of injection to complete sensory and motor block), duration of sensory and motor block, and morphine consumption via IV patient-controlled analgesia were compared. Venous blood samples of 5 mL were collected for determination of drug concentration at 0, 5, 15, 30, 45, 60, and 90 min after placement of the block.

RESULTS: Patient demographics and surgical times were similar for all four groups. Sciatic onset times (sensory and motor block) were reduced by combining lidocaine with the long-acting local anesthetic. The onset of bupivacaine-lidocaine was 16 ± 9 min versus 28 ± 12 min for bupivacaine alone. The onset of ropivacaine-lidocaine was 16 ± 12 min versus 23 ± 12 for ropivacaine alone. Sensory blocks were complete for all patients within 40 min for those receiving bupivacaine–lidocaine versus 60 min for those receiving bupivacaine alone and 30 min for those receiving ropivacaine–lidocaine versus 40 min for those receiving ropivacaine alone (P < 0.05). Duration of sensory and motor block was significantly shorter in mixture groups. There was no difference among groups for visual analog scale pain scores and morphine consumption during the 48 h postoperative period, except for bupivacaine alone (median: 9 mg) versus bupivacaine–lidocaine mixture (15 mg), P < 0.01. There was no difference in the incidence of adverse events among groups. Plasma concentrations of bupivacaine and ropivacaine were higher, and remained elevated longer, in patients who received only the long-acting local anesthetic compared to patients who received the mixture of long-acting local anesthetic with lidocaine (P < 0.01).

CONCLUSION: Mixtures of long-acting local anesthetics with lidocaine induced faster onset blocks of decreased duration. Whether there is a safety benefit is unclear, as the benefit of a decreased concentration of long-acting local anesthetic may be offset by the presence of a significant plasma concentration of lidocaine.



超声引导前路坐骨神经阻滞:与后路阻滞比较

Ultrasound-Guided Anterior Approach to Sciatic Nerve Block: A Comparison with the Posterior Approach

Junichi Ota, MD, Shinichi Sakura, MD, Kaoru Hara, MD, and Yoji Saito, MD

From the Department of Anesthesiology, Shimane University School of Medicine, Izumo City, Japan.

Anesth Analg 2009; 108:660-665

背景:虽然前路坐骨神经阻滞由于缺乏可靠的表面解剖标志和技术上的困难而很少进行,但是在超声引导下可能使之容易操作。在本次研究中,我们评价在成人超声引导的前路坐骨神经阻滞的临床使用并与后路阻滞相比较。

方法:100个膝关节小手术病人被随机地分为两组,分别接受前路和后路(臀下)坐骨神经阻滞,使用含肾上腺素的1.5%甲哌卡因20ml,并联合股神经和股外侧皮神经阻滞。使用低频5-2MHz弯曲的阵列传感器完成两种入路坐骨神经阻滞。测量阻滞执行时间、神经的深度和大小、入针深度、感觉和运动阻滞起效时间和阻滞持续时间。

结果:前路神经阻滞相对于臀下进路,病人坐骨神经位置更深和入针深度更大。两种入路在坐骨神经阻滞操作时间类似,但在实施所有的阻滞组合时所花的时间前路短于后路。虽然前路达到的股后皮神经感觉阻滞明显少于后路阻滞(分别为14.9% 和68.1%; P < 0.001),但两种入路的成功率、腓神经和胫神经阻滞起效时间和持续时间无统计学差异。

结论:使用超声引导前路坐骨神经阻滞同后路坐骨神经阻滞一样能容易和成功地完成。

(王宏 译 马皓琳、李士通 校)

BACKGROUND: Although the anterior approach to the sciatic nerve block has rarely been performed due to lack of reliable surface anatomical landmarks and technical difficulty, ultrasound guidance may make performance of this approach easier. In this study, we evaluated the clinical use of the ultrasound-guided anterior approach to sciatic nerve block and compared this approach with the posterior approach in adults.

METHODS: One hundred patients undergoing minor knee surgery were randomly divided into two groups to receive anterior and posterior (subgluteal) approaches to sciatic nerve block, using 1.5% mepivacaine 20 mL with epinephrine combined with femoral and lateral femoral cutaneous nerve blocks. Both approaches to sciatic nerve block were performed using a low-frequency, 5 to 2 MHz, curved array transducer. Measurements included block execution time, depth and size of the nerve, needle depth, onset time of sensory and motor blockade, and duration of the block.

RESULTS: The sciatic nerve was located significantly deeper and the needle depth was significantly greater in patients undergoing the anterior approach compared with the subgluteal approach. Both approaches were similar for execution time of sciatic nerve block, but the former took less time than the latter to perform all combinations of blocks. Although sensory block in the posterior femoral cutaneous nerve was achieved less often with the anterior approach compared with subgluteal approach (14.9% and 68.1%, respectively; P < 0.001), there were no differences in success rate, onset time or duration of blockade of the peroneal and tibial nerves between the two groups.

CONCLUSION: The anterior approach to sciatic nerve block is performed as easily and successfully as the posterior approach using ultrasound guidance.

 

小鼠缺血再灌注后抑肽酶对左室收缩功能的剂量依赖性改变及细胞因子的释放

Aprotinin Modifies Left Ventricular Contractility and Cytokine Release After Ischemia-Reperfusion in a Dose-Dependent Manner in a Murine Model

Matthew D. McEvoy, Michel J. Sabbagh, Anna Greta Taylor, Juozas A. Zavadzkas, Christine N. Koval, Robert E. Stroud, Rachael L. Ford, Julie E. McLean, Scott T. Reeves, Rupak Mukherjee, and Francis G. Spinale

From the *Departments of Anesthesiology and Perioperative Medicine, and {dagger}Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina; and {ddagger}Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina.

Anesth Analg 2009 108: 399-406.

 

背景:在心脏手术过程中缺血再灌注(I/R)期的长短是与短暂的左室功能障碍和炎症反应相关的。在本次研究中,我们监测了抑肽酶(APRO)对左室收缩功能的潜在剂量依赖效应以及缺血再灌注背景下的细胞因子释放。

方法:用容量微传感器在研究开始、缺血30分钟、再灌注60分钟时分别测量左室收缩功能指数,即左室最大收缩力(Emax)。小鼠随机分组如下:(a) APRO 20,000 抑制激肽释放酶单位/公斤 (KIU/kg)(数量n=11);(b) APRO 4 x 104 KIU/kg (n = 10);(c) APRO 8 x 104 KIU/kg (n = 10);(d) 空白对照 (盐水;n = 10)

结果:空白对照组、APRO 4 x 104 KIU/kg组以及APRO 8 x 104 KIU/kg组在缺血再灌注后,左室最大收缩力(Emax)减小为基础值的40%多(P < 0.05)。然而APRO 2 x 104 KIU/kg组的左室最大收缩力(Emax)却回到基础值的水平。肿瘤坏死因子(TNF)在缺血再灌注后增加了10倍,但它却随着APRO剂量的增加而减少。

结论 这一研究证实一个低剂量的APRO可以对左室收缩功能起到保护作用,而高剂量的APRO则会抑制TNF的释放。这一史无前例的研究发现提示我们在缺血再灌注的过程中APRO有着独特的作用机制。

(单嘉琪译 薛张纲校)

BACKGROUND: Periods of ischemia-reperfusion (I/R) during cardiac surgery are associated with transient left ventricular (LV) dysfunction and an inflammatory response. In this study, we examined the potential dose-dependent effects of aprotinin (APRO) on LV contractility and cytokine release in the setting of I/R.

METHODS: An index of LV contractility, LV maximal elastance (Emax), was measured at baseline, 30 min of ischemia, and 60 min of reperfusion by microtransducer volumetry. Mice were randomized as follows: (a) APRO 20,000 kallikrein-inhibiting units (KIU)/kg (n = 11); (b) APRO 4 x 104 KIU/kg (n = 10); (c) APRO 8 x 104 KIU/kg (n = 10); and (d) vehicle (saline; n = 10). APRO doses were calculated to reflect half, full, and twice the clinical Hammersmith dosing schedule. After I/R, plasma was collected for cytokine measurements.

RESULTS: After I/R, Emax decreased from the baseline value by more than 40% in the vehicle group as well as in the APRO 4 x 104 KIU/kg and APRO 8 x 104 KIU/kg groups (P < 0.05). However, Emax returned to near baseline values in the APRO 2 x 104 KIU/kg group. Tumor necrosis factor (TNF) increased 10-fold after I/R, but it was reduced with higher APRO doses.

CONCLUSIONS: This study demonstrated that a low dose of APRO provided protective effects on LV contractility, whereas higher doses suppressed TNF release. These unique findings suggest that there are distinct and independent mechanisms of action of APRO in the context of I/R.

 

 

抑肽酶对行体外循环的新生儿患者术后肾功能不全影响的回顾性分析

The impact of aprotinin on postoperative renal dysfunction in neonates undergoing cardiopulmonary bypass: a retrospective analysis.

Guzzetta NA, Evans FM, Rosenberg ES, Fazlollah TM, Baker MJ, Wilson EC, Kaiser AM, Tosone SR, Miller BE.

Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, GA 30322, USA. nina.guzzetta@emoryhealthcare.org

Anesth Analg. 2009 Feb;108(2):448-55.

 

背景:近期关于抑肽酶在成人使用过程中所暴露的安全性问题致使其在全球市场上被暂时搁置。然而,很少有研究指出其对于儿童患者使用的安全性。儿童病患的个体化和临床治疗策略的差异化妨碍了抑肽酶在儿童患者中的安全性评估。在此项调查中,我们回顾了200名在我机构实施心脏外科手术的新生儿患者,采用统一的给药方案,以术后肾功能不全为关注对象来评价抑肽酶运用的安全性。

方法:此项回顾性研究选取200511日起至2007228日间200名陆续于体外循环条件下行姑息或矫正心脏外科手术的新生儿患者。收集并分析其术前、术中及术后的各项数据。其中安全性指标包括术后72小时内是否发生肾功能不全,是否需行透析治疗(包括腹透和血透),是否有血栓形成以及住院死亡率。

结果:依据是否运用抑肽酶将上述新生儿患者分为抑肽酶组(n=156)和对照组(n=44)。比较两组患儿术后24小时和72小时的血肌酐浓度,发现两组均明显高于基线浓度,且两组患儿血肌酐水平的变化程度也极为相似。在抑肽酶组中,虽然较大多数新生儿患者发生了肾功能不全,但这种差异并无统计学意义。对于在抑肽酶组和对照组、术后肾功能不全组和正常组中具有指示意义的变量,运用逐步逻辑回归的方法评估其对于术后肾功能不全的影响,发现体外循环时间和年龄对于预示术后肾功能不全具有显著意义。无论是否运用抑肽酶,所有发生术后肾功能不全的新生儿患者其体外循环时间均超过了100分钟。而进一步采用亚组分析后却发现,抑肽酶组和对照组患儿发生肾功能不全的比例是近似的。利用多元回归分析同时对体外循环时间、患儿年龄以及是否运用抑肽酶等预示指标进行评价,发现体外循环时间是提示术后肾功能不全唯一有意义的指标。术后透析和术后血栓形成的发生率及住院死亡率在抑肽酶组和对照组之间并无明显的统计学差异。

结论:就新生儿患者而言,体外循环时间相比术中是否运用抑肽酶对于提示术后肾功能不全的发生更有显著意义。大于100分钟的体外循环术是发生术后肾功能不全的危险信号。而本次回顾性研究的有效性需有其他的随机前瞻性研究加以证实。

(范羽译 薛张纲校)

BACKGROUND: Recent concern about the safety of aprotinin administration to adults has led to its suspension from worldwide markets. However, few studies have examined its safety in pediatric patients. Studies in children evaluating aprotinin's safety have been hindered by the heterogeneity of pediatric patients and the inconsistency of clinical protocols. In this investigation, we retrospectively reviewed 200 neonatal cardiac surgical cases performed at our institution to examine the safety of aprotinin, focusing on postoperative renal dysfunction, using a consistent aprotinin dosing protocol.

METHODS: Two-hundred consecutive neonates scheduled for palliative or corrective congenital cardiac surgery requiring cardiopulmonary bypass (CPB) from January 1, 2005 through February 28, 2007 were included in this retrospective investigation. Preoperative, intraoperative and postoperative data were collected and analyzed. Markers of safety included 72-h postoperative renal dysfunction, need for dialysis (peritoneal or hemodialysis), thrombosis and in-hospital mortality.

RESULTS: Neonates were divided into those who received aprotinin (aprotinin group; n = 156) and those who did not (no aprotinin group; n = 44). Twenty-four and 72-h postoperative serum creatinine levels were significantly greater than baseline levels in both groups. The degree of change in creatinine levels was highly significant and similar between the two groups. A larger percentage of neonates in the aprotinin group developed renal dysfunction, although this difference was not statistically significant. Stepwise logistic regression, assessing the impact on renal dysfunction of all variables that indicated significance between neonates who did or did not receive aprotinin and between neonates who did or did not develop renal dysfunction, identified CPB time and age as significant predictors of postoperative renal dysfunction. All neonates who developed postoperative renal dysfunction had a CPB time of more than 100 min regardless of the use of aprotinin. Additionally, using this subset, similar percentages of renal dysfunction occurred in both groups. A second multivariable regression analysis to simultaneously account for the predictors of CPB time, age and aprotinin administration found CPB time to be the only significant predictor of renal dysfunction. Incidences of postoperative dialysis, postoperative thrombosis and in-hospital mortality were not statistically significantly different between the aprotinin and the no aprotinin groups.

CONCLUSION: The occurrence of postoperative renal dysfunction in neonates was more significantly predicted by the duration of CPB than by the intraoperative administration of aprotinin. CPB times of more than 100 min appeared to be a critical marker for the development of postoperative renal dysfunction. Randomized prospective trials are needed to confirm the validity of our retrospective findings.

 

 

 

门诊手术病人术前检查项目的略过

Elimination of preoperative testing in ambulatory surgery.

Frances Chung, FRCPC, Hongbo Yuan, PhD, Ling Yin, MSc, Santhira Vairavanathan, MBBS, and David T. Wong, MD

From the Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2009 108: 467-475.

 

背景:术前检查由于对手术期间各种情况的预估参考价值不高而受到质疑。我们设计了一个单盲的前瞻性对照研究来探讨在选定的门诊手术病人中,是否可以略过一些特定的术前检查而不增加手术期间不可逆损害事件的发生率。

方法:1060例选定的病人,随机分为两组,接受特定项目的术前检查组和不接受术前检查组。接受术前检查组,进行当前安大略省的常规术前检查,项目包括:全血细胞计数,电解质,血糖,肌酐,心电图和胸片。而不接受术前检查组则不要求进行任何检查。研究者,数据收集者及结果复核者都不知晓分组信息。主要的评价指标为手术期间及术后7天和术后30天的不可逆损害事件的发生率。

结果:病人年龄,性别,ASA分级,手术及麻醉类型在两组间具有可比性。两组在术中及术后30天内的不可逆损害事件的发生率均无显著性差异。术前检查组术后7天内需要再次就诊的发生率高于无检查组(P<0.5)。没有证实任何不可逆损害事件的发生与是否行术前检查有关。

结论:本次试验性研究表明,在我们的研究样本人群中,不进行术前检查,并不会增加术中不可逆损害事件的发生率。仍需要进行更大规模的研究来证明,在门诊手术病人中一部分特定的术前检查项目可以安全的略过而不增加手术期间重大并发症的发生率。

(黄剑译 薛张纲校)

BACKGROUND: Preoperative testing has been criticized as having little impact on perioperative outcomes. We conducted a randomized, single-blind, prospective, controlled pilot study to determine whether indicated preoperative testing can be eliminated without increasing the perioperative incidence of adverse events in selected patients undergoing ambulatory surgery.

METHODS: One thousand sixty-one eligible patients were randomized either to have indicated preoperative testing or no preoperative testing. In the indicated testing group, patients received indicated preoperative testing: a complete blood count, electrolytes, blood glucose, creatinine, electrocardiogram, and chest radiograph according to the Ontario Preoperative Testing Grid as per current practice, whereas in the no testing group, no testing was ordered. The investigators, data collectors, and patient outcome reviewers were blinded to the group assignment. The primary outcome measures were the rate of perioperative adverse events and the rates of adverse events within 7 and 30 days after surgery.

RESULTS: Patients' age, gender, American Society of Anesthesiologists status, type of surgery, and anesthesia were similar between the two groups. There were no significant differences in the rates of perioperative adverse events and the rates of adverse events within 30 days after surgery between the no testing group and the indicated testing group. Hospital revisits <or=7 days were higher in the indicated testing group (P < 0.05). None of the adverse events were related to the indicated testing or no testing.

 CONCLUSIONS: This pilot study showed that there was no increase in the perioperative adverse events as a result of no preoperative testing in our study population. A larger study is needed to demonstrate that indicated testing may be safely eliminated in selected patients undergoing ambulatory surgery without increasing perioperative complications.

 

 

促食素A缩短氯胺酮诱导鼠麻醉时间:与大脑去甲肾上腺素能神经元活性的相关性

Orexin A decreases ketamine-induced anesthesia time in the rat: the relevance to brain noradrenergic neuronal activity.

Ryuji Tose, Tetsuya Kushikata, Hitoshi Yoshida, Mihoko Kudo, Kenichi Furukawa, Shinya Ueno, and Kazuyoshi Hirota

Department of Anesthesiology, Institute of Brain Science, University of Hirosaki School of Medicine, Hirosaki, Japan.

Anesth Analg. 2009 Feb;108(2):491-5

 

背景:促食素可调控失眠,而缺乏促食素I型受体将导致嗜睡。促食素可以选择性地增加鼠大脑表皮去甲肾上腺素的释放,并且脑内去甲肾上腺素能神经元与睡眠觉醒周期相关。而氯胺酮增加鼠大脑皮层释放去甲肾上腺素。我们可假设促食素将影响ketamine对脑内去甲肾上腺素能神经元活性的麻醉作用。

方法:我们使用了Sprague Dawley鼠。我们研究1)促食素A (OXA)SB-334867-A (Orexin-1受体抗体)对氯胺酮诱导麻醉时间的活体作用;2)应用微量渗析来评估活体内促食素A对氯胺酮导致的大脑皮层去甲神肾上腺素释放增加的影响;3)氯胺酮对促食素A引起的大脑皮层去甲肾上腺素释放的影响。

结果1)在50 100125毫克/千克腹腔( IP )氯胺酮的用药量下,1nmol侧脑室的促食素可明显降低氯胺酮麻醉时间的20 -30 % 。而促食素-1受体抗体充分地扭转了促食素导致的减退。2)促食素也减少氯胺酮导致的去甲肾上腺素释放,即使促食素会增加大鼠前额皮质释放的去甲肾上腺素。合用促食素和氯胺酮的组别中获得的最大的去甲肾上腺素释放量为271%(侧脑室促食素1nmol+100毫克/千克腹腔氯胺酮),这显著少于单独使用氯胺酮组的释放量(100毫克/千克腹腔氯胺酮,释放量基线为390%P = 0.029)。3)临床IC50价值下氯胺酮抑制促食素引起的去甲肾上腺素释放。

结论:促食素相关的神经元可能是氯胺酮作用的一个重要目标。促食素通过去甲肾上腺素能神经元的促食素-1受体来对抗氯胺酮的麻醉作用。

(李莹译 薛张纲校)

BACKGROUND: Orexins (OXs) regulate wakefulness, and a lack of OX Type-I receptors cause narcolepsy. OX selectively increases norepinephrine (NE) release from rat cerebral cortical slices, and brain noradrenergic neurons are involved in the sleep-wakefulness cycle. Ketamine increases NE release from the rat cerebral cortex. We hypothesized that OX would affect ketamine anesthesia's interactions with brain noradrenergic neuronal activity.

METHODS: We used Sprague Dawley rats. We studied 1) in vivo effects of orexin A (OXA) and SB-334867-A (Orexin-1 receptor antagonist) on ketamine-induced anesthesia time, 2) in vivo effects of OXA on ketamine-induced increase in NE release from the frontal cortex assessed using microdialysis, and 3) in vitro effects of ketamine on OXA-evoked NE release from rat cerebrocortical slices.

RESULTS: 1) Intracerebroventricular OXA 1 nmol significantly decreased ketamine anesthesia time by 20%-30% at 50, 100, and 125 mg/kg intraperitoneal (IP) ketamine. SB-334867-A fully reversed the decrease produced by OXA. 2) OXA also decreased the release of NE induced by ketamine even though OXA increased the release of NE in rat prefrontal cortex. Maximum NE release in Group OX + K (intracerebroventricular OXA 1 nmol + IP ketamine 100 mg/kg) was 271% and was significantly smaller than that in Group K (ketamine 100 mg/kg IP, 390% of baseline, P = 0.029). 3) Ketamine inhibited OX-evoked NE release with clinically relevant IC(50) values.

CONCLUSION: Orexinergic neurons may be an important target for ketamine. OXA antagonized ketamine anesthesia via Orexin-1 receptor with noradrenergic neurons.

 

 

一项通过Vigileo/FloTrac 系统获得的每搏量变异来预测机械通气患者对液体治疗反应性的研究

The Ability of Stroke Volume Variations Obtained with Vigileo/FloTrac System to Monitor Fluid Responsiveness in Mechanically Ventilated Patients

Maxime Cannesson, MD*, Henri Musard, MD*, Olivier Desebbe, MD*, Cécile Boucau, MD*, Rémi Simon, MD*, Roland Hénaine, MD{dagger}, and Jean-Jacques Lehot, MD, PhD*

The Hospices Civils de Lyon, Departments of *Anesthesiology and Intensive Care, and {dagger}Cardiac Surgery, Louis Pradel Hospital, Claude Bernard Lyon 1 university, Lyon, France.

Anesth Analg 2009 108: 513-517

 

背景:肺动脉压变化可以准确预测机械通气患者对液体治疗的反应性。而我们此次研究的目的是评价一个新型的可自动估算每搏量变异的运算系统对于预测机械通气患者对液体治疗反应性的能力。

方法:我们研究了二十五名行冠状动脉旁路移植的患者。术中通过Vigileo/FloTrac系统连续监测每搏量变异。所有的25名患者都被施以全身麻醉,进行机械通气,并通过肺动脉导管监测肺动脉压的变化。在血管内扩容(给以500毫升羟乙基淀粉)之前和之后均同步记录每搏量和肺动脉压的变化。那些在扩容之后通过热稀释法获得的心脏指数升高15%以上者被定义为对扩容有反应者。

结果50对数据中肺动脉压和每搏量变异的一致性为1.3% ± 2.8%(平均偏差±标准差)。17位患者对扩容治疗有反应。肺动脉压变异阈值为10%识别对扩容有反应者的敏感度为88%,特异度为87%。每搏量变异阈值为10%时识别对扩容有反应的敏感度为82%,特异度为88%

结论:每搏量变异对于预测液体治疗反应有可令人接受的敏感度和特异度,同时它是替代连续肺动脉压监测的较有潜力的指标。

(姚敏敏译 薛张纲校)

BACKGROUND: Respiratory variations in arterial pulse pressure ({Delta}PP) are accurate predictors of fluid responsiveness in mechanically ventilated patients. The aim of our study was to assess the ability of a novel algorithm for automatic estimation of stroke volume variation (SVV) to predict fluid responsiveness in mechanically ventilated patients.

METHODS: We studied 25 patients referred for coronary artery bypass grafting. SVV was continuously displayed by the Vigileo/FloTrac system. All patients were under general anesthesia, mechanical ventilation and were also monitored with a pulmonary artery catheter. SVV and {Delta}PP were recorded simultaneously before and after an intravascular volume expansion (VE) (500 mL hetastarch). Responders to VE were defined as patients whose cardiac index obtained using thermodilution increased by more than 15% after VE.

RESULTS: Agreement between {Delta}PP and SVV over the 50 pairs of collected data was –1.3% ± 2.8% (mean bias ± sd). Seventeen patients were responders to VE. A threshold {Delta}PP value of 10% allowed discrimination of responders to VE with a sensitivity of 88% and a specificity of 87%. A threshold SVV value of 10% allowed discrimination of responders to VE with a sensitivity of 82% and a specificity of 88%.

CONCLUSION: SVV predicts fluid responsiveness with an acceptable sensitivity and specificity and is also a potential surrogate for continuous monitoring of {Delta}PP.

 

 

术中知晓:危险因素,诱因及后遗症:文献中报道病例的总结

Awareness During Anesthesia: Risk Factors, Causes and Sequelae: A Review of Reported Cases in the Literature

Mohamed M. Ghoneim, MD, Robert I. Block, PhD, Mary Haffarnan, CRNA, and Maya J. Mathews, CRNA

From the Department of Anesthesia, University of Iowa, Iowa City, Iowa.

Anesth Analg 2009 108: 527-535.

 

背景:术中知晓并不多见。在一项研究中发现的病例数目并不足以识别和评估其危险因素,诱因和后遗症。分析已经发表在科学期刊上的术中知晓病例成为研究大量病例的一种方法。

方法:我们在国家图书馆的医学数据库中对1950年到20058月关于知晓麻醉的病例报告进行了电子搜索。我们还手动查阅了这些报告以及其他关于术中知晓的文章的参考文献。我们使用了控制手术条件的两组病例用于比较。第一组来自Sebel等做的一项研究,由未发生术中知晓的病人组成。第二组来自NSAS 1996年的数据,包含了期间接受全身麻醉的病人。我们还使用了国家健康统计中心的数据来比较体重以及BMI

结论:我们把271例发生术中知晓的病例和19504例未发生术中知晓的病例进行比较。前者更容易发生在女性(P<0.05,年轻患者(P<0.001)以及接受心脏或产科手术的患者(P<0.0001)。只有35%的术中知晓患者在苏醒室中陈述了其中细节。他们接受了更少的麻醉药物(P<0.0001,更倾向于在手术过程中表现出心动过速和血压增高(P<0.0001)。这些病人中的很大一部分(52%P<0.0001)手术后诉说了关于术中知晓的抱怨。无法移动,无助感和无力感。听到噪音和讲话声与持续的抱怨如睡眠障碍、对将来的麻醉感到恐惧等有关(P < 0.041–0.0003)22%的患者受到之后发生的心理问题的困扰。

结论:我们的总结反映了浅麻醉和有术中知晓发生史是危险因素。肥胖和避免N2O的使用并不增加其发生的风险。浅麻醉是最常见的诱因。我们的发现显示预防措施可能会减少术中知晓的发生率。

(俞佳译 薛张纲校)

BACKGROUND: Awareness during anesthesia is uncommon. The number of cases that are found in one single study are insufficient to identify and estimate the risks, causal factors and sequelae. One method of studying a large number of cases is to analyze reports of cases of awareness that have been published in scientific journals.

METHODS: We conducted an electronic search of the literature in the National Library of Medicine’s PubMed database for case reports on "Awareness" and "Anesthesia" for the time period between 1950 through August, 2005. We also manually searched references cited in these reports and in other articles on awareness. We used two surgical control groups for comparative purposes. The first group in a study by Sebel et al. consisted of patients who did not experience awareness. The second group, from the 1996 data from the National Survey of Ambulatory Surgery included patients who received general anesthesia. We also used data from the National Center for Health Statistics to compare weight and Body Mass Index.

RESULTS: We compared the data of 271 cases of awareness with 19,504 patients who did not suffer it. Aware patients were more likely to be females (P < 0.05), younger (P < 0.001) and to have cardiac and obstetrics operations (P < 0.0001). Only 35% reported the awareness episode during the stay in the recovery room. They received fewer anesthetic drugs (P < 0.0001), and were more likely to exhibit episodes of tachycardia and hypertension during surgery (P < 0.0001). A much larger percentage of these patients (52%, P < 0.0001) voiced postoperative complaints related to awareness. Inability to move and feelings such as helplessness, sensation of weakness, and hearing noises and voices were related to the persistence of complaints such as sleep disturbances and fear about future anesthetics (P < 0.041–0.0003). Twenty-two percent of the patients suffered late psychological symptoms.

CONCLUSIONS: Our review suggested light anesthesia and a history of awareness as risk factors. Obesity and avoidance of nitrous oxide use did not seem to increase the risk. Light anesthesia was the most common cause. Our findings suggest preventive procedures that may lead to a decrease in the incidence of awareness.

 

 

灌注指数作为衡量成年异丙酚麻醉者血管内注射含肾上腺素的硬膜外试验剂量后变化的指标的有效性

The Efficacy of Perfusion Index as an Indicator for Intravascular Injection of Epinephrine-Containing Epidural Test Dose in Propofol-Anesthetized Adults

Hany A. Mowafi, MBBch, MSc, MD, Salah A. Ismail, MBBch, MSc, MD, Mohammed A. Shafi, MBBch, MSc, MD, and AbdulMohsin A. Al-Ghamdi, MBBch, MD

From the Department of Anesthesiology, Faculty of Medicine, King Faisal University, Saudi Arabia.

 

Anesth Analg 2009 108: 549-553.

 

背景:灌注指标是一种无创性的来自于血氧饱和度监测的反应外周循环灌注的数值指标。本研究中我们评价了灌注指数作为探索成人异丙酚麻醉过程中血管内注射一个包含15微克肾上腺素的硬膜外试验剂量药物后变化的指标的有效性,同时将它与常规评价标准——心率(如果>=10/分则阳性)及收缩压(如果>=15 mm Hg则阳性)进行了可靠性比较。

方法:40个预约做普外科手术的麻醉评分四级以上的病人随机接受3毫升含5 microg/mL肾上腺素的浓度为15 mg/mL的利多卡因或3毫升生理盐水(n = 20)。注射后5分钟监测心率,血压和灌注指数。

结果:注射试验剂量导致39 +/- 15秒后平均最大灌注指数降低65% +/- 13%。而且,心率和血压的最大增量分别为49 +/- 25 s 19 +/- 8 bpm102 +/- 34 s 17 +/- 7 mm Hg。用灌注指数作为血管内注射的评价指标(如果灌注指数较注射前降低>=10%则阳性),其敏感性、特异性、阳性预期值和阴性预期值是100%95%置信区间=83%-100%)。相对的,心率和血压指标的敏感性分别为95% (CI = 76%-99%)90% (CI = 70%-97%)

结论:灌注指数是一个评价成年异丙酚麻醉者血管内注射硬膜外试验剂量药物后常规血流动力学变化的可靠的选择。

(张玥琪译 薛张纲校)

BACKGROUND: Perfusion index (PI) is a noninvasive numerical value of peripheral perfusion obtained from a pulse oximeter. In this study, we evaluated the efficacy of PI for detecting intravascular injection of a simulated epidural test dose containing 15 mug of epinephrine in adults during propofol-based anesthesia and compared its reliability with the conventional heart rate (HR) (positive if >or=10 bpm) and systolic blood pressure (SBP) (positive if >or=15 mm Hg) criteria.

METHODS: Forty patients scheduled for elective general surgery under total IV anesthesia were randomized to receive either 3 mL of lidocaine 15 mg/mL with epinephrine 5 microg/mL or 3 mL of saline IV (n = 20 each). HR, SBP, and PI were monitored for 5 min after injection.

RESULTS: Injecting the test dose resulted in an average maximum PI decrease by 65% +/- 13% at 39 +/- 15 s. Moreover, maximal increases in HR and SBP were 19 +/- 8 bpm at 49 +/- 25 s and 17 +/- 7 mm Hg at 102 +/- 34 s after test dose injections, respectively. Using the PI criterion for intravascular injection (positive if PI decreases >or=10% from the preinjection value) the sensitivity, specificity, positive predictive, and negative predictive values were 100% (95% confidence interval [CI]; CI = 83%-100%). On the contrary, sensitivities of 95% (CI = 76%-99%) and 90% (CI = 70%-97%) were obtained based on HR and SBP criteria, respectively.

CONCLUSION: PI is a reliable alternative to conventional hemodynamic criteria for detection of an intravascular injection of epidural test dose in propofol-anesthetized adult patients.

 

 

妊娠期败血症和急性肾功能衰竭

Sepsis and Acute Renal Failure in Pregnancy

Samuel M. Galvagno, Jr., DO, and William Camann, MD

From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Anesth Analg 2009 108: 572-575.

 

临床医生诊疗重症孕期病人时遇到的很多问题都是由妊娠期独特的生理造成的。这篇综述针对性概括了在诊疗重症孕期病人遇到的两个问题:妊娠相关败血症和急性肾功能衰竭。就常见原因和妊娠期对诊断和治疗的影响加以讨论。

(张钊译 薛张纲校)

The unique physiology of pregnancy poses several problems for clinicians charged with caring for critically ill pregnant patients. This focused review summarizes two problems encountered in critically ill pregnant patients: pregnancy-related sepsis and acute renal failure. Common causes, and the effects of pregnancy on diagnosis and treatment are discussed.

 

 

七氟烷预处理对氧和葡萄糖缺乏的海马皮层的影响酪氨酸激酶与缺血期的作用

The Preconditioning Effect of Sevoflurane on the Oxygen Glucose-Deprived Hippocampal Slice: The Role of Tyrosine Kinases and Duration of Ischemia

Stéphanie Sigaut, MD*{dagger}, Virginie Jannier, MD*, Danielle Rouelle{dagger}, Pierre Gressens, MD, PhD{dagger}, Jean Mantz, MD, PhD*{dagger}, and Souhayl Dahmani, MD, PhD*{dagger}

From the *Department of Anesthesia, Beaujon University Hospital, Assistance Publique des Hôpitaux de Paris, Clichy, France; and {dagger}Institut National de la Santé et de la Recherche Médicale (INSERM) U 676, Robert Debré University Hospital, Paris, France.

Anesth Analg 2009 108: 601-608.

 

背景:在实验模型中所观察到的麻醉药物对神经细胞的保护作用仍未得到临床的证实。非受体酪氨酸激酶成簇黏附激酶被指出参与试验中所观察到的麻醉药的神经保护作用。在本项实验中,我们研究成簇黏附激酶与缺血期是否在七氟烷预处理对脑组织的影响中起作用。

方法:在逐渐增加的时间段里(102030455060分钟)使大鼠海马皮层遭受急性的缺氧和葡萄糖,然后予以1小时的再灌注。在进行缺氧和葡萄糖处理前,先对大鼠提供3小时的七氟烷预处理,预处理浓度为每小时10M成簇黏附激酶的蛋白表达和被裂解的半胱天冬酶3(凋亡级联激活标志物)通过免疫印迹法得到测量。细胞的死亡由碘化丙啶荧光法评定。

结果:缺血期间碘化丙啶荧光和被裂解的半胱天冬酶3均明显增加,缺血大于30 分钟后达到最大效应。七氟烷增加成簇黏附激酶的表达,并显著减少缺血时间为102030分钟时碘化丙啶荧光和被裂解的半胱天冬酶3的增加。然而,在对照组中,缺血时间大于30分钟后这种保护效果并未观察到。

结论:在大鼠海马急性缺血和葡萄糖模型中,临床相关浓度七氟烷的预处理效果与成簇黏附激酶密切相关,并且只在小于30分钟的缺血模型中观察到。

(朱兰芳译 薛张纲较)

BACKGROUND: The neuroprotective efficacy of anesthetics observed in experimental models remains unproven in the clinical setting. The nonreceptor tyrosine kinase focal adhesion kinase (FAK) has been suggested to be involved in the neuroprotective effect of anesthetics observed experimentally. In the present work, we investigated whether FAK and the duration of ischemia play a role in the preconditioning effect of sevoflurane on brain tissue.

METHODS: Rat acute hippocampal slices were subjected to oxygen and glucose deprivation (OGD) challenge during increasing periods of time (10, 20, 30, 45, 50, and 60 min) followed by 1 h reperfusion. A preconditioning sevoflurane concentration (10–4 M, 1 h) was applied 3 h before initiation of OGD. Protein expression of FAK and cleaved caspase 3 (a marker of activation of the apoptotic cascade) was measured by immunoblotting. Cell death was assessed by propidium iodide (PI) fluorescence.

RESULTS: Both PI fluorescence and expression of cleaved caspase 3 significantly increased with duration of ischemia until reaching a ceiling effect for durations of ischemia longer than 30 min. Sevoflurane (10–4 M) increased FAK expression and markedly reduced the increase in PI fluorescence and cleaved caspase 3 expression for periods of ischemia of 10, 20, and 30 min. In contrast, the protective effect was no longer observed for periods of ischemia longer than 30 min. 4-amino-5-(4-chlorophenyl)-7-(t-butyl) pyrazolo[3,4-d] pyrimidine (PP2, 10–5 M, an inhibitor of src tyrosine kinases) application 60 min before and throughout that of sevoflurane significantly reduced the neuroprotective effect of sevoflurane on both caspase 3 expression and PI fluorescence.

CONCLUSION: In the OGD rat acute hippocampal slice, the preconditioning effect of a clinically relevant concentration of sevoflurane was very li kely to involve FAK and was observed only for periods of ischemia ≤30 min.

 

 

脊柱手术后硬膜外注射可乐定的镇痛作用:一项随机对照研究

The Analgesic Effect of Epidural Clonidine After Spinal Surgery: A Randomized Placebo-Controlled Trial

Andrew D. Farmery, BSc, BS, MA, MD, FRCA*, and James Wilson-MacDonald, MCh, FRCS{dagger}

From the Nuffield Departments of *Anaesthetics and {dagger}Orthopaedic Surgery, University of Oxford, Oxford, UK.

Anesth Analg 2009 108: 631-634.

 

背景:可乐定是α2肾上腺素受体和咪做啉受体拮抗剂,具有镇痛、镇静和降低麻醉药MAC值的作用。使用途径包括口服、静脉输注和硬膜外给药。在脊椎手术中,术后并不用于硬膜外镇痛,原因是使用了硬膜外镇痛会掩盖了神经根和脊髓损伤的征象。

方法:我们选择66名接受不复杂的脊髓减压手术的患者,随机分成可乐定组(C组)和安慰剂组(P组)。术后病人使用PCA镇痛,记录术后36小时吗啡的用量。

结果C组吗啡的用量明显少于P组。36小时内C组平均吗啡的用量是35 mg (95% 的可信区间是 21–50 mg) ,而对照组是 61 mg (95% 的可信区间是48–74 mg)C组呕吐的发生率明显较低,是6.5%, 而安慰剂组的发生率是38.2%

结论:硬膜外小剂量的使用可乐定可以显著降低术后吗啡的用量,并且降低诸如呕吐等的副作用的发生率。

(陈珺珺译 薛张纲校)

BACKGROUND: Clonidine is an {alpha}2 adrenoreceptor and imidazoline receptor agonist, which has analgesic, sedative, and minimum alveolar anesthetic concentration-sparing effects. It has been used orally, IV, and epidurally. In spinal surgery, there is a reluctance to use local anesthetic-based epidural analgesia postoperatively because of fears of masking important signs of nerve root or spinal cord injury.

METHODS: We randomized 66 patients undergoing uncomplicated decompressive spinal surgery to receive an epidural infusion of either clonidine (Group C) or saline placebo (Group P) postoperatively. Morphine consumption by patient-controlled analgesia device was recorded for 36 h.

RESULTS: Morphine consumption was significantly lower in Group C. The mean consumption at 36 h was 35 mg (95% confidence interval 21–50 mg) in Group C, compared with 61 mg (95% confidence interval 48–74 mg) in the control group. Nausea was significantly reduced in Group C (6.5%), when compared with placebo (38.2%).

CONCLUSION: Low-dose epidural clonidine significantly reduced the demand for morphine and reduced postoperative nausea with few side effects.

 

 

比较利多卡因/普鲁卡因(EMLA®)和基于酒精的消毒剂对未受损皮肤上菌群的抗菌作用

A Comparison of the Antimicrobial Property of Lidocaine/Prilocaine Cream (EMLA®) and an Alcohol-Based Disinfectant on Intact Human Skin Flora

Istvan Batai, PhD, DEAA*, Lajos Bogar, PhD*, Vera Juhasz, MD*, Reka Batai{dagger}, and Monika Kerenyi, PhD{dagger}

From the Departments of *Anesthesia and Intensive Care, and {dagger}Medical Microbiology, Pecs University, Pecs, Hungary.

Anesth Analg 2009 108: 666-668.

 

背景EMLA® 软膏的应用是被涂在置静脉套管针的局部皮肤表面。最近我们在离体试验中发现EMLA具有抗菌作用。

方法:我们对利多卡因/普鲁卡因软膏(EMLA)和基于酒精的皮肤消毒剂(Skinsept Pur®)应用于未受损皮肤的杀菌作用进行比较。在治疗后012小时后提取样本。

结果:在最初一小时,无论是 EMLA还是Skinsept Pur ,使用后皮肤的菌落形成单位(cfu)数均显著降低,分别从44.9 ± 1.3 (42.4 ± 7.0) 0.9 ± 0.17 (1.61 ± 0. 7) cfu/cm2(平均数±标准差)。但是在使用后4,6,12小时,使用EMLA软膏的cfu数显著低于Skinsept Pur的。

结论:相比于Skinsept Pur ,EMLA软膏在早期杀菌后,具有较长的抑菌作用时间。

(陈珺珺译 薛张纲校)

BACKGROUND: The application of EMLA® cream is indicated for topical anesthesia of the skin in connection with IV cannulation. Recently, we described that EMLA cream has an antibacterial effect in vitro.

METHODS: The impact of the local anesthetic lidocaine/prilocaine cream (EMLA) on intact human skin flora was compared to that of an alcohol-based skin disinfectant (Skinsept Pur®). Samples were taken from 0 to 12 h after treatment.

RESULTS: The number of colony forming units (cfu) on the skin decreased significantly after both EMLA and Skinsept Pur treatment from 44.9 ± 1.3 (42.4 ± 7.0) to 0.9 ± 0.17 (1.61 ± 0.47) cfu/cm2, respectively (mean ± sem), at the first sampling time (1 h) and remained significantly below 0 h values for the study period. The cfu count was significantly lower with EMLA cream at 4, 6, and 12 h compared to Skinsept Pur.

CONCLUSION: EMLA cream has a longer bacteriostatic effect after early bactericidal impact compared to skin disinfection with Skinsept Pur.

 

心脏手术中的右心室:围手术期的解剖、生理和评估

The Right Ventricle in Cardiac Surgery, a Perioperative Perspective: I. Anatomy, Physiology, and Assessment

François Haddad, MD*{dagger}, Pierre Couture, MD*, Claude Tousignant, MD{ddagger}, and André Y. Denault, MD*

From the *Department of Anesthesiology, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada; {dagger}Division of Cardiovascular Medicine, Stanford University, Stanford, California; and {ddagger}Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2009 108: 407-421.

 

多年来,我们已经认识到右心室功能在心血管疾病及心脏手术中的重要性。研究显示,在心力衰竭、先天性心脏病、瓣膜疾病和心脏手术中,右室功能异常对疾病的预后具有重要意义。作者2篇文章中的第一篇主要回顾了右室解剖、生理的主要特征及其功能评估,其中主要的从右室结构和功能的超声评估展开。第二篇讨论了心脏手术中右室衰竭的病理生理学、临床意义和处理原则。

(周姝婧 译 陈杰 校)

The importance of right ventricular (RV) function in cardiovascular disease and cardiac surgery has been recognized for several years. RV dysfunction has been shown to be a significant prognostic factor in heart failure, congenital heart disease, valvular disease, and cardiac surgery. In the first of our two articles, we will review key features of RV anatomy, physiology, and assessment. In the first article, the main discussion will be centered on the echographic assessment of RV structure and function. In the second review article, pathophysiology, clinical importance, and management of RV failure in cardiac surgery will be discussed.

 

 

芬太尼联合异丙酚麻醉延长阵发性室上性心动过速患儿的窦房结恢复时间

Fentanyl Added to Propofol Anesthesia Elongates Sinus Node Recovery Time in Pediatric Patients with Paroxysmal Supraventricular Tachycardia

Keisuke Fujii, MD*, Hiroshi Iranami, MD, PhD*{dagger}, Yoshihide Nakamura, MD, PhD{ddagger}, and Yoshio Hatano, MD, PhD§

From the *Department of Anesthesiology, Japanese Red Cross Society Wakayama Medical Center, Wakayama City, Wakayama, Japan; {dagger}Department of Anesthesiology, Wakayama Medical University, Wakayama City, Wakayama, Japan; {ddagger}Department of Pediatric Cardiology, Japanese Red Cross Society Wakayama Medical Center, Wakayama City, Wakayama, Japan; and §Department of Anesthesiology, Wakayama Medical University, Wakayama City, Wakayama, Japan.

Anesth Analg 2009 108: 456-460.

 

背景:在小儿室上性心动过速的一些类型中,折返机制对增高的迷走神经张力很敏感。异丙酚麻醉常用于小儿电生理研究和射频消融术。尽管输注芬太尼和异丙酚都会提高迷走神经的张力,但两者联合是否有潜在提高迷走神经张力还尚未定论。在这项研究中,作者对芬太尼联合异丙酚是否可以改变电生理研究和射频消融术患儿的心脏电生理活动进行了评估。

方法:此项研究对象为27名患儿,其中9名患有预激综合征,7名存在隐匿性旁道,11名患有房室结折返性心动过速。用异丙酚(2.0mg/kg)进行麻醉诱导,并持续输注异丙酚(100–167 µg · kg–1 · min–1)作麻醉维持。在平稳的麻醉过程中,给予芬太尼(2.0ug/kg静脉注射,继以0.075ug/kg/min持续输注)并在给药前后测量窦房传导时间和校正窦房结恢复时间。

结果:整个检查中双频指数评分和全身血压保持不变。芬太尼显著延长校正窦房结恢复时间(P=0.005),但不延长窦房传导时间(P=0.35)。

结论:因为心脏迷走神经张力的增高是校正窦房结恢复时间延长的诱发因素之一,作者认为研究结果支持了芬太尼联合异丙酚有提高心脏迷走神经张力的假说。

(黄丹 译 陈杰 校)

BACKGROUND: In some types of pediatric supraventricular tachycardia, reentrant mechanisms are sensitive to enhanced vagal tone. Propofol is a feasible anesthetic for pediatric electrophysiological study and radiofrequency catheter ablation. Although fentanyl and propofol infusions both enhance cardiac vagal tone, it is unclear whether the combination of propofol and fentanyl has a potential to enhance it. In this study, we evaluated the hypothesis that fentanyl combined with propofol could alter cardiac electrophysiological activities in pediatric patients undergoing electrophysiological study and radiofrequency catheter ablation.

METHODS: Twenty-seven pediatric patients (9 Wolff-Parkinson-White syndrome, 7 concealed accessory pathway and 11 atrioventricular nodal reentry tachycardia) were enrolled in this study. Anesthesia was induced with propofol 2.0 mg/kg and was maintained with a continuous infusion of propofol at a rate of 100–167 µg · kg–1 · min–1. During a stable anesthetic state, the calculated sinoatrial conduction time and corrected sinus node recovery time (CSNRT) were measured before and after fentanyl administration. The fentanyl dose consisted of an initial 2.0 µg/kg IV bolus and subsequent continuous infusion of 0.075 µg · kg–1 · min–1.

RESULTS: Bispectral Index scores and systemic blood pressure remained unchanged throughout the examinations. Fentanyl administration significantly prolonged CSNRT (P = 0.005) but not calculated sinoatrial conduction time (P = 0.35).

CONCLUSION: Since an enhanced cardiac vagal tone is one of the causative factors for prolonged CSNRT, our findings greatly support the hypothesis that fentanyl combined with propofol has a potential to enhance cardiac vagal tone.

 

华人异丙酚-瑞芬太尼靶控输注时意识丧失和疼痛刺激无反应时的C50BIS值:一项多中心临床实验

C 50 for Propofol-Remifentanil Target-Controlled Infusion and Bispectral Index at Loss of Consciousness and Response to Painful Stimulus in Chinese Patients: A Multicenter Clinical Trial

Zhipeng Xu, MD, PhD*, Fang Liu, MD*, Yun Yue, MD*, Tiehu Ye, MD{dagger}, Bingxi Zhang, MD{ddagger}, Mingzhang Zuo, MD§, Mingjun Xu, MD||, Rongrong Hao, MD{dagger}, Yuan Xu, MD{ddagger}, Ning Yang, MD§, and Xiangming Che, MD||

From the *Beijing Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of China; {dagger}Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China; {ddagger}Beijing Tongren Hospital, Capital Medical University, Beijing, People’s Republic of China; §Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China; and ||Beijing Gynecology and Obstetrics Hospital, Capital Medical University, Beijing, People’s Republic of China.

Anesth Analg 2009 108: 478-483.

 

背景:在这项研究中,作者探讨了华人异丙酚-瑞芬太尼靶控输注时在意识丧失(LOC)及标准疼痛刺激下无反应时的预测血浆浓度及效应室的C50值,以及脑电双频指数(BIS值)。作者假设这些数值与先前报道的白种人的相关数值有所不同。

方法:本实验由五个临床中心完成,选择择期病人405例(男性97例,女性308例),ASAI-II,年龄18-65岁。输注丙泊酚至预测血浆浓度达1.2ug/mL,并持续输注使预测血浆浓度逐渐递增,递增幅度为每300.3ug/mL,术中维持OAA/S评分为1分。接着静脉输注瑞芬太尼至预测血浆浓度达2.0 ng/mL,并持续输注使其预测血浆浓度逐渐递增,递增幅度为每300.3 ng/mL,直至强直刺激反应消失,测定其脑电双频指数BIS值。

结果:异丙酚在意识丧失(LOC)时效应室C50值为2.2ug/mL,瑞芬太尼在疼痛刺激反应消失时效应室C50值为3.3ng/mL。约50%的患者意识丧失时的BIS值为58,其中95%BIS<40时意识丧失。疼痛刺激反应消失时BIS值为65.4,这一数值显著高于意识丧失时的BIS值(p<0.001)。

结论:LOC时异丙酚的预测血浆浓度及效应室浓度以及BIS值显著低于先前报道的白种人的相关数值。

(赵嫣红 译 陈杰 校)

BACKGROUND: In this study, we evaluated the predicted blood and effect-site C50 for propofol and remifentanil target-controlled infusion and the Bispectral Index (BIS) values at loss of consciousness (LOC) and response to a standard noxious painful stimulus in Chinese patients. We hypothesized that these values would be different from previously published data on Caucasians.

METHODS: Five medical centers enrolled 405 ASA physical status I and II unpremedicated Chinese patients (97 men, 308 women) aged 18–65 yr. Propofol was initially given to a predicted blood concentration of 1.2 µg/mL and thereafter increased by 0.3 µg/mL every 30 s until Observer’s Assessment of Alertness and Sedation score was 1. The propofol was kept constant, and remifentanil was given to provide a predict blood concentration of 2.0 ng/mL, and then increased by 0.3 ng/mL every 30 s until loss of response to a tetanic stimulus. BIS (version 3.22, BIS Quattro sensor) was also recorded.

RESULTS: The propofol effect-site C50 at LOC was 2.2 (2.2–2.3) µg/mL. The remifentanil effect-site C50 at loss of response to painful stimulus was 3.3 ng/mL. Fifty percent of patients lost consciousness at a BIS value of 58, and 95% had lost consciousness at BIS values <40. The BIS value at C50 at loss of response to painful stimulus was 65.4, which was higher than that at LOS (P < 0.001).

CONCLUSIONS: The predicted blood and effect-site concentrations of propofol and BIS values at LOC were lower than those in previously published studies of Caucasian populations.

 

依托咪酯对大鼠肠系膜阻力动脉血管反应性直接作用的机制

The Mechanisms of the Direct Action of Etomidate on Vascular Reactivity in Rat Mesenteric Resistance Arteries

Kazuhiro Shirozu, MD, Takashi Akata, MD, PhD, Jun Yoshino, MD, PhD, Hidekazu Setoguchi, MD, PhD, Keiko Morikawa, MD, PhD, and Sumio Hoka, MD, PhD

From the Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Anesth Analg 2009 108: 496-507.

 

背景:标准诱导剂量的依托咪酯对年轻健康患者的血流动力学影响较小,但是高剂量麻醉诱导或脑电暴发性抑制(例如,脑保护)对高龄或心脏疾病以及体外循环期间患者会造成显著低血压。然而,其对全身阻力动脉的作用还不明确。

方法:用等长张力记录法和fura-2荧光测定法研究依托咪酯对于年轻大鼠(7-8周,n=179)和老年鼠(96-98周,n=10)的小肠系膜动脉的作用。

结果:对于内皮完整的年轻鼠,3uM依托咪酯加强去甲肾上腺素或者KCL40mM)的血管收缩作用,但是高浓度(≥10uM)时抑制其作用。对NG1硝基精氨酸,四乙胺,双氯芬酸,去甲二氢愈创木酸,氯沙坦,酮色林,BQ-123或者BQ-788产生加强作用,但是在老年鼠上并没有观察到此现象。对于去内皮带的年轻鼠,依托咪酯(≥10uM)同样抑制去甲肾上腺素或者KCL的血管收缩作用,3uM时也没有加强作用。Fura-2荧光记录显示,去内皮的年轻鼠,依托咪酯抑制去甲肾上腺或KCL引发的细胞内钙离子聚集和作用力。斯里兰卡肉桂碱造成细胞内钙离子储备耗竭时,依托咪酯同样抑制去甲肾上腺诱发的钙离子浓聚,其对硝苯地平敏感。依托咪酯对去甲肾上腺数或者咖啡因诱发的细胞内钙离子释放或者细胞内钙离子吸收几乎没有作用。去甲肾上腺或者KCL刺激期间,低浓度(≤30uM)的依托咪酯对于钙离子浓聚几乎没有作用,但是100uM时能引起其下降。

结论:对于小肠系膜动脉,依托咪酯通过内皮依赖加强和内皮非依赖抑制作用影响去甲肾上腺或者膜去极化的血管收缩反应。其加强作用至少对于一氧化氮,内皮超极化因素,环氧化酶产物,脂肪氧化酶产物,血管紧张素II5-羟色胺或者内皮素I呈部分非依赖性,但可能不包括一些因年老而受损的信号通路。内皮非依赖性抑制归因于血管平滑肌细胞的钙离子浓聚和肌丝钙离子敏感性降低。此钙离子浓聚的降低可能和电压门控性钙离子内流的抑制有关。年轻个体的依托咪酯麻醉诱导时,低浓度(1-3uM)依托咪酯不能造成显著血管扩张,其对血流动力学同样只造成微小变化,然而高浓度依托咪酯能造成血管扩张可能解释了临床上高剂量依托咪酯引起的低血压现象。

(朱紫瑜 译 陈杰 校)

BACKGROUND: Etomidate minimally influences hemodynamics at a standard induction dose in young healthy patients, but can cause significant systemic hypotension at higher doses for induction or electroencephalographic burst suppression (i.e., cerebral protection) in patients with advanced age or heart disease, and during cardiopulmonary bypass. However, less is known about its action on systemic resistance arteries.

METHODS: Using an isometric force recording method and fura-2-fluorometry, we investigated the action of etomidate on vascular reactivity in small mesenteric arteries from young (7–8 wk old, n = 179) and aged (96–98 wk old, n = 10) rats.

RESULTS: In the endothelium-intact strips from young rats, etomidate enhanced the contractile response to norepinephrine or KCl (40 mM) at 3 µM but inhibited it at higher concentrations (≥10 µM). The enhancement was still observed after treatment with NG-nitro l-arginine, tetraethylammonium, diclofenac, nordihydroguaiaretic acid, losartan, ketanserin, BQ-123, or BQ-788, but was not observed in aged rats. In the endothelium-denuded strips from young rats, etomidate (≥10 µM) consistently inhibited the contractile response to norepinephrine or KCl without enhancement at 3 µM. In the fura-2-loaded, endothelium-denuded strips from young rats, etomidate inhibited norepinephrine- or KCl-induced increases in both intracellular Ca2+ concentration ([Ca2+]i) and force. Etomidate still inhibited the norepinephrine-induced increase in [Ca2+]i after depletion of the intracellular Ca2+ stores by ryanodine, which was sensitive to nifedipine. Etomidate had little effect on norepinephrine- or caffeine-induced Ca2+ release from the intracellular stores or Ca2+ uptake into the intracellular stores. During stimulation with norepinephrine or KCl, etomidate had little effect on the [Ca2+]i-force relation at low concentrations (≤30 µM) but caused its downward shift at 100 µM.

CONCLUSIONS: In small mesenteric arteries, etomidate influences the contractile response to norepinephrine or membrane depolarization through endothelium-dependent enhancing and endothelium-independent inhibitory actions. The enhancement is at least in part independent of nitric oxide, endothelium-derived hyperpolarizing factor, cyclooxygenase products, lipoxygenase products, angiotensin II, serotonin, or endothelin-1, but may involve some signaling pathway that is impaired by aging. The endothelium-independent inhibition is due to decreases in both the [Ca2+]i and myofilament Ca2+ sensitivity in vascular smooth muscle cells. The decrease in [Ca2+]i would be due mainly to inhibition of voltage-gated Ca2+ influx. The observed inability of lower concentrations (1–3 µM) of etomidate to cause significant vasodilation is consistent with minimal changes in hemodynamics during induction of anesthesia with etomidate in young subjects, whereas the observed vasodilator action of higher concentrations of etomidate might underlie systemic hypotension caused by higher doses of etomidate in the clinical setting.


 

多重输注线路延长对输注泵压力报警的影响

The Effects of Multiple Infusion Line Extensions on Occlusion Alarm Function of an Infusion Pump

Diana Deckert, MD, Christian Buerkle, MD, Andreas Neurauter, PhD, Peter Hamm, BS, Karl H. Lindner, MD, and Volker Wenzel, MD, MSc

From the Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2009 108: 518-520.

 

背景CTMRI成像的诊断或治疗过程中有时需麻醉或镇静,持续输注麻醉药或血管加压药时常需加长输注路线。在这项研究中,作者尝试测定输注路线的长度是否影响输注线路压力报警时间。

方法: 两种模型的输注泵系统,用12或者3个串联的输注路线,或者螺旋形不易折低顺应性的输注路线相连接,并且启动输注60s。输注路线最终通过按下结束开关来停止输液。输注路线中连接压力感应器记录线路中实际的压力改变。测量在流速为520、以及50ml/h时连续5次压力报警时间。

结果:当应用一个单独的输注线路时,在输注速度50ml/h时,输注泵12.4± 0.1 min后触发压力报警,输注泵22.6± 0.2 min后触发;输注速度为20ml/h时,报警触发时间分别为6.6 ± 0.4 min5.6 ± 0.5 min;输注速度为5ml/h,报警触发时间分别为23.0 ± 2.8 min 20.9 ± 3.6 min。当增加第二个输注线路时 ,在5ml/h情况下,输注泵1的压力报警在27.1 ± 1.8 min后触发(P = 0.1),而输注泵229.2 ± 1.4 min后触发(P = 0.07)。应用3个输注线路时,输注泵12的压力报警与1个输注路线相比较显著延长,输注速度为5ml/h时分别为31.6 ± 3.0 min (P = 0.01) and 35.1 ± 1.1 min (P = 0.001) 触发。两个输注泵的触发警报的压力水平范围在大约9001100Mbar

结论:当模拟低流速输注(5ml/h),如应用血管加压药,压力报警时间显著延长,尤其在输注路线长度增加时。

(怀晓蓉 译 陈杰 校)

BACKGROUND: For anesthesia or conscious sedation of patients undergoing diagnostic or therapeutic procedures in computed tomography or magnetic resonance imaging scans, an extension of infusion lines for continuous drug delivery of anesthetics or vasopressors is often necessary. In this study, we tried to determine if the length of the infusion line influenced the time until an alarm sounded after occlusion at the end of the infusion line.

METHODS: We connected 2 infusion pump systems of the same model with 1, 2 or 3 infusion lines in series or with a spiral nonkinking low compliance infusion line, and started the infusion for 60 s. The end of the infusion line was then occluded by turning a stopcock to occlude the fluid flow. A pressure sensor was connected to the infusion line to record the actual pressure change in the line. The time until the pressure occlusion alarm sounded was measured 5 consecutive times at flow rates of 5, 20, and 50 mL/h.

RESULTS: When using a single infusion line, pressure occlusion alarms were triggered after 2.4 ± 0.1 min for infusion pump 1 and 2.6 ± 0.2 min for infusion pump 2 at 50 mL/h, after 6.6 ± 0.4 min and 5.6 ± 0.5 min at 20 mL/h, and after 23.0 ± 2.8 min and 20.9 ± 3.6 min at 5 mL/h, respectively. When adding a second infusion line, a pressure occlusion alarm was triggered after 27.1 ± 1.8 min for infusion pump 1 (P = 0.1) and after 29.2 ± 1.4 min for infusion pump 2 (P = 0.07) at 5 mL/h. With 3 infusion lines, the pressure occlusion alarm of infusion pumps 1 and 2 were significantly prolonged when compared with 1 infusion line and were released at 31.6 ± 3.0 min (P = 0.01) and 35.1 ± 1.1 min (P = 0.001) at 5 mL/h, respectively. The pressure level triggering an alarm ranged in both infusion pumps between about 900 and 1100 Mbar.

CONCLUSIONS: When simulating low flow rate infusions (5 mL/h) as for vasopressor support, occlusion alarm time was critically prolonged, especially with an increased length of infusion lines.


困难气道患者喷雾式气道表面麻醉:2 %和4 %利多卡因的随机、双盲比较研究

Spray-As-You-Go Airway Topical Anesthesia in Patients with a Difficult Airway: A Randomized, Double-Blind Comparison of 2% and 4% Lidocaine

Fu S. Xue, MD*{dagger}, He P. Liu, MD{dagger}, Nong He, MD{ddagger}, Ya C. Xu, MD*, Quan Y. Yang, MD*, Xu Liao, MD*, Xiu Z. Xu, MD{ddagger}, Xin L. Guo, MD{dagger}, and Yan M. Zhang, MD*

From the *Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China; {dagger}Third Affiliated Hospital, XinXiang Medical University, XinXiang, Henan, People’s Republic of China; and {ddagger}ShouGang Hospital, Peking University, Beijing, People’s Republic of China.

Anesth Analg 2009 108: 536-543.

 

背景:作者设计这项随机、双盲临床研究,比较了在纤维支气管镜应用时用2 %和4 %利多卡因以喷雾法对呼吸道局部麻醉的安全性和有效性。

方法 52例困难气道的成年患者,以双盲的方式随机分为2组并在运用纤维支气管镜时分别使用2 % ( 1 )或4 %利多卡因(组2)的喷雾技术。气道局部麻醉后,清醒下纤维支气管镜经口气管插管。 镇静水平、不同目标区利多卡因喷雾次数、气道总喷雾次数、气道喷雾总剂量、插管时间、尝试插管次数。一个独立的调查员评定患者在气道局部麻醉时的舒适度,病人的反应,咳嗽严重性,并在清醒时进行插管条件评分,并观察每一个气道操作阶段中的动脉血压和心率变化。采集血液样本进行血浆利多卡因浓度分析。

结果:除利多卡因总剂量和血药浓度外,两组间的其它观察变量之间没有显著性差异。所有患者表现满意或达到可接受的插管条件。组1利多卡因总剂量( 3.4 ± 0.6 mg/kg)明显少于组2 7.1 ± 2.1 mg/kg)。声门上喷洒了利多卡因后所有观测点,组2的血浆浓度比组1高。

结论 2 %和4 %利多卡因以喷雾法局部处理后为临床上困难气道患者清醒镇静下提供可接受的气管插管条件。与4 %利多卡因相比, 2 %利多卡因组所需较小剂量并降低了血药浓度。

(张磊 译 陈杰 校)

BACKGROUND: We designed this randomized, double-blind clinical study to compare the safety and efficacy of 2% and 4% lidocaine during airway topical anesthesia with a spray-as-you-go technique via the fiberoptic bronchoscope.

METHODS: Fifty-two adult patients with a difficult airway were randomly assigned to 1 of 2 study groups to receive 2% (Group 1) or 4% lidocaine (Group 2) by a spray-as-you-go technique with the fiberoptic bronchoscope, in a double-blind manner. After airway topical anesthesia, awake fiberoptic orotracheal intubation (FOI) was performed. Level of sedation, time for each lidocaine spray in different targeted areas, total times for airway sprays, total dosages of lidocaine used for airway sprays, intubation times, and number of intubation attempts were noted. An independent investigator scored patients’ comfort during airway topical anesthesia, patients’ reaction, coughing severity, and intubating condition during awake FOI, and observed changes of arterial blood pressure and heart rate during each stage in the airway manipulation process. Serial blood samples were obtained for analysis of plasma lidocaine concentrations

RESULTS: Except for the total dosages and plasma concentrations of lidocaine, there were no significant differences in any of the observed variables between groups. All patients exhibited excellent or acceptable intubating conditions. The total dosages of lidocaine were significantly smaller in Group 1 (3.4 ± 0.6 mg/kg) than in Group 2 (7.1 ± 2.1 mg/kg). The plasma lidocaine concentrations in all observed points after the supraglottic sprays were larger in Group 2 than in Group 1.

CONCLUSIONS: Both 2% and 4% lidocaine administered topically by a spray-as-you-go technique can provide clinically acceptable intubating conditions for awake FOI in sedated patients with a difficult airway. As compared with 4% lidocaine, however, 2% lidocaine requires a smaller dosage and results in lower plasma concentrations.


短期吸入高浓度氧在兔的体外模型呼吸机所致肺损伤中并不加重损伤

Short-Term Administration of a High Oxygen Concentration Is Not Injurious in an Ex-Vivo Rabbit Model of Ventilator-Induced Lung Injury

Petros Kopterides, MD*{dagger}, Theodoros Kapetanakis, MD{dagger}, Ilias I. Siempos, MD{dagger}, Christina Magkou, MD{ddagger}, Aimilia Pelekanou, MD§, Thomas Tsaganos, MD§, Evangelos Giamarellos-Bourboulis, MD§, Charis Roussos, MD||, and Apostolos Armaganidis, MD*

From the *Second Critical Care Department, Attiko University Hospital, University of Athens Medical School, Athens, Greece; {dagger}Department of Experimental Surgery, Evangelismos Hospital, University of Athens Medical School, Athens, Greece; {ddagger}Department of Histopathology, Mitera Hospital, Athens, Greece; §Fourth Department of Internal Medicine, Attiko University Hospital, University of Athens Medical School, Athens, Greece; and ||First Critical Care Department-Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece.

Anesth Analg 2009 108: 556-564.

 

背景:呼吸衰竭时常需机械通气和吸入高浓度氧。作者进行这项研究,以探讨吸入高浓度氧对呼吸机所致肺损伤的影响。    
方法:在吸气压力为2515
cm H2O和呼气末正压为3 cm H2O的环境下,40例离体/灌注兔肺随机接收100 %或21 %的氧气压力控制通气60min。所有分组( n = 10为每个组)中维持灌流液的温度, pH值,二氧化碳分压相同 。评估肺损伤程度的项目包括:重量增加和超滤系数的改变,血管功能衰竭的频率,组织学病变及肿瘤坏死因子的浓度和支气管肺泡灌洗液中的丙二醛的量。
结果:与在较低吸气压力/潮气量通气的两组相比在较高吸气压力/潮气量通气的两组在重量增加和超滤系数的改变更明显,血管功能的衰竭更频繁,组织病理损害的综合得分更高。急性肺损伤的任何一项监测标志并未发现组织内氧有进一步增加。四个实验组的肺泡灌洗液中的肿瘤坏死因子或丙二醛发现无明显差异。
结论:上述实验模型的结果表明,短期吸入高浓度氧不是呼吸机所致肺损伤的一个主要因素。

(丁俊云 译 陈杰 校)

BACKGROUND: Mechanical ventilation and administration of a high oxygen concentration are simultaneously used in the management of respiratory failure. We conducted this study to evaluate the effect of a high inspired oxygen concentration on ventilator-induced lung injury.

METHODS: Forty sets of isolated/perfused rabbit lungs were randomized for 60 min of pressure-control ventilation at a plateau inspiratory pressure of 25 or 15 cm H2O and positive end-expiratory pressure of 3 cm H2O while receiving 100% or 21% O2. The temperature, pH, and partial pressure of CO2 in the perfusate were maintained the same in all groups (n = 10 for each group). The outcome measures used to assess lung injury included: the change in weight gain and ultrafiltration coefficient, the frequency of vascular failure, the histological lesions and the concentration of tumor necrosis factor-{alpha} and malondialdehyde in the bronchoalveolar lavage fluid.

RESULTS: The two groups ventilated at the higher inspiratory pressure/tidal volume experienced greater weight gain and increases in the ultrafiltration coefficient, more frequently suffered vascular failure, and presented higher composite scores of histological damage than the two groups ventilated at the lower inspiratory pressure/tidal volume. Hyperoxia was not found to further increase any of the monitored markers of lung injury. No difference was noticed among the four experimental groups in the alveolar lavage fluid levels of tumor necrosis factor-{alpha} or malondialdehyde.

CONCLUSIONS: These findings suggest that short-term administration of a high oxygen concentration is not a major determinant of ventilator-induced lung injury in this experimental model.

 

神经外科危重病人经皮气管切开术“ Percutwist ”期间颅内压的监测

Intracranial Pressure Monitoring During Percutaneous Tracheostomy "Percutwist" in Critically Ill Neurosurgery Patients

Carmela Imperiale, MD, Giuseppina Magni, MD, PhD, Roberto Favaro, MD, and Giovanni Rosa, MD

From the Department of Anesthesia and Intensive Care Medicine, La Sapienza University of Rome, Italy.

Anesth Analg 2009 108: 588-592.

 

背景:在重症脑损伤的管理中气管切开术是常用的一部分,经皮扩张气管切开术作为替代标准手术气管切开术在重症监护病房应用越来越多。但此过程中有发生神经系统并发症的危险,尤其是颅内压增高的患者。在这项研究中,作者在65名神经外科ICU危重病人,进行床边经皮穿刺气管切开术,并试图量化Percutwist ®气管切开术(Rusch-Teleflex医疗)在ICPCPPPaco2Pao2的影响。

方法65例( 男29名, 女36名,平均年龄43岁,± 10.6 )格拉斯哥昏迷评分≤8 ,需要长期通气支持,颅内压恒定在20mmHg, 在床边由纤维内窥镜下选择性经皮气管切开。术中连续监测:心电图,脉搏血氧饱和度,有创动脉血压,颅内压,脑灌注压。记录ICP增加超过20 mm Hg或脑灌注压减少低于60 mm Hg(持久超过3分钟),缺氧界定为氧分压低于90 mm Hg, 二氧化碳潴留定义为二氧化碳分压超过40 mm Hg

结果11例患者有18此次颅内高压记录。记录的监测变量无统计学意义,短暂的颅内压增加接近统计学意义( P = 0.051 )。没有发生脑灌注压低于60毫米汞柱,6%的病人出现二氧化碳潴留。

结论Percutwist气管切开术是一种单步方法,能有效的通气,从而减少了二氧化碳潴留的颅内压增高风险。该技术没有引起继发病理生理损伤的风险,在脑损伤患者中安全使用。

(刘世文 译 陈杰 校)

BACKGROUND: Tracheostomy is commonly required as part of the management of patients with severe brain damage. Percutaneous dilation tracheostomy is increasingly used in intensive care unit as an alternative to standard surgical tracheostomy. However, this procedure carries the risk of neurological complications, particularly in patients with intracranial hypertension. In this study, we sought to quantify the effects of Percutwist® tracheostomy (Rusch-Teleflex Medical) on intracranial pressure (ICP), cerebral perfusion pressure (CPP), arterial CO2 tension (Paco2), and arterial O2 tension (Pao2), in 65 consecutive critically ill patients admitted to the neurosurgical intensive care unit, undergoing bedside percutaneous tracheostomy.

METHODS: Sixty-five patients (29 men, 36 women, mean age 43 yr, 7 ± 10.6) Glasgow Coma Scale ≤8, requiring long-term ventilatory support with a stable ICP ≤20 mm Hg were included. Elective percutaneous tracheostomies were performed at the bedside under endoscopic fiberoptic control. Intraoperative monitoring included continuous: electrocardiogram, Spo2, invasive arterial blood pressure, ICP, CPP = mean arterial blood pressure-ICP). Episodes of ICP increment above 20 mm Hg or CPP decrease below 60 mm Hg (lasting more than 3 min) were recorded; hypoxia was defined as Pao2 below 90 mm Hg, hypercarbia as Paco2 more than 40 mm Hg.

RESULTS: Eighteen episodes of intracranial hypertension were recorded in 11 patients. No statistically significant modification of monitored variables was recorded, although the transient ICP increase was very close to statistical significance (P = 0.051). No episodes of CPP reduction below 60 mm Hg occurred. Six percent of patients developed hypercarbia.

CONCLUSIONS: Percutwist tracheostomy is a single-step method which allows for effective ventilation during the procedure, thus reducing the risk of hypercarbia and development of intracranial hypertension. The technique did not cause secondary pathophysiological insult and could be considered safe in a selected population of brain-injured patients.

 

经腹和腹腔镜下手术期间在维持前负荷及心指数平时乳酸林格液需求量

The Volume of Lactated Ringer's Solution Required to Maintain Preload and Cardiac Index During Open and Laparoscopic Surgery

Mario R. Concha, MD*, Verónica F. Mertz, MD*, Luis I. Cortínez, MD*, Katya A. González, MD*, Jean M. Butte, MD{dagger}, Francisco López, MD{dagger}, George Pinedo, MD{dagger}, and Alvaro Zúñiga, MD{dagger}

From the Departments of *Anesthesiology and {dagger}Digestive Surgery, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.

Anesth Analg 2009 108: 616-622.

 

背景:近期研究显示了围手术期液体限制的重要性。然而,液体限制方案可能增加围术期补液量不足可能性或可能导致血管内晶体液过量交换。作者假定使用经食管超声心动图可减少经腹和腹腔镜下结直肠手术围术期晶体使用量。

方法: 选择ASAIII级的患者,15例行开放结直肠手术, 15例行腹腔镜手术进行研究。术中输注乳酸林格氏液。围术期监测左心室舒张末容积指数( LVEDVI )和心脏指数用于指导乳酸林格氏液输注。统计学分析采用非配对样本St检验。

结果:为维持基础LVEDVI和心脏指数,围术期晶体输注速率在经腹手术时为5.9 ± 2 mL · kg–1 · h–1,腹腔镜下手术时为3.4 ± 0.8 mL · kg–1 · h–1(P < 0.01) 。腹腔镜下手术较慢的输注速度被较长的手术时间抵消了。

结论:为维持基础LVEDVI和心脏指数,经腹手术的晶体输注速率比要大于腹腔镜手术,但低于通常建议的结直肠手术的输注速率。

(叶乐 译 陈杰 校)

BACKGROUND: Recent studies have emphasized the importance of perioperative fluid restriction. However, fluid restriction regimens may increase the likelihood of insufficient perioperative fluid administration or may result in excess intravascular crystalloid replacement. We postulate that the use of transesophageal echocardiography may reduce the amount of crystalloid administered during open and laparoscopic colorectal surgery.

METHODS: Fifteen ASA I and II patients scheduled for open colorectal surgery, and 15 patients scheduled for laparoscopic surgery were studied. Lactated Ringer's solution was infused during the procedures. Left ventricular end diastolic volume index (LVEDVI) and cardiac index were assessed throughout surgery and used to guide the rate of lactated Ringer's solution administration. Statistical analysis was performed with Student's t-test for unpaired samples.

RESULTS: The rate of crystalloid administration required to maintain baseline LVEDVI and cardiac index was 5.9 ± 2 mL · kg–1 · h–1 for open surgery and 3.4 ± 0.8 mL · kg–1 · h–1 for laparoscopic surgery (P < 0.01). This slower rate for laparoscopic surgery was offset by the longer surgical duration.

CONCLUSION: The rate of crystalloid solution to maintain baseline LVEDVI and cardiac index was greater in open surgery than laparoscopic surgery, and lower than commonly recommended for colorectal surgery.

 

微循环对针刺刺激和光疗的反应。

Microcirculatory Responses to Acupuncture Stimulation and Phototherapy

Makiko Komori, MD*, Katsumi Takada, MD{dagger}, Yasuko Tomizawa, MD{ddagger}, Keiko Nishiyama, MD*, Izumi Kondo, MD*, Miwako Kawamata, MD*, and Makoto Ozaki, MD{dagger}

From the *Department of Anesthesiology, Medical Center East, Tokyo Women's Medical University, Nishiogu, Arakawa-ku, Tokyo, Japan; Departments of {dagger}Anesthesiology, and {ddagger}Cardiovascular Surgery, School of Medicine, Tokyo Women's Medical University, Kawadacho Shinjuku-ku, Tokyo, Japan.

Anesth Analg 2009 108: 635-640.

 

背景:针刺刺激和光疗被认为具有镇痛和改善微循环的作用。然而,很少有研究直接检测外周血管的变化。作者直视下观察小动脉血流量对针刺刺激和光疗的反应来评估这些方法的作用。

方法: 40只兔子在耳廓附上兔耳室。兔耳室在解剖显微镜下固定于耳廓。通过显微镜摄像头选定小动脉并用于观察。静脉注射戊巴比妥钠。气管插管维持自主呼吸。家兔随机分配接受针刺刺激(针刺组, n = 10 ) ,近红外灯照射(灯照组, n = 10 ) ,近红外低功率激光照射(激光组, n = 10 ) ,或没有照射(对照组, n = 10 )。在针刺组,针刺针放于耳廓20分钟。灯照每秒重复受到近红外辐射(1540mW),持续4秒钟结束。激光组不断受到60 mW的激光照射。在灯照组和激光组,耳廓(针刺组针刺针放置的相同位置)接受10分钟接触探头的照射。针刺和照射治疗60分钟后测量小动脉直径和血流速度。血流速率通过血流速度乘以横截面面积得到。

结果:与对照组(100%)比较,针刺组小动脉直径显着增加至131 % ± 14 %( P <0.005 ),灯照组增加为129 % ± 19 %( P < 0.005 ),激光组增加128 % ± 11 %( P <  0.005 )。针刺刺激结束后20分钟,光照和激光照射结束后10分钟达到最高值。这三组与对照组比较后显示小动脉直径显著增加(P<0.005)。血流速度和血流量变化与小动脉直径变化相似。治疗效果在刺激和照射结束后持续40-50分钟。

结论:针刺刺激和光疗直接增加外周小动脉直径并加快血流速度。针刺刺激和光照治疗,以最小的全身和局部副作用,改善微循环,可能成为外周循环不良所致疾病的有效辅助治疗方法。

(舒慧刚 译 陈杰 校)

BACKGROUND: Acupuncture stimulation and phototherapy have been reported to have analgesic effects and improve the microcirculation. However, few studies have directly examined changes in peripheral blood vessels, either quantitatively or objectively. We assessed the responses of arteriolar blood flow to acupuncture stimulation and phototherapy under direct vision to examine the effects of these treatments.

METHODS: We used 40 rabbits with a rabbit ear chamber attached to the auricle. The rabbit ear chamber was fixed to the auricle under a dissecting microscope. Arterioles were selected and observed with the use of a microscope video camera. Pentobarbital was injected IV. The trachea was intubated and spontaneous respiration was maintained. Rabbits were randomly assigned to receive acupuncture stimulation (acupuncture group, n = 10), near-infrared lamp irradiation (lamp group, n = 10), near-infrared low-powered laser irradiation (laser group, n = 10), or no irradiation (control group, n = 10). In the acupuncture group, an acupuncture needle was placed in the auricle for 20 min. The lamp group repeatedly received 1 s of near infrared irradiation (1540 mW) followed by 4 s of treatment cessation. The laser group continuously received 60 mW of laser irradiation. In the lamp and laser groups, the auricle (same site as that of the acupuncture needles in the acupuncture group) was irradiated for 10 min with a contact probe. Arteriolar diameter and blood flow velocity were measured at baseline and for 60 min after acupuncture or irradiation treatment. Blood flow rate was calculated by multiplying the blood flow velocity by the cross-sectional area of the vessels.

RESULTS: Arteriolar diameter significantly increased to 131% ± 14% in the acupuncture group (P < 0.005), 129% ± 19% in the lamp group (P < 0.005), and 128% ± 11% in the laser group (P < 0.005) when compared with the pretreatment value (100%). Maximum values were reached 20 min after the end of the acupuncture stimulation, and 10 min after the end of lamp and laser irradiation. The three groups showed significant increases in arteriolar diameter when compared with the control group (P < 0.005). Blood flow velocity and blood flow rate showed similar trends to arteriolar diameter. Treatment effect persisted for 40–50 min after the end of stimulation and irradiation.

CONCLUSIONS: Acupuncture stimulation and phototherapy were directly confirmed to increase the diameter and blood flow velocity of the peripheral arterioles. Acupuncture stimulation and phototherapy, associated with minimal systemic and local side effects, can enhance the microcirculation and may be a useful supportive treatment for diseases caused by poor peripheral blood flow.


老年患者脊髓麻醉前晶体/胶体与晶体血管内容量治疗对心输出量和每搏输出量影响的比较
Crystalloid/Colloid Versus Crystalloid Intravascular Volume Administration Before Spinal Anesthesia in Elderly Patients: The Influence on Cardiac Output and Stroke Volume

André Riesmeier, MD, Alexander Schellhaass, MD, Joachim Boldt, MD, and Stefan Suttner, MD

From the Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.

Anesth Analg 2009 108: 650-654.

 

背景:脊髓麻醉来说低血压是最常见的心血管反应。作者比较了脊髓麻醉前给予晶体/胶体与给予晶体在经尿道前列腺切除术的老年患者中心输出量( CO )的影响。

 方法: 60ASA I–III级的男性病人随机分为三组,对照组没有预先血管内容量治疗,在脊髓麻醉前20分钟内,生理盐水组接受了500毫升生理盐水,羟乙基淀粉(HES)组接受了500毫升生理盐水加500毫升6 130/0.4的羟乙基淀粉。用胸阻抗法测定平均动脉压( MAP )和心率,心输出量和每搏量。 


结果:对照组平均动脉压由104 ± 20
mm Hg下降至88 ± 11 mm Hg P=0.005) ,并显著低于羟乙基淀粉组(由107 ± 13 mm Hg97 ± 12 mm Hg P=0.001  ) 。生理盐水组, MAP下降( 103 ± 14 mm Hg92 ± 17 mm Hg) ,与对照组和羟乙基淀粉组相比没有显著差异。对照组心输出量显著降低( 从4.9 ± 1.6/分至3.8 ± 0.9/分, P=0.002  ),并显著低于羟乙基淀粉组病人。预先接受羟乙基淀粉容量治疗组心输出量显著增加(从5.2 ± 1.23/分至6.2 ± 1.43/分, P=0.003 ) ,并保持在基线水平直至研究结束。 

结论:血管内预充生理盐水加羟乙基淀粉能阻止心输出量的下降,但在经尿道前列腺切除术的老年患者,并不能阻止脊髓麻醉引起的低血压。

(张燕 译 陈杰 校)

BACKGROUND: Hypotension is the most common cardiovascular response to spinal anesthesia. We compared the effects of crystalloid/colloid versus crystalloid administration before spinal anesthesia on cardiac output (CO) in elderly patients undergoing transurethral resection of the prostate.

METHODS: Sixty male ASA I–III patients were randomized to one of three groups the control group received no intravascular volume preload, the saline group received 500 mL saline, and the hydroxyethyl starch (HES) group received 500 mL of saline plus 500 mL of 6% HES 130/0.4 within 20 min before spinal anesthesia. Mean arterial blood pressure (MAP) and heart rate, CO, and stroke volume were recorded with a thoracic electrical bioimpedance device.

RESULTS: MAP significantly decreased from baseline in the control group (from 104 ± 20 mm Hg to 88 ± 11 mm Hg [P = 0.005]) and was significantly lower than in the HES group (from 107 ± 13 mm Hg to 97 ± 12 mm Hg [P = 0.001]). In the saline group, MAP decreased (103 ± 14 mm Hg to 92 ± 17 mm Hg) with no significant differences compared with the control and HES groups. CO decreased significantly in the control group (from 4.9 ± 1.6 L/min to 3.8 ± 0.9 L/min [P = 0.002]) and was significantly lower than in the HES patients in whom CO increased significantly after volume preload (from 5.2 ± 1.23 L/min to 6.2 ± 1.43 L/min [P = 0.003]) and remained at baseline level until the end of the study.

CONCLUSION: Intravascular volume preload with saline plus HES prevented a decrease of CO, but did not prevent spinal anesthesia-induced hypotension in elderly patients undergoing transurethral resection of the prostate.

 

脊髓麻醉后头低脚高体位乳酸林格氏液和6 %羟乙基淀粉溶液对心输出量的影响

The Effect of Trendelenburg Position, Lactated Ringer’s Solution and 6% Hydroxyethyl Starch Solution on Cardiac Output After Spinal Anesthesia

Nusa Zorko, MD*, Mirt Kamenik, PhD, MD*, and Vito Starc, PhD, MD{dagger}

From the *Department of Anesthesiology, Intensive Care and Pain Management, University Clinical Center Maribor, Maribor, Slovenia, Europe; and {dagger}Institute of Physiology, Ljubljana University School of Medicine, Slovenia, Europe.

Anesth Analg 2009 108: 655-659.

 

背景:本研究的目的是评估50岁以上病人进行脊髓麻醉后头低脚高位,乳酸林格氏液和6 %羟乙基淀粉溶液对心输出量的影响。

方法:70例拟在脊髓麻醉的下肢矫形手术病人随机分为三组。一组在采取头低脚高位,病人在脊髓阻滞10min后改为头低脚高位。乳酸林格氏液和羟乙基淀粉溶液组,病人在脊髓阻滞发生后分别输注500mL乳酸林格氏液和6 %羟乙基淀粉溶液1000mL,输注时间20min。脊髓麻醉前15min到麻醉后30min连续监测心排血量,动脉血压。P<0.05时有统计学意义。

结果:各组心脏出量的差别不明显,没有统计学意义。但心排血量随时间变化较明显。在头低脚高组中,心排血量无显著变化。6 %羟乙基淀粉组,在阻滞发生后心排血量有明显增加并且在测量结束后持续增加了一段时间。乳酸林格氏液组中,心排血量在阻滞发生前10分钟和发生后20分钟内出现增加,但是在停止注射后,心排血量开始降低。

结论:研究表明:这三种方法都能有效阻止脊髓麻醉后心排血量的降低。注射乳酸林格氏液的影响是短暂的,而6 %羟乙基淀粉影响在注射结束后还能持续一段时间。

(王腾 译 陈杰 校)

BACKGROUND: The aim of our study was to evaluate the effects of Trendelenburg position, infusion of 6% hydroxyetyl starch solution or lactated Ringer’s solution on changes in cardiac output (CO) after spinal anesthesia in patients older than 50 yr.

METHODS: Seventy patients scheduled for lower extremity orthopedic surgery under spinal anesthesia were allocated randomly to one of the three treatment groups. In the Trendelenburg group, the patients were placed in the Trendelenburg position immediately after the spinal block for 10 min. In the hydroxyethyl starch group and the lactated Ringer’s group, the patients received an infusion of 500 mL of 6% hydroxyethyl starch solution or 1000 mL of lactated Ringer’s solution over 20 min after the spinal block. CO was measured continuously from 15 min before until 30 min after spinal anesthesia using the impedance cardiography method and arterial blood pressure with an automated device. P < 0.05 was considered statistically significant.

RESULTS: The differences among treatment groups in CO were not statistically significant. Differences in the CO changes from baseline over time were significant. In the Trendelenburg group, CO did not change while the patient was in the Trendelenburg position. In the hydroxyethyl starch group, CO increased significantly after the block and remained significantly increased until the end of measurements. In the lactated Ringer’s group, CO increased significantly 10 and 20 min after the block but, after stopping the infusion, CO started to decrease.

CONCLUSIONS: Our study demonstrated that a decrease in CO after spinal anesthesia is prevented by placing the patient in the Trendelenburg position, or infusion of either lactated Ringer’s solution or 6% hydroxyetyl starch solution. Although the effects of the infusion of the lactated Ringer’s solution are transient, the effects of the infusion of 6% hydroxyethyl starch solution are extended beyond the time the infusion.