Table of Contents

February 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

小鼠缺血再灌注後抑肽酶對左室收縮功能的劑量依賴性改變及細胞因數的釋放

單嘉琪譯 薛張綱校

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.

心臟手術中的右心室:圍手術期的解剖、生理和評估

周姝婧 譯 陳傑 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.

心臟手術中的右心室,一個圍術期角度:II. 病理生理學、臨床重要性和管理

彭中美 譯 馬皓琳 李士通

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:

抑肽酶對行體外迴圈的新生兒患者術後腎功能不全影響的回顧性分析

范羽譯 薛張綱校

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.

芬太尼聯合異丙酚麻醉延長陣發性室上性心動過速患兒的竇房結恢復時間

黃丹 譯 陳傑 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.

兒童的氣道管理:氣管插管即刻行超聲檢查?

黃麗娜   馬皓琳 李士通

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:

門診手術病人術前檢查專案的略過

黃劍譯 薛張綱校

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:

華人異丙酚-瑞芬太尼靶控輸注時意識喪失和疼痛刺激無反應時的C50BIS值:一項多中心臨床實驗

趙嫣紅 譯 陳傑 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.

麻醉藥對海馬CA1神經元持續性和位相性{gamma}-氨基丁酸受體的作用是有區別的

顏濤 譯, 馬皓琳 李士通

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縮短氯胺酮誘導鼠麻醉時間:與大腦去甲腎上腺素能神經元活性的相關性

李瑩譯 薛張綱校

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.

依託咪酯對大鼠腸系膜阻力動脈血管反應性直接作用的機制

朱紫瑜 譯 陳傑 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:

術後2年死亡率與術中腦電雙頻指數低和術前存在的惡性疾病間的關係

慧譯 馬皓琳 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.

一項通過Vigileo/FloTrac 系統獲得的每搏量變異來預測機械通氣患者對液體治療反應性的研究

姚敏敏譯 薛張綱校

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.

多重輸注線路延長對輸注泵壓力報警的影響

懷曉蓉 譯 陳傑 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:

一項有方法學含義的關於術中知曉的回顧性研究

裘毅敏譯,馬皓琳 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.

術中知曉:危險因素,誘因及後遺症:文獻中報導病例的總結

俞佳譯 薛張綱校

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.

困難氣道患者噴霧式氣道表面麻醉:2 %和4 %利多卡因的隨機、雙盲比較研究

張磊 譯 陳傑 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.

困難喉鏡檢查的診斷性預測指標:頦舌距離比

黃佳佳譯,馬皓琳 李士通

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.

灌注指數作為衡量成年異丙酚麻醉者血管內注射含腎上腺素的硬膜外試驗劑量後變化的指標的有效性

張玥琪譯 薛張綱校

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:

短期吸入高濃度氧在兔的體外模型呼吸機所致肺損傷中並不加重損傷

丁俊雲 譯 陳傑 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.

帶有自適應輔助通氣的脫機自動裝置:一項應用於心胸外科手術病人的隨機對照試驗

姜旭暉譯,馬皓琳 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:

妊娠期敗血症和急性腎功能衰竭

張釗譯 薛張綱校

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:

神經外科危重病人經皮氣管切開術“ Percutwist ”期間顱內壓的監測

劉世文 譯 陳傑 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.

氙氣麻醉對於健康受試者的腦葡萄糖代謝與腦血流之間的關係的效應:正電子斷層掃描研究

唐亮   馬皓琳 李士通   

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.

七氟烷預處理對氧和葡萄糖缺乏的海馬皮層的影響酪氨酸激酶與缺血期的作用

朱蘭芳譯 薛張綱較

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:

經腹和腹腔鏡下手術期間在維持前負荷及心指數平時乳酸林格液需求量

葉樂 譯 陳傑 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:

圍術期給予加巴噴丁、美洛昔康及其聯合應用對門診腹腔鏡膽囊切除術後自發和運動誘發疼痛的影響的隨機、雙盲、對照實驗

吳進   馬皓琳 李士通

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.

脊柱手術後硬膜外注射可樂定的鎮痛作用:一項隨機對照研究

陳珺珺譯 薛張綱校

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.

微循環對針刺刺激和光療的反應

舒慧剛 譯 陳傑 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、羅呱卡因(含腎上腺素)及等容積複合利多卡因合劑用於股神經和坐骨神經阻滯的藥效學和藥動學的比較:一個雙盲、隨機化研究

江繼宏   馬皓琳 李士通

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.

老年患者脊髓麻醉前晶體/膠體與晶體血管內容量治療對心輸出量和每搏輸出量影響的比較

張燕 譯 陳傑 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.

脊髓麻醉後頭低腳高體位乳酸林格氏液和6 %羥乙基澱粉溶液對心輸出量的影響

王騰 譯 陳傑 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.

超聲引導前路坐骨神經阻滯:與後路阻滯比較

王宏 馬皓琳、李士通

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.

比較利多卡因/普魯卡因(EMLA®)和基於酒精的消毒劑對未受損皮膚上菌群的抗菌作用

陳珺珺譯 薛張綱校

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.

心臟手術中的右心室,一個圍術期角度:II. 病理生理學、臨床重要性和管理

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

對於右室功能在心血管疾病和心臟手術中重要性的認識已經有很多年了。已有研究顯示心臟手術和心臟移植手術中右室功能障礙是重要的預後因素。這篇綜述的第一部分復習了右室的解剖、生理和評估。在第二部分,我們回顧了心臟手術中右室衰竭的病理生理學、臨床重要性和處理。

(彭中美 譯 馬皓琳 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.


兒童的氣道管理:氣管插管即刻行超聲檢查?

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:兒科病人的插管需要足夠的專業技能,對很多麻醉醫生來說可能是一個挑戰。證實正確的氣管插管位置依賴於直接可視或間接措施,如聽診和二氧化碳波形圖。這些方法在敏感性和特異性方面有差異,尤其對於嬰兒和幼兒。超聲檢查是無創的,對於麻醉醫生而言,變得越來越容易使用。在該項研究中,我們調查了氣管內插管期間正常兒童呼吸道特徵性的即刻超聲檢查結果,以及臨床應用的適應性。

方法:研究了30名需要氣管內插管的正常氣道的兒童。深吸入麻醉下對氣管插管的兒童氣道進行超聲檢查,設備為Sonosite Titan® (Sonosite, Bothell, WA)掃描器,在這一過程中記錄了特徵圖像。正確的氣管插管位置進一步通過聽診和滿意的呼氣末二氧化碳波形圖證實。

結果:研究病人的平均(±標準差)年齡為48 ± 37 mo,體重為19.7. ± 8.6 kg,性別比(男/女)為1:2。成功的氣管插管通過如下的標準證實:1)辨別氣管和氣管環,2)可見到聲帶,3)當氣管導管置入時聲門變寬,4)隆突上氣管導管的位置以及手控通氣時胸壁內臟壁胸膜介面的運動(如移動徵象)。通過導管在左側氣管旁空間的顯像,容易地發現了一例置入食管的病例。

結論:該研究描述了氣管插管過程中兒童氣道的特徵性超聲檢查圖像結果。提示我們超聲檢查可能會對兒童氣道管理有用。

(黃麗娜   馬皓琳 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.



麻醉藥對海馬CA1神經元持續性和位相性{gamma}-氨基丁酸受體的作用是有區別的

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:麻醉是通過抑制中樞神經系統(CNS)信號而產生的;然而,這種抑制的作用機制仍然不明。近來的研究表明麻醉藥能夠通過增加細胞膜中持續性{gamma}-氨基丁酸(GABAA)受體門控的氯離子通道電流來加強CNS神經元的抑制。持續性抑制增強可能促進麻醉藥產生的CNS抑制,但是麻醉藥對這些受體的作用在多大程度上促進CNS抑制還有待研究。在本研究中,我們比較和對照了持續性和突觸性GABAA受體在異氟烷和硫噴妥產生的CNS神經元功能性抑制中所起的作用。

方法:在大鼠海馬腦片上採用全細胞膜片鉗記錄來研究麻醉藥對CA1神經元自發興奮性的作用;採用群峰電位記錄來研究對突觸誘發放電的作用。選擇這些反應來檢驗麻醉藥對GABA受體的作用是否改變單個神經元放電和/或環路層次上突觸的功能。使用GABAA拮抗劑gabazine選擇性阻斷相位性(突觸)GABA受體,採用氯離子通道阻斷劑印防己毒素阻斷持續性反應。

結果:臨床應用範圍的等效濃度硫噴妥和異氟烷抑制CA1神經元突觸誘發的放電。使用gabazine20 µM)阻斷突觸GABAA受體可部分逆轉這種抑制效應。硫噴妥產生的抑制作用約60%可被逆轉,但異氟烷產生的抑制作用僅約20%可被逆轉。再添加100µM印防己毒素阻斷持續性GABAA受體可使硫噴妥產生的抑制再多逆轉40%,但對異氟烷產生的抑制沒有進一步的逆轉作用。硫噴妥抑制直流電直接注射引起的CA1神經元放電,並且增加膜電導。印防己毒素可逆轉這兩種作用,而gabazine無效。相反,異氟烷既不抑制電流誘發的放電,也不改變CA1神經元的膜電導。

結論:這些結果表明全麻藥能辨別突觸GABAA受體和持續性GABAA受體。對位相性受體和持續性受體的兩種作用結合起來抑制硫噴妥鈉產生的神經環路的反應;異氟烷僅對突觸GABAA受體作用具有重要意義。結合這兩種麻醉藥其他抑制作用位點,我們的結果支援麻醉藥作用機制是多位點的和具有藥物差異性的。

(顏濤 譯, 馬皓琳 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.


 

術後2年死亡率與術中腦電雙頻指數低和術前存在的惡性疾病間的關係

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(定義為腦電雙頻指數(BIS<45的時間;TBIS<45)與術後1年死亡間的關係曾被報導。為了確認或推翻這些發現,我們把TBIS<45作為術後1年和2年死亡的獨立危險因數進行評估,同時評估的還有以前報導的主要死因惡性疾病的影響。

方法:對4087例監測BIS的患者記錄其術後2年的死亡率、死亡原因和手術時發現的惡性疾病。確定對死亡率有統計學意義的單變數預測因數。為了考慮到對照先前的資料,接下來的多變數分析先不包括主要死因即事先存在的惡性疾病,再包括這些因素進行分析。

結果:1年內174(4.3%)患者死亡,另92例在第二年死亡(2年中共6.5%)。當事先存在的惡性疾病不是協變因數時,TBIS <451年和2年死亡率的顯著預測因數(危害比[HR]分別是1.13[1.01–1.27]1.18[1.08–1.29])。進一步的研究顯示在事先存在惡性疾病進行廣泛手術,預後不良的患者中術後死亡率和TBIS<45有顯著相關性。模型中2年死亡率的最強預測因數(包括事先存在惡性疾病)是ASA評分IV(HR 19.3 [7.31–51.1]), 年齡>80 (HR 2.93 [1.79–4.79]),以及事先存在惡性疾病與不良預後有關(HR 9.30 [6.60–13.1])。當使用事先存在的惡性疾病狀態作為模型中共同變數把最初的多元回歸分析重複進行時,之前1年死亡率、2年死亡率和TBIS<45之間的顯著相關性就沒有統計學意義了。

結論:我們在先前的工作中使用一套相似的協同因數,證實了1年死亡率和TBIS<45間在統計學上有相關性,並且我們把這個觀察結果延伸到了2年死亡率。然而,這個相關性對統計學模型中協同因數的選擇很敏感,且需要一個隨機化的研究來證明TBIS<45和術後死亡率確實有因果關係。如果是,其影響與用ASA評分、手術前存在的惡性疾病及年齡評估的協同發病率比較可能是很微弱的。

(朱 慧譯 馬皓琳 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.



一項有方法學含義的關於術中知曉的回顧性研究

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:全麻中的知曉問題正日益受到醫生和患者的關注。一項大的多中心研究確立了全麻知曉的可接受的發生率大約為每1000例中1-2例或0.15%。然而,最近更多的回顧性研究提出實際的發生率可能低至0.0068%

方法:我們回顧了3年內行外科手術的成年患者,以評估本機構內知曉的發生率。我們從圍術期資訊系統中術後第一天的標準評估中獲取術中知曉的資訊。並不就知曉特別詢問患者。

結果:我們回顧了116,478例病史;其中65,061個病例接受了全麻,另外51,417個病例接受了其他方式的麻醉。全麻中的44,006例有完整的術後資料。在此人群中被報導的不受歡迎的術中知曉發生率為10/44,006 (1/4401 0.023%)。在其他方式的麻醉患者中,22,885例有完整的術後資料。在未接受全麻的患者中報導的不受歡迎的術中知曉發生率為7/22,885(1/3269 0.03%)。兩組報導的術中知曉發生率無統計學差別(P = 0.54)。全麻與非全麻相比,術中知曉的相對危險為0.7495%可信區間[0.28, 2.0]

結論:使用回顧性方法學,全麻與非全麻術中知曉的發生率無統計學差別。這些結果提示,儘管回顧性資料能成功報導另外一些罕見的圍術期事件,然而回顧性資料分析的解析度可能太低了而不能用於研究術中知曉問題。

(裘毅敏譯,馬皓琳 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.



困難喉鏡檢查的診斷性預測指標:頦舌距離比

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:我們通過以下單一或混合的術前氣道指標評估了頦舌距離(HMD)(HMDR)在預測表面上正常的患者喉鏡檢查時發生困難視野(DVL)的可靠性:改良Mallampati 試驗、頭部中立位時的HMD、頭部最大伸展位時HMD和甲頦距離以及HMDRHMDR定義在為頭部最大伸展位和中立位時HMD的比值。

方法:我們在術前評估了213位進行插管全麻患者的上述5項氣道預測指標。一位有經驗的麻醉醫生參與了所有的直接喉鏡檢查,並且用改良的Cormack Lehane評分進行視野可視度評級。這位醫生不知道氣道評估結果。可視度3級或4級均被定義為DVL。每一個試驗的最佳終止點確定在受試者操作特徵曲線下面積達到最大點時。在改良Mallampati試驗中,預定義≥3級為DVL的一項預測指標。

結果26位(12.2%)病人中喉鏡視野困難。在單變數分析中,頭部最大伸展位時的HMD和甲頦距離以及HMDR都與DVL之間顯著相關。HMDR在最佳終止點為1.2時(曲線下面積0.782)比其他單一預測指標具有較大的診斷精確性 (P < 0.05),而且單純這個指標就比其他任何試驗組合具有更好的診斷有效性(敏感性88%,特異性60%)。

結論 HMDR的試驗閾值為1.2DVL的可靠臨床預測指標。

(黃佳佳譯,馬皓琳 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.


帶有自適應輔助通氣的脫機自動裝置:一項應用於心胸外科手術病人的隨機對照試驗

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:自適應輔助通氣(ASV)是一種微機控制模式的機械通氣裝置,它可自動地從控制通氣切換到輔助通氣,並且根據肺部機能選擇適合的通氣參數。

方法:在本次隨機對照實驗中,非快通道冠狀動脈旁路搭橋的病人在手術中通過ASV或者壓力控制/壓力支持通氣(對照)來進行肺部通氣,從而來比較氣管導管拔除的時間、控制通氣和輔助通氣持續時間的比例以及通氣特徵。

結果128位連續的病人隨機化入選實驗。ASV組病人氣管導管拔除時間為16.4hr(四分位範圍12.5-20.8hr),對照組是16.3 (13.7–19.3) hrP= 0.97)。病人輔助通氣時間比例(輔助通氣時間/總通氣時間)ASV組是43% (28%–67%),對照組是52% (33%–75%)P<0.05)。但是,ASV組病人發生從控制通氣切換到輔助通氣的病例數(43.0 [14.0–74.0])高於對照組(4.0 [2.0–9.0])(P < 0.001)。ASV組病人在控制通氣過程中的平均潮氣量(8.6 ± 0.8 mL/kg預計體重)顯著大於對照組(7.1 ± 1.4 mL/kg預計體重)(P= 0.05),但是在輔助通氣過程中兩組潮氣量沒有差別。

結論:帶有自適應輔助通氣的脫機自動裝置可行而且安全地應用於非快通道冠狀動脈旁路搭橋的病人。ASV組病人氣管導管拔除時間和標準脫機組病人相差不多,但是在手術中需要在控制通氣和輔助通氣間做頻繁的(自動)切換。

(姜旭暉譯,馬皓琳 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.



氙氣麻醉對於健康受試者的腦葡萄糖代謝與腦血流之間的關係的效應:正電子斷層掃描研究

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:全麻可以改變局部腦葡萄糖代謝(rCMRglc)和腦血流(rCBF).之間的關係。在這個正電子斷層掃描的研究中,我們的目的是評估同一個體在氙氣麻醉時的rCMRglcrCBF

方法:18F標記的氟去氧葡萄糖和15O標記的水分別來測定5名健康男性志願者處於基線水準(清醒)和1個最小肺泡麻醉濃度(MAC)的氙氣麻醉中的rCMRglcrCBF。麻醉中只使用氙氣。rCMRglcrCBF變化用感興趣區域和基於三維圖元的分析來量化。

結果:氙氣麻醉中的濃度平均值(標準差)是67.2 (0.8)%。氙氣麻醉導致所有人的rCMRglc下降,而rCBF13個腦區域中有7個下降。腦灰質的rCMRglcrCBF分別平均減少32.4 (4.0)% (P < 0.001) 14.8 (5.9)% (P = 0.007)。腦白質的rCMRglc減少10.9 (6.4)% (P = 0.030),而rCBF增加9.2 (7.3)% (P = 0.049)rCBF/rCMRglc比在間腦、前後回和軀體感覺皮質增加得特別明顯。

結論:總體來說,在1MAC的氙氣麻醉下rCMRglc減少程度超過rCBF的降低,因此rCBFrCMRglc比例有所升高。有趣的是,氙氣所導致的腦代謝和腦血流的改變和揮發性吸入麻醉藥所致的改變相似。

(唐亮   馬皓琳 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.

 

 

 

圍術期給予加巴噴丁、美洛昔康及其聯合應用對門診腹腔鏡膽囊切除術後自發和運動誘發疼痛的影響的隨機、雙盲、對照實驗

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

背景住院子宮切除和脊柱手術實驗提示環氧酶-2 抑制劑和加巴噴丁/普加巴林之間在術後12天有良好的相互作用。我們進行了把美洛昔康-加巴噴丁聯合應用於門診腹腔鏡膽囊切除術後的初次試驗。

方法:本實驗為隨機、雙盲實驗,比較術前1h開始到術後2天每天口服1)美洛昔康15mg2)加巴噴丁12001600mg以及3)聯合口服這兩種藥物的不同作用。主要的觀察指標包括手術當天自發和運動所誘發的疼痛。其次的觀察指標包括術後1230天的疼痛、不良反應、阿片類藥物的需求、呼吸量測定、疼痛相關的干擾、出院時間、恢復工作時間以及病人的滿意度。

結果:手術當天,單獨口服加巴噴丁的60分鐘靜息疼痛評分(2.0 ± 1.6)010數位分級評分±標準差)明顯比單獨口服美洛昔康(3.6 ± 2.1)(P < 0.05)。聯合口服兩種藥物(2.9 ± 2.1)與單獨口服加巴噴丁之間所觀察到的疼痛差別非常小(P > 0.05),且這種差別對單獨口服加巴噴丁有利。二次分析表明,聯合口服兩種藥物術後噁心的發生率(24%)明顯比單獨口服美洛昔康(57%)低。

結論:雖然聯合口服美洛昔康和加巴噴丁可以減少術後噁心,但是本實驗不能或幾乎不能支持聯合用藥用於緩解手術當天的疼痛。這表明圍術期給予多種鎮痛藥並不總是必要或者恰當的。

(吳進   馬皓琳 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、羅呱卡因(含腎上腺素)及等容積複合利多卡因合劑用於股神經和坐骨神經阻滯的藥效學和藥動學的比較:一個雙盲、隨機化研究

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:長效局麻藥複合利多卡因合劑常用于外周神經阻滯。目前關注局麻藥合劑安全性、有效性和藥代動力學的研究資料很少。我們的研究比較了0.5%布比卡因、0.75%羅呱卡因、等容量0.5%布比卡因複合2%利多卡因合劑以及等容量0.75%羅呱卡因複合2%利多卡因合劑用於股神經-坐骨神經阻滯後手術的效能。本研究主要終點指標是起效時間。

方法:82名接受股神經(20 mL)和坐骨神經(20 mL)阻滯的下肢手術成年病人,隨機、雙盲地給予0.5%布比卡因(200 mg)0.5%布比卡因20 mL (100 mg)複合2% 利多卡因 (400 mg)合劑、0.75%羅呱卡因(300 mg)0.75%羅呱卡因20 mL(150mg)複合2%利多卡因 (400 mg)合劑。每一種阻滯液中均含有1:200,000腎上腺素。我們比較了實施阻滯的時間、起效(注射結束至感覺及運動完全阻滯)時間、感覺及運動阻滯的持續時間、病人靜脈自控鎮痛的嗎啡用量。神經阻滯後051530456090 min分別靜脈采血5mL用於測定血藥濃度。

結果:四組病人一般情況和手術持續時間相似。利多卡因複合長效局麻藥縮短坐骨神經阻滯起效時間(感覺和運動阻滯)。與單獨應用布比卡因組(28 ± 12 min)相比,布比卡因複合利多卡因組起效時間為16 ± 9 min;與單獨應用羅呱卡因組(23 ± 12 min)相比,羅呱卡因複合利多卡因組起效時間為16 ± 12 min。與單獨應用布比卡因組(60 min)相比,布比卡因複合利多卡因組所有病人在40min內感覺完全阻滯;與單獨應用羅呱卡因組(40 min)相比,羅呱卡因複合利多卡因組所有病人在30 min內感覺完全阻滯(P < 0.05)。合劑組的感覺和運動覺阻滯持續時間明顯較短。除單獨應用布比卡因組嗎啡用量中位數(9 mg)少於布比卡因複合利多卡因組(15 mg)(P < 0.01)外,各組術後48 h內疼痛視覺類比評分和嗎啡使用量沒有差別。各組之間不良事件的發生率無差異。與長效局麻藥複合利多卡因組相比,單獨應用長效局麻藥組的病人血漿布比卡因和羅呱卡因濃度較高且持續升高時間較長(P < 0.01)

結論:長效局麻藥複合利多卡因合劑起效快,持續時間短。我們還不清楚長效局麻藥複合利多卡因是否具有安全性這一優點,因為血漿長效局麻藥濃度降低的益處可能被存在顯著增高的血漿利多卡因濃度所抵消。

(江繼宏   馬皓琳 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.



超聲引導前路坐骨神經阻滯:與後路阻滯比較

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:雖然前路坐骨神經阻滯由於缺乏可靠的表面解剖標誌和技術上的困難而很少進行,但是在超聲引導下可能使之容易操作。在本次研究中,我們評價在成人超聲引導的前路坐骨神經阻滯的臨床使用並與後路阻滯相比較。

方法100個膝關節小手術病人被隨機地分為兩組,分別接受前路和後路(臀下)坐骨神經阻滯,使用含腎上腺素的1.5%甲呱卡因20ml,並聯合股神經和股外側皮神經阻滯。使用低頻5-2MHz彎曲的陣列感測器完成兩種入路坐骨神經阻滯。測量阻滯執行時間、神經的深度和大小、入針深度、感覺和運動阻滯起效時間和阻滯持續時間。

結果:前路神經阻滯相對於臀下進路,病人坐骨神經位置更深和入針深度更大。兩種入路在坐骨神經阻滯操作時間類似,但在實施所有的阻滯組合時所花的時間前路短於後路。雖然前路達到的股後皮神經感覺阻滯明顯少於後路阻滯(分別為14.9% 68.1%; P < 0.001),但兩種入路的成功率、腓神經和脛神經阻滯起效時間和持續時間無統計學差異。

結論:使用超聲引導前路坐骨神經阻滯同後路坐骨神經阻滯一樣能容易和成功地完成。

(王宏 馬皓琳、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.

 

小鼠缺血再灌注後抑肽酶對左室收縮功能的劑量依賴性改變及細胞因數的釋放

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:在心臟手術過程中缺血再灌注(I/R)期的長短是與短暫的左室功能障礙和炎症反應相關的。在本次研究中,我們監測了抑肽酶(APRO)對左室收縮功能的潛在劑量依賴效應以及缺血再灌注背景下的細胞因數釋放。

方法:用容量微感測器在研究開始、缺血30分鐘、再灌注60分鐘時分別測量左室收縮功能指數,即左室最大收縮力(Emax)。小鼠隨機分組如下:(a) APRO 20,000 抑制激肽釋放酶單位/公斤 KIU/kg)(數量n=11);(b) APRO 4 x 104 KIU/kg n = 10);(c) APRO 8 x 104 KIU/kg n = 10);(d) 空白對照 (鹽水;n = 10

結果:空白對照組、APRO 4 x 104 KIU/kg組以及APRO 8 x 104 KIU/kg組在缺血再灌注後,左室最大收縮力(Emax)減小為基礎值的40%多(P < 0.05)。然而APRO 2 x 104 KIU/kg組的左室最大收縮力(Emax)卻回到基礎值的水準。腫瘤壞死因數(TNF)在缺血再灌注後增加了10倍,但它卻隨著APRO劑量的增加而減少。

結論 這一研究證實一個低劑量的APRO可以對左室收縮功能起到保護作用,而高劑量的APRO則會抑制TNF的釋放。這一史無前例的研究發現提示我們在缺血再灌注的過程中APRO有著獨特的作用機制。

(單嘉琪譯 薛張綱校)

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.

 

 

抑肽酶對行體外迴圈的新生兒患者術後腎功能不全影響的回顧性分析

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:近期關於抑肽酶在成人使用過程中所暴露的安全性問題致使其在全球市場上被暫時擱置。然而,很少有研究指出其對於兒童患者使用的安全性。兒童病患的個體化和臨床治療策略的差異化妨礙了抑肽酶在兒童患者中的安全性評估。在此項調查中,我們回顧了200名在我機構實施心臟外科手術的新生兒患者,採用統一的給藥方案,以術後腎功能不全為關注物件來評價抑肽酶運用的安全性。

方法:此項回顧性研究選取200511日起至2007228日間200名陸續於體外迴圈條件下行姑息或矯正心臟外科手術的新生兒患者。收集並分析其術前、術中及術後的各項資料。其中安全性指標包括術後72小時內是否發生腎功能不全,是否需行透析治療(包括腹透和血透),是否有血栓形成以及住院死亡率。

結果:依據是否運用抑肽酶將上述新生兒患者分為抑肽酶組(n=156)和對照組(n=44)。比較兩組患兒術後24小時和72小時的血肌酐濃度,發現兩組均明顯高於基線濃度,且兩組患兒血肌酐水準的變化程度也極為相似。在抑肽酶組中,雖然較大多數新生兒患者發生了腎功能不全,但這種差異並無統計學意義。對於在抑肽酶組和對照組、術後腎功能不全組和正常組中具有指示意義的變數,運用逐步邏輯回歸的方法評估其對於術後腎功能不全的影響,發現體外迴圈時間和年齡對於預示術後腎功能不全具有顯著意義。無論是否運用抑肽酶,所有發生術後腎功能不全的新生兒患者其體外迴圈時間均超過了100分鐘。而進一步採用亞組分析後卻發現,抑肽酶組和對照組患兒發生腎功能不全的比例是近似的。利用多元回歸分析同時對體外迴圈時間、患兒年齡以及是否運用抑肽酶等預示指標進行評價,發現體外迴圈時間是提示術後腎功能不全唯一有意義的指標。術後透析和術後血栓形成的發生率及住院死亡率在抑肽酶組和對照組之間並無明顯的統計學差異。

結論:就新生兒患者而言,體外迴圈時間相比術中是否運用抑肽酶對於提示術後腎功能不全的發生更有顯著意義。大於100分鐘的體外迴圈術是發生術後腎功能不全的危險信號。而本次回顧性研究的有效性需有其他的隨機前瞻性研究加以證實。

(范羽譯 薛張綱校)

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.

 

 

 

門診手術病人術前檢查專案的略過

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:術前檢查由於對手術期間各種情況的預估參考價值不高而受到質疑。我們設計了一個單盲的前瞻性對照研究來探討在選定的門診手術病人中,是否可以略過一些特定的術前檢查而不增加手術期間不可逆損害事件的發生率。

方法1060例選定的病人,隨機分為兩組,接受特定專案的術前檢查組和不接受術前檢查組。接受術前檢查組,進行當前安大略省的常規術前檢查,項目包括:全血細胞計數,電解質,血糖,肌酐,心電圖和胸片。而不接受術前檢查組則不要求進行任何檢查。研究者,資料收集者及結果復核者都不知曉分組資訊。主要的評價指標為手術期間及術後7天和術後30天的不可逆損害事件的發生率。

結果:病人年齡,性別,ASA分級,手術及麻醉類型在兩組間具有可比性。兩組在術中及術後30天內的不可逆損害事件的發生率均無顯著性差異。術前檢查組術後7天內需要再次就診的發生率高於無檢查組(P<0.5)。沒有證實任何不可逆損害事件的發生與是否行術前檢查有關。

結論:本次試驗性研究表明,在我們的研究樣本人群中,不進行術前檢查,並不會增加術中不可逆損害事件的發生率。仍需要進行更大規模的研究來證明,在門診手術病人中一部分特定的術前檢查項目可以安全的略過而不增加手術期間重大併發症的發生率。

(黃劍譯 薛張綱校)

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縮短氯胺酮誘導鼠麻醉時間:與大腦去甲腎上腺素能神經元活性的相關性

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:促食素可調控失眠,而缺乏促食素I型受體將導致嗜睡。促食素可以選擇性地增加鼠大腦表皮去甲腎上腺素的釋放,並且腦內去甲腎上腺素能神經元與睡眠覺醒週期相關。而氯胺酮增加鼠大腦皮層釋放去甲腎上腺素。我們可假設促食素將影響ketamine對腦內去甲腎上腺素能神經元活性的麻醉作用。

方法:我們使用了Sprague Dawley鼠。我們研究1)促食素A (OXA)SB-334867-A (Orexin-1受體抗體)對氯胺酮誘導麻醉時間的活體作用;2)應用微量滲析來評估活體內促食素A對氯胺酮導致的大腦皮層去甲神腎上腺素釋放增加的影響;3)氯胺酮對促食素A引起的大腦皮層去甲腎上腺素釋放的影響。

結果1)在50 100125毫克/千克腹腔( IP )氯胺酮的用藥量下,1nmol側腦室的促食素可明顯降低氯胺酮麻醉時間的20 -30 。而促食素-1受體抗體充分地扭轉了促食素導致的減退。2)促食素也減少氯胺酮導致的去甲腎上腺素釋放,即使促食素會增加大鼠前額皮質釋放的去甲腎上腺素。合用促食素和氯胺酮的組別中獲得的最大的去甲腎上腺素釋放量為271%(側腦室促食素1nmol+100毫克/千克腹腔氯胺酮),這顯著少於單獨使用氯胺酮組的釋放量(100毫克/千克腹腔氯胺酮,釋放量基線為390%P = 0.029)。3)臨床IC50價值下氯胺酮抑制促食素引起的去甲腎上腺素釋放。

結論:促食素相關的神經元可能是氯胺酮作用的一個重要目標。促食素通過去甲腎上腺素能神經元的促食素-1受體來對抗氯胺酮的麻醉作用。

(李瑩譯 薛張綱校)

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.

 

 

一項通過Vigileo/FloTrac 系統獲得的每搏量變異來預測機械通氣患者對液體治療反應性的研究

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:肺動脈壓變化可以準確預測機械通氣患者對液體治療的反應性。而我們此次研究的目的是評價一個新型的可自動估算每搏量變異的運算系統對於預測機械通氣患者對液體治療反應性的能力。

方法:我們研究了二十五名行冠狀動脈旁路移植的患者。術中通過Vigileo/FloTrac系統連續監測每搏量變異。所有的25名患者都被施以全身麻醉,進行機械通氣,並通過肺動脈導管監測肺動脈壓的變化。在血管內擴容(給以500毫升羥乙基澱粉)之前和之後均同步記錄每搏量和肺動脈壓的變化。那些在擴容之後通過熱稀釋法獲得的心臟指數升高15%以上者被定義為對擴容有反應者。

結果50對資料中肺動脈壓和每搏量變異的一致性為1.3% ± 2.8%(平均偏差±標準差)。17位患者對擴容治療有反應。肺動脈壓變異閾值為10%識別對擴容有反應者的敏感度為88%,特異度為87%。每搏量變異閾值為10%時識別對擴容有反應的敏感度為82%,特異度為88%

結論:每搏量變異對於預測液體治療反應有可令人接受的敏感度和特異度,同時它是替代連續肺動脈壓監測的較有潛力的指標。

(姚敏敏譯 薛張綱校)

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.

 

 

術中知曉:危險因素,誘因及後遺症:文獻中報導病例的總結

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:術中知曉並不多見。在一項研究中發現的病例數目並不足以識別和評估其危險因素,誘因和後遺症。分析已經發表在科學期刊上的術中知曉病例成為研究大量病例的一種方法。

方法:我們在國家圖書館的醫學資料庫中對1950年到20058月關於“知曉”和“麻醉的病例報告進行了電子搜索。我們還手動查閱了這些報告以及其他關於術中知曉的文章的參考文獻。我們使用了控制手術條件的兩組病例用於比較。第一組來自Sebel等做的一項研究,由未發生術中知曉的病人組成。第二組來自NSAS 1996年的資料,包含了期間接受全身麻醉的病人。我們還使用了國家健康統計中心的資料來比較體重以及BMI

結論:我們把271例發生術中知曉的病例和19504例未發生術中知曉的病例進行比較。前者更容易發生在女性(P<0.05,年輕患者(P<0.001)以及接受心臟或產科手術的患者(P<0.0001)。只有35%的術中知曉患者在蘇醒室中陳述了其中細節。他們接受了更少的麻醉藥物(P<0.0001,更傾向於在手術過程中表現出心動過速和血壓增高(P<0.0001)。這些病人中的很大一部分(52%P<0.0001)手術後訴說了關於術中知曉的抱怨。無法移動,無助感和無力感。聽到噪音和講話聲與持續的抱怨如睡眠障礙、對將來的麻醉感到恐懼等有關(P < 0.041–0.0003)22%的患者受到之後發生的心理問題的困擾。

結論:我們的總結反映了淺麻醉和有術中知曉發生史是危險因素。肥胖和避免N2O的使用並不增加其發生的風險。淺麻醉是最常見的誘因。我們的發現顯示預防措施可能會減少術中知曉的發生率。

(俞佳譯 薛張綱校)

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.

 

 

灌注指數作為衡量成年異丙酚麻醉者血管內注射含腎上腺素的硬膜外試驗劑量後變化的指標的有效性

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:灌注指標是一種無創性的來自於血氧飽和度監測的反應外周迴圈灌注的數值指標。本研究中我們評價了灌注指數作為探索成人異丙酚麻醉過程中血管內注射一個包含15微克腎上腺素的硬膜外試驗劑量藥物後變化的指標的有效性,同時將它與常規評價標準——心率(如果>=10/分則陽性)及收縮壓(如果>=15 mm Hg則陽性)進行了可靠性比較。

方法:40個預約做普外科手術的麻醉評分四級以上的病人隨機接受3毫升含5 microg/mL腎上腺素的濃度為15 mg/mL的利多卡因或3毫升生理鹽水(n = 20)。注射後5分鐘監測心率,血壓和灌注指數。

結果:注射試驗劑量導致39 +/- 15秒後平均最大灌注指數降低65% +/- 13%。而且,心率和血壓的最大增量分別為49 +/- 25 s 19 +/- 8 bpm102 +/- 34 s 17 +/- 7 mm Hg。用灌注指數作為血管內注射的評價指標(如果灌注指數較注射前降低>=10%則陽性),其敏感性、特異性、陽性預期值和陰性預期值是100%95%置信區間=83%-100%)。相對的,心率和血壓指標的敏感性分別為95% (CI = 76%-99%)90% (CI = 70%-97%)

結論:灌注指數是一個評價成年異丙酚麻醉者血管內注射硬膜外試驗劑量藥物後常規血流動力學變化的可靠的選擇。

(張玥琪譯 薛張綱校)

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.

 

 

妊娠期敗血症和急性腎功能衰竭

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.

 

臨床醫生診療重症孕期病人時遇到的很多問題都是由妊娠期獨特的生理造成的。這篇綜述針對性概括了在診療重症孕期病人遇到的兩個問題:妊娠相關敗血症和急性腎功能衰竭。就常見原因和妊娠期對診斷和治療的影響加以討論。

(張釗譯 薛張綱校)

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.

 

 

七氟烷預處理對氧和葡萄糖缺乏的海馬皮層的影響酪氨酸激酶與缺血期的作用

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:在實驗模型中所觀察到的麻醉藥物對神經細胞的保護作用仍未得到臨床的證實。非受體酪氨酸激酶成簇黏附激酶被指出參與試驗中所觀察到的麻醉藥的神經保護作用。在本項實驗中,我們研究成簇黏附激酶與缺血期是否在七氟烷預處理對腦組織的影響中起作用。

方法:在逐漸增加的時間段裏(102030455060分鐘)使大鼠海馬皮層遭受急性的缺氧和葡萄糖,然後予以1小時的再灌注。在進行缺氧和葡萄糖處理前,先對大鼠提供3小時的七氟烷預處理,預處理濃度為每小時10M成簇黏附激酶的蛋白表達和被裂解的半胱天冬酶3(凋亡級聯啟動標誌物)通過免疫印跡法得到測量。細胞的死亡由碘化丙啶螢光法評定。

結果:缺血期間碘化丙啶螢光和被裂解的半胱天冬酶3均明顯增加,缺血大於30 分鐘後達到最大效應。七氟烷增加成簇黏附激酶的表達,並顯著減少缺血時間為102030分鐘時碘化丙啶螢光和被裂解的半胱天冬酶3的增加。然而,在對照組中,缺血時間大於30分鐘後這種保護效果並未觀察到。

結論:在大鼠海馬急性缺血和葡萄糖模型中,臨床相關濃度七氟烷的預處理效果與成簇黏附激酶密切相關,並且只在小於30分鐘的缺血模型中觀察到。

(朱蘭芳譯 薛張綱較)

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.

 

 

脊柱手術後硬膜外注射可樂定的鎮痛作用:一項隨機對照研究

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:可樂定是α2腎上腺素受體和咪做啉受體拮抗劑,具有鎮痛、鎮靜和降低麻醉藥MAC值的作用。使用途徑包括口服、靜脈輸注和硬膜外給藥。在脊椎手術中,術後並不用於硬膜外鎮痛,原因是使用了硬膜外鎮痛會掩蓋了神經根和脊髓損傷的徵象。

方法:我們選擇66名接受不複雜的脊髓減壓手術的患者,隨機分成可樂定組(C組)和安慰劑組(P組)。術後病人使用PCA鎮痛,記錄術後36小時嗎啡的用量。

結果C組嗎啡的用量明顯少於P組。36小時內C組平均嗎啡的用量是35 mg (95% 的可信區間是 21–50 mg) ,而對照組是 61 mg (95% 的可信區間是48–74 mg)C組嘔吐的發生率明顯較低,是6.5%, 而安慰劑組的發生率是38.2%

結論:硬膜外小劑量的使用可樂定可以顯著降低術後嗎啡的用量,並且降低諸如嘔吐等的副作用的發生率。

(陳珺珺譯 薛張綱校)

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.

 

 

比較利多卡因/普魯卡因(EMLA®)和基於酒精的消毒劑對未受損皮膚上菌群的抗菌作用

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® 軟膏的應用是被塗在置靜脈套管針的局部皮膚表面。最近我們在離體試驗中發現EMLA具有抗菌作用。

方法:我們對利多卡因/普魯卡因軟膏(EMLA)和基於酒精的皮膚消毒劑(Skinsept Pur®)應用於未受損皮膚的殺菌作用進行比較。在治療後012小時後提取樣本。

結果:在最初一小時,無論是 EMLA還是Skinsept Pur ,使用後皮膚的菌落形成單位(cfu)數均顯著降低,分別從44.9 ± 1.3 (42.4 ± 7.0) 0.9 ± 0.17 (1.61 ± 0. 7) cfu/cm2(平均數±標準差)。但是在使用後4612小時,使用EMLA軟膏的cfu數顯著低於Skinsept Pur的。

結論:相比於Skinsept Pur EMLA軟膏在早期殺菌後,具有較長的抑菌作用時間。

(陳珺珺譯 薛張綱校)

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.

 

心臟手術中的右心室:圍手術期的解剖、生理和評估

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.

 

多年來,我們已經認識到右心室功能在心血管疾病及心臟手術中的重要性。研究顯示,在心力衰竭、先天性心臟病、瓣膜疾病和心臟手術中,右室功能異常對疾病的預後具有重要意義。作者2篇文章中的第一篇主要回顧了右室解剖、生理的主要特徵及其功能評估,其中主要的從右室結構和功能的超聲評估展開。第二篇討論了心臟手術中右室衰竭的病理生理學、臨床意義和處理原則。

(周姝婧 譯 陳傑 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.

 

 

芬太尼聯合異丙酚麻醉延長陣發性室上性心動過速患兒的竇房結恢復時間

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:在小兒室上性心動過速的一些類型中,折返機制對增高的迷走神經張力很敏感。異丙酚麻醉常用于小兒電生理研究和射頻消融術。儘管輸注芬太尼和異丙酚都會提高迷走神經的張力,但兩者聯合是否有潛在提高迷走神經張力還尚未定論。在這項研究中,作者對芬太尼聯合異丙酚是否可以改變電生理研究和射頻消融術患兒的心臟電生理活動進行了評估。

方法:此項研究物件為27名患兒,其中9名患有預激綜合征,7名存在隱匿性旁道,11名患有房室結折返性心動過速。用異丙酚(2.0mg/kg)進行麻醉誘導,並持續輸注異丙酚(100–167 µg · kg–1 · min–1)作麻醉維持。在平穩的麻醉過程中,給予芬太尼(2.0ug/kg靜脈注射,繼以0.075ug/kg/min持續輸注)並在給藥前後測量竇房傳導時間和校正竇房結恢復時間。

結果:整個檢查中雙頻指數評分和全身血壓保持不變。芬太尼顯著延長校正竇房結恢復時間(P=0.005),但不延長竇房傳導時間(P=0.35)。

結論:因為心臟迷走神經張力的增高是校正竇房結恢復時間延長的誘發因素之一,作者認為研究結果支持了芬太尼聯合異丙酚有提高心臟迷走神經張力的假說。

(黃丹 譯 陳傑 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.

 

華人異丙酚-瑞芬太尼靶控輸注時意識喪失和疼痛刺激無反應時的C50BIS值:一項多中心臨床實驗

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:在這項研究中,作者探討了華人異丙酚-瑞芬太尼靶控輸注時在意識喪失(LOC)及標準疼痛刺激下無反應時的預測血漿濃度及效應室的C50值,以及腦電雙頻指數(BIS值)。作者假設這些數值與先前報導的白種人的相關數值有所不同。

方法:本實驗由五個臨床中心完成,選擇擇期病人405例(男性97例,女性308例),ASAI-II,年齡18-65歲。輸注丙泊酚至預測血漿濃度達1.2ug/mL,並持續輸注使預測血漿濃度逐漸遞增,遞增幅度為每300.3ug/mL,術中維持OAA/S評分為1分。接著靜脈輸注瑞芬太尼至預測血漿濃度達2.0 ng/mL,並持續輸注使其預測血漿濃度逐漸遞增,遞增幅度為每300.3 ng/mL,直至強直刺激反應消失,測定其腦電雙頻指數BIS值。

結果:異丙酚在意識喪失(LOC)時效應室C50值為2.2ug/mL,瑞芬太尼在疼痛刺激反應消失時效應室C50值為3.3ng/mL。約50%的患者意識喪失時的BIS值為58,其中95%BIS<40時意識喪失。疼痛刺激反應消失時BIS值為65.4,這一數值顯著高於意識喪失時的BIS值(p<0.001)。

結論:LOC時異丙酚的預測血漿濃度及效應室濃度以及BIS值顯著低於先前報導的白種人的相關數值。

(趙嫣紅 譯 陳傑 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.

 

依託咪酯對大鼠腸系膜阻力動脈血管反應性直接作用的機制

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:標準誘導劑量的依託咪酯對年輕健康患者的血流動力學影響較小,但是高劑量麻醉誘導或腦電暴發性抑制(例如,腦保護)對高齡或心臟疾病以及體外迴圈期間患者會造成顯著低血壓。然而,其對全身阻力動脈的作用還不明確。

方法:用等長張力記錄法和fura-2螢光測定法研究依託咪酯對於年輕大鼠(7-8周,n=179)和老年鼠(96-98周,n=10)的小腸系膜動脈的作用。

結果:對於內皮完整的年輕鼠,3uM依託咪酯加強去甲腎上腺素或者KCL40mM)的血管收縮作用,但是高濃度(≥10uM)時抑制其作用。對NG1硝基精氨酸,四乙胺,雙氯芬酸,去甲二氫愈創木酸,氯沙坦,酮色林,BQ-123或者BQ-788產生加強作用,但是在老年鼠上並沒有觀察到此現象。對於去內皮帶的年輕鼠,依託咪酯(≥10uM)同樣抑制去甲腎上腺素或者KCL的血管收縮作用,3uM時也沒有加強作用。Fura-2螢光記錄顯示,去內皮的年輕鼠,依託咪酯抑制去甲腎上腺或KCL引發的細胞內鈣離子聚集和作用力。斯里蘭卡肉桂堿造成細胞內鈣離子儲備耗竭時,依託咪酯同樣抑制去甲腎上腺誘發的鈣離子濃聚,其對硝苯地平敏感。依託咪酯對去甲腎上腺數或者咖啡因誘發的細胞內鈣離子釋放或者細胞內鈣離子吸收幾乎沒有作用。去甲腎上腺或者KCL刺激期間,低濃度(≤30uM)的依託咪酯對於鈣離子濃聚幾乎沒有作用,但是100uM時能引起其下降。

結論:對於小腸系膜動脈,依託咪酯通過內皮依賴加強和內皮非依賴抑制作用影響去甲腎上腺或者膜去極化的血管收縮反應。其加強作用至少對於一氧化氮,內皮超極化因素,環氧化酶產物,脂肪氧化酶產物,血管緊張素II5-羥色胺或者內皮素I呈部分非依賴性,但可能不包括一些因年老而受損的信號通路。內皮非依賴性抑制歸因於血管平滑肌細胞的鈣離子濃聚和肌絲鈣離子敏感性降低。此鈣離子濃聚的降低可能和電壓門控性鈣離子內流的抑制有關。年輕個體的依託咪酯麻醉誘導時,低濃度(1-3uM)依託咪酯不能造成顯著血管擴張,其對血流動力學同樣只造成微小變化,然而高濃度依託咪酯能造成血管擴張可能解釋了臨床上高劑量依託咪酯引起的低血壓現象。

(朱紫瑜 譯 陳傑 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.


 

多重輸注線路延長對輸注泵壓力報警的影響

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成像的診斷或治療過程中有時需麻醉或鎮靜,持續輸注麻醉藥或血管加壓藥時常需加長輸注路線。在這項研究中,作者嘗試測定輸注路線的長度是否影響輸注線路壓力報警時間。

方法: 兩種模型的輸注泵系統,用12或者3個串聯的輸注路線,或者螺旋形不易折低順應性的輸注路線相連接,並且啟動輸注60s。輸注路線最終通過按下結束開關來停止輸液。輸注路線中連接壓力感應器記錄線路中實際的壓力改變。測量在流速為520、以及50ml/h時連續5次壓力報警時間。

結果:當應用一個單獨的輸注線路時,在輸注速度50ml/h時,輸注泵12.4± 0.1 min後觸發壓力報警,輸注泵22.6± 0.2 min後觸發;輸注速度為20ml/h時,報警觸發時間分別為6.6 ± 0.4 min5.6 ± 0.5 min;輸注速度為5ml/h,報警觸發時間分別為23.0 ± 2.8 min 20.9 ± 3.6 min。當增加第二個輸注線路時 ,在5ml/h情況下,輸注泵1的壓力報警在27.1 ± 1.8 min後觸發(P = 0.1),而輸注泵229.2 ± 1.4 min後觸發(P = 0.07)。應用3個輸注線路時,輸注泵12的壓力報警與1個輸注路線相比較顯著延長,輸注速度為5ml/h時分別為31.6 ± 3.0 min (P = 0.01) and 35.1 ± 1.1 min (P = 0.001) 觸發。兩個輸注泵的觸發警報的壓力水準範圍在大約9001100Mbar

結論:當模擬低流速輸注(5ml/h),如應用血管加壓藥,壓力報警時間顯著延長,尤其在輸注路線長度增加時。

(懷曉蓉 譯 陳傑 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.


困難氣道患者噴霧式氣道表面麻醉:2 %和4 %利多卡因的隨機、雙盲比較研究

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:作者設計這項隨機、雙盲臨床研究,比較了在纖維支氣管鏡應用時用2 %和4 %利多卡因以噴霧法對呼吸道局部麻醉的安全性和有效性。

方法 52例困難氣道的成年患者,以雙盲的方式隨機分為2組並在運用纖維支氣管鏡時分別使用2 1 )或4 %利多卡因(組2)的噴霧技術。氣道局部麻醉後,清醒下纖維支氣管鏡經口氣管插管。 鎮靜水準、不同目標區利多卡因噴霧次數、氣道總噴霧次數、氣道噴霧總劑量、插管時間、嘗試插管次數。一個獨立的調查員評定患者在氣道局部麻醉時的舒適度,病人的反應,咳嗽嚴重性,並在清醒時進行插管條件評分,並觀察每一個氣道操作階段中的動脈血壓和心率變化。採集血液樣本進行血漿利多卡因濃度分析。

結果:除利多卡因總劑量和血藥濃度外,兩組間的其他觀察變數之間沒有顯著性差異。所有患者表現滿意或達到可接受的插管條件。組1利多卡因總劑量( 3.4 ± 0.6 mg/kg)明顯少於組2 7.1 ± 2.1 mg/kg)。聲門上噴灑了利多卡因後所有觀測點,組2的血漿濃度比組1高。

結論 2 %和4 %利多卡因以噴霧法局部處理後為臨床上困難氣道患者清醒鎮靜下提供可接受的氣管插管條件。與4 %利多卡因相比, 2 %利多卡因組所需較小劑量並降低了血藥濃度。

(張磊 譯 陳傑 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.


短期吸入高濃度氧在兔的體外模型呼吸機所致肺損傷中並不加重損傷

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:呼吸衰竭時常需機械通氣和吸入高濃度氧。作者進行這項研究,以探討吸入高濃度氧對呼吸機所致肺損傷的影響。   
方法:在吸氣壓力為2515 cm H2O和呼氣末正壓為3 cm H2O的環境下,40例離體/灌注兔肺隨機接收100 %或21 %的氧氣壓力控制通氣60min。所有分組( n = 10為每個組)中維持灌流液的溫度, pH值,二氧化碳分壓相同 。評估肺損傷程度的項目包括:重量增加和超濾係數的改變,血管功能衰竭的頻率,組織學病變及腫瘤壞死因數的濃度和支氣管肺泡灌洗液中的丙二醛的量。
結果:與在較低吸氣壓力/潮氣量通氣的兩組相比在較高吸氣壓力/潮氣量通氣的兩組在重量增加和超濾係數的改變更明顯,血管功能的衰竭更頻繁,組織病理損害的綜合得分更高。急性肺損傷的任何一項監測標誌並未發現組織內氧有進一步增加。四個實驗組的肺泡灌洗液中的腫瘤壞死因數或丙二醛發現無明顯差異。
結論:上述實驗模型的結果表明,短期吸入高濃度氧不是呼吸機所致肺損傷的一個主要因素。

(丁俊雲 譯 陳傑 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.

 

神經外科危重病人經皮氣管切開術“ Percutwist ”期間顱內壓的監測

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:在重症腦損傷的管理中氣管切開術是常用的一部分,經皮擴張氣管切開術作為替代標準手術氣管切開術在重症監護病房應用越來越多。但此過程中有發生神經系統併發症的危險,尤其是顱內壓增高的患者。在這項研究中,作者在65名神經外科ICU危重病人,進行床邊經皮穿刺氣管切開術,並試圖量化Percutwist ®氣管切開術(Rusch-Teleflex醫療)在ICPCPPPaco2Pao2的影響。

方法 65例( 29名, 36名,平均年齡43歲,± 10.6 )格拉斯哥昏迷評分≤8 ,需要長期通氣支援,顱內壓恒定在20mmHg, 在床邊由纖維內窺鏡下選擇性經皮氣管切開。術中連續監測:心電圖,脈搏血氧飽和度,有創動脈血壓,顱內壓,腦灌注壓。記錄ICP增加超過20 mm Hg或腦灌注壓減少低於60 mm Hg(持久超過3分鐘),缺氧界定為氧分壓低於90 mm Hg 二氧化碳瀦留定義為二氧化碳分壓超過40 mm Hg

結果11例患者有18此次顱內高壓記錄。記錄的監測變數無統計學意義,短暫的顱內壓增加接近統計學意義( P = 0.051 )。沒有發生腦灌注壓低於60毫米汞柱,6%的病人出現二氧化碳瀦留。

結論Percutwist氣管切開術是一種單步方法,能有效的通氣,從而減少了二氧化碳瀦留的顱內壓增高風險。該技術沒有引起繼發病理生理損傷的風險,在腦損傷患者中安全使用。

(劉世文 譯 陳傑 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.

 

經腹和腹腔鏡下手術期間在維持前負荷及心指數平時乳酸林格液需求量

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:近期研究顯示了圍手術期液體限制的重要性。然而,液體限制方案可能增加圍術期補液量不足可能性或可能導致血管內晶體液過量交換。作者假定使用經食管超聲心動圖可減少經腹和腹腔鏡下結直腸手術圍術期晶體使用量。

方法 選擇ASAIII級的患者,15例行開放結直腸手術, 15例行腹腔鏡手術進行研究。術中輸注乳酸林格氏液。圍術期監測左心室舒張末容積指數( LVEDVI )和心臟指數用於指導乳酸林格氏液輸注。統計學分析採用非配對樣本St檢驗。

結果:為維持基礎LVEDVI和心臟指數,圍術期晶體輸注速率在經腹手術時為5.9 ± 2 mL · kg–1 · h–1,腹腔鏡下手術時為3.4 ± 0.8 mL · kg–1 · h–1(P < 0.01) 。腹腔鏡下手術較慢的輸注速度被較長的手術時間抵消了。

結論:為維持基礎LVEDVI和心臟指數,經腹手術的晶體輸注速率比要大於腹腔鏡手術,但低於通常建議的結直腸手術的輸注速率。

(葉樂 譯 陳傑 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.

 

微循環對針刺刺激和光療的反應。

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:針刺刺激和光療被認為具有鎮痛和改善微循環的作用。然而,很少有研究直接檢測外周血管的變化。作者直視下觀察小動脈血流量對針刺刺激和光療的反應來評估這些方法的作用。

方法 40只兔子在耳廓附上兔耳室。兔耳室在解剖顯微鏡下固定於耳廓。通過顯微鏡攝像頭選定小動脈並用於觀察。靜脈注射戊巴比妥鈉。氣管插管維持自主呼吸。家兔隨機分配接受針刺刺激(針刺組, n = 10 ,近紅外燈照射(燈照組, n = 10 ,近紅外低功率鐳射照射(鐳射組, n = 10 ,或沒有照射(對照組, n = 10 )。在針刺組,針刺針放於耳廓20分鐘。燈照每秒重複受到近紅外輻射(1540mW,持續4秒鐘結束。鐳射組不斷受到60 mW的鐳射照射。在燈照組和鐳射組,耳廓(針刺組針刺針放置的相同位置)接受10分鐘接觸探頭的照射。針刺和照射治療60分鐘後測量小動脈直徑和血流速度。血流速率通過血流速度乘以橫截面面積得到。

結果:與對照組(100%)比較,針刺組小動脈直徑顯著增加至131 ± 14 %( P <0.005 ),燈照組增加為129 ± 19 %( P < 0.005 ),鐳射組增加128 ± 11 %( P <  0.005 )。針刺刺激結束後20分鐘,光照和鐳射照射結束後10分鐘達到最高值。這三組與對照組比較後顯示小動脈直徑顯著增加(P<0.005)。血流速度和血流量變化與小動脈直徑變化相似。治療效果在刺激和照射結束後持續40-50分鐘。

結論:針刺刺激和光療直接增加外周小動脈直徑並加快血流速度。針刺刺激和光照治療,以最小的全身和局部副作用,改善微循環,可能成為外周迴圈不良所致疾病的有效輔助治療方法。

(舒慧剛 譯 陳傑 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體/膠體與晶體血管內容量治療對心輸出量和每搏輸出量影響的比較
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:脊髓麻醉來說低血壓是最常見的心血管反應。作者比較了脊髓麻醉前給予晶體/膠體與給予晶體在經尿道前列腺切除術的老年患者中心輸出量( CO )的影響。

 方法: 60ASA I–III級的男性病人隨機分為三組,對照組沒有預先血管內容量治療,在脊髓麻醉前20分鐘內,生理鹽水組接受了500毫升生理鹽水,羥乙基澱粉(HES)組接受了500毫升生理鹽水加500毫升6 130/0.4的羥乙基澱粉。用胸阻抗法測定平均動脈壓( MAP )和心率,心輸出量和每搏量。 


結果:對照組平均動脈壓由104 ± 20 mm Hg下降至88 ± 11 mm Hg P=0.005 ,並顯著低於羥乙基澱粉組(由107 ± 13 mm Hg97 ± 12 mm Hg P=0.001  。生理鹽水組, MAP下降( 103 ± 14 mm Hg92 ± 17 mm Hg ,與對照組和羥乙基澱粉組相比沒有顯著差異。對照組心輸出量顯著降低( 4.9 ± 1.6/分至3.8 ± 0.9/分, P=0.002  ),並顯著低於羥乙基澱粉組病人。預先接受羥乙基澱粉容量治療組心輸出量顯著增加(從5.2 ± 1.23/分至6.2 ± 1.43/分, P=0.003 ,並保持在基線水準直至研究結束。 

結論:血管內預充生理鹽水加羥乙基澱粉能阻止心輸出量的下降,但在經尿道前列腺切除術的老年患者,並不能阻止脊髓麻醉引起的低血壓。

(張燕 譯 陳傑 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.

 

脊髓麻醉後頭低腳高體位乳酸林格氏液和6 %羥乙基澱粉溶液對心輸出量的影響

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:本研究的目的是評估50歲以上病人進行脊髓麻醉後頭低腳高位,乳酸林格氏液和6 %羥乙基澱粉溶液對心輸出量的影響。

方法:70例擬在脊髓麻醉的下肢矯形手術病人隨機分為三組。一組在採取頭低腳高位,病人在脊髓阻滯10min後改為頭低腳高位。乳酸林格氏液和羥乙基澱粉溶液組,病人在脊髓阻滯發生後分別輸注500mL乳酸林格氏液和6 %羥乙基澱粉溶液1000mL,輸注時間20min。脊髓麻醉前15min到麻醉後30min連續監測心排血量,動脈血壓。P<0.05時有統計學意義。

結果:各組心臟出量的差別不明顯,沒有統計學意義。但心排血量隨時間變化較明顯。在頭低腳高組中,心排血量無顯著變化。6 %羥乙基澱粉組,在阻滯發生後心排血量有明顯增加並且在測量結束後持續增加了一段時間。乳酸林格氏液組中,心排血量在阻滯發生前10分鐘和發生後20分鐘內出現增加,但是在停止注射後,心排血量開始降低。

結論:研究表明:這三種方法都能有效阻止脊髓麻醉後心排血量的降低。注射乳酸林格氏液的影響是短暫的,而6 %羥乙基澱粉影響在注射結束後還能持續一段時間。

(王騰 譯 陳傑 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.