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.
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 校
The Right Ventricle
in Cardiac Surgery, a Perioperative Perspective: II. Pathophysiology, Clinical
Importance, and Management (Review Article)
François Haddad, Pierre
Couture, Claude Tousignant, and André Y. Denault
Anesth Analg 2009 108:
422-433.
PEDIATRIC ANESTHESIOLOGY:
抑肽酶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.
黃麗娜
譯 馬皓琳 李士通 校
Airway Management in
Children: Ultrasonography Assessment of Tracheal Intubation in Real Time?
Bruno Marciniak, Pierre Fayoux, Anne Hébrard, Renée Krivosic-Horber, Thomas Engelhardt, and Bruno Bissonnette
Anesth Analg 2009 108:
461-465.
AMBULATORY ANESTHESIOLOGY:
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C50及BIS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_files/image002.gif){kind=small}
-氨基丁酸受體的作用是有區別的
顏濤 譯， 馬皓琳 李士通 校
Anesthetics
Discriminate Between Tonic and Phasic 
-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.
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
朱
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.
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:
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.
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.
黃佳佳譯，馬皓琳 李士通 校
Diagnostic Predictor
of Difficult Laryngoscopy: The Hyomental Distance Ratio
Jin Huh, Hwa-Yong Shin, Seong-Hyop Kim, Tae-Kyoon Yoon, and Duk-Kyung Kim
Anesth Analg 2009 108:
544-548.
灌注指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:
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 譯 馬皓琳 李士通 校
The
Effects of Xenon Anesthesia on the Relationship Between Cerebral Glucose
Metabolism and Blood Flow in Healthy Subjects: A Positron Emission Tomography
Study
Ruut M. Laitio, Jaakko W. Långsjö, Sargo Aalto, Kaike K. Kaisti, Elina Salmi, Anu Maksimow, Riku Aantaa, Vesa Oikonen, Tapio Viljanen, Riitta Parkkola, and Harry Scheinin
Anesth Analg 2009 108: 593-600.
七氟烷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
譯 馬皓琳 李士通 校
A Randomized,
Double-Blind, Controlled Trial of Perioperative Administration of Gabapentin,
Meloxicam and Their Combination for Spontaneous and Movement-Evoked Pain After
Ambulatory Laparoscopic Cholecystectomy
Ian Gilron, Elizabeth Orr, Dongsheng Tu, C. Dale Mercer, and David Bond
Anesth Analg 2009 108: 623-630.
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.
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
譯 馬皓琳 李士通 校
A Comparison of the
Pharmacodynamics and Pharmacokinetics of Bupivacaine, Ropivacaine (with
Epinephrine) and Their Equal Volume Mixtures with Lidocaine Used for Femoral
and Sciatic Nerve Blocks: A Double-Blind Randomized Study
Philippe Cuvillon, Emmanuel Nouvellon, Jacques Ripart, Jean-Christophe Boyer, Laurence Dehour, Aba Mahamat, Joel L’Hermite, Christophe Boisson, Nathalie Vialles, Jean Yves Lefrant, and Jean Emmanuel de La Coussaye
Anesth Analg 2009 108: 641-649.
老年患者脊髓麻醉前晶體/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.
王宏
譯
馬皓琳、李士通 校
Ultrasound-Guided
Anterior Approach to Sciatic Nerve Block: A Comparison with the Posterior
Approach
Junichi Ota, Shinichi Sakura, Kaoru Hara, and Yoji Saito
Anesth Analg 2009 108: 660-665.
比較利多卡因/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*_files/image004.gif){kind=small}
, Pierre Couture, MD*,
Claude Tousignant, MD_files/image006.gif){kind=small}
, and André Y. Denault, MD*
From
the *Department of Anesthesiology, Montreal Heart Institute and Université de
Montréal, Montreal, Quebec, Canada; _files/image007.gif){kind=small}
Division of Cardiovascular
Medicine, Stanford University, Stanford, California; and _files/image008.gif){kind=small}
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_files/image009.gif){kind=small}
_files/image010.gif){kind=small}
, Anne Hébrard, MD*,
Renée Krivosic-Horber, MD*, Thomas Engelhardt, MD, PhD_files/image012.gif){kind=small}
, and Bruno Bissonnette, BSc,
MD, FRCPC||
From
the *Pôle d’Anesthésie Réanimation, Hôpital Jeanne de Flandre, CHRU, Rue Eugène
Aviné, 59037 Lille Cedex France; _files/image013.gif){kind=small}
UPRES JE2490, Preclinical
research group in perinatal medicine, Lille 2 University, Lille, France; _files/image014.gif){kind=small}
U.F. d’ORL pédiatrique, Pôle
d’ORL Hôpital Claude Huriez. CHRU Lille, France; _files/image015.gif){kind=small}
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 譯 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_files/image016.gif){kind=small}
-氨基丁酸受體的作用是有區別的
Anesthetics
Discriminate Between Tonic and Phasic _files/image017.gif){kind=small}
-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_files/image019.gif){kind=small}
-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gabazine（20 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 _files/image020.gif){kind=small}
-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_files/image021.gif){kind=small}
, Fredrik Granath, PhD_files/image022.gif){kind=small}
, Scott D. Greenwald, PhD_files/image023.gif){kind=small}
, Anders Ekbom, MD, PhD_files/image024.gif){kind=small}
, Claes Lennmarken, MD, PhD_files/image025.gif){kind=small}
, and Rolf H. Sandin, MD, PhD*
From
the *Department of Physiology and Pharmacology, Section for Anesthesia and
Intensive Care, Karolinska Institutet, Stockholm, Sweden; _files/image026.gif){kind=small}
Department of Anesthesia and
Intensive Care, University Hospital, Linköping, Sweden; _files/image027.gif){kind=small}
Department of Medicine, Clinical
Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden; and _files/image028.gif){kind=small}
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例(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 <45是1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]和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級(HR 19.3 [7.31–51.1]), 年齡>80 歲(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.
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或 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 或 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0.74，95%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.
Diagnostic
Predictor of Difficult Laryngoscopy: The Hyomental Distance Ratio
Jin
Huh, MD*, Hwa-Yong Shin, MD_files/image029.gif){kind=small}
, Seong-Hyop Kim, MD_files/image030.gif){kind=small}
, Tae-Kyoon Yoon, MD_files/image031.gif){kind=small}
, and Duk-Kyung Kim, MD_files/image032.gif){kind=small}
From
the *Department of Anesthesiology, Seoul National University Borame Municipal
Hospital; and _files/image033.gif){kind=small}
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)比(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HMDR。HMDR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 和 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1.2是DVL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 _files/image035.gif){kind=small}
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*_files/image036.gif){kind=small}
_files/image037.gif){kind=small}
, Frederique Paulus, RN*,
Bas A. J. M. de Mol, MD, PhD_files/image038.gif){kind=small}
, Johanna C. Korevaar, PhD||,
Anna Kudoga, MS*, Pauline Middelhoek, RN*, Jan M.
Binnekade, PhD*, and Marcus J. Schultz, MD, PhD*_files/image039.gif){kind=small}
¶
From
the Departments of *Intensive Care Medicine and _files/image040.gif){kind=small}
Anesthesiology, _files/image041.gif){kind=small}
Laboratory of Experimental
Intensive Care and Anesthesiology (L.E.I.C.A.), Departments of _files/image042.gif){kind=small}
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) hr（P= 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*_files/image043.gif){kind=small}
, Jaakko W. Långsjö, MD*_files/image044.gif){kind=small}
, Sargo Aalto, MSc*_files/image045.gif){kind=small}
, Kaike K. Kaisti, MD*_files/image046.gif){kind=small}
, Elina Salmi, MD*_files/image047.gif){kind=small}
, Anu Maksimow, MD*_files/image048.gif){kind=small}
, Riku Aantaa, MD_files/image049.gif){kind=small}
, Vesa Oikonen, MSc*,
Tapio Viljanen, MSc*, Riitta Parkkola, MD||, and Harry
Scheinin, MD*
From
the *Turku PET Centre, University of Turku; _files/image050.gif){kind=small}
Departments of Anesthesiology
and Intensive Care, _files/image051.gif){kind=small}
Otorhinolaryngology, and
||Radiology, Turku University Hospital; and _files/image052.gif){kind=small}
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rCMRglc和rCBF。
方法：用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rCMRglc和rCBF。麻醉中只使用氙氣。rCMRglc和rCBF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rCBF在13個腦區域中有7個下降。腦灰質的rCMRglc和rCBF分別平均減少32.4 (4.0)% (P < 0.001) 和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rCBF和rCMRglc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 譯 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*_files/image053.gif){kind=small}
, Elizabeth Orr, RN*,
Dongsheng Tu, PhD_files/image054.gif){kind=small}
, C. Dale Mercer, MD, FRCSC_files/image055.gif){kind=small}
, and David Bond, MB, BChir, MA,
MSc, CCFP, FRCPC||
From
the *Department of Anesthesiology, Kingston General Hospital, and the Departments
of _files/image056.gif){kind=small}
Pharmacology and Toxicology, _files/image057.gif){kind=small}
Mathematics and Statistics, and _files/image058.gif){kind=small}
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1－2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15mg、2）加巴噴丁1200－1600mg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1、2和30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)（0－10數位分級評分±標準差）明顯比單獨口服美洛昔康(3.6 ± 2.1)低(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 譯 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_files/image059.gif){kind=small}
, Laurence Dehour, MD*,
Aba Mahamat, MD_files/image060.gif){kind=small}
, 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; _files/image061.gif){kind=small}
Laboratoire de Biochimie,
University Groupe Caremeau Hospital, Place Professeur Debré, 30029 Nîmes,
France; and _files/image062.gif){kind=small}
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)或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0、5、15、30、45、60和90 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 譯 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.
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% 和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 譯 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 _files/image063.gif){kind=small}
Cardiothoracic Surgery, Medical University
of South Carolina, Charleston, South Carolina; and _files/image064.gif){kind=small}
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2005年1月1日起至2007年2月28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.
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)和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 ， 100和125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_files/image065.gif){kind=small}
, and Jean-Jacques Lehot, MD, PhD*
The Hospices Civils
de Lyon, Departments of *Anesthesiology and Intensive Care, and _files/image066.gif){kind=small}
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 (_files/image068.gif){kind=small}
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 _files/image069.gif){kind=small}
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 _files/image070.gif){kind=small}
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 _files/image071.gif){kind=small}
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 _files/image072.gif){kind=small}
PP.
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2005年8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>或=10次/分則陽性）及收縮壓（如果>或=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 後19 +/- 8 bpm和102 +/- 34 s 後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>或=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%)和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.
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*_files/image073.gif){kind=small}
, Virginie Jannier, MD*,
Danielle Rouelle_files/image074.gif){kind=small}
, Pierre Gressens, MD, PhD_files/image075.gif){kind=small}
, Jean Mantz, MD, PhD*_files/image076.gif){kind=small}
, and Souhayl Dahmani, MD, PhD*_files/image077.gif){kind=small}
From the
*Department of Anesthesia, Beaujon University Hospital, Assistance Publique des
Hôpitaux de Paris, Clichy, France; and _files/image078.gif){kind=small}
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（10、20、30、45、50和60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10、20、30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 _files/image080.gif){kind=small}
30 min.
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_files/image081.gif){kind=small}
From the Nuffield
Departments of *Anaesthetics and _files/image082.gif){kind=small}
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 _files/image084.gif){kind=small}
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_files/image085.gif){kind=small}
, and Monika Kerenyi, PhD_files/image086.gif){kind=small}
From the
Departments of *Anesthesia and Intensive Care, and _files/image087.gif){kind=small}
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0至12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)到 0.9 ± 0.17 (1.61 ± 0. 7) cfu/cm2（平均數±標準差）。但是在使用後4，6，12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.
The Right
Ventricle in Cardiac Surgery, a Perioperative Perspective: I. Anatomy,
Physiology, and Assessment
François Haddad, MD*_files/image088.gif){kind=small}
, Pierre Couture, MD*, Claude
Tousignant, MD_files/image089.gif){kind=small}
, and André Y. Denault, MD*
From the
*Department of Anesthesiology, Montreal Heart Institute and Université de
Montréal, Montreal, Quebec, Canada; _files/image090.gif){kind=small}
Division of Cardiovascular Medicine,
Stanford University, Stanford, California; and _files/image091.gif){kind=small}
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*_files/image092.gif){kind=small}
, Yoshihide Nakamura, MD, PhD_files/image093.gif){kind=small}
, and Yoshio Hatano, MD, PhD_files/image094.gif){kind=small}
From the
*Department of Anesthesiology, Japanese Red Cross Society Wakayama Medical
Center, Wakayama City, Wakayama, Japan; _files/image095.gif){kind=small}
Department of Anesthesiology, Wakayama
Medical University, Wakayama City, Wakayama, Japan; _files/image096.gif){kind=small}
Department of Pediatric Cardiology, Japanese
Red Cross Society Wakayama Medical Center, Wakayama City, Wakayama, Japan; and _files/image097.gif){kind=small}
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C50及BIS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_files/image098.gif){kind=small}
, Bingxi Zhang, MD_files/image099.gif){kind=small}
, Mingzhang Zuo, MD_files/image100.gif){kind=small}
, Mingjun Xu, MD||, Rongrong Hao,
MD_files/image101.gif){kind=small}
, Yuan Xu, MD_files/image102.gif){kind=small}
, Ning Yang, MD_files/image103.gif){kind=small}
, and Xiangming Che, MD||
From the *Beijing
Chaoyang Hospital, Capital Medical University, Beijing, People’s Republic of
China; _files/image104.gif){kind=small}
Peking Union Medical College Hospital,
Chinese Academy of Medical Sciences, Beijing, People’s Republic of China; _files/image105.gif){kind=small}
Beijing Tongren Hospital, Capital Medical
University, Beijing, People’s Republic of China; _files/image106.gif){kind=small}
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30秒0.3ug/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30秒0.3 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%在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：在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.
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KCL（40mM）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II，5-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 (_files/image107.gif){kind=small}
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 (_files/image108.gif){kind=small}
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 (_files/image109.gif){kind=small}
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.
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：CT或MRI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1、2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5、20、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1在2.4± 0.1 min後觸發壓力報警，輸注泵2在2.6± 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 min和5.6 ± 0.5 min；輸注速度為5ml/h，報警觸發時間分別為23.0 ± 2.8 min 和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2在29.2 ± 1.4 min後觸發(P = 0.07)。應用3個輸注線路時，輸注泵1和2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900～1100Mbar。
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*_files/image110.gif){kind=small}
, He P. Liu, MD_files/image111.gif){kind=small}
, Nong He, MD_files/image112.gif){kind=small}
, Ya C. Xu, MD*, Quan Y. Yang, MD*,
Xu Liao, MD*, Xiu Z. Xu, MD_files/image113.gif){kind=small}
, Xin L. Guo, MD_files/image114.gif){kind=small}
, 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; _files/image115.gif){kind=small}
Third Affiliated Hospital, XinXiang Medical
University, XinXiang, Henan, People’s Republic of China; and _files/image116.gif){kind=small}
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 ％ （ 組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*_files/image117.gif){kind=small}
, Theodoros Kapetanakis, MD_files/image118.gif){kind=small}
, Ilias I. Siempos, MD_files/image119.gif){kind=small}
, Christina Magkou, MD_files/image120.gif){kind=small}
, Aimilia Pelekanou, MD_files/image121.gif){kind=small}
, Thomas Tsaganos, MD_files/image122.gif){kind=small}
, Evangelos Giamarellos-Bourboulis, MD_files/image123.gif){kind=small}
, Charis Roussos, MD||, and
Apostolos Armaganidis, MD*
From the *Second
Critical Care Department, Attiko University Hospital, University of Athens
Medical School, Athens, Greece; _files/image124.gif){kind=small}
Department of Experimental Surgery,
Evangelismos Hospital, University of Athens Medical School, Athens, Greece; _files/image125.gif){kind=small}
Department of Histopathology, Mitera
Hospital, Athens, Greece; _files/image126.gif){kind=small}
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25或15
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-_files/image127.gif){kind=small}
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-_files/image128.gif){kind=small}
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ICP，CPP，Paco2，Pao2的影響。
方法：：
65例（ 男29名， 女36名，平均年齡43歲，± 10.6 ）格拉斯哥昏迷評分_files/image129.gif){kind=small}
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 _files/image130.gif){kind=small}
8, requiring long-term ventilatory
support with a stable ICP _files/image131.gif){kind=small}
20 mm Hg were i