Table of Contents

March 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

肌钙蛋白I水平在预测绝经后妇女行心血管手术后发生不良心血管事件预后的价值

单嘉琪译 薛张纲校

Prognostic Value of Troponin I Levels for Predicting Adverse Cardiovascular Outcomes in Postmenopausal Women Undergoing Cardiac Surgery

Joshua D. Stearns, Victor G. Dávila-Román, Benico Barzilai, Richard E. Thompson, Kelly L. Grogan, Betsy Thomas, and Charles W. Hogue, Jr

Anesth Analg 2009 108: 719-726.

快通道麻醉与心脏手术:7989例患者的回顾性队列研究

郑丽 译 陈杰 校

Fast-Track Anesthesia and Cardiac Surgery: A Retrospective Cohort Study of 7989 Patients

Vesna Svircevic, Arno P. Nierich, Karel G. M. Moons, George J. Brandon Bravo Bruinsma, Cor J. Kalkman, and Diederik van Dijk

Anesth Analg 2009 108: 727-733.

一篇就文献进行的系统性回顾:血栓弹性描计法可以预测术后血栓栓塞的发生么?

姜旭晖译,马皓琳,李士通校

Does Thromboelastography Predict Postoperative Thromboembolic Events? A Systematic Review of the Literature

Yue Dai, Anna Lee, Lester A. H. Critchley, and Paul F. White
Anesth Analg 2009 108: 734-742.

血栓弹性测定法(ROTEM)检测体外循环术后肝素和鱼精蛋白的试点研究及结果

范羽译 薛张纲校

Detection of Protamine and Heparin After Termination of Cardiopulmonary Bypass by Thrombelastometry (ROTEM®): Results of a Pilot Study

Markus Mittermayr, Corinna Velik-Salchner, Berndt Stalzer, Josef Margreiter, Anton Klingler, Werner Streif, Dietmar Fries, and Petra Innerhofer

Anesth Analg 2009 108: 743-750.

血小板减少的情况下纤维蛋白原的水平对弹性血栓变量的影响

刘世文 译 陈杰 校

The Effects of Fibrinogen Levels on Thromboelastometric Variables in the Presence of Thrombocytopenia

Thomas Lang, Kai Johanning, Helfried Metzler, Siegfried Piepenbrock, Cristina Solomon, Niels Rahe-Meyer, and Kenichi A. Tanaka

Anesth Analg 2009 108: 751-758.

输血的非感染性严重风险

裘毅敏译,马皓 琳 李士通校

Noninfectious Serious Hazards of Transfusion (Review Article)

Jeanne E. Hendrickson and Christopher D. Hillyer

Anesth Analg 2009 108: 759-769.

输血相关急性肺损伤:对临床医师的进展

叶乐 译 陈杰 校

Transfusion-Related Acute Lung Injury: Current Concepts for the Clinician (Review Article)

Darrell J. Triulzi

Anesth Analg 2009 108: 770-776.

产妇的心脏手术

周雅春 译   马皓琳 李士通 校

Cardiac Surgery in the Parturient (Review Article)

Shobana Chandrasekhar, Christopher R. Cook, and Charles D. Collard

Anesth Analg 2009 108: 777-785.

PEDIATRIC ANESTHESIOLOGY:

儿科手术室外异丙酚行镇静/麻醉治疗的不良反应及其发生率来自儿科镇静研究协会的报道

黄剑译 薛张纲校

The Incidence and Nature of Adverse Events During Pediatric Sedation/Anesthesia With Propofol for Procedures Outside the Operating Room: A Report From the Pediatric Sedation Research Consortium

Joseph P. Cravero, Michael L. Beach, George T. Blike, Susan M. Gallagher, James H. Hertzog, and Pediatric Sedation Research Consortium

Anesth Analg 2009 108: 795-804.

4左旋布比卡因和罗哌卡因用于小儿骶管麻醉的相对镇痛效应

张磊 译 陈杰 校

Relative Analgesic Potencies of Levobupivacaine and Ropivacaine for Caudal Anesthesia in Children

Pablo Ingelmo, Geoff Frawley, Marinella Astuto, Chris Duffy, Susan Donath, Nicola Disma, Giuseppe Rosano, Roberto Fumagalli, and Antonio Gullo

Anesth Analg 2009 108: 805-813.

重症患儿使用持续指尖无创血压监测的可靠性

李莹译 薛张纲校

The Reliability of Continuous Noninvasive Finger Blood Pressure Measurement in Critically Ill Children

Joris Lemson, Charlotte M. Hofhuizen, Olaf Schraa, Jos J. Settels, Gert Jan Scheffer, and Johannes G. van der Hoeven

Anesth Analg 2009 108: 814-821.

实时评估围术期行为和预计围术期预后

张莹译 李士通 马皓琳

Real-Time Assessment of Perioperative Behaviors and Prediction of Perioperative Outcomes (Brief Report)

Senthilkumar Sadhasivam, Lindsey L. Cohen, Alexandra Szabova, Anna Varughese, Charles Dean Kurth, Paul Willging, Yu Wang, Todd G. Nick, and Joel Gunter Anesth

Analg 2009 108: 822-826.

AMBULATORY ANESTHESIOLOGY:

人工控制输注和靶控输注瑞芬太尼在保留自主呼吸患者中的比较

姚敏敏译 薛张纲校

Manual Versus Target-Controlled Infusion Remifentanil Administration in Spontaneously Breathing Patients

Annelies T. Moerman, Luc L. Herregods, Martine M. De Vos, Eric P. Mortier, and Michel M. R. F. Struys

Anesth Analg 2009 108: 828-834.

ANESTHETIC PHARMACOLOGY:

高铁血红蛋白症与局麻药关系242个案的总结

张燕 译 陈杰 校

Methemoglobinemia Related to Local Anesthetics: A Summary of 242 Episodes

Joanne Guay

Anesth Analg 2009 108: 837-845.

残余肌松对Sugammadex肌松拮抗速度的影响

黄丽娜  译 马皓琳 李士通 校

The Effect of Residual Neuromuscular Blockade on the Speed of Reversal with Sugammadex

Paul F. White, Burcu Tufanogullari, Ozlem Sacan, Edward G. Pavlin, Oscar J. Viegas, Harold S. Minkowitz, and M. E. Hudson

Anesth Analg 2009 108: 846-851.

丙酚和瑞芬太尼靶控输注使光纤下经鼻气管插管更便利的比较

俞佳译 薛张纲校

A Comparison of Propofol and Remifentanil Target-Controlled Infusions to Facilitate Fiberoptic Nasotracheal Intubation

Alexandre Lallo, Valerie Billard, and Jean-Louis Bourgain

Anesth Analg 2009 108: 852-857.

大鼠氙气预处理:促存活信号、线粒体渗透性转变和生物能学的作用

舒慧刚 译 陈杰 校

Xenon Preconditioning: The Role of Prosurvival Signaling, Mitochondrial Permeability Transition and Bioenergetics in Rats

Yasushi Mio, Yon Hee Shim, Ebony Richards, Zeljko J. Bosnjak, Paul S. Pagel, and Martin Bienengraeber

Anesth Analg 2009 108: 858-866.

本体感受功能对地氟烷麻醉的敏感性高于运动功能

江继宏 译  马皓琳 李士通 校

Proprioceptive Function Is More Sensitive than Motor Function to Desflurane Anesthesia

Linda S. Barter, Laurie O. Mark, and Joseph F. Antognini

Anesth Analg 2009 108: 867-872.

TECHNOLOGY, COMPUTING, AND SIMULATION:

探测生理监测的变化的一种新型软件工具的评估。

张玥琪译,薛张纲校

An Evaluation of a Novel Software Tool for Detecting Changes in Physiological Monitoring

J. Mark Ansermino, Jeremy P. Daniels, Randy T. Hewgill, Joanne Lim, Ping Yang, Chris J. Brouse, Guy A. Dumont, and John B. Bowering

Anesth Analg 2009 108: 873-880.

心衰患者循环支持时的无创心排出量监测

丁俊云 译 陈杰 校

Noninvasive Cardiac Output Measurement in Heart Failure Subjects on Circulatory Support

Rob Phillips, Peter Lichtenthal, Julie Sloniger, Darryl Burstow, Malcolm West, and Jack Copeland

Anesth Analg 2009 108: 881-886.

围术期微创监测心排出量

周姝婧 译 陈杰 校

Minimally Invasive Cardiac Output Monitoring in the Perioperative Setting (Review Article)

Duane J. Funk, Eugene W. Moretti, and Tong J. Gan

Anesth Analg 2009 108: 887-897.

CRITICAL CARE AND TRAUMA:

机械通气脱机期功能残气量的变化:一项前瞻性研究

张钊译 薛张纲校

Changes in Functional Residual Capacity During Weaning from Mechanical Ventilation: A Pilot Study

Hermann Heinze, Beate Sedemund-Adib, Matthias Heringlake, Torsten Meier, and Wolfgang Eichler

Anesth Analg 2009 108: 911-915.

酒精滥用和围术期中免疫功能紊乱

王宏翻译,马皓琳,李士通校正

Alcohol Use Disorder and Perioperative Immune Dysfunction (Review Article)

Alexandra Lau, Vera von Dossow, Michael Sander, Martin MacGuill, Nadine Lanzke, and Claudia Spies

Anesth Analg 2009 108: 916-920.

OBSTETRIC ANESTHESIOLOGY:

病人自控硬膜外镇痛在分娩中的应用

黄佳佳译,马皓琳 李士通校

Patient-Controlled Epidural Analgesia for Labor (Review Article)

Stephen H. Halpern and Brendan Carvalho

Anesth Analg 2009 108: 921-928.

ECONOMICS, EDUCATION, AND POLICY:

住院医师专业化培训:失败的原因与改进措施

朱兰芳译 薛张纲

The Teaching of Professionalism During Residency: Why It Is Failing and a Suggestion to Improve Its Success (Review Article)

Robert R. Gaiser

Anesth Analg 2009 108: 948-954.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:Back

混合皮层神经元-神经胶质细胞培养遭受氧糖缺失时的早期麻醉预处理:在七氟醚诱导时产生的神经保护作用中,三磷酸腺苷依赖性钾通道和活性氧所起的作用

黄丹 译 陈杰 校

Early Anesthetic Preconditioning in Mixed Cortical Neuronal-Glial Cell Cultures Subjected to Oxygen-Glucose Deprivation: The Role of Adenosine Triphosphate Dependent Potassium Channels and Reactive Oxygen Species in Sevoflurane-Induced Neuroprotection

Lionel J. Velly, Paula T. Canas, Benjamin A. Guillet, Christelle N. Labrande, Frédérique M. Masmejean, André L. Nieoullon, François M. Gouin, Nicolas J. Bruder, and Pascale S. Pisano

Anesth Analg 2009 108: 955-963.

环磷腺苷反应单元结合蛋白磷酰化和4-苯基-14-苯丁基)哌啶(PPBP)的神经保护作用

颜涛 译 马皓琳 李士通 校

Cyclic Adenosine Monophosphate Response Element-Binding Protein Phosphorylation and Neuroprotection by 4-Phenyl-1-(4-Phenylbutyl) Piperidine (PPBP)

Sufang Yang, Nabil J. Alkayed, Patricia D. Hurn, and Jeffrey R. Kirsch

Anesth Analg 2009 108: 964-970.

心脏循环停止后的脑复苏

陈珺珺译 薛张纲校

Cerebral Resuscitation After Cardiocirculatory Arrest (Review Article)

Andreas Schneider, Bernd W. Böttiger, and Erik Popp

Anesth Analg 2009 108: 971-979.

ANALGESIA:

8%定量利多卡因喷雾泵对创伤后外周神经病变的镇痛作用:一项初步研究

周姝婧 译 陈杰 校

The Analgesic Effect of a Metered-Dose 8% Lidocaine Pump Spray In Posttraumatic Peripheral Neuropathy: A Pilot Study

Akifumi Kanai, Yuka Segawa, Takashi Okamoto, Masanori Koto, and Hirotsugu Okamoto

Anesth Analg 2009 108: 987-991.

辣椒膏用于合谷穴可减少正颌手术术后镇痛剂的需求

唐李隽    马皓琳  李士通 

Capsicum Plaster at the Hegu Point Reduces Postoperative Analgesic Requirement After Orthognathic Surgery

Kyo S. Kim, Kyu N. Kim, Kyung G. Hwang, and Chang J. Park

Anesth Analg 2009 108: 992-996.

局麻药对人类神经细胞的细胞毒性作用

陈珺珺译 薛张纲校

Cytotoxicity of Local Anesthetics in Human Neuronal Cells

Rosalia Perez-Castro, Sohin Patel, Zayra V. Garavito-Aguilar, Andrew Rosenberg, Esperanza Recio-Pinto, Jin Zhang, Thomas J. J. Blanck, and Fang Xu

Anesth Analg 2009 108: 997-1007.

一种新型异二氢吲哚衍生物JM-1232(-)的镇痛效应和药理特性

黄施伟 译,马皓琳 李士通 校

The Antinociceptive Effects and Pharmacological Properties of JM-1232(-): A Novel Isoindoline Derivative

Shunsuke Chiba, Tomoki Nishiyama, and Yoshitsugu Yamada

Anesth Analg 2009 108: 1008-1014.

苄哌酚醇导致的抗伤害感觉和降低慢性后根神经节压缩小鼠的脊髓背角NR2B亚单位的表达

陈珺珺译 薛张纲校

Ifenprodil Induced Antinociception and Decreased the Expression of NR2B Subunits in the Dorsal Horn After Chronic Dorsal Root Ganglia Compression in Rats

Wei Zhang, Chang-Xi Shi, Xiao-ping Gu, Zheng-Liang Ma, and Wei Zhu

Anesth Analg 2009 108: 1015-1020.

大鼠后根神经节内注射利多卡因引起神经炎症

朱 慧译 马皓琳 李士通校

Lidocaine Injection into the Rat Dorsal Root Ganglion Causes Neuroinflammation

Livia Puljak, Sanja Lovric Kojundzic, Quinn H. Hogan, and Damir Sapunar

Anesth Analg 2009 108: 1021-1026.

一个可吸收的局麻药装置提供数天的功能性坐骨神经阻滞

怀晓蓉 译 陈杰 校

An Absorbable Local Anesthetic Matrix Provides Several Days of Functional Sciatic Nerve Blockade

Chi-Fei Wang, Alimorad G. Djalali, Ankur Gandhi, David Knaack, Umberto De Girolami, Gary Strichartz, and Peter Gerner

Anesth Analg 2009 108: 1027-1033.

应用皮肤温度评估锁骨下臂丛神经阻滞效果的有效性

赵嫣红 译 陈杰 校

The Efficacy of Skin Temperature for Block Assessment After Infraclavicular Brachial Plexus Block

Vincent Minville, Agnés Gendre, Jan Hirsch, Stein Silva, Benoît Bourdet, Carole Barbero, Olivier Fourcade, Kamran Samii, and Hervé Bouaziz

Anesth Analg 2009 108: 1034-1036.

超声引导下的闭孔神经阻滞:一种新的关于超声方法的研究

陈珺珺译 薛张纲校

Ultrasound-Guided Obturator Nerve Block: A Sonoanatomic Study of a New Methodologic Approach

Taylan Akkaya, Emine Ozturk, Ayhan Comert, Yesim Ates, Haluk Gumus, Halil Ozturk,

Ibrahim Tekdemir, and Alaittin Elhan

Anesth Analg 2009 108: 1037-1041.

肌钙蛋白I水平在预测绝经后妇女行心血管手术后发生不良心血管事件预后的价值

Prognostic Value of Troponin I Levels for Predicting Adverse Cardiovascular Outcomes in Postmenopausal Women Undergoing Cardiac Surgery

Stearns, Joshua D. MD; Davila-Roman, Victor G. MD; Barzilai, Benico MD; Thompson, Richard E. PhD; Grogan, Kelly L. MD; Thomas, Betsy RN; Hogue, Charles W. Jr MD

From the *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; {dagger}Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; {ddagger}Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and §Department of Clinical Research, Washington University School of Medicine, St. Louis, Missouri.

Anesthesia & Analgesia  March 2009.108(3):719-726,

 

背景:心血管手术后的不良心血管事件是影响妇女围手术期发病率和死亡率的重要因素。肌钙蛋白I提供了一个心血管损伤敏感的检测指标,但其在心血管手术后的水平因性别而异。我们此次研究的目的就是评估肌钙蛋白I水平在预测绝经后妇女行心血管手术后产生心血管并发症上的价值。

方法:此次研究的队列来自于先前一个已报道的临床试验,那个研究旨在评估老年妇女中17[beta]-雌二醇的神经保护潜能。在那个研究中,175名未接受雌激素替代治疗且将择期行冠脉旁路移植术(有无瓣膜手术均可)的绝经后妇女经双盲随机分成两组,分别自手术前一天开始接受17[beta]-雌二醇或安慰剂治疗,至术后五天。在术前,术后入重症监护室当日以及术后头四天分别进行连续十二导联心电图及血清肌钙蛋白I浓度检测。我们这次研究的主要终检值是重大的心血管不良事件(MACE),即Q波型心肌梗死,低心排量以及术后三十天内死亡。Q波型心肌梗死的诊断需有两位内科医生分别独立进行评估,两者意见一致方为最终诊断。低心排量状态是指在不考虑具体治疗的情况下心脏指数小于2.0 L · min-1 · m-2超过八个小时。

结果:术后第一天的肌钙蛋白I水平被用于预测重大的心血管不良事件(MACE)(受试者曲线下面级=0.862)。将肌钙蛋白I的终检值定于>7.6 ng/mL95%可信区间,6.4–10.8)可提供鉴别患者是否存在发生重大心血管不良事件(MACE)风险的最佳敏感性和特异性。由肌钙蛋白水平来识别一个患者是否合并有心血管事件,其阴性预测价值很高(96%),而阳性预测价值却一般(40%)。围手术期接受17[beta]-雌二醇治疗的妇女与安慰剂组比较,术后肌钙蛋白I的水平并无差异;并且重大心血管不良事件(MACE)的发生率并不受17[beta]-雌二醇治疗的影响。

结论:对于绝经后妇女而言,术后第一天肌钙蛋白I水平升高预示着重大心血管不良事件(MACE)发生的可能。监测围手术期的肌钙蛋白I水平也许可以作为预测患者不良心血管事件发生风险的一种手段。

(单嘉琪译 薛张纲校)

BACKGROUND: Adverse cardiac events that follow cardiac surgery are an important source of perioperative morbidity and mortality for women. Troponin I provides a sensitive measure of cardiac injury, but the levels after cardiac surgery may vary between sexes. Our purpose in this study was to evaluate the prognostic value of troponin I levels for predicting cardiovascular complications in postmenopausal women undergoing cardiac surgery.

METHODS: The cohort of this study were women enrolled in a previously reported clinical trial evaluating the neuroprotective potential of 17[beta]-estradiol in elderly women. In that study, 175 postmenopausal women not receiving estrogen replacement therapy and scheduled to undergo coronary artery bypass graft (with or without valve surgery) were prospectively randomized to receive 17[beta]-estradiol or placebo in a double-blind manner beginning the day before surgery and continuing for 5 days postoperatively. Serial 12-lead electrocardiograms were performed and serum troponin I concentrations were measured before surgery, after surgery on arrival in the intensive care unit, and for the first four postoperative days. The primary end-point of the present study was major adverse cardiovascular events (MACE) defined as a Q-wave myocardial infarction, low cardiac output state or death within 30 days of surgery. The diagnosis of Q-wave myocardial infarction was made independently by two physicians blinded to treatment and patient outcomes with the final diagnosis requiring consensus. Low cardiac output state was defined as cardiac index <2.0 L [middle dot] min-1 [middle dot] m-2 for >8 h regardless of treatment.

RESULTS: Troponin I levels on postoperative day 1 were predictive of MACE (area under the receiver operator curve = 0.862). A cutoff point for troponin I of >7.6 ng/mL (95% confidence interval, 6.4-10.8) provided the optimal sensitivity and specificity for identifying patients at risk for MACE. The negative predictive value of a troponin I level for identifying a patient with a composite cardiovascular outcome was high (96%) and the positive predictive value moderate (40%). Postoperative troponin I levels were not different between women receiving perioperative 17[beta]-estradiol treatment compared with placebo and the frequency of MACE was not influenced by 17[beta]-estradiol treatment.

CONCLUSIONS: In postmenopausal women, elevated troponin I levels on postoperative day 1 are predictive of MACE. Monitoring of perioperative troponin I levels might provide a means for stratifying patients at risk for adverse cardiovascular events.

 

 

血栓弹性测定法(ROTEM)检测体外循环术后肝素和鱼精蛋白的试点研究及结果

Detection of protamine and heparin after termination of cardiopulmonary bypass by thrombelastometry (ROTEM): results of a pilot study.

Mittermayr M, Velik-Salchner C, Stalzer B, Margreiter J, Klingler A, Streif W, Fries D, Innerhofer PFrom the *Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria; {dagger}Assign Data Management and Biostatistics GmbH, Innsbruck, Austria; and {ddagger}Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2009 Mar; 108(3):743-50.

 

背景:此次研究的目的为确定血栓弹性测定法(ROTEM)是否可检出鱼精蛋白对于凝血功能的影响以及其区别于肝素的不同之处。

方法:为了逆转体外循环术后肝素的效应,22名相继行主动脉或冠状动脉手术的患者被选取入组。依据临床惯例,所有入组病人按手术时所被给予的肝素总量接受其初始对应的鱼精蛋白用量。若患者激活凝固时间(ACT)延长或出现弥漫性出血的临床征兆,则可继续给予其额外剂量的鱼精蛋白(70U/kg)。同时须完成常规ACT测定、ROTEM分析(包括肝素敏感性[INTEM]测试和肝素酶包含性[HEPTEM]测试)及标准凝固试验,并测量凝血因子和抗凝因子Xa的活性。

结果:比较肝素敏感性(INTEM)测试的结果(均数[+/-标准差]):219.8(+/-19.1)秒至241.1(+/-21.7)秒(P<0.001)和肝素酶包含性(HEPTEM)测试的结果:210.2(+/-19.9)秒至226.8(+/-21.8)秒(P<0.001),两者均显示额外使用鱼精蛋白(n=16)对于延长患者凝血时间具有显著的统计学意义;而在仅给予单次鱼精蛋白剂量的患者中(n=6)这些变化并没有被发现。此外,运用INTEM测试与HEPTEM测试的比率,可成功地从58名不含残余肝素的患者中检出56例;从仅有的6名在体外循环术后抗凝因子Xa升高的患者中检出3例。

结论:初步资料显示体外循环术后额外使用鱼精蛋白可导致凝血时间在INTEM测试与HEPTEM测试中短暂延长。而在ACT延长的病例中,ROTEM分析对于检出残余肝素可能有效。

(范羽译 薛张纲校)

BACKGROUND: Our goal of this study was to determine whether protamine's effects on coagulation can be detected and differentiated from those of heparin when using thrombelastometry (ROTEM).
METHODS: To reverse the effects of heparin after cardiopulmonary bypass (CPB), 22 consecutive patients undergoing aortocoronary bypass graft surgery were included. According to clinical routine, all patients received a first dose of protamine calculated from the total amount of heparin given; additional protamine (70 U/kg) was administered to patients with activated clotting time (ACT) above baseline and clinical signs of diffuse bleeding. Simultaneously, routine ACT measurements, ROTEM assays (heparin-sensitive INTEM, and heparinase-containing HEPTEM test) and standard coagulation tests were performed, and the activity of coagulation factors as well as antifactor Xa activity measured.
RESULTS: Administration of additional protamine (n = 16) resulted in a statistically significant increase in coagulation times on the intrinsically activated test (INTEM-CT), namely from (mean [+/-SD]) 219.8 (+/-19.1) s to 241.1 (+/-21.7) s (P < 0.001), and on the heparinase-containing test (HEPTEM-CT), namely from 210.2 (+/-19.9) s to 226.8 (+/-21.8) s (P < 0.001). These changes were not observed in patients receiving a single protamine dose (n = 6). The INTEM-CT:HEPTEM-CT ratio correctly identified 56 of the 58 samples as not containing residual heparin and correctly detected residual heparin in 3 of the only 6 samples showing elevated antifactor Xa values after CPB.
CONCLUSION: Our preliminary data show that at termination of CPB administration of additional protamine results in a brief prolongation of coagulation times on the INTEM and HEPTEM test and that ROTEM might be useful in excluding residual heparin in cases showing prolonged ACT.

 

 

儿科手术室外异丙酚行镇静/麻醉治疗的不良反应及其发生率:来自儿科镇静研究协会的报道

The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium.

Joseph P. Cravero, Michael L. Beach, George T. Blike, Susan M. Gallagher, James H. Hertzog, and Pediatric Sedation Research Consortium

From the *Department of Anesthesiology and Pediatrics; {dagger}Department of Anesthesiology and Community and Family Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire; and {ddagger}Department of Anesthesiology, Division of Critical Care Medicine, Alfred I duPont Hospital for Children, Wilmington, Delaware.

Anesth Analg 2009 108: 795-804.

 

目标研究异丙酚的镇静/麻醉作用的特性及其不良事件的发生率。为此我们使用了一个由专业的儿科工作者提供的关于儿科手术室外镇静/麻醉的大样本前瞻性数据库。

病例选择和方法:数据由儿科镇静研究协会(Pediatric Sedation Research Consortium,PSRC)收集。这一国际性的协会致力于改进镇静/麻醉在儿童中的应用。协会的成员们按一定的规程前瞻性持续收集接受镇静及镇静/麻醉治疗的病例数据。主要的入选标准是在手术室外诊疗中对某些形式的镇静/麻醉的需求度,无排除标准。统计数据,主要疾病,并存疾病,治疗方法,所用药物,治疗和恢复时间,麻醉药物剂量效用关系,气道控制及恶性事件都由网络化的数据收集工具进行收集汇总。本研究中,我们评价了所有以异丙酚为主要镇静/麻醉治疗药物的情况。

结果:37个地区汇报了自2004.6.1至2007.9.1间共49836例以异丙酚行镇静/麻醉的病例。无死亡病例,需心肺复苏2例,镇静/麻醉状态下发生误吸4例。稍轻的不良事件还有O2饱和度低于90%超过30s,其发生率为154:10000。窒息或气道阻塞发生率为575:10000。喘鸣,喉痉挛,分泌物过多及呕吐的发生率分别为50,96,341和49:10000。预期外的住院治疗(所需治疗级别上升)发生率在7.1:10000。据粗略分析,肺部不良事件的发生率在麻醉科和其它科室间无显著性差异。

结论:我们报道了最大数量的儿科手术室外异丙酚镇静/麻醉的病例分析。由一些较偏好并且较有组织计划进行镇静/麻醉治疗的组织提供的数据显示使用异丙酚进行镇静/麻醉严重不良反应的发生率并不高。但是这一操作的安全性还取决于处理一些相对较轻微的不良反应的能力。希望我们的数据能为使用异丙酚进行镇静/麻醉治疗的培训教育提供一定的参考价值以促进更加安全的使用这一药物。

(黄剑译 薛张纲校)

OBJECTIVE: We used a large database of prospectively collected data on pediatric sedation/anesthesia outside the operating room provided by a wide range of pediatric specialists to delineate the nature and frequency of adverse events associated with propofol-based sedation/anesthesia care.

PATIENTS AND METHODS: Data were collected by the Pediatric Sedation Research Consortium, a collaborative group of institutions dedicated to improving sedation/anesthesia care for children internationally. Members prospectively enrolled consecutive patients receiving sedation or sedation/anesthesia for procedures. The primary inclusion criterion was the need for some form of sedation/anesthesia to perform a diagnostic or therapeutic procedure outside the operating room. There were no exclusion criteria. Data on demographics, primary illness, coexisting illness, procedure performed, medications used, procedure and recovery times, medication doses outcomes of anesthesia, airway interventions and adverse events were collected and reported using web-based data collection tool. For this study, we evaluated all instances where propofol was used as the primary drug in the sedation/anesthesia technique.

RESULTS: Thirty-seven locations submitted data on 49,836 propofol sedation/anesthesia encounters during the study period from July 1, 2004 until September 1, 2007. There were no deaths. Cardiopulmonary resuscitation was required twice. Aspiration during sedation/anesthesia occurred four times. Less serious events were more common with O(2) desaturation below 90% for more than 30 s, occurring 154 times per 10,000 sedation/anesthesia administrations. Central apnea or airway obstruction occurred 575 times per 10,000 sedation/anesthesia administrations. Stridor, laryngospasm, excessive secretions, and vomiting had frequencies of 50, 96, 341, and 49 per 10,000 encounters, respectively. Unexpected admissions (increases in levels of care required) occurred at a rate of 7.1 per 10,000 encounters. In an unadjusted analysis, the rate of pulmonary adverse events was not different for anesthesiologists versus other providers.

CONCLUSIONS: We report the largest series of pediatric propofol sedation/anesthesia for procedures outside the operating room. The data indicate that propofol sedation/anesthesia is unlikely to yield serious adverse outcomes in a collection of institutions with highly motivated and organized sedation/anesthesia services. However, the safety of this practice is dependent on a system's ability to manage less serious events. We propose that our data suggest variables for training and credentialing providers of propofol sedation/anesthesia and the system characteristics that promote safe use of this drug.

 

 

重症患儿使用持续指尖无创血压监测的可靠性

The Reliability of Continuous Noninvasive Finger Blood Pressure Measurement in Critically Ill Children

Joris Lemson, MD*, Charlotte M. Hofhuizen, MD{dagger}, Olaf Schraa, MSc{ddagger}, Jos J. Settels, MSc{ddagger}, Gert Jan Scheffer, MD, PhD{dagger}, and Johannes G. van der Hoeven, MD, PhD*

From the Departments of *Intensive Care Medicine, {dagger}Anesthesiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; and {ddagger}BMEYE BV, Amsterdam, The Netherlands.

Anesth Analg 2009 108: 814-821.

 

介绍:使用有特殊装置的充气指套(FINAP),通过指尖动脉可以对成人进行持续无创血压测定,并且它的可行性和可靠性均较高。在重症患儿,我们使用标准的儿童指套并经软件计算,对这种无创血压测定的方法与有创动脉测定(IAP)进行比较。

方法:我们的研究对象是镇静及呼吸机辅助通气的送入重症监护室的患儿。在血流动力学相对平稳期间,分别使用三种方法测定血压,从而比较FINAPIAP和无创振动测压装置的结果。我们还比较了IAP和由指尖血压换算的肱动脉血压的值。

结果:试验包括了35222kg的患儿。总共测定了152FINAP,其中4.6%没有成功。比较FINAPIAP,收缩压、舒张压、平均动脉压的偏差分别是–16.2, –7.7, and –10.2 mm Hg。置信区间(LOA)分别是26.1%, 30.1%,22.6%.。经指尖血压换算的肱动脉血压与IAP相比较,偏差分别是–11.8, 0.6–0.9 mm Hg LOA分别是21.7%, 8.9%, 8.9% 。无创的振动法血压测定与IAP相比偏差分别是–6.8, –0.9,–3.8 mm HgLOA分别是18.2%, 38.6%, 22.1%

结论:在血流动力学稳定的重症患儿,使用Beta指套测定指尖血压并换算成肱动脉血压进行的持续无创血压监测的结果是可靠的。

(李莹译 薛张纲校)

INTRODUCTION: Continuous noninvasive arterial blood pressure can be measured in finger arteries using an inflatable finger cuff (FINAP) with a special device and has proven to be feasible and reliable in adults. We studied prototype pediatric finger cuffs and pediatric software to compare this blood pressure measurement with intraarterially measured blood pressure (IAP) in critically ill children.

METHODS: We included sedated and mechanically ventilated children admitted to our pediatric intensive care unit. We performed simultaneous arterial blood pressure measurements during a relatively stable hemodynamic period and compared FINAP, IAP, and the noninvasive blood pressure oscillometric technique. We also compared IAP to a reconstruction of brachial pressure from finger pressure.

RESULTS: Thirty-five children between 2 and 22 kg body weight were included. In total, 152 attempts to record a FINAP pressure were performed of which 4.6% were unsuccessful. When comparing FINAP to IAP, bias was –16.2, –7.7, and –10.2 mm Hg for systolic arterial blood pressure, diastolic arterial blood pressure, and mean arterial blood pressure. Limits of  agreement (LOA) were respectively 26.1%, 30.1%, and 22.6%. When reconstruction of brachial pressure from finger pressure was compared to IAP, these results were –11.8, 0.6, and –0.9 mm Hg for bias and 21.7%, 8.9%, and 8.9% for LOA. When noninvasive blood pressure oscillometric technique was compared to IAP, the results were: –6.8, –0.9, and –3.8 mm Hg for bias and 18.2%, 38.6%, and 22.1% for LOA.

CONCLUSION: Beta type continuous noninvasive arterial blood pressure monitoring using a finger cuff with brachial arterial waveform reconstruction seems reliable in hemodynamically stable critically ill children.

 

 

人工控制输注和靶控输注瑞芬太尼在保留自主呼吸患者中的比较

Manual Versus Target-Controlled Infusion Remifentanil Administration in Spontaneously Breathing Patients

Annelies T. Moerman, MD*, Luc L. Herregods, MD, PhD*, Martine M. De Vos, MD, PhD{dagger}, Eric P. Mortier, MD, Dsc*, and Michel M. R. F. Struys, MD, PhD

From the Departments of *Anesthesiology and Gastro-Enterology, Ghent University Hospital; Department of Anesthesiology, Ghent University, Gent, Belgium; and Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

Anesth Analg 2009 108: 828-834

 

背景:联合输注丙泊酚及瑞芬太尼进行深度镇静时一项显著的特点就是其频繁发生的副作用,特别是呼吸抑制。这些副作用有可能是联合应用这两种药物引起,也有可能是由输注技术引起。而靶控输注(TCI)可以将输注技术最优化。我们希望在进行肠镜检查的病人中通过随机双盲对照来回答这样两个问题:第一,加用瑞芬太尼是否会增加其副作用?第二:同手控输注相比,靶控输注瑞芬太尼是否能减少副作用的发生?

方法:进行肠镜检查的病人被随机分配接受人工控制输注瑞芬太尼(MCI)(0.125µg每公斤每分钟的速度输注两分钟,然后以0.05µg每公斤每分钟的速度持续输注)、靶控输注瑞芬太尼(1 ng/mL)或安慰剂(普通生理盐水靶控输注或同样的速度手控输注)。所有的病人都接受靶控输注丙泊酚,靶浓度调整至能提供深度镇静,病人对口头指令没有反应,但是在没有帮助的情况下保持自主通气。

结果:很明显,接受安慰剂组的病人更多地出现了体动、咳嗽、和呃逆,短暂的影响了检查。三组间在血流动力学及恢复期的差异没有临床意义。通过靶控输注瑞芬太尼减少了丙泊酚的用量。同人工控制输注瑞芬太尼相比,靶控输注瑞芬太尼时通气不足及呼吸暂停的发生率下降。(TCI n = 7, MCI n = 16, P < 0.05)

结论:同单用丙泊酚相比,在保持自主呼吸的深度镇静病人中,联用瑞芬太尼和丙泊酚能为肠镜检查提供更好的条件。同人工控制输注相比,靶控输注瑞芬太尼减少了丙泊酚的用量,同时呼吸暂停和呼吸抑制的发生率更低(TCI n = 7, MCI n = 16, P < 0.05)。

(姚敏敏译 薛张纲校)

BACKGROUND: The combination of propofol-remifentanil for procedural deep sedation in spontaneously breathing patients is characterized by the frequent incidence of side effects, especially respiratory depression. These side effects may be due to either the drug combination or the drug delivery technique. Target-controlled infusion (TCI) might optimize drug delivery. In this prospective, randomized, double-blind study in patients undergoing elective colonoscopy, we thus tried to answer two questions: first, if adding remifentanil to propofol surpasses the disadvantages of the combination of these two products, and second, if administration of remifentanil via TCI decreases the incidence of side effects, compared to manually controlled administration.

METHODS: Patients undergoing elective colonoscopy were randomly assigned to receive remifentanil via manually controlled continuous infusion (MCI) (0.125 µg · kg–1 · min–1 for 2 min followed by a continuous infusion of 0.05 µg · kg–1 · min–1), TCI remifentanil (1 ng/mL), or placebo (normal saline either as TCI or manual infusion of equivalent rate). All patients received TCI propofol, adjusted to a target concentration level that provided deep sedation in which patients were not responsive to verbal commands, but maintained spontaneous ventilation without assistance.

RESULTS: Significantly more patients in the placebo group showed movement, cough and hiccup, which transiently interfered with the examination. There were no clinically significant differences in hemodynamic or recovery variables among all groups. Remifentanil administered via TCI resulted in a decrease in propofol requirements. The incidence of hypopnea and apnea was less frequent when remifentanil was administered via TCI compared to MCI (TCI n = 7, MCI n = 16, P < 0.05).

CONCLUSION: The combination of remifentanil and propofol for deep sedation in spontaneously breathing patients, offered better conditions for colonoscopy than propofol used as a single drug. Remifentanil administered via TCI resulted in a decrease in propofol dosing and in a lower incidence in apnea and respiratory depression (TCI n = 7, MCI n = 16, P < 0.05), compared to manually controlled administration of remifentanil.

 

 

丙酚和瑞芬太尼靶控输注使光纤下经鼻气管插管更便利的比较

A Comparison of Propofol and Remifentanil Target-Controlled Infusions to Facilitate Fiberoptic Nasotracheal Intubation

Alexandre Lallo, MD, FRCPC*{dagger}, Valerie Billard, MD*, and Jean-Louis Bourgain, MD*

From the *Department of Anesthesiology, Institut Gustave Roussy, Villejuif, France; and {dagger}Department of Anesthesiology, Centre Hospitalier de l’université de Montréal, Hopital Notre-Dame. Montréal, Quebec, Canada.

Anesth Analg 2009 108: 852-857

 

介绍:成功的光纤下插管要求患者的舒适和良好的插管条件。在这个研究中我们比较异丙酚(P)和瑞芬太尼(R)靶控输注(TCI)在光纤下气管插管的效果和舒适程度。

方法60名需要光纤下经鼻气管插管的患者经随机分配接受PR靶控输注。局部麻醉后,TCI一开始设置为2.5 µg/mL (P) 1.5 ng/mL (R),然后根据患者的反应增量,每次1 µg/mL (P) 0.5 ng/mL (R)。目标血药浓度和镇静水平在每一步都被记录,以及在手术以后评估总药量,调整次数,插管条件,患者不舒适和回忆。

结果:插管持续时间,成功率和药物增加的次数在两组之间并无差异。最终血药浓度在3.9 ± 1.4 µg/mL (P)2.4 ± 0.8 ng/mL (R)(各自总量142 ± 55 mg 77 ± 27 µg)之时,插管条件在两组中同样好。插管后最低的spO2和最高的呼末CO2没有差别。没有观察到喉痉挛和重大的血流动力学改变。在P组中出现了一例由于阻塞性呼吸暂停引起的缺氧。P组的患者显著的更镇静和不合作。在R组中回忆发生更频繁,而疼痛分数在两组中同样低。

结论RP靶控输注可以迅速滴定,取得良好的插管条件和患者的舒适。R使患者更合作,在保持自主呼吸非常重要时使气管插管更安全。

(俞佳译 薛张纲校)

INTRODUCTION: Successful fiberoptic intubation requires both patient comfort and good intubating conditions. In this study we compared the efficacy and ease of titration of propofol (P) and remifentanil (R) target-controlled infusions (TCI) during fiberoptic intubation.

METHODS: Sixty patients requiring fiberoptic nasotracheal intubation were randomized to receive (P) or (R) effect-site TCI. After topical anesthesia, TCI was set to 2.5 µg/mL (P) or 1.5 ng/mL (R) then titrated by 1 µg/mL (P) or 0.5 ng/mL (R) increments according to patient reactions. Targets and level of sedation were recorded at each step as well as total dose, number of adjustments, intubating conditions, discomfort, and recall assessed after surgery.

RESULTS: Intubation duration, success rate, and number of increments did not differ between groups. Intubating conditions were good  in both groups, with a final target of 3.9 ± 1.4 µg/mL (P) or 2.4 ± 0.8 ng/mL (R) (total dose 142 ± 55 mg and 77 ± 27 µg, respectively). There was no difference in minimal Spo2 and maximal end-tidal CO2 after intubation. No laryngospasm or significant hemodynamic instability was observed. There was one major hypoxemia due to obstructive apnea in group P. Patients in group P were significantly more sedated and less cooperative. Recall was more frequent in group R, whereas pain scores were equally low in both groups.

CONCLUSION: Both R and P TCI can be rapidly titrated to achieve good intubating conditions and patient comfort. R allows for more patient cooperation, making it safer when spontaneous ventilation is paramount.

 

 

探测生理监测的变化的一种新型软件工具的评估。

An Evaluation of a Novel Software Tool for Detecting Changes in Physiological Monitoring

J. Mark Ansermino, Jeremy P. Daniels, Randy T. Hewgill, Joanne Lim, Ping Yang, Chris J. Brouse, Guy A. Dumont, and John B. Bowering From the *Department of Anesthesiology, Pharmacology and Therapeutics, and {dagger}Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada.

Anesth Analg 2009 108: 873-880.

 

背景:我们已经开发了一种软件工具(iAssist)协助临床医生在麻醉过程中监测生理数据以指导其医疗行为。这个系统有跟踪多种动态生理过程的统计性能和识别新的动态趋势的能力。我们报道我们对这个工具的最新探索(在非第一时间)并将其对动态变化的探测结果与事后对动态变化的总体回顾进行了比较。我们假设了一个评价的综合体,这个综合体评价了旨在增强动态探测功能的监测设备。

方法:19名儿童和38名成人进入试验,接受超过68小时的麻醉。在每个手术病例中,麻醉师在第一时间报告所有的监视器中已知的临床变化。一个训练有素的观察者同时记录口头报告的变化和每个麻醉师的医疗行为。同一个病例随后由新型软件工具(iAssist)离线评价。心率、呼末二氧化碳,潮气量和呼吸频率被用一个动态线性增长模型来模仿,这个模型的噪音分布由一个适应性的卡尔曼滤波通过一个递归的期望最大化方法来估计。变化由自适应累积求和试验来探测。无创平均动脉血压和氧饱和度的变化通过一个从指数级重量移动平均滤波分离出来的滤波的自适应累积求和试验来探测。在事后分析中,每个由iAssist探测到的变化被两名临床医生用一个完整病例图表的方式来独立分级。遗漏的变化被记录下来。

结果iAssist软件工具探测到896例真阳性变化(平均12.76/小时),敏感度0.91,阳性预测值0.87.事后回顾鉴定出91个遗漏的变化(平均1.34/小时),真阳性率与假阴性率的总比例为9.55。临床医生第一时间报导了209个变化趋势(平均3.07/小时)。

结论:该算法与视觉观测整个趋势相比较执行起来更有优势。需要进一步的研究,以确定何时以及如何提请临床医师注意这些变化。

(张玥琪译,薛张纲校)

BACKGROUND: We have developed a software tool (iAssist) to assist clinicians as they monitor the physiological data that guide their actions during anesthesia. The system tracks the statistical properties of multiple dynamic physiological processes and identifies new trend patterns. We report our initial evaluation of this tool (in pseudo real-time) and compare the detection of trend changes to a post hoc visual review of the full trend. We suggest a combination of criteria by which to evaluate the performance of monitoring devices that aim to enhance trend detection.

METHODS: Nineteen children and 28 adults consented to be included in the study, encompassing more than 68 h of anesthesia. In each surgical case, an anesthesiologist reported all perceived clinical changes in monitoring in real-time. A trained observer simultaneously documented the verbally reported changes and every anesthesiologist action. The same cases were subsequently evaluated offline (in pseudo real-time) by a novel software tool (iAssist). Heart rate, end-tidal carbon dioxide, exhaled minute ventilation, and respiratory rate were modeled using a dynamic linear growth model whose noise distribution was estimated by an adaptive Kalman filter based on a recursive expectation-maximization method. Changes were detected by adaptive local Cumulative Sum testing. Changes in the mean arterial noninvasive blood pressures and oxygen saturation were detected using adaptive Cumulative Sum testing on a filtered residual from an exponentially weighted moving averaging filter. In post hoc analysis, each change detected by iAssist was graded independently by two clinicians using a graphical display of the whole case. Missed changes were recorded.

RESULTS: The iAssist software tool detected 869 true positive changes (at an average of 12.76/h) with a sensitivity of 0.91 and positive predictive value of 0.87. The post hoc review identified 91 missed changes (at an average of 1.34/h), resulting in an overall ratio of true positive rates to false-negative rates of 9.55. The clinicians in real-time reported 209 changes in trend (at an average of 3.07/h).

CONCLUSION: The algorithms perform favorably compared with a visual inspection of the complete trend. Further research is needed to identify when and how to draw the clinician's attention to these changes.

                                                      

 

机械通气脱机期功能残气量的变化:一项前瞻性研究

Changes in functional residual capacity during weaning from mechanical ventilation: a pilot study.

Heinze H, Sedemund-Adib B, Heringlake M, Meier T, Eichler W

.From the *Department of Anesthesiology, Pharmacology and Therapeutics, and {dagger}Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada.

Anesth Analg 2009 108: 911-915.

 

背景:降低压力支持(PSV)下呼气末正压(PEEP)水平的通气模式常在气管插管危重病人拔管前使用,但是PSV对于功能残气量(FRC)的有何影响尚不清楚。在这项研究中,我们试图探寻心脏手术病人术后脱机期FRC和肺功能的变化。

方法:LUFU系统(Dräger Medical, Lübeck, Germany)通过使用旁流氧气分析仪分析混有氮气的呼出气体中的氧气来估计FRC。心脏手术病人术后首先使用双相正压通气(BiPAP),并附加10 mbar的PEEP。适当调整供气压力上限使潮气量达到of 6-8 mL/kg (BIPAP 10)。30分钟后,上压和下压限值均降低3 mbar (BIPAP 7)。当可测得患者自主呼吸时,将机械通气模式转换为PSV下的持续气道正压通气 (CPAP) 模式,并且使用之前与BIPAP相符合的压力支持及压力下限作为CPAP的压力水平。30分钟后重复测量(CPAP 7_2)

结果10名患者入组研究,FRC减少(BIPAP 10: 3.6 [1.0] L; BIPAP 7: 3.1 [0.9] L; CPAP 7_1: 2.9 [0.9] L; CPAP 7_2: 2.7 [0.6] L [Mean (SD)]; 方差多变量分析: P = 0.017), PF (BIPAP 10: 420 [114] mm Hg; BIPAP 7: 405 [110] mm Hg; CPAP 7_1: 353 [70] mm Hg; CPAP 7_2: 340 [70] mm Hg [Mean (SD)]; 方差多变量分析: P = 0.045)。全程PaCO(2)无显著性变化(P = 0.221)

结论在心脏手术脱管期间FRC的下降最终可以(部分) 用肺泡不张的原因来解释。这种变化能否对脱管期间有指导意义仍然需要进一步研究。

(张钊译 薛张纲校)

BACKGROUND: Reduction of high positive end-expiratory pressure levels and pressure support ventilation (PSV) are frequently used before tracheal extubation in critically ill patients, but the impact of PSV on functional residual capacity (FRC) is unknown. In this study, we sought to detect the changes of FRC and pulmonary function during a weaning protocol in patients ventilated after cardiac surgery.

METHODS: The LUFU system (Dräger Medical, Lübeck, Germany) estimates FRC by oxygen washout, a variant of multiple breath nitrogen washout, using a sidestream O(2) analyzer. Postoperative cardiac surgery patients were initially ventilated using biphasic positive airway pressure ventilation (BiPAP) with a positive end-expiratory pressure of 10 mbar. The upper pressure limit was adjusted to deliver a tidal volume of 6-8 mL/kg (BIPAP 10). After 30 min, the upper and lower pressure limits were both reduced by 3 mbar (BIPAP 7). When spontaneous breathing efforts were detected, ventilation mode was switched to continuous positive airway pressure (CPAP) with PSV using the former lower pressure limit as the CPAP level and the corresponding pressure support of the former BIPAP adjustment (CPAP 7_1). Measurements were repeated after 30 min (CPAP 7_2).

RESULTS: Ten patients were studied. FRC decreased (BIPAP 10: 3.6 [1.0] L; BIPAP 7: 3.1 [0.9] L; CPAP 7_1: 2.9 [0.9] L; CPAP 7_2: 2.7 [0.6] L [Mean (SD)]; MANOVA: P = 0.017), as did PF ratio (BIPAP 10: 420 [114] mm Hg; BIPAP 7: 405 [110] mm Hg; CPAP 7_1: 353 [70] mm Hg; CPAP 7_2: 340 [70] mm Hg [Mean (SD)]; MANOVA: P = 0.045). PaCO(2) did not change significantly over time (P = 0.221).

CONCLUSION: Decreasing FRC during the weaning process after cardiac surgery may, at least in part, be explained by alveolar derecruitment. Whether this variable could help guide a weaning protocol has to be studied further.

 

 

住院医师专业化培训:失败的原因与改进措施

The Teaching of Professionalism During Residency: Why It Is Failing and a Suggestion to Improve Its Success (Review Article)
Robert R. Gaiser

From the Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Anesth Analg 2009 108: 948-954.

 

专业化是住院医师期间需要学习和被考核的主要内容之一。有综述性文献指出,专业化培训并未得到完全地理解和实施。专业化培训已经纳入住院医师教育计划。但是,住院医师有两种学习途径:明确安排的课程和潜移默化地学习。后者指住院医师通过观察院内同事所学到的行为。这种潜移默化地学习对住院医师专业行为影响很大。针对这种情况,一项可以改进专业化培训的措施不仅要包括主题学习,还应该给予个人思考各自知识和行为的时间。这种自我反思有利于对专业的真正理解和实践的发展,并可能提高专业能力。

(朱兰芳译 薛张纲)

Professionalism is one of the core competencies to be taught and evaluated during residency. A review of the literature suggests that professionalism is not completely understood or practiced. The teaching of professionalism has been incorporated into the educational programs for residents. However, residents learn from two curriculums: the stated curriculum and a hidden curriculum. The hidden curriculum represents the actions observed by the resident of the faculty in the hospital. The impact of this hidden curriculum upon professional behavior by the resident is significant. Due to the hidden curriculum, a possible means of improving professionalism involves the development of a program for faculty. This program must include not only topics but time for personal reflection of one’s knowledge and actions. Self-reflection allows for the development of a true understanding and practice of professionalism and may improve professional behavior.

                                                          

 

心脏循环停止后的脑复苏

Cerebral Resuscitation After Cardiocirculatory Arrest

Andreas Schneider, MD*, Bernd W. Böttiger, MD*, and Erik Popp, MD{dagger}

From the *Department of Anesthesiology and Postoperative Intensive Care Medicine, University of Cologne, Germany; and {dagger}Department of Anesthesiology, University of Heidelberg, Germany.

Anesth Analg 2009 108: 971-979.

 

对于心脏骤停的病人,经心肺复苏可以恢复50%的自主循环。然而大多数病人在复苏后最终仍然死亡了。死亡原因主要是由于全脑的缺血。因此有必要在心跳停止后进行一些针对保护和保存脑功能的治疗。几年前,低温治疗被用于临床。在一项随机临床试验中,上述方法是可以改善心跳停止病人的生存率及神经系统结局。除了低温治疗,临床或试验中还有其他一些治疗方法。这些方法包括血栓溶解治疗,输注特殊药物,抗细胞凋亡药物。在这篇文献中,我们回顾了不同方法的病理生理背景及对大脑复苏的疗效。

(陈珺珺译 薛张纲校)

Cardiopulmonary resuscitation can restore spontaneous circulation in up to 50% of patients suffering from cardiac arrest. However, most of these patients still die during the postresuscitation period. Mortality is largely due to neuronal injury after global cerebral ischemia. There is, therefore, a clear need for therapies, which restore and protect brain function after cardiac arrest. Several years ago, mild therapeutic hypothermia was introduced into clinical practice. It represents the first treatment to improve both survival and neurological outcome of patients after out-of-hospital cardiac arrest, according to randomized clinical trials. In addition to therapeutic hypothermia, various other therapeutic options are currently being investigated experimentally and/or clinically. These include thrombolytic therapy, specific infusion regimens, or antiapoptotic drugs. In this article, we review both the pathophysiological background and the efficacy  of different measures that might be useful for cerebral resuscitation.


局麻药对人类神经细胞的细胞毒性作用

Cytotoxicity of Local Anesthetics in Human Neuronal Cells

Rosalia Perez-Castro, MS*, Sohin Patel, MD*, Zayra V. Garavito-Aguilar, BS*, Andrew Rosenberg, MD{dagger}, Esperanza Recio-Pinto, PhD*, Jin Zhang, MD*, Thomas J. J. Blanck, MD, PhD*, and Fang Xu, PhD*

From the *Department of Anesthesiology, New York University School of Medicine; and {dagger}Department of Anesthesiology, NYU Hospital for Joint Diseases, New York, New York.

Anesth Analg 2009 108: 997-1007.

 

背景:除了抑制外周神经的兴奋传导,局麻药对中枢神经系统、心血管系统、神经肌接头和细胞代谢有毒性作用。术后不同的神经系统的并发症与局麻药的细胞毒性有关,但根本机制尚不清楚。由于临床上应用局麻药的浓度远高于抑制离子通道的EC50,因此离子通道被阻滞不能解释局麻药所致的细胞死亡,应该有其他作用参与了细胞死亡。在我们的研究中,我们比较了6种我们常用的局麻药的细胞毒性作用,从而讨论其根本的毒性机制。

方法:人SH-SY5Y神经瘤细胞暴露于六种局麻药(布比卡因、罗派卡因、甲派卡因、利多卡因、普鲁卡因和氯普鲁卡因),通过MTT-(3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetra-odium bromide) 比色法测定生存的数量,通过荧光成像的方法,测定LIVE/DEAD®反应物(calcein/AM and ethidium homodimer-1)评估质量。 此外,通过FLICATM测定与细胞凋亡相关的caspase-3/-7的激活。此外,还评估了局麻药介导的去极化和氯化氨甲酰胆碱激动引起的胞内Ca2+的反应。

结果1)治疗十分钟后,所有六种局麻药均可以浓度依赖性的降低细胞的存活率。它们的致死的能力为普鲁卡因甲派卡因<利多卡因<氯普鲁卡因<罗派卡因<布比卡因(LD50,指50%的细胞死亡的浓度)。在这六种局麻药中,只有布比卡因和利多卡因在增加浓度的情况下可以杀灭所有的细胞。2)布比卡因和利多卡因都可以激活caspase-3/-7Caspase的激动依赖于高浓度的利多卡因和布比卡因。此外,布比卡因激活caspase的速率低于利多卡因。高浓度的利多卡因可以立刻激活caspase,但是在浓度低于10mM时,不能显著激动caspase3)普鲁卡因和氯普鲁卡因可以浓度依赖性地抑制由去极化和受体激动介导的胞浆Ca2+的反应,这一现象在先前的有关布比卡因、罗派卡因、甲派卡因的利多卡因的研究中也观察到。没有一种局麻药可以显著增加基础或Ca2+诱导胞浆Ca2+水平。

结论:局麻药可以造成细胞的快速死亡,主要的原因是坏死。利多卡因和布比卡因可以时间或浓度依赖性的触发细胞凋亡。这可能与术后神经系统损伤有关。利多卡因可以导致短暂的神经系统症状,但并不是毒性最大的局麻药;而布比卡因很少导致暂时的神经系统症状却是毒性最大的局麻药。这提示了不同的局麻药的细胞毒性导致的神经系统损伤有多种机制参与。

(陈珺珺译 薛张纲校)

BACKGROUND: In addition to inhibiting the excitation conduction process in peripheral nerves, local anesthetics (LAs) cause toxic effects on the central nervous system, cardiovascular system, neuromuscular junction, and cell metabolism. Different postoperative neurological complications are ascribed to the cytotoxicity of LAs, but the underlying mechanisms remain unclear. Because the clinical concentrations of LAs far exceed their EC50 for inhibiting ion channel activity, ion channel block alone might not be sufficient to explain LA-induced cell death. However, it may contribute to cell death in combination with other actions. In this study, we compared the cytotoxicity of six frequently used LAs and will discuss the possible mechanism(s) underlying their toxicity.

METHODS: In human SH-SY5Y neuroblastoma cells, viability upon exposure to six LAs (bupivacaine, ropivacaine, mepivacaine, lidocaine, procaine, and chloroprocaine) was quantitatively determined by the MTT-(3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetra-odium bromide) colorimetry assay and qualitatively confirmed by fluorescence imaging, using the LIVE/DEAD® assay reagents (calcein/AM and ethidium homodimer-1). In addition, apoptotic activity was assessed by measuring the activation of caspase-3/-7 by imaging using a fluorescent caspase inhibitor (FLICATM). Furthermore, LA effects on depolarization- and carbachol-stimulated intracellular Ca2+-responses were also evaluated.

RESULTS: 1) After a 10-min treatment, all six LAs decreased cell viability in a concentration-dependent fashion. Their killing potency was procaine ≤mepivacaine < lidocaine < chloroprocaine < ropivacaine < bupivacaine (based on LD50, the concentration at which 50% of cells were dead). Among these six LAs, only bupivacaine and lidocaine killed all cells with increasing concentration. 2) Both bupivacaine and lidocaine activated caspase-3/-7. Caspase activation required higher levels of lidocaine than bupivacaine. Moreover, the caspase activation by bupivacaine was slower than by lidocaine. Lidocaine at high concentrations caused an immediate caspase activation, but did not cause significant caspase activation at concentrations lower than 10 mM. 3) Procaine and chloroprocaine concentration-dependently inhibited the cytosolic Ca2+-response evoked by depolarization or receptor-activation in a similar manner as a previous observation made with bupivacaine, ropivacaine, mepivacaine, and lidocaine. None of the LAs caused a significant increase in the basal and Ca2+-evoked cytosolic Ca2+-level.

CONCLUSION: LAs can cause rapid cell death, which is primarily due to necrosis. Lidocaine and bupivacaine can trigger apoptosis with either increased time of exposure or increased concentration. These effects might be related to postoperative neurologic injury. Lidocaine, linked to the highest incidence of transient neurological symptoms, was not the most toxic LA, whereas bupivacaine, a drug causing a very low incidence of transient neurological symptoms, was the most toxic LA in our cell model. This suggests that cytotoxicity-induced nerve injury might have different mechanisms for different LAs and different target(s) other than neurons.

 

 

苄哌酚醇导致的抗伤害感觉和降低慢性后根神经节压缩小鼠的脊髓背角NR2B亚单位的表达

Ifenprodil Induced Antinociception and Decreased the Expression of NR2B Subunits in the Dorsal Horn After Chronic Dorsal Root Ganglia Compression in Rats

Wei Zhang, MD, Chang-Xi Shi, MD, Xiao-ping Gu, MD, PhD, Zheng-Liang Ma, MD, PhD, and Wei Zhu, MD

From the Department of Anesthesiology, Drum Tower Hospital, Medical Department of Nanjing University, Jiangsu Province, China.

Anesth Analg 2009 108: 1015-1020.

 

背景:脊髓N-右旋甲基-天冬氨酸在神经性疼痛的发病机制中起了重要的作用,给予N-右旋甲基-天冬氨酸受体拮抗剂可以减弱这种痛觉过敏。苄哌酚醇是N-右旋甲基-天冬氨酸受体2B(NR2B)的选择性拮抗剂。有一些研究证明,在动物实验中,苄哌酚醇对神经性疼痛有镇痛作用。我们将这方面的研究延伸至后根神经节慢性压缩(CCD)引起的反应。

方法:我们通过测试小鼠手掌对机械刺激和温度刺激反应阈值变化,来评估CCD小鼠在鞘内注射苄哌酚醇后对机械刺激和温度痛觉过敏的情况。我们使用了免疫组化和免疫印迹的方法来研究苄哌酚醇对CCD小鼠NR2B亚单位表达的影响。

结果:这些数据揭示了,在CCD小鼠上,脊髓背角表面NR2B的表达有所增加。我们发现,除了抑制对温度和机械刺激的痛觉反应,鞘内注射苄哌酚醇还可以抑制脊髓NR2B的表达。

结论:这些数据表明,在CCD小鼠身上,苄哌酚醇可以对抗伤害性感觉,并进一步证明NR2B与神经性疼痛有关。

(陈珺珺译 薛张纲校)

BACKGROUND: Spinal N-methyl d-aspartate receptors play an important role in the pathogenesis of neuropathic pain, and administration of N-methyl d-aspartate receptor antagonists can attenuate this hyperpathia. Ifenprodil is an antagonist selective for N-methyl d-aspartate receptor 2B (NR2B) subunits. Several researches have reported effective analgesia of ifenprodil in animal models of neuropathic pain. We extended this work to include chronic compression of the dorsal root ganglia (CCD).

METHODS: The paw withdrawal mechanical threshold and paw withdrawal thermal latency tests were used to assess mechanical allodynia  and thermal hyperalgesia after a CCD operation and intrathecal injection of ifenprodil. We used immunohistochemistry and immunoblotting to investigate the effect of ifenprodil on NR2B subunits expression in CCD rats.

RESULTS: The data revealed increased expression of NR2B subunits in the superficial dorsal horn in CCD rats. We found that, in addition to a marked suppression of thermal hyperalgesia and mechanical allodynia, intrathecal injection ifenprodil treatment causes a decreased expression of NR2B in the spinal cord.

CONCLUSIONS: These data suggest that ifenprodil induced anti nociception in CCD rats and provided further evidence for the important role of NR2B subunits in the development of neuropathic pain.

 

 

超声引导下的闭孔神经阻滞:一种新的关于超声方法的研究

Ultrasound-Guided Obturator Nerve Block: A Sonoanatomic Study of a New Methodologic Approach

Taylan Akkaya, MD*, Emine Ozturk, MD{dagger}, Ayhan Comert, MD{ddagger}, Yesim Ates, MD§, Haluk Gumus, MD*, Halil Ozturk, MD{dagger}, Ibrahim Tekdemir, MD{ddagger}, and Alaittin Elhan, MD{ddagger}

From the Departments of *Anesthesia and Pain Unit, {dagger}Radiology, Ministry of Health Diskapi Yildirim Beyazit Research and Educational Hospital, Ankara-Turkey; Departments of {ddagger}Anatomy, and §Anesthesiology and Reanimation, Ankara University, Ankara-Turkey.

Anesth Analg 2009 108: 1037-1041.

 

背景:闭孔神经阻滞是对技术有最高挑战性的区域阻滞中的一种。最近,通过超声手段描述了神经的特性。然而,临床上尚没有应用超声引导下对病人进行闭孔神经阻滞的报道。在我们的研究中,我们使用了超声手段,分别对尸体、志愿者及病人的闭孔神经及其两分支的解剖位置进行描述。

方法:通过超声对尸体进行研究,高回声三角区由耻骨支上缘,耻骨肌内侧缘和闭孔肌的外侧缘组成,其中包括闭孔血管和神经。在八名志愿者中,我们获得了两根闭孔神经的影像学及其到特定标志的距离(股动脉、股静脉和耻骨结节)。通过先前确定的进路,在超声引导下对15名病人进行了闭孔神经阻滞。我们记录了针尖到股动脉的距离,穿刺点到耻骨结节的距离和进针深度。

结果:在志愿者上,通过超声可见闭孔神经主干、前后分支的的比例分别是12/16,13/16和7/16。在志愿者身上获得的特定标志间的距离分别是:闭孔神经-股静脉为12.9 ± 2.9 mm ,闭孔神经-耻骨结节为19.9 ± 2.6 mm。在病人身上获得的测量数据为:股动脉-针尖距离为 18.5 ± 2.4 mm,进针深度为 48.3 ± 10.4 mm,耻骨结节- 穿刺点的水平距离为 18.8 ± 2.0 mm,耻骨结节-穿刺点的垂直距离为 21.1 ± 2.9 mm。与基础值相比,在病人处得到的直观类比标度计分较低。93%的病人(15人中14人)对阻滞的效果表示满意。

结论:在超声引导下,可以通过标志对病人进行闭孔神经阻滞。

(陈珺珺译 薛张纲校)

BACKGROUND: Obturator nerve block is one of the most technically challenging regional anesthesia techniques. Recently, the characteristics of the nerve have been described using ultrasound. However, clinical application of proximal ultrasound-guided obturator nerve block on patients has not been reported. In this study, we used ultrasound to describe the anatomical localization of the obturator nerve and its two branches in cadavers, volunteers, and also patients.

METHODS: A hyperechoic triangular shape formed by the superior  pubic ramus, posterior margin of the pectineus muscle and anterior aspect of the external obturator muscle containing the obturator vessels and nerve was defined by ultrasound imaging in cadavers. In eight volunteers, bilateral obturator nerve images were obtained and the distances to specific landmarks (femoral artery, femoral vein, and pubic tubercle) were recorded. Ultrasound-guided obturator nerve block was further performed in 15 patients by using the previously defined approach. The final distance of the needle tip to the femoral artery, distances between the needle insertion point to the pubic tubercle and the depth of needle insertion were recorded.

RESULTS: The rates of common obturator nerve, anterior and branching obturator nerve pattern visibility with ultrasound were determined in 12/16, 13/16, and 7/16 sites in volunteers, respectively. Mean (sd) values of critical landmarks obtained from volunteers were obturator nerve-femoral vein 12.9 ± 2.9 mm and obturator nerve-pubic tubercle 19.9 ± 2.6 mm. Mean measurements obtained from patients were: femoral artery- needle tip 18.5 ± 2.4 mm, needle depth 48.3 ± 10.4 mm, pubic tubercle- needle insertion point (horizontal) 18.8 ± 2.0 mm, and pubic tubercle- needle insertion point (vertical) 21.1 ± 2.9 mm. Visual analog scale scores obtained from patients at 1 and 24 h were lower compared to baseline values (P < 0.001). Ninety-three percent (14 of 15) of the patients reported satisfaction from the block.

CONCLUSIONS: Landmarks defined in this clinical trial can be used in patients for obturator nerve block with ultrasound guidance.

 

快通道麻醉与心脏手术:7989例患者的回顾性队列研究

Fast-Track Anesthesia and Cardiac Surgery: A Retrospective Cohort Study of 7989 Patients

Vesna Svircevic, MD*, Arno P. Nierich, MD, PhD{dagger}, Karel G. M. Moons, PhD*{ddagger}, George J. Brandon Bravo Bruinsma, MD, PhD§, Cor J. Kalkman, MD, PhD*, and Diederik van Dijk, MD, PhD*||

From the *Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands; {dagger}Department of Anesthesiology, Isala Clinics, Groot Weezenland 20, Zwolle, The Netherlands; {ddagger}Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; §Department of Cardiothoracic Surgery, Isala Clinics, Groot Weezenland 20, Zwolle, The Netherlands; and ||Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands.

Anesth Analg 2009 108: 727-733.

 

背景:快通道心脏麻醉(FTCA)已被广泛地应用于临床,但它的安全性还没有得到强有力的研究支持。

方法:作者比较了FTCA患者及既往常规大剂量阿片类药物心脏麻醉(CCA)的患者的预后。主要预后指标为住院期间死亡率。次要预后指标为住院期间急性心肌梗死、肾衰及中风的发生率。同时比较机械通气的持续时间,ICU住院天数以及术后住院天数。

结果 CCA4020例,FTCA3969例。FTCA组病人年龄略大,较多并存疾病及较多的换瓣手术。住院期间死亡率CCA组为1.9%FTCA2.3%FTCACCA组与死亡率比值为1.2095%区间,0.65-1.32P=0.66),调整后比值为0.92。住院期间心肌梗死率CCA5.2%FTCA5.5%P=0.61,中风发生率CCA0.9%,FTCA1.3%(P=0.06),肾衰发生率组间相当(0.8%P=0.84)。FTCA组机械通气时间短于CCA组(6vs12hP ≤0.001),但ICU入驻时间平均值要比CCA组长1小时(23vs22hP ≤0.001)。虽然两组的住院时间平均值都是6 天,但CCA组第90百分位病人的住院天数为13 天,FTCA组为18 天(P ≤0.001)。

结论: 源自7989例心脏手术病人的数据显示没有证据表明应用FTCA增加不良后果的风险。

(郑丽 译 陈杰 校)

BACKGROUND: Fast-track cardiac anesthesia (FTCA) has been widely implemented but its safety has not been evaluated in sufficiently powered studies.

METHODS: We compared outcomes of patients undergoing FTCA with a historical control group undergoing conventional high-dose opioid cardiac anesthesia (CCA). The primary outcome measure was the incidence of in-hospital mortality. Secondary outcome measures were the incidence of in-hospital acute myocardial infarction, renal failure, and stroke. We also compared duration of mechanical ventilation and length of hospitalization in the intensive care unit and postoperative ward.

RESULTS: The CCA group comprised 4020 patients and the FTCA Group 3969 patients. The patients in the FTCA group were slightly older, had more comorbidities, and were more likely to undergo valve surgery than the CCA group. The incidence of in-hospital mortality was 1.9% in the CCA group and 2.3% in the FTCA group. Compared with the CCA group, the crude odds ratio for mortality in the FTCA group was 1.20 (95% confidence interval 0.88–1.64, P = 0.25) and the adjusted odds ratio was 0.92 (95% confidence interval, 0.65–1.32, P = 0.66). The incidence of myocardial infarction and stroke in the CCA and FTCA groups were 5.2% and 5.5% (P = 0.61), and 0.9% and 1.3%, (P = 0.06), respectively, whereas the incidence of acute renal failure was similar in both groups (0.8%, P = 0.84). The duration of mechanical ventilation was shorter in the FTCA patients compared with the CCA group (6 vs 12 h, P ≤0.001), but their median intensive care stay was 1 h longer (23 vs 22 h, P ≤0.001). Although the median duration of hospitalization was 6.0 days in both groups, the 90th percentile of the hospitalization time was 13 days in the CCA group and 18 days in the FTCA group (P ≤0.001).

CONCLUSIONS: These data from 7989 cardiac surgical patients showed no evidence of an increased risk of adverse outcomes in patients undergoing FTCA.


血小板减少的情况下纤维蛋白原的水平对弹性血栓变量的影响

The Effects of Fibrinogen Levels on Thromboelastometric Variables in the Presence of Thrombocytopenia

Thomas Lang, MD*{dagger}, Kai Johanning, MD*, Helfried Metzler, MD{ddagger}, Siegfried Piepenbrock, MD*, Cristina Solomon, MD*, Niels Rahe-Meyer, MD, PhD*, and Kenichi A. Tanaka, MD, MSc§

From the *Department of Anesthesiology, Medical School, Hannover, Germany; {dagger}Werlhof Institut, Hannover, Germany, {ddagger}Department of Anesthesiology, University Medical School, Graz, Austria; and §Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA.

Anesth Analg 2009 108: 751-758.

 

背景:纤维蛋白原和纤维蛋白与血小板结合在正常的止血过程中非常重要。ROTEM法常用于测量血凝块粘弹性强度以衡量血小板纤维蛋白结合的程度。在这个研究中,作者用ROTEM法研究纤维蛋白原浓度及其在总血块强度中的作用。

方法:采集健康志愿者血液标本。血小板计数对血凝块强度〔通过测量血凝块最大弹性(MCE)〕的影响通过ROTEM评估。富含血小板血浆(PRP)用自体血浆调节到一般水平血小板计数再测量。PRPs被调整为10 x 103 mm–3 50 x 103 mm–3100 x 103 mm–3,纤维蛋白原浓度集中在550780mg/dl。用FIBTEM法在不依赖血小板附着作用下分析纤维蛋白对血块的聚合作用。另外回顾性分析两组中血小板减少患者血块强度(MCE)。

结果:血块强度在血小板计数低于100 x 103 mm–3时减少,计数多于400 x 103 mm–3时血块强度增强。即使在低血小板计数(10 x 103 mm–3)时,增加纤维蛋白原浓度呈浓度依赖性增加血凝块强度。在904例血小板减少患者分析获得的数据证实了血凝块强度和血浆纤维蛋白原水平呈正相关。

结论ROTEM法分析体外及临床数据表明:纤维蛋白原浓度是独立于血小板计数之外的血栓强度影响因素。在血小板减少症的患者中维护纤维蛋白原浓度是至关重要。EXTEMFIBTEM在指导纤维蛋白原补充治疗中有重要意义。

(刘世文 译 陈杰 校)

BACKGROUND: The binding of fibrinogen and fibrin to platelets is important in normal hemostasis. The extent of platelet-fibrin interaction can be measured as the viscoelastic strength of clot by rotational thromboelastometry (ROTEM®). In this study, we investigated the effect of fibrinogen concentration and its relative contribution to overall clot strength using ROTEM.

METHODS: Blood samples were collected from healthy volunteers. The effects of platelet count on clot strength, determined by maximum clot elasticity (MCE), were evaluated on ROTEM using platelet-rich plasma (PRP) adjusted with autologous plasma to generate a range of platelet counts. PRPs were adjusted to 10 x 103 mm–3, 50 x 103 mm–3, and 100 x 103 mm–3 and spiked with fibrinogen concentrates at 550 and 780 mg/dL. The effect of fibrin polymerization on clot strength, independent of platelet attachment, was analyzed by the cytochalasin D-modified thromboelastometry (FIBTEM®) method. Additional retrospective analysis of clot strength (MCE) in two groups of thrombocytopenic patients was conducted.

RESULTS: Clot strength (MCE) decreased at a platelet count below 100 x 103 mm–3, whereas increases in MCE peaked and reached a plateau at platelet counts from 400 x 103 mm–3. Increasing fibrinogen concentrations in PRP increased clot strength in a concentration-dependent manner, even at low platelet counts (10 x 103 mm–3). The positive correlation between clot strength and plasma fibrinogen level was also confirmed in the analysis of the data obtained from 904 thrombocytopenic patients.

CONCLUSIONS: These in vitro and clinical data indicate that the clot strength increases in a fibrinogen concentration-dependent manner independent of platelet count, when analyzed by ROTEM. The maintenance of fibrinogen concentration is critical in the presence of thrombocytopenia. EXTEM® (extrinsic activation) and FIBTEM may be useful in guiding fibrinogen repletion therapy.


输血相关急性肺损伤:对临床医师的进展

Transfusion-Related Acute Lung Injury: Current Concepts for the Clinician

Darrell J. Triulzi, MD

From the Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh Medical Center, Institute for Transfusion Medicine, Pittsburgh, Pennsylvania.

Anesth Analg 2009 108: 770-776.

 

在美国输血相关的发病率和死亡率的首要原因是输血相关的急性肺损伤(TRALI)TRALI诊断标准为:在可以排除心衰或血管容量负荷过重的情况下,输血6小时内的发生的缺氧和双肺水肿。主要的鉴别诊断是输血相关循环超负荷。支持治疗的方法包括给氧和机械通气。利尿并无特效,激素的作用也未证实。患者通常数天内痊愈。所有类型的血液制品都曾与急性肺损伤相关。但是,富含血浆成分的制品,如新鲜冰冻血浆和血浆分离置换法血小板,最常发生。目前尚不能完全解释急性肺损伤的发病机制。多数情况下与针对人类白细胞抗原( HLA I/人类白细胞抗原II类或中性粒细胞特异性抗原[尤其是HNA- 3A]的抗体, 和供血者血浆里的白细胞抗体有关。肺血管内皮细胞的活化是导致急性肺损伤的重要因素,可能解释了手术或重症监护病房里观察到的患者的大多数情况。输血中的白细胞凝集抗体结合肺血管内皮细胞局部的中性粒细胞,导致激活和释放氧化酶和其他有害生物活性物质,造成毛细血管渗漏。在少数急性肺损伤中下,不能证实存在抗体,则假定输注的血液成分里的中性粒细胞促发因素可以调节急性肺损伤患者肺血管内皮活化,所谓的两次打击的机制。对抗白细胞抗体作用的进一步认识,以减少了引起急性肺损伤风险。曾经怀孕过一次的女性血液中常常带有HLA抗体,总患病率为24 %,其发生概率随曾经怀孕的次数而递增。自从认识到HLA抗体同急性肺损伤有关,中心血站已采取策略是主要从男性的捐助者获取血浆成分。为了降低机采血小板相应的风险,采取事先检测女性血小板捐助者的HLA抗体。需要更进一步的研究来了解导致急性肺损伤相关血液成分和患者的危险因素,推广新的治疗方案和措施,以减少发生急性肺损伤的风险。

(叶乐 译 陈杰 校)

The leading cause of transfusion-related morbidity and mortality in the United States is transfusion-related acute lung injury (TRALI). Diagnostic criteria for TRALI have recently been developed and primarily consist of hypoxia and bilateral pulmonary edema occurring during or within 6 h of a transfusion in the absence of cardiac failure or intravascular volume overload. The primary differential diagnosis is transfusion-associated circulatory overload and differentiation can be difficult. Treatment is supportive with oxygen and mechanical ventilation. Diuresis is not indicated and the role of steroids is unproven. Patients typically recover within a few days. All types of blood products have been associated with TRALI, however, the plasma-rich components, such as fresh frozen plasma and apheresis platelets, have been most frequently implicated. The pathogenesis of TRALI is not completely understood. Leukocyte antibodies in donor plasma have been implicated in most cases with antibodies directed at human leukocyte antigen (HLA) class I, HLA class II or neutrophil-specific antigens, particularly HNA-3a. Activation of pulmonary endothelium is important in the development of TRALI and may account for most cases being observed in surgical or intensive care unit patients. Transfused leukoagglutinating antibodies bind to recipients’ neutrophils localized to pulmonary endothelium resulting in activation and release of oxidases and other damaging biologic response modifiers that cause capillary leak. In a minority of TRALI cases, no antibodies are identified and it is postulated that neutrophil priming factors in the transfused component can mediate TRALI in a patient with pulmonary endothelial activation, the so called "two hit" mechanism. Recognition of the role of anti-leukocyte antibodies has led to new strategies to reduce the risk of TRALI. Female blood donors with a previous pregnancy frequently have HLA antibodies with an overall prevalence of 24% and increasing prevalence related to the number of previous pregnancies. Since HLA antibodies have been implicated in TRALI, blood centers have adopted policies to produce plasma components primarily from male donors. Strategies to reduce the risk from apheresis platelets are problematic and are likely to involve testing female apheresis platelet donors for HLA antibodies. Much more research is needed to understand the blood component and patient risk factors for TRALI so that novel strategies for treatment and additional measures to reduce the risk of TRALI can be developed.



4左旋布比卡因和罗哌卡因用于小儿骶管麻醉的相对镇痛效应

Relative Analgesic Potencies of Levobupivacaine and Ropivacaine for Caudal Anesthesia in Children

Pablo Ingelmo, MD*, Geoff Frawley, MD{dagger}, Marinella Astuto, MD*, Chris Duffy, MD{dagger}, Susan Donath, PhD{ddagger}, Nicola Disma, MD§, Giuseppe Rosano, MD§, Roberto Fumagalli, MD*, and Antonio Gullo, MD§

From the *Department of Perioperative Medicine and Intensive, A.O. San Gerardo, Monza, Dipartimento di medicina sperimentale ambientale e biotecnologie mediche, Università degli Studi Milano Bicocca, Milan, Italy; {dagger}Department of Paediatric Anesthesia and Pain Management, Royal Children’s Hospital. Melbourne Australia; {ddagger}Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, University of Melbourne Australia; and §Department of Anesthesia, A.O.U. Policlinico Catania, Università degli Studi di Catania, Italy.

Anesth Analg 2009 108: 805-813.

 

背景:目前尚无新型局部麻醉剂左旋布比卡因和罗哌卡因骶管麻醉最小镇痛浓度的相对效应比较研究。本文作者进行了一项前瞻性,随机,双盲研究,以确定在儿童骶管单次罗哌卡因和左旋布比卡因最低镇痛浓度和剂量反应曲线。

方法:前瞻性、随机、双盲研究比较儿童骶管罗哌卡因和左旋布比卡因镇痛的剂量反应曲线。第一部分, 80名男童随机接受罗哌卡因或左旋布比卡因。第二部分,32名患者随机接受剂量为ED50-ED95 范围内50%有效剂量以描绘剂量反应曲线。

结果:以罗哌卡因和左旋布比卡因行骶管阻滞的ED50无显着差异。以狄克逊法估计左旋布比卡因ED500.069 % ( 95 CI0.056 -0.082 % )和罗哌卡因是0.075 % ( 95 CI0.058 -0.092 % ) 。左旋布比卡因等张回归法ED50ED95分别为0.068 0.04-0.09 )和0.20 % ( 95 CI0.16 -0.24 % ) 。罗哌卡因ED50ED95分别为0.066 0.033-0.098 )和0.225 % ( 95 CI0.21 -0.24 % ) 。

结论:儿童接受一个MAC的七氟醚下,左旋布比卡因和罗哌卡因骶管阻滞ED50没有显着性差异的。ED50药效比为0.92ED95药效比为0.89 ,表明左旋布比卡因和罗哌卡因在骶管麻醉时有相似的效力。

(张磊 译 陈杰 校)

BACKGROUND: Comparing relative potency of new local anesthetics, such as levobupivacaine and ropivacaine, by the minimum local analgesic concentration model has not been described for caudal anesthesia. Therefore, we performed a prospective, randomized, double-blind study to determine the minimum local analgesic concentrations of a caudal single shot of ropivacaine and levobupivacaine in children and to describe the upper dose-response curve.

METHODS: We performed a two-stage prospective, randomized, double-blind study comparing the dose-response curves of caudal ropivacaine and levobupivacaine in children. In phase 1, 80 boys were randomized to receive either ropivacaine or levobupivacaine. In the second phase a further 32 patients were randomly allocated to receive caudal anesthesia with doses designed to delineate the upper dose-response range (the 50% effective dose [ED50]-ED95 range).

RESULTS: There were no significant differences in ED50 values for caudal ropivacaine and levobupivacaine. The ED50 for levobupivacaine estimated from the Dixon Massey method was 0.069% (95% CI 0.056%-0.082%) and for ropivacaine was 0.075% (95% CI 0.058%-0.092%). Estimated by isotonic regression the ED50 and ED95 respectively of levobupivacaine were 0.068 (0.04-0.09) and 0.20% (95% CI 0.16%-0.24%). For ropivacaine ED 50 and ED95 were 0.066 (0.033-0.098) and 0.225% (95% CI 0.21%-0.24%).

CONCLUSIONS: In children receiving one minimum alveolar anesthetic concentration of sevoflurane, there were no significant differences in the ED50 for caudal levobupivacaine and ropivacaine. The potency ratio at ED50 was 0.92 and 0.89 at ED95, indicating that caudal levobupivacaine and ropivacaine have a similar potency.


高铁血红蛋白症与局麻药关系:242例个案的总结

Methemoglobinemia Related to Local Anesthetics: A Summary of 242 Episodes

Joanne Guay, MD, FRCPC

From the Department of Anesthesia, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal Canada.

Anesth Analg 2009 108: 837-845.


背景:本文的目的是总结在医学文献中有关局部麻醉剂相关高铁血红蛋白血症的个案。 
方法:作者用以下的关键词:局部麻醉剂高铁血红蛋白血症在美国国立图书馆的医学文献中进行了检索。
结果:共有242个个案( 40.1 %刊登在2000年或之后)。红褐色的血液表明高铁血红蛋白血症,但其它颜色可能会被发现。在91.8%的个案中脉搏血氧仪饱和度( 小于或等于 90 % )与动脉血氧分压( 大于或等于 70毫米汞柱)存在偏差。用脉搏血氧仪测定的血氧饱和度和共同血氧饱和度之间的差异从-6.2 %至44.7 % 。6个月以上的儿童使用剂量超过2.5
mg/kg的单纯丙胺卡因可诱导高铁血红蛋白血症。在成人,丙胺卡因的剂量应低于5.0mg/kg.,存在肾功能不全时减少到3.2 mg/kg.和如果同时使用其他氧化药物时减少到1.3 mg/kg.。一个单纯苯佐卡因喷雾剂可能导致高铁血红蛋白血症。在相对较低的血红蛋白值时可以观察到临床症状,包括32.2%的儿童和29.1 %的成人出现昏迷。在给予亚甲蓝后,59.9 %患者出现反弹性高铁血红蛋白血症并持续18h。高铁血红蛋白血症的并发症包括缺氧性脑病,心肌梗塞和死亡。 
结论:苯佐卡因不应继续使用;丙胺卡因不应使用于6个月以下儿童,孕妇,或服用其他氧化药物的病人。其他患者应用剂量应限制在2.5
mg/kg以内。

(张燕 译 陈杰 校)

BACKGROUND: The purpose of this article is to summarize all episodes of local anesthetic-related methemoglobinemia found in the medical literature.

METHODS: I performed a search of the American National Library of Medicine's PubMed with the following key words: "local anesthetic" and "methemoglobinemia."

RESULTS: Two-hundred-forty-two episodes (40.1% published in year 2000 or after) were found. Chocolate-colored blood suggests methemoglobinemia but other colors may be found. A discrepancy between the pulse oximeter saturation (≤90%) and the arterial oxygen partial pressure (≥70 mm Hg) was present in 91.8% of the episodes. The difference between oxygen saturation measured by pulse oximetry and co-oximetry varied from –6.2% to 44.7%. Plain prilocaine may induce clinically symptomatic methemoglobinemia in children older than 6 mo at doses exceeding 2.5 mg/kg. In adults, the dose of prilocaine should be kept lower than 5.0 mg/kg, which is reduced to 3.2 mg/kg in the presence of renal insufficiency and to 1.3 mg/kg if other oxidizing drugs are used concurrently. A single spray of benzocaine may induce methemoglobinemia. Clinical symptoms may be observed at relatively low methemoglobin values, including coma at 32.2 and 29.1% in children and adults, respectively. Rebound methemoglobinemia (benzocaine on mucous membranes) with methemoglobin values as high as 59.9% may occur up to 18 h after methylene blue administration. Complications of methemoglobinemia include hypoxic encephalopathy, myocardial infarction, and death.

CONCLUSION: Benzocaine should no longer be used. Prilocaine should not be used in children younger than 6-mo-old, in pregnant women, or in patients taking other oxidizing drugs. The dose should be limited to 2.5 mg/kg.



大鼠氙气预处理:促存活信号、线粒体渗透性转变和生物能学的作用

Xenon Preconditioning: The Role of Prosurvival Signaling, Mitochondrial Permeability Transition and Bioenergetics in Rats

Yasushi Mio, MD*{dagger}, Yon Hee Shim, MD*, Ebony Richards, BS*, Zeljko J. Bosnjak, PhD*, Paul S. Pagel, MD, PhD*, and Martin Bienengraeber, PhD*{ddagger}

From the *Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin; {dagger}Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan; and {ddagger}Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee; Wisconsin.

Anesth Analg 2009 108: 858-866.

 

背景:挥发性麻醉惰性气体氙气对心脏缺血/再灌注损伤具有保护作用,但对这一现象的机制并不完全理解。作者测试了氙气激活促存活信号激酶这一目标线粒体来诱发心肌保护这一假设。

方法:雄性Wistar大鼠在血流动力学监测下接受30min左冠状动脉前降支阻塞和2 h再灌注。大鼠随机接受70 % 氮气/30 %的氧气(对照组)或三个周期的吸入70 % 氙气/30 %氧气5min间隙吸入氧/氮混合气体5min。使用三苯染色测量心肌梗死面积。对照组和氙气处理组大鼠的离体心脏用于磷酸化AktGSK - 3βWestern免疫印迹和孤立的线粒体。线粒体缺氧/复氧前后的氧耗决定了线粒体通透性转换孔的开放。

结果:与对照组相比,氙气显著减少心肌梗死面积( 32 ± 459 ± 4 %,P < 0.05 )和增加磷酸化AktGSK- 3β 。与对照组相比,氙气预处理保存分离线粒体的呼吸状态。氙气预处理组诱导线粒体膜去极化所需的Ca2 +浓度较大(分别为 78 ± 1756 ± 17 μm) 。磷酸肌醇-3激酶的抑制剂wortmannin阻止了氙气对梗死面积和呼吸的效应。

结论:结果表明,氙气预处理减少心肌梗死面积, 磷酸化 AktGSK-3β,维护线粒体功能,抑制钙离子诱导的线粒体通透性转换孔开放。这些数据表明,氙气诱导心脏保护的发生,是因为激活促存活线粒体,并使它们更不容易受到缺血再灌注损伤。

(舒慧刚 译 陈杰 校)

BACKGROUND: Similar to volatile anesthetics, the anesthetic noble gas xenon protects the heart from ischemia/reperfusion injury, but the mechanisms responsible for this phenomenon are not fully understood. We tested the hypothesis that xenon-induced cardioprotection is mediated by prosurvival signaling kinases that target mitochondria.

METHODS: Male Wistar rats instrumented for hemodynamic measurements were subjected to a 30 min left anterior descending coronary artery occlusion and 2 h reperfusion. Rats were randomly assigned to receive 70% nitrogen/30% oxygen (control) or three 5-min cycles of 70% xenon/30% oxygen interspersed with the oxygen/nitrogen mixture administered for 5 min followed by a 15 min memory period. Myocardial infarct size was measured using triphenyltetrazolium staining. Additional hearts from control and xenon-pretreated rats were excised for Western blotting of Akt and glycogen synthase kinase 3 β (GSK-3β) phosphorylation and isolation of mitochondria. Mitochondrial oxygen consumption before and after hypoxia/reoxygenation and mitochondrial permeability transition pore opening were determined.

RESULTS: Xenon significantly (P < 0.05) reduced myocardial infarct size compared with control (32 ± 4 and 59% ± 4% of the left ventricular area at risk; mean ± sd) and enhanced phosphorylation of Akt and GSK-3β. Xenon pretreatment preserved state 3 respiration of isolated mitochondria compared with the results obtained in the absence of the gas. The Ca2+ concentration required to induce mitochondrial membrane depolarization was larger in the presence compared with the absence of xenon pretreatment (78 ± 17 and 56 ± 17 µM, respectively). The phosphoinositol-3-kinase-kinase inhibitor wortmannin blocked the effect of xenon on infarct size and respiration.

CONCLUSIONS: These results indicate that xenon preconditioning reduces myocardial infarct size, phosphorylates Akt, and GSK-3β, preserves mitochondrial function, and inhibits Ca2+-induced mitochondrial permeability transition pore opening. These data suggest that xenon-induced cardioprotection occurs because of activation of prosurvival signaling that targets mitochondria and renders them less vulnerable to ischemia-reperfusion injury.


心衰患者循环支持时的无创心排出量监测

Noninvasive Cardiac Output Measurement in Heart Failure Subjects on Circulatory Support

Rob Phillips, MPhil*, Peter Lichtenthal, MD{dagger}, Julie Sloniger, MS{dagger}, Darryl Burstow, MD*, Malcolm West, MD*, and Jack Copeland, MD{ddagger}

From the *Department of Medicine, The University of Queensland, Brisbane, Australia; {dagger}Department of Anesthesiology, and {ddagger}Department of Surgery, The University of Arizona College of Medicine, Tucson, Arizona.

Anesth Analg 2009 108: 881-886.

 

背景:尽管存在效力不明、使用困难、安全性等问题,肺动脉导管(PAC)监测仍广泛用于围术期心脏外科重症监护室病人血流动力学的监测和管理。 USCOM是一种无创性连续多普勒波直接测量心输出量( CO )的装置,可作为PAC的替代者。 尽管USCOM的可靠性未获公认,相对于PAC该方法在心脏外科重症监护病房中有着更好的可用性。作者在应用完全型人工心脏 (TAH)控制心衰患者中比较了应用USCOMCardioWest监测心输出量的差别。
方法:使用CardioWestUSCOM装置来双盲监测心衰行
TAH患者的心输出量、每搏输出量(SV)和心率( HR ) 。CardioWest 通过187个项目的测试获得了508个不同的配对数据。用Bland-Altman法分析比较。

结果CardioWest USCOM测得的心输出量、每搏输出量和心率的平均值及标准差( ±标准差)分别为7.33 ± 0.467.34 ± 0.51L/min 56.2 ± 3.856.6 ± 3.8 mL131 ± 3130 ± 4bpm。心输出量在5.29.3 L/min之间。两种方法对测量心输出量、每搏输出量和心率的平均差分别是-0.01 ± 0.23 L/min -0.34 ± 1.97 mL0.9 ± 2.3bpm,平均百分比差异分别为-0.3 % , -0.6 %和0.7 % 。心输出量、每搏输出量和心率的一致性百分比分别为6.4 % , 7.1 %和3.6 % 。
结论: 对心衰行
TAH的患者USCOM是一种可行的、准确的测量和监测心输出量的方法,可能在心血管疾病诊断和处理上有更广泛地的应用价值。

(丁俊云 译 陈杰 校)

BACKGROUND: Pulmonary artery catheter (PAC) thermodilution is commonly used in the perioperative cardiac surgical intensive care unit for measurement and management of central hemodynamics despite questions about effectiveness, difficulty of use, and safety. USCOM is a noninvasive continuous wave Doppler device for direct measurement of cardiac output (CO) and is an alternative to PAC. USCOM validation has predominantly been in the cardiac surgical intensive care unit against PAC, despite the recognized limitations in reliability of the method. We compared USCOM CO measurements with the CardioWest, an orthotopic total artificial heart (TAH), in heart failure (HF) subjects during controlled interventions.

METHOD: CO, stroke volume (SV), and heart rate (HR) were measured in a blinded fashion using the CardioWest and the USCOM device in TAH HF patients. Five-hundred eight paired measures from 18 examinations of seven subjects were acquired as flow was varied by the CardioWest controller. Bland-Altman analysis was used to compare agreement.

RESULTS: Mean values and standard deviations (±sd) for CO, SV, and HR by CardioWest and USCOM were 7.33 ± 0.46 and 7.34 ± 0.51 L/min, 56.2 ± 3.8 and 56.6 ± 3.8 mL, and 131 ± 3 and 130 ± 4 bpm, respectively. CO ranged from 5.2 to 9.3 L/min. The mean differences between methods for CO, SV, and HR were –0.01 ± 0.23 L/min, –0.34 ± 1.97 mL, and 0.9 ± 2.3 bpm, respectively, with mean percentage differences of –0.3%, –0.6%, and 0.7%. The percentage limits of agreement for CO, SV, and HR were 6.4%, 7.1%, and 3.6%.

DISCUSSION: USCOM is a feasible and accurate method for noninvasive measurement and monitoring of CO in TAH HF patients and may have a wider application in diagnosis and management of cardiovascular disease.

 

 

围术期微创监测心排出量

Minimally Invasive Cardiac Output Monitoring in the Perioperative Setting

Duane J. Funk, MD, FRCPC, Eugene W. Moretti, MD, MHsc, and Tong J. Gan, MB, MHS, FRCA, FFARCS(I)

From the Department of Anesthesiology, Division of Critical Care, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2009 108: 887-897.

 

随着患者年龄的增长及其并存病的升高,我们日益需求围术期对患者的生理学指标,如心排出量(cardiac outputCO)、液体治疗后的响应性和组织灌注情况进行跟踪监测的设备。 麻醉医师所持有的用于监测患者CO的工具 是肺动脉导管或者经食管超声心动图。这些装置都存在着一定的缺陷,并且可能会引起并发症。最近,已有一些新的装置投入市场(包括食管多普勒监测、脉搏波形分析、指示剂稀释、胸部生物电阻抗和部分无重复吸入系统等),它们能够无创监测CO,并且在某些情况下评估患者对液体治疗的反应。在这篇综述中,作者描述了这些新装置所涉及的技术,有关应用的研究,以及它们在应用过程中的缺陷。

(周姝婧 译 陈杰 校)

With advancing age and increased co-morbidities in patients, the need for monitoring devices during the perioperative period that allow clinicians to track physiologic variables, such as cardiac output (CO), fluid responsiveness and tissue perfusion, is increasing. Until recently, the only tool available to anesthesiologists to monitor CO was either a pulmonary artery catheter or transesophageal echocardiograph. These devices have their limitations and potential for morbidity. Several new devices (including esophageal Doppler monitors, pulse contour analysis, indicator dilution, thoracic bioimpedance and partial non-rebreathing systems) have recently been marketed which have the ability to monitor CO noninvasively and, in some cases, assess the patient’s ability to respond to fluid challenges. In this review, we will describe these new devices including the technology, studies on their efficacy and the limitations of their use.


混合皮层神经元-神经胶质细胞培养遭受氧糖缺失时的早期麻醉预处理:在七氟醚诱导时产生的神经保护作用中,三磷酸腺苷依赖性钾通道和活性氧所起的作用

Early Anesthetic Preconditioning in Mixed Cortical Neuronal-Glial Cell Cultures Subjected to Oxygen-Glucose Deprivation: The Role of Adenosine Triphosphate Dependent Potassium Channels and Reactive Oxygen Species in Sevoflurane-Induced Neuroprotection

Lionel J. Velly, MD*{dagger}, Paula T. Canas, MD*, Benjamin A. Guillet, PhD{dagger};, Christelle N. Labrande, PhD{dagger}, Frédérique M. Masmejean, BS{ddagger}, André L. Nieoullon, PhD{ddagger}, François M. Gouin, MD*, Nicolas J. Bruder, MD*, and Pascale S. Pisano, PhD{dagger}

From the *Department of Anesthesia, Centre Hospitalier Universitaire Timone Adultes, Marseille, France; {dagger}Laboratory of Pharmacodynamic, UMR INSERM 608, Marseille, France; and {ddagger}Laboratory IC2N, UMR6186 CNRS, Université de la Méditerranée, Marseille, France.

Anesth Analg 2009 108: 955-963.

 

背景:这项关于混合皮层神经元-神经胶质细胞培养遭受短时氧糖缺失(OGD)的研究的目的是 :1)比较在氧糖缺失之前(预处理)或期间(直接神经保护)增加七氟醚所产生的神经保护作用。2)探讨在七氟醚的早期预处理作用机制中,三磷酸腺苷敏感性钾(KATP)通道参与的可能性和细胞内活性氧(ROS)的水平。

方法:成熟的混合皮层神经元-神经胶质细胞在厌氧培养室里暴露90min的氧糖缺失,随后复氧。OGD前随机给予七氟醚(0.03-3.4Mm90min和停用60min(早期预处理)或 OGD期间应用七氟醚90min(直接神经保护作用)。在乳酸脱氢酶释放到培养基法量化24小时细胞死亡数。用2’-7’ 二氯荧光素乙酰乙酸盐来评估七氟醚预处理后细胞内活性氧的产生。

结果:七氟醚浓度高于0.07Mm的预处理产生强大的阈值依赖性神经保护作用,氧糖缺失时七氟醚引起剂量依赖性神经保护作用。三磷酸腺苷敏感性钾通道阻滞剂(格列本脲0.3μM5羟基癸酸50μM),或者活性氧清除剂(N-2-巯丙酰氨基乙酸100μMN-乙酰半胱氨酸50μM),尽管它们不影响细胞活力,但抵消了由七氟醚早期预处理产生的神经保护作用。在预处理期间的七氟醚暴露使得活性氧水平显著提高,而这可以被活性氧清除剂和三磷酸腺苷敏感性钾通道阻滞剂所阻止。

结论:早期的七氟醚预处理产生混合皮层神经元-神经胶质细胞培养的阈值依赖性保护,可能通过打开三磷酸腺苷敏感性钾通道,从而产生活性氧的机制来对抗氧糖缺失。

(黄丹 译 陈杰 校)

BACKGROUND: The purpose of the present study, on mixed cortical neuronal-glial cell cultures subjected to transient oxygen-glucose deprivation (OGD) was: i) to compare the neuroprotection afforded by sevoflurane added either before (preconditioning) or during (direct neuroprotection) the OGD and ii) to explore the possible involvement of adenosine triphosphate-sensitive potassium (KATP) channels and intracellular reactive oxygen species (ROS) levels in the mechanism of the early preconditioning effect of sevoflurane.

METHODS: Mature mixed cortical neuronal-glial cell cultures were exposed to 90-min OGD in an anaerobic chamber followed by reoxygenation. Sevoflurane (0.03–3.4 mM) was randomly administered for 90 min and discontinued 60 min before OGD (early preconditioning) or during the 90-min OGD (direct neuroprotection). Cell death was quantified 24 h after the OGD by lactate dehydrogenase release into the bathing medium. Intracellular ROS generation was assessed at the end of sevoflurane preconditioning using 2',7'-dichlorofluorescin diacetate.

RESULTS: Sevoflurane preconditioning elicited a potent threshold-dependent neuroprotective effect at concentrations higher than 0.07 mM and sevoflurane added during OGD elicited a dose dependent neuroprotective effect. Blockers of KATP channels (glibenclamide 0.3 µM and 5 hydroxydecanoic acid 50 µM), or ROS-scavengers (N-2-mercaptopropionyl glycine 100 µM and N-acetylcysteine 50 µM), although they did not affect cell viability, counteracted the neuroprotection produced by early sevoflurane preconditioning. Sevoflurane exposure during preconditioning induced a significant increase in ROS levels which was prevented by both ROS scavengers and blockers of KATP channels.

CONCLUSION: Early sevoflurane preconditioning induced a threshold-dependent protection of mixed cortical neuronal-glial cell cultures against OGD by mechanisms that seem to involve opening KATP channels, thereby leading to generation of ROS.


 8%定量利多卡因喷雾泵对创伤后外周神经病变的镇痛作用:一项初步研究

The Analgesic Effect of a Metered-Dose 8% Lidocaine Pump Spray In Posttraumatic Peripheral Neuropathy: A Pilot Study

Akifumi Kanai, MD, PhD, Yuka Segawa, MD, Takashi Okamoto, MD, Masanori Koto, MD, and Hirotsugu Okamoto, MD, PhD

From the Department of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Japan.

Anesth Analg 2009 108: 987-991.

 

背景:利多卡因表面贴片能够有效地治疗创伤后外周神经病变(posttraumatic peripheral neuropathy,PTPN),但由于需要额外使用,它不适用于爆发性疼痛。在这里,作者评估了8%利多卡因喷雾泵(Xylocaine pump spray,XPS)对由手术或损伤所致的外周神经病理性疼痛的效果。

方法:31PTPN患者被随机分为2组,一组接受XPS,另一组接受生理盐水喷雾泵作为空白对照组,将药物喷洒于两组患者疼痛部位的皮肤表面。喷洒的最佳剂量为能够完全覆盖疼痛区域,据个人情况而定,最多可达30喷(0.1ml/喷,30次)。7天后,将两组患者交叉接受另一喷剂的治疗。用视觉模拟评分评估患者的疼痛情况。

结果XPS而不是空白喷雾泵能够显著地降低持续疼痛和触觉异常的视觉模拟评分。应用后,其镇痛效果平均可持续5h(范围,2-60h)。在3位应用XPS的患者中发生了轻微的并发症,包括局部激惹症状(n=3)和局部烧灼感(n=1)。这些并发症无需药物治疗而在数小时后消失。

结论:目前的研究显示,XPS可以有效地改善PTPN,能够迅速镇痛,没有全身性的副作用,且使用方便。

(周姝婧 译 陈杰 校)

BACKGROUND: A topical lidocaine patch is effective in the treatment of posttraumatic peripheral neuropathy (PTPN), but it is not suited for breakthrough pain because of difficulty with an additional application. Here, we examined the effect of 8% lidocaine pump spray (Xylocaine pump spray®, XPS) on peripheral neuropathic pain caused by surgery or injury.

METHODS: Thirty-one patients with PTPN were randomized to receive either XPS or saline placebo pump spray applied to painful skin areas. The optimal dose of up to 30 sprays (0.1 mL/single spray, 30 times) was individually determined as the dose which completely covered the painful site. After a 7-day period, the patients were crossed over to receive the optimal dose of the alternative spray. Pain was assessed with a visual analog scale.

RESULTS: XPS, but not placebo pump spray, significantly decreased the visual analog scale for continuing pain and tactile allodynia. The effect persisted for a median of 5 h (range, 2–60 h) after application. Mild side effects were reported in three patients with XPS consisting of local irritation (n = 3) and local flare (n = 1). All adverse events disappeared without medication within a few hours.

CONCLUSIONS: The present study suggests that XPS provides a significant improvement in PTPN due to its prompt analgesia, lack of systemic side effects and convenience.

 

一个可吸收的局麻药装置提供数天的功能性坐骨神经阻滞

An Absorbable Local Anesthetic Matrix Provides Several Days of Functional Sciatic Nerve Blockade

Chi-Fei Wang, MD*, Alimorad G. Djalali, MD, PhD*, Ankur Gandhi, PhD{dagger}, David Knaack, PhD{dagger}, Umberto De Girolami, MD{ddagger}, Gary Strichartz, PhD*, and Peter Gerner, MD*

From the *Pain Research Center, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; {dagger}Orthocon, Inc., North Brunswick, New Jersey; and {ddagger}Division of Neuropathology, Department of Pathology, Brigham and Women’s Hospital Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2009 108: 1027-1033.

 

背景:周围神经的功能性阻滞是局部麻醉的基本目的,期待其作用持久,涵盖或超过整个手术期。现有的局麻药在一个单剂量给药后提供的有效镇痛时间小于8—12h。作者报告了一个可用于骨科,植入性的、可控制释放的药物给予装置, 包括一个FDA批准的包含利多卡因基质),能够局部释放几天之久。

方法Xybrex,一个可吸收,控制释放的给药装置,包括16%w/w)利多卡因,在雄性大鼠(300-350 gm)中植入在坐骨神经附近,每只大鼠的利多卡因剂量分别为5.310.61632mg。作为对照,盐酸利多卡因溶液(0.2 mL 2% = 4 mg)注射在非常靠近坐骨神经的地方。通过用镊子夹捏外侧脚趾的行为来评估大鼠痛觉,同时通过量化伸肌的推力来评估运动阻滞。在植入后24h4d4wk评估可能的坐骨神经的神经毒性。在体外测量利多卡因从装置中释放动力学。在2.56.51024.25h时收集样本测定利多卡因。

结果Xybrex在高剂量(分别为300600mg/ka,包含1632mg的利多卡因游离碱)提供了对于一个强烈的夹捏完全的镇痛分别为7.0 ± 2.0 h, 6.9± 1.7 h ,和一个不完全的镇痛分别为60.0 ± 5.4 h, 58.8 ±4.2 h,相对于由2%的利多卡因溶液(包含4mg利多卡因)引起的坐骨神经阻滞完全镇痛为 0.61± 0.03 h 和不完全镇痛为0.96 ±0.03 h 。这些同样高剂量的Xybrex 产生了完全的运动阻滞分别为17.0± 3.3 h, 17.6 ± 3.3 h ,并且完全恢复分别为352.0 ± 55.7 h (14.7 ± 2.3 d) 579.0 ±36.1 h (24.1 ± 1.5 d)。数据以平均 ± SE的形式记录。所有的Xybrex 组和2%利多卡因组相比时P < 0.001 。在靠近坐骨神经0.1mm的结缔组织和肌肉中小的局部组织炎症/病状,两组动物中均能观察到。实验中没有全身中毒征象。离体研究显示药物释放呈指数动力学特征,对比无时程性伤害缺乏意味着持续伤害性刺激在神经与该药装置间利多卡因直接的、局部作用,而无先前释放药物的累积效应

结论:Xybrex是一个可吸收的,控制释放的药物给予装置,能够提供大鼠周围神经数天的镇痛,无显著的局部神经毒性或者系统性毒性。

(怀晓蓉 译 陈杰 校)

BACKGROUND: Functional blockade of peripheral nerves is the primary objective of local anesthesia, and it is often desirable to have a persistent blockade, sustained throughout and beyond a surgical procedure. Current local anesthetics give effective analgesia for <8–12 h after a single bolus injection. We report on an implantable, controlled-release drug delivery system intended for use in bone and consisting of a Food and Drug Administration-approved matrix containing lidocaine that is capable of local delivery for several days.

METHODS: XybrexTM, an absorbable, controlled-release delivery system containing 16% (w/w) lidocaine, was implanted next to the sciatic nerve of male rats (300–350 gm), at lidocaine doses of 5.3, 10.6, 16, and 32 mg lidocaine per rat. For comparison, a lidocaine HCl solution (0.2 mL, 2% = 4 mg) was injected in close proximity to the sciatic nerve. Rats were assessed behaviorally for analgesia by a forceps pinch of the lateral digits, and for motor block by quantifying the extensor postural thrust. Potential neurotoxicity of sciatic nerves was evaluated histologically at 24 h, 4 days, and 4 wk after implantation. The kinetics of lidocaine’s release from the matrix was measured in vitro by ultraviolet detection of lidocaine in samples collected at 2.5, 6.5, 20, and 24.25 h.

RESULTS: Xybrex at the highest doses (300 and 600 mg/kg, containing 16 and 32 mg of lidocaine free base, respectively) provided complete analgesia to an intense pinch for 7.0 ± 2.0 h, 6.9 ± 1.7 h and partial analgesia for 60.0 ± 5.4 h, 58.8 ± 4.2 h, respectively, compared to 0.61 ± 0.03 h of complete analgesia and 0.96 ± 0.03 h of partial analgesia by sciatic block from the 2% lidocaine solution (containing 4 mg lidocaine). These same high doses of Xybrex produced complete motor block for 17.0 ± 3.3 h, 17.6 ± 3.3 h with full recovery in 352.0 ± 55.7 h (14.7 ± 2.3 days), 579.0 ± 36.1 h (24.1 ± 1.5 days) respectively. Data are reported as mean ± se. P < 0.001 for all Xybrex groups compared to the 2% lidocaine group. Minor local tissue inflammation/pathology, primarily in the connective tissue and muscle 0.1 mm adjacent to the nerve, was observed equally in animals treated with Xybrex and 2% lidocaine solution. There were no behavioral signs of systemic toxicity. The in vitro release followed exponential kinetics and。its comparison to the time-course of functional nociceptive deficit implied that the duration of nociception represented the local, immediate interaction of lidocaine between the nerve and the matrix and not a cumulative effect of previously released drug.

CONCLUSIONS: Xybrex is an absorbable, controlled-release drug delivery system that provides several days of analgesia for rat peripheral nerves without apparent significant local neurotoxicity or systemic toxicity.

 

应用皮肤温度评估锁骨下臂丛神经阻滞效果的有效性

The Efficacy of Skin Temperature for Block Assessment After Infraclavicular Brachial Plexus Block

Vincent Minville, MD*, Agnés Gendre, MD*, Jan Hirsch, MD{dagger}, Stein Silva, MD*, Benoît Bourdet, MD*, Carole Barbero, MD*, Olivier Fourcade, MD, PhD*, Kamran Samii, MD*, and Hervé Bouaziz, MD, PhD{ddagger}

From the *Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Paul Sabatier, Toulouse, France; {dagger}Cardiovascular Research Institute, University of California, San Francisco, California; and {ddagger}Department of Anesthesiology and Intensive Care, University Hospital of Nancy, Nancy, France.

Anesth Analg 2009 108: 1034-1036.

 

背景:尽管有研究表明应用皮温升高来评估神经阻滞效果比应用针刺觉及温度觉改变来评估具有更高的特异性和敏感性,但原先应用的方法需要计算机辅助红外热成像,该方法价格昂贵且需要严格的专业培训。在本前瞻性观察研究中,作者使用简易红外温度仪评估锁骨下臂丛神经阻滞效果是否可靠。

方法:选择应用锁骨下臂丛神经阻滞行上肢手术的患者30名。自局麻药注射后起,在四个主要神经分布区域进行皮肤温度测量,同时在注药后30min内每隔5min测量感觉阻滞(痛温觉丧失评分为0,正常痛温觉为2)。本研究中神经阻滞成功的定义为:在局麻药注射后30min内,四个主要神经分布区域(桡神经,尺神经,正中神经,肌皮神经)的温度觉(酒精棉球擦拭)和痛觉(针刺觉)评分为0。以非接触式温度探头测量皮肤温度。

结果:被阻滞神经总数为12030位患者,每位患者4根神经)。其中25例患者神经阻滞成功,4例由于阻滞失败需要静脉麻醉辅助,1例患者实施全麻。不同神经分布区域的皮肤温度变化无显著性差异。同一区域的皮肤温度在神经阻滞后升高,与阻滞前相比有显著性差异(T5T30P < 0.0001)。同一时间神经阻滞区域与非神经阻滞区域的平均皮肤温度有显著性差异(T5P < 0.05 T10T30P< 0.0001)。当阻滞后5分钟和10分钟,特定感觉区域的皮肤温度升高≥1°C,则对应的神经被阻滞(评分=0)。因此,当阻滞后5分钟和10分钟四条神经区域的皮肤温度都发生变化,那么在30分钟后神经成功阻滞。本研究中,患者的对侧上肢和中心体温无变化。

结论:使用简易红外温度仪通过测定皮肤温度来评估神经阻滞效果,这一方法简单、可靠,且能在早期预示神经阻滞的成功。

(赵嫣红 译 陈杰 校)

BACKGROUND: Although it has been reported that an increase in skin temperature indicates block success with higher specificity and sensibility than skin sensitivity to pinprick and cold, the methodology previously used computer-assisted infrared thermography, a technique that is expensive and requires substantial personnel training. In this prospective observational study, we evaluated whether a simple infrared thermometer can reliably predict block effectiveness after infraclavicular brachial plexus blockade.

METHODS: Thirty consecutive patients undergoing upper limb surgery under infraclavicular block were enrolled. From the end of the local anesthetic injection, skin temperature was measured in all four major nerve distribution areas, and the sensory block onset (using cold and pinprick with 0 = no sensation to 2 = normal) were evaluated every 5 min for 30 min. A successful block was defined as the absence of sensation to cold (swab soaked with alcohol) and pinprick (needle) with a score of "0" within 30 min after the injection in the 4 major nerve distribution areas (radial, ulnar, median and musculocutaneous). Skin temperature measurements were performed using a noncontact temperature probe.

RESULTS: One-hundred-twenty nerves (30 patients, 4 nerves per patient) were anesthetized. Twenty-five patients had a successful block. Four patients required supplementation for block failure. General anesthesia was performed in one patient. Skin temperature variation was not different among different nerves. There was a statistically significant increase in cutaneous temperature after nerve block compared to the same skin area before the procedure (P < 0.0001 from T5 to T30). Average temperature variations in blocked versus unblocked nerves at the same time were significantly different (P < 0.05 at T5 then P < 0.0001 from T10 to T30). When temperature in a specific sensory territory increased 1°C or more, at 5 and 10 min, the specific nerve was blocked (the score was "0"). Thus, when temperature changes in all 4 nerves were noted at 5 and 10 min, the block was successful at 30 min. No change in temperature in the contralateral arm or in the core temperature was observed.

CONCLUSION: Skin temperature assessment with an infrared thermometer is a reliable, simple and early indicator of a successful nerve block.

 

一篇就文献进行的系统性回顾:血栓弹性描计法可以预测术后血栓栓塞的发生么?

Does Thromboelastography Predict Postoperative Thromboembolic Events? A Systematic Review of the Literature

Yue Dai, MB, MSc*, Anna Lee, PhD*, Lester A. H. Critchley, MD*, and Paul F. White, PhD, MD{dagger}

From the *Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, China; and {dagger}Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.

Anesth Analg 2009; 108:734-742

背景:由于血栓弹性描计法(TEG)可以检测出高凝状态,因此它可以作为预测术后血栓栓塞发生的有效方法,就此我们系统性地回顾了文献来评估TEG预测术后血栓发生的准确性。

方法:两位互不干扰的研究人员分别搜索了PUBMED和EMBASE电子数据库,查找出包含围术期进行TEG测试并用参考标准判断结果的成年手术病人的前瞻性研究。评价包括的研究的质量并评估包括的每一项研究的诊断性测试准确性值。

结果:本次分析有10篇研究入选(共1056位病人),但是只有5篇文献报道了TEG测试的准确性

 

 

 

。研究的总体质量和诊断评估的水平从好到差

异很大。由于血液高凝的定义、TEG方法、病人的特

征、

所用

的参考标准和测得的结果有变异性,所以没有采用荟萃分析。敏感度和特异性的范围分别从0%到100%和62%到92%。诊断优势比从1.5到27.7,曲线下面积从0.57到0.91。在TEG的各变量中,最大振幅可以作为鉴别

血液高凝状态和预测血栓栓塞发生的最好参数。

结论:TEG预测术后血栓栓塞的发生的准确性变异较大。为了确定TEG是否是高危外科手术人群中临床上有用的筛选试验,我们还需要进行更多的前瞻性研究。

(姜旭晖译,马皓琳,李士通校)

BACKGROUND: Since thromboelastography (TEG) can detect hypercoagulable states, it is a potentially useful test for predicting postoperative thromboembolic complications. Therefore, we performed a systematic review of the literature to evaluate the accuracy of TEG in predicting postoperative thromboembolic events.

METHODS: PUBMED and EMBASE electronic databases were searched by two independent investigators to identify prospective studies involving adult patients undergoing operative procedures in which a TEG test was performed perioperatively and outcomes were measured by reference standards. The quality of included studies was assessed and measures of diagnostic test accuracy were estimated for each included study.

RESULTS: Ten studies (with a total of 1056 patients) were included in this analysis; however, only five reported measures of TEG test accuracy. The overall quality of the studies and level of diagnostic evaluation of the studies were highly variable, from poor to good. As there were variations in the definition of hypercoagulability, TEG methodology and patient characteristics, reference standards used and outcomes measured, a meta-analysis was not undertaken. The sensitivity and specificity ranged from 0% to 100% and 62% to 92%, respectively. The diagnostic odds ratio ranged from 1.5 to 27.7; area under the curve ranged from 0.57 to 0.91. Of the TEG variables, maximum amplitude seems to be the best parameter to identify hypercoagulable states and to predict thromboembolic events.

CONCLUSIONS: The predictive accuracy of TEG for postoperative thromboembolic events is highly variable. To determine if the TEG is a clinically useful screening test in high-risk surgical populations, more prospective studies are needed.

 

输血的非感染性严重风险

Noninfectious Serious Hazards of Transfusion

Jeanne E. Hendrickson, MD*{dagger}, and Christopher D. Hillyer, MD*

From the *Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, and {dagger}AFLAC Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta, Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, Georgia.

Anesth Analg 2009; 108:759-769

由于献血者问卷的改良及尖端的感染性疾病的血液筛选技术,非感染性严重风险(NISHOTs)已成为输血最常见的并发症。NISHOTs的种类很广泛,包括从能恰当描述的

 

且已归类的输血反应(溶血、发热

、脓毒血症和变应/ 荨麻疹/过敏)到更罕见的并发症。这些包括误输血、输血相关的急性肺损伤

、输血相关的循环超负荷、输血后紫癜、输血相关的移植物抗宿主病、微嵌合状态、输血相关的免疫调制、同种异体免疫、代谢紊乱、大量输血导致的凝血障碍、红细胞存储损伤引起的并发症、输血过多或输血不足导致的并发症及铁超负荷。

近几年,NISHOTs在出版社及科学界均比以前受到更多关注。由于输血引起的潜在并发症越来越多,研究者们已

关注自由与限制红细胞输注的发病率及病死率比较,及输注“陈旧血”与“新鲜血”潜在危险的对比。本文回顾了集中于最近的关注和文献的NISHOTs。

(裘毅敏译,马皓

琳 李士通校)

As infectious complications from blood transfusion have decreased because of improved donor questionnaires and sophisticated infectious disease blood screening, noninfectious serious hazards of transfusion (NISHOTs) have emerged as the most common complications of transfusion. The category of NISHOTs is very broad, including everything from well-described and categorized transfusion reactions (hemolytic, febrile, septic, and allergic/urticarial/anaphylactic) to lesser known complications. These include mistransfusion, transfusion-related acute lung injury, transfusion-associated circulatory overload, posttransfusion purpura, transfusion-associated graft versus host disease, microchimerism, transfusion-related immunomodulation, alloimmunization, metabolic derangements, coagulopathic complications of massive transfusion, complications from red cell storage lesions, complications from over or undertransfusion, and iron overload.

In recent years, NISHOTs have attracted more attention than ever before, both in the lay press and in the scientific community. As the list of potential complications from blood transfusion grows, investigators have focused on the morbidity and mortality of liberal versus restrictive red blood cell transfusion, as well as the potential dangers of transfusing "older" versus "younger" blood. In this article, we review NISHOTs, focusing on the most recent concerns and literature.


产妇的心脏手术

Cardiac Surgery in the Parturient

Shobana Chandrasekhar, MD, Christopher R. Cook, DO, and Charles D. Collard, MD

From the Division of Cardiovascular Anesthesiology, Department of Anesthesiology, Baylor College of Medicine, Texas Heart® Institute, St. Luke’s Episcopal Hospital, Houston, TX.

Anesth Analg 2009; 108:777-785

心脏疾病为妊娠期非产科性死亡的主要原因,在产妇中的发病率为1%-3%,由此引起的孕产妇死亡率为10%—15%。先天性心脏病在育龄妇女已越来越多见,占妊娠期心脏疾病的比例越来越高(可达75%)。孕产妇未经治疗的心脏疾病使得胎儿也处于危险之中。新生儿并发症的独立预测因素包括产妇纽约心脏协会心衰分级>2、妊娠期抗凝药物的运用、吸烟史,多胎妊娠和左室流出道梗阻。由于产妇心外科手术发病率和死亡率高于非妊娠患者,故大多数有心脏疾病的产妇首先接受药物治疗,同时准备在药物治疗失败后接受心外科手术治疗。心外科手术期产妇死亡的危险因素包括血管活性药物、年龄、手术类型、二次手术和产妇心功能分级。胎儿死亡的危险因素包括产妇年龄>35岁、心功能分级、二次手术、急诊手术、心肌保护的类型和缺氧时间。虽然如此,通过如下措施可达到可以接受的产妇和胎儿围术期死亡率:术前早期发现产妇心血管失代偿状态、采用胎儿监护、在手术前分娩可存活胎儿以及在妊娠4月到6月时安排择期手术。此外,体外循环期间使产妇携氧能力和子宫血流量达到最佳状态也可降低胎儿死亡率。目前产妇体外循环的建议包括:1)维持泵流量>2.5 L · min–1 · m–2 、灌注压 >70 mm Hg;2)维持血细胞比容> 28%;3)如果可行,采用常温灌注;4)采用搏动血流;5)采用α-pH稳态管理。

(周雅春 译   马皓琳 李士通 校)

Heart disease is the primary cause of nonobstetric mortality in pregnancy, occurring in 1%–3% of pregnancies and accounting for 10%–15% of maternal deaths. Congenital heart disease has become more prevalent in women of childbearing age, representing an increasing percentage (up to 75%) of heart disease in pregnancy. Untreated maternal heart disease also places the fetus at risk. Independent predictors of neonatal complications include a maternal New York Heart Association heart failure classification >2, anticoagulation use during pregnancy, smoking, multiple gestation, and left heart obstruction. Because cardiac surgical morbidity and mortality in the parturient is higher than nonpregnant patients, most parturients with cardiac disease are first managed medically, with cardiac surgery being reserved when medical management fails. Risk factors for maternal mortality during cardiac surgery include the use of vasoactive drugs, age, type of surgery, reoperation, and maternal functional class. Risk factors for fetal mortality include maternal age >35 yr, functional class, reoperation, emergency surgery, type of myocardial protection, and anoxic time. Nonetheless, acceptable maternal and fetal perioperative mortality rates may be achieved through such measures as early preoperative detection of maternal cardiovascular decompensation, use of fetal monitoring, delivery of a viable fetus before the operation and scheduling surgery on an elective basis during the second trimester. Additionally, fetal morbidity may be reduced during cardiopulmonary bypass by optimizing maternal oxygen-carrying capacity and uterine blood flow. Current maternal bypass recommendations include: 1) maintaining the pump flow rate >2.5 L · min–1 · m–2 and perfusion pressure >70 mm Hg; 2) maintaining the hematocrit > 28%; 3) using normothermic perfusion when feasible; 4) using pulsatile flow; and 5) using {alpha}-stat pH management.


实时评估围术期行为和预计围术期预后

Real-Time Assessment of Perioperative Behaviors and Prediction of Perioperative Outcomes

Senthilkumar Sadhasivam, MD, MPH*, Lindsey L. Cohen, PhD{dagger}, Alexandra Szabova, MD*, Anna Varughese, MD*, Charles Dean Kurth, MD*, Paul Willging, MD{ddagger}, Yu Wang, MS§, Todd G. Nick, PhD§, and Joel Gunter, MD*

From the *Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; {dagger}Department of Psychology, Georgia State University, Atlanta, Georgia; {ddagger}Department of Otorhinolaryngology, and §Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.

Anesth Analg 2009; 108:822-826

背景和目的:新出现的适应不良行为,例如发脾气、做噩梦、遗尿、注意力障碍和害怕孤独常见于小儿门诊手术后。术前焦虑、恐惧和困扰行为常预示小儿术后会有适应不良行为和谵妄。父母的焦虑也会影响到小儿的术前焦虑。到目前为止还没有实时和可行的方法可以有效地测定小儿及其父母围术期的行为。我们建立了一个简单的实时评分方法——围术期成人小儿行为相互作用评分(PACBIS),用来评估围术期小儿及其父母的行为,这可能有助于预测小儿术后是否会出现有问题或苏醒期兴奋的行为。

方法:我们使用PACBIS评估89例行扁桃体切除术或增殖体切除术的小儿及其父母在麻醉诱导和恢复期的行为。记录用改良耶鲁术前焦虑评分法测定的术前焦虑状况、用诱导顺应评分表评估小儿在麻醉诱导时的顺从程度以及苏醒期兴奋的发生率。

结果:PACBIS与改良耶鲁术前焦虑评分法和诱导顺应评分表在有效性方面高度一致,能很好预期小儿麻醉后苏醒期兴奋。

讨论: PACBIS是第一种可用来评估小儿及其父母围术期行为的实时评分方法。PACBIS鉴别出的特殊行为可提供干预的目标,以改善围术期经历和术后预后。

(张莹译 李士通 马皓琳 校)

Background and Aims: New onset maladaptive behaviors, such as temper tantrums, nightmares, bed-wetting, attention-seeking, and fear of being alone are common in children after outpatient surgery. Preoperative anxiety, fear and distress behaviors of children predict postoperative maladaptive behaviors as well as emergence delirium. Parental anxiety has also been found to influence children’s preoperative anxiety. Currently, there is no real-time and feasible tool to effectively measure perioperative behaviors of children and parents. We developed a simple and real-time scale, the Perioperative Adult Child Behavioral Interaction Scale (PACBIS) to assess perioperative child and parent behaviors that might predict postoperative problematic behavior and emergence excitement.

METHODS: We used the PACBIS to evaluate perioperative behaviors during anesthetic induction and recovery in a sample of 89 children undergoing tonsillectomies and adenoidectomies, and their parents. Preoperative anxiety with the modified Yale Preoperative Anxiety Scale, compliance with induction of anesthesia with Induction Compliance Checklist, and incidence of emergence excitement were also recorded.

RESULTS: The PACBIS demonstrated good concurrent validity with modified Yale Preoperative Anxiety Scale and Induction Compliance Checklist and predicted postanesthetic emergence excitement.

DISCUSSION: The PACBIS is the first real-time scoring instrument that evaluates children’s and parents’ perioperative behavior. The specific behaviors identified by the PACBIS might provide targets for interventions to improve perioperative experiences and postoperative outcomes.


残余肌松对Sugammadex肌松拮抗速度的影响

The Effect of Residual Neuromuscular Blockade on the Speed of Reversal with Sugammadex

Paul F. White, PhD, MD*, Burcu Tufanogullari, MD*, Ozlem Sacan, MD*, Edward G. Pavlin, MD{dagger}, Oscar J. Viegas, MD{ddagger}, Harold S. Minkowitz, MD§, and M. E. Hudson, MD||

From the *Departments of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas; {dagger}Departments of Anesthesiology and Pain Management, University of Washington, Seattle, Washington; {ddagger}Departments of Anesthesiology and Pain Management, Indiana University, Indianapolis, Indiana; §Departments of Anesthesiology and Pain Management Memorial Hermann Memorial City Hospital, Houston, Texas; and ||Departments of Anesthesiology and Pain Management University of Pittsburgh, Pittsburg, Pennsylvania.

Anesth Analg 2009; 108:846-851

背景:Sugammadex是一种改良的γ环糊精复合物其将罗库溴铵包裹起来导致残余肌松的快速逆转。我们对一个多中心的研究得到的数据进行了post hoc分析,模仿了标准的临床试验以验证假说,即在给予拮抗药时对神经肌肉刺激肌有无颤搐反应是否会影响sugammadex的逆转效应的速度和完全性。

方法:171名行以挥发性麻醉药为基础行全身麻醉并同意进行试验的病人加入了多中心观察性研究。所有的病人用罗库溴铵0.6 mg/kg静脉注射行气管内插管,手术中需要时用0.15 mg/kg推注维持。从麻醉诱导到手术过程结束后四个成串(TOF)比率(TOFR)恢复到≥0.9,用TOF-Watch®-SX加速度肌松监测仪在笔记本电脑记录TOF反应,评价罗库溴铵引起的阻滞深度。在罗库溴铵末次剂量后>15min给予sugammadex 4 mg/kg静推,以拮抗其神经肌肉阻滞。将在给予拮抗药时对TOF刺激没有反应 (n = 89)或有≥1个肌颤搐 (n = 82)的病人的恢复数据进行比较。

结果:没有肌颤搐出现的病人较多是女性(占60%),并且这些病人的罗库溴铵末次剂量与给予拮抗药之间的时间间隔较短 (31±18比45±23 min, P < 0.05)。无肌颤搐组的TOFR恢复到0.9的时间较出现1个以上肌颤搐组长(173±162比104±73 s, P < 0.05)。总起来说,无肌颤搐组有84%的病人的TOFR于5min内恢复到0.9,而出现1个以上肌颤搐组则有91%病人(P < 0.05)。在无肌颤搐组和出现1个以上肌颤搐组,达到TOFR0.9的时间分别从0.8min到 22.3min,0.7min 到8.5min。

结论:用sugammadex拮抗罗库溴铵引起的神经肌肉阻滞,受到给予拮抗药时残余肌松程度的影响。尽管有很大的变异度,不管给予拮抗药时肌颤搐计数多少,都有多于80%的病人在5min以内TOFR恢复到0.9。

(黄丽娜  译 马皓琳 李士通 校)

BACKGROUND: Sugammadex is a modified {gamma}cyclodextrin compound which encapsulates rocuronium resulting in rapid reversal of residual neuromuscular blockade. We performed a post hoc analysis of data from a multicenter study designed to mimic standard clinical practice which would test the hypothesis that the presence (versus the absence) of a twitch response to neuromuscular stimulation at the time of reversal drug administration would influence the speed and completeness of the reversal effect of sugammadex.

METHODS: One-hundred-seventy-one consenting patients undergoing general anesthesia with a volatile-based anesthetic technique were enrolled in a multicenter observational study. All patients received rocuronium, 0.6 mg/kg IV for tracheal intubation and maintenance boluses of 0.15 mg/kg IV as needed during surgery. The degree of rocuronium-induced blockade was assessed during anesthesia using a TOF-Watch®-SX acceleromyograph to record the train-of-four (TOF) responses on a laptop computer from induction of anesthesia until the TOF ratio returned to ≥0.9 after completion of the surgical procedure. The patients received sugammadex, 4 mg/kg IV, for reversal of neuromuscular blockade >15 min after the last dose of rocuronium. Recovery data were compared in patients with either no (0) (n = 89) or ≥1 twitch (n = 82) in response to TOF stimulation at the time of reversal drug administration.

RESULTS: The patients without a twitch response were more likely to be female (60% vs 40%) and had a shorter time interval between the last bolus dose of rocuronium and the administration of the reversal drug (31±18 vs 45±23 min, P < 0.05). The time to achieve a TOF ratio of 0.9 was prolonged in the 0 twitch group compared with the ≥1 twitch response group (173±162 vs 104±73 s, P < 0.05). Overall, 84% of the patients in the 0 twitch group recovered to a TOF of 0.9 in ≤5 min compared to 91% of the patients in the group with ≥1 twitch (P < 0.05). The times to achieve a TOF of 0.9 varied from 0.8 to 22.3 and 0.7 to 8.5 min in the 0 twitch and ≥1 twitch groups, respectively.

CONCLUSION: Reversal of rocuronium-induced neuromuscular blockade by sugammadex was influenced by the degree of residual blockade at the time the reversal drug was administered. Despite the wide variability, reversal of the TOF ratio to 0.9 occurred ≤5 min in more than 80% of the patients regardless of the number of twitches at the time of reversal drug administration.


本体感受功能对地氟烷麻醉的敏感性高于运动功能

Proprioceptive Function Is More Sensitive than Motor Function to Desflurane Anesthesia

Linda S. Barter, MVSc, PhD*, Laurie O. Mark, BA*, and Joseph F. Antognini, MD*{dagger}

From the Departments of *Anesthesiology and Pain Medicine, and the {dagger}Section of Neurobiology, Physiology and Behavior, University of California, Davis, California.

Anesth Analg 2009; 108:867-872

背景:评估亚制动麻醉剂量对运动的影响有助于明确麻醉剂引起制动的神经回路作用靶点。

方法:给予11只刺毁脑脊髓的北方豹蛙0、0.4、0.8和1.2倍产生制动效果的半数有效量(ED50)的地氟烷,额外7只随机顺序给予0和0.4 ED50地氟烷。采用前肢电刺激引出后肢擦拭反射,录像记录用于随后分析。测量30s刺激过程中引出的后肢等长张力。

结果:与0 ED50相比,0.4 ED50地氟烷组擦拭潜伏期从0.8(0.1, 4.0)明显延长至17.3 (0.4, 30.0)s(中位数[最小值,最大值]);后足运动距离从0.42 (0.09, 1.82) 增加至 0.89 (0.16, 4.82) m;后足与刺激源之间的最短距离从1 (0, 5) 增加至7 (1, 40) mm。后足最大运动速度和等长张力没有变化,但是后肢力从7.3 (1.7, 23.6) 减少至3.2 (1.4, 13.8) N. s,这相当于运动次数从12 (3, 28) 减少至 8 (2, 14)次。地氟烷剂量从0.4增加至0.8 ED50,运动功能的抑制效应开始显现,表现为最大张力从2.0 (0.6, 5.5)降低至0.8 (0.1, 1.6) N,总力从3.2 (1.4, 13.8)减少至0.9 (0.0, 2.5) N.s。

结论:蛙类本体感受功能对麻醉剂引起抑制作用的敏感性高于运动功能。这表明,大多数参与伤害性刺激产生运动反应的脊髓神经回运动通路中对麻醉剂最敏感的成份快于运动神经元的水平。

(江继宏 译  马皓琳 李士通 校)

BACKGROUND: Evaluating the effects of sub-immobilizing anesthetic doses on movement will identify target neural circuits for investigation as sites of action for anesthetic-induced immobility.

METHODS: Eleven pithed Northern Leopard frogs received 0, 0.4, 0.8, and 1.2 times the 50% effective dose for production of immobility (ED50) of desflurane and a further 7 received 0 and 0.4 ED50 desflurane in random order. An electric stimulus applied to the forelimb elicited a hindlimb wiping reflex that was captured on video for later analysis. Isometric tension developed in the hindlimb during the 30 s stimulus application was measured.

RESULTS: Compared to 0 ED50, 0.4 ED50 desflurane significantly increased latency to wipe 0.8 (0.1, 4.0) to 17.3 (0.4, 30.0) s (median [min max]), distance traveled by the hindfoot 0.42 (0.09, 1.82) to 0.89 (0.16, 4.82) m, and proximity of the hindfoot to stimulus 1 (0, 5) to 7 (1, 40) mm. It did not alter hindlimb maximum velocity or isometric tension but significantly reduced total hindlimb force 7.3 (1.7, 23.6) to 3.2 (1.4, 13.8) N. s proportionate to a reduced number of movements from 12 (3, 28) to 8 (2, 14). From 0.4 to 0.8 ED50, motor depressant effects of desflurane became apparent with significant reductions in maximum tension from 2.0 (0.6, 5.5) to 0.8 (0.1, 1.6) N and total force from 3.2 (1.4, 13.8) to 0.9 (0.0, 2.5) N.s.

CONCLUSIONS: Proprioceptive function is more sensitive to anesthetic-induced depression than motor function in frogs. This suggests that the most anesthetic-sensitive component of the spinal neural circuitry underlying movement generation in response to noxious stimulus is prior to the level of the motoneuron.

 

酒精滥用和围术期中免疫功能紊乱

Alcohol Use Disorder and Perioperative Immune Dysfunction

Alexandra Lau, MD, Vera von Dossow, MD, Michael Sander, MD, Martin MacGuill, MD, Nadine Lanzke, DVM, and Claudia Spies, MD

From the Department of Anesthesiology and Intensive Care Medicine Unit, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-University Hospital Berlin, Berlin, Germany.

Anesth Analg 2009; 108:916-920

长期酒精滥用的麻醉学结局包括术后感染、重症监护病房滞留期延长和住院期延长的风险增加3-5倍。感染率增高的原因是改变长期酗酒病人的免疫反应改变。术前长期酗酒病人辅助型T细胞1/辅助型T细胞2比率受抑制,术后仍然受抑制。术前较更低的辅助型T细胞1/辅助型T细胞2比率预期着迟发的感染。长期酗酒病人术后细胞毒性淋巴细胞(Tc1/Tc2)比率降低,并且抑制持续5天。长期酗酒病人术后全血细胞中白细胞介素(IL)-6/IL-10比率和脂多糖刺激的干扰素γ/IL10比率降低。术后期Tc1/Tc2、IL-6/IL10和脂多糖刺激的干扰素γ/IL-10比率抑制是术后并发感染的先兆。围术期干预目的应该是使免疫系统的调节失常降到最小。

(王宏翻译,马皓琳,李士通校正)

The anesthesiological sequelae of long-term alcohol abuse include a three to fivefold increased risk of postoperative infection, prolonged intensive care unit stays and longer hospital stays. The cause of the higher infection rates is an altered immune response in long-term alcoholic patients. Preoperatively, the T helper cells 1 to T helper cells 2 ratio is depressed in long-term alcoholic patients and remains suppressed after surgery. The lower preoperative T helper cells 1 to T helper cells 2 ratio is predictive of later onset of infections. Postoperatively, the cytotoxic lymphocyte (Tc1/Tc2) ratio is decreased in long-term alcoholic patients and remains depressed for 5 days. The interleukin (IL)-6/IL-10 ratio and the lipopolysaccharide-stimulated interferon {gamma}/IL-10 ratio in whole blood cells are decreased after surgery in long-term alcoholic patients. Depressed Tc1/Tc2, IL-6/IL-10 and lipopolysaccharide-stimulated interferon {gamma}/IL-10 ratios in the postoperative period are predictive of subsequent postoperative infections. Perioperative interventions should aim to minimize dysregulation of the immune system.


病人自控硬膜外镇痛在分娩中的应用

Patient-Controlled Epidural Analgesia for Labor

Stephen H. Halpern, MD, MSc, FRCPC*, and Brendan Carvalho, MBBCh, FRCA{dagger}

From the *Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada; and {dagger}Department of Anesthesia, Stanford University School of Medicine, Stanford, California.

Anesth Analg 2009; 108:921-928

病人自控硬膜外镇痛(PCEA)在20年前就已应用于临床分娩。PCEA技术与持续硬膜外输注相比具有明显的优势。我们利用MEDLINE 和EMBASE(1988–2008年4月1日)中所有在分娩中应用PCEA进行如下比较之一的随机对照实验进行了一个系统回顾:有无背景输注剂量,用罗哌卡因还是布比卡因,高浓度还是低浓度局部麻醉药,以及新方法或是标准方法。重要的结果数据有:母亲镇痛情况、满意度评分、运动阻滞以及额外临床医生介入的发生率。持续背景剂量输注提高了母亲镇痛水平,并减少了额外临床医生介入。高单次剂量(5mL以上)比低单次剂量能提供更好的镇痛。低浓度的布比卡因或罗哌卡因可以提供极好的镇痛并且无明显的运动阻滞。PCEA的很多方法可提供有效的分娩镇痛。持续背景剂量输注的高容量稀释局麻药溶液似乎是一个最成功的方法。对新的给药方式(例如程序控制强制性间断剂量注射和电脑控制的反馈给药)的研究正在进行中。

(黄佳佳译,马皓琳 李士通校)

Patient-controlled epidural analgesia (PCEA) for labor was introduced into clinical practice 20 yr ago. The PCEA technique has been shown to have significant benefits when compared with continuous epidural infusion. We conducted a systematic review using MEDLINE and EMBASE (1988–April 1, 2008) of all randomized, controlled trials in parturients who received PCEA in labor in which one of the following comparisons were made: background infusion versus none; ropivacaine versus bupivacaine; high versus low concentrations of local anesthetics; and new strategies versus standard strategies. The outcomes of interest were maternal analgesia, satisfaction, motor block, and the incidence of unscheduled clinician interventions.

A continuous background infusion improved maternal analgesia and reduced unscheduled clinician interventions. Larger bolus doses (more than 5 mL) may provide better analgesia compared with small boluses. Low concentrations of bupivacaine or ropivacaine provide excellent analgesia without significant motor block. Many strategies with PCEA can provide effective labor analgesia. High volume, dilute local anesthetic solutions with a continuous background infusion appear to be the most successful strategy. Research into new delivery strategies, such as mandatory programmed intermittent boluses and computerized feedback dosing, is ongoing.


环磷腺苷反应单元结合蛋白磷酰化和4-苯基-1(4-苯丁基)哌啶(PPBP)的神经保护作用

Cyclic Adenosine Monophosphate Response Element-Binding Protein Phosphorylation and Neuroprotection by 4-Phenyl-1-(4-Phenylbutyl) Piperidine (PPBP)

Sufang Yang, MD, Nabil J. Alkayed, MD, PhD, Patricia D. Hurn, PhD, and Jeffrey R. Kirsch, MD

From the Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon.

Anesth Analg 2009; 108:964-970

背景:已有研究表明有效的原型ς1-受体激动剂4-苯基-1-(4-b苯基丁基) 哌啶(PPBP)能阻止初级培养的皮层神经元剥夺氧糖后细胞死亡。我们假设PPBP通过激活转录因子环磷腺苷反应元素结合蛋白(CREB)相关的机制来保护神经元并对该假设进行了验证。

方法: 原代培养皮层神经元暴露于OGD2小时,恢复24小时。在损伤前15分钟开始PPBP处理,同时使用或不使用ς1-受体拮抗剂林卡唑以及已知能激活信号传导链而导致CREB磷酸化的蛋白激酶抑制剂,例如H89 (蛋白激酶A抑制剂)、 LY294002(PI3K抑制剂)、U0126(MEK1/2抑制剂)或KN62(钙调蛋白激酶II抑制剂)。在OGD处理后24小时用乳酸脱氢酶测试法分析神经元细胞死亡。用免疫印迹分析法检测再充氧后30min、1h和3h的CREB磷酸化水平。用Quantity One图像分析软件对斑点作定量分析。

结果: PPBP 增加OGD恢复1h 后CREB磷酸化,该作用可被林卡唑取消(PPBP组1.7 ± 0.2,PPBP加林卡唑组0.8 ± 0.1,对照于只有OGD组为0.9 ± 0.1,p-CREB/CREB)。PPBP引起的CREB磷酸化增加可被H89阻断(0.5 ± 0.07) 而非U0126、KN62或LY294002阻断。PPBP处理能预防OGD导致的细胞死亡,而H89预处理会阻断这种保护作用(PPBP组0.18 ± 0.02,PPBP加H89组0.27 ± 0.03,对照于只有OGD组0.33 ± 0.02,乳酸脱氢酶分析法)。LY294002、UO126或KN62预处理对PPBP的神经保护作用无影响。

结论:这些数据提示PPEP的神经保护机制可能与CREB磷酰化有关

(颜涛 译 马皓琳 李士通 校)

BACKGROUND: Previous studies show that the potent, prototypical {varsigma}1-receptor agonist 4-phenyl-1-(4-phenylbutyl) piperidine (PPBP) prevents cell death after oxygen-glucose deprivation (OGD) in primary cortical neuronal cultures. We tested the hypothesis that PPBP protects neurons by a mechanism involving activation of the transcription factor cyclic adenosine monophosphate response element-binding protein (CREB).

METHODS: Primary cultured cortical neurons were exposed to 2 h of OGD and allowed to recover for 24 h, and PPBP treatment was initiated 15 min before the insult in the presence and absence of the {varsigma}1-receptor antagonist rimcazole and inhibitors against protein kinases known to activate signal transduction cascades that result in CREB phosphorylation, such as H89 (protein kinase A inhibitor), LY294002 (PI3K inhibitor), U0126 (MEK1/2 inhibitor), or KN62 calmodulin kinase II inhibitor). Neuronal cell death was assayed by lactate dehydrogenase measurement 24 h after OGD. CREB phosphorylation was measured by immunoblot analysis at 30 min, 1 h, and 3 h of reoxygenation. Blots were quantitatively analyzed using Quantity One image analysis software.

RESULTS: PPBP increased CREB phosphorylation at 1 h after recovery from OGD, which was abolished by rimcazole (1.7 ± 0.2 in PPBP and 0.8 ± 0.1 in PPBP plus rimcazole with OGD compared with 0.9 ± 0.1 in OGD alone, p-CREB/CREB). The PPBP-induced increase in CREB phosphorylation was blocked by H89 (0.5 ± 0.07) but not U0126, KN62, or LY294002. PPBP treatment prevented OGD-induced cell death and pretreatment with H89 blocked this protection (0.18 ± 0.02 in PPBP and 0.27 ± 0.03 in PPBP plus H89 with OGD compared with 0.33 ± 0.02 in OGD alone, lactate dehydrogenase assay). Pretreatment with LY294002, UO126, or KN62 had no effect on neuronal protection by PPBP.

CONCLUSIONS: These data suggest that the mechanism of neuroprotection by PPBP may be linked to CREB phosphorylation.


辣椒膏用于合谷穴可减少正颌手术术后镇痛剂的需求

Capsicum Plaster at the Hegu Point Reduces Postoperative Analgesic Requirement After Orthognathic Surgery

Kyo S. Kim, MD, PhD*, Kyu N. Kim, MD*, Kyung G. Hwang, DMD, PhD{dagger}, and Chang J. Park, DMD, PhD{dagger}

From the Departments of *Anesthesiology, and {dagger}Dental Surgery, Hanyang University Hospital, Seoul, Korea.

Anesth Analg 2009; 108:992-996

背景:辣椒膏用于经典的中国针刺穴位,是除针灸外的另一种能有效预防术后恶心呕吐、咽喉痛和疼痛的方法。在本研究中,我们调查了辣椒膏用于合谷穴(LI 4)对双侧下颌升支矢状劈开切骨术病人的术后镇痛效果。

方法:一项双盲、假性对照的研究在84名行正颌手术的患者中进行,患者被随机指定到三个治疗组(每组各28例)。合谷组:辣椒膏用于合谷穴,安慰剂贴在双肩的非穴位处;假性组:辣椒膏用于双肩,安慰剂贴在合谷穴;对照组:安慰剂贴在合谷穴和双肩。辣椒膏在麻醉诱导前使用并在术后三天内每天维持8小时。

结果:术后24小时内病人自控镇痛的总量(含6.5 µg/mL芬太尼和1.2 mg/mL酮咯酸)在合谷组(26.8 ± 3.4 mL)较对照组(44.2 ± 7.3 mL)和假性组(42.1 ± 6.9 mL)减少(P < 0.01)。合谷组较其他组,术后恶心呕吐的发生率和额外药物的需要减少,而且总体满意得分更高(P < 0.01)。

结论:辣椒膏用于合谷穴可减少正颌手术患者术后阿片类药物的需求量以及阿片类相关的副作用。

(唐李隽    马皓琳  李士通  校)

BACKGROUND: Capsicum plaster at classical Chinese acupoints is an alternative to acupuncture, which has been used as an effective method for preventing postoperative nausea and vomiting, sore throat, and pain. In this study, we investigated the postoperative analgesic efficacy of capsicum plaster at Hegu (LI 4) acupoints in patients after bilateral sagittal split ramus osteotomy.

METHODS: A double-blind, sham-controlled study was conducted with 84 patients undergoing orthognathic surgery, and who were randomly assigned to three treatment regimens (n = 28 each): Hegu group = capsicum plaster at Hegu acupoints and placebo tape on the shoulders as a nonacupoint; sham group = capsicum plaster on the shoulders and placebo tape at Hegu acupoints; and control group = placebo tape at Hegu acupoints and on the shoulders. The capsicum plaster was applied before induction of anesthesia and maintained for 8 h per day for 3 postoperative days.

RESULTS: The total amount of patient-controlled analgesia, containing 6.5 µg/mL fentanyl and 1.2 mg/mL ketorolac, administered in the first 24 h after the operation was decreased in the Hegu group (26.8 ± 3.4 mL) compared with the control (44.2 ± 7.3 mL) and sham (42.1 ± 6.9 mL) groups (P < 0.01). The incidence of postoperative nausea and vomiting and the need for rescue medication were reduced, and the overall satisfaction score was greater in the Hegu group compared with other groups (P < 0.01).

CONCLUSION: The capsicum plaster at the Hegu acupoints decreased the postoperative opioid requirements and opioid-related side effects in patients after orthognathic surgery.


一种新型异二氢吲哚衍生物JM-1232(-)的镇痛效应和药理特性

The Antinociceptive Effects and Pharmacological Properties of JM-1232(-): A Novel Isoindoline Derivative

Shunsuke Chiba, MD, Tomoki Nishiyama, MD, PhD, and Yoshitsugu Yamada, MD, PhD

From the Department of Anesthesiology, The University of Tokyo, Tokyo, Japan.

Anesth Analg 2009; 108:1008-1014

背景:一种异二氢吲哚衍生物JM-1232(-) 被作为一种镇静和镇痛药来开发。我们进行本研究以观察其对小鼠身上三种不同的伤害性感受的镇痛效应。

方法:雄性ddY小鼠分别接受腹腔内(IP)注射JM-1232(-)1、3或10 mg/kg(每一试验的每一剂量n = 8)。使用生理盐水作为对照。IP注药后120min进行热板或夹尾试验。乙酸试验:在IP注药后15min将0.6%的乙酸溶液按10mL/kg进行IP注射。IP注酸后5min开始记录腹部收缩的次数10min。当观察镇痛效应时,在给予最大有效剂量的JM-1232(-)之前分别皮下注射纳络酮或氟吗泽尼。使用转轮试验,每5min记录一次轮子转动的数量,共记录120min。

结果:在热板、夹尾和乙酸试验中,IP JM-1232(-) 产生明显的镇痛效应,其50%有效剂量分别为2.96 mg/kg (CI: 2.65–3.30 mg/kg)、3.06 mg/kg (CI: 2.69–3.47 mg/kg)和2.27 mg/kg (CI: 1.46–3.53 mg/kg)。在所有试验中,JM-1232(-) 产生的镇痛效应被氟吗泽尼(5 mg/kg)而非纳络酮(10 mg/kg)所拮抗。在转轮试验中,JM-1232(-)对运动行为无剂量依赖性作用。

结论:小鼠全身应用JM-1232(-)对急性热、机械引起的疼痛以及内脏痛有镇痛效应。这些效应可能通过苯二氮卓-{gamma}-氨基丁酸A型受体而不是阿片受体来介导。

(黄施伟 译,马皓琳 李士通 校)

BACKGROUND: An isoindoline derivative, JM-1232(-) was developed as a sedative and analgesic drug. We performed the present study to investigate its antinociceptive effects on three different nociceptions in mice.

METHODS: Mail ddY mice were administered intraperitoneal (IP) JM-1232(-) 1,3 or 10 mg/kg (n = 8 for each dose in each test). Saline was used as a control. The hotplate or tail pressure test was performed for 120 min after IP drug injection. Acetic acid 0.6% solution in 10 mL/kg was IP administered 15 min after IP drug injection in the acetic acid test. The number of abdominal constriction episodes was counted for 10 min, starting 5 min after IP administration of the acid. When the analgesic effect was observed, naloxone or flumazenil was subcutaneously administered before administration of the maximum effective dose of JM-1232(-). Using the wheel running test, the number of wheel revolutions was recorded every 5 min for 120 min.

RESULTS: In the hotplate, tail pressure and acetic acid tests, IP JM-1232(-) produced significant antinociceptive effects with a 50% effective dose of 2.96 mg/kg (CI: 2.65–3.30 mg/kg), 3.06 mg/kg (CI: 2.69–3.47 mg/kg) and 2.27 mg/kg (CI: 1.46–3.53 mg/kg), respectively. In all tests, JM-1232(-)-induced antinociception was antagonized by flumazenil (5 mg/kg) but not by naloxone (10 mg/kg). In the running wheel test, there was no dose-dependent effect of JM-1232(-) on locomotor activity.

CONCLUSION: Systemically administered JM-1232(-) had antinociceptive effects on acute thermal, mechanical-induced pain, and visceral pain in mice. These effects might be mediated by benzodiazepine- {gamma}-aminobutyric acid type A receptors but not by opioid receptors.


大鼠后根神经节内注射利多卡因引起神经炎症

Lidocaine Injection into the Rat Dorsal Root Ganglion Causes Neuroinflammation

Livia Puljak, MD, PhD*, Sanja Lovric Kojundzic, MD*, Quinn H. Hogan, MD{dagger}, and Damir Sapunar, MD, PhD*

From the *Department of Histology and Embryology, University of Split School of Medicine, Croatia; and {dagger}Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Anesth Analg 2009; 108:1021-1026

背景: 选择性脊神经阻滞过程中脊神经或后根神经节(DRG)的损伤是潜在的严重并发症,至今仍未被充分地研究。我们假设局麻药注入这些组织会导致炎性反应及痛觉过敏。

方法:在部分椎板切除术后的大鼠L5脊神经或后根神经节注入4 µL利多卡因或生理盐水,评估其炎性和行为反应。在术前和术后通过足部伤害性机械刺激的反应来进行行为测试,以此研究痛觉过敏。DRG被收集染色,计数神经元周围的免疫反应性神经胶质细胞环。

结果:动物试验证明在利多卡因注入DRG后4天,而非在注入脊神经后,身体同侧爪有痛觉过敏。DRGs中代表卫星细胞活化的神经胶质原纤维酸性蛋白免疫阳性胶质细胞环的数量在利多卡因注入DRG或脊神经后都明显减少。注射利多卡因组的神经胶质原纤维酸性蛋白阳性细胞数量显著大于注射生理盐水组。零星的OX-42免疫阳性细胞代表有活性的小胶质细胞,在注射利多卡因的DRG中也能发现。标记活性T淋巴细胞的Pan-T表达试验显示无阳性细胞。

结论:DRG内注射利多卡因可能会引起痛觉过敏,可能由于固有的卫星胶质细胞活化所致。在临床上,在选择性脊神经阻滞中应该避免DRG内注射局麻药。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Injury of a spinal nerve or dorsal root ganglion (DRG) during selective spinal nerve blocks is a potentially serious complication that has not been adequately investigated. Our hypothesis was that local anesthetic injection into these structures may result in an inflammatory response and hyperalgesia.

METHODS: We evaluated inflammatory and behavioral responses after injection of 4 µL lidocaine or saline into the L5 spinal nerve or DRG of rats after partial laminectomy. Behavioral testing was performed before and after surgery to examine hyperalgesia in response to nociceptive mechanical stimulation of the foot. DRGs were harvested and stained, and rings of immunoreactive glial cells around neurons were counted.

RESULTS: Animals demonstrated hyperalgesia on the ipsilateral paw up to 4 days after lidocaine injection into the DRG but not after injection into the spinal nerve. The number of glial fibrillary acid protein immunopositive glial cell rings, which represent activation of satellite cells, significantly increased in DRGs after injection of lidocaine into either the DRG or the spinal nerve. The number of glial fibrillary acid protein-positive cells in the lidocaine-injected group was significantly larger than in the saline-injected group. Sporadic OX-42 immunopositive cells, which represent activated microglia, were also seen in lidocaine-injected DRGs. Testing for Pan-T expression, which labels activated T lymphocytes, showed no positive cells.

CONCLUSIONS: Lidocaine injection into the DRG may produce hyperalgesia, possibly due to activation of resident satellite glial cells. In a clinical setting, local anesthetic injection into the DRG should be avoided during selective spinal nerve blocks.