Table of Contents

March 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

肌鈣蛋白I水平在預測絕經後婦女行心血管手術後發生不良心血管事件預後的價值

單嘉琪譯 薛張綱校

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.

快通道麻醉與心臟手術:7989例患者的回顧性佇列研究

鄭麗 陳傑

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.

一篇就文獻進行的系統性回顧:血栓彈性描計法可以預測術後血栓栓塞的發生麽?

姜旭暉譯,馬皓琳,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.

血栓彈性測定法(ROTEM)檢測體外迴圈術後肝素和魚精蛋白的試點研究及結果

范羽譯 薛張綱校

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.

血小板減少的情況下纖維蛋白原的水平對彈性血栓變數的影響

劉世文 陳傑

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.

輸血的非感染性嚴重風險

裘毅敏譯,馬皓 李士通校

Noninfectious Serious Hazards of Transfusion (Review Article)

Jeanne E. Hendrickson and Christopher D. Hillyer

Anesth Analg 2009 108: 759-769.

輸血相關急性肺損傷:對臨床醫師的進展

葉樂 陳傑

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

Darrell J. Triulzi

Anesth Analg 2009 108: 770-776.

産婦的心臟手術

周雅春    馬皓琳 李士通

Cardiac Surgery in the Parturient (Review Article)

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

Anesth Analg 2009 108: 777-785.

PEDIATRIC ANESTHESIOLOGY:

兒科手術室外異丙酚行鎮靜/麻醉治療的不良反應及其發生率來自兒科鎮靜研究協會的報道

黃劍譯 薛張綱校

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左旋布比卡因和羅呱卡因用於小兒骶管麻醉的相對鎮痛效應

張磊 陳傑

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.

重症患兒使用持續指尖無創血壓監測的可靠性

李瑩譯 薛張綱校

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.

即時評估圍術期行爲和預計圍術期預後

張瑩譯 李士通 馬皓琳

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:

人工控制輸注和靶控輸注瑞芬太尼在保留自主呼吸患者中的比較

姚敏敏譯 薛張綱校

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:

高鐵血紅蛋白症與局麻藥關係:242例個案的總結

張燕 陳傑

Methemoglobinemia Related to Local Anesthetics: A Summary of 242 Episodes

Joanne Guay

Anesth Analg 2009 108: 837-845.

殘餘肌松對Sugammadex肌松拮抗速度的影響

黃麗娜  馬皓琳 李士通

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輸注使光纖下經鼻氣管插管更便利的比較

俞佳譯 薛張綱校

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.

大鼠氙氣預處理:促存活信號、線粒體滲透性轉變和生物能學的作用

舒慧剛 陳傑

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.

本體感受功能對地氟烷麻醉的敏感性高於運動功能

江繼宏   馬皓琳 李士通

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:

探測生理監測的變化的一種新型軟體工具的評估。

張玥琪譯,薛張綱校

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.

心衰患者迴圈支援時的無創心排出量監測

丁俊雲 陳傑

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.

圍術期微創監測心排出量

周姝婧 陳傑

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:

機械通氣脫機期功能殘氣量的變化:一項前瞻性研究

張釗譯 薛張綱校

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.

酒精濫用和圍術期中免疫功能紊亂

王宏翻譯,馬皓琳,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:

病人自控硬膜外鎮痛在分娩中的應用

黃佳佳譯,馬皓琳 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:

住院醫師專業化培訓:失敗的原因與改進措施

朱蘭芳譯 薛張綱

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

混合皮層神經元-神經膠質細胞培養遭受氧糖缺失時的早期麻醉預處理:在七氟醚誘導時産生的神經保護作用中,三磷酸腺苷依賴性鉀通道和活性氧所起的作用

黃丹 陳傑

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.

環磷腺苷反應單元結合蛋白磷酰化和4-苯基-14-苯丁基)呱啶(PPBP)的神經保護作用

顔濤 馬皓琳 李士通

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.

心臟迴圈停止後的腦復蘇

陳珺珺譯 薛張綱校

Cerebral Resuscitation After Cardiocirculatory Arrest (Review Article)

Andreas Schneider, Bernd W. Böttiger, and Erik Popp

Anesth Analg 2009 108: 971-979.

ANALGESIA:

8%定量利多卡因噴霧泵對創傷後外周神經病變的鎮痛作用:一項初步研究

周姝婧 陳傑

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.

辣椒膏用於合穀穴可減少正頜手術術後鎮痛劑的需求

唐李雋    馬皓琳  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.

局麻藥對人類神經細胞的細胞毒性作用

陳珺珺譯 薛張綱校

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.

一種新型異二氫吲哚衍生物JM-1232(-)的鎮痛效應和藥理特性

黃施偉 譯,馬皓琳 李士通

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.

苄呱酚醇導致的抗傷害感覺和降低慢性後根神經節壓縮小鼠的脊髓背角NR2B亞單位的表達

陳珺珺譯 薛張綱校

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.

大鼠後根神經節內注射利多卡因引起神經炎症

慧譯 馬皓琳 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.

一個可吸收的局麻藥裝置提供數天的功能性坐骨神經阻滯

懷曉蓉 陳傑

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.

應用皮膚溫度評估鎖骨下臂叢神經阻滯效果的有效性

趙嫣紅 陳傑

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.

超聲引導下的閉孔神經阻滯:一種新的關於超聲方法的研究

陳珺珺譯 薛張綱校

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.

肌鈣蛋白I水平在預測絕經後婦女行心血管手術後發生不良心血管事件預後的價值

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:心血管手術後的不良心血管事件是影響婦女圍手術期發病率和死亡率的重要因素。肌鈣蛋白I提供了一個心血管損傷敏感的檢測指標,但其在心血管手術後的水平因性別而異。我們此次研究的目的就是評估肌鈣蛋白I水平在預測絕經後婦女行心血管手術後産生心血管並發症上的價值。

方法:此次研究的佇列來自於先前一個已報道的臨床試驗,那個研究旨在評估老年婦女中17[beta]-雌二醇的神經保護潛能。在那個研究中,175名未接受雌激素替代治療且將擇期行冠脈旁路移植術(有無瓣膜手術均可)的絕經後婦女經雙盲隨機分成兩組,分別自手術前一天開始接受17[beta]-雌二醇或安慰劑治療,至術後五天。在術前,術後入重症監護室當日以及術後頭四天分別進行連續十二導聯心電圖及血清肌鈣蛋白I濃度檢測。我們這次研究的主要終檢值是重大的心血管不良事件(MACE),即Q波型心肌梗死,低心排量以及術後三十天內死亡。Q波型心肌梗死的診斷需有兩位內科醫生分別獨立進行評估,兩者意見一致方爲最終診斷。低心排量狀態是指在不考慮具體治療的情況下心臟指數小於2.0 L · min-1 · m-2超過八個小時。

結果:術後第一天的肌鈣蛋白I水平被用於預測重大的心血管不良事件(MACE)(受試者曲線下面級=0.862)。將肌鈣蛋白I的終檢值定於>7.6 ng/mL95%可信區間,6.4–10.8)可提供鑒別患者是否存在發生重大心血管不良事件(MACE)風險的最佳敏感性和特異性。由肌鈣蛋白水平來識別一個患者是否合併有心血管事件,其陰性預測價值很高(96%),而陽性預測價值卻一般(40%)。圍手術期接受17[beta]-雌二醇治療的婦女與安慰劑組比較,術後肌鈣蛋白I的水平並無差異;並且重大心血管不良事件(MACE)的發生率並不受17[beta]-雌二醇治療的影響。

結論:對於絕經後婦女而言,術後第一天肌鈣蛋白I水平升高預示著重大心血管不良事件(MACE)發生的可能。監測圍手術期的肌鈣蛋白I水平也許可以作爲預測患者不良心血管事件發生風險的一種手段。

(單嘉琪譯 薛張綱校)

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.

 

 

血栓彈性測定法(ROTEM)檢測體外迴圈術後肝素和魚精蛋白的試點研究及結果

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:此次研究的目的爲確定血栓彈性測定法(ROTEM)是否可檢出魚精蛋白對於凝血功能的影響以及其區別於肝素的不同之處。

方法:爲了逆轉體外迴圈術後肝素的效應,22名相繼行主動脈或冠狀動脈手術的患者被選取入組。依據臨床慣例,所有入組病人按手術時所被給予的肝素總量接受其初始對應的魚精蛋白用量。若患者啟動凝固時間(ACT)延長或出現彌漫性出血的臨床徵兆,則可繼續給予其額外劑量的魚精蛋白(70U/kg)。同時須完成常規ACT測定、ROTEM分析(包括肝素敏感性[INTEM]測試和肝素酶包含性[HEPTEM]測試)及標準凝固試驗,並測量凝血因數和抗凝因數Xa的活性。

結果:比較肝素敏感性(INTEM)測試的結果(均數[+/-標準差]):219.8+/-19.1)秒至241.1+/-21.7)秒(P<0.001)和肝素酶包含性(HEPTEM)測試的結果:210.2+/-19.9)秒至226.8+/-21.8)秒(P<0.001),兩者均顯示額外使用魚精蛋白(n=16)對於延長患者凝血時間具有顯著的統計學意義;而在僅給予單次魚精蛋白劑量的患者中(n=6)這些變化並沒有被發現。此外,運用INTEM測試與HEPTEM測試的比率,可成功地從58名不含殘餘肝素的患者中檢出56例;從僅有的6名在體外迴圈術後抗凝因數Xa升高的患者中檢出3例。

結論:初步資料顯示體外迴圈術後額外使用魚精蛋白可導致凝血時間在INTEM測試與HEPTEM測試中短暫延長。而在ACT延長的病例中,ROTEM分析對於檢出殘餘肝素可能有效。

(范羽譯 薛張綱校)

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.

 

 

兒科手術室外異丙酚行鎮靜/麻醉治療的不良反應及其發生率:來自兒科鎮靜研究協會的報道

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.

 

目標研究異丙酚的鎮靜/麻醉作用的特性及其不良事件的發生率。爲此我們使用了一個由專業的兒科工作者提供的關於兒科手術室外鎮靜/麻醉的大樣本前瞻性資料庫。

病例選擇和方法:資料由兒科鎮靜研究協會(Pediatric Sedation Research Consortium,PSRC)收集。這一國際性的協會致力於改進鎮靜/麻醉在兒童中的應用。協會的成員們按一定的規程前瞻性持續收集接受鎮靜及鎮靜/麻醉治療的病例資料。主要的入選標準是在手術室外診療中對某些形式的鎮靜/麻醉的需求度,無排除標準。統計資料,主要疾病,並存疾病,治療方法,所用藥物,治療和恢復時間,麻醉藥物劑量效用關係,氣道控制及惡性事件都由網路化的資料收集工具進行收集匯總。本研究中,我們評價了所有以異丙酚爲主要鎮靜/麻醉治療藥物的情況。

結果37個地區彙報了自2004.6.12007.9.1間共49836例以異丙酚行鎮靜/麻醉的病例。無死亡病例,需心肺復蘇2例,鎮靜/麻醉狀態下發生誤吸4例。稍輕的不良事件還有O2飽和度低於90%超過30s,其發生率爲154:10000。窒息或氣道阻塞發生率爲575:10000。喘鳴,喉痙攣,分泌物過多及嘔吐的發生率分別爲50,96,34149:10000。預期外的住院治療(所需治療級別上升)發生率在7.1:10000。據粗略分析,肺部不良事件的發生率在麻醉科和其他科室間無顯著性差異。

結論:我們報道了最大數量的兒科手術室外異丙酚鎮靜/麻醉的病例分析。由一些較偏好並且較有組織計劃進行鎮靜/麻醉治療的組織提供的資料顯示使用異丙酚進行鎮靜/麻醉嚴重不良反應的發生率並不高。但是這一操作的安全性還取決於處理一些相對較輕微的不良反應的能力。希望我們的資料能爲使用異丙酚進行鎮靜/麻醉治療的培訓教育提供一定的參考價值以促進更加安全的使用這一藥物。

(黃劍譯 薛張綱校)

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.

 

 

重症患兒使用持續指尖無創血壓監測的可靠性

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.

 

介紹:使用有特殊裝置的充氣指套(FINAP),通過指尖動脈可以對成人進行持續無創血壓測定,並且它的可行性和可靠性均較高。在重症患兒,我們使用標準的兒童指套並經軟體計算,對這種無創血壓測定的方法與有創動脈測定(IAP)進行比較。

方法:我們的研究物件是鎮靜及呼吸機輔助通氣的送入重症監護室的患兒。在血流動力學相對平穩期間,分別使用三種方法測定血壓,從而比較FINAPIAP和無創振動測壓裝置的結果。我們還比較了IAP和由指尖血壓換算的肱動脈血壓的值。

結果:試驗包括了35222kg的患兒。總共測定了152FINAP,其中4.6%沒有成功。比較FINAPIAP,收縮壓、舒張壓、平均動脈壓的偏差分別是–16.2, –7.7, and –10.2 mm Hg。置信區間(LOA)分別是26.1%, 30.1%,22.6%.。經指尖血壓換算的肱動脈血壓與IAP相比較,偏差分別是–11.8, 0.6–0.9 mm Hg LOA分別是21.7%, 8.9%, 8.9% 。無創的振動法血壓測定與IAP相比偏差分別是–6.8, –0.9,–3.8 mm HgLOA分別是18.2%, 38.6%, 22.1%

結論:在血流動力學穩定的重症患兒,使用Beta型指套測定指尖血壓並換算成肱動脈血壓進行的持續無創血壓監測的結果是可靠的。

(李瑩譯 薛張綱校)

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.

 

 

人工控制輸注和靶控輸注瑞芬太尼在保留自主呼吸患者中的比較

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:聯合輸注丙泊酚及瑞芬太尼進行深度鎮靜時一項顯著的特點就是其頻繁發生的副作用,特別是呼吸抑制。這些副作用有可能是聯合應用這兩種藥物引起,也有可能是由輸注技術引起。而靶控輸注(TCI)可以將輸注技術最優化。我們希望在進行腸鏡檢查的病人中通過隨機雙盲對照來回答這樣兩個問題:第一,加用瑞芬太尼是否會增加其副作用?第二:同手控輸注相比,靶控輸注瑞芬太尼是否能減少副作用的發生?

方法:進行腸鏡檢查的病人被隨機分配接受人工控制輸注瑞芬太尼(MCI)(0.125µg每公斤每分鐘的速度輸注兩分鐘,然後以0.05µg每公斤每分鐘的速度持續輸注)、靶控輸注瑞芬太尼(1 ng/mL)或安慰劑(普通生理鹽水靶控輸注或同樣的速度手控輸注)。所有的病人都接受靶控輸注丙泊酚,靶濃度調整至能提供深度鎮靜,病人對口頭指令沒有反應,但是在沒有幫助的情況下保持自主通氣。

結果:很明顯,接受安慰劑組的病人更多地出現了體動、咳嗽、和呃逆,短暫的影響了檢查。三組間在血流動力學及恢復期的差異沒有臨床意義。通過靶控輸注瑞芬太尼減少了丙泊酚的用量。同人工控制輸注瑞芬太尼相比,靶控輸注瑞芬太尼時通氣不足及呼吸暫停的發生率下降。(TCI n = 7, MCI n = 16, P < 0.05

結論:同單用丙泊酚相比,在保持自主呼吸的深度鎮靜病人中,聯用瑞芬太尼和丙泊酚能爲腸鏡檢查提供更好的條件。同人工控制輸注相比,靶控輸注瑞芬太尼減少了丙泊酚的用量,同時呼吸暫停和呼吸抑制的發生率更低(TCI n = 7, MCI n = 16, P < 0.05)。

(姚敏敏譯 薛張綱校)

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.

 

 

異丙酚和瑞芬太尼靶控輸注使光纖下經鼻氣管插管更便利的比較

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

 

介紹:成功的光纖下插管要求患者的舒適和良好的插管條件。在這個研究中我們比較異丙酚(P)和瑞芬太尼(R)靶控輸注(TCI)在光纖下氣管插管的效果和舒適程度。

方法60名需要光纖下經鼻氣管插管的患者經隨機分配接受PR靶控輸注。局部麻醉後,TCI一開始設置爲2.5 µg/mL (P) 1.5 ng/mL (R),然後根據患者的反應增量,每次1 µg/mL (P) 0.5 ng/mL (R)。目標血藥濃度和鎮靜水平在每一步都被記錄,以及在手術以後評估總藥量,調整次數,插管條件,患者不舒適和回憶。

結果:插管持續時間,成功率和藥物增加的次數在兩組之間並無差異。最終血藥濃度在3.9 ± 1.4 µg/mL (P)2.4 ± 0.8 ng/mL (R)(各自總量142 ± 55 mg 77 ± 27 µg)之時,插管條件在兩組中同樣好。插管後最低的spO2和最高的呼末CO2沒有差別。沒有觀察到喉痙攣和重大的血流動力學改變。在P組中出現了一例由於阻塞性呼吸暫停引起的缺氧。P組的患者顯著的更鎮靜和不合作。在R組中回憶發生更頻繁,而疼痛分數在兩組中同樣低。

結論RP靶控輸注可以迅速滴定,取得良好的插管條件和患者的舒適。R使患者更合作,在保持自主呼吸非常重要時使氣管插管更安全。

(俞佳譯 薛張綱校)

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.

 

 

探測生理監測的變化的一種新型軟體工具的評估。

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:我們已經開發了一種軟體工具(iAssist)協助臨床醫生在麻醉過程中監測生理資料以指導其醫療行爲。這個系統有跟蹤多種動態生理過程的統計性能和識別新的動態趨勢的能力。我們報道我們對這個工具的最新探索(在非第一時間)並將其對動態變化的探測結果與事後對動態變化的總體回顧進行了比較。我們假設了一個評價的綜合體,這個綜合體評價了旨在增強動態探測功能的監測設備。

方法:19名兒童和38名成人進入試驗,接受超過68小時的麻醉。在每個手術病例中,麻醉師在第一時間報告所有的監視器中已知的臨床變化。一個訓練有素的觀察者同時記錄口頭報告的變化和每個麻醉師的醫療行爲。同一個病例隨後由新型軟體工具(iAssist)離線評價。心率、呼末二氧化碳,潮氣量和呼吸頻率被用一個動態線性增長模型來模仿,這個模型的噪音分佈由一個適應性的卡爾曼濾波通過一個遞迴的期望最大化方法來估計。變化由自適應累積求和試驗來探測。無創平均動脈血壓和氧飽和度的變化通過一個從指數級重量移動平均濾波分離出來的濾波的自適應累積求和試驗來探測。在事後分析中,每個由iAssist探測到的變化被兩名臨床醫生用一個完整病例圖表的方式來獨立分級。遺漏的變化被記錄下來。

結果iAssist軟體工具探測到896例真陽性變化(平均12.76/小時),敏感度0.91,陽性預測值0.87.事後回顧鑒定出91個遺漏的變化(平均1.34/小時),真陽性率與假陰性率的總比例爲9.55。臨床醫生第一時間報導了209個變化趨勢(平均3.07/小時)。

結論:該演算法與視覺觀測整個趨勢相比較執行起來更有優勢。需要進一步的研究,以確定何時以及如何提請臨床醫師注意這些變化。

(張玥琪譯,薛張綱校)

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.

                                                      

 

機械通氣脫機期功能殘氣量的變化:一項前瞻性研究

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:降低壓力支援(PSV)下呼氣末正壓(PEEP)水平的通氣模式常在氣管插管危重病人拔管前使用,但是PSV對於功能殘氣量(FRC)的有何影響尚不清楚。在這項研究中,我們試圖探尋心臟手術病人術後脫機期FRC和肺功能的變化。

方法:LUFU系統(Dräger Medical, Lübeck, Germany)通過使用旁流氧氣分析儀分析混有氮氣的呼出氣體中的氧氣來估計FRC。心臟手術病人術後首先使用雙相正壓通氣(BiPAP),並附加10 mbarPEEP。適當調整供氣壓力上限使潮氣量達到of 6-8 mL/kg (BIPAP 10)30分鐘後,上壓和下壓限值均降低3 mbar (BIPAP 7)。當可測得患者自主呼吸時,將機械通氣模式轉換爲PSV下的持續氣道正壓通氣 (CPAP) 模式,並且使用之前與BIPAP相符合的壓力支援及壓力下限作爲CPAP的壓力水平。30分鐘後重復測量(CPAP 7_2)

結果10名患者入組研究,FRC減少(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)]; 方差多變數分析: 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)]; 方差多變數分析: P = 0.045)。全程PaCO(2)無顯著性變化(P = 0.221)

結論在心臟手術脫管期間FRC的下降最終可以(部分) 用肺泡不張的原因來解釋。這種變化能否對脫管期間有指導意義仍然需要進一步研究。

(張釗譯 薛張綱校)

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.

 

 

住院醫師專業化培訓:失敗的原因與改進措施

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.

 

專業化是住院醫師期間需要學習和被考核的主要內容之一。有綜述性文獻指出,專業化培訓並未得到完全地理解和實施。專業化培訓已經納入住院醫師教育計劃。但是,住院醫師有兩種學習途徑:明確安排的課程和潛移默化地學習。後者指住院醫師通過觀察院內同事所學到的行爲。這種潛移默化地學習對住院醫師專業行爲影響很大。針對這種情況,一項可以改進專業化培訓的措施不僅要包括主題學習,還應該給予個人思考各自知識和行爲的時間。這種自我反思有利於對專業的真正理解和實踐的發展,並可能提高專業能力。

(朱蘭芳譯 薛張綱)

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.

                                                          

 

心臟迴圈停止後的腦復蘇

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.

 

對於心臟驟停的病人,經心肺復蘇可以恢復50%的自主迴圈。然而大多數病人在復蘇後最終仍然死亡了。死亡原因主要是由於全腦的缺血。因此有必要在心跳停止後進行一些針對保護和保存腦功能的治療。幾年前,低溫治療被用於臨床。在一項隨機臨床試驗中,上述方法是可以改善心跳停止病人的生存率及神經系統結局。除了低溫治療,臨床或試驗中還有其他一些治療方法。這些方法包括血栓溶解治療,輸注特殊藥物,抗細胞凋亡藥物。在這篇文獻中,我們回顧了不同方法的病理生理背景及對大腦復蘇的療效。

(陳珺珺譯 薛張綱校)

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.


局麻藥對人類神經細胞的細胞毒性作用

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:除了抑制外周神經的興奮傳導,局麻藥對中樞神經系統、心血管系統、神經肌接頭和細胞代謝有毒性作用。術後不同的神經系統的並發症與局麻藥的細胞毒性有關,但根本機制尚不清楚。由於臨床上應用局麻藥的濃度遠高於抑制離子通道的EC50,因此離子通道被阻滯不能解釋局麻藥所致的細胞死亡,應該有其他作用參與了細胞死亡。在我們的研究中,我們比較了6種我們常用的局麻藥的細胞毒性作用,從而討論其根本的毒性機制。

方法:人SH-SY5Y神經瘤細胞暴露於六種局麻藥(布比卡因、羅派卡因、甲派卡因、利多卡因、普魯卡因和氯普魯卡因),通過MTT-(3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetra-odium bromide) 比色法測定生存的數量,通過熒光成像的方法,測定LIVE/DEAD®反應物(calcein/AM and ethidium homodimer-1)評估質量。 此外,通過FLICATM測定與細胞凋亡相關的caspase-3/-7的啟動。此外,還評估了局麻藥介導的去極化和氯化氨甲酰膽鹼激動引起的胞內Ca2+的反應。

結果1)治療十分鐘後,所有六種局麻藥均可以濃度依賴性的降低細胞的存活率。它們的致死的能力爲普魯卡因≤甲派卡因<利多卡因<氯普魯卡因<羅派卡因<布比卡因(LD50,指50%的細胞死亡的濃度)。在這六種局麻藥中,只有布比卡因和利多卡因在增加濃度的情況下可以殺滅所有的細胞。2)布比卡因和利多卡因都可以啟動caspase-3/-7Caspase的激動依賴于高濃度的利多卡因和布比卡因。此外,布比卡因啟動caspase的速率低於利多卡因。高濃度的利多卡因可以立刻啟動caspase,但是在濃度低於10mM時,不能顯著激動caspase3)普魯卡因和氯普魯卡因可以濃度依賴性地抑制由去極化和受體激動介導的胞漿Ca2+的反應,這一現象在先前的有關布比卡因、羅派卡因、甲派卡因的利多卡因的研究中也觀察到。沒有一種局麻藥可以顯著增加基礎或Ca2+誘導胞漿Ca2+水平。

結論:局麻藥可以造成細胞的快速死亡,主要的原因是壞死。利多卡因和布比卡因可以時間或濃度依賴性的觸發細胞凋亡。這可能與術後神經系統損傷有關。利多卡因可以導致短暫的神經系統症狀,但並不是毒性最大的局麻藥;而布比卡因很少導致暫時的神經系統症狀卻是毒性最大的局麻藥。這提示了不同的局麻藥的細胞毒性導致的神經系統損傷有多種機制參與。

(陳珺珺譯 薛張綱校)

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.

 

 

苄呱酚醇導致的抗傷害感覺和降低慢性後根神經節壓縮小鼠的脊髓背角NR2B亞單位的表達

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-天冬氨酸在神經性疼痛的發病機制中起了重要的作用,給予N-右旋甲基-天冬氨酸受體拮抗劑可以減弱這種痛覺過敏。苄呱酚醇是N-右旋甲基-天冬氨酸受體2B(NR2B)的選擇性拮抗劑。有一些研究證明,在動物實驗中,苄呱酚醇對神經性疼痛有鎮痛作用。我們將這方面的研究延伸至後根神經節慢性壓縮(CCD)引起的反應。

方法:我們通過測試小鼠手掌對機械刺激和溫度刺激反應閾值變化,來評估CCD小鼠在鞘內注射苄呱酚醇後對機械刺激和溫度痛覺過敏的情況。我們使用了免疫組化和免疫印迹的方法來研究苄呱酚醇對CCD小鼠NR2B亞單位表達的影響。

結果:這些資料揭示了,在CCD小鼠上,脊髓背角表面NR2B的表達有所增加。我們發現,除了抑制對溫度和機械刺激的痛覺反應,鞘內注射苄呱酚醇還可以抑制脊髓NR2B的表達。

結論:這些資料表明,在CCD小鼠身上,苄呱酚醇可以對抗傷害性感覺,並進一步證明NR2B與神經性疼痛有關。

(陳珺珺譯 薛張綱校)

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.

 

 

超聲引導下的閉孔神經阻滯:一種新的關於超聲方法的研究

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:閉孔神經阻滯是對技術有最高挑戰性的區域阻滯中的一種。最近,通過超聲手段描述了神經的特性。然而,臨床上尚沒有應用超聲引導下對病人進行閉孔神經阻滯的報道。在我們的研究中,我們使用了超聲手段,分別對屍體、志願者及病人的閉孔神經及其兩分支的解剖位置進行描述。

方法:通過超聲對屍體進行研究,高回聲三角區由恥骨支上緣,恥骨肌內側緣和閉孔肌的外側緣組成,其中包括閉孔血管和神經。在八名志願者中,我們獲得了兩根閉孔神經的影像學及其到特定標誌的距離(股動脈、股靜脈和恥骨結節)。通過先前確定的進路,在超聲引導下對15名病人進行了閉孔神經阻滯。我們記錄了針尖到股動脈的距離,穿刺點到恥骨結節的距離和進針深度。

結果:在志願者上,通過超聲可見閉孔神經主幹、前後分支的的比例分別是12/16,13/167/16。在志願者身上獲得的特定標誌間的距離分別是:閉孔神經-股靜脈爲12.9 ± 2.9 mm ,閉孔神經-恥骨結節爲19.9 ± 2.6 mm。在病人身上獲得的測量資料爲:股動脈-針尖距離爲 18.5 ± 2.4 mm,進針深度爲 48.3 ± 10.4 mm,恥骨結節- 穿刺點的水平距離爲 18.8 ± 2.0 mm,恥骨結節-穿刺點的垂直距離爲 21.1 ± 2.9 mm。與基礎值相比,在病人處得到的直觀類比標度計分較低。93%的病人(15人中14人)對阻滯的效果表示滿意。

結論:在超聲引導下,可以通過標誌對病人進行閉孔神經阻滯。

(陳珺珺譯 薛張綱校)

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.

 

快通道麻醉與心臟手術:7989例患者的回顧性佇列研究

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:快通道心臟麻醉(FTCA)已被廣泛地應用於臨床,但它的安全性還沒有得到強有力的研究支援。

方法:作者比較了FTCA患者及既往常規大劑量阿片類藥物心臟麻醉(CCA)的患者的預後。主要預後指標爲住院期間死亡率。次要預後指標爲住院期間急性心肌梗死、腎衰及中風的發生率。同時比較機械通氣的持續時間,ICU住院天數以及術後住院天數。

結果 CCA4020例,FTCA3969例。FTCA組病人年齡略大,較多並存疾病及較多的換瓣手術。住院期間死亡率CCA組爲1.9%FTCA2.3%FTCACCA組與死亡率比值爲1.2095%區間,0.65-1.32P=0.66),調整後比值爲0.92。住院期間心肌梗死率CCA5.2%FTCA5.5%P=0.61,中風發生率CCA0.9%,FTCA1.3%(P=0.06),腎衰發生率組間相當(0.8%P=0.84)。FTCA組機械通氣時間短於CCA組(6vs12hP ≤0.001),但ICU入駐時間平均值要比CCA組長1小時(23vs22hP ≤0.001)。雖然兩組的住院時間平均值都是6 天,但CCA組第90百分位病人的住院天數爲13 天,FTCA組爲18 天(P ≤0.001)。

結論 源自7989例心臟手術病人的資料顯示沒有證據表明應用FTCA增加不良後果的風險。

(鄭麗 陳傑 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.


血小板減少的情況下纖維蛋白原的水平對彈性血栓變數的影響

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:纖維蛋白原和纖維蛋白與血小板結合在正常的止血過程中非常重要。ROTEM法常用於測量血凝塊粘彈性強度以衡量血小板纖維蛋白結合的程度。在這個研究中,作者用ROTEM法研究纖維蛋白原濃度及其在總血塊強度中的作用。

方法:採集健康志願者血液標本。血小板計數對血凝塊強度〔通過測量血凝塊最大彈性(MCE)〕的影響通過ROTEM評估。富含血小板血漿(PRP)用自體血漿調節到一般水平血小板計數再測量。PRPs被調整爲10 x 103 mm–3 50 x 103 mm–3100 x 103 mm–3,纖維蛋白原濃度集中在550780mg/dl。用FIBTEM法在不依賴血小板附著作用下分析纖維蛋白對血塊的聚合作用。另外回顧性分析兩組中血小板減少患者血塊強度(MCE)。

結果:血塊強度在血小板計數低於100 x 103 mm–3時減少,計數多於400 x 103 mm–3時血塊強度增強。即使在低血小板計數(10 x 103 mm–3)時,增加纖維蛋白原濃度呈濃度依賴性增加血凝塊強度。在904例血小板減少患者分析獲得的資料證實了血凝塊強度和血漿纖維蛋白原水平呈正相關。

結論ROTEM法分析體外及臨床資料表明:纖維蛋白原濃度是獨立於血小板計數之外的血栓強度影響因素。在血小板減少症的患者中維護纖維蛋白原濃度是至關重要。EXTEMFIBTEM在指導纖維蛋白原補充治療中有重要意義。

(劉世文 陳傑 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.


輸血相關急性肺損傷:對臨床醫師的進展

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.

 

在美國輸血相關的發病率和死亡率的首要原因是輸血相關的急性肺損傷(TRALI)TRALI診斷標準爲:在可以排除心衰或血管容量負荷過重的情況下,輸血6小時內的發生的缺氧和雙肺水腫。主要的鑒別診斷是輸血相關迴圈超負荷。支援治療的方法包括給氧和機械通氣。利尿並無特效,激素的作用也未證實。患者通常數天內痊愈。所有類型的血液製品都曾與急性肺損傷相關。但是,富含血漿成分的製品,如新鮮冰凍血漿和血漿分離置換法血小板,最常發生。目前尚不能完全解釋急性肺損傷的發病機制。多數情況下與針對人類白細胞抗原( HLA I/人類白細胞抗原II類或中性粒細胞特異性抗原[尤其是HNA- 3A]的抗體, 和供血者血漿裏的白細胞抗體有關。肺血管內皮細胞的活化是導致急性肺損傷的重要因素,可能解釋了手術或重症監護病房裏觀察到的患者的大多數情況。輸血中的白細胞凝集抗體結合肺血管內皮細胞局部的中性粒細胞,導致啟動和釋放氧化酶和其他有害生物活性物質,造成毛細血管滲漏。在少數急性肺損傷中下,不能證實存在抗體,則假定輸注的血液成分裏的中性粒細胞促發因素可以調節急性肺損傷患者肺血管內皮活化,所謂的兩次打擊的機制。對抗白細胞抗體作用的進一步認識,以減少了引起急性肺損傷風險。曾經懷孕過一次的女性血液中常常帶有HLA抗體,總患病率爲24 %,其發生概率隨曾經懷孕的次數而遞增。自從認識到HLA抗體同急性肺損傷有關,中心血站已採取策略是主要從男性的捐助者獲取血漿成分。爲了降低機采血小板相應的風險,採取事先檢測女性血小板捐助者的HLA抗體。需要更進一步的研究來瞭解導致急性肺損傷相關血液成分和患者的危險因素,推廣新的治療方案和措施,以減少發生急性肺損傷的風險。

(葉樂 陳傑 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左旋布比卡因和羅呱卡因用於小兒骶管麻醉的相對鎮痛效應

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:目前尚無新型局部麻醉劑左旋布比卡因和羅呱卡因骶管麻醉最小鎮痛濃度的相對效應比較研究。本文作者進行了一項前瞻性,隨機,雙盲研究,以確定在兒童骶管單次羅呱卡因和左旋布比卡因最低鎮痛濃度和劑量反應曲線。

方法:前瞻性、隨機、雙盲研究比較兒童骶管羅呱卡因和左旋布比卡因鎮痛的劑量反應曲線。第一部分, 80名男童隨機接受羅呱卡因或左旋布比卡因。第二部分,32名患者隨機接受劑量爲ED50-ED95 範圍內50%有效劑量以描繪劑量反應曲線。

結果:以羅呱卡因和左旋布比卡因行骶管阻滯的ED50無顯著差異。以狄克遜法估計左旋布比卡因ED500.069 95 CI0.056 -0.082 )和羅呱卡因是0.075 95 CI0.058 -0.092 。左旋布比卡因等張回歸法ED50ED95分別爲0.068 0.04-0.09 )和0.20 95 CI0.16 -0.24 。羅呱卡因ED50ED95分別爲0.066 0.033-0.098 )和0.225 95 CI0.21 -0.24

結論:兒童接受一個MAC的七氟醚下,左旋布比卡因和羅呱卡因骶管阻滯ED50沒有顯著性差異的。ED50藥效比爲0.92ED95藥效比爲0.89 ,表明左旋布比卡因和羅呱卡因在骶管麻醉時有相似的效力。

(張磊 陳傑 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.


高鐵血紅蛋白症與局麻藥關係:242例個案的總結

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:本文的目的是總結在醫學文獻中有關局部麻醉劑相關高鐵血紅蛋白血症的個案。 
方法:作者用以下的關鍵字:局部麻醉劑高鐵血紅蛋白血症在美國國立圖書館的醫學文獻中進行了檢索。
結果:共有242個個案( 40.1 %刊登在2000年或之後)。紅褐色的血液表明高鐵血紅蛋白血症,但其他顔色可能會被發現。在91.8%的個案中脈搏血氧儀飽和度( 小於或等於 90 )與動脈血氧分壓( 大於或等於 70毫米汞柱)存在偏差。用脈搏血氧儀測定的血氧飽和度和共同血氧飽和度之間的差異從-6.2 %至44.7 6個月以上的兒童使用劑量超過2.5 mg/kg的單純丙胺卡因可誘導高鐵血紅蛋白血症。在成人,丙胺卡因的劑量應低於5.0mg/kg.,存在腎功能不全時減少到3.2 mg/kg.和如果同時使用其他氧化藥物時減少到1.3 mg/kg.。一個單純苯佐卡因噴霧劑可能導致高鐵血紅蛋白血症。在相對較低的血紅蛋白值時可以觀察到臨床症狀,包括32.2%的兒童和29.1 %的成人出現昏迷。在給予亞甲藍後,59.9 %患者出現反彈性高鐵血紅蛋白血症並持續18h。高鐵血紅蛋白血症的並發症包括缺氧性腦病,心肌梗塞和死亡。 
結論:苯佐卡因不應繼續使用;丙胺卡因不應使用於6個月以下兒童,孕婦,或服用其他氧化藥物的病人。其他患者應用劑量應限制在2.5 mg/kg以內。

(張燕 陳傑 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.



大鼠氙氣預處理:促存活信號、線粒體滲透性轉變和生物能學的作用

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:揮發性麻醉惰性氣體氙氣對心臟缺血/再灌注損傷具有保護作用,但對這一現象的機制並不完全理解。作者測試了氙氣啟動促存活信號激酶這一目標線粒體來誘發心肌保護這一假設。

方法:雄性Wistar大鼠在血流動力學監測下接受30min左冠狀動脈前降支阻塞和2 h再灌注。大鼠隨機接受70 氮氣/30 %的氧氣(對照組)或三個周期的吸入70 氙氣/30 %氧氣5min間隙吸入氧/氮混合氣體5min。使用三苯染色測量心肌梗死面積。對照組和氙氣處理組大鼠的離體心臟用於磷酸化AktGSK - 3βWestern免疫印迹和孤立的線粒體。線粒體缺氧/複氧前後的氧耗決定了線粒體通透性轉換孔的開放。

結果:與對照組相比,氙氣顯著減少心肌梗死面積( 32 ± 459 ± 4 %,P < 0.05 )和增加磷酸化AktGSK- 3β 。與對照組相比,氙氣預處理保存分離線粒體的呼吸狀態。氙氣預處理組誘導線粒體膜去極化所需的Ca2 +濃度較大(分別爲 78 ± 1756 ± 17 μm 。磷酸肌醇-3激酶的抑制劑wortmannin阻止了氙氣對梗死面積和呼吸的效應。

結論:結果表明,氙氣預處理減少心肌梗死面積, 磷酸化 AktGSK-3β,維護線粒體功能,抑制鈣離子誘導的線粒體通透性轉換孔開放。這些資料表明,氙氣誘導心臟保護的發生,是因爲啟動促存活線粒體,並使它們更不容易受到缺血再灌注損傷。

(舒慧剛 陳傑 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.


心衰患者迴圈支援時的無創心排出量監測

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:儘管存在效力不明、使用困難、安全性等問題,肺動脈導管(PAC)監測仍廣泛用於圍術期心臟外科重症監護室病人血流動力學的監測和管理。 USCOM是一種無創性連續多普勒波直接測量心輸出量( CO )的裝置,可作爲PAC的替代者。 儘管USCOM的可靠性未獲公認,相對於PAC該方法在心臟外科重症監護病房中有著更好的可用性。作者在應用完全型人工心臟 (TAH)控制心衰患者中比較了應用USCOMCardioWest監測心輸出量的差別。
方法:使用CardioWestUSCOM裝置來雙盲監測心衰行TAH患者的心輸出量、每搏輸出量(SV)和心率( HR CardioWest 通過187個專案的測試獲得了508個不同的配對資料。用Bland-Altman法分析比較。

結果CardioWest USCOM測得的心輸出量、每搏輸出量和心率的平均值及標準差( ±標準差)分別爲7.33 ± 0.467.34 ± 0.51L/min 56.2 ± 3.856.6 ± 3.8 mL131 ± 3130 ± 4bpm。心輸出量在5.29.3 L/min之間。兩種方法對測量心輸出量、每搏輸出量和心率的平均差分別是-0.01 ± 0.23 L/min -0.34 ± 1.97 mL0.9 ± 2.3bpm,平均百分比差異分別爲-0.3 -0.6 %和0.7 。心輸出量、每搏輸出量和心率的一致性百分比分別爲6.4 7.1 %和3.6
結論 對心衰行TAH的患者USCOM是一種可行的、準確的測量和監測心輸出量的方法,可能在心血管疾病診斷和處理上有更廣泛地的應用價值。

(丁俊雲 陳傑 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.

 

 

圍術期微創監測心排出量

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.

 

隨著患者年齡的增長及其並存病的升高,我們日益需求圍術期對患者的生理學指標,如心排出量(cardiac outputCO)、液體治療後的回應性和組織灌注情況進行跟蹤監測的設備。 麻醉醫師所持有的用於監測患者CO的工具 是肺動脈導管或者經食管超聲心動圖。這些裝置都存在著一定的缺陷,並且可能會引起並發症。最近,已有一些新的裝置投入市場(包括食管多普勒監測、脈搏波形分析、指示劑稀釋、胸部生物電阻抗和部分無重復吸入系統等),它們能夠無創監測CO,並且在某些情況下評估患者對液體治療的反應。在這篇綜述中,作者描述了這些新裝置所涉及的技術,有關應用的研究,以及它們在應用過程中的缺陷。

(周姝婧 陳傑 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.


混合皮層神經元-神經膠質細胞培養遭受氧糖缺失時的早期麻醉預處理:在七氟醚誘導時産生的神經保護作用中,三磷酸腺苷依賴性鉀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:這項關於混合皮層神經元-神經膠質細胞培養遭受短時氧糖缺失(OGD)的研究的目的是 1)比較在氧糖缺失之前(預處理)或期間(直接神經保護)增加七氟醚所産生的神經保護作用。2)探討在七氟醚的早期預處理作用機制中,三磷酸腺苷敏感性鉀(KATP)通道參與的可能性和細胞內活性氧(ROS)的水平。

方法:成熟的混合皮層神經元-神經膠質細胞在厭氧培養室裏暴露90min的氧糖缺失,隨後複氧。OGD前隨機給予七氟醚(0.03-3.4Mm90min和停用60min(早期預處理)或 OGD期間應用七氟醚90min(直接神經保護作用)。在乳酸脫氫酶釋放到培養基法量化24小時細胞死亡數。用2’-7’ 二氯熒光素乙酰乙酸鹽來評估七氟醚預處理後細胞內活性氧的産生。

結果:七氟醚濃度高於0.07Mm的預處理産生強大的閾值依賴性神經保護作用,氧糖缺失時七氟醚引起劑量依賴性神經保護作用。三磷酸腺苷敏感性鉀通道阻滯劑(格列本脲0.3μM5羥基癸酸50μM),或者活性氧清除劑(N-2-巰丙酰氨基乙酸100μMN-乙酰半胱氨酸50μM),儘管它們不影響細胞活力,但抵消了由七氟醚早期預處理産生的神經保護作用。在預處理期間的七氟醚暴露使得活性氧水平顯著提高,而這可以被活性氧清除劑和三磷酸腺苷敏感性鉀通道阻滯劑所阻止。

結論:早期的七氟醚預處理産生混合皮層神經元-神經膠質細胞培養的閾值依賴性保護,可能通過打開三磷酸腺苷敏感性鉀通道,從而産生活性氧的機制來對抗氧糖缺失。

(黃丹 陳傑 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%定量利多卡因噴霧泵對創傷後外周神經病變的鎮痛作用:一項初步研究

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:利多卡因表面貼片能夠有效地治療創傷後外周神經病變(posttraumatic peripheral neuropathyPTPN),但由於需要額外使用,它不適用於爆發性疼痛。在這裏,作者評估了8%利多卡因噴霧泵(Xylocaine pump sprayXPS)對由手術或損傷所致的外周神經病理性疼痛的效果。

方法:31PTPN患者被隨機分爲2組,一組接受XPS,另一組接受生理鹽水噴霧泵作爲空白對照組,將藥物噴灑于兩組患者疼痛部位的皮膚表面。噴灑的最佳劑量爲能夠完全覆蓋疼痛區域,據個人情況而定,最多可達30噴(0.1ml/噴,30次)。7天後,將兩組患者交叉接受另一噴劑的治療。用視覺類比評分評估患者的疼痛情況。

結果XPS而不是空白噴霧泵能夠顯著地降低持續疼痛和觸覺異常的視覺類比評分。應用後,其鎮痛效果平均可持續5h(範圍,2-60h)。在3位元應用XPS的患者中發生了輕微的並發症,包括局部激惹症狀(n=3)和局部燒灼感(n=1)。這些並發症無需藥物治療而在數小時後消失。

結論:目前的研究顯示,XPS可以有效地改善PTPN,能夠迅速鎮痛,沒有全身性的副作用,且使用方便。

(周姝婧 陳傑 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.

 

一個可吸收的局麻藥裝置提供數天的功能性坐骨神經阻滯

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:周圍神經的功能性阻滯是局部麻醉的基本目的,期待其作用持久,涵蓋或超過整個手術期。現有的局麻藥在一個單劑量給藥後提供的有效鎮痛時間小於8—12h。作者報告了一個可用於骨科,植入性的、可控制釋放的藥物給予裝置, 包括一個FDA批准的包含利多卡因基質),能夠局部釋放幾天之久。

方法Xybrex,一個可吸收,控制釋放的給藥裝置,包括16%w/w)利多卡因,在雄性大鼠(300-350 gm)中植入在坐骨神經附近,每只大鼠的利多卡因劑量分別爲5.310.61632mg。作爲對照,鹽酸利多卡因溶液(0.2 mL 2% = 4 mg)注射在非常靠近坐骨神經的地方。通過用鑷子夾捏外側腳趾的行爲來評估大鼠痛覺,同時通過量化伸肌的推力來評估運動阻滯。在植入後24h4d4wk評估可能的坐骨神經的神經毒性。在體外測量利多卡因從裝置中釋放動力學。在2.56.51024.25h時收集樣本測定利多卡因。

結果Xybrex在高劑量(分別爲300600mg/ka,包含1632mg的利多卡因游離堿)提供了對於一個強烈的夾捏完全的鎮痛分別爲7.0 ± 2.0 h, 6.9± 1.7 h ,和一個不完全的鎮痛分別爲60.0 ± 5.4 h, 58.8 ±4.2 h,相對於由2%的利多卡因溶液(包含4mg利多卡因)引起的坐骨神經阻滯完全鎮痛爲 0.61± 0.03 h 和不完全鎮痛爲0.96 ±0.03 h 。這些同樣高劑量的Xybrex 産生了完全的運動阻滯分別爲17.0± 3.3 h, 17.6 ± 3.3 h ,並且完全恢復分別爲352.0 ± 55.7 h (14.7 ± 2.3 d) 579.0 ±36.1 h (24.1 ± 1.5 d)。資料以平均 ± SE的形式記錄。所有的Xybrex 組和2%利多卡因組相比時P < 0.001 。在靠近坐骨神經0.1mm的結締組織和肌肉中小的局部組織炎症/病狀,兩組動物中均能觀察到。實驗中沒有全身中毒徵象。離體研究顯示藥物釋放呈指數動力學特徵,對比無時程性傷害缺乏意味著持續傷害性刺激在神經與該藥裝置間利多卡因直接的、局部作用,而無先前釋放藥物的累積效應

結論:Xybrex是一個可吸收的,控制釋放的藥物給予裝置,能夠提供大鼠周圍神經數天的鎮痛,無顯著的局部神經毒性或者系統性毒性。

(懷曉蓉 陳傑 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 andits 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.

 

應用皮膚溫度評估鎖骨下臂叢神經阻滯效果的有效性

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:儘管有研究表明應用皮溫升高來評估神經阻滯效果比應用針刺覺及溫度覺改變來評估具有更高的特異性和敏感性,但原先應用的方法需要電腦輔助紅外熱成像,該方法價格昂貴且需要嚴格的專業培訓。在本前瞻性觀察研究中,作者使用簡易紅外溫度儀評估鎖骨下臂叢神經阻滯效果是否可靠。

方法:選擇應用鎖骨下臂叢神經阻滯行上肢手術的患者30名。自局麻藥注射後起,在四個主要神經分佈區域進行皮膚溫度測量,同時在注藥後30min內每隔5min測量感覺阻滯(痛溫覺喪失評分爲0,正常痛溫覺爲2)。本研究中神經阻滯成功的定義爲:在局麻藥注射後30min內,四個主要神經分佈區域(橈神經,尺神經,正中神經,肌皮神經)的溫度覺(酒精棉球擦拭)和痛覺(針刺覺)評分爲0。以非接觸式溫度探頭測量皮膚溫度。

結果:被阻滯神經總數爲12030位患者,每位患者4根神經)。其中25例患者神經阻滯成功,4例由於阻滯失敗需要靜脈麻醉輔助,1例患者實施全麻。不同神經分佈區域的皮膚溫度變化無顯著性差異。同一區域的皮膚溫度在神經阻滯後升高,與阻滯前相比有顯著性差異(T5T30P < 0.0001)。同一時間神經阻滯區域與非神經阻滯區域的平均皮膚溫度有顯著性差異(T5P < 0.05 T10T30P< 0.0001)。當阻滯後5分鐘和10分鐘,特定感覺區域的皮膚溫度升高≥1°C,則對應的神經被阻滯(評分=0)。因此,當阻滯後5分鐘和10分鐘四條神經區域的皮膚溫度都發生變化,那麽在30分鐘後神經成功阻滯。本研究中,患者的對側上肢和中心體溫無變化。

結論:使用簡易紅外溫度儀通過測定皮膚溫度來評估神經阻滯效果,這一方法簡單、可靠,且能在早期預示神經阻滯的成功。

(趙嫣紅 陳傑 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.

 

一篇就文獻進行的系統性回顧:血栓彈性描計法可以預測術後血栓栓塞的發生麽?

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:由於血栓彈性描計法(TEG)可以檢測出高凝狀態,因此它可以作爲預測術後血栓栓塞發生的有效方法,就此我們系統性地回顧了文獻來評估TEG預測術後血栓發生的準確性。

方法:兩位互不干擾的研究人員分別搜索了PUBMEDEMBASE電子資料庫,查找出包含圍術期進行TEG測試並用參考標準判斷結果的成年手術病人的前瞻性研究。評價包括的研究的質量並評估包括的每一項研究的診斷性測試準確性值。

結果:本次分析有10篇研究入選(共1056位病人),但是只有5篇文獻報道了TEG測試的準確性

 

 

 

。研究的總體質量和診斷評估的水平從好到差

異很大。由於血液高凝的定義、TEG方法、病人的特

征、

所用

的參考標準和測得的結果有變異性,所以沒有採用薈萃分析。敏感度和特異性的範圍分別從0%100%62%92%。診斷優勢比從1.527.7,曲線下面積從0.570.91。在TEG的各變數中,最大振幅可以作爲鑒別

血液高凝狀態和預測血栓栓塞發生的最好參數。

結論TEG預測術後血栓栓塞的發生的準確性變異較大。爲了確定TEG是否是高危外科手術人群中臨床上有用的篩選試驗,我們還需要進行更多的前瞻性研究。

(姜旭暉譯,馬皓琳,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.

 

輸血的非感染性嚴重風險

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

由於獻血者問卷的改良及尖端的感染性疾病的血液篩選技術,非感染性嚴重風險(NISHOTs)已成爲輸血最常見的並發症。NISHOTs的種類很廣泛,包括從能恰當描述的

 

且已歸類的輸血反應(溶血、發熱

、膿毒血症和變應/ 蕁麻疹/過敏)到更罕見的並發症。這些包括誤輸血、輸血相關的急性肺損傷

、輸血相關的迴圈超負荷、輸血後紫癜、輸血相關的移植物抗宿主病、微嵌合狀態、輸血相關的免疫調製、同種異體免疫、代謝紊亂、大量輸血導致的凝血障礙、紅細胞存儲損傷引起的並發症、輸血過多或輸血不足導致的並發症及鐵超負荷。

近幾年,NISHOTs在出版社及科學界均比以前受到更多關注。由於輸血引起的潛在並發症越來越多,研究者們已

關注自由與限制紅細胞輸注的發病率及病死率比較,及輸注“陳舊血”與“新鮮血”潛在危險的對比。本文回顧了集中於最近的關注和文獻的NISHOTs

(裘毅敏譯,馬皓

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.


産婦的心臟手術

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

心臟疾病爲妊娠期非産科性死亡的主要原因,在産婦中的發病率爲1-3%,由此引起的孕産婦死亡率爲10%—15%。先天性心臟病在育齡婦女已越來越多見,占妊娠期心臟疾病的比例越來越高(可達75%)。孕産婦未經治療的心臟疾病使得胎兒也處於危險之中。新生兒並發症的獨立預測因素包括産婦紐約心臟協會心衰分級>2、妊娠期抗凝藥物的運用、吸煙史,多胎妊娠和左室流出道梗阻。由於産婦心外科手術發病率和死亡率高於非妊娠患者,故大多數有心臟疾病的産婦首先接受藥物治療,同時準備在藥物治療失敗後接受心外科手術治療。心外科手術期産婦死亡的危險因素包括血管活性藥物、年齡、手術類型、二次手術和産婦心功能分級。胎兒死亡的危險因素包括産婦年齡>35歲、心功能分級、二次手術、急診手術、心肌保護的類型和缺氧時間。雖然如此,通過如下措施可達到可以接受的産婦和胎兒圍術期死亡率:術前早期發現産婦心血管失代償狀態、採用胎兒監護、在手術前分娩可存活胎兒以及在妊娠4月到6月時安排擇期手術。此外,體外迴圈期間使産婦攜氧能力和子宮血流量達到最佳狀態也可降低胎兒死亡率。目前産婦體外迴圈的建議包括:1)維持泵流量>2.5 L · min–1 · m–2 、灌注壓 >70 mm Hg2)維持血細胞比容> 28%3)如果可行,採用常溫灌注;4)採用搏動血流;5)採用α-pH穩態管理。

(周雅春    馬皓琳 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.


即時評估圍術期行爲和預計圍術期預後

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:新出現的適應不良行爲,例如發脾氣、做噩夢、遺尿、注意力障礙和害怕孤獨常見於小兒門診手術後。術前焦慮、恐懼和困擾行爲常預示小兒術後會有適應不良行爲和譫妄。父母的焦慮也會影響到小兒的術前焦慮。到目前爲止還沒有即時和可行的方法可以有效地測定小兒及其父母圍術期的行爲。我們建立了一個簡單的即時評分方法——圍術期成人小兒行爲相互作用評分(PACBIS),用來評估圍術期小兒及其父母的行爲,這可能有助於預測小兒術後是否會出現有問題或蘇醒期興奮的行爲。

方法:我們使用PACBIS評估89例行扁桃體切除術或增殖體切除術的小兒及其父母在麻醉誘導和恢復期的行爲。記錄用改良耶魯術前焦慮評分法測定的術前焦慮狀況、用誘導順應評分表評估小兒在麻醉誘導時的順從程度以及蘇醒期興奮的發生率。

結果:PACBIS與改良耶魯術前焦慮評分法和誘導順應評分表在有效性方面高度一致,能很好預期小兒麻醉後蘇醒期興奮。

討論: PACBIS是第一種可用來評估小兒及其父母圍術期行爲的即時評分方法。PACBIS鑒別出的特殊行爲可提供干預的目標,以改善圍術期經歷和術後預後。

(張瑩譯 李士通 馬皓琳 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.


殘餘肌松對Sugammadex肌松拮抗速度的影響

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是一種改良的γ環糊精複合物其將羅庫溴銨包裹起來導致殘餘肌松的快速逆轉。我們對一個多中心的研究得到的資料進行了post hoc分析,模仿了標準的臨床試驗以驗證假說,即在給予拮抗藥時對神經肌肉刺激肌有無顫搐反應是否會影響sugammadex的逆轉效應的速度和完全性。

方法:171名行以揮發性麻醉藥爲基礎行全身麻醉並同意進行試驗的病人加入了多中心觀察性研究。所有的病人用羅庫溴銨0.6 mg/kg靜脈注射行氣管內插管,手術中需要時用0.15 mg/kg推注維持。從麻醉誘導到手術過程結束後四個成串(TOF)比率(TOFR)恢復到≥0.9,用TOF-Watch®-SX加速度肌松監測儀在筆記本電腦記錄TOF反應,評價羅庫溴銨引起的阻滯深度。在羅庫溴銨末次劑量後>15min給予sugammadex 4 mg/kg靜推,以拮抗其神經肌肉阻滯。將在給予拮抗藥時對TOF刺激沒有反應 (n = 89)或有≥1個肌顫搐 (n = 82)的病人的恢復資料進行比較。

結果:沒有肌顫搐出現的病人較多是女性(占60%),並且這些病人的羅庫溴銨末次劑量與給予拮抗藥之間的時間間隔較短 (31±1845±23 min, P < 0.05)。無肌顫搐組的TOFR恢復到0.9的時間較出現1個以上肌顫搐組長(173±162104±73 s, P < 0.05)。總起來說,無肌顫搐組有84%的病人的TOFR5min內恢復到0.9,而出現1個以上肌顫搐組則有91%病人(P < 0.05)。在無肌顫搐組和出現1個以上肌顫搐組,達到TOFR0.9的時間分別從0.8min 22.3min0.7min 8.5min

結論:sugammadex拮抗羅庫溴銨引起的神經肌肉阻滯,受到給予拮抗藥時殘餘肌松程度的影響。儘管有很大的變異度,不管給予拮抗藥時肌顫搐計數多少,都有多於80%的病人在5min以內TOFR恢復到0.9

(黃麗娜  馬皓琳 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.


本體感受功能對地氟烷麻醉的敏感性高於運動功能

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:評估亞制動麻醉劑量對運動的影響有助於明確麻醉劑引起制動的神經回路作用靶點。

方法:給予11只刺毀腦脊髓的北方豹蛙00.40.81.2倍産生制動效果的半數有效量(ED50)的地氟烷,額外7只隨機順序給予00.4 ED50地氟烷。採用前肢電刺激引出後肢擦拭反射,錄影記錄用於隨後分析。測量30s刺激過程中引出的後肢等長張力。

結果:0 ED50相比,0.4 ED50地氟烷組擦拭潛伏期從0.8(0.1, 4.0)明顯延長至17.3 (0.4, 30.0)s(中位數[最小值,最大值]);後足運動距離從0.42 (0.09, 1.82) 增加至 0.89 (0.16, 4.82) m;後足與刺激源之間的最短距離從1 (0, 5) 增加至7 (1, 40) mm。後足最大運動速度和等長張力沒有變化,但是後肢力從7.3 (1.7, 23.6) 減少至3.2 (1.4, 13.8) N. s,這相當於運動次數從12 (3, 28) 減少至 8 (2, 14)次。地氟烷劑量從0.4增加至0.8 ED50,運動功能的抑制效應開始顯現,表現爲最大張力從2.0 (0.6, 5.5)降低至0.8 (0.1, 1.6) N,總力從3.2 (1.4, 13.8)減少至0.9 (0.0, 2.5) N.s

結論:蛙類本體感受功能對麻醉劑引起抑制作用的敏感性高於運動功能。這表明,大多數參與傷害性刺激産生運動反應的脊髓神經回運動通路中對麻醉劑最敏感的成份快於運動神經元的水平。

(江繼宏   馬皓琳 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.

 

酒精濫用和圍術期中免疫功能紊亂

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

長期酒精濫用的麻醉學結局包括術後感染、重症監護病房滯留期延長和住院期延長的風險增加3-5倍。感染率增高的原因是改變長期酗酒病人的免疫反應改變。術前長期酗酒病人輔助型T細胞1/輔助型T細胞2比率受抑制,術後仍然受抑制。術前較更低的輔助型T細胞1/輔助型T細胞2比率預期著遲發的感染。長期酗酒病人術後細胞毒性淋巴細胞(Tc1/Tc2)比率降低,並且抑制持續5天。長期酗酒病人術後全血細胞中白細胞介素(IL-6/IL-10比率和脂多糖刺激的干擾素γ/IL10比率降低。術後期Tc1/Tc2IL-6/IL10和脂多糖刺激的干擾素γ/IL-10比率抑制是術後並發感染的先兆。圍術期干預目的應該是使免疫系統的調節失常降到最小。

(王宏翻譯,馬皓琳,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.


病人自控硬膜外鎮痛在分娩中的應用

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

病人自控硬膜外鎮痛(PCEA)在20年前就已應用於臨床分娩。PCEA技術與持續硬膜外輸注相比具有明顯的優勢。我們利用MEDLINE EMBASE(1988–200841)中所有在分娩中應用PCEA進行如下比較之一的隨機對照實驗進行了一個系統回顧:有無背景輸注劑量,用羅呱卡因還是布比卡因,高濃度還是低濃度局部麻醉藥,以及新方法或是標準方法。重要的結果資料有:母親鎮痛情況、滿意度評分、運動阻滯以及額外臨床醫生介入的發生率。持續背景劑量輸注提高了母親鎮痛水平,並減少了額外臨床醫生介入。高單次劑量(5mL以上)比低單次劑量能提供更好的鎮痛。低濃度的布比卡因或羅呱卡因可以提供極好的鎮痛並且無明顯的運動阻滯。PCEA的很多方法可提供有效的分娩鎮痛。持續背景劑量輸注的高容量稀釋局麻藥溶液似乎是一個最成功的方法。對新的給藥方式(例如程式控制強制性間斷劑量注射和電腦控制的反饋給藥)的研究正在進行中。

(黃佳佳譯,馬皓琳 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.


環磷腺苷反應單元結合蛋白磷酰化和4-苯基-14-苯丁基)呱啶(PPBP)的神經保護作用

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-受體激動劑4-苯基-1-(4-b苯基丁基) 呱啶(PPBP)能阻止初級培養的皮層神經元剝奪氧糖後細胞死亡。我們假設PPBP通過啟動轉錄因數環磷腺苷反應元素結合蛋白(CREB)相關的機制來保護神經元並對該假設進行了驗證。

方法: 原代培養皮層神經元暴露於OGD2小時,恢復24小時。在損傷前15分鐘開始PPBP處理,同時使用或不使用ς1-受體拮抗劑林卡唑以及已知能啟動信號傳導鏈而導致CREB磷酸化的蛋白激酶抑制劑,例如H89 (蛋白激酶A抑制劑)、 LY294002PI3K抑制劑)、U0126MEK1/2抑制劑)或KN62(鈣調蛋白激酶II抑制劑)。在OGD處理後24小時用乳酸脫氫酶測試法分析神經元細胞死亡。用免疫印迹分析法檢測再充氧後30min1h3hCREB磷酸化水平。用Quantity One圖像分析軟體對斑點作定量分析。

結果: PPBP 增加OGD恢復1h CREB磷酸化,該作用可被林卡唑取消(PPBP1.7 ± 0.2PPBP加林卡唑組0.8 ± 0.1,對照於只有OGD組爲0.9 ± 0.1p-CREB/CREB)。PPBP引起的CREB磷酸化增加可被H89阻斷(0.5 ± 0.07) 而非U0126KN62LY294002阻斷。PPBP處理能預防OGD導致的細胞死亡,而H89預處理會阻斷這種保護作用(PPBP0.18 ± 0.02PPBPH890.27 ± 0.03,對照於只有OGD0.33 ± 0.02,乳酸脫氫酶分析法)。LY294002UO126KN62預處理對PPBP的神經保護作用無影響。

結論:這些資料提示PPEP的神經保護機制可能與CREB磷酰化有關

(顔濤 馬皓琳 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.


辣椒膏用於合穀穴可減少正頜手術術後鎮痛劑的需求

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:辣椒膏用於經典的中國針刺穴位,是除針灸外的另一種能有效預防術後噁心嘔吐、咽喉痛和疼痛的方法。在本研究中,我們調查了辣椒膏用於合穀穴(LI 4)對雙側下頜升支矢狀劈開切骨術病人的術後鎮痛效果。

方法:一項雙盲、假性對照的研究在84名行正頜手術的患者中進行,患者被隨機指定到三個治療組(每組各28例)。合穀組:辣椒膏用於合穀穴,安慰劑貼在雙肩的非穴位處;假性組:辣椒膏用於雙肩,安慰劑貼在合穀穴;對照組:安慰劑貼在合穀穴和雙肩。辣椒膏在麻醉誘導前使用並在術後三天內每天維持8小時。

結果:術後24小時內病人自控鎮痛的總量(含6.5 µg/mL芬太尼和1.2 mg/mL酮咯酸)在合穀組(26.8 ± 3.4 mL)較對照組(44.2 ± 7.3 mL)和假性組(42.1 ± 6.9 mL)減少(P < 0.01)。合穀組較其他組,術後噁心嘔吐的發生率和額外藥物的需要減少,而且總體滿意得分更高(P < 0.01)

結論:辣椒膏用於合穀穴可減少正頜手術患者術後阿片類藥物的需求量以及阿片類相關的副作用。

(唐李雋    馬皓琳  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.


一種新型異二氫吲哚衍生物JM-1232(-)的鎮痛效應和藥理特性

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:一種異二氫吲哚衍生物JM-1232(-) 被作爲一種鎮靜和鎮痛藥來開發。我們進行本研究以觀察其對小鼠身上三種不同的傷害性感受的鎮痛效應。

方法:雄性ddY小鼠分別接受腹腔內(IP)注射JM-1232(-)1310 mg/kg(每一試驗的每一劑量n = 8)。使用生理鹽水作爲對照。IP注藥後120min進行熱板或夾尾試驗。乙酸試驗:在IP注藥後15min0.6%的乙酸溶液按10mL/kg進行IP注射。IP注酸後5min開始記錄腹部收縮的次數10min。當觀察鎮痛效應時,在給予最大有效劑量的JM-1232(-)之前分別皮下注射納絡酮或氟嗎澤尼。使用轉輪試驗,每5min記錄一次輪子轉動的數量,共記錄120min

結果:在熱板、夾尾和乙酸試驗中,IP JM-1232(-) 産生明顯的鎮痛效應,其50%有效劑量分別爲2.96 mg/kg (CI: 2.65–3.30 mg/kg)3.06 mg/kg (CI: 2.69–3.47 mg/kg)2.27 mg/kg (CI: 1.46–3.53 mg/kg)。在所有試驗中,JM-1232(-) 産生的鎮痛效應被氟嗎澤尼(5 mg/kg)而非納絡酮(10 mg/kg)所拮抗。在轉輪試驗中,JM-1232(-)對運動行爲無劑量依賴性作用。

結論:小鼠全身應用JM-1232(-)對急性熱、機械引起的疼痛以及內臟痛有鎮痛效應。這些效應可能通過苯二氮卓-{gamma}-氨基丁酸A型受體而不是阿片受體來介導。

(黃施偉 譯,馬皓琳 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.


大鼠後根神經節內注射利多卡因引起神經炎症

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: 選擇性脊神經阻滯過程中脊神經或後根神經節(DRG)的損傷是潛在的嚴重並發症,至今仍未被充分地研究。我們假設局麻藥注入這些組織會導致炎性反應及痛覺過敏。

方法:在部分椎板切除術後的大鼠L5脊神經或後根神經節注入4 µL利多卡因或生理鹽水,評估其炎性和行爲反應。在術前和術後通過足部傷害性機械刺激的反應來進行行爲測試,以此研究痛覺過敏。DRG被收集染色,計數神經元周圍的免疫反應性神經膠質細胞環。

結果:動物試驗證明在利多卡因注入DRG4天,而非在注入脊神經後,身體同側爪有痛覺過敏。DRGs中代表衛星細胞活化的神經膠質原纖維酸性蛋白免疫陽性膠質細胞環的數量在利多卡因注入DRG或脊神經後都明顯減少。注射利多卡因組的神經膠質原纖維酸性蛋白陽性細胞數量顯著大於注射生理鹽水組。零星的OX-42免疫陽性細胞代表有活性的小膠質細胞,在注射利多卡因的DRG中也能發現。標記活性T淋巴細胞的Pan-T表達試驗顯示無陽性細胞。

結論:DRG內注射利多卡因可能會引起痛覺過敏,可能由於固有的衛星膠質細胞活化所致。在臨床上,在選擇性脊神經阻滯中應該避免DRG內注射局麻藥。

(朱 慧譯 馬皓琳 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.