Table of Contents

April 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

术前脑利钠肽和术后肌钙蛋白水平对大血管手术患者预后意义的初步报告
舒慧刚 陈杰

A Preliminary Report on the Prognostic Significance of Preoperative Brain Natriuretic Peptide and Postoperative Cardiac Troponin in Patients Undergoing Major Vascular Surgery

Daniel Bolliger, Manfred D. Seeberger, Giovanna A. L. Lurati Buse, Peter Christen, Brian Rupinski, Lorenz Gürke, and Miodrag Filipovic

Anesth Analg 2009 108: 1069-1075.

再灌注早期的短暂性代谢性碱中毒中会消除氦预处理防止心肌梗塞能力:通过环孢霉素A对兔子心脏保护功能的恢复

唐亮   马皓琳 李士通

Transient Metabolic Alkalosis During Early Reperfusion Abolishes Helium Preconditioning Against Myocardial Infarction: Restoration of Cardioprotection by Cyclosporin A in Rabbits

Paul S. Pagel and John G. Krolikowski

Anesth Analg 2009 108: 1076-1082.

肝移植术中血小板输注与术后死于急性肺损伤情况增多有关

单嘉琪译 薛张纲校

Platelet Transfusion During Liver Transplantation Is Associated with Increased Postoperative Mortality Due to Acute Lung Injury

Ilona T. A. Pereboom, Marieke T. de Boer, Elizabeth B. Haagsma, Herman G. D. Hendriks, Ton Lisman, and Robert J. Porte

Anesth Analg 2009 108: 1083-1091.

双肺通气时在吸入的气体混合中使用空气延迟单肺通气时肺塌陷

刘世文 陈杰

The Use of Air in the Inspired Gas Mixture During Two-Lung Ventilation Delays Lung Collapse During One-Lung Ventilation

Raynauld Ko, Karen McRae, Gail Darling, Thomas K. Waddell, Desmond McGlade, Ken Cheung, Joel Katz, and Peter Slinger

Anesth Analg 2009 108: 1092-1096.

为胸外科手术选择合适的单肺通气装置:三种支气管阻塞器与传统双腔管的随机对照临床试验

范羽译 薛张纲校

Choosing a Lung Isolation Device for Thoracic Surgery: A Randomized Trial of Three Bronchial Blockers Versus Double-Lumen Tubes

Manu Narayanaswamy, Karen McRae, Peter Slinger, Geoffrey Dugas, George W. Kanellakos, Andy Roscoe, and Melanie Lacroix

Anesth Analg 2009 108: 1097-1101.

PEDIATRIC ANESTHESIOLOGY:

婴幼儿心脏外科手术中脑血氧含量:评估和术后早期结局的关系

丁俊云 陈杰

Cerebral Oximetry During Infant Cardiac Surgery: Evaluation and Relationship to Early Postoperative Outcome

Barry D. Kussman, David Wypij, James A. DiNardo, Jane W. Newburger, John E. Mayer, Jr, Pedro J. del Nido, Emile A. Bacha, Frank Pigula, Ellen McGrath, Peter C. Laussen, and Peter J. Davis

Anesth Analg 2009 108: 1122-1131.

结膜下阻滞与芬太尼静脉注射用于小儿白内障手术的围术期镇痛的比较

裘毅敏译,马皓琳、李士通校

Subtenon Block Compared to Intravenous Fentanyl for Perioperative Analgesia in Pediatric Cataract Surgery

Babita Ghai, Jagat Ram, Jeetinder Kaur Makkar, Jyotsna Wig, and Sushmita Kaushik

Anesth Analg 2009 108: 1132-1138.

AMBULATORY ANESTHESIOLOGY:

普瑞巴林对术前焦虑和镇静水平的效应:剂量范围的研究

王宏 译,马皓琳 李士通校

The Effect of Pregabalin on Preoperative Anxiety and Sedation Levels: A Dose-Ranging Study

Paul F. White, Burcu Tufanogullari, Jimmie Taylor, and Kevin Klein

Anesth Analg 2009 108: 1140-1145.

褪黑素在局麻下眼科白内障手术中的应用具有抗焦虑,镇痛,减低眼内压和改善手术条件的作用。

黄剑译 薛张纲校

Melatonin Provides Anxiolysis, Enhances Analgesia, Decreases Intraocular Pressure, and Promotes Better Operating Conditions During Cataract Surgery Under Topical Anesthesia

Salah A. Ismail and Hany A. Mowafi

Anesth Analg 2009 108: 1146-1151.

褪黑激素对腹腔镜胆囊切除术后患者睡眠质量的影响:一项随机,安慰剂对照试验

叶乐 陈杰

The Effect of Melatonin on Sleep Quality After Laparoscopic Cholecystectomy: A Randomized, Placebo-Controlled Trial (Brief Report)

Ismail Gögenur, Bülent Kücükakin, Thue Bisgaard, Viggo Kristiansen, Niels-Christian Hjortsø, Debra J. Skene, and Jacob Rosenberg

Anesth Analg 2009 108: 1152-1156.

小剂量瑞芬太尼对全麻苏醒期间气管导管的反应的影响

彭中美 马皓琳 李士通

The Effect of Low-Dose Remifentanil on Responses to the Endotracheal Tube During Emergence from General Anesthesia (Brief Report)

Marie T. Aouad, Achir A. Al-Alami, Viviane G. Nasr, Fouad G. Souki, Reine A. Zbeidy, and Sahar M. Siddik-Sayyid

Anesth Analg 2009 108: 1157-1160.

ANESTHETIC PHARMACOLOGY:

家兔心脏骤停后自主循环返回的脂肪乳注入减少

李莹译 薛张纲校

Intralipid Infusion Diminishes Return of Spontaneous Circulation After Hypoxic Cardiac Arrest in Rabbits

Martyn Harvey, Grant Cave, and Alex Kazemi

Anesth Analg 2009 108: 1163-1168.

大鼠原位和在体应用5-羟色胺1A激动剂8OHDPAT能拮抗阿片类药所致的通气抑制而不拮抗抗伤害作用

张磊 陈杰

The Counteraction of Opioid-Induced Ventilatory Depression by the Serotonin 1A-Agonist 8-OH-DPAT Does Not Antagonize Antinociception in Rats In Situ and In Vivo

Ulf Guenther, Till Manzke, Hermann Wrigge, Matthias Dutschmann, Joerg Zinserling, Christian Putensen, and Andreas Hoeft

Anesth Analg 2009 108: 1169-1176.

苯二氮卓类药物对硬骨鱼紧张肽II刺激的大鼠大脑皮质切片去甲肾上腺素释放的影响

江继宏   马皓琳 李士通

The Effects of Benzodiazepines on Urotensin II-Stimulated Norepinephrine Release from Rat Cerebrocortical Slices

Yoko Kawaguchi, Tomoko Ono, Mihoko Kudo, Tetsuya Kushikata, Eiji Hashiba, Hitoshi Yoshida, Tsuyoshi Kudo, Kenichi Furukawa, Stephen A. Douglas, and Kazuyoshi Hirota Anesth

Analg 2009 108: 1177-1181.

TECHNOLOGY, COMPUTING, AND SIMULATION:

可见光谱学活体检测猪心肌缺血

姚敏敏译 薛张纲校

In Vivo Detection of Myocardial Ischemia in Pigs Using Visible Light Spectroscopy

Jonathan K. Ho, Oliver J. Liakopoulos, Ryan Crowley, Aaron B. Yezbick, Elizabeth Sanchez, Kalyanam Shivkumar, and Aman Mahajan

Anesth Analg 2009 108: 1185-1192.

气体浓度改变90%所需时间:三种半紧闭麻醉呼吸系统间的比较

吴进   马皓琳 李士通

Time to a 90% Change in Gas Concentration: A Comparison of Three Semi-Closed Anesthesia Breathing Systems

Michael P. Dosch, Robert G. Loeb, Tiffany L. Brainerd, John F. Stallwood, and Steven Lechner

Anesth Analg 2009 108: 1193-1197.

一个临床模式下通过静脉套管的液体流量.

俞佳译 薛张纲校

Fluid Flow Through Intravenous Cannulae in a Clinical Model

Duncan McPherson, Olukorede Adekanye, Antony R. Wilkes, and Judith E. Hall

Anesth Analg 2009 108: 1198-1202.

中心静脉压测量中的错误

潘钱玲 陈杰

Error in Central Venous Pressure Measurement (Brief Report)

Katie K. Figg and Edward C. Nemergut

Anesth Analg 2009 108: 1209-1211.

PATIENT SAFETY:

光柱(Surch-LiteTM)和直接喉镜气管插管用于高Mallampati评分患者的对比

黄佳佳译,马皓琳 李士通校

A Comparison of Lighted Stylet (Surch-LiteTM) and Direct Laryngoscopic Intubation in Patients with High Mallampati Scores

Ka-young Rhee, Jeong-rim Lee, Jinhee Kim, Sanghyon Park, Won-Kyong Kwon, and SungHee Han

Anesth Analg 2009 108: 1215-1219.

CRITICAL CARE AND TRAUMA:

气管插管变革:最新喉镜辅助下持续声门观察的可行性。

张玥琪译,薛张纲校

Tracheal Tube Exchange: Feasibility of Continuous Glottic Viewing with Advanced Laryngoscopy Assistance (Brief Report)

Thomas C. Mort

Anesth Analg 2009 108: 1228-1231.

OBSTETRIC ANESTHESIOLOGY:

关于产妇实施硬膜外置管时避免误置入硬膜外静脉的策略的随机对照研究的系统总数

周姝婧 陈杰

A Systematic Review of Randomized Controlled Trials That Evaluate Strategies to Avoid Epidural Vein Cannulation During Obstetric Epidural Catheter Placement

Jill M. Mhyre, Mary Lou V. H. Greenfield, Lawrence C. Tsen, and Linda S. Polley

Anesth Analg 2009 108: 1232-1242.

“冲技术与用标准技术比较局麻药溶液中肾上腺素的浓度

黄丽娜 马皓琳 李士通

A Comparison of Epinephrine Concentrations in Local Anesthetic Solutions Using a "Wash" Versus Measured Technique (Brief Report)

Kyle G. Wojciechowski, Michael J. Avram, Kiril Raikoff, Robert J. McCarthy, and Cynthia A. Wong

Anesth Analg 2009 108: 1243-1245.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

幼猪低氧-缺血性损伤的脑血氧饱和度-时间阈值

赵嫣红 陈杰

Cerebral Oxygen Saturation-Time Threshold for Hypoxic-Ischemic Injury in Piglets

C. Dean Kurth, John C. McCann, Jun Wu, Lili Miles, and Andreas W. Loepke

Anesth Analg 2009 108: 1268-1277.

提高颅内压可以增加脑血流量自身调节的下限

姜旭晖译,马皓琳 李士通校

The Lower Limit of Cerebral Blood Flow Autoregulation Is Increased with Elevated Intracranial Pressure

Ken M. Brady, Jennifer K. Lee, Kathleen K. Kibler, Ronald B. Easley, Raymond C. Koehler, Marek Czosnyka, Peter Smielewski, and Donald H. Shaffner

Anesth Analg 2009 108: 1278-1283.

异氟醚麻醉期间低碳酸血症和脑自主调节功能对脑血管阻力和血管内壁流体静压的影响

张钊译 薛张纲校

The Effects of Hypocapnia and the Cerebral Autoregulatory Response on Cerebrovascular Resistance and Apparent Zero Flow Pressure During Isoflurane Anesthesia

Timothy J. McCulloch and Martin J. Turner

Anesth Analg 2009 108: 1284-1290.

超高龄患者脊麻对脑血流的影响

朱紫瑜 陈杰

The Effects of Spinal Anesthesia on Cerebral Blood Flow in the Very Elderly

Vincent Minville, Karim Asehnoune, Sabrina Salau, Benoît Bourdet, Bernard Tissot, Vincent Lubrano, and Olivier Fourcade

Anesth Analg 2009 108: 1291-1294.

ANALGESIA:

在脊椎麻醉及多重机制镇痛用于前交叉韧带重建术后7~12周时的一般健康状况和膝功能预后情况

慧译 马皓琳 李士通校

General Health and Knee Function Outcomes from 7 Days to 12 Weeks After Spinal Anesthesia and Multimodal Analgesia for Anterior Cruciate Ligament Reconstruction

Brian A. Williams, Qainyu Dang, James E. Bost, James J. Irrgang, Steven L. Orebaugh, Matthew T. Bottegal, and Michael L. Kentor

Anesth Analg 2009 108: 1296-1302.

C-藻蓝蛋白的抗炎与镇痛活性

朱兰芳译 薛张纲校

Antiinflammatory and Antihyperalgesic Activity of C-Phycocyanin

Chao-Ming Shih, Shin-Nan Cheng, Chih-Shung Wong, Yu-Ling Kuo, and Tz-Chong Chou

Anesth Analg 2009 108: 1303-1310.

AMPA受体拮抗剂NS1209和利多卡因在神经损伤性疼痛中的效应:一个随机、双盲、安慰剂对照、三向交叉设计研究

怀晓蓉 陈杰

The Efficacy of the AMPA Receptor Antagonist NS1209 and Lidocaine in Nerve Injury Pain: A Randomized, Double-Blind, Placebo-Controlled, Three-Way Crossover Study

Lise Gormsen, Nanna B. Finnerup, Per M. Almqvist, and Troels S. Jensen

Anesth Analg 2009 108: 1311-1319.

长期持续股神经阻滞对膝关节三髁成形术后与健康相关的生活质量的影响:一项前瞻、随机、三盲、安慰剂对照的1年随访实验

张莹译  马皓琳 李士通校

Health-Related Quality of Life After Tricompartment Knee Arthroplasty With and Without an Extended-Duration Continuous Femoral Nerve Block: A Prospective, 1-Year Follow-Up of a Randomized, Triple-Masked, Placebo-Controlled Study

Brian M. Ilfeld, R. Scott Meyer, Linda T. Le, Edward R. Mariano, Brian A. Williams, Krista Vandenborne, Pamela W. Duncan, Daniel I. Sessler, F. Kayser Enneking, Jonathan J. Shuster, Rosalita C. Maldonado, and Peter F. Gearen

Anesth Analg 2009 108: 1320-1325.

402名放置外周神经导管后的皮下隧道中细菌定植情况:一项前瞻性研究

陈珺珺译 薛张纲校

Bacterial Colonization After Tunneling in 402 Perineural Catheters: A Prospective Study

Vincent Compère, J. F. Legrand, P. G. Guitard, K. Azougagh, O. Baert, A. Ouennich, V. Fourdrinier, N. Frebourg, and B. Dureuil

Anesth Analg 2009 108: 1326-1330.

胸段硬膜外麻醉对全麻患者肝血流量的影响

黄丹 陈杰

The Effects of Thoracic Epidural Anesthesia on Hepatic Blood Flow in Patients Under General Anesthesia

Rainer Meierhenrich, Florian Wagner, Wolfram Schütz, Michael Rockemann, Peter Steffen, Uwe Senftleben, and Albrecht Gauss

Anesth Analg 2009 108: 1331-1337.

神经刺激的电流阈值依赖于组织的电阻:一项关于在超声引导下正中神经电刺激的研究

陈珺珺译 薛张纲校

Current Threshold for Nerve Stimulation Depends on Electrical Impedance of the Tissue: A Study of Ultrasound-Guided Electrical Nerve Stimulation of the Median Nerve

Axel R. Sauter, Michael S. Dodgson, Håvard Kalvøy, Sverre Grimnes, Audun Stubhaug, and Øivind Klaastad

Anesth Analg 2009 108: 1338-1343.

肝移植术中血小板输注与术后死于急性肺损伤情况增多有关

Platelet Transfusion During Liver Transplantation Is Associated with Increased Postoperative Mortality Due to Acute Lung Injury

Ilona T. A. Pereboom, Marieke T. de Boer, Elizabeth B. Haagsma, Herman G. D. Hendriks, Ton Lisman, and Robert J. Porte

From the Departments of *Surgery, Section Hepatobiliary Surgery and Liver Transplantation, {dagger}Gastroenterology and Hepatology, and {ddagger}Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

Anesth Analg 2009 108: 1083-1091.

 

背景:血小板输注目前被认为是正位肝移植(OLT)术后存活的一个独立的危险因子。在这一研究中,我们试图分析出正位肝移植(OLT)术中与输注血小板相关的死亡事件及移植物功能丧失事件发生的特异性原因。

方法:本次研究的是一个连续性样本,449位初次行正位肝移植(OLT)的成年患者组成。无论这些患者在术中有无行血小板输注,都对其死因及移植物功能衰减原因进行分析。

结果:相对于那些未行血小板输注的患者,输血小板的患者其患者存活率和移植物存活率均明显下降(分别是74%92%69%85%,差异性为1年,P < 0.001)。在接受血小板输注的患者中早期死于急性肺损伤的比率明显增高((4.4%0.4%P = 0.004),是导致该人群低存活率的原因。两组病人中因其他原因死亡的比率并无明显差异。在接受血小板输注的患者中致移植物功能丧失的主要原因是移植物功能存活的患者死亡。

结论:这些研究发现提示血小板输注是正位肝移植(OLT)术后死亡的一个重要的危险因子。根据现在的研究结果可进一步衍生,将急性肺损伤的确诊作为死亡率增加的主要决定因素,从而做前瞻性的观察。在接受血小板输注的患者中,其移植物功能丧失比率的增高是由于总体死亡率的增高,而非因为输注血小板会对移植肝产生特异性的副作用。

(单嘉琪译 薛张纲校)

BACKGROUND: Platelet transfusions have been identified as an independent risk factor for survival after orthotopic liver transplantation (OLT). In this study, we analyzed the specific causes of mortality and graft loss in relation to platelet transfusions during OLT.

METHODS: In a series of 449 consecutive adult patients undergoing a first OLT, the causes of patient death and graft failure were studied in patients who did or did not receive perioperative platelet transfusions.

RESULTS: Patient and graft survival were significantly reduced in patients who received platelet transfusions, compared with those who did not (74% vs 92%, and 69% vs 85%, respectively at 1 yr; P < 0.001). Lower survival rates in patients who received platelets were attributed to a significantly higher rate of early mortality because of acute lung injury (4.4% vs 0.4%; P = 0.004). There were no significant differences in other causes of mortality between the two groups. The main cause of graft loss in patients receiving platelets was patient death with a functioning graft.

CONCLUSIONS: These findings suggest that platelet transfusions are an important risk factor for mortality after OLT. The current study extends previous observations by identifying acute lung injury as the main determinant of increased mortality. The higher rate of graft loss in patients receiving platelets is related to the higher overall mortality rate and does not result from specific adverse effects of transfused platelets on the grafted liver.

 

 

为胸外科手术选择合适的单肺通气装置:三种支气管阻塞器与传统双腔管的随机对照临床试验

Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes.

Narayanaswamy M, McRae K, Slinger P, Dugas G, Kanellakos GW, Roscoe A, Lacroix M

From the *Gosford Hospital, Gosford, New South Wales, Australia; {dagger}Toronto General Hospital, Toronto, Canada; {ddagger}Department of Anethesia, University of Toronto, Toronto General Hospital, Toronto, Canada; §Credit Valley Hospital, Mississauga, Ontario, Canada; ||University Hospital of South Manchester, Manchester, UK; and ¶Hotel-Dieu de Levis, Quebec, Canada.

Anesth Analg 2009 108(4):1097-101.

 

背景:就胸外科手术而言,目前并没有公认为最好的单肺通气技术。在此次研究中,我们将北美市场上的三种支气管阻塞器(BBs)与传统左侧双腔管(DLTs)进行对比,比较其在左侧胸部外科手术患者中的单肺通气表现。

方法:随机将104名行左侧开胸手术或胸腔镜手术的患者分成四个单肺通气组(n=26/组)。四组的单肺通气装置分别为有导线引导的Arndt支气管阻塞器(Cook Critical Care,伯明顿,印第安纳州)、头部可旋转的Cohen支气管阻塞器(Cook Critical Care)、 Fuji单腔支气管阻塞器(Fuji Systems,东京)和左侧双腔支气管导管(Mallinckrodt Medical,克纳梅德,阿斯隆,韦斯特米斯郡,爱尔兰)。术中的麻醉管理和单肺通气的实施均遵循统一的标准化方案。根据吸引器运用于支气管阻塞器吸引管腔或双腔管支气管腔的时间,每一单肺通气组又随机地细分为两个亚组(n=13/亚组):即即刻吸引组(插入单肺通气装置即刻)(亚组I)和延迟吸引组(插入单肺通气装置后20分钟)(亚组D)。运用口头评分标尺,由对单肺通气技术不知情的外科医生对肺萎陷的程度进行评价。

结果:各种单肺通气装置的肺萎陷评分在胸膜开放后即刻(P = 0.66)、10分钟(P = 0.78)和20分钟(P = 0.51)时均无任何统计学差异。但双腔管(93 +/- 62秒)较支气管阻塞器(203 +/- 132秒)更快地完成初次肺萎陷(P = 0.0001)。而各种支气管阻塞器完成肺萎陷的时间并无统计学差异(P = 0.78)。在最初置入单肺通气装置后,支气管阻塞器(35次)明显较双腔管(2次)复位频繁(P = 0.009)。与Cohen支气管阻塞器(8次)和Fuji 支气管阻塞器(11次)相比,Arndt支气管阻塞器(16次)在术中需要更频繁地进行复位(P = 0.032)。

结论:在左侧开胸手术和胸腔镜手术的操作过程中,三种支气管阻塞器可提供与左侧双腔管等价的外科暴露。但支气管阻塞器完成肺萎陷的时间较长,术中复位也较为频繁。与其他支气管阻塞器相比,Arndt支气管阻塞器的复位最为频繁。

(范羽译 薛张纲校)

BACKGROUND: There is no consensus on the best technique for lung isolation for thoracic surgery. In this study, we compared the clinical performance of three bronchial blockers (BBs) available in North America with left-sided double-lumen tubes (DLTs) for lung isolation in patients undergoing left-sided thoracic surgery.

METHODS: One hundred four patients undergoing left-sided thoracotomy or video-assisted thoracoscopic surgery were randomly assigned to one of the four lung isolation groups (n = 26/group). Lung isolation was with an Arndt wire-guided BB (Cook Critical Care, Bloomington, IN), a Cohen Flexi-tip BB (Cook Critical Care) or a Fuji Uni-blocker (Fuji Systems, Tokyo) or with a left-sided DLT (Mallinckrodt Medical, Cornamadde, Athlone, Westmeath, Ireland). Anesthetic management and lung isolation were performed according to a standardized protocol. Each group was randomly subdivided into two subgroups (n = 13/subgroup): immediate suction (at the time of insertion of the lung isolation device) (Subgroup I) or delayed suction (20 min after insertion of the lung separation device) (Subgroup D) according to when suction was applied to the BB suction channel or the bronchial lumen of the DLT. Using a verbal analog scale, lung collapse was assessed by the surgeons, who were blinded to the lung isolation technique.

RESULTS: There was no difference among the lung isolation devices in lung collapse scores at 0 (P = 0.66), 10 (P = 0.78), or 20 min (P = 0.51) after pleural opening. The time to initial lung isolation was less for DLTs (93 +/- 62 s) than BBs (203 +/- 132) (P = 0.0001). There were no differences among the BBs in the time to lung isolation (P = 0.78). There were significantly more repositions after initial placement of the lung isolation device with BBs (35 incidents) than with DLTs (two incidents) (P = 0.009). The Arndt BB required repositioning more frequently (16 incidents) than the Cohen BB (8) or the Fuji BB (11) (P = 0.032).

CONCLUSIONS: The three BBs provided equivalent surgical exposure to left-sided DLTs during left-sided open or video-assisted thoracoscopic surgery thoracic procedures. BBs required longer to position and required intraoperative repositioning more often. The Arndt BB needed to be repositioned more often than the other BBs.

 

 

褪黑素在局麻下眼科白内障手术中的应用具有抗焦虑,镇痛,减低眼内压和改善手术条件的作用。

Melatonin provides anxiolysis, enhances analgesia, decreases intraocular pressure, and promotes better operating conditions during cataract surgery under topical anesthesia.

Salah A. Ismail and Hany A. Mowafi

Department of Anesthesiology, Faculty of Medicine, King Fahd University, Saudi Arabia.

Anesth Analg. 2009108(4):1146-51.

 

背景:褪黑素具有抗焦虑和潜在的镇痛作用。本研究中,我们评价了局麻下眼科白内障术前应用褪黑素对疼痛,焦虑和眼内压及手术条件的影响。

方法40名欲局麻下行白内障手术的病人随机分为2(每组20)。术前90分钟,实验组给于褪黑素一片10mg,对照组给于安慰剂,均口服给药。记录焦虑评分、自觉疼痛评分、心率、平均动脉压及眼内压。并且,请外科医生评价手术条件分级。

结果:褪黑素显著降低焦虑评分。给药前中位数及四分位数间距为5, 3.5-6。给药后中位数及四分位数间距为3, 2-3,术中为3, 2-3.5(P=0.04并且和分别和对照组相比P=0.005)。褪黑素组手术期间自觉疼痛评分明显低于对照组,并且术中芬太尼的需要量也减少。和对照组相比,褪黑素组的中位数及四分位数间距为0,0-32.5,而对照组为47.5, 30-65ug.P=0.007。给予褪黑素后眼内压(平均数+/-标准差)17.9+/-显著地降至14.2+/-1.0 mmHg,并且术中达到13.8+/-1.1mmHg(P<0.001)。褪黑素同时也提供了更好的手术条件。

结论:我们认为对于局麻下行白内障手术的病人,术前口服给予褪黑素具有抗焦虑,镇痛及降眼内压的作用,因此可提供更好的手术条件。

(黄剑译 薛张纲校)

BACKGROUND: Melatonin has anxiolytic and potential analgesic effects. In this study, we assessed the effects of melatonin premedication on pain, anxiety, intraocular pressure (IOP), and operative conditions during cataract surgery under topical analgesia.

METHODS: Forty patients undergoing cataract surgery under topical anesthesia were randomly assigned into two groups (20 patients each) to receive either melatonin 10 mg tablet (melatonin group) or placebo tablet (control group) as oral premedication 90 min before surgery. Anxiety scores, verbal pain scores, heart rate, mean arterial blood pressure, and IOP were recorded. In addition, the surgeon was asked to rate operating conditions.

RESULTS: Melatonin significantly reduced the anxiety scores (median, interquartile range) from 5, 3.5-6 to 3, 2-3 after premedication and to 3, 2-3.5 during surgery (P = 0.04 and P = 0.005 compared with the placebo group, respectively). Perioperative verbal pain scores were significantly lower in the melatonin group with less intraoperative fentanyl requirement (median, interquartile range) compared with the control group, 0, 0-32.5 vs 47.5, 30-65 microg, respectively, P = 0.007. Melatonin also decreased IOP (mean +/- sd) significantly from 17.9 +/- 0.9 to 14.2 +/- 1.0 mm Hg after premedication and to 13.8 +/- 1.1 mm Hg during surgery (P < 0.001). It also provided better quality of operative conditions.

CONCLUSION: We concluded that oral melatonin premedication for patients undergoing cataract surgery under topical anesthesia provided anxiolytic effects, enhanced analgesia, and decreased IOP resulting in good operating conditions.

 

 

家兔心脏骤停后自主循环返回的脂肪乳注入减少

Intralipid Infusion Diminishes Return of Spontaneous Circulation After Hypoxic Cardiac Arrest in Rabbits

Martyn Harvey, Grant Cave, and Alex Kazemi

Department of Emergency Medicine, Waikato Hospital, Pembroke Street, Hamilton, New Zealand.

Anesth Analg. 2009 108(4):1062-4.

 

背景:在实验模型和人体都已证明注入亲脂性乳剂可以扭转因亲脂性药物诱发的心血管事件。但是,对于非药物引起的心搏停止,高剂量脂肪乳剂的作用仍不明确。在窒息无脉性电活动的家兔模型中,我们比较了注入脂肪乳剂和使用标准高级心脏救命术的家兔复生。

方法:成熟的新西兰白兔通过气管钳夹造成缺氧性无脉性电活动。心脏骤停2分钟后,开始基本的生命维持心肺复苏术,同时注入3 mL/kg 20%脂肪乳剂或者3 mL/kg 0.9%生理盐水。第4分钟和第5分钟给予100 microg/kg的肾上腺素。记录自发循环恢复、血流动力学指标及50分钟生存率。

结果:自发循环回复,注入盐水组为7/11,而注入乳剂组为1/12P=0.009。而50分钟生存率未观察到有统计学意义的差异(注入盐水组为3/11,注入乳剂组为0/12P=0.211)。

结论:在这种窒息导致的无脉性电活动模型中,相对于高级心脏救命术加用注入乳剂,标准高级心脏救命术可导致更好的主动脉灌注压并可增加自主循环恢复。脂肪乳剂在严重低氧血症复杂化的心脏骤停中使用也许是不恰当的。

(李莹译 薛张纲校)

BACKGROUND: Infusion of lipid emulsion has been shown to reverse lipophilic drug-induced cardiovascular collapse in laboratory models and humans. The effect of high dose lipid in nondrug-induced cardiac arrest is, however, uncertain. In a rabbit model of asphyxial pulseless electrical activity (PEA) we compared lipid augmented with standard advanced cardiac life support (ACLS) resuscitation.

METHOD: Adult New Zealand White rabbits underwent hypoxic PEA via tracheal clamping. After 2 min of cardiac arrest, basic life support cardiopulmonary resuscitation was commenced and 3 mL/kg 20% Intralipid or 3 mL/kg 0.9% saline solution infused. Adrenaline (100 microg/kg) was administered at 4 and 5 min. Return of spontaneous circulation (ROSC), hemodynamic metrics, and survival to 50 min were recorded.

RESULTS: Seven of 11 saline-treated rabbits developed ROSC versus 1 of 12 Intralipid-treated animals; P = 0.009. No significant difference in survival to 50 min was observed (3/11 saline vs 0/12 Intralipid; P = 0.211).

CONCLUSION: In this model of hypoxia-induced PEA, standard ACLS resulted in greater coronary perfusion pressure and increased ROSC compared with ACLS plus lipid infusion. Lipid emulsion may be contraindicated in cardiac arrest complicated by significant hypoxia.

 

 

可见光谱学活体检测猪心肌缺血

In Vivo Detection of Myocardial Ischemia in Pigs Using Visible Light Spectroscopy

Jonathan K. Ho, MD*, Oliver J. Liakopoulos, MD{dagger}{ddagger}, Ryan Crowley, MD*, Aaron B. Yezbick, MD*, Elizabeth Sanchez, BS*, Kalyanam Shivkumar, MD, PhD§, and Aman Mahajan, MD, PhD*§

From the Departments of *Anesthesiology, {dagger}Cardiothoracic Surgery, David Geffen School of Medicine, University of California, Los Angeles, California; {ddagger}Department of Cardiothoracic Surgery, University of Cologne, Germany; and §Division of Cardiology, David Geffen School of Medicine, University of California Los Angeles, California.

Anesth Analg 2009 108: 1185-1192

 

背景:可见光谱学监测组织氧含量可识别组织缺血,但是它用来检测心肌缺血的可行性是未知的。我们假设可见光谱学能可靠的检测出猪急性区域性或广泛性心肌缺血模型中的心肌氧含量的变化。

方法:11头猪中,区域性心肌缺血通过结扎左前降支动脉建立。心肌的氧含量决定于左室缺血及非缺血区域,同时将它与冠状静脉的氧饱和度相比较。心肌的功能则通过心超来评估。在六头猪中,左室组织氧含量在停跳液诱使心脏停跳后体外循环期间及未给予充分心肌保护下测定。此外,右室及左室组织氧含量还在肺动脉绷扎使右室压力负荷剧增时测定。

结果:在结扎左前降支动脉前猪的缺血区心肌与非缺血区心肌的组织氧含量基线水平相似(70% ± 8% vs 74% ± 5%)。在左前降支结扎后,缺血区心肌的组织氧含量迅速下降(30 : 59% ± 8%; 1 分钟:50 ± 9; 5 分钟:42% ± 4%; P < 0.05)。组织氧含量的下降和冠状静脉氧饱和度(r = 0.88)及心肌功能障碍具相关性。在进行体外循环的猪中,停跳液诱使心脏停跳后及体外循环开始时左室的组织氧含量保持不变,但是在没有充分心肌保护下夹闭主动脉后运用组织氧含量检测到了左室缺血。相似的,肺动脉绷扎使得右室组织氧含量明显下降,从69% ± 6% 下降至 52% ± 7% (P < 0.05),且在肺动脉开放后恢复。

结论:可见光谱学是检测心肌组织氧含量的一种可靠方法,且可作为心肌缺血时快速检测的有效的监测手段。

(姚敏敏译 薛张纲校)

BACKGROUND: Monitoring tissue oxygenation (StO2) by visible light spectroscopy (VLS) can identify tissue ischemia, but its feasibility for detecting myocardial ischemia is not known. We hypothesized that VLS can reliably detect changes in myocardial StO2 in pigs subjected to acute regional or global myocardial ischemia.

METHODS: In 11 pigs, regional myocardial ischemia was created by ligation of left anterior descending artery (LAD). Myocardial StO2 was determined from the ischemic and nonischemic left ventricular (LV) regions and compared to coronary venous saturations. Myocardial function was assessed by echocardiography. In six pigs, LV-StO2 was measured during cardiopulmonary bypass (CPB), after cardioplegic cardiac arrest, and during CPB with inadequate myocardial protection. Additionally, right ventricular (RV)- and LV-StO2 were assessed during acute RV pressure overload from pulmonary artery (PA) banding.

RESULTS: StO2 baselines in pigs undergoing LAD occlusion were similar in the ischemic and nonischemic myocardium (70% ± 8% vs 74% ± 5%). After LAD ligation, StO2 rapidly declined (30 s: 59% ± 8%; 1 min:50 ± 9; 5 min:42% ± 4%; P < 0.05) in the ischemic myocardium. Decreases in StO2 correlated with coronary venous saturations (r = 0.88) and were associated with myocardial dysfunction. In pigs undergoing CPB, LV-StO2 remained unchanged with initiation of CPB or after cardioplegic cardiac arrest, but LV ischemia was detected by StO2 after aortic cross-clamp without adequate myocardial protection. Similarly, PA banding resulted in a profound decrease of RV-StO2 from 69% ± 6% to 52% ± 7% (P < 0.05) with recovery after PA release.

CONCLUSIONS: VLS is a reliable method of detecting alterations in myocardial StO2 and can be a useful monitor for rapid identification of myocardial ischemia.

 

 

一个临床模式下通过静脉套管的液体流量.

Fluid Flow Through Intravenous Cannulae in a Clinical Model

Duncan McPherson, MBBS, Olukorede Adekanye, MBBS, FCARCSI, Antony R. Wilkes, PhD, and Judith E. Hall, MD, FRCA

From the Department of Anaesthesia and Intensive Care Medicine, University Hospital of Wales, Cardiff, UK.

Anesth Analg 2009 108: 1198-1202.

 

背景:预测通过静脉套管的液体流量对临床医生有帮助(如果流量改变是必需的),同时用来指导套管的选择。我们通过预测实际的流量和描述此流量来寻求制造商提供流量的有效性。

方法:我们建立一个静脉模型,分别置入从14号到20号套管。在第一个实验中,我们使用去离子水,hartmann溶液和佳乐施来比较制造商提供的流量。在第二个实验中,我们给予不同的压力作用于套管上,测量所产生的流量。

结果:通过套管的流量不是一个由制造商提供流量计算的简单比率,甚至控制液体类型和给予压力。在我们测量的范围内,血流不是完全的层流,也不是完全的湍流。在国际标准化组织的试验中雷诺指数常常低于2000

结论:通过套管的血流在较高范围的临床使用流量内不是层流,因此泊素叶法则在预测流量上不适用,改变套管半径的效果比通常相信的要小。提供的最大流量也不适用。除雷诺指数外层流还需要很多条件。进一步的工作会决定对于流量有用的预测方法。

(俞佳译 薛张纲校)

BACKGROUND: Predicting flow through an IV cannula is useful to clinicians if changes in flow are required and to guide selection of cannula. We sought the usefulness of manufacturers’ quoted flows in predicting actual flow and to characterize that flow.

METHODS: We built a vein model and inserted cannulae between 14 and 20-gauge. In the first experiment, we compared the manufacturer’s quoted flows using deionized water, Hartmann’s solution and Gelofusine. In the second experiment, we varied the pressure feeding the cannula and measured the resulting flow.

RESULTS: Flow through a cannula is not a simple ratio of the manufacturers’ quoted flow rate, even controlling for fluid type and feeding pressure. Flow is neither fully laminar, nor fully turbulent in the range of rates we have measured and in the International Organization for Standardization test. The Reynolds number is often below 2000.

CONCLUSIONS: Flow through cannulae is not laminar at the upper range of clinically used flows, therefore Poiseuille’s law is not useful in predicting flow and the effect of changing radius is less than commonly believed. The quoted maximum flows are also not useful. There are many conditions for laminar flow apart from Reynolds number. Further work would determine useful predictors of flow.

 

 

气管插管变革:最新喉镜辅助下持续声门观察的可行性。

Tracheal Tube Exchange: Feasibility of Continuous Glottic Viewing with Advanced Laryngoscopy Assistance

Thomas C. Mort

From the Department of Anesthesiology, Hartford Hospital, University of Connecticut School of Medicine, Hartford, Connecticut.

Anesth Analg 2009 108: 1228-1231.

 

通过气道交换气管导管通常与常规喉镜协助下气管插管相结合。困难气道可能难以看见声门。由于气管内导管尺寸过大或强烈挤压气道结构所导致的置管延迟、气道损伤或气管插管失败可能恶化盲视气管插管。最新的喉镜技术所提供的各个角度可视化可能能克服许多常规喉镜的视线限制 。在这个数据调查中,我检测了将一个高风险的气管导管交换从一个盲视过程变成一个声门可见的过程的可行性和实用性。

(张玥琪译,薛张纲校)

Trachea tube exchange via an airway exchange catheter is commonly combined with conventional laryngoscopy to assist intubation of the trachea. Glottic visualization may not be possible in the difficult airway. A delay in reintubation, airway injury, or intubation failure may complicate "blind" tracheal intubation because of excessive endotracheal tube size or tip impingement on airway structures. Advanced laryngoscopic techniques offering "around the corner" visualization may overcome many of the limitations of conventional laryngoscopy's "line of sight." In this data review, I examined the feasibility and usefulness of transforming a high-risk exchange from a blind procedure into one with improved glottic visualization.

                                                    

 

异氟醚麻醉期间低碳酸血症和脑自主调节功能对脑血管阻力和血管内壁流体静压的影响

The effects of hypocapnia and the cerebral autoregulatory response on cerebrovascular resistance and apparent zero flow pressure during isoflurane anesthesia.

McCulloch TJ, Turner MJ.

Department of Anaesthetics, University of Sydney, Sydney, NSW, Australia.

Anesth Analg 2009108:1284-90.

 

背景:动态动脉血压(arterial blood pressure ABP)和大脑中动脉血流流速监测可用于计算血管内壁流体静压(表面流体静压apparent zero flow pressure aZFP)。血压-流速关系的反斜率即为阻力面积乘积(RAP),该指数反应了脑血管阻力的大小。关于全麻时血管活性药物、动脉二氧化碳分压(Paco(2))以及脑自主调节功能受损对aZFPRAP的影响的研究并不多。我们研究了异氟醚全身麻醉时低碳酸血症和注射新福林对aZFPRAP的影响。

方法:对11例使用异氟醚麻醉的成年患者记录其桡动脉有创动脉血压和多普勒大脑中动脉血流流速。应用新福林调整血压,调节潮气量控制动脉二氧化碳分压。分别在两个不同的平均动脉压水平(大约在80100mmHg之间)和动脉二氧化碳分压水平:正常水平(Paco(2) 38-43 mm Hg) 和低二氧化碳水平(Paco(2) 27-34 mm Hg),比较脑血流动力学的变化。两种aZFP分析方法相比较:一种基于线性回归,一种基于波形的傅里叶分析。

结果:在较低血压水平,血碳酸正常时,aZFP 23 +/- 11 mm Hg RAP 0.76 +/- 0.97 mm Hg x s x cm(-1);低碳酸血症时,aZFP30 +/- 13 mm Hg (mean +/- sd) RAP 1.16 +/- 0.16 mm Hg x s x cm(-1) P 值均<0.001 。在较高血压水平可见到低碳酸血症带来的相似影响。血碳酸水平正常时,异氟醚对脑自主调节功能及aZFP的影响不随血压升高而变化。低碳酸血症时,脑自主调节功能受血压影响不显著,但血压的升高会使aZFP 升高(from 30 +/- 13 to 35 +/- 13 mm Hg, P < 0.01) RAP升高 (from 1.16 +/- 0.16 to 1.52 +/- 0.20 mm Hg x s x cm(-1), P < 0.001)aZFPRAP相比,对反应脑血流动力学的作用,RAP的变化显然较aZFP的改变带来了更大影响。两种分析aZFP的方法(傅里叶回归)的平均差为 0.5 +/- 3.6 mm Hg (mean +/- 2sd)

结论:使用异氟醚全身麻醉时,低碳酸血症和对ABP升高的自主调节反应两个因素可增加脑小动脉的收缩节律,这两种因素与RAPaZFP的升高相关。RAP的改变所带来的影响在数值上大于aZFP。这些结果意味着小动脉通过收缩控制血管阻力和有效灌注压来影响脑血流。

(张钊译 薛张纲校)

BACKGROUND: Simultaneous recordings of arterial blood pressure (ABP) and middle cerebral artery blood velocity can be used to calculate the apparent zero flow pressure (aZFP). The inverse of the slope of the pressure-velocity relationship is known as resistance area product (RAP) and is an index of cerebrovascular resistance. There is little information available regarding the effects of vasoactive drugs, arterial carbon dioxide (Paco(2)), and impaired cerebral autoregulation on aZFP and RAP during general anesthesia. During isoflurane anesthesia, we investigated the effects of hypocapnia and the effects of a phenylephrine infusion, on aZFP and RAP.

METHODS: Radial ABP and transcranial Doppler middle cerebral artery blood velocity signals were recorded in 11 adults undergoing isoflurane anesthesia. A phenylephrine infusion was used to increase ABP and ventilation was adjusted to control Paco(2). Cerebral hemodynamic variables were compared at two levels of mean ABP (approximately 80 and 100 mm Hg) and at two levels of Paco(2): normocapnia (Paco(2) 38-43 mm Hg) and hypocapnia (Paco(2) 27-34 mm Hg). Two aZFP analysis methods were compared: one based on linear regression and one based on Fourier analysis of the waveforms.

RESULTS: At the lower ABP, aZFP was 23 +/- 11 mm Hg and 30 +/- 13 mm Hg (mean +/- sd) with normocapnia and hypocapnia, respectively (P <0.001) and RAP was 0.76 +/- 0.97 mm Hg x s x cm(-1) and 1.16 +/- 0.16 mm Hg x s x cm(-1) with normocapnia and hypocapnia, respectively (P < 0.001). Similar effects of hypocapnia were seen at the higher ABP. With normocapnia, isoflurane impaired cerebral autoregulation and aZFP did not change with the increase in ABP. With hypocapnia, cerebral autoregulation was not significantly impaired and increasing ABP was associated with increased aZFP (from 30 +/- 13 to 35 +/- 13 mm Hg, P < 0.01) and increased RAP (from 1.16 +/- 0.16 to 1.52 +/- 0.20 mm Hg x s x cm(-1), P < 0.001). Calculation of the relative contributions of aZFP and RAP to the cerebral hemodynamic responses indicated that changes in RAP appeared to have a greater influence than changes in aZFP. The mean difference between the two methods of determining aZFP (Fourier-regression) was 0.5 +/- 3.6 mm Hg (mean +/- 2sd).

CONCLUSIONS: During isoflurane anesthesia, two interventions that increase cerebral arteriolar tone, hypocapnia and the autoregulatory response to increasing ABP, were associated with increased RAP and increased aZFP. The effect of changes in RAP appeared to be quantitatively greater than the effects of changes in aZFP. These results imply that arteriolar tone influences cerebral blood flow by controlling both resistance and effective downstream pressure.

    

 

C-藻蓝蛋白的抗炎与镇痛活性

Antiinflammatory and Antihyperalgesic Activity of C-Phycocyanin
Chao-Ming Shih, Shin-Nan Cheng, Chih-Shung Wong, Yu-Ling Kuo, and Tz-Chong Chou

From the *Chia-Yi Christian Hospital; {dagger}Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center; {ddagger}Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center; and §Department of Physiology, National Defense Medical Center, Taipei, Taiwan, Republic of China.

Anesth Analg 2009 108: 1303-1310.

 

背景C-藻蓝蛋白(C-PC)是在青绿色藻类如螺旋藻中发现的一种脂蛋白,由于具有多种治疗价值而常作为饮食营养补充。另外,C-PC通过部分抑制致炎因子的形成、可诱导的NO合酶(iNOS)与环氧合酶-2(COX-2)的表达而产生的抗炎活性在很多体外和体内的研究中均有过描述。然而,C-PC是否具有减弱炎症伤害性感受的镇痛活性还未曾观察到。

方法:我们使用角叉藻聚糖诱导的热致痛模型,通过测量大鼠爪子退缩的潜伏期来评估C-PC对大鼠伤害性刺激感受的影响。阐明相关机制,确定iNOSCOX-2以及硝酸酯和肿瘤坏死因子-(TNF-)在大鼠爪子内的表达。

结果:在角叉藻聚糖诱导前或诱导后使用C-PC (30 or 50 mg/kg, IP)可明显减弱炎症伤害性感受以及后期(4小时)iNOSCOX-2的诱导作用,并抑制TNF-、前列腺素E2、硝酸酯的形成及髓过氧化物酶的活性。

结论:这些研究结果提示,C-PC的镇痛活性至少部分是通过抑制炎症部位iNOSCOX-2的诱导作用和减少TNF-的形成及中性粒细胞的浸润来抑制NO和前列腺素E2的过多生成而产生。

(朱兰芳译 薛张纲校)

BACKGROUND: C-phycocyanin (C-PC), a biliprotein found in blue green algae, such as Spirulina platensis, is often used as a dietary nutritional supplement due to its various therapeutic values. In addition, the antiinflammatory activity of C-PC partly through inhibition of proinflammatory cytokine formation, inducible nitric oxide synthase (iNOS) and cyclooxygeanase-2 (COX-2) expression has been demonstrated in many in vitro and in vivo studies. However, whether C-PC also has antihyperalgesic activity in inflammatory nociception has not been investigated.

METHODS: Using a carrageenan-induced thermal hyperalgesia model, we evaluated the effect of C-PC on nociception by measuring  paw withdrawal latency. To clarify the mechanisms involved, the expression of iNOS and COX-2 and the formation of nitrate and tumor necrosis factor-{alpha} (TNF-{alpha}) in the rat paw were determined.

RESULTS: Pre- or posttreatment with C-PC (30 or 50 mg/kg, IP) significantly attenuated carrageenan-induced inflammatory nociception and the induction of iNOS and COX-2 at the late phase, (4 h) accompanied by an inhibition of the formation of TNF-{alpha}, prostaglandin E2, nitrate and myeloperoxidase activity.

CONCLUSIONS: Based on these results, it is suggested that the inhibition of NO and prostaglandin E2 over-production through suppressing iNOS and COX-2 induction and attenuation of TNF-{alpha} formation and neutrophil infiltration into inflammatory sites by C-PC may contribute, at least in part, to its antihyperalgesic activity.

 

402名放置外周神经导管后的皮下隧道中细菌定植情况:一项前瞻性研究

Bacterial Colonization After Tunneling in 402 Perineural Catheters: A Prospective Study

Vincent Compère*, J. F. Legrand*, P. G. Guitard*, K. Azougagh*, O. Baert*, A. Ouennich, V. Fourdrinier*, N. Frebourg, and B. Dureuil*

From the *Department of Anesthesia and Intensive Care, Rouen University Hospital, Rouen, France; Department of Anesthesia, Hôpital Charles Nicolle, Tunis, Tunisia; and Department of Bacteriology, Rouen University Hospital, Rouen, France.

Anesth Analg 2009 108: 1326-1330.

 

背景:外周神经导管处经常出现细菌定植,尽管很少会出现感染症状。在中心静脉导管,皮下组织的导管隧道显著降低了细菌定植和导管相关性败血症。我们评估了成人外周静脉导管隧道细菌定植的发生率。

方法:外周神经导管在无菌情况下穿刺用来术后镇痛,使用前瞻性研究的方法评估。在导管拔出后分析导管的细菌定植情况。用培养的数量结果进行描述,这种方法既往使用于静脉导管。每天监测穿刺部位有无任何感染迹象。

方法:在两年内研究了402名病人。外周静脉导管的平均放置时间为48h4750.4)。25根导管有阳性培养结果,提示细菌定植的发生率为6.22%(3.88.5)。导管尖端培养的微生物中72%为凝固酶阴性葡萄球菌。25根导管中有22根培养出一种微生物,3根培养出2种微生物。所有的病人均没有感染迹象。

结论:皮下隧道中外周神经导管细菌定植的发生率较低。随机研究观察到操作方法可以降低感染的发生率。

(陈珺珺译 薛张纲校)

BACKGROUND: Bacterial colonization of peripheral nerve catheters is frequent, although infection is relatively rare. With central venous catheters, the tunneling of the catheter into the subcutaneous tissue significantly decreases catheter colonization and catheter-related sepsis. We evaluated the incidence of bacterial colonization in adult patients with tunnelized perineural nerve catheters.

METHODS: Peripheral nerve catheters placed under sterile conditions for postoperative analgesia were evaluated prospectively. After removal, they were analyzed for colonization. Quantitative culture was used as described by Brun-Buisson for intravascular catheters. The site of insertion was monitored daily for any signs of infection.

RESULTS: Four-hundred-two patients were included in the study during a 2-yr period. The mean duration of peripheral nerve catheters was 48 h (47–50.4). Positive culture occurred in 25 catheters, indicating that the incidence of colonization was 6.22% (3.8–8.5). The microbiological analysis of the catheter tip cultures revealed coagulase-negative staphylococci in 72%. Twenty-two catheters of 25 catheters each had one microorganism, and for three catheters, two microorganisms were identified. No infection was found in any patient.

CONCLUSION: The incidence of perineural catheter colonization is low with subcutaneous tunneling. Controlled randomized studies are warranted to determine whether this procedure decreases the risk for infection.

 

 

神经刺激的电流阈值依赖于组织的电阻:一项关于在超声引导下正中神经电刺激的研究

Current Threshold for Nerve Stimulation Depends on Electrical Impedance of the Tissue: A Study of Ultrasound-Guided Electrical Nerve Stimulation of the Median Nerve

Axel R. Sauter, MD*{dagger}, Michael S. Dodgson, FRCA{dagger}, Håvard Kalvøy, MSc{ddagger}, Sverre Grimnes, PhD{ddagger}§, Audun Stubhaug, DMSc{dagger}, and Øivind Klaastad, DMSc

From the *Faculty of Medicine, University of Oslo; {dagger}Division of Anesthesiology and Intensive Care Medicine, {ddagger}Department of Clinical and Biomedical Engineering, Rikshospitalet University Hospital; and §Department of Physics, University of Oslo, Oslo, Norway.

Anesth Analg 2009 108: 1338-1343.

 

背景:了解电刺激神经法的不同阈值的机制可以改善外周神经阻滞的安全性和成功率。神经周围的电阻可以影响对神经刺激的反应。在志愿者身上进行的研究中,我们研究了电阻和神经肌应答所需刺激阈值的关系。

方法:我们在29名志愿者身上测定了对腋窝和肘部正中神经对电神经刺激反应的强度和电阻。针尖的位置通过超声引导,分别位于神经的52.50mm。用于神经刺激的脉冲的宽度分别是0.10.3ms

结果:在肘部,针尖至神经的距离为52.5mm时,阻抗和电流的阈值呈负相关(P = 0.001 P = 0.036)。相比于肘部(平均36.6, sd 13.4 kohm),腋窝处阻抗的值明显较低(平均21.1, sd 9.7 kohm) (P < 0.001)。反过来,在腋窝神经刺激的电流的阈值高于在肘部的(P < 0.001, P < 0.001, P = 0.024)。脉冲持续时间 0.1 0.3 ms相比较,电流的阈值的比值为1.82.

结论:我们的结果证明了电阻和电流阈值呈负相关,这提示了组织类型的不同应调整电流的设置。进一步的研究需要进行来研究我们这项发现的临床意义。

(陈珺珺译 薛张纲校)

BACKGROUND: Understanding the mechanisms causing variation in current thresholds for electrical nerve stimulation may improve the safety and success rate of peripheral nerve blocks. Electrical impedance of the tissue surrounding a nerve may affect the response to nerve stimulation. In this volunteer study, we investigated the relationship between impedance and current threshold needed to obtain a neuromuscular response.

METHODS: Electrical nerve stimulation and impedance measurements were performed for the median nerve in the axilla and at the elbow in 29 volunteers. The needletip was positioned at a distance of 5, 2.5, and 0 mm from the nerve as judged by ultrasound. Impulse widths of 0.1 and 0.3 ms were used for nerve stimulation.

RESULTS: A significant inverse relationship between impedance and current threshold was found at the elbow, at nerve-to-needle distances of 5 and 2.5 mm (P = 0.001 and P = 0.036). Impedance values were significantly lower in the axilla (mean 21.1, sd 9.7 kohm) than at the elbow (mean 36.6, sd 13.4 kohm) (P < 0.001). Conversely, current thresholds for nerve stimulation were significantly higher in the axilla than at the elbow (P < 0.001, P < 0.001, P = 0.024). A mean ratio of 1.82 was found for the measurements of current thresholds with 0.1 versus 0.3 ms impulse duration.

CONCLUSIONS: Our results demonstrate an inverse relationship between impedance measurements and current thresholds and suggest that current settings used for nerve stimulation may require adjustment based on the tissue type. Further studies should be performed to investigate the clinical impact of our findings.

 

术前脑利钠肽和术后肌钙蛋白水平对大血管手术患者预后意义的初步报告
A Preliminary Report on the Prognostic Significance of Preoperative Brain Natriuretic Peptide and Postoperative Cardiac Troponin in Patients Undergoing Major Vascular Surgery

Daniel Bolliger, MD*, Manfred D. Seeberger, MD*, Giovanna A. L. Lurati Buse, MD*, Peter Christen, MD{dagger}, Brian Rupinski, MD*, Lorenz Gürke, MD{ddagger}, and Miodrag Filipovic, MD*

From the *Department of Anesthesia, University Hospital Basel, Basel, Switzerland; {dagger}Department of Anesthesia, Cantonal Hospital Lucerne, Lucerne, Switzerland; and {ddagger}Division of Vascular Surgery, University Hospital Basel, Basel, Switzerland.

Anesth Analg 2009 108: 1069-1075.

 

 背景:有研究显示大手术后主要心脏不良事件( MACE )的发生与术前脑利钠肽( BNP )或术后心肌肌钙蛋白升高(肌钙蛋白)相关。本研究中,作者评估术前脑利钠肽和术后肌钙蛋白水平的衍生数据预测大血管手术术后MACE
方法:本研究是前瞻性研究,对纳入评估交感神经系统抑制药物莫索尼定减少MACE 的有效性的临床试验中133例接受大血管手术的临床病例的队列研究数据进行二次分析。术前测定BNP和肌钙蛋白浓度。术后立即测定肌钙蛋白浓度,并于术后1 2 3 7 天测定肌钙蛋白浓度。主要评价指标为术后一年内MACE(心肌血管重建术需入院治疗,急性冠状动脉综合征,急性充血性心力衰竭,任何原因造成的死亡)的发生情况。通过住院期间院内访视图表和术后12个月的电话回访评估患者术后MACE
结果:手术后1年内, 19例( 14 )患者发生MACE,其中包括14例( 11 )死亡。调整年龄,性别,和修订后心脏风险指数后,无论随后肌钙蛋白I的浓度如何,术前BNP升高>50pg/mlMACE相关 (调整后的危险比[HR] 6.5 95 %置信区间[CI]1.4-29.5 )。联合术前BNP升高>50 pg / ml和术后肌钙蛋白I升高>2ng/ml两个指标与MACE (调整后 HR 25.2 95 CI为: 5.0-128.4 )以及各种原因的死亡率(调整后 HR 18.7 95 CI 3.1-112.5 )相关 。阴性预测值显示正常术前BNP值随后的不良事件是0.965 95 CI 0.879-0.996 )。
结论:上述数据表明,术前测量BNP以及术后肌钙蛋白浓度为预测大血管术后死亡率和MACE提供了更多的信息。

(舒慧刚 陈杰 校)

BACKGROUND: Associations between preoperative elevation of brain natriuretic peptide (BNP) or postoperative elevation of cardiac troponins (cTn) with major adverse cardiac events (MACE) after major surgery have been shown previously. In this study, we evaluated the added value of preoperative BNP with postoperative cTn levels for the prediction of MACE in patients undergoing major vascular surgery.

METHODS: This is a prospectively prespecified, secondary analysis of data from a cohort of 133 clinically stable patients undergoing major vascular surgery enrolled in a clinical trial evaluating the effectiveness of the sympathetic nervous system-inhibiting drug moxonidine on reducing MACE. Concentrations of BNP and cTn were determined before surgery, and concentrations of cTn were measured immediately after surgery and on postoperative days 1, 2, 3, and 7. The primary end point was the occurrence of MACE (defined as any hospitalization for myocardial revascularization, acute coronary syndrome, acute congestive heart failure, or death by any cause) within 1 yr after surgery. Patients were evaluated for MACE by hospital chart review during hospitalization and by telephone interviews 12 mo after surgery.

RESULTS: Within 1 yr after surgery, 19 patients (14%) had a MACE, including 14 patients (11%) who died. After adjustment for age, gender, and the revised cardiac risk index, preoperative BNP elevation ≥50 pg/mL was associated with MACE (adjusted hazard ratio [HR]: 6.5, 95% confidence interval [CI]: 1.4–29.5) regardless of the subsequent cTn I concentrations. The combination of preoperative BNP elevation ≥50 pg/mL and postoperative cTn I elevation ≥2 ng/mL was associated with MACE (adjusted HR: 25.2, 95% CI: 5.0–128.4) and all-cause mortality (adjusted HR: 18.7, 95% CI: 3.1–112.5). The negative predictive value of a normal preoperative BNP value for subsequent adverse events was 0.965 (95% CI: 0.879–0.996).

CONCLUSION: These data suggest that measurement of preoperative BNP concentrations in addition to postoperative cTn concentrations provides additive prognostic information for MACE and mortality after major vascular surgery.


双肺通气时在吸入的气体混合中使用空气延迟单肺通气时肺塌陷

The Use of Air in the Inspired Gas Mixture During Two-Lung Ventilation Delays Lung Collapse During One-Lung Ventilation

Raynauld Ko, MD*, Karen McRae, MDCM*, Gail Darling, MD{dagger}, Thomas K. Waddell, MD, PhD{dagger}, Desmond McGlade, MBBS FANZCA*, Ken Cheung, MD*, Joel Katz, PhD*, and Peter Slinger, MD*

From the Departments of *Anesthesia and Pain Management, and {dagger}Surgery, Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.

Anesth Analg 2009 108: 1092-1096.

 

背景:胸外科手术中同侧肺塌陷有利于手术野的暴露。双肺通气时使用不同的混合气体通过增加或延迟肺塌陷从而促进或妨碍随后进行单肺通气时的手术条件。作者拟研究双肺通气时使用三种不同的混合气体对肺塌陷和随后单肺通气时氧合的影响:空气/氧气(吸入氧气分数 [Fio2] = 0.4), 氧化亚氮/氧气 ("N2O," Fio2 = 0.4) 和氧气 ("O2," Fio2 = 1.0).

方法:研究对象随机分为三组: 空气/氧气 (n = 33), 氧化亚氮 (n = 34) 或氧气 (n = 33)。这些患者从诱导到单肺通气前吸入指定的混合气体,单肺通气予以纯氧即Fio2 = 1.0。在单肺通气开始10分钟和20分钟时,外科医生运用口述评分量表随机双盲评估肺排气的情况。麻醉诱导前,双肺通气时( 5分钟一次,持续30分钟),单肺通气开始后分别做动脉血气检查。

结果:双肺通气时吸入含有空气的混合气体可以导致单肺通气时肺排气的延迟,而N2O可以促进肺塌陷。动脉氧合仅仅在吸入纯氧组单肺通气前10分钟有明显改善,之后平均动脉血氧分压值各组间无差异。

结论:双肺通气期间肺去氮化对改进单肺通气的手术条件是一有用的策略。在双肺通气中的Fio2 1.0 N2O/O2 (Fio2 0.4)对于随后的单肺通气时的氧合无不良影响。

(刘世文 陈杰 校)

BACKGROUND: Collapse of the ipsilateral lung facilitates surgical exposure during thoracic procedures. The use of different gas mixtures during two-lung ventilation (2LV) may improve or impede surgical conditions during subsequent one-lung ventilation (OLV) by increasing or delaying lung collapse. We investigated the effects of three different gas mixtures during 2LV on lung collapse and oxygenation during subsequent OLV: Air/Oxygen (fraction of inspired oxygen [Fio2] = 0.4), Nitrous Oxide/Oxygen ("N2O," Fio2 = 0.4) and Oxygen ("O2," Fio2 = 1.0).

METHODS: Subjects were randomized into three groups: Air/Oxygen (n = 33), N2O (n = 34) or O2 (n = 33) and received the designated gas mixture during induction and until the start of OLV. Subjects’ lungs in all groups were then ventilated with Fio2 = 1.0 during OLV. The surgeons, who were blinded to the randomization, evaluated the lung deflation using a verbal rating scale at 10 and 20 min after the start of OLV. Serial arterial blood gases were performed before anesthesia induction, during 2LV, and every 5 min, for 30 min, after initiation of OLV.

RESULTS: The use of air in the inspired gas mixture during 2LV led to delayed lung deflation during OLV, whereas N2O improved lung collapse. Arterial oxygenation was significantly improved in the O2 group only for the first 10 min of OLV, after which there were no differences in mean Pao2 values among groups.

CONCLUSIONS: De-nitrogenation of the lung during 2LV is a useful strategy to improve surgical conditions during OLV. The use of Fio2 1.0 or N2O/O2 (Fio2 0.4) during 2LV did not have an adverse effect on subsequent oxygenation during OLV.

 

婴幼儿心脏外科手术中脑血氧含量:评估和术后早期结局的关系

Cerebral Oximetry During Infant Cardiac Surgery: Evaluation and Relationship to Early Postoperative Outcome

Barry D. Kussman, MBBCh*{dagger}, David Wypij, PhD{ddagger}§||, James A. DiNardo, MD*{dagger}, Jane W. Newburger, MD, MPH{ddagger}§, John E. Mayer, Jr, MD#**, Pedro J. del Nido, MD#**, Emile A. Bacha, MD#**, Frank Pigula, MD#**, Ellen McGrath, RN{ddagger}, Peter C. Laussen, MBBS*{dagger}{ddagger}, and Section Editor Peter J. Davis

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston; {dagger}Department of Anaesthesia, Harvard Medical School; {ddagger}Department of Cardiology, Children’s Hospital Boston; §Department of Pediatrics, Harvard Medical School; ||Department of Biostatistics, Harvard School of Public Health; ¶Department of Cardiology, Harvard Medical School; #Department of Cardiovascular Surgery, Children’s Hospital Boston; and **Department of Surgery, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2009 108: 1122-1131.

 

背景:作者检测了婴儿心脏手术中脑血氧饱和度的变化及其与解剖学诊断和早期结局的关系。

方法104名婴幼儿无主动脉弓梗阻行双心室修复术中,用近红外光法测定血液随机稀释至血细胞比容为25% vs 35%时的脑局部氧饱和度( rSO2 )。

结果:在心肺转流( CPB )前 ,与患D -大动脉转位(D-TGA))或室间隔缺损的患儿相比,患法洛氏四联症的婴幼儿有较高的rSO2值( P <0.001 )。 CPB控制性降温,降流量和体外循环终止期间,D-TGA患儿rSO2值最高( P <0.001 )。术中rSO2值与调整诊断后的术后早期结局无显著相关。在深低温停循环(DHCA)≥5分钟的39D-TGA患儿中, 停循环开始时的rSO2 91 ± 6 )或血细胞比容( 29.2 ± 5.5 )与停循环后rSO2的下降率无相关性。
结论:术中rSO2的变化取决于解剖学诊断,但与术后早期结局的相关性不明显。通过近红外光谱测量rSO2,更高水平的血细胞比容和目前的灌注技术可为深低温停循环前的相对短的时期提供充足的氧供。

(丁俊云 陈杰 校)

BACKGROUND: We examined changes in cerebral oxygen saturation during infant heart surgery and its relationship to anatomic diagnosis and early outcome.

METHODS: Regional cerebral oxygen saturation (rSO2) was measured by near-infrared spectroscopy in 104 infants undergoing biventricular repair without aortic arch obstruction as part of a randomized trial of hemodilution to a hematocrit of 25% vs 35%.

RESULTS: Before cardiopulmonary bypass (CPB), infants with tetralogy of Fallot had higher rSO2 values compared to those with D-transposition of the great arteries (D-TGA) or ventricular septal defect (P < 0.001). During CPB cooling, low flow, and at the termination of CPB, D-TGA subjects had the highest rSO2 values (P < 0.001). There were no significant associations between intraoperative rSO2 and early postoperative outcomes after adjustment for diagnosis. In 39 D-TGA subjects with ≥5 min of deep hypothermic circulatory arrest (DHCA), there was no correlation between the rSO2 (91% ± 6%) or hematocrit (29.2% ± 5.5%) at the onset of arrest and the rate of decline in rSO2 during arrest.

CONCLUSIONS: Intraoperative rSO2 varies according to anatomic diagnosis but accounts for very little of the variance in early outcome. As measured by frontal near-infrared spectroscopy, higher levels of hematocrit and current perfusion techniques appear to provide an adequate oxygen reservoir prior to relatively short periods of DHCA.

 

褪黑激素对腹腔镜胆囊切除术后患者睡眠质量的影响:一项随机,安慰剂对照试验

The Effect of Melatonin on Sleep Quality After Laparoscopic Cholecystectomy: A Randomized, Placebo-Controlled Trial

Ismail Gögenur, MD*, Bülent Kücükakin, MD*, Thue Bisgaard, MD, DSc{dagger}, Viggo Kristiansen, MD{dagger}, Niels-Christian Hjortsø, MD{dagger}, Debra J. Skene, PhD{ddagger}, and Jacob Rosenberg, MD, DSc*

From the *Department of Surgical Gastroenterology D, University of Copenhagen, Gentofte Hospital, Hellerup, Denmark; {dagger}Department of Surgical Gastroenterology D, University of Copenhagen, Glostrup Hospital, Glostrup, Denmark; and {ddagger}Center for Chronobiology, School of Biomedical and Molecular Sciences, University of Surrey, Guildford, Surrey, UK.

Anesth Analg 2009 108: 1152-1156.

 

背景:本研究中,作者观察了使用褪黑激素后能否改善患者术后主观睡眠质量并减少不适。

方法 121例拟行腹腔镜胆囊切除术的择期日间手术患者,术后3夜随机给予口服5毫克褪黑激素( 60例)或安慰剂( 61 )。监测患者的主观睡眠质量,睡眠持续时间和主观不适(疲劳,舒适度和痛苦)的变化。

结果:褪黑激素组(均数 [标准差] 14 min [18],与安慰剂组相比(28 min [41], 术后第一夜睡眠潜伏期明显缩短( P=0.015 )。其余的观察变量在两组间无明显差异。

结论:与安慰剂相比褪黑激素没有改善腹腔镜胆囊切除术后主观睡眠质量或不适.

(叶乐 陈杰 校)

BACKGROUND: In this study, we investigated whether melatonin administration could improve postoperative subjective sleep quality and reduce discomfort.

METHODS: One hundred twenty-one patients scheduled for elective ambulatory laparoscopic cholecystectomy were randomized to oral 5 mg melatonin (n = 60) or placebo (n = 61) for 3 nights after surgery. Subjective sleep quality, sleep duration, sleep timing, and subjective discomfort (fatigue, general well-being, and pain) were measured.

RESULTS: Sleep latency was significantly reduced in the melatonin group (mean [sd] 14 min [18]) compared with placebo (28 min [41]) on the first postoperative night (P = 0.015). The rest of the measured outcome variables did not differ between groups.

CONCLUSIONS: Melatonin did not improve subjective sleep quality or discomfort compared with placebo after laparoscopic cholecystectomy.


大鼠原位和在体应用5-羟色胺1A激动剂8OHDPAT能拮抗阿片类药所致的通气抑制而不拮抗抗伤害作用

The Counteraction of Opioid-Induced Ventilatory Depression by the Serotonin 1A-Agonist 8-OH-DPAT Does Not Antagonize Antinociception in Rats In Situ and In Vivo

Ulf Guenther, MD*, Till Manzke, PhD{dagger}, Hermann Wrigge, PhD*, Matthias Dutschmann, PhD{dagger}, Joerg Zinserling, PhD*, Christian Putensen, PhD*, and Andreas Hoeft, PhD*

From the *Clinic of Anesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Strasse 25, Bonn, Germany; and {dagger}DFG Research Center Molecular Physiology of the Brain (CMPB), Goettingen, Humboldtallee 23, Goettingen, Germany.

Anesth Analg 2009 108: 1169-1176.

 

背景:在重症监护的机械通气治疗期间,自主呼吸的重要性日益重视,但其可被麻醉药所抑制,如阿片类药物等。5-羟色胺1A受体( 5 - HT1A受体)激动剂可拮抗阿片类药物引起的通气抑制,但在不同的实验模型上发现其可增强和减弱伤害反射。为了澄清矛盾,作者同时测定标准的5 - HT1A受体激动剂8-OH-DPAT和两个不同的阿片类药物对自主通气和伤害感受性的量效关系。验证两个假设: 1 8-OH-DPAT在某一剂量下可刺激自主呼吸而不激活伤害反射。 2 8-OH-DPAT并不减少阿片类药物诱导的镇痛作用。
方法:(A)在准备好的原位灌注,未麻醉的大鼠脑干-脊髓上同时建立8-OH-DPAT的量效关系,自发膈神经活动和疼痛C -纤维反射( CFR )(B)原位给予芬太尼观察其与8-OH-DPAT对膈神经活动和疼痛C -纤维反射的相互影响。附加试验给予选择性5 - HT1A受体拮抗剂WAY100 635以排除5 - HT1A受体以外其他受体的影响。(C)在麻醉的大鼠上在体研究8-OH-DPAT对自主通气以及有和无吗啡时的疼痛甩尾反射的影响。
结果:低剂量8-OH-DPAT(原位应用 0.0010.01µM 在体应用0.1微克/千克)增强伤害反射,但没有激活自主通气。相反,高剂量的8-OH-DPAT (原位应用 1µM和在体应用10-100µg/kg)刺激通气,而原位研究中疼痛C -纤维反射幅度回落至基线水平,同时在体研究中甩尾反射被抑制。阿片类药物诱导的通气抑制被8-OH-DPAT (原位应用 1µM 体内应用10µg/kg)拮抗 ,而伤害作用仍存在。原位实验中,选择性5 - HT1A受体拮抗剂WAY100 635 1µM)可阻止8-OH-DPAT的作用。
结论: 5 - HT1A受体激动剂8-OH-DPAT激活大鼠自主呼吸而未减少阿片类药物诱导的镇痛作用。

(张磊 陈杰 校)

BACKGROUND: Spontaneous breathing during mechanical ventilation is gaining increasing importance during intensive care but is depressed by narcotics, such as opioids. Serotonin 1A-receptor (5-HT1A-R) agonists have been shown to antagonize opioid-induced ventilatory depression, but both enhancement and attenuation of nociceptive reflexes have been found with different experimental models. To clarify contradictory findings, we simultaneously determined dose-response functions of the standard 5-HT1A-R-agonist 8-OH-DPAT and two different opioids for spontaneous ventilation and nociception. Two hypotheses were tested: 1) 8-OH-DPAT at a dose to stimulate spontaneous breathing does not activate nociceptive reflexes. 2) 8-OH-DPAT does not diminish opioid-induced antinociception.

METHODS: (A) A dose-response relationship of 8-OH-DPAT, spontaneous phrenic nerve activity and a nociceptive C-fiber reflex (CFR) were established simultaneously in an in situ perfused, nonanesthetized, rat brainstem-spinal cord preparation. (B) Fentanyl was administered in situ to investigate the interaction with 8-OH-DPAT on phrenic nerve activity and nociceptive CFR. Additional experiments involved the selective 5-HT1A-R-antagonist WAY 100 635 to exclude effects of receptors other than 5-HT1A-R. (C) The effects of 8-OH-DPAT on spontaneous ventilation and nociceptive tail-flick reflex with and without morphine were verified in in vivo anesthetized rats.

RESULTS: Low-dose 8-OH-DPAT (0.001 and 0.01 µM in situ, 0.1 µg/kg in vivo) enhanced nociceptive reflexes but did not activate spontaneous ventilation. On the contrary, high doses of 8-OH-DPAT (1 µM in situ and 10–100 µg/kg in vivo) stimulated ventilation, whereas nociceptive CFR amplitude in situ returned to baseline and tail-flick reflex was depressed in vivo. Opioid-induced ventilatory depression was antagonized by 8-OH-DPAT (1 µM in situ, and 10 µg/kg in vivo), whereas antinociception sustained. Selective 5-HT1A-R-antagonist WAY 100 635 (1 µM) prevented the effects of 8-OH-DPAT in situ.

CONCLUSION: 5-HT1A-R-agonist 8-OH-DPAT activates spontaneous breathing without diminishing opioid-induced antinociception in rats.

 

中心静脉压测量中的错误

Error in Central Venous Pressure Measurement

Katie K. Figg, MD*, and Edward C. Nemergut, MD*{dagger}

From the Departments of *Anesthesiology, and {dagger}Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, Virginia.

Anesth Analg 2009 108: 1209-1211.

 

背景:有创监测中压力传感器的放置位置不同所产生的差异可导致明显的测量错误。本研究的目的是对医护人员所产生的这种差异性程度进行量化,并确立一个能减少这错误的简单方法。

方法:50名围术期医护人员纳入本研究,让其在两种不同的情况下监测中心静脉压:第一次没有任何标准化的工具来定位传感器的放置位置,第二次通过激光水平仪引导定位。计算不同医生之间的差异,并将两次结果进行比较。

结果:两次放置传感器的位置差异明显,有时这种变异程度大于正常值。使用激光水平仪并不能明显减少这种差异。

结论:不同医护人员放置传感器的位置差异明显。激光水平仪不能减少这种差异,在解释CVP值时须考虑这种差异。应该考虑建立一个医院范围或整个行业范围内的标准化的零点位置。

(潘钱玲 陈杰 校)

BACKGROUND: The variability introduced by inconsistent placement of pressure transducers for invasive monitoring may result in significant measurement error. Our goals in this study were to quantify the degree of variation among health care providers and to identify a simple tool for reducing this error.

METHODS: A sample of 50 perioperative health care providers was recruited and asked to place a transducer at the appropriate level for central venous pressure (CVP) monitoring on two separate occasions: first without any additional standardization tools and second with a laser level to guide transducer placement. The variability among providers was calculated, and the results between sessions compared.

RESULTS: There was significant variation in transducer placement during both sessions, in some instances, of greater magnitude than a normal CVP value. The laser level did not significantly reduce this variation.

CONCLUSION: There is significant variation in transducer placement among health care providers. This variation is not reduced by a laser level and must be considered when interpreting CVP data. Hospital- or institution-wide standardization of a zero-level should be considered.

 

关于产妇实施硬膜外置管时避免误置入硬膜外静脉的策略的随机对照研究的系统总数

A Systematic Review of Randomized Controlled Trials That Evaluate Strategies to Avoid Epidural Vein Cannulation During Obstetric Epidural Catheter Placement

Jill M. Mhyre, MD*, Mary Lou V. H. Greenfield, MPH, MS*, Lawrence C. Tsen, MD{dagger}, and Linda S. Polley, MD*

From the *Department of Anesthesiology, The University of Michigan Health System, Ann Arbor, Michigan; and {dagger}Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2009 108: 1232-1242.

 

背景:本文中,作者对7种被认为可在对产妇实施腰硬膜外置管时减少发生误置入硬膜外静脉概率的策略的相关证据进行评估。

方法:搜索多个数据库,选择在196612月至200710月期间对产妇行腰椎硬膜外置管时避免误置入硬膜外静脉的前瞻性、随机、对照研究。用一种量化的评价工具对已出版的试验进行评估,并结合结果来评价该策略对防止误置入硬膜外静脉的效力。

结果:在筛查所得的90个研究中,共有30个入选(n12738人)。5种策略可减少发生误置入硬膜外静脉的风险:相对左侧坐位(6例研究,平均(标准差)质量评分=35%11%],优势比(OR0.5395%置信区间(CI0.32-0.86]),置管前从硬膜外穿刺针内注入液体(8例研究,质量评分=48%18%],OR 0.49,[95%CI 0.25-0.97]),采用单孔而不是多孔导管(5例研究,平均(标准差)质量评分=30%6%],OR 0.64,[95%CI 0.45-0.91]),硬膜外导管的取材选用线埋式聚氨基树脂与聚酰胺的对比(1例研究,31%,外加4例摘要未作评分,OR 0.14,[95%CI 0.06-0.30])以及置管深度≤6 cm2例研究, 47%6%],OR 0.27,[95%CI 0.10-0.74])。以下两种策略未能降低误置入硬膜外静脉的风险:旁正中进针穿刺法相比中线进针法和采用较小号硬膜外穿刺针或导管。

结论:在对产妇实施腰硬膜外置管时,以下策略可能可以减少误置入血管的发生:患者相对左侧坐位、置管前用液体对硬膜外腔进行预扩容、采用单孔导管、硬膜外导管的取材选用线埋式聚氨基树脂以及限制置管深度短于或等于6 cm。总的来说,原文质量较低削弱了这些结论的效力。

(周姝婧 陈杰 校)

BACKGROUND: In this systematic review, we evaluated the evidence for seven strategies which have been proposed to minimize the incidence of epidural vein cannulation during lumbar epidural catheter placement in pregnant women.

METHODS: Multiple databases were searched to identify prospective, randomized, controlled trials between December 1966 and October 2007 that evaluated methods to avoid epidural vein cannulation after lumbar epidural catheter placement in pregnant women. Published trials were evaluated using a quality assessment tool, and results were combined to evaluate efficacy to prevent epidural vein cannulation.

RESULTS: Of 90 trials screened, 30 trials were included (n = 12,738 subjects). Five strategies reduce the risk of epidural vein cannulation: the lateral as opposed to sitting position (six trials, mean (sd) quality score = 35% [11%], odds ratio (OR) 0.53 [95% confidence interval (CI) 0.32–0.86]), fluid administered through the epidural needle before catheter insertion (8 trials, quality score 48% [18%], OR 0.49 [95% CI 0.25–0.97]), single rather than multiorifice catheter (5 trials, quality score 30% [6%], OR 0.64 [95% CI 0.45–0.91]), a wire-embedded polyurethane compared with polyamide epidural catheter (1 trial, 31%, plus 4 unscored abstracts, OR 0.14 [95% CI 0.06–0.30]) and catheter insertion depth ≤6 cm (2 trials, 47% [11%], OR 0.27 [95% CI 0.10–0.74]). The paramedian as opposed to midline needle approach and smaller epidural needle or catheter gauges do not reduce the risk of epidural vein cannulation.

CONCLUSION: The risk of intravascular placement of a lumbar epidural catheter in pregnancy may be reduced with the lateral patient position, fluid predistension, a single orifice catheter, a wire-embedded polyurethane epidural catheter and limiting the depth of catheter insertion to 6 cm or less. In general, low manuscript quality weakens the strength of these conclusions.


幼猪低氧-缺血性损伤的脑血氧饱和度-时间阈值

Cerebral Oxygen Saturation-Time Threshold for Hypoxic-Ischemic Injury in Piglets

C. Dean Kurth, MD, John C. McCann, BS, Jun Wu, MD, Lili Miles, MD, and Andreas W. Loepke, MD, PhD

From the Departments of Anesthesiology, Pathology, and Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio.

Anesth Analg 2009 108: 1268-1277.

 

背景:发现危重新生儿脑低氧-缺血(H-I)以及预防脑损伤至今仍未解决。近红外光谱仪(NIRS),作为一种无创伤性床边仪器,可以实现这个目的。发生脑损伤的脑血氧饱和度(SCO2-时间阈值仍未确定。本实验中,作者研究脑血氧饱和度为35%时(引起神经生理损害的阈值),脑缺血-低氧持续时间和神经功能预后的关系。

方法:本实验用芬太尼-咪唑安定对46只幼猪进行麻醉,使用近红外光谱仪(NIRS)及脑功能监测仪(CFM)记录脑血氧饱和度(SCO2)以及大脑皮层电生理活性(ECA)。幼猪颈动脉阻塞后,调整吸入氧浓度使产生脑低氧-缺血(H-I)(保持SCO235%ECA持续下降)。脑缺血-缺氧持续时间在不同组分别为1, 2, 3, 4, 68小时,然后通过行为学及组织学检查评估神经功能预后。

结果:脑低氧-缺血持续12小时的幼猪中,缺血再灌注后脑血氧饱和度快速恢复正常水平,神经功能也正常。而脑缺氧-缺血持续时间超过2-3小时的幼猪中,再灌注时大脑皮层电生理活性显著下降,而脑血氧饱和度显著上升,提示组织中有氧代谢的持续性降低。当脑缺氧-缺血时程超过2小时,其神经功能呈线性下降,约每小时下降15%

结论:脑低氧-缺血(H-I)的程度-时间阈值为脑血氧饱和度(SCO235%持续2-3小时,并可以由近红外光谱仪(NIRS)及脑功能监测仪(CFM)监测其再灌注时的异常数值。这一实验结果表明联合使用近红外光谱仪(NIRS)及脑功能监测仪(CFM)可以预测患儿的神经功能预后,并且表明在患儿发生脑缺氧-缺血后仍有数小时的机会来预防神经功能的损伤。

(赵嫣红 陈杰 校)

BACKGROUND: Detection of cerebral hypoxia-ischemia (H-I) and prevention of brain injury remains problematic in critically ill neonates. Near-infrared spectroscopy (NIRS), a noninvasive bedside technology could fill this role, although NIRS cerebral O2 saturation (ScO2) viability-time thresholds for brain injury have not been determined. We investigated the relationship between H-I duration at ScO2 35%, a viability threshold which causes neurophysiological impairment, to neurological outcome.

METHODS: Forty-six fentanyl-midazolam anesthetized piglets were equipped with NIRS and cerebral function monitor (CFM) to record ScO2 and electrocortical activity (ECA). After carotid occlusion, inspired O2 was adjusted to produce H-I (ScO2 35% with decreased ECA) for 1, 2, 3, 4, 6 or 8 h in different groups, followed by survival to assess neurological outcome by behavioral and histological examination.

RESULTS: For H-I lasting 1 or 2 h, ECA and ScO2 during reperfusion rapidly returned to normal and neurological outcomes were normal. For H-I more than 2–3 h, ECA was significantly decreased and ScO2 was significantly increased during reperfusion, suggesting continued depression of tissue O2 metabolism. As H-I increased beyond 2 h, the incidence of neurological injury increased linearly, approximately 15% per h.

CONCLUSION: A viability-time threshold for H-I injury is ScO2 of 35% for 2–3 h, heralded by abnormalities in NIRS and CFM during reperfusion. These findings suggest that NIRS and CFM might be used together to predict neurological outcome, and illustrate that there is a several hour window of opportunity during H-I to prevent neurological injury.

 

超高龄患者脊麻对脑血流的影响

The Effects of Spinal Anesthesia on Cerebral Blood Flow in the Very Elderly

Vincent Minville, MD*, Karim Asehnoune, MD, PhD{dagger}, Sabrina Salau, MD*, Benoît Bourdet, MD*, Bernard Tissot, MD*, Vincent Lubrano, MD{ddagger}, and Olivier Fourcade, MD, PhD*

From the *Department of Anesthesiology and Intensive Care, GRCB 48, University Hospital of Toulouse, University Paul Sabatier, Toulouse, France; {dagger}Department of Anesthesiology and Intensive Care, University Hospital of Nantes, Nantes, France; and {ddagger}Institut National de la Santé et de la Recherche Médicale (Unité 455), Federation of Neurosurgery, University Hospital of Toulouse, Toulouse, France.

Anesth Analg 2009 108: 1291-1294.

 

背景:年老和疾病使高龄患者在脊椎麻醉中特别容易发生低血压。然而,小剂量布比卡因对脑血流动力学的作用尚不了解。本研究中,作者评估了脊椎麻醉对高龄患者脑血流(CBF)的影响。

方法: 20名年龄大于75岁的髋骨骨折开放修复手术的患者进行前瞻性研究,并与年龄小于60岁组的患者作比较。患者取侧卧位,在L4-5水平进行脊椎麻醉。在脊椎麻醉前(基线=T0)、局麻药注射后5分钟(T1)、脊椎麻醉后10分钟(T2)以及在麻醉后监护室(T3),分别行无创自动化动脉血压,心率以及经颅多普勒监测。

结果:T0136 ± 21 mm Hg)相比,高龄组的收缩压在T1115 ± 25 mm Hg)与T2114 ± 24 mm Hg)明显降低。T1T2的收缩期与舒张期速度与基线值相比明显降低。T2相的搏动指数(PI)以及阻力指数显著降低。所有患者均未出现心动过缓。心率变异性与T0相比相比无显著变化。对照组在血流动力学和脑部影响均无变化。

结论:脊椎麻醉可导致超高龄患者的脑血流速度的降低,降低的数值虽小但差异有统计学意义。

(朱紫瑜 陈杰 校)

BACKGROUND: Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia. However, the impact of small-dose bupivacaine on cerebral hemodynamics is not known. In this study, we assessed the effects of spinal anesthesia on cerebral blood flow (CBF) in very elderly patients.

METHODS: We prospectively studied 20 patients aged >75 yr who underwent open surgical repair of a hip fracture and compared them with a control group of patients younger than 60 yr. Patients were placed in the lateral decubitus position to receive spinal anesthesia at L4–5 level. Noninvasive automated arterial blood pressure, heart rate, and transcranial Doppler measurements were recorded before spinal anesthesia (baseline = T0), 5 min after the end of local anesthetic injection (T1), 10 min after spinal anesthesia (T2), and in the postanesthesia care unit (T3).

RESULTS: Systolic blood pressure significantly decreased at T1 (115 ± 25 mm Hg) and T2 (114 ± 24 mm Hg) compared with T0 (136 ± 21 mm Hg) in the elderly group. Systolic and diastolic velocities significantly decreased compared to baseline values (at T1, T2). Significant modifications of the pulsatility index (PI) and resistance index occurred at T2 for PI and resistance index. No patient experienced an episode of bradycardia. Heart rate variations were not significantly different compared to T0. Neither hemodynamics nor cerebral effects were observed in the control group.

CONCLUSION: In summary, spinal anesthesia results in a very small but statistically significant reduction of CBF velocity in very elderly patients.

 

AMPA受体拮抗剂NS1209和利多卡因在神经损伤性疼痛中的效应:一个随机、双盲、安慰剂对照、三向交叉设计研究

The Efficacy of the AMPA Receptor Antagonist NS1209 and Lidocaine in Nerve Injury Pain: A Randomized, Double-Blind, Placebo-Controlled, Three-Way Crossover Study

Lise Gormsen, MD*, Nanna B. Finnerup, MD*, Per M. Almqvist, MD, PhD{dagger}, and Troels S. Jensen, MD, PhD*

From the *Danish Pain Research Center and Department of Neurology, Aarhus University Hospital, Aarhus; and {dagger}NeuroSearch A/S, Ballerup, Denmark.

Anesth Analg 2009 108: 1311-1319.

 

背景:应用现在的疗法并不能充分治疗慢性神经性疼痛,只有不足半数的患者的疼痛能够达到临床显著缓解(定义为疼痛减轻大于50%)。本研究中,通过与安慰剂和利多卡因比较 评估了AMPA/GluR5受体拮抗剂NS1209治疗慢性神经病理性疼痛和周围神经损伤引起的异常性疼痛的有效性、安全性和耐受性。

方法:一个随机、双盲、安慰剂对照,三向交叉设计的研究,纳入的慢性神经性疼痛的患者分别静脉注射NS1209 (322 mg), 利多卡因 (5 mg/kg)和安慰剂。分别在筛选时和治疗开始后的0246824h测量当前自发痛以及刷、针刺、冷、热刺激引起的疼痛。

结果:有13例患者完成研究。与安慰剂相比,无论NS1209 还是利多卡因对于主要终点指标(当下的自发痛)无显著影响,但是两药在第二终点继发痛的缓解好于安慰剂。与利多卡因类似,NS1209在减轻一些神经病理性疼痛的主要症状上优于安慰剂,如各种类型的刺激痛,包括机械性和冷刺激引起的异常性疼痛。

结论:这些发现与已报道的在其他疼痛模型中NS1209的作用一致,并且提示AMPA受体在人类的神经性疼痛具有一定的作用。此外,NS1209具有良好的安全性,并且对本实验中使用的剂量具有良好的耐受性,这与安慰剂相似。

(怀晓蓉 陈杰 校)

BACKGROUND: Chronic neuropathic pain is inadequately treated using current therapies, with less than half of patients achieving clinically significant pain relief (defined as more than 50% pain reduction). In this study, we evaluated the AMPA/GluR5 receptor antagonist NS1209 for efficacy, safety, and tolerability in comparison with placebo and lidocaine for the treatment of chronic neuropathic pain and allodynia in patients with peripheral nerve injury.

METHODS: A randomized, double-blind, placebo-controlled, three-way crossover study was designed to recruit patients with chronic neuropathic pain for IV treatment with NS1209 (322 mg), lidocaine (5 mg/kg), and placebo. Measures of spontaneous current pain and pain evoked by brush, pinprick, cold, and heat stimulation were performed at screening and at 0, 2, 4, 6, 8, and 24 h after the start of the treatment session.

RESULTS: Thirteen patients completed the study. Neither NS1209 nor lidocaine showed a statistically significant effect over placebo on the primary end-point spontaneous current pain, but both compounds exhibited a statistically significant effect on the secondary end-point pain relief of overall spontaneous pain compared with placebo. Similar to lidocaine, NS1209 was superior to placebo in alleviating some key symptoms of neuropathic pain, i.e., evoked types of pain, including mechanical and cold allodynia.

CONCLUSIONS: These findings are consistent with those reported for NS1209 in other models of pain and suggest that there is a role for AMPA receptor involvement in neuropathic pain in humans. Furthermore, NS1209 was safe and well tolerated at the given doses with a safety profile similar to placebo.

 

胸段硬膜外麻醉对全麻患者肝血流量的影响

The Effects of Thoracic Epidural Anesthesia on Hepatic Blood Flow in Patients Under General Anesthesia

Rainer Meierhenrich, MD, Florian Wagner, MD, Wolfram Schütz, MD, Michael Rockemann, MD, Peter Steffen, MD, Uwe Senftleben, MD, and Albrecht Gauss, MD

From the Department of Anesthesiology, University of Ulm, Ulm, Germany.

Anesth Analg 2009 108: 1331-1337.

 

背景:肝脏低灌注被认为是围术期肝损伤病理生理学中的重要因素。尽管硬膜外麻醉(EDA)是一种广泛应用的麻醉技术,但是胸段硬膜外阻滞(阻滞仅限制在胸段)对患者肝血流影响的相关数据几乎没有。

方法:在20位全麻病人中,作者在进行硬膜外阻滞前后采用多平面经食道超声技术对右肝和中肝静脉的血流指数进行评估。在T7-T9置入硬膜外导管,注入中等剂量的1%甲哌卡因10ml8-16ml)。硬膜外阻滞后平均动脉压低于60mmHg的患者持续输注去甲肾上腺素(EDA-NE)。其他患者研究期间没有给予任何儿茶酚胺类药物(EDA组),另外没有进行硬膜外阻滞的10个病人作为对照(对照组)。

结果:其中5位患者必须使用去甲肾上腺素以避免平均动脉压低于60mmHg。因此,EDA-NE组包括了5名患者,而EDA组有15名患者。在EDA组中,硬膜外阻滞与两条肝静脉的血流指数下降24%有关 (P < 0.01)。在EDA-NE组中,5名患者的肝血流指数下降(右肝静脉平均下降39 [11–45] %,中肝静脉平均下降32 [7–49] %)。与对照组相比,EDA组和EDA-NE组中两条肝静脉的血流指数均显著下降(P < 0.05) 。与肝血流相比,心输出量不受硬膜外阻滞影响。

结论 作者推断,在人类胸段硬膜外阻滞和肝血流下降相关,胸段硬膜外阻滞加上持续静脉输注去甲肾上腺素似乎导致肝血流的进一步减少。

(黄丹 陈杰 校)

BACKGROUND: Hepatic hypoperfusion is regarded as an important factor in the pathophysiology of perioperative liver injury. Although epidural anesthesia (EDA) is a widely used technique, no data are available about the effects on hepatic blood flow of thoracic EDA with blockade restricted to thoracic segments in humans.

METHODS: In 20 patients under general anesthesia, we assessed hepatic blood flow index in the right and middle hepatic vein by use of multiplane transesophageal echocardiography before and after induction of EDA. The epidural catheter was inserted at TH7-9, and mepivacaine 1% with a median (range) dose of 10 (8–16) mL was injected. Norepinephrine (NE) was continuously administered to patients who demonstrated a decrease in mean arterial blood pressure below 60 mm Hg after induction of EDA (EDA-NE group). The other patients did not receive any catecholamine during the study period (EDA group). A further 10 patients without EDA served as controls (control group).

RESULTS: In five patients, administration of NE was necessary to avoid a decrease in mean arterial blood pressure below 60 mm Hg. Thus, the EDA-NE group consisted of five patients and the EDA group of 15. In the EDA group, EDA was associated with a median decrease in hepatic blood flow index of 24% in both hepatic veins (P < 0.01). In the EDA-NE group, all five patients showed a decrease in the blood flow index of the right (median decrease 39 [11–45] %) and middle hepatic vein (median decrease 32 [7–49] %). Patients in the control group showed a constant blood flow index in both hepatic veins. Reduction in blood flow index in the EDA group and the EDA-NE group was significant in comparison with the control group (P < 0.05). In contrast to hepatic blood flow, cardiac output was not affected by EDA.

CONCLUSIONS: We conclude that, in humans, thoracic EDA is associated with a decrease in hepatic blood flow. Thoracic EDA combined with continuous infusion of NE seems to result in a further decrease in hepatic blood flow.

 

再灌注早期的短暂性代谢性碱中毒中会消除氦预处理防止心肌梗塞能力:通过环孢霉素A对兔子心脏保护功能的恢复

Transient Metabolic Alkalosis During Early Reperfusion Abolishes Helium Preconditioning Against Myocardial Infarction: Restoration of Cardioprotection by Cyclosporin A in Rabbits

Paul S. Pagel, MD, PhD*{dagger}, and John G. Krolikowski, BS*

From the *Department of Anesthesiology, The Medical College of Wisconsin, Milwaukee, Wisconsin; and {dagger}The Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center Milwaukee, Wisconsin.

Anesth Analg 2009; 108:1076-1082

背景:近来发现冠脉梗阻后再灌注早期的细胞内酸中毒和心肌缺血后处理引起的保护心肌有关系。我们来证明这一假设,再灌注早期的短暂性碱中毒会消除用氦预处理的作用,以及用线粒体通透性环核转录抑制剂环孢菌素A(CsA)恢复活体体内氦的心肌保护效应。

方法:兔子(n = 36)进行血流动力学仪器监测,冠脉左前降支阻断30分钟后,再灌注3小时。在冠脉左前降支阻断前给予兔子0.9%生理盐水(对照组)或三个周期的每5分钟70%-30%氧间隔5分钟空氧混合,其中部分兔子在再灌注之前静注2分钟碳酸氢钠(10 mEq)产生碱中毒。其他进行氦预处理的兔子在碱中毒时予以CsA (5 mg/kg)或仅给予CsA

结果:氦预处理减少了心肌梗死的面积(25% ± 4%左室有风险,P < 0.05),对照组是46% ± 2%。在灌注早期碱中毒没有改变梗死面积(46% ± 2%),但该干预消除了氦介导的心肌保护(45% ± 3%)。在碱中毒的情况下时,CsA恢复了氦预处理减少的梗死面积(28% ± 6%; 与对照组相比P < 0.05),但是不影响单纯的心肌坏死(43% ± 6%)

讨论:结果说明兔子中再灌注早期短暂的碱中毒会消除氦预处理的作用。CsA能恢复了碱中毒时氦介导的心肌保护,意味着氦预处理通过维持再灌注早期细胞内酸环境来抑制线粒体通透性转换孔的形成。

(唐亮   马皓琳 李士通 校)

BACKGROUND: Intracellular acidosis during early reperfusion after coronary artery occlusion was recently linked to cardioprotection resulting from myocardial ischemic postconditioning. We tested the hypotheses that transient alkalosis during early reperfusion abolishes helium preconditioning and that the mitochondrial permeability transition pore inhibitor cyclosporin A (CsA) restores the cardioprotective effects of helium during alkalosis in vivo.

METHODS: Rabbits (n = 36) instrumented for hemodynamics measurement were subjected to a 30-min left anterior descending coronary artery occlusion and 3-h reperfusion. The rabbits received 0.9% saline (control) or three cycles of 70% helium–30% oxygen administered for 5 min interspersed with 5 min of an air-oxygen mixture before left anterior descending coronary artery occlusion in the absence or presence of transient alkalosis (pH = 7.5) produced by administration of IV sodium bicarbonate (10 mEq) 2 min before reperfusion. Other rabbits preconditioned with helium received CsA (5 mg/kg) in the presence of alkalosis or CsA alone.

RESULTS: Helium reduced myocardial infarct size (25% ± 4% of left ventricular area at risk; P < 0.05) compared with control (44% ± 6%). Alkalosis during early reperfusion did not alter infarct size alone (46% ± 2%), but this intervention abolished helium-induced cardioprotection (45% ± 3%). CsA restored reductions in infarct size produced by helium preconditioning in the presence of alkalosis (28% ± 6%; P < 0.05 versus control) but did not affect myocardial necrosis alone (43% ± 6%).

CONCLUSIONS: The results demonstrate that transient alkalosis during early reperfusion abolishes helium preconditioning in rabbits. CsA restored helium-induced cardioprotection during alkalosis, suggesting that helium preconditioning inhibits mitochondrial permeability transition pore formation by maintaining intracellular acidosis during early reperfusion.


结膜下阻滞与芬太尼静脉注射用于小儿白内障手术的围术期镇痛的比较

Subtenon Block Compared to Intravenous Fentanyl for Perioperative Analgesia in Pediatric Cataract Surgery

Babita Ghai, MD, DNB*, Jagat Ram, MS{dagger}, Jeetinder Kaur Makkar, MD, DNB*, Jyotsna Wig, MD, FAMS*, and Sushmita Kaushik, MS{dagger}

From the *Departments of Anaesthesia and Intensive Care, and {dagger}Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Anesth Analg 2009; 108:1132-1138

背景:在小儿眼球手术中,使用阿片类药物的全麻可提供很好的手术条件;然而术后疼痛的处理仍是一个很重要的问题。在小儿全麻中常辅助使用区域麻醉。我们在白内障手术患儿中比较了结膜下阻滞(SB)与静脉注射芬太尼用于围术期镇痛的有效性及安全性。我们假设使用结膜下阻滞与芬太尼相比可减少术后额外镇痛的需求。

方法:这是一项前瞻性、随机、对照、双盲试验。我们研究了114ASA I II级(6个月-6岁)在全麻下择期行单眼白内障手术的患儿。患儿在确保气道后随机分成两组,即SB(n = 58) F (n = 56)SB组患儿接受0.06–0.08 mL/kg 2%利多卡因和0.5%布比卡因(5050)混合液行结膜下阻滞,同时静脉注射0.2 mL/kg生理盐水,而F组患儿接受1 µg/kg (浓度5 µg/kg,容量0.2 mL/kg)的芬太尼静脉注射,同时结膜下注射生理盐水(0.06–0.08 mL/kg)。研究药物使用后5分钟开始手术。在术后0.51234 24 小时评估术后疼痛、镇静、恶心/呕吐。初级结果是术后24小时内需额外镇痛的病人数。分析的第二个结果是疼痛及镇静评分、首次需要额外镇痛的时间、眼心反射的发生率及恶心/呕吐。

结果SB组术后24小时内需要额外镇痛的病人数(n = 17/58, 29.3%)明显少于F(n = 39/56, 69.6%, P < 0.001)SB组术后所有时间段的疼痛评分明显较低。SB组首次需要镇痛的时间中位数(范围)(16 [2–13]小时)明显较F组(4 [0.5–8.5]小时)晚 (P < 0.001)。术后半小时时的镇静评分两组相当,而之后F组焦虑或哭闹的患儿较多,而SB组镇静、坐着或舒适地睁眼躺着的患儿更多(P < 0.05)。与SB组相比,F组记录到的眼心反射的发生率明显更高(P = 0.019)SB组未发现相关的并发症。

结论:对于小儿白内障手术的围术期镇痛,与静注芬太尼相比,SB是安全且更好的选择。

(裘毅敏译,马皓琳、李士通校)

BACKGROUND: General anesthesia with opioids provides good operative conditions for ocular surgery in children; however, postoperative pain management remains a significant problem. Regional anesthesia is commonly used as an adjunct to general anesthesia in children. We compared the efficacy and safety of subtenon block (SB) versus IV fentanyl for perioperative analgesia in pediatric cataract surgery. We hypothesized that perioperative analgesia using SB may reduce the requirement of postoperative rescue analgesia compared with fentanyl.

METHODS: This was a prospective, randomized, controlled, double-blind trial. One hundred fourteen ASA I and II children (6 mo–6 yr) undergoing elective cataract surgery in one eye under general anesthesia were studied. Children were randomly allocated to one of the two groups, i.e., Group SB (n = 58) or Group F (n = 56) after securing the airway. Children in Group SB received SB with 0.06–0.08 mL/kg of 2% lidocaine and 0.5% bupivacaine (50:50) mixture and simultaneous 0.2 mL/kg normal saline IV, whereas children in Group F received 1 µg/kg (0.2 mL/kg of 5 µg/kg) of fentanyl IV and simultaneous subtenon injection with normal saline (0.06–0.08 mL/kg). Surgery started after 5 min of study drug administration. Postoperative assessment for pain, sedation, and nausea/vomiting was done at 0.5, 1, 2, 3, 4, and 24 h. The primary outcome was number of patients requiring rescue analgesia during the 24-h study period. Secondary outcomes assessed were pain and sedation scores, time to first rescue analgesia, incidence of occulocardiac reflex, and nausea/vomiting.

RESULTS: The number of patients requiring rescue analgesia during the 24 h was significantly less in Group SB (n = 17/58, 29.3%) compared with Group F (n = 39/56, 69.6%, P < 0.001). The postoperative pain scores were statistically lower in Group SB at all time intervals. The median (range) time to first analgesic requirement was significantly prolonged in Group SB (16 [2–13] vs 4 [0.5–8.5] h in Group F) (P < 0.001). Sedation scores at 1/2h were comparable, after which significantly more children were anxious or crying in Group F compared with Group SB in which more children were calm, sitting, or lying with eyes open and relaxed (P < 0.05). A significantly higher incidence of oculocardiac reflex was recorded in Group F versus Group SB (P = 0.019). No complication related to SB was noticed.

CONCLUSIONS: SB is a safe and superior alternative to IV fentanyl for perioperative analgesia in pediatric cataract surgery.


普瑞巴林对术前焦虑和镇静水平的效应:剂量范围的研究

The Effect of Pregabalin on Preoperative Anxiety and Sedation Levels: A Dose-Ranging Study

Paul F. White, PhD, MD, Burcu Tufanogullari, MD, Jimmie Taylor, MS, and Kevin Klein, MD

From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas.

Anesth Analg 2009; 108:1140-1145

背景:普瑞巴林是加巴喷丁类复合物,已有报道称其有抗焦虑、镇痛和抗惊厥特性。我们设想把口服普瑞巴林作为麻醉前用药将在全麻诱导前剂量相关性的减少急性(状态)焦虑和增加镇静(睡意)。第二个目的是检测是否麻醉前服用普瑞巴林将减少术后疼痛。

方法108ASA I–III门诊择期手术病人被随机地分到四个术前用药治疗组中:1)对照组,接受安慰剂胶囊;2)普瑞巴林75组,口服普瑞巴林75mg3)普瑞巴林150组,口服普瑞巴林150mg4)普瑞巴林300组,口服普瑞巴林300mg。在基线(给予研究药物前即刻)、给予药物后3060分钟、麻醉诱导前即刻和在麻醉后监护病房(PACU)里每隔30分钟,评估研究药物对病人焦虑、镇静和疼痛水平的影响。评估采用标准11点口诉言词评分法:0=没有影响,10=最大效应。术后七天随访询问以评估需要术后阿片镇痛用药、恶心和呕吐发生率、止吐药需要量、离开PACU和出院时间、病人恢复质量评分和后期恢复结局(例如,恢复正常饮食摄入和肠道功能恢复)。

结果:在人口学特征、从服用研究药物到麻醉诱导的时间、外科手术类型、麻醉持续时间、离开PACU和医院时间和在PACU的芬太尼需要量,四组病人没有差异。在术前评估期间,焦虑水平没有变化,并且四组病人没有差异。普瑞巴林300组在诱导前评估期间和在手术后90120分钟的镇静评分显著高于对照组(分别为5 ± 33 ± 2, 7 ± 45 ± 3, 8 ± 44 ± 4, P < 0.05)。

结论:普瑞巴林术前使用(75-300mg po)剂量相关性增加术前镇静,但没有减少术前焦虑状态、术后疼痛或改善择期外科小手术后的恢复过程。

(王宏 译,马皓琳 李士通校)

BACKGROUND: Pregabalin is a gabapentinoid compound, which has been alleged to possess anxiolytic, analgesic, and anticonvulsant properties. We hypothesized that premedication with oral pregabalin would produce dose-related reductions in acute (state) anxiety and increases in sedation (sleepiness) before induction of general anesthesia. A secondary objective was to determine if premedication with pregabalin would reduce postoperative pain.

METHODS: One hundred eight ASA I–III outpatients undergoing elective surgery were randomly assigned to one of the four premedication treatment groups: 1) control group received placebo capsules, 2) pregabalin 75 group received pregabalin 75 mg, po, 3) pregabalin 150 group received pregabalin 150 mg, po, and 4) pregabalin 300 group received pregabalin 300 mg, po. The effects of the study drug on the patients’ level of anxiety, sedation, and pain were assessed at baseline (immediately before study drug administration), at 30 and 60 min after drug administration, and immediately before induction of anesthesia, as well as at 30-min intervals in the postanesthesia care unit (PACU) using standardized 11-point verbal rating scales, with 0 = none to 10 = maximal effect. The need for postoperative opioid analgesic medication, incidence of nausea and vomiting, requirement for rescue antiemetics, and times to discharge from the PACU and hospital, as well as the patients’ quality of recovery scores, and late recovery outcomes (e.g., resumption of dietary intake and recovery of bowel function) were assessed at a 7-day follow-up interview.

RESULTS: Demographic characteristics, times between study drug administration to anesthetic induction, type of surgical procedures, duration of anesthesia, PACU and hospital discharge time, as well as the requirement for fentanyl in the PACU, did not differ among the four study groups. Anxiety levels remained unchanged during the preoperative evaluation period, and did not differ among the four study groups. Sedation scores were significantly higher in the pregabalin 300 group at the preinduction assessment interval and at 90 and 120 min after surgery compared with the control group (5 ± 3 vs 3 ± 2, 7 ± 4 vs 5 ± 3, 8 ± 4 vs 4 ± 4, respectively, P < 0.05).

CONCLUSION: Preoperative pregabalin administration (75–300 mg po) increased perioperative sedation in a dose-related fashion, but failed to reduce preoperative state anxiety, postoperative pain, or to improve the recovery process after minor elective surgery procedures.


小剂量瑞芬太尼对全麻苏醒期间气管导管的反应的影响

The Effect of Low-Dose Remifentanil on Responses to the Endotracheal Tube During Emergence from General Anesthesia

Marie T. Aouad, MD, Achir A. Al-Alami, MD, Viviane G. Nasr, MD, Fouad G. Souki, MD, Reine A. Zbeidy, MD, and Sahar M. Siddik-Sayyid, MD

From the Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon.

Anesth Analg 2009; 108:1157-1160

背景:全麻苏醒常伴有咳嗽、激动和血流动力学不稳定。瑞芬太尼可缓解这些反应。

方法:在前瞻性、双盲、随机试验中,我们选择60例在瑞芬太尼麻醉下行鼻部手术的成年患者。在苏醒阶段,瑞芬太尼组的瑞芬太尼减少至1/10的维持速率,而对照组停用瑞芬太尼。

结果:两组唤醒时间和拔气管导管时间相似。在苏醒期间,瑞芬太尼组 (输注速率 0.014 ± 0.011 µg · kg–1 · min–1) 与对照组相比,咳嗽的发生率明显较低(40%80%, P = 0.002),且程度较轻,同时,无意识动作(3.3%30%, P = 0.006)和低心率的发生率也较低。

结论:苏醒期间的小剂量瑞芬太尼并不延长苏醒时间,但减少气管导管引起咳嗽的发生率和严重度。

(彭中美 马皓琳 李士通 校)

BACKGROUND: Emergence from general anesthesia can be associated with coughing, agitation, and hemodynamic disturbances. Remifentanil may attenuate these responses.

METHODS: In a prospective, double-blind, randomized trial, we enrolled 60 adult patients undergoing nasal surgery using remifentanil-based anesthesia. During the emergence phase, the remifentanil group had remifentanil reduced to one tenth of the maintenance rate, whereas the control group had remifentanil discontinued.

RESULTS: Times to awakening and tracheal extubation were similar between the two groups. During emergence, the remifentanil group (infusion rate 0.014 ± 0.011 µg · kg–1 · min–1) had a significantly lower incidence (40% vs 80%, P = 0.002) and less severe coughing compared with the control group, as well as a lower incidence of nonpurposeful movement (3.3% vs 30%, P = 0.006) and slower heart rates.

CONCLUSIONS: Low-dose remifentanil during emergence did not prolong wake-up but reduced the incidence and severity of coughing from the endotracheal tube.


苯二氮卓类药物对硬骨鱼紧张肽II刺激的大鼠大脑皮质切片去甲肾上腺素释放的影响

The Effects of Benzodiazepines on Urotensin II-Stimulated Norepinephrine Release from Rat Cerebrocortical Slices

Yoko Kawaguchi, MD*, Tomoko Ono, MD*, Mihoko Kudo, PhD*, Tetsuya Kushikata, MD*, Eiji Hashiba, MD*, Hitoshi Yoshida, MD*, Tsuyoshi Kudo, PhD*, Kenichi Furukawa, PhD{dagger}, Stephen A. Douglas, PhD{ddagger}, and Kazuyoshi Hirota, MD, FRCA*

From the Departments of *Anesthesiology and {dagger}Pharmacology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan; and {ddagger}Cardiovascular and Urogenital Centre of Excellence for Drug Discovery GlaxoSmithKline, King of Prussia, Pennsylvania.

Anesth Analg 2009; 108:1177-1181

背景: 紧张、焦虑等心境障碍与硬骨鱼紧张肽II (UII)及其受体(UT)有关;其原因至少部分是大脑皮层去甲肾上腺素的释放增加。苯二氮卓类药物因降低大脑皮质去甲肾上腺素释放而广泛用作安眠药和抗焦虑剂。我们推测苯二氮卓类药物与大脑皮层UII系统之间存在某种相互作用。

方法:本研究观察苯二氮卓类对UII增加大鼠大脑皮质切片去甲肾上腺素释放的影响,同时测定了表达大鼠UT受体的HEK293细胞(HEK293-rUT细胞)的胞内Ca2+浓度([Ca2+]i)

结果:咪达唑仑、地西泮和氟硝西泮浓度依赖性地抑制UII诱发的去甲肾上腺素释放而不影响[Ca2+]i。咪达唑仑抑制UII诱发的去甲肾上腺素释放的IC50(0.32 µM, P < 0.01)明显低于地西泮(187 µM)和氟硝西泮(40 µM)。苯二氮卓位点拮抗剂氟马西尼明显减弱咪达唑仑对UII诱发的去甲肾上腺素释放的抑制效应。

结论:本研究显示,临床相关剂量的咪达唑仑能明显抑制UII诱发的去甲肾上腺素释放。该抑制作用可能部分地通过中枢苯二氮卓受体介导。

(江继宏   马皓琳 李士通 校)

BACKGROUND: Urotensin II (UII) and its receptor (UT) are implicated in mood disorders, such as stress and anxiety, and this may result, at least in part, from increased norepinephrine release from the cerebral cortex. Benzodiazepines have been widely used as hypnotics and anxiolytics, producing a decrease in cerebrocortical norepinephrine release. We hypothesized that there was some interaction between benzodiazepines and the UII system in the cerebral cortex.

METHODS: In the present study, we have examined the effects of benzodiazepines on UII-increased norepinephrine release from rat cerebrocortical slices and intracellular Ca2+ concentrations ([Ca2+]i) in HEK293 cells expressing rat UT receptor (HEK293-rUT cells).

RESULTS: Midazolam, diazepam and flunitrazepam concentration-dependently inhibited UII-evoked norepinephrine release but did not affect [Ca2+]i. The IC50 of midazolam for inhibition of UII-evoked norepinephrine release (0.32 µM, P < 0.01) was significantly lower than that of diazepam (187 µM) or flunitrazepam (40 µM). The inhibitory effects of midazolam on UII-evoked norepinephrine release were significantly attenuated by flumazenil, a benzodiazepine site antagonist.

CONCLUSION: The present study suggests that midazolam, at clinically relevant concentration, significantly inhibited UII-evoked norepinephrine release. This inhibitory effect may be partially mediated via central benzodiazepine receptors.


气体浓度改变90%所需时间:三种半紧闭麻醉呼吸系统间的比较

Time to a 90% Change in Gas Concentration: A Comparison of Three Semi-Closed Anesthesia Breathing Systems

Michael P. Dosch, MS, CRNA*, Robert G. Loeb, MD{dagger}, Tiffany L. Brainerd, MD{dagger}, John F. Stallwood, MS, CRNA*, and Steven Lechner, MS, CRNA*

From the *Nurse Anesthesia, University of Detroit Mercy, Detroit, Michigan; and {dagger}Department of Anesthesiology, University of Arizona, Tucson, Arizona.

Anesth Analg 2009; 108:1193-1197

背景麻醉呼吸系统中气体浓度改变的速度影响着去氮、麻醉诱导以及苏醒的速率。呼吸系统的设计也影响着麻醉维持中气体浓度改变的速率。本研究中,我们试图找出现代半紧闭呼吸系统中气体浓度改变的速率。我们的假设是呼吸系统的容积越小,新鲜气体流量越大,就越容易最先达到平衡。

方法:本研究为离体实验,包括三种麻醉工作站:ADU(Datex-Ohmeda公司,现为GE医疗公司(麦迪逊, 威斯康辛州)的一个分部),带有COSY-1 呼吸系统的 Fabius GS(Draeger医疗公司,泰尔福, 宾夕法尼亚州)以及Aestiva (Datex-Ohmeda公司,现为GE医疗公司(麦迪逊, 威斯康辛州)的一个分部)。呼吸系统与测试肺模型相连接并用空气进行通气。然后改用纯氧,调节氧流量分别为1246或者8 L/min,记录下测试肺模型中氧浓度改变50%63%66%75%以及90%所需时间。每种呼吸系统分别在不同的新鲜气流下各进行10次实验。结果先用分块绘图方差分析进行分析,然后再用Bonferroni校正法进行后续的检验。

结果:当流量为6或者8 L/min时,三种呼吸系统中气体达到平衡所需时间没有差别。当流量为12L/min时,ADU中气体浓度的改变比AestivaFabius(P < 0.001)。当流量为4L/min时,ADU中气体浓度的改变仍比Aestivalai(P < 0.001),但与Fabius相比没有差别。

结论:我们认为,当新鲜吸入气流的组成发生改变时,除了新鲜气体流速以外,呼吸系统的容积对气体达到平衡所需时间的影响最大。相比而言,呼吸系统中一些部件的位置(比如活瓣、二氧化碳吸收罐、新鲜气体入口、通气波纹管或者活塞)的影响较小。

(吴进   马皓琳 李士通 校)

BACKGROUND: The speed with which gas concentration can be changed in the anesthesia breathing system affects the rate of denitrogenation, anesthesia induction, and emergence. Breathing system design also affects the speed at which gas concentration can be changed during maintenance. In this study, we sought to determine the speed of changes in gas concentration in modern semi-closed breathing systems. We hypothesized that equilibrium would be reached most quickly in breathing systems with smaller volume, and at high fresh gas flows.

METHODS: Three anesthesia workstations were studied in vitro: the ADU (Datex-Ohmeda, now a division of GE Medical, Madison, WI), the Fabius GS with a COSY-1 breathing system (Draeger Medical, Telford, PA), and the Aestiva (Datex-Ohmeda, now a division of GE Medical, Madison, WI). The breathing systems were connected to a test lung and ventilated with air. The fresh gas flow was then changed to oxygen at rates of 1, 2, 4, 6, or 8 L/min, and times to 50%, 63%, 66%, 75%, and 90% change in oxygen concentration within the test lung were recorded. Ten trials were performed for each breathing system, at each fresh gas flow. The results were analyzed with a split-plot analysis of variance followed by post hoc tests with a Bonferroni correction.

RESULTS: At flows of 6 or 8 L/min, times to equilibration did not differ among the three breathing systems. At flows of 1 to 2 L/min, the gas concentration changed faster with the ADU than with the Aestiva or Fabius (P < 0.001). At 4 L/min, the ADU was faster than Aestiva (P < 0.001), but not Fabius.

CONCLUSIONS: We concluded that, other than fresh gas flow rate, breathing system volume has the biggest effect on time to equilibrium when the composition of the fresh gas inflow is changed. The position of components (e.g., valves, carbon dioxide absorber, fresh gas inlet, ventilator bellows or piston) within the breathing system has a less pronounced effect.


光柱(Surch-LiteTM)和直接喉镜气管插管用于高Mallampati评分患者的对比

A Comparison of Lighted Stylet (Surch-LiteTM) and Direct Laryngoscopic Intubation in Patients with High Mallampati Scores

Ka-young Rhee, MD*, Jeong-rim Lee, MD{ddagger}, Jinhee Kim, MD{dagger}, Sanghyon Park, MD{dagger}, Won-Kyong Kwon, MD*, and SungHee Han, MD{dagger}

From the *Department of Anesthesiology and Pain Medicine, School of Medicine, Konkuk University, Seoul, Korea; {dagger}Department of Anesthesiology and Pain Medicine, School of Medicine, Seoul National University, Seoul, Korea; {ddagger}Department of Anesthesiology and Pain Medicine, Yousei University, Seoul, Korea.

Anesth Analg 2009; 108:1215-1219

背景:光柱(Surch-LiteTM,SL)作为直接喉镜的有效替代品,在困难气道患者中尤其具有应用价值。  Mallampati评分高意味着口咽部结构可视性差。因为灯仗不需要依赖看清口咽部结构,我们推测,在Mallampati高评分患者中,光柱比直接喉镜更易于使用。为了试验这个猜测,我们完成了一个前瞻性、随机试验,以比较光柱(Surch-LiteTM)和直接喉镜在高Mallampati评分患者中的应用。比较成功率、插管所需时间和血流动力学变化。

方法:Mallampati Ⅲ级的患者随机分至光柱(S L)组和直接喉镜(DL)组。全麻诱导后用随机分配的设备进行气管插管。测定插管前即刻及插管后5min内每隔30s的心率和平均动脉压。记录插管的时间和插管成功率。还评估术后咽喉部不适症状。

结果:每组各有30位患者。SL组的首次插管成功率(29/30)明显高于DL(24/30)。心率最高值和基础心率间的差别在DL(25 ± 13 bpm)明显高于SL(16 ± 10 bpm)。平均动脉压的变化也是DL(38 ± 14 mm Hg)高于SL(20 ± 13 mm Hg)。且SL组的插管时间(12 ± 6 s)显著比DL(17 ± 12 s)短。两组间术后咽喉部不适主诉无明显差异。

结论:在高Mallampati评分的患者中,Surch-Lite可以有较高的首次插管成功率和较小的血流动力学变化。因此,在这些患者中,Surch-Lite是直接喉镜的一个有效替代品。

(黄佳佳译,马皓琳 李士通校)

BACKGROUND: A lighted stylet is an effective alternative to a direct laryngoscope and has been reported to be particularly useful in patients with difficult airways. A high Mallampati class indicates poor visibility of the oropharyngeal structures. Because a lighted stylet does not require direct oropharyngeal visualization, we hypothesized that the lighted stylet would be easier to use than a direct laryngoscope in patients with a high Mallampati score. To examine our hypothesis, we performed a prospective, randomized study comparing a lighted stylet (Surch-LiteTM) with direct laryngoscopy in patients with high Mallampati scores. Success rate, time required for intubation, and hemodynamic changes were compared.

METHODS: Mallampati Class III patients were enrolled and were randomly assigned to the Surch-Lite group (Group SL) or the direct laryngoscopy group (Group DL). Patients' tracheas were intubated with the randomly selected intubation device after induction of general anesthesia. Heart rate (HR) and mean arterial blood pressure were measured immediately before and every 30 s after intubation for 5 min. The time to intubation and success rate were recorded. Postoperative pharyngolaryngeal complaints were also assessed.

RESULTS: Thirty patients were enrolled in each group. The success rate on the first attempt was significantly higher in Group SL (29 of 30) than in Group DL (24 of 30). The difference between maximal HR and baseline HR was significantly higher in Group DL (25 ± 13 bpm) than in Group SL (16 ± 10 bpm). The change in mean arterial blood pressure was also higher in Group DL (38 ± 14 mm Hg) than in Group SL (20 ± 13 mm Hg). The time to intubation was significantly shorter in Group SL (12 ± 6 s) than in Group DL (17 ± 12 s). Postoperative pharyngolaryngeal complaints were not significantly different between the two groups.

CONCLUSIONS: The Surch-Lite showed a higher success rate on the first intubation attempt and produced an attenuated hemodynamic response to endotracheal intubation of patients with high Mallampati score. Thus, the Surch-Lite is an effective alternative to direct laryngoscopy in these patients.



“冲技术与用标准技术比较局麻药溶液中肾上腺素的浓度

A Comparison of Epinephrine Concentrations in Local Anesthetic Solutions Using a "Wash" Versus Measured Technique

Kyle G. Wojciechowski, MD, Michael J. Avram, PhD, Kiril Raikoff, MS, Robert J. McCarthy, PharmD, and Cynthia A. Wong, MD

From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Anesth Analg 2009; 108:1243-1245

介绍:麻醉医生经常会配制含肾上腺素的局麻药溶液。我们比较了应用“冲洗”的技术与应用标准技术(用胰岛素注射器)配制的溶液的肾上腺素浓度,并且比较了不同麻醉医生所用的肾上腺素浓度。

方法:五位麻醉医生在进行脊椎麻醉和硬膜外麻醉使用两种技术准备了注射器。用高效液相色谱法测定肾上腺素的浓度

结果:对于脊椎麻醉来说,标准技术所得到的浓度比用“洗”的技术时测定的浓度高,而对于硬膜外来讲,并不如此。

结论:所有脊椎麻醉时溶液的肾上腺素浓度比靶浓度要高,5位麻醉医生配制的硬膜外溶液中有3位的浓度也是如此。在不同的麻醉医生之间,有明显的差异。

(黄丽娜 马皓琳 李士通 校)

INTRODUCTION: Anesthesiologists often prepare epinephrine-containing local anesthetic solutions. We compared epinephrine concentrations of solutions prepared using the "wash" technique with solutions prepared using the measured technique (using an insulin syringe), and compared epinephrine concentrations among anesthesiologists.

METHODS: Five anesthesiologists prepared syringes for spinal and epidural anesthesia using both techniques. Epinephrine concentrations were measured using high-performance liquid chromatography.

RESULTS: Measured technique concentrations were higher than those of the wash technique for the spinal but not epidural solutions.

CONCLUSIONS: Concentrations of all measured spinal solutions were higher than the target concentrations, as were concentrations of three of five measured epidural solutions. There were significant differences among anesthesiologists.


提高颅内压可以增加脑血流量自身调节的下限

The Lower Limit of Cerebral Blood Flow Autoregulation Is Increased with Elevated Intracranial Pressure

 

Ken M. Brady, MD*, Jennifer K. Lee, MD*, Kathleen K. Kibler, BS*, Ronald B. Easley, MD*, Raymond C. Koehler, PhD*, Marek Czosnyka, PhD{dagger}, Peter Smielewski, PhD{dagger}, and Donald H. Shaffner, MD*

From the *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and {dagger}Department of Academic Neurosurgery, Addenbrooke's Hospital, Cambridge, UK.

Anesth Analg 2009; 108:1278-1283

背景:脑灌注压决定了脑血流量自身调节(LLA)的下限,人们普遍认为这相当于减少了动脉血压(ABP)或增加了颅内压(ICP)。但是在不同颅内压水平降低动脉血压所取得的效果还未完全研究透彻。我们本次研究的目的是确定不同颅内压情况下低血压时的脑血流量下限是否不变。

方法:通过连续脑室液灌注,麻醉后的小猪被分成三组:基础ICP组(n = 10),中度升高ICP(20 mm Hg; n = 11)和重度升高ICP(40 mm Hg; n = 9)。我们通过在下腔静脉植入气囊式导管充气的方法来逐渐降低血压。通过监测皮层激光多普勒流量来测定脑血流量自身调节的下限。

结果:基础ICP组在脑血流量自身调节下限时的脑灌注压平均是29.8 mm Hg (95% 可信区间: 26.5–33.0 mm Hg),但是中度升高ICP组在脑血流量自身调节下限时的脑灌注压平均是37.6 mm Hg (95%可信区间: 32.0–43.2 mm Hg),重度升高ICP组在脑血流量自身调节下限时的脑灌注压平均是51.4 mm Hg (95%可信区间: 41.2–61.7 mm Hg)。每组间的脑血流量自身调节下限各不相同,脑血流量自身调节下限的增加与颅内压增加相关。

结论:在本次无创的提高颅内压的小猪模型中,脑血流量自身调节下限与颅内压呈正相关,这一结果提示了作为对颅内压急性升高伴和动脉血压相同程度升高的补偿并不能够足以预防脑缺血。

(姜旭晖译,马皓琳 李士通校)

 

BACKGROUND: The cerebral perfusion pressure that denotes the lower limit of cerebral blood flow autoregulation (LLA) is generally considered to be equivalent for reductions in arterial blood pressure (ABP) or increases in intracranial pressure (ICP). However, the effect of decreasing ABP at different levels of ICP has not been well studied. Our objective in the present study was to determine if the LLA during arterial hypotension was invariant with ICP.

METHODS: Using continuous ventricular fluid infusion, anesthetized piglets were assigned to 1 of 3 groups: naïve ICP (n = 10), moderately elevated ICP (20 mm Hg; n = 11), or severely elevated ICP (40 mm Hg; n = 9). Gradual hypotension was induced by inflation of a balloon catheter in the inferior vena cava. The LLA was determined by monitoring cortical laser-Doppler flux.

RESULTS: The naïve ICP group had an average CPP at the LLA (LLACPP) of 29.8 mm Hg (95% CI: 26.5–33.0 mm Hg). However, the moderately elevated ICP group had a mean LLACPP of 37.6 mm Hg (95% CI: 32.0–43.2 mm Hg), and the severely elevated ICP group had a mean LLACPP of 51.4 mm Hg (95% CI: 41.2–61.7 mm Hg). The LLA significantly differed among groups, and the increase in LLA correlated with the increase in ICP.

CONCLUSIONS: In this atraumatic, elevated ICP model in piglets, the LLA had a positive correlation with ICP, which suggests that compensating for an acute increase in ICP with an equal increase in ABP may not be sufficient to prevent cerebral ischemia.


在脊椎麻醉及多重机制镇痛用于前交叉韧带重建术后7~12周时的一般健康状况和膝功能预后情况

General Health and Knee Function Outcomes from 7 Days to 12 Weeks After Spinal Anesthesia and Multimodal Analgesia for Anterior Cruciate Ligament Reconstruction

Brian A. Williams, MD, MBA*, Qainyu Dang, PhD{dagger}{ddagger}, James E. Bost, PhD{dagger}{ddagger}, James J. Irrgang, PhD, PT, ATC§, Steven L. Orebaugh, MD*, Matthew T. Bottegal, BS§, and Michael L. Kentor, MD*

From the *Department of Anesthesiology, School of Medicine, {dagger}Department of Internal Medicine, School of Medicine, {ddagger}Center for Research on Health Care—Data Center, and §Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.

Anesth Analg 2009 108: 1296-1302.

 

背景:我们以前报道过与多重机制镇痛和股神经周围注射安慰剂比较,股神经周围神经持续镇痛能减轻前交叉韧带重建(ACLR, n = 270) 术后2天的疼痛。现在我们报告同样这些患者术后7~12周时的一般健康状况和膝功能预后。

方法:ACLR术后12周内的3个时间点,患者完成SF-36一般健康状况调查和膝功能调查(KOS)。进行广义估计方程分析来评估患者报告的调查结果和术前基准调查评分、术后时间及3个神经阻滞治疗组之间的联系。

结果:完成了270例患者的数据用于分析。在单变量和多变量回归的广义估计方程模型中,神经阻滞治疗组与术后SF-36KOS评分并不相关(都为P ≥0.05)。该模型显示SF-36中的体格检查部分总结(P < 0.0001)和KOS总分(P < 0.0001)随术后时间而增加(改善),且也受基准评分的影响。

结论:脊椎麻醉和多重机制镇痛用于ACLR后,神经阻滞治疗组并不能预示在术后7~12周的SF-36或膝功能预后。需要更多的研究来确定这些结论是否也适用于非标准化的麻醉剂,或者包括全身麻醉和/或高剂量阿片类药镇痛。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: We previously reported that continuous perineural femoral analgesia reduces pain with movement during the first 2 days after anterior cruciate ligament reconstruction (ACLR, n = 270), when compared with multimodal analgesia and placebo perineural femoral infusion. We now report the prospectively collected general health and knee function outcomes in the 7 days to 12 wk after surgery in these same patients.

METHODS: At three points during 12 wk after ACLR surgery, patients completed the SF-36 General Health Survey, and the Knee Outcome Survey (KOS). Generalized Estimating Equations were implemented to evaluate the association between patient-reported survey outcomes and (1) preoperative baseline survey scores, (2) time after surgery, and (3) three nerve block treatment groups.

RESULTS: Two hundred seventeen patients’ data were complete for analysis. In univariate and multiple regression Generalized Estimating Equations models, nerve block treatment group was not associated with SF-36 and KOS scores after surgery (all with P ≥0.05). The models showed that the physical component summary of the SF-36 (P < 0.0001) and the KOS total score (P < 0.0001) increased (improved) over time after surgery and were also influenced by baseline scores.

CONCLUSIONS: After spinal anesthesia and multimodal analgesia for ACLR, the nerve block treatment group did not predict SF-36 or knee function outcomes from 7 days to 12 wk after surgery. Further research is needed to determine whether these conclusions also apply to a nonstandardized anesthetic, or one that includes general anesthesia and/or high-dose opioid analgesia.


长期持续股神经阻滞对膝关节三髁成形术后与健康相关的生活质量的影响:一项前瞻、随机、三盲、安慰剂对照的1年随访实验

Health-Related Quality of Life After Tricompartment Knee Arthroplasty With and Without an Extended-Duration Continuous Femoral Nerve Block: A Prospective, 1-Year Follow-Up of a Randomized, Triple-Masked, Placebo-Controlled Study

Brian M. Ilfeld, MD, MS*, R. Scott Meyer, MD{dagger}, Linda T. Le, MD{ddagger}, Edward R. Mariano, MD*, Brian A. Williams, MD, MBA§, Krista Vandenborne, PhD, PT||, Pamela W. Duncan, PhD, PT, Daniel I. Sessler, MD#, F. Kayser Enneking, MD{ddagger}, Jonathan J. Shuster, PhD**, Rosalita C. Maldonado, BS*, and Peter F. Gearen, MD{dagger}{dagger}

From the Departments of *Anesthesiology, {dagger}Orthopaedic Surgery, University of California San Diego, San Diego, California; {ddagger}Department of Anesthesiology, The University of Florida, Gainesville, Florida; §Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania; ||Department of Physical Therapy, the University of Florida, Gainesville, Florida; ¶Division of Doctor of Physical Therapy, Department of Community and Family Medicine, Duke Center for Clinical Health Policy Research, and Duke Center on Aging, Duke University, Durham, North Carolina; #Department of Outcomes Research, and the Cleveland Clinic, Cleveland, Ohio; Departments of **Epidemiology and Health Policy Research, and {dagger}{dagger}Orthopaedics and Rehabilitation, The University of Florida, Gainesville, Florida.

Anesth Analg 2009; 108:1320-1325

背景:我们以前的研究发现把膝关节三髁成形术(TKA)术后整晚的持续股神经阻滞延长到术后4天,可以给病人在术后即刻神经周围输注期间带来很明确的好处。但延长的持续神经阻滞是否能提高病人以后的也就是术后7天到12月的健康生活质量,目前仍不清楚。

方法:膝关节三髁成形术的病人自手术时给予0.2%罗哌卡因股神经周围持续输注直至第二天早晨。此时病人以双盲形式被随机分为两组,一组股神经周围继续输注罗哌卡因(n = 25),另一组给予生理盐水(n = 25)。病人带着导管和便携式输注泵出院,术后第4天拔除导管。术前及术后第7天、123612月时,使用西安大略和麦克玛斯特大学骨关节炎(WOMAC)指数测定病人的生活健康质量。WOMAC从三个方面评价生活健康质量:疼痛、关节的活动程度和生理功能残疾。为行分析总结,在6个时间点中我们至少需要4个,包括术后第7天,和术后3612月中的至少两个。

结果:两个治疗组病人用于曲线下平均面积均值计算的WOMAC评分相似(两组的曲线下面积均值差异[整夜输注组-延长输注组]的点估计值=1.2, 95%可信区间–5.6 ─ +8.0; P = 0.72),在各个时间点两组病人WOMAC评分也相似(P > 0.05)

结论:我们发现膝关节三髁成形术病人行持续股神经阻滞的时间由术后整晚延长到术后4天,并不能提高(或降低)病人术后7天直至12月的生活健康质量。 (临床试验政府号NCT00135889.)

(张莹译  马皓琳 李士通校)

BACKGROUND: We previously provided evidence that extending an overnight continuous femoral nerve block to 4 days after tricompartment knee arthroplasty (TKA) provides clear benefits during the perineural infusion in the immediate postoperative period. However, it remains unknown if the extended infusion improves subsequent health-related quality of life between 7 days and 12 mo.

METHODS: Patients undergoing TKA received a femoral perineural infusion of ropivacaine 0.2% from surgery until the following morning, at which time patients were randomized to either continue perineural ropivacaine (n = 25) or normal saline (n = 25) in a double-masked fashion. Patients were discharged with their catheter and a portable infusion pump, and catheters were removed on postoperative day 4. Health-related quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index preoperatively and then at 7 days, as well as 1, 2, 3, 6, and 12 mo after surgery. The WOMAC evaluates three dimensions of health-related quality of life: pain, stiffness, and physical functional disability. For inclusion in the analysis, we required a minimum of 4 of the 6 time points, including day 7 and at least 2 of mo 3, 6, and 12.

RESULTS: The two treatment groups had similar WOMAC scores for the mean area under the curve calculations (point estimate for the difference in mean area under the curve for the two groups [overnight infusion group–extended infusion group] = 1.2, 95% confidence interval: –5.6 to +8.0; P = 0.72) and at all individual time points (P > 0.05).

CONCLUSIONS: We found no evidence that extending an overnight continuous femoral nerve block to 4 days improves (or worsens) subsequent health-related quality of life between 7 days and 12 mo after TKA. (ClinicalTrials.gov number, NCT00135889.)