Table of Contents

April 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

術前腦利鈉肽和術後肌鈣蛋白水準對大血管手術患者預後意義的初步報告
舒慧剛 陳傑

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.

再灌注早期的短暫性代謝性堿中毒中會消除氦預處理防止心肌梗塞能力:通過環孢黴素A對兔子心臟保護功能的恢復

唐亮   馬皓琳 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.

肝移植術中血小板輸注與術後死於急性肺損傷情況增多有關

單嘉琪譯 薛張綱校

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.

雙肺通氣時在吸入的氣體混合中使用空氣延遲單肺通氣時肺塌陷

劉世文 陳傑

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.

為胸外科手術選擇合適的單肺通氣裝置:三種支氣管阻塞器與傳統雙腔管的隨機對照臨床試驗

范羽譯 薛張綱校

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:

嬰幼兒心臟外科手術中腦血氧含量:評估和術後早期結局的關係

丁俊雲 陳傑

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.

結膜下阻滯與芬太尼靜脈注射用於小兒白內障手術的圍術期鎮痛的比較

裘毅敏譯,馬皓琳、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:

普瑞巴林對術前焦慮和鎮靜水準的效應:劑量範圍的研究

王宏 譯,馬皓琳 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內障手術中的應用具有抗焦慮,鎮痛,減低眼內壓和改善手術條件的作用。

黃劍譯 薛張綱校

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.

褪黑激素對腹腔鏡膽囊切除術後患者睡眠品質的影響:一項隨機,安慰劑對照試驗

葉樂 陳傑

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.

小劑量瑞芬太尼對全麻蘇醒期間氣管導管的反應的影響

彭中美 馬皓琳 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:

家兔心臟驟停後自主迴圈返回的脂肪乳注入減少

李瑩譯 薛張綱校

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.

大鼠原位和在體應用5-羥色胺1A激動劑8OHDPAT能拮抗阿片類藥所致的通氣抑制而不拮抗抗傷害作用

張磊 陳傑

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.

苯二氮卓類藥物對硬骨魚緊張肽II刺激的大鼠大腦皮質切片去甲腎上腺素釋放的影響

江繼宏   馬皓琳 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:

可見光譜學活體檢測豬心肌缺血

姚敏敏譯 薛張綱校

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.

氣體濃度改變90%所需時間:三種半緊閉麻醉呼吸系統間的比較

吳進   馬皓琳 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.

一個臨床模式下通過靜脈套管的液體流量.

俞佳譯 薛張綱校

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.

中心靜脈壓測量中的錯誤

潘錢玲 陳傑

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)和直接喉鏡氣管插管用于高Mallampati評分患者的對比

黃佳佳譯,馬皓琳 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:

氣管插管變革:最新喉鏡輔助下持續聲門觀察的可行性。

張玥琪譯,薛張綱校

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:

關於產婦實施硬膜外置管時避免誤置入硬膜外靜脈的策略的隨機對照研究的系統總數

周姝婧 陳傑

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.

“沖技術與用標準技術比較局麻藥溶液中腎上腺素的濃度

黃麗娜 馬皓琳 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:

幼豬低氧-缺血性損傷的腦血氧飽和度-時間閾值

趙嫣紅 陳傑

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.

提高顱內壓可以增加腦血流量自身調節的下限

姜旭暉譯,馬皓琳 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.

異氟醚麻醉期間低碳酸血症和腦自主調節功能對腦血管阻力和血管內壁流體靜壓的影響

張釗譯 薛張綱校

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.

超高齡患者脊麻對腦血流的影響

朱紫瑜 陳傑

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:

在脊椎麻醉及多重機制鎮痛用於前交叉韌帶重建術後7~12周時的一般健康狀況和膝功能預後情況

慧譯 馬皓琳 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-藻藍蛋白的抗炎與鎮痛活性

朱蘭芳譯 薛張綱校

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受體拮抗劑NS1209和利多卡因在神經損傷性疼痛中的效應:一個隨機、雙盲、安慰劑對照、三向交叉設計研究

懷曉蓉 陳傑

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.

長期持續股神經阻滯對膝關節三髁成形術後與健康相關的生活品質的影響:一項前瞻、隨機、三盲、安慰劑對照的1年隨訪實驗

張瑩譯  馬皓琳 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名放置外周神經導管後的皮下隧道中細菌定植情況:一項前瞻性研究

陳珺珺譯 薛張綱校

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.

胸段硬膜外麻醉對全麻患者肝血流量的影響

黃丹 陳傑

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.

神經刺激的電流閾值依賴於組織的電阻:一項關於在超聲引導下正中神經電刺激的研究

陳珺珺譯 薛張綱校

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.

肝移植術中血小板輸注與術後死於急性肺損傷情況增多有關

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:血小板輸注目前被認為是正位肝移植(OLT)術後存活的一個獨立的危險因數。在這一研究中,我們試圖分析出正位肝移植(OLT)術中與輸注血小板相關的死亡事件及移植物功能喪失事件發生的特異性原因。

方法:本次研究的是一個連續性樣本,449位元初次行正位肝移植(OLT)的成年患者組成。無論這些患者在術中有無行血小板輸注,都對其死因及移植物功能衰減原因進行分析。

結果:相對於那些未行血小板輸注的患者,輸血小板的患者其患者存活率和移植物存活率均明顯下降(分別是74%92%69%85%,差異性為1年,P < 0.001)。在接受血小板輸注的患者中早期死於急性肺損傷的比率明顯增高((4.4%0.4%P = 0.004),是導致該人群低存活率的原因。兩組病人中因其他原因死亡的比率並無明顯差異。在接受血小板輸注的患者中致移植物功能喪失的主要原因是移植物功能存活的患者死亡。

結論:這些研究發現提示血小板輸注是正位肝移植(OLT)術後死亡的一個重要的危險因數。根據現在的研究結果可進一步衍生,將急性肺損傷的確診作為死亡率增加的主要決定因素,從而做前瞻性的觀察。在接受血小板輸注的患者中,其移植物功能喪失比率的增高是由於總體死亡率的增高,而非因為輸注血小板會對移植肝產生特異性的副作用。

(單嘉琪譯 薛張綱校)

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.

 

 

為胸外科手術選擇合適的單肺通氣裝置:三種支氣管阻塞器與傳統雙腔管的隨機對照臨床試驗

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:就胸外科手術而言,目前並沒有公認為最好的單肺通氣技術。在此次研究中,我們將北美市場上的三種支氣管阻塞器(BBs)與傳統左側雙腔管(DLTs)進行對比,比較其在左側胸部外科手術患者中的單肺通氣表現。

方法:隨機將104名行左側開胸手術或胸腔鏡手術的患者分成四個單肺通氣組(n=26/組)。四組的單肺通氣裝置分別為有導線引導的Arndt支氣管阻塞器(Cook Critical Care,伯明頓,印第安那州)、頭部可旋轉的Cohen支氣管阻塞器(Cook Critical Care)、 Fuji單腔支氣管阻塞器(Fuji Systems,東京)和左側雙腔支氣管導管(Mallinckrodt Medical,克納梅德,阿斯隆,韋斯特米斯郡,愛爾蘭)。術中的麻醉管理和單肺通氣的實施均遵循統一的標準化方案。根據吸引器運用於支氣管阻塞器吸引管腔或雙腔管支氣管腔的時間,每一單肺通氣組又隨機地細分為兩個亞組(n=13/亞組):即即刻吸引組(插入單肺通氣裝置即刻)(亞組I)和延遲吸引組(插入單肺通氣裝置後20分鐘)(亞組D)。運用口頭評分尺規,由對單肺通氣技術不知情的外科醫生對肺萎陷的程度進行評價。

結果:各種單肺通氣裝置的肺萎陷評分在胸膜開放後即刻(P = 0.66)、10分鐘(P = 0.78)和20分鐘(P = 0.51)時均無任何統計學差異。但雙腔管(93 +/- 62秒)較支氣管阻塞器(203 +/- 132秒)更快地完成初次肺萎陷(P = 0.0001)。而各種支氣管阻塞器完成肺萎陷的時間並無統計學差異(P = 0.78)。在最初置入單肺通氣裝置後,支氣管阻塞器(35次)明顯較雙腔管(2次)復位頻繁(P = 0.009)。與Cohen支氣管阻塞器(8次)和Fuji 支氣管阻塞器(11次)相比,Arndt支氣管阻塞器(16次)在術中需要更頻繁地進行重定(P = 0.032)。

結論:在左側開胸手術和胸腔鏡手術的操作過程中,三種支氣管阻塞器可提供與左側雙腔管等價的外科暴露。但支氣管阻塞器完成肺萎陷的時間較長,術中復位也較為頻繁。與其他支氣管阻塞器相比,Arndt支氣管阻塞器的復位最為頻繁。

(范羽譯 薛張綱校)

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內障手術中的應用具有抗焦慮,鎮痛,減低眼內壓和改善手術條件的作用。

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:褪黑素具有抗焦慮和潛在的鎮痛作用。本研究中,我們評價了局麻下眼科白內障術前應用褪黑素對疼痛,焦慮和眼內壓及手術條件的影響。

方法40名欲局麻下行白內障手術的病人隨機分為2(每組20)。術前90分鐘,實驗組給于褪黑素一片10mg,對照組給於安慰劑,均口服給藥。記錄焦慮評分、自覺疼痛評分、心率、平均動脈壓及眼內壓。並且,請外科醫生評價手術條件分級。

結果:褪黑素顯著降低焦慮評分。給藥前中位數及四分位數間距為5, 3.5-6。給藥後中位數及四分位數間距為3, 2-3,術中為3, 2-3.5(P=0.04並且和分別和對照組相比P=0.005)。褪黑素組手術期間自覺疼痛評分明顯低於對照組,並且術中芬太尼的需要量也減少。和對照組相比,褪黑素組的中位數及四分位數間距為0,0-32.5,而對照組為47.5, 30-65ug.P=0.007。給予褪黑素後眼內壓(平均數+/-標準差)17.9+/-顯著地降至14.2+/-1.0 mmHg,並且術中達到13.8+/-1.1mmHg(P<0.001)。褪黑素同時也提供了更好的手術條件。

結論:我們認為對於局麻下行白內障手術的病人,術前口服給予褪黑素具有抗焦慮,鎮痛及降眼內壓的作用,因此可提供更好的手術條件。

(黃劍譯 薛張綱校)

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.

 

 

家兔心臟驟停後自主迴圈返回的脂肪乳注入減少

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:在實驗模型和人體都已證明注入親脂性乳劑可以扭轉因親脂性藥物誘發的心血管事件。但是,對於非藥物引起的心搏停止,高劑量脂肪乳劑的作用仍不明確。在窒息無脈性電活動的家兔模型中,我們比較了注入脂肪乳劑和使用標準高級心臟救命術的家兔複生。

方法:成熟的新西蘭白兔通過氣管鉗夾造成缺氧性無脈性電活動。心臟驟停2分鐘後,開始基本的生命維持心肺復蘇術,同時注入3 mL/kg 20%脂肪乳劑或者3 mL/kg 0.9%生理鹽水。第4分鐘和第5分鐘給予100 microg/kg的腎上腺素。記錄自發迴圈恢復、血流動力學指標及50分鐘生存率。

結果:自發迴圈回復,注入鹽水組為7/11,而注入乳劑組為1/12P=0.009。而50分鐘生存率未觀察到有統計學意義的差異(注入鹽水組為3/11,注入乳劑組為0/12P=0.211)。

結論:在這種窒息導致的無脈性電活動模型中,相對於高級心臟救命術加用注入乳劑,標準高級心臟救命術可導致更好的主動脈灌注壓並可增加自主迴圈恢復。脂肪乳劑在嚴重低氧血症複雜化的心臟驟停中使用也許是不恰當的。

(李瑩譯 薛張綱校)

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.

 

 

可見光譜學活體檢測豬心肌缺血

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:可見光譜學監測組織氧含量可識別組織缺血,但是它用來檢測心肌缺血的可行性是未知的。我們假設可見光譜學能可靠的檢測出豬急性區域性或廣泛性心肌缺血模型中的心肌氧含量的變化。

方法:11頭豬中,區域性心肌缺血通過結紮左前降支動脈建立。心肌的氧含量決定于左室缺血及非缺血區域,同時將它與冠狀靜脈的氧飽和度相比較。心肌的功能則通過心超來評估。在六頭豬中,左室組織氧含量在停跳液誘使心臟停跳後體外迴圈期間及未給予充分心肌保護下測定。此外,右室及左室組織氧含量還在肺動脈繃紮使右室壓力負荷劇增時測定。

結果:在結紮左前降支動脈前豬的缺血區心肌與非缺血區心肌的組織氧含量基線水準相似(70% ± 8% vs 74% ± 5%)。在左前降支結紮後,缺血區心肌的組織氧含量迅速下降(30 : 59% ± 8%; 1 分鐘:50 ± 9; 5 分鐘:42% ± 4%; P < 0.05)。組織氧含量的下降和冠狀靜脈氧飽和度(r = 0.88)及心肌功能障礙具相關性。在進行體外迴圈的豬中,停跳液誘使心臟停跳後及體外迴圈開始時左室的組織氧含量保持不變,但是在沒有充分心肌保護下夾閉主動脈後運用組織氧含量檢測到了左室缺血。相似的,肺動脈繃紮使得右室組織氧含量明顯下降,從69% ± 6% 下降至 52% ± 7% (P < 0.05),且在肺動脈開放後恢復。

結論:可見光譜學是檢測心肌組織氧含量的一種可靠方法,且可作為心肌缺血時快速檢測的有效的監測手段。

(姚敏敏譯 薛張綱校)

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.

 

 

一個臨床模式下通過靜脈套管的液體流量.

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:預測通過靜脈套管的液體流量對臨床醫生有幫助(如果流量改變是必需的),同時用來指導套管的選擇。我們通過預測實際的流量和描述此流量來尋求製造商提供流量的有效性。

方法:我們建立一個靜脈模型,分別置入從14號到20號套管。在第一個實驗中,我們使用去離子水,hartmann溶液和佳樂施來比較製造商提供的流量。在第二個實驗中,我們給予不同的壓力作用于套管上,測量所產生的流量。

結果:通過套管的流量不是一個由製造商提供流量計算的簡單比率,甚至控制液體類型和給予壓力。在我們測量的範圍內,血流不是完全的層流,也不是完全的湍流。在國際標準化組織的試驗中雷諾指數常常低於2000

結論:通過套管的血流在較高範圍的臨床使用流量內不是層流,因此泊素葉法則在預測流量上不適用,改變套管半徑的效果比通常相信的要小。提供的最大流量也不適用。除雷諾指數外層流還需要很多條件。進一步的工作會決定對於流量有用的預測方法。

(俞佳譯 薛張綱校)

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.

 

 

氣管插管變革:最新喉鏡輔助下持續聲門觀察的可行性。

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.

 

通過氣道交換氣管導管通常與常規喉鏡協助下氣管插管相結合。困難氣道可能難以看見聲門。由於氣管內導管尺寸過大或強烈擠壓氣道結構所導致的置管延遲、氣道損傷或氣管插管失敗可能惡化盲視氣管插管。最新的喉鏡技術所提供的各個角度視覺化可能能克服許多常規喉鏡的視線限制 。在這個資料調查中,我檢測了將一個高風險的氣管導管交換從一個盲視過程變成一個聲門可見的過程的可行性和實用性。

(張玥琪譯,薛張綱校)

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.

                                                    

 

異氟醚麻醉期間低碳酸血症和腦自主調節功能對腦血管阻力和血管內壁流體靜壓的影響

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:動態動脈血壓(arterial blood pressure ABP)和大腦中動脈血流流速監測可用於計算血管內壁流體靜壓(表面流體靜壓apparent zero flow pressure aZFP)。血壓-流速關係的反斜率即為阻力面積乘積(RAP),該指數反應了腦血管阻力的大小。關於全麻時血管活性藥物、動脈二氧化碳分壓(Paco(2))以及腦自主調節功能受損對aZFPRAP的影響的研究並不多。我們研究了異氟醚全身麻醉時低碳酸血症和注射新福林對aZFPRAP的影響。

方法:對11例使用異氟醚麻醉的成年患者記錄其橈動脈有創動脈血壓和多普勒大腦中動脈血流流速。應用新福林調整血壓,調節潮氣量控制動脈二氧化碳分壓。分別在兩個不同的平均動脈壓水準(大約在80100mmHg之間)和動脈二氧化碳分壓水準:正常水準(Paco(2) 38-43 mm Hg) 和低二氧化碳水準(Paco(2) 27-34 mm Hg),比較腦血流動力學的變化。兩種aZFP分析方法相比較:一種基於線性回歸,一種基於波形的傅裏葉分析。

結果:在較低血壓水準,血碳酸正常時,aZFP 23 +/- 11 mm Hg RAP 0.76 +/- 0.97 mm Hg x s x cm(-1);低碳酸血症時,aZFP30 +/- 13 mm Hg (mean +/- sd) RAP 1.16 +/- 0.16 mm Hg x s x cm(-1) P 值均<0.001 。在較高血壓水準可見到低碳酸血症帶來的相似影響。血碳酸水準正常時,異氟醚對腦自主調節功能及aZFP的影響不隨血壓升高而變化。低碳酸血症時,腦自主調節功能受血壓影響不顯著,但血壓的升高會使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,對反應腦血流動力學的作用,RAP的變化顯然較aZFP的改變帶來了更大影響。兩種分析aZFP的方法(傅裏葉回歸)的平均差為 0.5 +/- 3.6 mm Hg (mean +/- 2sd)

結論:使用異氟醚全身麻醉時,低碳酸血症和對ABP升高的自主調節反應兩個因素可增加腦小動脈的收縮節律,這兩種因素與RAPaZFP的升高相關。RAP的改變所帶來的影響在數值上大於aZFP。這些結果意味著小動脈通過收縮控制血管阻力和有效灌注壓來影響腦血流。

(張釗譯 薛張綱校)

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-藻藍蛋白的抗炎與鎮痛活性

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-藻藍蛋白(C-PC)是在青綠色藻類如螺旋藻中發現的一種脂蛋白,由於具有多種治療價值而常作為飲食營養補充。另外,C-PC通過部分抑制致炎因數的形成、可誘導的NO合酶(iNOS)與環氧合酶-2(COX-2)的表達而產生的抗炎活性在很多體外和體內的研究中均有過描述。然而,C-PC是否具有減弱炎症傷害性感受的鎮痛活性還未曾觀察到。

方法:我們使用角叉藻聚糖誘導的熱致痛模型,通過測量大鼠爪子退縮的潛伏期來評估C-PC對大鼠傷害性刺激感受的影響。闡明相關機制,確定iNOSCOX-2以及硝酸酯和腫瘤壞死因數-(TNF-)在大鼠爪子內的表達。

結果:在角叉藻聚糖誘導前或誘導後使用C-PC (30 or 50 mg/kg, IP)可明顯減弱炎症傷害性感受以及後期(4小時)iNOSCOX-2的誘導作用,並抑制TNF-、前列腺素E2、硝酸酯的形成及髓過氧化物酶的活性。

結論:這些研究結果提示,C-PC的鎮痛活性至少部分是通過抑制炎症部位iNOSCOX-2的誘導作用和減少TNF-的形成及中性粒細胞的浸潤來抑制NO和前列腺素E2的過多生成而產生。

(朱蘭芳譯 薛張綱校)

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名放置外周神經導管後的皮下隧道中細菌定植情況:一項前瞻性研究

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:外周神經導管處經常出現細菌定植,儘管很少會出現感染症狀。在中心靜脈導管,皮下組織的導管隧道顯著降低了細菌定植和導管相關性敗血症。我們評估了成人外周靜脈導管隧道細菌定植的發生率。

方法:外周神經導管在無菌情況下穿刺用來術後鎮痛,使用前瞻性研究的方法評估。在導管拔出後分析導管的細菌定植情況。用培養的數量結果進行描述,這種方法既往使用於靜脈導管。每天監測穿刺部位有無任何感染跡象。

方法:在兩年內研究了402名病人。外周靜脈導管的平均放置時間為48h4750.4)。25根導管有陽性培養結果,提示細菌定植的發生率為6.22%(3.88.5)。導管尖端培養的微生物中72%為凝固酶陰性葡萄球菌。25根導管中有22根培養出一種微生物,3根培養出2種微生物。所有的病人均沒有感染跡象。

結論:皮下隧道中外周神經導管細菌定植的發生率較低。隨機研究觀察到操作方法可以降低感染的發生率。

(陳珺珺譯 薛張綱校)

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.

 

 

神經刺激的電流閾值依賴於組織的電阻:一項關於在超聲引導下正中神經電刺激的研究

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:瞭解電刺激神經法的不同閾值的機制可以改善外周神經阻滯的安全性和成功率。神經周圍的電阻可以影響對神經刺激的反應。在志願者身上進行的研究中,我們研究了電阻和神經肌應答所需刺激閾值的關係。

方法:我們在29名志願者身上測定了對腋窩和肘部正中神經對電神經刺激反應的強度和電阻。針尖的位置通過超聲引導,分別位於神經的52.50mm。用於神經刺激的脈衝的寬度分別是0.10.3ms

結果:在肘部,針尖至神經的距離為52.5mm時,阻抗和電流的閾值呈負相關(P = 0.001 P = 0.036)。相比於肘部(平均36.6, sd 13.4 kohm),腋窩處阻抗的值明顯較低(平均21.1, sd 9.7 kohm) (P < 0.001)。反過來,在腋窩神經刺激的電流的閾值高於在肘部的(P < 0.001, P < 0.001, P = 0.024)。脈衝持續時間 0.1 0.3 ms相比較,電流的閾值的比值為1.82.

結論:我們的結果證明了電阻和電流閾值呈負相關,這提示了組織類型的不同應調整電流的設置。進一步的研究需要進行來研究我們這項發現的臨床意義。

(陳珺珺譯 薛張綱校)

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.

 

術前腦利鈉肽和術後肌鈣蛋白水準對大血管手術患者預後意義的初步報告
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:有研究顯示大手術後主要心臟不良事件( MACE )的發生與術前腦利鈉肽( BNP )或術後心肌肌鈣蛋白升高(肌鈣蛋白)相關。本研究中,作者評估術前腦利鈉肽和術後肌鈣蛋白水準的衍生資料預測大血管手術術後MACE
方法:本研究是前瞻性研究,對納入評估交感神經系統抑制藥物莫索尼定減少MACE 的有效性的臨床試驗中133例接受大血管手術的臨床病例的佇列研究資料進行二次分析。術前測定BNP和肌鈣蛋白濃度。術後立即測定肌鈣蛋白濃度,並於術後1 2 3 7 天測定肌鈣蛋白濃度。主要評價指標為術後一年內MACE(心肌血管重建術需入院治療,急性冠狀動脈綜合征,急性充血性心力衰竭,任何原因造成的死亡)的發生情況。通過住院期間院內訪視圖表和術後12個月的電話回訪評估患者術後MACE
結果:手術後1年內, 19例( 14 )患者發生MACE,其中包括14例( 11 )死亡。調整年齡,性別,和修訂後心臟風險指數後,無論隨後肌鈣蛋白I的濃度如何,術前BNP升高>50pg/mlMACE相關 (調整後的危險比[HR] 6.5 95 %置信區間[CI]1.4-29.5 )。聯合術前BNP升高>50 pg / ml和術後肌鈣蛋白I升高>2ng/ml兩個指標與MACE (調整後 HR 25.2 95 CI為: 5.0-128.4 )以及各種原因的死亡率(調整後 HR 18.7 95 CI 3.1-112.5 )相關 。陰性預測值顯示正常術前BNP值隨後的不良事件是0.965 95 CI 0.879-0.996 )。
結論:上述資料表明,術前測量BNP以及術後肌鈣蛋白濃度為預測大血管術後死亡率和MACE提供了更多的資訊。

(舒慧剛 陳傑 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.


雙肺通氣時在吸入的氣體混合中使用空氣延遲單肺通氣時肺塌陷

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:胸外科手術中同側肺塌陷有利於手術野的暴露。雙肺通氣時使用不同的混合氣體通過增加或延遲肺塌陷從而促進或妨礙隨後進行單肺通氣時的手術條件。作者擬研究雙肺通氣時使用三種不同的混合氣體對肺塌陷和隨後單肺通氣時氧合的影響:空氣/氧氣(吸入氧氣分數 [Fio2] = 0.4), 氧化亞氮/氧氣 ("N2O," Fio2 = 0.4) 和氧氣 ("O2," Fio2 = 1.0).

方法:研究物件隨機分為三組: 空氣/氧氣 (n = 33), 氧化亞氮 (n = 34) 或氧氣 (n = 33)。這些患者從誘導到單肺通氣前吸入指定的混合氣體,單肺通氣予以純氧即Fio2 = 1.0。在單肺通氣開始10分鐘和20分鐘時,外科醫生運用口述評分量表隨機雙盲評估肺排氣的情況。麻醉誘導前,雙肺通氣時( 5分鐘一次,持續30分鐘),單肺通氣開始後分別做動脈血氣檢查。

結果:雙肺通氣時吸入含有空氣的混合氣體可以導致單肺通氣時肺排氣的延遲,而N2O可以促進肺塌陷。動脈氧合僅僅在吸入純氧組單肺通氣前10分鐘有明顯改善,之後平均動脈血氧分壓值各組間無差異。

結論:雙肺通氣期間肺去氮化對改進單肺通氣的手術條件是一有用的策略。在雙肺通氣中的Fio2 1.0 N2O/O2 (Fio2 0.4)對於隨後的單肺通氣時的氧合無不良影響。

(劉世文 陳傑 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.

 

嬰幼兒心臟外科手術中腦血氧含量:評估和術後早期結局的關係

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:作者檢測了嬰兒心臟手術中腦血氧飽和度的變化及其與解剖學診斷和早期結局的關係。

方法104名嬰幼兒無主動脈弓梗阻行雙心室修復術中,用近紅外光法測定血液隨機稀釋至血細胞比容為25% vs 35%時的腦局部氧飽和度( rSO2 )。

結果:在心肺轉流( CPB )前 ,與患D -大動脈轉位(D-TGA))或室間隔缺損的患兒相比,患法洛氏四聯症的嬰幼兒有較高的rSO2值( P <0.001 )。 CPB控制性降溫,降流量和體外迴圈終止期間,D-TGA患兒rSO2值最高( P <0.001 )。術中rSO2值與調整診斷後的術後早期結局無顯著相關。在深低溫停迴圈(DHCA5分鐘的39D-TGA患兒中, 停迴圈開始時的rSO2 91 ± 6 )或血細胞比容( 29.2 ± 5.5 )與停迴圈後rSO2的下降率無相關性。
結論:術中rSO2的變化取決於解剖學診斷,但與術後早期結局的相關性不明顯。通過近紅外光譜測量rSO2,更高水準的血細胞比容和目前的灌注技術可為深低溫停迴圈前的相對短的時期提供充足的氧供。

(丁俊雲 陳傑 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.

 

褪黑激素對腹腔鏡膽囊切除術後患者睡眠品質的影響:一項隨機,安慰劑對照試驗

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,作者觀察了使用褪黑激素後能否改善患者術後主觀睡眠品質並減少不適。

方法 121例擬行腹腔鏡膽囊切除術的擇期日間手術患者,術後3夜隨機給予口服5毫克褪黑激素( 60例)或安慰劑( 61 )。監測患者的主觀睡眠品質,睡眠持續時間和主觀不適(疲勞,舒適度和痛苦)的變化。

結果:褪黑激素組(均數 [標準差] 14 min [18],與安慰劑組相比(28 min [41], 術後第一夜睡眠潛伏期明顯縮短( P=0.015 )。其餘的觀察變數在兩組間無明顯差異。

結論:與安慰劑相比褪黑激素沒有改善腹腔鏡膽囊切除術後主觀睡眠品質或不適.

(葉樂 陳傑 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.


大鼠原位和在體應用5-羥色胺1A激動劑8OHDPAT能拮抗阿片類藥所致的通氣抑制而不拮抗抗傷害作用

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:在重症監護的機械通氣治療期間,自主呼吸的重要性日益重視,但其可被麻醉藥所抑制,如阿片類藥物等。5-羥色胺1A受體( 5 - HT1A受體)激動劑可拮抗阿片類藥物引起的通氣抑制,但在不同的實驗模型上發現其可增強和減弱傷害反射。為了澄清矛盾,作者同時測定標準的5 - HT1A受體激動劑8-OH-DPAT和兩個不同的阿片類藥物對自主通氣和傷害感受性的量效關係。驗證兩個假設: 1 8-OH-DPAT在某一劑量下可刺激自主呼吸而不啟動傷害反射。 2 8-OH-DPAT並不減少阿片類藥物誘導的鎮痛作用。
方法:(A)在準備好的原位灌注,未麻醉的大鼠腦幹-脊髓上同時建立8-OH-DPAT的量效關係,自發膈神經活動和疼痛C -纖維反射( CFR )(B)原位給予芬太尼觀察其與8-OH-DPAT對膈神經活動和疼痛C -纖維反射的相互影響。附加試驗給予選擇性5 - HT1A受體拮抗劑WAY100 635以排除5 - HT1A受體以外其他受體的影響。(C)在麻醉的大鼠上在體研究8-OH-DPAT對自主通氣以及有和無嗎啡時的疼痛甩尾反射的影響。
結果:低劑量8-OH-DPAT(原位應用 0.0010.01µM 在體應用0.1微克/千克)增強傷害反射,但沒有啟動自主通氣。相反,高劑量的8-OH-DPAT (原位應用 1µM和在體應用10-100µg/kg)刺激通氣,而原位研究中疼痛C -纖維反射幅度回落至基線水準,同時在體研究中甩尾反射被抑制。阿片類藥物誘導的通氣抑制被8-OH-DPAT (原位應用 1µM 體內應用10µg/kg)拮抗 ,而傷害作用仍存在。原位實驗中,選擇性5 - HT1A受體拮抗劑WAY100 635 1µM)可阻止8-OH-DPAT的作用。
結論: 5 - HT1A受體激動劑8-OH-DPAT啟動大鼠自主呼吸而未減少阿片類藥物誘導的鎮痛作用。

(張磊 陳傑 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.

 

中心靜脈壓測量中的錯誤

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:有創監測中壓力感測器的放置位置不同所產生的差異可導致明顯的測量錯誤。本研究的目的是對醫護人員所產生的這種差異性程度進行量化,並確立一個能減少這錯誤的簡單方法。

方法:50名圍術期醫護人員納入本研究,讓其在兩種不同的情況下監測中心靜脈壓:第一次沒有任何標準化的工具來定位感測器的放置位置,第二次通過鐳射水平儀引導定位。計算不同醫生之間的差異,並將兩次結果進行比較。

結果:兩次放置感測器的位置差異明顯,有時這種變異程度大於正常值。使用鐳射水平儀並不能明顯減少這種差異。

結論:不同醫護人員放置感測器的位置差異明顯。鐳射水平儀不能減少這種差異,在解釋CVP值時須考慮這種差異。應該考慮建立一個醫院範圍或整個行業範圍內的標準化的零點位置。

(潘錢玲 陳傑 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.

 

關於產婦實施硬膜外置管時避免誤置入硬膜外靜脈的策略的隨機對照研究的系統總數

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,作者對7種被認為可在對產婦實施腰硬膜外置管時減少發生誤置入硬膜外靜脈概率的策略的相關證據進行評估。

方法:搜索多個資料庫,選擇在196612月至200710月期間對產婦行腰椎硬膜外置管時避免誤置入硬膜外靜脈的前瞻性、隨機、對照研究。用一種量化的評價工具對已出版的試驗進行評估,並結合結果來評價該策略對防止誤置入硬膜外靜脈的效力。

結果:在篩查所得的90個研究中,共有30個入選(n12738人)。5種策略可減少發生誤置入硬膜外靜脈的風險:相對左側坐位(6例研究,平均(標準差)品質評分=35%11%],優勢比(OR0.5395%置信區間(CI0.32-0.86]),置管前從硬膜外穿刺針內注入液體(8例研究,品質評分=48%18%],OR 0.49,[95%CI 0.25-0.97]),採用單孔而不是多孔導管(5例研究,平均(標準差)品質評分=30%6%],OR 0.64,[95%CI 0.45-0.91]),硬膜外導管的取材選用線埋式聚氨基樹脂與聚醯胺的對比(1例研究,31%,外加4例摘要未作評分,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])。以下兩種策略未能降低誤置入硬膜外靜脈的風險:旁正中進針穿刺法相比中線進針法和採用較小號硬膜外穿刺針或導管。

結論:在對產婦實施腰硬膜外置管時,以下策略可能可以減少誤置入血管的發生:患者相對左側坐位、置管前用液體對硬膜外腔進行預擴容、採用單孔導管、硬膜外導管的取材選用線埋式聚氨基樹脂以及限制置管深度短於或等於6 cm。總的來說,原文品質較低削弱了這些結論的效力。

(周姝婧 陳傑 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.


幼豬低氧-缺血性損傷的腦血氧飽和度-時間閾值

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:發現危重新生兒腦低氧-缺血(H-I)以及預防腦損傷至今仍未解決。近紅外光譜儀(NIRS),作為一種無創傷性床邊儀器,可以實現這個目的。發生腦損傷的腦血氧飽和度(SCO2-時間閾值仍未確定。本實驗中,作者研究腦血氧飽和度為35%時(引起神經生理損害的閾值),腦缺血-低氧持續時間和神經功能預後的關係。

方法:本實驗用芬太尼-咪唑安定對46只幼豬進行麻醉,使用近紅外光譜儀(NIRS)及腦功能監測儀(CFM)記錄腦血氧飽和度(SCO2)以及大腦皮層電生理活性(ECA)。幼豬頸動脈阻塞後,調整吸入氧濃度使產生腦低氧-缺血(H-I)(保持SCO235%ECA持續下降)。腦缺血-缺氧持續時間在不同組分別為1, 2, 3, 4, 68小時,然後通過行為學及組織學檢查評估神經功能預後。

結果:腦低氧-缺血持續12小時的幼豬中,缺血再灌注後腦血氧飽和度快速恢復正常水準,神經功能也正常。而腦缺氧-缺血持續時間超過2-3小時的幼豬中,再灌注時大腦皮層電生理活性顯著下降,而腦血氧飽和度顯著上升,提示組織中有氧代謝的持續性降低。當腦缺氧-缺血時程超過2小時,其神經功能呈線性下降,約每小時下降15%

結論:腦低氧-缺血(H-I)的程度-時間閾值為腦血氧飽和度(SCO235%持續2-3小時,並可以由近紅外光譜儀(NIRS)及腦功能監測儀(CFM)監測其再灌注時的異常數值。這一實驗結果表明聯合使用近紅外光譜儀(NIRS)及腦功能監測儀(CFM)可以預測患兒的神經功能預後,並且表明在患兒發生腦缺氧-缺血後仍有數小時的機會來預防神經功能的損傷。

(趙嫣紅 陳傑 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.

 

超高齡患者脊麻對腦血流的影響

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:年老和疾病使高齡患者在脊椎麻醉中特別容易發生低血壓。然而,小劑量布比卡因對腦血流動力學的作用尚不瞭解。本研究中,作者評估了脊椎麻醉對高齡患者腦血流(CBF)的影響。

方法: 20名年齡大於75歲的髖骨骨折開放修復手術的患者進行前瞻性研究,並與年齡小於60歲組的患者作比較。患者取側臥位,在L4-5水準進行脊椎麻醉。在脊椎麻醉前(基線=T0)、局麻藥注射後5分鐘(T1)、脊椎麻醉後10分鐘(T2)以及在麻醉後監護室(T3),分別行無創自動化動脈血壓,心率以及經顱多普勒監測。

結果:T0136 ± 21 mm Hg)相比,高齡組的收縮壓在T1115 ± 25 mm Hg)與T2114 ± 24 mm Hg)明顯降低。T1T2的收縮期與舒張期速度與基線值相比明顯降低。T2相的搏動指數(PI)以及阻力指數顯著降低。所有患者均未出現心動過緩。心率變異性與T0相比相比無顯著變化。對照組在血流動力學和腦部影響均無變化。

結論:脊椎麻醉可導致超高齡患者的腦血流速度的降低,降低的數值雖小但差異有統計學意義。

(朱紫瑜 陳傑 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受體拮抗劑NS1209和利多卡因在神經損傷性疼痛中的效應:一個隨機、雙盲、安慰劑對照、三向交叉設計研究

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:應用現在的療法並不能充分治療慢性神經性疼痛,只有不足半數的患者的疼痛能夠達到臨床顯著緩解(定義為疼痛減輕大於50%)。本研究中,通過與安慰劑和利多卡因比較 評估了AMPA/GluR5受體拮抗劑NS1209治療慢性神經病理性疼痛和周圍神經損傷引起的異常性疼痛的有效性、安全性和耐受性。

方法:一個隨機、雙盲、安慰劑對照,三向交叉設計的研究,納入的慢性神經性疼痛的患者分別靜脈注射NS1209 (322 mg), 利多卡因 (5 mg/kg)和安慰劑。分別在篩選時和治療開始後的0246824h測量當前自發痛以及刷、針刺、冷、熱刺激引起的疼痛。

結果:有13例患者完成研究。與安慰劑相比,無論NS1209 還是利多卡因對於主要終點指標(當下的自發痛)無顯著影響,但是兩藥在第二終點繼發痛的緩解好於安慰劑。與利多卡因類似,NS1209在減輕一些神經病理性疼痛的主要症狀上優於安慰劑,如各種類型的刺激痛,包括機械性和冷刺激引起的異常性疼痛。

結論:這些發現與已報導的在其他疼痛模型中NS1209的作用一致,並且提示AMPA受體在人類的神經性疼痛具有一定的作用。此外,NS1209具有良好的安全性,並且對本實驗中使用的劑量具有良好的耐受性,這與安慰劑相似。

(懷曉蓉 陳傑 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.

 

胸段硬膜外麻醉對全麻患者肝血流量的影響

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:肝臟低灌注被認為是圍術期肝損傷病理生理學中的重要因素。儘管硬膜外麻醉(EDA)是一種廣泛應用的麻醉技術,但是胸段硬膜外阻滯(阻滯僅限制在胸段)對患者肝血流影響的相關資料幾乎沒有。

方法:在20位全麻病人中,作者在進行硬膜外阻滯前後採用多平面經食道超聲技術對右肝和中肝靜脈的血流指數進行評估。在T7-T9置入硬膜外導管,注入中等劑量的1%甲呱卡因10ml8-16ml)。硬膜外阻滯後平均動脈壓低於60mmHg的患者持續輸注去甲腎上腺素(EDA-NE)。其他患者研究期間沒有給予任何兒茶酚胺類藥物(EDA組),另外沒有進行硬膜外阻滯的10個病人作為對照(對照組)。

結果:其中5位患者必須使用去甲腎上腺素以避免平均動脈壓低於60mmHg。因此,EDA-NE組包括了5名患者,而EDA組有15名患者。在EDA組中,硬膜外阻滯與兩條肝靜脈的血流指數下降24%有關 (P < 0.01)。在EDA-NE組中,5名患者的肝血流指數下降(右肝靜脈平均下降39 [11–45] %,中肝靜脈平均下降32 [7–49] %)。與對照組相比,EDA組和EDA-NE組中兩條肝靜脈的血流指數均顯著下降(P < 0.05) 。與肝血流相比,心輸出量不受硬膜外阻滯影響。

結論 作者推斷,在人類胸段硬膜外阻滯和肝血流下降相關,胸段硬膜外阻滯加上持續靜脈輸注去甲腎上腺素似乎導致肝血流的進一步減少。

(黃丹 陳傑 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.

 

再灌注早期的短暫性代謝性堿中毒中會消除氦預處理防止心肌梗塞能力:通過環孢黴素A對兔子心臟保護功能的恢復

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:近來發現冠脈梗阻後再灌注早期的細胞內酸中毒和心肌缺血後處理引起的保護心肌有關係。我們來證明這一假設,再灌注早期的短暫性堿中毒會消除用氦預處理的作用,以及用線粒體通透性環核轉錄抑制劑環孢菌素A(CsA)恢復活體體內氦的心肌保護效應。

方法:兔子(n = 36)進行血流動力學儀器監測,冠脈左前降支阻斷30分鐘後,再灌注3小時。在冠脈左前降支阻斷前給予兔子0.9%生理鹽水(對照組)或三個週期的每5分鐘70%-30%氧間隔5分鐘空氧混合,其中部分兔子在再灌注之前靜注2分鐘碳酸氫鈉(10 mEq)產生堿中毒。其他進行氦預處理的兔子在堿中毒時予以CsA (5 mg/kg)或僅給予CsA

結果:氦預處理減少了心肌梗死的面積(25% ± 4%左室有風險,P < 0.05),對照組是46% ± 2%。在灌注早期堿中毒沒有改變梗死面積(46% ± 2%),但該干預消除了氦介導的心肌保護(45% ± 3%)。在堿中毒的情況下時,CsA恢復了氦預處理減少的梗死面積(28% ± 6%; 與對照組相比P < 0.05),但是不影響單純的心肌壞死(43% ± 6%)

討論:結果說明兔子中再灌注早期短暫的堿中毒會消除氦預處理的作用。CsA能恢復了堿中毒時氦介導的心肌保護,意味著氦預處理通過維持再灌注早期細胞內酸環境來抑制線粒體通透性轉換孔的形成。

(唐亮   馬皓琳 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.


結膜下阻滯與芬太尼靜脈注射用於小兒白內障手術的圍術期鎮痛的比較

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:在小兒眼球手術中,使用阿片類藥物的全麻可提供很好的手術條件;然而術後疼痛的處理仍是一個很重要的問題。在小兒全麻中常輔助使用區域麻醉。我們在白內障手術患兒中比較了結膜下阻滯(SB)與靜脈注射芬太尼用於圍術期鎮痛的有效性及安全性。我們假設使用結膜下阻滯與芬太尼相比可減少術後額外鎮痛的需求。

方法:這是一項前瞻性、隨機、對照、雙盲試驗。我們研究了114ASA I II級(6個月-6歲)在全麻下擇期行單眼白內障手術的患兒。患兒在確保氣道後隨機分成兩組,即SB(n = 58) F (n = 56)SB組患兒接受0.06–0.08 mL/kg 2%利多卡因和0.5%布比卡因(5050)混合液行結膜下阻滯,同時靜脈注射0.2 mL/kg生理鹽水,而F組患兒接受1 µg/kg (濃度5 µg/kg,容量0.2 mL/kg)的芬太尼靜脈注射,同時結膜下注射生理鹽水(0.06–0.08 mL/kg)。研究藥物使用後5分鐘開始手術。在術後0.51234 24 小時評估術後疼痛、鎮靜、噁心/嘔吐。初級結果是術後24小時內需額外鎮痛的病人數。分析的第二個結果是疼痛及鎮靜評分、首次需要額外鎮痛的時間、眼心反射的發生率及噁心/嘔吐。

結果SB組術後24小時內需要額外鎮痛的病人數(n = 17/58, 29.3%)明顯少於F(n = 39/56, 69.6%, P < 0.001)SB組術後所有時間段的疼痛評分明顯較低。SB組首次需要鎮痛的時間中位數(範圍)(16 [2–13]小時)明顯較F組(4 [0.5–8.5]小時)晚 (P < 0.001)。術後半小時時的鎮靜評分兩組相當,而之後F組焦慮或哭鬧的患兒較多,而SB組鎮靜、坐著或舒適地睜眼躺著的患兒更多(P < 0.05)。與SB組相比,F組記錄到的眼心反射的發生率明顯更高(P = 0.019)SB組未發現相關的併發症。

結論:對於小兒白內障手術的圍術期鎮痛,與靜注芬太尼相比,SB是安全且更好的選擇。

(裘毅敏譯,馬皓琳、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.


普瑞巴林對術前焦慮和鎮靜水準的效應:劑量範圍的研究

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:普瑞巴林是加巴噴丁類複合物,已有報導稱其有抗焦慮、鎮痛和抗驚厥特性。我們設想把口服普瑞巴林作為麻醉前用藥將在全麻誘導前劑量相關性的減少急性(狀態)焦慮和增加鎮靜(睡意)。第二個目的是檢測是否麻醉前服用普瑞巴林將減少術後疼痛。

方法108ASA I–III門診擇期手術病人被隨機地分到四個術前用藥治療組中:1)對照組,接受安慰劑膠囊;2)普瑞巴林75組,口服普瑞巴林75mg3)普瑞巴林150組,口服普瑞巴林150mg4)普瑞巴林300組,口服普瑞巴林300mg。在基線(給予研究藥物前即刻)、給予藥物後3060分鐘、麻醉誘導前即刻和在麻醉後監護病房(PACU)裏每隔30分鐘,評估研究藥物對病人焦慮、鎮靜和疼痛水準的影響。評估採用標準11點口訴言詞評分法:0=沒有影響,10=最大效應。術後七天隨訪詢問以評估需要術後阿片鎮痛用藥、噁心和嘔吐發生率、止吐藥需要量、離開PACU和出院時間、病人恢復品質評分和後期恢復結局(例如,恢復正常飲食攝入和腸道功能恢復)。

結果:在人口學特徵、從服用研究藥物到麻醉誘導的時間、外科手術類型、麻醉持續時間、離開PACU和醫院時間和在PACU的芬太尼需要量,四組病人沒有差異。在術前評估期間,焦慮水準沒有變化,並且四組病人沒有差異。普瑞巴林300組在誘導前評估期間和在手術後90120分鐘的鎮靜評分顯著高於對照組(分別為5 ± 33 ± 2, 7 ± 45 ± 3, 8 ± 44 ± 4, P < 0.05)。

結論:普瑞巴林術前使用(75-300mg po)劑量相關性增加術前鎮靜,但沒有減少術前焦慮狀態、術後疼痛或改善擇期外科小手術後的恢復過程。

(王宏 譯,馬皓琳 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.


小劑量瑞芬太尼對全麻蘇醒期間氣管導管的反應的影響

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:全麻蘇醒常伴有咳嗽、激動和血流動力學不穩定。瑞芬太尼可緩解這些反應。

方法:在前瞻性、雙盲、隨機試驗中,我們選擇60例在瑞芬太尼麻醉下行鼻部手術的成年患者。在蘇醒階段,瑞芬太尼組的瑞芬太尼減少至1/10的維持速率,而對照組停用瑞芬太尼。

結果:兩組喚醒時間和拔氣管導管時間相似。在蘇醒期間,瑞芬太尼組 (輸注速率 0.014 ± 0.011 µg · kg–1 · min–1) 與對照組相比,咳嗽的發生率明顯較低(40%80%, P = 0.002),且程度較輕,同時,無意識動作(3.3%30%, P = 0.006)和低心率的發生率也較低。

結論:蘇醒期間的小劑量瑞芬太尼並不延長蘇醒時間,但減少氣管導管引起咳嗽的發生率和嚴重度。

(彭中美 馬皓琳 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.


苯二氮卓類藥物對硬骨魚緊張肽II刺激的大鼠大腦皮質切片去甲腎上腺素釋放的影響

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: 緊張、焦慮等心境障礙與硬骨魚緊張肽II (UII)及其受體(UT)有關;其原因至少部分是大腦皮層去甲腎上腺素的釋放增加。苯二氮卓類藥物因降低大腦皮質去甲腎上腺素釋放而廣泛用作安眠藥和抗焦慮劑。我們推測苯二氮卓類藥物與大腦皮層UII系統之間存在某種相互作用。

方法:本研究觀察苯二氮卓類對UII增加大鼠大腦皮質切片去甲腎上腺素釋放的影響,同時測定了表達大鼠UT受體的HEK293細胞(HEK293-rUT細胞)的胞內Ca2+濃度([Ca2+]i)

結果:咪達唑侖、地西泮和氟硝西泮濃度依賴性地抑制UII誘發的去甲腎上腺素釋放而不影響[Ca2+]i。咪達唑侖抑制UII誘發的去甲腎上腺素釋放的IC50(0.32 µM, P < 0.01)明顯低於地西泮(187 µM)和氟硝西泮(40 µM)。苯二氮卓位點拮抗劑氟馬西尼明顯減弱咪達唑侖對UII誘發的去甲腎上腺素釋放的抑制效應。

結論:本研究顯示,臨床相關劑量的咪達唑侖能明顯抑制UII誘發的去甲腎上腺素釋放。該抑制作用可能部分地通過中樞苯二氮卓受體介導。

(江繼宏   馬皓琳 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.


氣體濃度改變90%所需時間:三種半緊閉麻醉呼吸系統間的比較

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

背景麻醉呼吸系統中氣體濃度改變的速度影響著去氮、麻醉誘導以及蘇醒的速率。呼吸系統的設計也影響著麻醉維持中氣體濃度改變的速率。本研究中,我們試圖找出現代半緊閉呼吸系統中氣體濃度改變的速率。我們的假設是呼吸系統的容積越小,新鮮氣體流量越大,就越容易最先達到平衡。

方法:本研究為離體實驗,包括三種麻醉工作站:ADU(Datex-Ohmeda公司,現為GE醫療公司(麥迪森, 威斯康辛州)的一個分部),帶有COSY-1 呼吸系統的 Fabius GS(Draeger醫療公司,泰爾福, 賓夕法尼亞州)以及Aestiva (Datex-Ohmeda公司,現為GE醫療公司(麥迪森, 威斯康辛州)的一個分部)。呼吸系統與測試肺模型相連接並用空氣進行通氣。然後改用純氧,調節氧流量分別為1246或者8 L/min,記錄下測試肺模型中氧濃度改變50%63%66%75%以及90%所需時間。每種呼吸系統分別在不同的新鮮氣流下各進行10次實驗。結果先用分塊繪圖方差分析進行分析,然後再用Bonferroni校正法進行後續的檢驗。

結果:當流量為6或者8 L/min時,三種呼吸系統中氣體達到平衡所需時間沒有差別。當流量為12L/min時,ADU中氣體濃度的改變比AestivaFabius(P < 0.001)。當流量為4L/min時,ADU中氣體濃度的改變仍比Aestivalai(P < 0.001),但與Fabius相比沒有差別。

結論:我們認為,當新鮮吸入氣流的組成發生改變時,除了新鮮氣體流速以外,呼吸系統的容積對氣體達到平衡所需時間的影響最大。相比而言,呼吸系統中一些部件的位置(比如活瓣、二氧化碳吸收罐、新鮮氣體入口、通氣波紋管或者活塞)的影響較小。

(吳進   馬皓琳 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)和直接喉鏡氣管插管用于高Mallampati評分患者的對比

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)作為直接喉鏡的有效替代品,在困難氣道患者中尤其具有應用價值。  Mallampati評分高意味著口咽部結構可視性差。因為燈仗不需要依賴看清口咽部結構,我們推測,在Mallampati高評分患者中,光柱比直接喉鏡更易於使用。為了試驗這個猜測,我們完成了一個前瞻性、隨機試驗,以比較光柱(Surch-LiteTM)和直接喉鏡在高Mallampati評分患者中的應用。比較成功率、插管所需時間和血流動力學變化。

方法:Mallampati Ⅲ級的患者隨機分至光柱(S L)組和直接喉鏡(DL)組。全麻誘導後用隨機分配的設備進行氣管插管。測定插管前即刻及插管後5min內每隔30s的心率和平均動脈壓。記錄插管的時間和插管成功率。還評估術後咽喉部不適症狀。

結果:每組各有30位患者。SL組的首次插管成功率(29/30)明顯高於DL(24/30)。心率最高值和基礎心率間的差別在DL(25 ± 13 bpm)明顯高於SL(16 ± 10 bpm)。平均動脈壓的變化也是DL(38 ± 14 mm Hg)高於SL(20 ± 13 mm Hg)。且SL組的插管時間(12 ± 6 s)顯著比DL(17 ± 12 s)短。兩組間術後咽喉部不適主訴無明顯差異。

結論:在高Mallampati評分的患者中,Surch-Lite可以有較高的首次插管成功率和較小的血流動力學變化。因此,在這些患者中,Surch-Lite是直接喉鏡的一個有效替代品。

(黃佳佳譯,馬皓琳 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.



“沖技術與用標準技術比較局麻藥溶液中腎上腺素的濃度

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

介紹:麻醉醫生經常會配製含腎上腺素的局麻藥溶液。我們比較了應用“沖洗”的技術與應用標準技術(用胰島素注射器)配製的溶液的腎上腺素濃度,並且比較了不同麻醉醫生所用的腎上腺素濃度。

方法:五位麻醉醫生在進行脊椎麻醉和硬膜外麻醉使用兩種技術準備了注射器。用高效液相色譜法測定腎上腺素的濃度

結果:對於脊椎麻醉來說,標準技術所得到的濃度比用“洗”的技術時測定的濃度高,而對於硬膜外來講,並不如此。

結論:所有脊椎麻醉時溶液的腎上腺素濃度比靶濃度要高,5位麻醉醫生配製的硬膜外溶液中有3位的濃度也是如此。在不同的麻醉醫生之間,有明顯的差異。

(黃麗娜 馬皓琳 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.


提高顱內壓可以增加腦血流量自身調節的下限

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:腦灌注壓決定了腦血流量自身調節(LLA)的下限,人們普遍認為這相當於減少了動脈血壓(ABP)或增加了顱內壓(ICP)。但是在不同顱內壓水準降低動脈血壓所取得的效果還未完全研究透徹。我們本次研究的目的是確定不同顱內壓情況下低血壓時的腦血流量下限是否不變。

方法:通過連續腦室液灌注,麻醉後的小豬被分成三組:基礎ICP組(n = 10),中度升高ICP(20 mm Hg; n = 11)和重度升高ICP(40 mm Hg; n = 9)。我們通過在下腔靜脈植入氣囊式導管充氣的方法來逐漸降低血壓。通過監測皮層鐳射多普勒流量來測定腦血流量自身調節的下限。

結果:基礎ICP組在腦血流量自身調節下限時的腦灌注壓平均是29.8 mm Hg (95% 可信區間: 26.5–33.0 mm Hg),但是中度升高ICP組在腦血流量自身調節下限時的腦灌注壓平均是37.6 mm Hg (95%可信區間: 32.0–43.2 mm Hg),重度升高ICP組在腦血流量自身調節下限時的腦灌注壓平均是51.4 mm Hg (95%可信區間: 41.2–61.7 mm Hg)。每組間的腦血流量自身調節下限各不相同,腦血流量自身調節下限的增加與顱內壓增加相關。

結論:在本次無創的提高顱內壓的小豬模型中,腦血流量自身調節下限與顱內壓呈正相關,這一結果提示了作為對顱內壓急性升高伴和動脈血壓相同程度升高的補償並不能夠足以預防腦缺血。

(姜旭暉譯,馬皓琳 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.


在脊椎麻醉及多重機制鎮痛用於前交叉韌帶重建術後7~12周時的一般健康狀況和膝功能預後情況

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:我們以前報導過與多重機制鎮痛和股神經周圍注射安慰劑比較,股神經周圍神經持續鎮痛能減輕前交叉韌帶重建(ACLR, n = 270) 術後2天的疼痛。現在我們報告同樣這些患者術後7~12周時的一般健康狀況和膝功能預後。

方法:ACLR術後12周內的3個時間點,患者完成SF-36一般健康狀況調查和膝功能調查(KOS)。進行廣義估計方程分析來評估患者報告的調查結果和術前基準調查評分、術後時間及3個神經阻滯治療組之間的聯繫。

結果:完成了270例患者的資料用於分析。在單變數和多變數回歸的廣義估計方程模型中,神經阻滯治療組與術後SF-36KOS評分並不相關(都為P ≥0.05)。該模型顯示SF-36中的體格檢查部分總結(P < 0.0001)和KOS總分(P < 0.0001)隨術後時間而增加(改善),且也受基準評分的影響。

結論:脊椎麻醉和多重機制鎮痛用於ACLR後,神經阻滯治療組並不能預示在術後7~12周的SF-36或膝功能預後。需要更多的研究來確定這些結論是否也適用於非標準化的麻醉劑,或者包括全身麻醉和/或高劑量阿片類藥鎮痛。

(朱 慧譯 馬皓琳 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.


長期持續股神經阻滯對膝關節三髁成形術後與健康相關的生活品質的影響:一項前瞻、隨機、三盲、安慰劑對照的1年隨訪實驗

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:我們以前的研究發現把膝關節三髁成形術(TKA)術後整晚的持續股神經阻滯延長到術後4天,可以給病人在術後即刻神經周圍輸注期間帶來很明確的好處。但延長的持續神經阻滯是否能提高病人以後的也就是術後7天到12月的健康生活品質,目前仍不清楚。

方法:膝關節三髁成形術的病人自手術時給予0.2%羅呱卡因股神經周圍持續輸注直至第二天早晨。此時病人以雙盲形式被隨機分為兩組,一組股神經周圍繼續輸注羅呱卡因(n = 25),另一組給予生理鹽水(n = 25)。病人帶著導管和可擕式輸注泵出院,術後第4天拔除導管。術前及術後第7天、123612月時,使用西安大略和麥克瑪斯特大學骨關節炎(WOMAC)指數測定病人的生活健康品質。WOMAC從三個方面評價生活健康品質:疼痛、關節的活動程度和生理功能殘疾。為行分析總結,在6個時間點中我們至少需要4個,包括術後第7天,和術後3612月中的至少兩個。

結果:兩個治療組病人用於曲線下平均面積均值計算的WOMAC評分相似(兩組的曲線下面積均值差異[整夜輸注組-延長輸注組]的點估計值=1.2, 95%可信區間–5.6 +8.0; P = 0.72),在各個時間點兩組病人WOMAC評分也相似(P > 0.05)

結論:我們發現膝關節三髁成形術病人行持續股神經阻滯的時間由術後整晚延長到術後4天,並不能提高(或降低)病人術後7天直至12月的生活健康品質。 (臨床試驗政府號NCT00135889.)

(張瑩譯  馬皓琳 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.)