Time Table of Contents

May 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

在有脑自身调节异常风险的病人中行低温心肺旁路期间的颈静脉氧合:{alpha}-固定计与pH-固定计血气处理的影响比较

彭中美 译 马皓琳 李士通 校

Jugular Venous Oxygenation During Hypothermic Cardiopulmonary Bypass in Patients at Risk for Abnormal Cerebral Autoregulation: Influence of {alpha}-Stat Versus pH-Stat Blood Gas Management (Brief Report)

Lance R. Hoover, Radhika Dinavahi, Wei-Ping Cheng, John R. Cooper, Jr, Maria Rosa Marino, Tyler C. Spata, Gaile L. Daniels, William K. Vaughn, and Nancy A. Nussmeier

Anesth Analg 2009 108: 1389-1393.

体外循环期间的最佳灌注:一项循证研究

怀晓蓉 译 陈杰 校

Optimal Perfusion During Cardiopulmonary Bypass: An Evidence-Based Approach (Review Article)

Glenn S. Murphy, Eugene A. Hessel, II, and Robert C. Groom

Anesth Analg 2009 108: 1394-1417.

心脏手术病人术中应用经食道超声心动描记术测量肾血流量的可行性研究

单嘉琪译 薛张纲校

The Feasibility of Measuring Renal Blood Flow Using Transesophageal Echocardiography in Patients Undergoing Cardiac Surgery

Ping-Liang Yang, David T. Wong, Shuang-Bo Dai, Hai-Bo Song, Ling Ye, Jin Liu, and Bin Liu

Anesth Analg 2009 108: 1418-1424.

TEG®血小板图TM测得的米力农对血小板活化的作用

裘毅敏译,马皓琳、李士通校

The Effect of Milrinone on Platelet Activation as Determined by TEG® Platelet MappingTM

Mark C. Wesley, Francis X. McGowan, Robert A. Castro, Sheahan Dissanayake, David Zurakowski, and James A. DiNardo

Anesth Analg 2009 108: 1425-1429.

使用旋转血栓弹力测定仪评估血小板输注的效果

朱紫瑜 译 陈杰 校

The Effects of Platelet Transfusions Evaluated Using Rotational Thromboelastometry (Brief Report)

Per Flisberg, Malin Rundgren, and Martin Engström

Anesth Analg 2009 108: 1430-1432.

血液凝固止血措施与凝血酶的调节

范羽译 薛张纲校

Blood Coagulation: Hemostasis and Thrombin Regulation (Review Article)

Kenichi A. Tanaka, Nigel S. Key, and Jerrold H. Levy

Anesth Analg 2009 108: 1433-1446

在止血中组织因子和VIIa因子的作用

唐亮   马皓琳 李士通

The Role of Tissue Factor and Factor VIIa in Hemostasis (Review Article)

Nigel Mackman

Anesth Analg 2009 108: 1447-1452.

经导管内主动脉瓣移植麻醉学方面的思考

周姝婧 译 陈杰 校

Transcatheter Aortic Valve Implantation: Anesthetic Considerations (Review Article)

Frederic T. Billings, IV, Susheel K. Kodali, and Jack S. Shanewise

Anesth Analg 2009 108: 1453-1462.

PEDIATRIC ANESTHESIOLOGY:

儿童喉部度量的年龄相关分析

黄剑译 薛张纲校

Pediatric Laryngeal Dimensions: An Age-Based Analysis

Priti G. Dalal, David Murray, Anna H. Messner, Angela Feng, John McAllister, and David Molter

Anesth Analg 2009 108: 1475-1479.

全麻药对耳蜗植入手术患儿电激发镫骨肌反射的剂量依赖抑制作用

张莹译  马皓琳 李士通校

Dose-Dependent Suppression of the Electrically Elicited Stapedius Reflex by General Anesthetics in Children Undergoing Cochlear Implant Surgery

Mark W. Crawford, Michelle C. White, Evan J. Propst, Christian Zaarour, Sharon Cushing, Carolyne Pehora, Adrian L. James, Karen A. Gordon, and Blake C. Papsin

Anesth Analg 2009 108: 1480-1487.

超声引导技术与体表标志定位技术用于小儿髂腹股沟-髂腹下神经阻滞:罗哌卡因血浆浓度的意义

黄丹 译 陈杰 校

Ultrasound Versus Landmark-Based Technique for Ilioinguinal-Iliohypogastric Nerve Blockade in Children: The Implications on Plasma Levels of Ropivacaine

Marion Weintraud, Märit Lundblad, Stephan C. Kettner, Harald Willschke, Stephan Kapral, Per-Arne Lönnqvist, Karl Koppatz, Klaus Turnheim, Adrian Bsenberg, and Peter Marhofer

Anesth Analg 2009 108: 1488-1492.

腹股沟压迫,瓦耳萨耳瓦氏手法以及反向特伦德伦伯氏卧位对儿童股动脉横截面积的影响

李莹译 薛张纲校

The Effect of Inguinal Compression, Valsalva Maneuver, and Reverse Trendelenburg Position on the Cross-Sectional Area of the Femoral Vein in Children

Jin-Tae Kim, Chun-Soo Park, Hyun Jung Kim, Jung-Man Lee, Hee-Soo Kim, Chong-Sung Kim, and Seong-Deok Kim

Anesth Analg 2009 108: 1493-1496.

AMBULATORY ANESTHESIOLOGY:

比较经皮吸收东莨菪碱复合昂丹司琼和单独使用昂丹司琼对预防门诊病人手术后恶心和呕吐的一个随机、双盲、多中心试验

王宏 译,马皓琳 李士通 校

A Randomized, Double-Blind, Multicenter Trial Comparing Transdermal Scopolamine Plus Ondansetron to Ondansetron Alone for the Prevention of Postoperative Nausea and Vomiting in the Outpatient Setting

Tong J. Gan, Ashish C. Sinha, Anthony L. Kovac, R. Kevin Jones, Stephen A. Cohen, Jean P. Battikha, Jonathan S. Deutsch, Joseph V. Pergolizzi, Jr, the TDS Study Group, and Peter S. A. Glass

Anesth Analg 2009 108: 1498-1504.

使用瑞芬太尼有利于插入Cobra喉周通气道(Cobra PLA)

潘钱玲 译 陈杰 校

The Use of Remifentanil to Facilitate the Insertion of the Cobra Perilaryngeal Airway

Woo Jae Jeon, Kyoung Hun Kim, Jung Kook Suh, and Sang Yun Cho

Anesth Analg 2009 108: 1505-1509.

ANESTHETIC PHARMACOLOGY:

志愿者中联合应用脑电图和听觉诱发电位鉴别麻醉深度

姚敏敏译 薛张纲校

A Combination of Electroencephalogram and Auditory Evoked Potentials Separates Different Levels of Anesthesia in Volunteers

Bettina Horn, Stefanie Pilge, Eberhard F. Kochs, Gudrun Stockmanns, Andreas Hock, and Gerhard Schneider

Anesth Analg 2009 108: 1512-1521.

咪达唑仑对丙泊酚药动学影响的混合效应模型的建立

江继宏 译  马皓琳 李士通 校

Mixed-Effects Modeling of the Influence of Midazolam on Propofol Pharmacokinetics

Jaap Vuyk, Bart Jan Lichtenbelt, Erik Olofsen, Jack W. van Kleef, and Albert Dahan

Anesth Analg 2009 108: 1522-1530.

蝌蚪实验显示异戊酸、甲基丙二酸及丙酸能减少麻醉药物EC50值,调节甘氨酸受体功能以及与二棕榈酸磷脂酰胆碱相互作用

(赵嫣红 译 陈杰 校)

Yun Weng, Tienyi Theresa Hsu, Jing Zhao, Stefanie Nishimura, Gerald G. Fuller, and James M. Sonner

Isovaleric, Methylmalonic, and Propionic Acid Decrease Anesthetic EC50 in Tadpoles, Modulate Glycine Receptor Function, and Interact with the Lipid 1,2-Dipalmitoyl-Sn-Glycero-3-Phosphocholine

Anesth Analg 2009 108: 1538-1545

TECHNOLOGY, COMPUTING, AND SIMULATION:

通过报警延迟和临床表现改善重症监护室的报警

俞佳译 薛张纲校

Improving Alarm Performance in the Medical Intensive Care Unit Using Delays and Clinical Context

Matthias Görges, Boaz A. Markewitz, and Dwayne R. Westenskow

Anesth Analg 2009 108: 1546-1552.

在健康志愿者中心脏指数的无创评估:比较胸廓阻抗心动描记法和多普勒超声心动描记法

周雅春 译 李士通 马皓琳 校

Noninvasive Assessment of Cardiac Index in Healthy Volunteers: A Comparison Between Thoracic Impedance Cardiography and Doppler Echocardiography

Jean-Luc Fellahi, Vincent Caille, Cyril Charron, Pierre-Hervé Deschamps-Berger, and Antoine Vieillard-Baron

Anesth Analg 2009 108: 1553-1559.

PATIENT SAFETY:

局部麻醉和监护下麻醉时的意识水平:患者的期望和体验

张燕 译 陈杰 校

Levels of Consciousness During Regional Anesthesia and Monitored Anesthesia Care: Patient Expectations and Experiences (Brief Report)

Roy K. Esaki and George A. Mashour

Anesth Analg 2009 108: 1560-1563.

围手术期麻醉医师关于口腔问题的考虑

张玥琪译,薛张纲校

Perioperative Dental Considerations for the Anesthesiologist (Review Article)

Jeffrey S. Yasny

Anesth Analg 2009 108: 1564-1573.

现代的快速可降解的羟乙基淀粉:最近的概念

唐李隽 译  马皓琳  李士通 校

Modern Rapidly Degradable Hydroxyethyl Starches: Current Concepts (Review Article)

Joachim Boldt

Anesth Analg 2009 108: 1574-1582.

CRITICAL CARE AND TRAUMA:

在模拟未插管呼吸骤停患者的台式模型上研究气道阻塞时的通气策略

张磊 译 陈杰 校

Ventilation Strategies in the Obstructed Airway in a Bench Model Simulating a Nonintubated Respiratory Arrest Patient (Technical Communication)

Holger Herff, Peter Paal, Achim von Goedecke, Thomas Mitterlechner, Christian A. Schmittinger, and Volker Wenzel

Anesth Analg 2009 108: 1585-1588.

OBSTETRIC ANESTHESIOLOGY:

在脊麻剖宫产中应用单一胶体扩容与晶胶合用相比对母体心输出量的影响

张钊译 薛张纲校

Colloid Preload Versus Coload for Spinal Anesthesia for Cesarean Delivery: The Effects on Maternal Cardiac Output

Wendy H. L. Teoh and Alex T. H. Sia

Anesth Analg 2009 108: 1592-1598.

羊水栓塞

黄佳佳译,马皓琳 李士通校

Amniotic Fluid Embolism (Review Article)

Richard S. Gist, Irene P. Stafford, Andrew B. Leibowitz, and Yaakov Beilin

Anesth Analg 2009 108: 1599-1602.

ECONOMICS, EDUCATION, AND POLICY:

儿科诊断成像和使用镇静的增长率

舒慧刚 译 陈杰 校

Growth Rates in Pediatric Diagnostic Imaging and Sedation

Ruth E. Wachtel, Franklin Dexter, and Angella J. Dow

Anesth Analg 2009 108: 1616-1621.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

一致声明:首届麻醉药与阿尔海默茨病国际研讨会                        

朱兰芳译 薛张纲校

Consensus Statement: First International Workshop on Anesthetics and Alzheimer’s Disease (Special Article)

Dmitri Baranov, Philip E. Bickler, Gregory J. Crosby, Deborah J. Culley, Maryellen F. Eckenhoff, Roderic G. Eckenhoff, Kirk J. Hogan, Vesna Jevtovic-Todorovic, András Palotás, Misha Perouansky, Emmanuel Planel, Jeffrey H. Silverstein, Huafeng Wei, Robert A. Whittington, Zhongcong Xie, and Zhiyi Zuo

Anesth Analg 2009 108: 1627-1630.

在一侧颈动脉完全性结扎加严重低血压的小鼠模型中去氧肾上腺素可以改善大脑细胞毒性水肿并减少脑梗塞体积

姜旭晖译,马皓琳,李士通校

Phenylephrine Ameliorates Cerebral Cytotoxic Edema and Reduces Cerebral Infarction Volume in a Rat Model of Complete Unilateral Carotid Artery Occlusion with Severe Hypotension

Seiji Ishikawa, Hiroyuki Ito, Kuninori Yokoyama, and Koshi Makita
Anesth Analg 2009 108: 1631-1637.

引导或可曲纤维支气管镜引导经口气管插管对颈椎移动影响的比较

丁俊云 译 陈杰 校

A Comparison of Cervical Spine Motion During Orotracheal Intubation with the Trachlight® or the Flexible Fiberoptic Bronchoscope

Bryan J. Houde, Stephan R. Williams, Alexandre Cadrin-Chênevert, François Guilbert, and Pierre Drolet

Anesth Analg 2009 108: 1638-1643.

ANALGESIA:

脑卒中后神经痛:关于其病理生理机制及治疗的综述

陈珺珺译 薛张纲校

Central Poststroke Pain: A Review of Pathophysiology and Treatment

Bishwanath Kumar, Jayantee Kalita, Gyanendra Kumar, and Usha K. Misra

Anesth Analg 2009 108: 1645-1657.

透视引导下正中入路颈段硬膜外注射:硬膜外腔造影图分析

叶乐 译 陈杰 校

Fluoroscopically Guided Cervical Interlaminar Epidural Injections Using the Midline Approach: An Analysis of Epidurography Contrast Patterns (Brief Report)

Kwang Su Kim, Sung Sik Shin, Tae Sam Kim, Chang Young Jeong, Myung Ha Yoon, and Jeong Il Choi

Anesth Analg 2009 108: 1658-1661.

大转子疼痛综合征:关于解剖、诊断和治疗方面的综述

陈珺珺译 薛张纲校

Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment (Review Article)

Bryan S. Williams and Steven P. Cohen

Anesth Analg 2009 108: 1662-1670.

阿米替林在一种大鼠神经性疼痛模型中对L5背根初级传入纤维异位放电的影响

颜涛 译, 马皓琳  李士通 校

The Effect of Amitriptyline on Ectopic Discharge of Primary Afferent Fibers in the L5 Dorsal Root in a Rat Model of Neuropathic Pain

Xin Su, Annie H. Liang, and Mark O. Urban

Anesth Analg 2009 108: 1671-1679.

急性炎性疼痛模型中外周给予胞二磷胆碱(CDP-胆碱)的效应:{alpha}7烟碱乙酰胆碱受体的作用

宋翠侠 译 陈杰 校

The Effect of Peripherally Administered CDP-Choline in an Acute Inflammatory Pain Model: The Role of {alpha}7 Nicotinic Acetylcholine Receptor

Mine Sibel Gurun, Renee Parker, James C. Eisenach, and Michelle Vincler

Anesth Analg 2009 108: 1680-1687.

在超声引导下持续肌间沟臂丛神经阻滞:一项随机、三盲、安慰剂对照研究

陈珺珺译 薛张纲校

Continuous Interscalene Brachial Plexus Block via an Ultrasound-Guided Posterior Approach: A Randomized, Triple-Masked, Placebo-Controlled Study

Edward R. Mariano, Robert Afra, Vanessa J. Loland, NavParkash S. Sandhu, Richard H. Bellars, Michael L. Bishop, Gloria S. Cheng, Lynna P. Choy, Rosalita C. Maldonado, and Brian M. Ilfeld

Anesth Analg 2009 108: 1688-1694.

一项比较超声和神经刺激作为穿刺针引导行肌间沟导管放置的前瞻性随机试验

黄施伟 译,马皓琳 李士通 校

A Prospective Randomized Comparison of Ultrasound and Neurostimulation as Needle End Points for Interscalene Catheter Placement

Michael J. Fredrickson, Craig M. Ball, Adam J. Dalgleish, Alistair W. Stewart, and Tim G. Short

Anesth Analg 2009 108: 1695-1700.

大鼠侧路经皮星状神经节阻滞技术

张燕 译 陈杰 校)

A Lateral Percutaneous Technique for Stellate Ganglion Blockade in Rats

Nebahat Gulcu, Ersoz Gonca, and Hasan Kocoglu

Anesth Analg 2009 108: 1701-1704.

体表解剖标志判断棘突节段用来行胸段硬膜外穿刺

陈珺珺译 薛张纲校

Surface Anatomy as a Guide to Vertebral Level for Thoracic Epidural Placement

Desiree A. Teoh, Kristi L. Santosham, Carmen C. Lydell, Dean F. Smith, and Michael T. Beriault

Anesth Analg 2009 108: 1705-1707.

在健康志愿者应用磁共振成像进行骶旁阻滞的解剖学研究

朱 慧译 马皓琳 李士通校

An Anatomical Study of the Parasacral Block Using Magnetic Resonance Imaging of Healthy Volunteers

Maeve O'Connor, Margaret Coleman, Fintan Wallis, and Dominic Harmon

Anesth Analg 2009 108: 1708-1712.

心脏手术病人术中应用经食道超声心动描记术测量肾血流量的可行性研究

The Feasibility of Measuring Renal Blood Flow Using Transesophageal Echocardiography in Patients Undergoing Cardiac Surgery

Ping-Liang Yang, David T. Wong, Shuang-Bo Dai, Hai-Bo Song, Ling Ye, Jin Liu, and Bin Liu

From the *Department of Anesthesiology, West China Second University Hospital, Sichuan University, People's Republic of China; {dagger}Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada; and {ddagger}Department of Anesthesiology, West China Hospital, Sichuan University, People's Republic of China.

Anesth Analg 2009 108: 1418-1424.

 

背景:现在尚没有可在术中监控肾血流量的可靠方法。在本次研究中,我们评估了在心脏手术术中应用经食道超声心动描记术进行左肾血流量测量的可行性及其可重复性。

方法:此次前瞻性研究应用经食道超声心动描记术对行心脏手术的60位患者进行左肾血流量的测量,并无人为干预因素,共有三个测量时间点(分别为心肺动脉分流术术前,术中和术后)。六份超声图样本是通过双盲的方法由两位独立的技术员在测量即刻及六个月之后分别进行分析解释获得的。各个测量组内及组间的可重复性已通过计算变异率和层级相关系数的方法进行了量化。

结果:多普勒角度大于30度的病人(60个样本中有20个)被排除在这次肾血流量测量研究之外。在所有的60个样本中有36个样本(60%)的左肾血流量被成功的测量分析。各个测量组内及组间的变异率均小于10%。左肾血流量测量组内及组间的可重复性也达到好甚至极好的水平(层级相关系数为0.604-0.999)。心肺动脉分流术术前,术中和术后三个阶段的左肾动脉管腔直径范围为3.84.1mm,肾动脉血流速度范围为2535cm/s,肾血流量为192299mL/min

结论:在行心脏手术的病人中,应用经食道超声心动描记术测量左肾血流量的方法对于60%的病例具有可行性。各个肾血流量测量组内及组间的可重复性也已达到好甚至

(单嘉琪译 薛张纲校)

BACKGROUND: There is no reliable method to monitor renal blood flow intraoperatively. In this study, we evaluated the feasibility and reproducibility of left renal blood flow measurements using transesophageal echocardiography during cardiac surgery.

METHODS: In this prospective noninterventional study, left renal blood flow was measured with transesophageal echocardiography during three time points (pre-, intra-, and postcardiopulmonary bypass) in 60 patients undergoing cardiac surgery. Sonograms from 6 subjects were interpreted by 2 blinded independent assessors at the time of acquisition and 6 mo later. Interobserver and intraobserver reproducibility were quantified by calculating variability and intraclass correlation coefficients.

RESULTS: Patients with Doppler angles of >30[degrees] (20 of 60 subjects) were eliminated from renal blood flow measurements. Left renal blood flow was successfully measured and analyzed in 36 of 60 (60%) subjects. Both interobserver and intraobserver variability were <10%. Interobserver and intraobserver reproducibility in left renal blood flow measurements were good to excellent (intraclass correlation coefficients 0.604-0.999). Left renal arterial luminal diameter for the pre, intra, and postcardiopulmonary bypass phases, ranged from 3.8 to 4.1 mm, renal arterial velocity from 25 to 35 cm/s, and left renal blood flow from 192 to 299 mL/min.

CONCLUSION: In patients undergoing cardiac surgery, it was feasible in 60% of the subjects to measure left renal blood flow using intraoperative transesophageal echocardiography. The interobserver and intraobserver reproducibility of renal blood flow measurements was good to excellent.

 

血液凝固:止血措施与凝血酶的调节

Blood coagulation: hemostasis and thrombin regulation.

Tanaka KA, Key NS, Levy JH

From the *Division of Cardiothoracic Anesthesia and Critical Care, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia; and {dagger}Division of Hematology, Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Anesth Analg 2009 108: 1433-1446.

                                                                          

随着越来越多的强效抗凝药物在临床使用,控制围手术期出血显然已成为一项重要挑战。了解最新的血液凝固概念对于在术前探讨患者的出血风险和制定围手术期止血措施是十分重要的。丝氨酸蛋白凝血酶在其他丝氨酸蛋白酶原(无效酶前体)、辅助因子及细胞表面受体的激活过程中起着决定性作用。当创伤发生后,凝血酶被就近调节生成并迅速达到局部产生止血作用,但其却不会导致全身失控性的血栓形成。出血/血液稀释、输血和外科手术压迫是手术过程中干扰血液凝固和炎症系统的最主要因素。术后出血往往需要异体输血,异体输血不仅提供止血措施,更可促成凝血酶的生成。然而,由于术后促凝活性物质和炎症反应的增加,抗栓治疗可能被用于预防围手术期血栓并发症。随着新型止血药物和抗凝药物的引入,实施围手术期止血及预防血栓形成的方法已取得重要进展。可由于传统的血凝试验并不能完整反映血液凝固的生理过程,故目前的治疗局限了最佳的药理学疗法的实施。了解凝血酶的体内调节机制和药理学变化可有助于控制围手术期出血,并显著减少血栓形成的危险性。此篇综述运用多个简化的血液凝固模型来关注止血措施和凝血酶形成的调节机制。

(范羽译 薛张纲校)

Perioperative bleeding is a major challenge particularly because of increasing clinical use of potent antithrombotic drugs. Understanding current concepts of coagulation is important in determining the preoperative bleeding risk of patients, and in managing hemostatic therapy perioperatively. The serine protease thrombin plays pivotal roles in the activation of additional serine protease zymogens (inactive enzymatic precursors), cofactors, and cell-surface receptors. Thrombin generation is closely regulated to locally achieve rapid hemostasis after injury without causing uncontrolled systemic thrombosis. During surgery, there are major disturbances in coagulation and inflammatory systems because of hemorrhage/hemodilution, blood transfusion, and surgical stresses. Postoperative bleeding often requires allogeneic blood transfusions, which support thrombin generation and hemostasis. However, procoagulant activity and inflammation are increased postoperatively; thus, antithrombotic therapy may be required to prevent perioperative thrombotic complications. There have been significant advances in the management of perioperative hemostasis and thrombosis because of the introduction of novel hemostatic and antithrombotic drugs. However, a limitation of current treatment is that conventional clotting tests do not reflect the entire physiological processes of coagulation making optimal pharmacologic therapy difficult. Understanding the in vivo regulatory mechanisms and pharmacologic modulation of thrombin generation may help control bleeding without potentially increasing prothrombotic risks. In this review, we focus on the regulatory mechanisms of hemostasis and thrombin generation using multiple, simplified models of coagulation.

 

儿童喉部度量的年龄相关分析

Pediatric laryngeal dimensions: an age-based analysis.

Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D.

From the *Department of Anesthesiology, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania; {dagger}Department of Anesthesiology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri; {ddagger}Department of Otolaryngology/Head and Neck Surgery Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; ||Kaiser Foundation Hospital, Oakland, California; ¶Department of Anesthesiology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri; and #Department of Otolaryngology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri.

Anesth Analg 2009 108: 1475-1479

 

背景在儿童环状软骨是漏斗状气道的最狭窄部分。随着生长发育,它逐渐转变成为成人的圆筒状气道。许多的儿童气道评估正是基于这种气道转变过程的理论。本研究的主要目标是测量各年龄儿童的气道。我们通过测量声门和环状软骨区,来观察用可视支气管镜图像是否可以分辨由儿童的漏斗状气道向成人的圆筒状气道转化的过程。

方法:年龄在6个月至13岁,共135名ASA分级在1~2级的儿童在全麻下经由可视支气管镜接受了喉部测量。测量数据包括声门和环状软骨水平的横断面积(C-CSA),前后径和横径。

结果:在135名接受检测的儿童中,有7例由于检测所得图像质量较差而被剔除。实际参与研究的儿童有128名,其中男孩79名和女孩49名。平均年龄5.9+/-3.3岁,平均身高为113.5+/-22.2cm,平均体重为23.5+/-13Kg。C-CSA平均值为48.9+/-15.5mm,大于G-CSA的平均值30+/-16.5mm,且在自6月龄开始(P<0.001,r=0.45,power=1)的所有研究对象中,C-CSA值均大于G-CSA。C-CSA:G-CSA的平均率为2.1+/-1.2。G-CSA和C-CSA的具有正相关性,相对于与年龄(r=0.36,P<0.001;r=0.27,P=0.001),身高(r=0.34,P<0.001;r =0.29,P<0.001)及体重(r=0.35,P<0.001;r=0.25,P=0.003).未观察到研究数据中在不同性别间存在显著差异。

结论:本次关于婴幼儿的研究中,与环状软骨相比,声门才是儿童气道最狭窄的部位。由支气管镜图像可看出,儿童气道与成人相似,更为接近圆筒状而不是漏斗状。还需要进一步的研究来证实,这些麻醉状态下对气道的静态测量是否可以反应儿童声门和环状软骨的动态特性。

(黄剑译 薛张纲校)

BACKGROUND: In children, the cricoid is considered the narrowest portion of the "funnel-shaped" airway. Growth and development lead to a transition to the more cylindrical adult airway. A number of airway decisions in pediatric airway practice are based on this transition from the pediatric to the adult airway. Our primary aim in this study was to measure airway dimensions in children of various ages. The measures of the glottis and cricoid regions were used to determine whether a transition from the funnel-shaped pediatric airway to the cylindrical adult airway could be identified based on images obtained from video bronchoscopy.

METHODS: One hundred thirty-five children (ASA physical status 1 or 2) aged 6 mo to 13 yr were enrolled for measurement of laryngeal dimensions, including cross-sectional area (G-CSA), anteroposterior and transverse diameters at the level of the glottis and the cricoid (C-CSA), using the video bronchoscopic technique under general anesthesia.

RESULTS: Of the 135 children enrolled in the study, seven patients were excluded from the analysis mainly because of poor image quality. Of the 128 children studied (79 boys and 49 girls), mean values (+/-standard deviation) for the demographic data were age 5.9 (+/-3.3) yr, height 113.5 (+/-22.2) cm and weight 23.5 (+/-13) kg. Overall, the mean C-CSA was larger than the G-CSA (48.9 +/- 15.5 mm(2) vs 30 +/- 16.5 mm(2), respectively). This relationship was maintained throughout the study population starting from 6 mo of age (P < 0.001, r = 0.45, power = 1). The mean ratio for C-CSA: G-CSA was 2.1 +/- 1.2. There was a positive correlation between G- and the C-CSA versus age (r = 0.36, P < 0.001; r = 0.27, P = 0.001, respectively), height (r = 0.34, P < 0.001; r = 0.29, P < 0.001, respectively), and weight (r = 0.35, P < 0.001; r = 0.25, P = 0.003, respectively). No significant gender differences in the mean values of the studied variables were observed.

CONCLUSION: In this study of infants and children, the glottis rather than cricoid was the narrowest portion of the pediatric airway. Similar to adults, the pediatric airway is more cylindrical than funnel shaped based on these video bronchoscopic images. Further studies are needed to determine whether these static airway measurements in anesthetized and paralyzed children reflect the dynamic characteristics of the glottis and cricoid in children.

 

 

腹股沟压迫,瓦耳萨耳瓦氏手法以及反向特伦德伦伯氏卧位对儿童股动脉横截面积的影响

The effect of inguinal compression, Valsalva maneuver, and reverse Trendelenburg position on the cross-sectional area of the femoral vein in children.

Jin-Tae Kim, Chun-Soo Park, Hyun Jung Kim, Jung-Man Lee, Hee-Soo Kim, Chong-Sung Kim, and Seong-Deok Kim

From the Departments of *Anesthesiology and Pain Medicine, and {dagger}Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea.

Anesth Analg 2009 108: 1493-1496.

     

背景: 对于简易化股静脉插管术,更大横断面积(CSA)的静脉是有利的,并且可以通过腹股沟压迫、瓦耳萨耳瓦氏手法或者反向特伦德伦伯卧位来获得。在本研究中,我们通过超生波检查评估了这些方法在儿童中应用的效果。

方法:用超声检查测量50位已麻醉小儿科患者的股静脉横截面积(小组L25名患者大于2岁;小组S25名患者小于2)。分别测量了以下六种情况下的股静脉横截面:1)仰卧位(控制)2)用手指压迫腹股沟韧带,3)15度的特伦德伦伯卧位,4)15度特伦德伦伯卧位加腹股沟压迫,5)瓦耳萨耳瓦氏手法,6)在反向15度的特伦德伦伯卧位。我们定义20%的横截面积改变为具有临床意义。

结果: 腹股沟压迫在小组L增加了股静脉40%的横截面积,而在小组S增加了57% (P < 0.001)。腹股沟压迫加特伦德伦伯卧位在小组L也增加了43%的横截面,在小组S则增加了73%(P < 0.001)。 瓦耳萨耳瓦氏手法对于股静脉横截面积的增加在小组S中比小组L更有效。特伦德伦伯卧位或者反向特伦德伦伯卧位对于股静脉横截面积的改变都不具有临床意义。

结论: 腹股沟压迫可有效地增加股静脉的横截面积,并且在特伦德伦伯卧位时它的作用也是显著的。瓦耳萨耳瓦氏手法对2岁以下儿童更有效。而重心位置改变对儿童股静脉横截面的改变影响很小。

(李莹译 薛张纲校)

BACKGROUNDS: For facilitation of femoral venous cannulation, the larger cross-sectional area (CSA) of the vein is helpful and can be achieved by inguinal compression, Valsalva maneuver, or the reverse Trendelenburg position. In this study, we evaluated these methods using ultrasonography in children.

METHODS: Ultrasound was used to measure the CSA of the common femoral vein of 50 anesthetized pediatric patients (Group L: 25 patients more than 2 yr, Group S: 25 patients younger than 2 yr). The following six measurements of the CSA of the femoral vein were made: 1) in the supine position (control), 2) with digital compression above the inguinal ligament, 3) in the Trendelenburg position 15 degrees , 4) in the Trendelenburg position 15 degrees plus inguinal compression, 5) with Valsalva maneuver, and 6) in the reverse Trendelenburg position 15 degrees . We defined 20% change of the CSA as clinically significant.

RESULTS: Inguinal compression increased the CSA of the femoral vein by 40% in Group L and by 57% in Group S (each P < 0.001). Inguinal compression during the Trendelenburg position also increased the CSA by 43% in Group L and by 73% in Group S (each P < 0.001). Valsalva maneuver for increasing the CSA of the femoral vein was more effective in Group S (increased by 35%) than in Group L (by 19%). The changes in the CSA were not clinically significant during the Trendelenburg position or the reverse Trendelenburg position.

CONCLUSIONS: Inguinal compression effectively increases the CSA of the femoral vein and its effect is also prominent in the Trendelenburg position. Valsalva maneuver is more effective in small children. Gravitational position changes have little effect on the size of the femoral vein in children.

 

 

志愿者中联合应用脑电图和听觉诱发电位鉴别麻醉深度

A Combination of Electroencephalogram and Auditory Evoked Potentials Separates Different Levels of Anesthesia in Volunteers

Bettina Horn, MD*, Stefanie Pilge, MD*, Eberhard F. Kochs, MD*, Gudrun Stockmanns, PhD{dagger}, Andreas Hock, MSc*, and Gerhard Schneider, MD*

From the *Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich; and {dagger}Institute of Information Logistics, Department of Computer Science and Applied Cognitive Science, University of Duisburg-Essen, Germany.

Anesth Analg 2009 108: 1512-1521.

 

背景:研究显示联合应用脑电图和听觉诱发电位能很好的鉴别有意识和无意识状态。在这个研究中,我们找到一种结合脑电图和听觉诱发电位的指示器,不但能鉴别有意识和无意识,同时能区分出不同的麻醉深度。

方法:十五名试验前未用药的志愿者在这个随机化交叉对照试验的两个连续试验阶段中分别接受七氟醚或者异丙酚单纯麻醉。意识丧失和脑电爆发抑制分别作为全麻的起点和终点。除了这两个极点外,两个介于意识消失和脑电爆发抑制之间的麻醉深度将整个过程分成三个等分的阶段。这样的信息设计用于检测先前描述过的联合脑电听觉诱发电位指示器(意识检测器)能否区别出清醒状态和脑电爆发抑制之间不同的麻醉状态。还有,一个在现有研究基础上改进的联合脑电和听觉诱发电位的指示器随后在同样的病人信息下用于检测区别清醒和意识消失的能力。

结果:先前的意识指示器在本次研究中区分不同麻醉深度的预测概率(PK)为0.77,改进后的新的指示器的预测概率为0.94。这个新的指示器应用于先前的研究中的预测概率为0.89

结论:这些结果显示结合了脑电图和听觉诱发电位的新型指示器能够区分出从清醒状态至深度麻醉(即脑电爆发抑制)之间不同的麻醉深度。

(姚敏敏译 薛张纲校)

BACKGROUND: It has been shown that the combination of electroencephalogram (EEG) and auditory evoked potentials (AEP) allows a good separation of consciousness from unconsciousness. In the present study, we sought a combined EEG/AEP indicator that allows both separation of consciousness from unconsciousness and discrimination among different levels of sedation and hypnosis over a wider range of anesthesia.

METHODS: Fifteen unpremedicated volunteers received mono-anesthesia with sevoflurane or propofol in a randomized crossover design in two consecutive sessions. Loss of consciousness (LOC) and EEG burst suppression (BSP) defined end-points from the upper and lower range of general anesthesia. In addition to those two extremes, the difference between anesthetic concentration at BSP and LOC was divided into three equal intervals, resulting in two intermediate levels which divided the concentration from LOC (minimum) to BSP (maximum) into three equal steps. This data set was used to test whether a previously described combined EEG/AEP indicator "detector of consciousness" can also discriminate among degrees of anesthetic effects from the awake state to BSP. Furthermore, a new improved combined EEG/AEP indicator was developed on the basis of the data from the current study, and subsequently this new indicator was tested for its ability to separate consciousness from unconsciousness with the patient data set.

RESULTS: The former "detector of consciousness" showed a prediction probability (PK) of 0.77 to separate different levels of anesthesia from the current study, whereas for the new combined EEG/AEP indicator, PK was 0.94. The new indicator was further applied to the previous study and achieved a PK of 0.89.

CONCLUSIONS: These results show that with the new indicator presented here, a combination of EEG and AEP parameters can be used to differentiate degrees of anesthetic effects over a wide range of hypnosis, from the conscious state to deep anesthesia (i.e., BSP).

 

 

通过报警延迟和临床表现改善重症监护室的报警

Improving Alarm Performance in the Medical Intensive Care Unit Using Delays and Clinical Context

Matthias Görges, MS, Boaz A. Markewitz, MD, and Dwayne R. Westenskow, PhD

From the Department of Anesthesiology, University of Utah; and {dagger}Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah.

Anesth Analg 2009 108: 1546-1552.

 

介绍:在重症监护室,报警器用来引起对病人的注意,警惕病人的生理学变化,或者对医学设备故障发出警告;然而,高达94%的报警器是错误的。我们在这项研究中的目的是确定一种方法以减少错误报警的数量。

方法:一个观察员记录警报计时打印信息和健康监护组员在病人房间里出场的情况;每个警报反应被分类成有效(5分钟之内采取行动),无效(对警报无反应),和忽略(警报被有意忽略或者静音)。

结果:在200个小时的研究期间,1271个单独个体进入被观察的房间,发生1214次警报以及2344次任务被执行。平均而言,警报每小时发生6.07次,每小时中有3.28分钟处于报警状态;23%是有效的,36%无效,41%被忽略。报警持续时间平均为17秒。14秒的报警延迟可以减少50%的被忽略和无效报警,而19秒的延迟可以减少67%。吸引器,洗涤,重新配置和口腔护理引发152次被忽略或者无效呼吸机报警。

讨论:介绍了19秒的报警延迟和自动检测吸引器,重新配置,口腔护理和洗涤器可以将无效和被忽略报警次数从934减少到274。更多可靠的报警可以引起计时的反应,减少工作负担,减轻噪音污染,潜在的提高病人的安全。

(俞佳译 薛张纲校)

INTRODUCTION: In an intensive care unit, alarms are used to call attention to a patient, to alert a change in the patient's physiology, or to warn of a failure in a medical device; however, up to 94% of the alarms are false. Our purpose in this study was to identify a means of reducing the number of false alarms.

METHODS: An observer recorded time-stamped information of alarms and the presence of health care team members in the patient room; each alarm response was classified as effective (action taken within 5 min), ineffective (no response to the alarm), and ignored (alarm consciously ignored or actively silenced).

RESULTS: During the 200-h study period, 1271 separate entries by an individual to the room being observed were recorded, 1214 alarms occurred and 2344 tasks were performed. On average, alarms occurred 6.07 times per hour and were active for 3.28 min per hour; 23% were effective, 36% were ineffective, and 41% were ignored. The median alarm duration was 17 s. A 14-s delay before alarm presentation would remove 50% of the ignored and ineffective alarms, and a 19-s delay would remove 67%. Suctioning, washing, repositioning, and oral care caused 152 ignored or ineffective ventilator alarms.

DISCUSSION: Introducing a 19-s alarm delay and automatically detecting suctioning, repositioning, oral care, and washing could reduce the number of ineffective and ignored alarms from 934 to 274. More reliable alarms could elicit more timely response, reduce workload, reduce noise pollution, and potentially improve patient safety.

 

 

围手术期麻醉医师关于口腔问题的考虑

Perioperative Dental Considerations for the Anesthesiologist

Jeffrey S. Yasny

From the Department of Anesthesiology, The Mount Sinai School of Medicine, New York.

Anesth Analg 2009 108: 1564-1573.

 

尽管麻醉医师一贯在病人口腔里进行操作,但他们可能并没有接受过有关牙齿及其周围组织以及口腔修复的系统性的教育。由于围手术期口腔损伤是最常见的麻醉相关性不良事件之一并且是众多针对麻醉医师的医疗事故投诉的元凶,所以一系列口腔问题的考虑是值得的。围手术期口腔创伤的可能性随着病人牙齿最弱性和相关麻醉危险因素出现的增加而增加。减少口腔损伤始于麻醉医师术前对病人牙齿和口腔组织状况的评估。清楚地记录病人术前口腔条件并告知病人口腔损害的可能性将减少相关的术后口腔治疗。基于发现一个潜在的危险的口腔条件,外科处理前需考虑求助口腔科医生提供解决之道。在做诸如喉镜检查和气管内插管等刺激性操作时实施谨慎的措施可帮助预防口腔损伤。在一个这样的损伤事件中,数种处理策略可提供一个快速有效的解决方法。给予口内条件和相关围术期风险因素更多的关注可减少发生口腔损伤的几率和经济代价。

(张玥琪译,薛张纲校)

Although anesthesiologists consistently work in the mouth of patients, they may not have been exposed to a comprehensive education of teeth, surrounding tissues, and intraoral prostheses. Since perioperative dental damage is one of the most common anesthesia-related adverse events and is responsible for the greatest number of malpractice claims against anesthesiologists, several dental considerations are warranted. The likelihood of perioperative dental trauma increases with the vulnerability of a patient's dentition and the presence of associated anesthesia risk factors. Minimizing dental injuries begins with the anesthesiologist's preoperative assessment of the patient's dentition and intraoral tissues. Clear documentation of the patient's preoperative dental condition and notifying the patient of the potential dental damage will diminish costs for any related postoperative dental treatment. Upon discovery of a potentially hazardous dental condition, a consultation with a dentist should be considered before proceeding with the surgical procedure. Exercising cautionary measures during provocative events, such as laryngoscopy and tracheal extubation, can aid in the prevention of dental trauma. In the event of such an injury, several management tactics can promote a swift and reasonable resolution. Establishing an increased awareness of intraoral conditions and the related perioperative risk factors may diminish the incidence of dental damage and financial costs.

 

 

在脊麻剖宫产中应用单一胶体扩容与晶胶合用相比对母体心输出量的影响

Colloid preload versus coload for spinal anesthesia for cesarean delivery: the effects on maternal cardiac output.

Teoh WH, Sia AT.

Department of Women's Anesthesia, KK Women's and Children's Hospital, Singapore.

Anesth Analg 2009 108: 1592-1598.

 

背景:脊麻对于剖宫产病人可引发严重的母体低血压,心输出量(CO)减少和胎盘血流量降低。由于快速的组织再分布,预先输入晶体液对脊麻的副作用无效。在脊麻过程回抽到脑脊液的同时给予晶胶混合扩容可能有更好的效果。这里所说的无效假设是:给予脊麻剖宫产妇胶体扩容(15 mL/kg羟乙基淀粉(贺斯)130/0.4 [Voluven 6%])和同等量的晶胶混合扩容对于母体心排量和低血压的发生率无区别。其次研究分娩后新生儿体内酸碱平衡及分娩前血管升压药的需要量。

方法:募集40ASA评分I II的择期剖宫产妇,随机分配到P组(给予15 mL/kg 贺斯扩容)或C组(在确认回抽到脑脊液时给予晶胶混合扩容)。使用USCOM超声心排量监测仪记录患者心率、动脉血压、每搏输出量、和心排血量基线,每分钟记录一次连续10分钟,后每2.5分钟记录一次连续10分钟。脊麻需右侧卧位于腰3/4椎间隙实施。弹丸式注射新福林维持动脉血压在基线的90%-100%

结果:人口学特征、麻醉剂以及外科特点相似。基线收缩压、心率和胶体容量无组间差异。脊麻后5分钟内P组病人的心排量和每搏输出量显著增加(P = 0.01) ,但心排量的增加维持不到10分钟。而低血压的发生率、绝对动脉血压值(P = 0.73)、分娩前新福林需要量(P组需要量中位值300毫克(01000mg),C组中位值150毫克(0850mg),P = 0.24),新生儿出生后的Apgar评分以及脐动脉和脐静脉的血气分析均无显著差异。

结论:静脉使用15 mL/kg贺斯130/0.4扩容增加前负荷相对于晶胶混合使用可使脊麻剖宫产病人的心排量在麻醉后5分钟内有显著增加,然而,对于母体和新生儿的影响无差异。

(张钊译 薛张纲校)

BACKGROUND: Spinal anesthesia for cesarean delivery may cause severe maternal hypotension, and a decrease in cardiac output (CO) and blood flow to the placenta. Fluid preloading with crystalloid is ineffective due to rapid redistribution. A "coload" given at the time of cerebrospinal fluid identification may be more effective. Our null hypothesis was that there would be no difference between the effect of a colloid preload (15 mL/kg hydroxyethyl starch (HES) 130/0.4 [Voluven 6%]) and an identical coload on maternal CO and the incidence of hypotension after spinal anesthesia for cesarean delivery. Secondary outcomes studied were neonatal acid- base status and predelivery vasopressor requirements.

METHODS: Forty ASA PS I and II women scheduled for elective cesarean delivery were recruited. Patients were randomized to Group P (preload of 15 mL/kg HES) or Group C (coload, given when cerebrospinal fluid identified). Heart rate, arterial blood pressure, stroke volume and CO measurements were recorded at baseline, every minute for 10 min, and every 2.5 min interval for 10 min with the USCOM ultrasonic CO monitor. Spinal anesthesia was performed at the L3/4 interspace in the right lateral position. Arterial blood pressure was maintained at 90%-100% of baseline values using IV phenylephrine boluses.

RESULTS: Demographic, anesthetic, and surgical characteristics were similar. There were no between-group differences in baseline systolic blood pressure, heart rate, and colloid volume. CO and stroke volume were significantly increased in Group P (P = 0.01) in the 5 min after spinal anesthesia. This increase in CO was not sustained at 10 min. There were no significant between-group differences in the incidence of hypotension, absolute arterial blood pressure values (P = 0.73), predelivery median (range) phenylephrine requirements (300[0-1000] in Group P versus 150 [0-850]microg in Group C, P = 0.24), or neonatal outcome as measured by Apgar scores and umbilical arterial and venous blood gas values.

CONCLUSION: Intravascular volume expansion with 15 mL/kg HES 130/0.4 given as a preload, but not coload, significantly increased maternal CO for the first 5 min after spinal anesthesia for cesarean delivery, however, maternal and neonatal outcomes were not different.

 

 

一致声明:首届麻醉药与阿尔海默茨病国际研讨会                        

Consensus Statement: First International Workshop on Anesthetics and Alzheimer’s Disease 
Dmitri Baranov, Philip E. Bickler, Gregory J. Crosby, Deborah J. Culley, Maryellen F. Eckenhoff, Roderic G. Eckenhoff, Kirk J. Hogan, Vesna Jevtovic-Todorovic, András Palotás, Misha Perouansky, Emmanuel Planel, Jeffrey H. Silverstein, Huafeng Wei, Robert A. Whittington, Zhongcong Xie, and Zhiyi Zuo

From the *Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; {dagger}Department of Anesthesia, University of California San Francisco Medical Center, San Francisco, California; {ddagger}Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; §Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin; ||Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia; ¶Asklepios-Med Bt, Szeged, Hungary; #Department of Pathology, Taub Institute for Alzheimer’s Disease Research, Columbia University Medical Center; **Department of Anesthesiology, Mount Sinai School of Medicine of New York University; {dagger}{dagger}Department of Anesthesiology, Columbia University Medical Center, New York City, New York; and {ddagger}{ddagger}Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2009 108: 1627-1630.

 

为了综合考查麻醉药与阿尔还默茨病潜在关系研究的目前状况,一些科学家最近在费城开了整天的会来陈述和讨论相关内容。这篇文章提出了阿尔还默茨病与麻醉药可能存在关联的一致观点,并指出了接下来为决定性测试这一结论所需要的措施。

(朱兰芳译 薛张纲校)

In order to review the current status of the potential relationship between anesthesia and Alzheimer’s disease, a group of scientists recently met in Philadelphia for a full day of presentations and discussions. This special article represents a consensus view on the possible link between Alzheimer’s disease and anesthesia and the steps required to test this more definitively.

 

 

脑卒中后神经痛:关于其病理生理机制及治疗的综述

Central Poststroke Pain: A Review of Pathophysiology and Treatment

Bishwanath Kumar, MD, Jayantee Kalita, DM, Gyanendra Kumar, MD, and Usha K. Misra, DM

From the Department of Neurology Sanjay Gandhi PGIMS, Lucknow, India.

Anesth Analg 2009 108: 1645-1657

 

背景:脑卒中后神经痛(CPSP)可以导致患者劳动力丧失,它在脑卒中病人中的发生率是8%–14%。这种现象没有得到重视且没有很好的治疗方法。

目的:我们系统的回顾了CPSP的病理生理及治疗。

方法:我们使用Medline,输入关键词" central post-stroke pain," "post-stroke pain," "CPSP and basic studies," "CPSP and clinical features," "CPSP and pharmacological treatment," "CPSP and nonpharmacological treatment" 和"CPSP and treatment guideline." 文章分成几类:临床表现、病理生理和治疗,然后系统地复习。

结果:脑卒中后一段时间,通常是1-2月,脑卒中引起的脊髓丘脑束通路受损可引起CPSPCPSP可以是自发的或是有诱因的,它的严重程度不尽相同。随着时间它的症状回有所缓解。CPSP的症状可以是轻度的运动障碍或是关节的位置觉和振动觉受损。CPSP的病理生理尚不是十分清楚,但是和中枢去抑制、中枢刺激和致敏的失衡有关。关于治疗有III两种。阿米替林和拉莫三嗪(IIB类)是一线用药,慢心律、氟甲沙明和加巴喷丁是二线用药。对于产生耐药的病人,反复的经颅磁刺激和深部脑刺激是可选的方法

结论CPSP的病人会出现不同的感觉症状,它发生的病理生理机制尚不是十分清楚。阿米替林和拉莫三嗪是有效的治疗药物。我们尚需要进一步研究其发生的病理生理机制,并探索新的治疗方法。

(陈珺珺译 薛张纲校)

BACKGROUND: Central poststroke pain (CPSP) is a disabling morbidity occurring in 8%–14% of patients with stroke. It is infrequently recognized and difficult to manage.

OBJECTIVE: We systematically reviewed the pathophysiology and treatment of CPSP.

METHODS: We conducted a Medline search using the key words "central post-stroke pain," "post-stroke pain," "CPSP and basic studies," "CPSP and clinical features," "CPSP and pharmacological treatment," "CPSP and nonpharmacological treatment" and "CPSP and treatment guideline." The articles related to CPSP were categorized into clinical features, pathophysiology and treatment, and then systematically reviewed.

RESULTS: Stroke along the spinothal amocortical pathway may result in CPSP after a variable period, usually after 1–2 mo. CPSP may be spontaneous or evoked, variable in intensity and quality. It tends to improve with time. CPSP is associated with mild motor symptoms with relative sparing of joint position and vibration sensations. The pathophysiology of CPSP is not well understood, but central disinhibition, imbalance of stimuli and central sensitization have been suggested. There are few class I and class II studies regarding its management. Amitriptyline and lamotrigine (class IIB) are recommended as first-line and  mexiletine, fluvoxamine and gabapentin as second-line drugs. In pharmacoresistant patients, repetitive transcranial magnetic stimulation and deep brain stimulation have been beneficial.

CONCLUSIONS: CPSP patients present with diverse sensory symptoms and its pathophysiology is still poorly understood. Amitriptyline and lamotrigine are effective treatments. Further studies are needed to understand the pathophysiology and investigate newer therapeutic modalities.


大转子疼痛综合征:关于解剖、诊断和治疗方面的综述

Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment

Bryan S. Williams, MD, MPH*, and Steven P. Cohen, MD{dagger}{ddagger}

From the *Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois; {dagger}Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, and {ddagger}Walter Reed, Army Medical Center, Washington, DC.

Anesth Analg 2009 108: 1662-1670

 

大转子疼痛综合征(GTPS)指的是髋部外侧部的慢性疼痛。这种局部疼痛症状曾在转子窝滑囊炎中被描述,它与其他来源的疼痛的表现相仿,包括关节盘痛、关节退行性病变和脊柱病理性疼痛。GTPS的发生率大约是每年每1000分之1.8,女性、合并腰背痛、骨关节炎、髂胫带触痛和肥胖的病人发生率较高。

GTPS的症状包括髋外侧持续疼痛,并放射到大腿到膝关节外侧,偶尔也会放射到膝关节以下或臀部。理学检查提示大转子后外侧区域触痛。大多数GTPS是自限性的,一些保守治疗如理疗、减肥、非甾体类抗炎治疗和行为矫正可以缓解症状。其他的治疗方法包括关节囊或髋关节内注射皮质激素或局麻药。当保守治疗无效时可以采用有创的手术治疗来减轻疼痛症状。

(陈珺珺译 薛张纲校)

Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity.

Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative  measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.


在超声引导下持续肌间沟臂丛神经阻滞:一项随机、三盲、安慰剂对照研究

Continuous Inter scalene Brachial Plexus Block via an Ultrasound-Guided Posterior Approach: A Randomized, Triple-Masked, Placebo-Controlled Study

Edward R. Mariano, MD, MAS*, Robert Afra, MD{dagger}, Vanessa J. Loland, MD*, NavParkash S. Sandhu, MD*, Richard H. Bellars, MD*, Michael L. Bishop, MD*, Gloria S. Cheng, MD*, Lynna P. Choy, MD*, Rosalita C. Maldonado, BS*, and Brian M. Ilfeld, MD, MS*

From the Departments of *Anesthesiology, and {dagger}Orthopedic Surgery, University of California, San Diego Medical Center, San Diego, California.

Anesth Analg 2009 108: 1688-1694

 

背景:关于经后路在肌间沟放置持续输注导管尚没有进行过对照研究。在一项随机、三盲、安慰剂对照研究中,我们试图验证了一下假设:对于肩关节手术引起的中度疼痛,超声引导下的经后路在肌间沟持续神经阻滞的镇痛效果优于单次给予罗哌卡因的效果。

方法:术前,受试者在超声引导下经斜角肌间隙放置了导管。所有的受试者接受了初始剂量的罗哌卡因。术后两天,受试者按需给予口服阿片类药物,实验组和对照组分别给予装有0.2%的罗哌卡因或生理盐水的装置。原始结果指的是术后第一天(POD1)平均疼痛评分,用0-10表示。其它结果包括最重及最轻疼痛评分,口服阿片药物的需要量,睡眠障碍、病人的满意度及并发症的发生率。

结果:试验者共有32名受试者,记录了30根周围神经导管。相比于给予初始剂量的罗哌卡因后持续给予生理盐水组,持续输注罗哌卡因在POD1可以提供很好的镇痛效果(n=15)(疼痛分数分别是0.0 [0.0–5.0] versus 3.0 [0.0–6.0], P < 0.001)。在POD1POD2,比较口服阿片类药物的消耗量,罗哌卡因组低于对照组。接受罗哌卡因的受试者较少有睡眠障碍,与生理盐水组相比对于镇痛的满意度较高。

结论:对于肩关节手术引起的中到重度疼痛的额病人,相比于肌间沟内单次给药神经组织,术后两天持续神经阻滞可以减缓疼痛,降低阿片类药物的需要量,提高睡眠质量,增加病人的满意度。

(陈珺珺译 薛张纲校)

BACKGROUND: The posterior approach for placing continuous interscalene  catheters has not been studied in a controlled investigation. In this randomized, triple-masked, placebo-controlled study, we tested the hypothesis that an ultrasound-guided continuous posterior interscalene block provides superior postoperative analgesia compared to a single-injection ropivacaine interscalene block after moderately painful shoulder surgery.

METHODS: Preoperatively, subjects received a stimulating interscalene catheter using an ultrasound-guided, in-plane posterior approach. All subjects received an initial bolus of ropivacaine. Postoperatively, subjects were discharged with oral analgesics and a portable infusion device containing either ropivacaine 0.2% or normal saline programmed to deliver a perineural infusion over 2 days. The primary outcome was average pain on postoperative day (POD) 1 (scale: 0–10). Secondary outcomes included least and worst pain scores, oral opioid requirements, sleep disturbances, patient satisfaction, and incidence of complications.

RESULTS: Of the 32 subjects enrolled, 30 perineural catheters were placed per protocol. Continuous ropivacaine perineural infusion (n = 15) produced a statistically and clinically significant reduction in average pain (median [10th–90th percentile]) on POD 1 compared with saline infusion (n = 15) after initial ropivacaine bolus (0.0 [0.0–5.0] versus 3.0 [0.0–6.0], respectively; P < 0.001). Median oral opioid consumption (oxycodone) was lower in the ropivacaine group than in the placebo group on POD 1 (P = 0.002) and POD 2 (P = 0.002). Subjects who received a ropivacaine infusion suffered fewer sleep disturbances than those in the placebo group (P = 0.005 on POD 0 and 1 nights) and rated their satisfaction with analgesia higher than subjects who received normal saline (P < 0.001).

CONCLUSIONS: Compared to a single-injection interscalene block, a 2-day continuous posterior interscalene block provides greater pain relief, minimizes supplemental opioid requirements, greatly improves sleep quality, and increases patient satisfaction after moderate-to-severe painful outpatient shoulder surgery

 

 

体表解剖标志判断棘突节段用来行胸段硬膜外穿刺

Surface Anatomy as a Guide to Vertebral Level for Thoracic Epidural Placement

Desiree A. Teoh, FRPC, MD*, Kristi L. Santosham, MD*, Carmen C. Lydell, MD{dagger}, Dean F. Smith, FRCPC, MD{dagger}, and Michael T. Beriault, FRCPC, MD*

From the Departments of *Anesthesia, and {dagger}Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.

Anesth Analg 2009 108: 1705-1707.

 

背景:术后最佳镇痛及最小副作用要求胸段硬膜外导管位置能准确放置。先前的研究表明,麻醉医生依靠体表解剖定位来判断脊椎的节段是不准确的。在这项研究中,我们比较了两种不同的体表标志物来判断第七胸椎(T7)的位置。

方法210名行胸片检查的病人随机分为两组。患者取直立位,通过C7和肩胛骨假定的T7用不透光的标志固定。放射医生通过盲法判断标志实际确定的棘突的位置。然后通过Fisher’精确检验的统计学方法进行统计。并且准确判断了病人的一般特点(年龄、性别、BMI、身高、体重)。

结果:病人的一般情况是相似的。第七颈椎横突作为确定T7的骨性标志,它的准确性是29%,而通过肩胛骨确定的准确性是10%P < 0.001)。如果确定的是T7  ± 1水平,它的准确性分别是78%42%(P = 5.84 x 10–8)。越向尾部,出错的可能越大(比如确定T8 T9)。C7作为标志在BMI<25的病人准确性较高(P = 6.51 x 10–5)。在那些BMI ≥25的病人,两种标志的准确性都不是很高 (P = 0.312)

结论:对于BMI<25的病人,通过第七颈椎横突确定的T7棘突的位置在78%的病人是准确的。对于BMI≥25的病人,第七颈椎横突和肩胛下角都不能准确确定T7的位置。

(陈珺珺译 薛张纲校)

BACKGROUND: Precise placement of thoracic epidural catheters is required to optimize postoperative analgesia and minimize adverse effects. Previous research demonstrated that anesthesiologists are inaccurate when using surface anatomy to locate vertebral levels. In this study, we compared the accuracy of two different landmarks to identify the seventh thoracic (T7) spinous process.

METHODS: Two-hundred-ten patients referred for chest radiography were randomized to two groups. With patients in the anatomic (upright) position, one investigator identified and placed a radioopaque marker over the presumed T7 spinous process using either the vertebra prominens (C7) or the inferior scapular tip as a surface landmark. A radiologist, blinded to the identification technique, reported the spinous process corresponding to the radioopaque label. Marker positions were then compared using the Fisher's exact test. The influence of patient characteristics (age, gender, Body Mass Index [BMI], and height and weight) on accuracy was also examined.

RESULTS: Patient characteristics were similar between groups. The T7 spinous process was identified correctly 29% of the time with the C7 landmark and 10% of the time with the scapular landmark (P < 0.001). Accuracy improved for T7 ± 1 level to 78% and 42%, respectively (P = 5.84 x 10–8). Errors were more common in the caudal direction (i.e., T8 or T9 identified). The C7 landmark was more accurate among those with a BMI <25 (P = 6.51 x 10–5). In those with a BMI ≥25, both landmarking methods were frequently inaccurate (P = 0.312).

CONCLUSIONS: For patients with a BMI <25, the T7 spinous process can be reliably identified to within one interspace in 78% of patients using the C7 (vertebra prominens) surface landmark. Neither the vertebra prominens nor the tip of scapula is a reliable landmark to identify T7 in patients with a BMI ≥25.


在有脑自身调节异常风险的病人中行低温心肺旁路期间的颈静脉氧合:{alpha}-固定计与pH-固定计血气处理的影响比较

Jugular Venous Oxygenation During Hypothermic Cardiopulmonary Bypass in Patients at Risk for Abnormal Cerebral Autoregulation: Influence of {alpha}-Stat Versus pH-Stat Blood Gas Management

Lance R. Hoover, MD*, Radhika Dinavahi, MD{dagger}, Wei-Ping Cheng, MD{ddagger}, John R. Cooper, Jr, MD{dagger}§, Maria Rosa Marino, MD||, Tyler C. Spata, BA{dagger}, Gaile L. Daniels, EMT{dagger}, William K. Vaughn, PhD, and Nancy A. Nussmeier, MD#

From the *Department of Cardiothoracic Anesthesia, San Antonio Uniform Health Education Consortium, San Antonio, Texas; {dagger}Division of Cardiovascular Anesthesiology, the Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas; {ddagger}Department of Anesthesiology, The Cardiovascular Institute and Fu Wai Hospital at the Chinese Academy of Medical Sciences, Beijing; §Department of Anesthesiology, Baylor College of Medicine, Houston, Texas; ||Department of Cardiovascular Anaesthesia, Centro Cardiologico Monzino IRCCS, Milano, Italy; ¶Department of Biostatistics and Epidemiology, the Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas; and #Department of Anesthesiology, SUNY Upstate Medical University, Syracuse, New York.

Anesth Analg 2009; 108:1389-1393

在一项对有脑血流自身调节受损风险的心脏手术病人的前瞻性、随机研究中,我们比较了{alpha}-固定计和pH-固定计下血气处理。选择40例年龄〉70岁、糖尿病、以前有中风史或未控制的高血压病人。在低温和复温早期,{alpha}-固定计病人(n = 12)的颈静脉氧分压明显低于pH-固定计病人(n = 19; P < 0.05)。在复温期间,颈静脉去饱和( SjvO2 <50%){alpha}-固定计病人中的发生率6/12,而pH-固定计病人没有发生(P = 0.0006)。如果在心肺旁路期间用pH-固定计血气处理,有脑自身调节功能较差风险的病人可有较高的氧分压和氧饱和度。

(彭中美 译 马皓琳 李士通 校)

In a prospective, randomized study of cardiac surgical patients at risk for impaired cerebral blood flow autoregulation, we compared {alpha}-stat and pH-stat blood gas management. The 40 patients enrolled had age >70 yr, diabetes, prior stroke, or uncontrolled hypertension. During hypothermia and early rewarming, jugular oxygen tensions were significantly lower in {alpha}-stat patients (n = 12) than pH-stat patients (n = 19; P < 0.05). During rewarming, jugular venous desaturation (i.e., SjvO2 <50%) occurred in 6 of 12 {alpha}-stat patients, but no pH-stat patients (P = 0.0006). Patients at risk for poor cerebral autoregulation have higher oxygen tensions and saturations if pH-stat blood gas management is used during cardiopulmonary bypass.


 

TEG®血小板图TM测得的米力农对血小板活化的作用

The Effect of Milrinone on Platelet Activation as Determined by TEG® Platelet MappingTM

 

Mark C. Wesley, MD*, Francis X. McGowan, MD*, Robert A. Castro, MT*, Sheahan Dissanayake, MT*, David Zurakowski, PhD{dagger}, and James A. DiNardo, MD*

From the Departments of *Anesthesia, Perioperative and Pain Medicine, and {dagger}Orthopaedic Surgery and Biostatistics, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2009; 108:1425-1429

背景:米力农是一种磷酸二酯酶III的抑制剂,通过增加细胞内的环磷腺苷来改善心室功能及血管扩张。细胞内环磷腺苷水平的增高也可抑制二磷酸腺苷(ADP)及花生四烯酸(AA)诱导的血小板凝集。我们假设通过TEG®血小板图TM.测绘法的监测,可定量地评价血液治疗浓度的米力农对ADPAA诱导的血小板活化的抑制作用。

方法:15位无抗血小板用药史的健康成人身上抽取血样。加入米力农到全血中达到三个临床相关的浓度(30100300 ng/mL)。在无米力农及以上三个浓度的全血中实施传统的凝血弹力描记法(TEG®)TEG血小板测绘法。

结果:米力农血浓度的增加伴随着对ADPAA诱导的血小板活化的抑制作用增大(P < 0.0001)。当米力农浓度达到300 ng/mL时,可明显破坏对ADPAA的血小板活化反应。

结论:通过TEG血小板TM.测绘法可发现治疗性血药浓度的米力农显著抑制ADPAA诱导的血小板活化作用,而对传统的陶土-活化的TEG无影响。

我们建议:对于使用米力农及其它改变血小板环核苷酸浓度的药物的患者,须谨慎解释TEG血小板测绘法的结果。

(裘毅敏译,马皓琳、李士通校)

BACKGROUND: Milrinone is a phosphodiesterase III inhibitor that increases intracellular cyclic adenosine monophosphate resulting in improved ventricular function and vasodilation. Increased intracellular levels of cyclic adenosine monophosphate also inhibit adenosine diphosphate (ADP) and arachidonic acid (AA)-induced platelet aggregation. We hypothesized that inhibition of ADP and AA-induced platelet activation by therapeutic blood concentrations of milrinone could be quantified using TEG® Platelet MappingTM.

METHODS: Blood was taken from 15 healthy adults who had not been taking antiplatelet medications. Milrinone was added to whole blood in three clinically relevant concentrations (30, 100, and 300 ng/mL). Conventional thromboelastography (TEG®) and TEG Platelet Mapping were performed on whole blood without milrinone and at each of these three concentrations.

RESULTS: Increased blood concentrations of milrinone were associated with increased inhibition of ADP and AA-induced platelet activation (P < 0.0001). Milrinone at a blood concentration of 300 ng/mL markedly impaired the platelet activation response to ADP and AA.

CONCLUSIONS: Therapeutic blood concentrations of milrinone exhibit a significant inhibitory effect on ADP and AA-induced platelet activation as determined by TEG Platelet Mapping, without affecting the conventional kaolin-activated TEG.

We suggest that TEG Platelet Mapping results be interpreted with caution in patients being treated with milrinone, and other drugs that modify platelet cyclic nucleotide concentrations.


 

在止血中组织因子和VIIa因子的作用

The Role of Tissue Factor and Factor VIIa in Hemostasis

Nigel Mackman, PhD

From the Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Anesth Analg 2009; 108:1447-1452

组织因子(TF)VII/VIIa 因子(FVII/VIIa)的一个跨膜受体。它在血管周围的细胞构成性表达。内皮将这个强效的“激活剂”与循环中的配体FVII/FVIIa完全分隔开来,防止不适当的激活凝血途径。内皮屏障的破坏导致血管外TF的暴露和迅速激活凝血途径。TF还在其他的一些组织中表达,如心脏和大脑,且能提供这些组织更多的凝血功能的保障。少量的TF还以微粒的形式存在于血液中,这些微粒是从活化的和凋亡的细胞出来的小膜囊。微粒TF的浓度在许多疾病中会增加,如败血症和癌症,且这种所谓的“血源传染性”TF可能促成这些疾病伴随的血栓形成。已开发出了重组FVIIa作为有抑制性抗体的血友病患者的一个有效止血药物。此外,它可用于对于常规治疗没有反应的出血患者。然而,重组FVIIa恢复止血的机制尚未清楚地确定。总之,TF:FVIIa复合物对于止血是非常必要的,重组FVIIa是一个非常有效的止血药物。

(唐亮 译  马皓琳 李士通 校)      

Tissue factor (TF) is a transmembrane receptor for Factor VII/VIIa (FVII/VIIa). It is constitutively expressed by cells surrounding blood vessels. The endothelium physically separates this potent "activator" from its circulating ligand FVII/FVIIa and prevents inappropriate activation of the clotting cascade. Breakage of the endothelial barrier leads to exposure of extravascular TF and rapid activation of the clotting cascade. TF is also expressed in certain tissues, such as the heart and brain, and provides additional hemostatic protection to these tissues. Small amounts of TF are also present in blood in the form of microparticles, which are small membrane vesicles derived from activated and apoptotic cells. Levels of microparticle TF increase in a variety of diseases, such as sepsis and cancer, and this so-called "blood-borne" TF may contribute to thrombosis associated with these diseases. Recombinant FVIIa has been developed as an effective hemostatic drug for the treatment of hemophilia patients with inhibitory antibodies. In addition, it is used for patients with bleeding that do not respond to conventional therapy. However, the mechanism by which recombinant FVIIa restores hemostasis has not been clearly defined. In conclusion, the TF:FVIIa complex is essential for hemostasis and recombinant FVIIa is an effective hemostatic drug.


全麻药对耳蜗植入手术患儿电激发镫骨肌反射的剂量依赖抑制作用

Dose-Dependent Suppression of the Electrically Elicited Stapedius Reflex by General Anesthetics in Children Undergoing Cochlear Implant Surgery

Mark W. Crawford, MBBS, FRCPC*, Michelle C. White, MBChB, DCH, FRCA*, Evan J. Propst, MSc, MD{dagger}, Christian Zaarour, MD*, Sharon Cushing, MD{dagger}, Carolyne Pehora, RN, MN*, Adrian L. James, DM, FRCS{dagger}, Karen A. Gordon, PhD{dagger}, and Blake C. Papsin, MD, FRCSC{dagger}

From the Departments of *Anesthesia and Pain Medicine, and {dagger}Otolaryngology/Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2009; 108:1480-1487

背景: 耳蜗植入物可以刺激听神经产生听觉。确定刺激合适的上下限是耳蜗植入手术成功所必须的。术中激发镫骨肌反射的阈值(ESRT)和激发复合动作电位(ECAP)常用于确定植入物刺激的极限。在本研究中,我们评估了七氟烷、地氟烷、异氟烷和丙泊酚对术中 ESRTECAP的剂量相关作用。

方法: 44 名行耳蜗植入手术患儿,年龄6个月至17岁,随机分组接受七氟烷、地氟烷、异氟烷或丙泊酚麻醉。由一位不知分组的研究者在呼气末麻醉药浓度为经年龄校正、随机顺序的00.751.5倍最低肺泡有效浓度,或丙泊酚的血液靶浓度为01.53.0 µg/mL时的激发反应。使用单因素重复测量方差分析数据,P < 0.05为差异有统计学意义。

结果:ESRT呈浓度依赖地随挥发性麻醉药浓度的升高而升高(P < 0.01)。有超过半数的患儿吸入挥发性麻醉药后镫骨肌反射消失。丙泊酚对ESRT影响最小。与ESRT相反,ECAP不受麻醉的影响。

结论:挥发性麻醉药呈浓度依赖地抑制镫骨肌反射,表明术中使用了挥发性麻醉药测定得到的ESRT值会过高估计最大舒适水平,这将会导致患儿术后的不适,妨碍患儿对植入物的适应。我们建议在耳蜗植入手术需要测定镫骨肌反射阈值时,不要使用挥发性麻醉药。

(张莹译  马皓琳 李士通校)

 BACKGROUND: Cochlear implants stimulate the auditory nerve to enable hearing. Determining appropriate upper and lower limits of stimulation is essential for successful cochlear implantation. The intraoperative evoked stapedius reflex threshold (ESRT) and evoked compound action potential (ECAP) are commonly used to determine the limits of implant stimulation. In this study, we evaluated the dose-related effects of sevoflurane, desflurane, isoflurane, and propofol on the intraoperative ESRT and ECAP.

METHODS: Forty-four children aged 6 mo to 17 yr undergoing cochlear implantation were recruited. Each child was randomly assigned to receive sevoflurane, desflurane, isoflurane, or propofol. Evoked responses were measured by a blinded investigator at end-tidal anesthetic concentrations corresponding to 0, 0.75, and 1.5 age-adjusted minimum alveolar concentration administered in random sequence and at targeted blood concentrations of propofol of 0, 1.5, and 3.0 µg/mL. Data were analyzed using one-way repeated-measures analysis of variance. P < 0.05 was considered statistically significant.

RESULTS: The ESRT increased dose dependently with increasing volatile anesthetic concentration (P < 0.01). The stapedius reflex was completely abolished by volatile anesthesia in more than half of children. Propofol minimally affected the ESRT. In contrast, the ECAP was unaffected by anesthesia.

CONCLUSIONS: Volatile anesthetics suppress the stapedius reflex in a dose-dependent manner, suggesting that ESRT measurements acquired during volatile anesthesia will overestimate the maximum comfort level, which may cause discomfort postoperatively and adversely affect the child’s adaptation to the implant. We advise against the use of volatile anesthetics for measurement of the stapedius reflex threshold during cochlear implant surgery.



比较经皮吸收东莨菪碱复合昂丹司琼和单独使用昂丹司琼对预防门诊病人手术后恶心和呕吐的一个随机、双盲、多中心试验

A Randomized, Double-Blind, Multicenter Trial Comparing Transdermal Scopolamine Plus Ondansetron to Ondansetron Alone for the Prevention of Postoperative Nausea and Vomiting in the Outpatient Setting

Tong J. Gan, MD*, Ashish C. Sinha, MD, PhD{dagger}, Anthony L. Kovac, MD{ddagger}, R. Kevin Jones, MD, CPI§, Stephen A. Cohen, MD, MBA||, Jean P. Battikha, MS, Jonathan S. Deutsch, MD, Joseph V. Pergolizzi, Jr, MD#, the TDS Study Group**, and Section Editor Peter S. A. Glass

From the *Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; {dagger}University of Pennsylvania, Philadelphia, Pennsylvania; {ddagger}University of Kansas Medical Center, Kansas City, Kansas; §Accurate Clinical Trials Inc./Saddleback Memorial Medical Center, Laguna Hills, California; ||Beth Israel Deaconess Medical Center, Boston, Massachusetts; ¶Baxter Healthcare Corporation, New Providence, New Jersey; #Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and **The TDS Study Group consists of the following members: Gregory H. Adkisson (St. Agnes Healthcare Inc., Baltimore, MD, St. Agnes Healthcare Inc. Clinical Research Center, Baltimore, MD), Keith Candiotti (University of Miami School of Medicine, Jackson Health Systems, Miami, FL), Stephen A. Cohen (Beth Israel Deaconess Medical Center, Boston, MA), Neil R. Connelly (Baystate Medical Center, Springfield, MA), Patricia L. Dalby (Magee Women's Hospital of UPMC, Pittsburgh, PA), Robert D'Angelo (Forsyth Medical Center, Winston-Salem, NC), Albert R. Davis (Loyola University Medical Center, Chicago, IL), David R. Drover (Stanford Hospital and Clinics, Stanford, CA), Tong J. Gan, Fernando Altermatt, Dianne Scott (Duke University Medical Center, Durham, NC, Duke Health Raleigh Hospital, Raleigh, NC, and Duke Center for Aesthetic Services, Durham, NC), Joseph S. Gimbel (AZ Research Center, John C. Lincoln Hospital, North Mountain, and John C. Lincoln Hospital, Deer Valley, Phoenix, AZ), R. Kevin Jones (Saddleback Memorial Medical Center, Laguna Hills, CA), Anthony L. Kovac (University of Kansas Medical Center, Kansas City, Kansas, KS), John B. Leslie (Mayo Clinic Hospital, Phoenix, AZ), Robert A. McKinney, Jr. (Trinity Clinic, North Park, Mother Frances Hospital, and Tyler Square, Tyler, TX), Tricia A. Meyer (Scott and White Hospital, Temple, TX), Joseph Pergolizzi (Physicians Day Surgery Center, Naples, FL), Beverly K. Philip (Brigham and Women's Hospital, Boston, MA), Martin J. Redmond (State University of New York at Stony Brook Ambulatory Surgical Center, Stony Brook, NY), Denise A. Scaringe (Cooper University Hospital, Camden, NJ, Cooper Surgery Center, Voorhees, NJ), Ashish C. Sinha (Hospital of the University of Pennsylvania, Philadelphia, PA), Jeffrey M. Varga (The Western Pennsylvania Hospital-Forbes Regional Campus, Monroeville, PA), Eugene R. Viscusi (Thomas Jefferson University Hospital and Jefferson Surgical Center, Philadelphia, PA), Elliott C. Wohlner (St. Anthony Central Hospital, Denver, CO), and Mark C. Ziegler (Mercy Hospital Anderson and Mercy Anderson Ambulatory Surgery Center, Cincinnati, OH).

Anesth Analg 2009; 108:1498-1504

背景:术后恶心和呕吐(PONV)是门诊手术后常见的并发症。我们想检测是否使用东莨菪碱经皮吸收剂(TDS)联合静脉注射昂丹司琼(OND)较单独使用OND更能减少门诊病人的PONV

方法:在随机、双盲、多中心试验中,620例接受门诊腹腔镜检查或隆胸手术有PONV风险的女性病人进入手术室前2h给予活性的TDS贴片或无TDS的贴片。所有病人在全麻诱导前2-5分钟静脉注射OND 4 毫克,随后进行全麻。完全止吐反应的定义为无呕吐/干呕或无解救药物治疗使用,在术后24小时和48小时判断完全止吐反应。还收集了病人呕吐/干呕、恶心或使用解救药物治疗的比例、手术结束到第一次上述反应发作的时间、离开医院/外科中心的时间、呕吐/干呕和恶心发作的次数和严重性以及病人对止吐治疗的满意度。

结果:相对于单独使用OND,联合使用TDSOND显著地减少术后24小时恶心和呕吐/干呕,但在术后48小时没有显著性差异出现。联合使用TDSOND的病人没有出现呕吐/干呕和没有使用解救药物治疗的比例是48%,而单独使用OND 的病人的比例是39%P < 0.02)。相对于单独使用OND组,联合使用TDSOND组完全反应(没有恶心,没有呕吐/干呕以及没有使用解救药物治疗)的比例显著更高(35%25%, P < 0.01)。相对于单独使用OND组,联合使用TDSOND组第一次恶心、呕吐/干呕或解救治疗的时间显著更晚(P < 0.05)。相对于OND组,联合使用TDSOND组不良事件的累积总发生率更低(36.7%49%, P < 0.01)

结论:联合使用TDSOND较单独使用OND更能减少PONV,并能减少不良事件的发生。

(王宏 译,马皓琳 李士通 校)

BACKGROUND: Postoperative nausea and vomiting (PONV) are common complications after ambulatory surgery. We sought to determine whether the use of transdermal scopolamine (TDS) in combination with IV ondansetron (OND) is more effective than one alone for reducing PONV in outpatient settings.

METHODS: In a randomized, double blind, multicenter trial, 620 at-risk female patients undergoing outpatient laparoscopic or breast augmentation surgery received either an active TDS patch or a similar appearing sham 2 h before entering the operating room. All patients received IV OND (4 mg) 2–5 min before induction of anesthesia followed by a general anesthetic regimen. Complete antiemetic response, defined as no vomiting/retching or rescue medication use, was measured through 24 h and 48 h after surgery. The proportion of patients with vomiting/retching, nausea, or use of rescue medication, the time from the end of surgery to the first episode of these events and the time to discharge from the hospital/surgery center, as well as the number and severity of vomiting/retching and nausea episodes, and patient satisfaction with antiemetic therapy were also collected.

RESULTS: The combination of TDS + OND statistically significantly reduced nausea and vomiting/retching compared with OND alone 24 h after surgery but not at 48 h. The proportion of patients who did not experience vomiting/retching and did not use rescue medication was 48% for TDS + OND and 39% for OND alone (P < 0.02). Total response (no nausea, no vomiting/retching, and no use of rescue medication) was also statistically higher for the TDS + OND group compared with the OND-only group (35% vs 25%, P < 0.01). The time to first nausea, vomiting/retching, or rescue episode was statistically significantly longer for the TDS + OND group compared with the OND-only group (P < 0.05). The cumulative overall incidence of adverse events was lower in the TDS + OND group compared with the OND group (36.7% vs 49%, P < 0.01).

CONCLUSIONS: TDS + OND reduces PONV compared with OND alone. This is achieved with a reduction in adverse events.



咪达唑仑对丙泊酚药动学影响的混合效应模型的建立

Mixed-Effects Modeling of the Influence of Midazolam on Propofol Pharmacokinetics

Jaap Vuyk, MD, PhD*, Bart Jan Lichtenbelt, MD{dagger}, Erik Olofsen, MSc*, Jack W. van Kleef, MD, PhD*, and Albert Dahan, MD, PhD*

From the Department of Anesthesiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands; and {dagger}Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

Anesth Analg 2009; 108:1522-1530

背景:混合使用麻醉药产生药物动力学相互作用导致药物浓度变化高达30%。咪达唑仑常在基于丙泊酚的麻醉前用作术前镇静药。我们在本研究中明确了咪达唑仑对丙泊酚药动学的影响。

方法:我们采用随机交叉的方式在两个时段对8名健康男性志愿者进行研究。在A期间,1 min内给予志愿者1 mg/kg丙泊酚,随后59 min连续输注2.5 mg · kg–1 · h–1丙泊酚。在B期间,除按A方案输注丙泊酚外,输注丙泊酚前15 min至停止输注后6 h采用靶控输注咪达唑仑 (常数Ct: 125 ng/mL)。采集动脉血标本分析血液丙泊酚和血浆咪达唑仑浓度,直到丙泊酚输注停止后6 h。采用Akaike模型选择准则建立非线性混合效应模型研究咪达唑仑和血液动力学参数对丙泊酚药动学的影响。

结果:与单独输注丙泊酚相比,联合输注咪达唑仑(Cblood: 224.8 ± 41.6 ng/mL)时丙泊酚血药浓度增加25.1% ± 13.3%咪达唑仑(Cblood: 225 ng/mL)使得丙泊酚Cl1从1.94 下降至1.61 L/min,Cl2从2.86下降至1.52 L/min, 而Cl3从0.95下降至0.73 L/min。包含平均动脉压进一步改良了丙泊酚药动学模型。

结论:咪达唑仑降低了丙泊酚的代谢和快慢分布清除率此外,平均动脉压的降低产生丙泊酚药动学变化而导致其血液浓度增加。

(江继宏 译  马皓琳 李士通 校)

BACKGROUND: The combined administration of anesthetics has been associated with pharmacokinetic interactions that induce concentration changes of up to 30%. Midazolam is often used as a preoperative sedative in advance of a propofol-based anesthetic. In this study, we identified the influence of midazolam on the pharmacokinetics of propofol.

METHODS: Eight healthy male volunteers were studied on two occasions in a random crossover manner. During Session A, volunteers received propofol 1 mg/kg in 1 min followed by an infusion of 2.5 mg · kg–1 · h–1 for 59 min. During Session B, in addition to this propofol infusion scheme, a target-controlled infusion of midazolam (constant Ct: 125 ng/mL) was given from 15 min before the start until 6 h after termination of the propofol infusion. Arterial blood samples for blood propofol and plasma midazolam concentration analysis were taken until 6 h after termination of the propofol infusion. Nonlinear mixed-effects models examining the influence of midazolam and hemodynamic variables on propofol pharmacokinetics were constructed using Akaike criterion for model selection.

RESULTS: In the presence of midazolam (Cblood: 224.8 ± 41.6 ng/mL), the blood propofol concentration increased by 25.1% ± 13.3% compared with when propofol was given as single drug. Midazolam (Cblood: 225 ng/mL) reduced propofol Cl1 from 1.94 to 1.61 L/min, Cl2 from 2.86 to 1.52 L/min, and Cl3 from 0.95 to 0.73 L/min. Inclusion of mean arterial blood pressure further improved the propofol pharmacokinetic model.

CONCLUSIONS: Midazolam reduces the metabolic and rapid and slow distribution clearances of propofol. In addition, a reduction in mean arterial blood pressure is associated with propofol pharmacokinetic alterations that increase the blood propofol concentration.



在健康志愿者中心脏指数的无创评估:比较胸廓阻抗心动描记法和多普勒超声心动描记法

Noninvasive Assessment of Cardiac Index in Healthy Volunteers: A Comparison Between Thoracic Impedance Cardiography and Doppler Echocardiography

Jean-Luc Fellahi, MD, PhD*, Vincent Caille, MD{dagger}, Cyril Charron, MD{dagger}, Pierre-Hervé Deschamps-Berger, MD{ddagger}, and Antoine Vieillard-Baron, MD, PhD{dagger}

From the *Department of Anesthesiology, Centre Hospitalier Privé Saint-Martin, Caen, France; {dagger}The Intensive Care Unit, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France; and {ddagger}The Department of Cardiology, Polyclinique, Deauville, France.

Anesth Analg 2009; 108:1553-1559

背景:胸廓生物阻抗心动描记法(ICG)被认为是一种无创、持续、不依赖操作者且信价比高的一种心输出量监测方法。本研究比较采用ICGNiccomoTM设备)和经胸多普勒心动超声法在健康志愿者静息状态下接受血流动力学负荷挑战时的心脏指数(CI)的测定结果。

方法:25名健康志愿者(男性7名,女性18名,平均年龄36 ± 6岁,体表面积1.75 ± 0.17 m2)在下述三种实验状态下接受测定:基础状态,呼气末正压+ 10 cm H2O和通过将医用抗休克裤腹部部分充气至30cm H2O使得下体产生正压。

结果:ICG信号质量>89%超过所有测量设定。观察到CITTE CIICG之间有微弱但有显著意义的联系(r = 0.36; P = 0.002)。两种技术之间的一致性为0.94 L · min–1 · m–2 (95% CI: 0.77–1.11),一致性的界限为–0.472.35 L · min–1 · m–2,而百分误差为53%。在采用呼气末正压+ 10 cm H2O (r = 0.21; P = 0.31)和医用抗休克裤(r = 0.22; P = 0.30)CITTE CIICG的百分比改变之间的联系不具有统计学意义。

结论:静息状态下健康志愿者采用ICG和经胸多普勒超声心动法测定的CI绝对值之间关联性弱且缺乏一致性。Niccomo设备对于监测处于血流动力负荷挑战状态下CI的变化并不可靠。

(周雅春 译 李士通 马皓琳 校)

BACKGROUND: Thoracic bioimpedance cardiography (ICG) has been proposed as a noninvasive, continuous, operator-independent, and cost-effective method for cardiac output monitoring. In the present study, we compared cardiac index (CI) measurements with ICG (NiccomoTM device) and transthoracic Doppler echocardiography in resting healthy volunteers undergoing hemodynamic load challenge.

METHODS: Twenty-five healthy volunteers (7 men and 18 women, mean age 36 ± 6 yr, body surface area 1.75 ± 0.17 m2) were investigated during three experimental conditions: baseline, positive end-expiratory pressure + 10 cm H2O and lower body positive pressure by means of medical antishock trousers inflated to 30 cm H2O in the abdominal compartment.

RESULTS: ICG signal quality was >89% over all sets of measurements. A weak but significant relationship was observed between CITTE and CIICG (r = 0.36; P = 0.002). Agreement between both techniques was 0.94 L · min–1 · m–2 (95% CI: 0.77–1.11), limits of agreement were –0.47 to 2.35 L · min–1 · m–2, and percentage error was 53%. No statistically significant relationships were found between percent changes in CITTE and CIICG after applications of positive end-expiratory pressure + 10 cm H2O (r = 0.21; P = 0.31) and medical antishock trousers (r = 0.22; P = 0.30).

CONCLUSIONS: Poor correlation and lack of agreement between absolute values of CI measured by ICG and transthoracic Doppler echocardiography were found in resting healthy volunteers. The Niccomo device was also unreliable for monitoring changes in CI during hemodynamic load challenge.



现代的快速可降解的羟乙基淀粉:最近的概念

Modern Rapidly Degradable Hydroxyethyl Starches: Current Concepts

Joachim Boldt, MD

From the Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.

Anesth Analg 2009; 108:1574-1582

羟乙基淀粉(HES)是一种被广泛应用于纠正围手术期血容量过低的血浆替代物。HES制剂是由浓度、摩尔取代度(MS)、平均分子量(Mw)C2/C6取代比、溶剂和起源定义的。HES可能存在的不愿见到的副作用是过敏反应、凝血功能的改变导致的出血增加、肾功能障碍、蓄积和瘙痒症。基于潜在副作用的考虑,区分不同HES制剂很重要,因为HES制剂不尽相同。第一代HES制剂表现出的高Mw (>450 kD)和高MS (>0.7) 产生了与凝血、器官功能和蓄积有关的不良作用。本综述聚焦于Mw (130 kD)MS (<0.5)较低的现代(第三代)、降解更快的HES制剂是否更安全及副作用较少。几项研究证明了这类现代HES制剂在凝血、肾功能、瘙痒和蓄积等方面显示出安全性。现代HES制剂能溶解于适合于血浆的平衡溶液,不含非生理含量的钠和氯,因此适用于纠正低血容量。

(唐李隽 译  马皓琳  李士通 校)

Hydroxyethyl starch (HES) is a widely used plasma substitute for correcting perioperative hypovolemia. HES preparations are defined by concentration, molar substitution (MS), mean molecular weight (Mw), the C2/C6 ratio of substitution, the solvent, and the origin. The possible unwanted side effects of HES are anaphylactic reactions, alterations of hemostasis resulting in increased bleeding, kidney dysfunction, accumulation, and pruritus. In view of the potential side effects, it is crucial to distinguish among the different HES preparations; all HES preparations are not the same. The first generation of HES preparation showing a high Mw (>450 kD) and a high MS (>0.7) was associated with negative effects with regard to coagulation, organ function, and accumulation. This review is focused on whether modern (third generation), more rapidly degradable HES preparations with a lower Mw (130 kD) and a lower MS (<0.5) are safer and have fewer side effects. Several studies demonstrated that such modern HES preparations appear to be safe with regard to hemostasis, kidney function, itching, and accumulation. Modern HES preparations are dissolved in balanced, plasma-adapted solutions that no longer contain unphysiological amounts of sodium and chloride and are thus suitable for correcting hypovolemia.



羊水栓塞

Amniotic Fluid Embolism

 

Richard S. Gist, MD*, Irene P. Stafford, MD{dagger}, Andrew B. Leibowitz, MD*, and Yaakov Beilin, MD*{ddagger}

From the *Department of Anesthesiology, Mount Sinai School of Medicine of New York University, New York City, New York; {dagger}Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas; and {ddagger}Department of Obstetrics and Gynecology, Mount Sinai School of Medicine of New York University, New York City, New York.

Anesth Analg 2009; 108:1599-1602

羊水栓塞是怀孕期间最具灾难性的并发症之一。首次描述羊水栓塞是在1941年,发生羊水栓塞的情况非常少见,其确切的病理生理学机制还不是很清楚。原本以为病原学的本质是血栓,但是更多最近的证据提示可能和免疫有关。临床症状多表现为:呼吸困难、胎儿状况不可靠、低血压、惊厥以及弥漫性血管内凝血。早期发现羊水栓塞对于成功的预后非常重要。然而,即使及时抢救,婴儿和母亲的预后常常都很差。目前已报道的有创且成功抢救羊水栓塞的方法包括重组VIIa因子的应用、心室辅助装置、吸入NO、心肺转流和主动脉内球囊泵和体外膜式氧合,应该考虑在某些特定病例中使用。

(黄佳佳译,马皓琳 李士通校)

Amniotic fluid embolism is one of the most catastrophic complications of pregnancy. First described in 1941, the condition is exceedingly rare and the exact pathophysiology is still unknown. The etiology was thought to be embolic in nature, but more recent evidence suggests an immunologic basis. Common presenting symptoms include dyspnea, nonreassuring fetal status, hypotension, seizures, and disseminated intravascular coagulation. Early recognition of amniotic fluid embolism is critical to a successful outcome. However, despite intensive resuscitation, outcomes are frequently poor for both infant and mother. Recently, aggressive and successful management of amniotic fluid embolism with recombinant factor VIIa and a ventricular assist device, inhaled nitric oxide, cardiopulmonary bypass and intraaortic balloon pump with extracorporeal membrane oxygenation have been reported and should be considered in select cases.



在一侧颈动脉完全性结扎加严重低血压的小鼠模型中去氧肾上腺素可以改善大脑细胞毒性水肿并减少脑梗塞体积

Phenylephrine Ameliorates Cerebral Cytotoxic Edema and Reduces Cerebral Infarction Volume in a Rat Model of Complete Unilateral Carotid Artery Occlusion with Severe Hypotension

Seiji Ishikawa, MD, Hiroyuki Ito, MD, Kuninori Yokoyama, PhD, and Koshi Makita, MD

From the Department of Anesthesiology, Tokyo Medical and Dental University, Graduate School of Medicine, Yushima, Bunkyo-ku, Tokyo, Japan.

Anesth Analg 2009; 108:1631-1637

背景:去氧肾上腺素是一种选择性{alpha}1肾上腺素能受体激动剂,通过外周血管收缩来升高动脉血压。但是当颈内动脉存在疾病的病人发生出血性休克时去氧肾上腺素是否可以改善脑缺血的预后还不清楚。

方法:(实验121只成年雄性斯普拉-道来大鼠吸入异氟烷进行麻醉,肺部机械通气。在右侧颈总动脉被结扎后,抽取动脉血直至平均动脉压(MAP)低至30 mm Hg以造成脑缺血。当平均动脉压在30 mm Hg持续10分钟后小鼠被随机分成三组(每组7只)。去氧肾上腺素组静脉注射去氧肾上腺素来维持平均动脉压至70 ± 3 mm Hg维持5分钟,安慰剂组与苯肾同等体积的生理盐水持续给予5分钟,对照组什么药都不给予,维持平均动脉压在30 mm Hg。驱血后30分钟,以0.25 mL/min的速度重新静脉输注抽取的血液。连续获得弥散加权的磁共振成像,建立表现弥散系数图像来测定细胞毒性水肿的量。(实验2)为了分析去氧肾上腺素对右大脑中动脉范围中局部脑血流量(rCBF)的影响,另外添加的15只小鼠(每组5只)用激光多普勒血流仪测得rCBF

结果:(实验1)在驱血后10分钟,去氧肾上腺素组(357.5 ± 93.5 mm3)、安慰剂组(333.5 ± 69.6 mm3)和对照组(303.1 ± 85.8 mm3)的细胞毒性水肿量之间没有显著区别。对照组随着时间延长,低表现弥散系数的区域显著扩大,然而在去氧肾上腺素组去氧肾上腺素输注后这种区域开始减小,而且在30分钟内就几乎全部消失了。去氧肾上腺素组最终的脑梗塞量(3.9 ± 2.6 mm3)比安慰剂组(341.5 ± 213.7 mm3)和对照组(509.1 ± 197.0 mm3)都明显要小(P < 0.01)。(实验2)虽然在10分钟驱血后rCBF 比减少到了基础值的40%–50%,但是去氧肾上腺素立即增加了rCBF值超过基础水平。在安慰剂组rCBF显著增加,但是和去氧肾上腺素组相比稍有滞后。

结论:在一侧颈动脉完全性结扎加严重低血压的大鼠模型中去氧肾上腺素可以改善大脑细胞毒性水肿并减少梗塞量。这些发现提示了在出血性休克时去氧肾上腺素可以瞬间升高CBF而不增加大脑血管的强直性痉挛。

(姜旭晖译,马皓琳,李士通校)

BACKGROUND: Phenylephrine is a selective {alpha}1 adrenergic receptor agonist that increases arterial blood pressure by peripheral vasoconstriction. However, whether phenylephrine improves the outcome of cerebral ischemia in patients with internal carotid artery disease during hemorrhagic shock is unclear.

METHODS: (Experiment 1) Twenty-one adult male Sprague-Dawley rats were anesthetized with isoflurane and their lungs mechanically ventilated. After the right common carotid artery was ligated, arterial blood was withdrawn until mean arterial blood pressure (MAP) reached 30 mm Hg to induce cerebral ischemia. After MAP was maintained at 30 mm Hg for 10 min, the animals were randomly allocated to three groups (n = 7 each). In the phenylephrine group, phenylephrine was administered IV to maintain a MAP of 70 ± 3 mm Hg for 5 min. In the saline group, an identical volume of normal physiologic saline was continuously administered for 5 min. In the control group, neither phenylephrine nor saline was administered and MAP was maintained at 30 mm Hg. At 30 min of exsanguination, the withdrawn blood was reinfused IV at a rate of 0.25 mL/min. Diffusion-weighted magnetic resonance images were serially acquired and apparent diffusion coefficient maps were created to determine the volume of cytotoxic edema. (Experiment 2) To analyze the effect of phenylephrine on the regional cerebral blood flow (rCBF) in the right middle cerebral artery territory, rCBF was measured using laser Doppler flowmetry in 15 additional rats (n = 5 each).

RESULTS: (Experiment 1) At 10 min of exsanguination, there were no significant differences in the volume of cytotoxic edema among the phenylephrine (357.5 ± 93.5 mm3), saline (333.5 ± 69.6 mm3), and control (303.1 ± 85.8 mm3) groups. Low apparent diffusion coefficient regions significantly expanded with time in the control group, whereas they started to decrease just after phenylephrine infusion and almost all had disappeared within 30 min in the phenylephrine group. The final infarction volume in the phenylephrine group (3.9 ± 2.6 mm3, P < 0.01) was significantly lower than that in the saline group (341.5 ± 213.7 mm3) and control group (509.1 ± 197.0 mm3). (Experiment 2) Although rCBF decreased to 40%–50% of the baseline at 10 min of exsanguination, phenylephrine immediately increased rCBF over the baseline level. In the saline group, rCBF increased significantly, but there was some delay compared with the phenylephrine group.

CONCLUSIONS: Phenylephrine ameliorated cytotoxic edema and decreased the infarction volume in a rat model of complete unilateral carotid artery occlusion with severe hypotension. These findings suggest that phenylephrine transiently increased CBF without increasing the tonus of cerebral vasculature during hemorrhagic shock.



阿米替林在一种大鼠神经性疼痛模型中对L5背根初级传入纤维异位放电的影响

The Effect of Amitriptyline on Ectopic Discharge of Primary Afferent Fibers in the L5 Dorsal Root in a Rat Model of Neuropathic Pain

Xin Su, MD, Annie H. Liang, MD, and Mark O. Urban, PhD

From the Department of Pain Research, Merck Research Laboratories, West Point, Pennsylvania.

Anesth Analg 2009; 108:1671-1679

背景:已有研究显示钠通道阻滞剂阿米替林能够抑制受损神经的异位放电。在本研究中,我们描述了在L5/L6脊神经结扎(SNL)大鼠的L5背根传入纤维异位放电的电生理学特性以及对阿米替林抑制作用的敏感性特征。

方法:本研究选择在SNL后缩爪阈值<4.0g的大鼠。在戊巴比妥麻醉的大鼠行椎板切除后,在接近进入脊髓处将L5背根纤维分散,在外周分别记录静脉注射阿米替林前后的单个单位自发电活动。测量传入纤维的平均放电频率和瞬间频率。

结果:由瞬间频率和放电峰间隙的分布来看,未手术大鼠的传入纤维具有高频(35.23 ± 6.63 Hz)和模式化自发放电。在SNL手术后大鼠,传入神经纤维呈无规律模式自发放电(平均11.05 ± 3.66 Hz)或在某些动物呈短暂爆发活动。未手术大鼠仅5/13(38%)传入纤维在应用阿米替林(2 mg/kg, IV)后自发电活动减少,而阿米替林显著抑制SNL大鼠13/18(72%)传入纤维的异位放电(ID50 = 1.66 ± 0.17 mg/kg)。而且,阿米替林的最大抑制效应总是出现于具有低频(<20 Hz)/或爆发放电的传入纤维。

结论:这些结果为临床上用于治疗神经性疼痛的药物阿米替林可选择性抑制神经性疼痛模型大鼠的低频异位放电和爆发放电提

(颜涛 译, 马皓琳  李士通 校)

BACKGROUND: The sodium channel blocker amitriptyline has been shown to inhibit ectopic discharge in injured nerves. In the present study, we characterized ectopic discharges of afferent fibers following L5/L6 spinal nerve ligation (SNL) by their electrophysiological properties and sensitivities to inhibition by amitriptyline in the decentralized L5 dorsal root in SNL rats.

METHODS: Rats exhibiting withdrawal thresholds <4.0 g after SNL were selected for the present study. After laminectomy in pentobarbital-anesthetized rats, the L5 dorsal root was decentralized close to its entry to the spinal cord, and the spontaneous activities of single units were recorded peripherally before and after IV administration of amitriptyline. The mean frequency of afferent fiber activity and instantaneous frequency were measured.

RESULTS: The spontaneous activities of afferent fibers in naïve rats had high frequency (35.23 ± 6.63 Hz) and pattern discharge based on their instantaneous frequencies and interspike interval distributions. In rats that had received SNL, afferent fibers exhibited spontaneous discharge (mean of 11.05 ± 3.66 Hz) with an irregular discharge pattern or short bursting activity in some cases. Only 5/13 (38%) afferent fibers from naïve rats showed reduced spontaneous activities after amitriptyline (2 mg/kg, IV), whereas amitriptyline significantly inhibited ectopic discharge in 13/18 (72%) afferent fibers from SNL rats (ID50 = 1.66 ± 0.17 mg/kg). Furthermore, the greatest inhibitory effect of amitriptyline was consistently observed on those afferent fibers exhibiting low frequency (<20 Hz) and/or bursting discharge.

CONCLUSION: These results provide direct evidence that amitriptyline, which is used clinically for the treatment of neuropathic pain, selectively inhibits ectopic discharge of low frequency and bursting discharge in the rat neuropathic pain model.



一项比较超声和神经刺激作为穿刺针引导行肌间沟导管放置的前瞻性随机试验

A Prospective Randomized Comparison of Ultrasound and Neurostimulation as Needle End Points for Interscalene Catheter Placement

Michael J. Fredrickson, MD*{ddagger}, Craig M. Ball, MD{dagger}, Adam J. Dalgleish, MD§, Alistair W. Stewart, BSc{ddagger}, and Tim G. Short, MD*{ddagger}

From the Departments of *Anesthesia and {dagger}Orthopedic Surgery, Auckland City Hospital; {ddagger}Department of Anesthesiology, Faculty of Medical and Health Sciences, The University of Auckland, Grafton, Auckland, New Zealand; and §Department of Orthopedic Surgery, Middlemore Hospital, Manukau City, Auckland, New Zealand.

Anesth Analg 2009; 108:1695-1700

背景:在本前瞻性、随机试验中,我们对假设进行验证:肌间沟导管放置用于肩部手术术后镇痛时,采用超声与神经刺激引导穿刺时效果相似。次级终点包括针在皮肤下的时间、操作相关的疼痛以及早期神经并发症的发生率。

方法:招募行肩部手术的患者。套管针进针一开始在out-of-plane超声成像的引导下进行,随后前瞻性随机分为超声下将针放至肌间沟交界面的侧方(n = 41)或在电流 <0.5 mA 时获得合适的运动反应(n = 40)。然后导管被盲目地送入超过针尖2-3cm的部位。所有手术在全麻下进行。手术结束时,设置0.2%罗哌卡因2mL/h输注,并按需随时给予5mL的单次输注量,在家持续2-5天。记录针在皮肤下的时间以及进针时数字等级疼痛评分(NRPS)。病人记录术后第1天和第2天最严重的NRPS以及追加的罗哌卡因单次输注和曲马多的需要量。第10天,就新的神经症状询问所有病人。

结果:术后48h内,静息下和活动时最差的NRPS和追加罗哌卡因单次输注或曲马多的需要量均无显著差别。在超声组,有一例未获得满意的超声成像。在神经刺激组,所有病人获得合适的运动反应。针在皮肤下时间的中位数(四分位数)在超声组为78 (65–101) s,而在神经刺激组为108 (94–129) s (P < 0.001)。穿刺时NRPS的中位数(四分位数)在超声组为2 (0–4),而在神经刺激组为3 (1–5) (P < 0.048)。两组间神经并发症的发生率没有差别。

结论:肌间沟导管放置用于肩部手术术后镇痛时,采用超声与神经刺激引导穿刺效果相似。超声引导减少针在皮肤下的时间和操作相关的疼痛。

(黄施伟 译,马皓琳 李士通 校)

BACKGROUND: In this prospective, randomized study, we tested the hypothesis that interscalene catheters placed for shoulder surgery using an ultrasound needle end point provide postoperative analgesia similar in quality to those placed using a neurostimulation needle end point. Secondary end points included needle time under the skin, procedure-related pain, and the incidence of early neurological complications.

METHODS: Patients presenting for shoulder surgery were recruited. Needles introduced for catheter insertion were initially guided with out-of-plane ultrasound imaging but were prospectively randomized to either sonographic placement immediately lateral to the interscalene interface (n = 41) or to an appropriate motor response at <0.5 mA (n = 40). Catheters were then advanced blindly 2–3 cm beyond needle tip. All surgery was conducted under general anesthesia. At the end of surgery, an infusion of ropivacaine 0.2% 2 mL/h with as-required hourly 5 mL boluses was instituted and continued at home for 2–5 days. Needle time under the skin and numerical rating pain score (NRPS) during insertion were recorded. Patients recorded worst NRPS, the need for supplementary ropivacaine boluses and tramadol on postoperative days 1 and 2. All patients were questioned at Day 10 for new neurological symptoms.

RESULTS: There was no significant difference in the worst NRPS at rest and on movement and the requirement for supplementary ropivacaine boluses or tramadol during the first 48 postoperative hours. In one patient in group ultrasound, a satisfactory ultrasound image was unobtainable. An appropriate motor response was obtained in all subjects in group neurostimulation. The median (quartiles) needle time under the skin was 78 (65–101) s in group ultrasound and 108 (94–129) s in group neurostimulation (P < 0.001). The median (quartiles) insertion NRPS was 2 (0–4) in group ultrasound and 3 (1–5) in group neurostimulation (P < 0.048). There was no difference in the frequency of neurological complications between groups.

CONCLUSIONS: Interscalene catheters placed for shoulder surgery using an ultrasound needle end point provide postoperative analgesia that is of similar quality to that obtained when using a neurostimulation needle end point. The ultrasound end point was associated with a reduction in needle under the skin time and procedure-related pain.



在健康志愿者应用磁共振成像进行骶旁阻滞的解剖学研究

An Anatomical Study of the Parasacral Block Using Magnetic Resonance Imaging of Healthy Volunteers

Maeve O'Connor, MB, BCh, BAO*, Margaret Coleman, FFARCSI*, Fintan Wallis, FRCR{dagger}, and Dominic Harmon, MD, FCARCSI*

From the Departments of *Anesthesia and Intensive Care Medicine, and {dagger}Radiology, Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland.

Anesth Analg 2009; 108:1708-1712

背景:据报道骶旁入路进行坐骨神经阻滞是易学易操作的,成功率高,并发症少。

方法:10名志愿者身上使用磁共振成像来评估模拟针(垂直于皮肤)以骶旁入路到达骶丛。还同时记录模拟骶旁阻滞过程中所遇到的盆内结构。

结果:10名志愿者中4名用模拟针到达了骶丛,1名志愿者到达了坐骨神经。骶丛精确地位于多种内脏结构旁,包括小肠、血管和卵巢。剩下的5名志愿者(第一次进针入路未接触骶丛)遇到了小肠、直肠、血管、精囊和骨性结构。以前,没有碰到骶丛的话,推荐重新调整进针点使其靠近尾部。我们发现这样的调整会导致盆内脏器穿孔或肛周凹陷。

结论:这些发现对骶旁阻滞解剖标志的可靠性提出了质疑,提高了使用这项技术造成常见内脏穿孔的可能性。

(朱 慧译 马皓琳 李士通校)

 

BACKGROUND: The parasacral approach to sciatic blockade is reported to be easy to learn and perform, with a high success rate and few complications.

METHODS: Using magnetic resonance imaging, we evaluated the accuracy of a simulated needle (perpendicular to skin) in contacting the sacral plexus with this approach in 10 volunteers. Intrapelvic structures encountered during the simulated parasacral blocks were also recorded.

RESULTS: The sacral plexus was contacted by the simulated needle in 4 of the 10 volunteers, and the sciatic nerve itself in one volunteer. The plexus was accurately located adjacent to a variety of visceral structures, including small bowel, blood vessels, and ovary. In the remaining five volunteers (in whom the plexus was not contacted on first needle pass), small bowel, rectum, blood vessels, seminal vesicles, and bony structures were encountered. Historically, when plexus is not encountered, readjustment of the needle insertion point more caudally has been recommended. We found that such an adjustment resulted in simulated perforation of intrapelvic organs or the perianal fossa.

CONCLUSIONS: These findings question the reliability of the anatomical landmarks of the parasacral block and raise the possibility of frequent visceral puncture using this technique.

 

体外循环期间的最佳灌注:一项循证研究

Optimal Perfusion During Cardiopulmonary Bypass: An Evidence-Based Approach

Glenn S. Murphy, MD*, Eugene A. Hessel, II, MD{dagger}, and Robert C. Groom, MS, CCP{ddagger}

From the *Department of Anesthesiology, Evanston Northwestern Healthcare and Northwestern University Feinberg School of Medicine, Evanston, Illinois; {dagger}Department of Anesthesiology and Surgery (Cardiothoracic), University of Kentucky College of Medicine, Lexigton Kentucky; and {ddagger}Department of Cardiovascular Perfusion, Maine Medical Center, Portland, Maine.

Anesth Analg 2009 108: 1394-1417.

 

在这个综述中,作者总结了现有的最佳证据以指导成人体外循环(CPB)时达到“最佳”灌注。目前,有关体外循环期间生理变化这一问题上存在较大争议。尽管有少数的资料提示高风险患者可能维持平均动脉血压>70mmHg更有利,但是低风险患者能够耐受平均动脉血压在50-60mmHg而无明显的并发症。体外循环时最佳的血细胞比容尚未界定,以大量数据资料为基础的研究表明,严重的血液稀释和输注浓缩红细胞均可增加术后不良结果的风险。氧输送取决于泵流量和动脉血氧含量。因此,在更严重的血液稀释时通过增加泵流量可能避免器官损伤。此外,体外循环期间最佳温度可能随生理目标变化而改变,近来数据表明过度的复温可能导致神经损伤。体外循环回路组成的设计也可能影响组织灌注和结局。尽管从理论讲离心式血泵优于滚柱泵,但是尚难以说明使用离心泵能改善临床结局。体外循环回路肝素预充可能减轻炎症反应和凝血途径,但难以明确其可以减少主要不良反应的发病率和死亡率。同样,与封闭系统相比,开放式静脉储血器无明显的临床优势。总之,目前关于如何实施最佳的体外循环能够作出强烈推荐的证据依然有限。迫切需要随机试验来评价患者,特别是高风险患者临床结局的差异。

(怀晓蓉 译 陈杰 校)

In this review, we summarize the best available evidence to guide the conduct of adult cardiopulmonary bypass (CPB) to achieve "optimal" perfusion. At the present time, there is considerable controversy relating to appropriate management of physiologic variables during CPB. Low-risk patients tolerate mean arterial blood pressures of 50–60 mm Hg without apparent complications, although limited data suggest that higher-risk patients may benefit from mean arterial blood pressures >70 mm Hg. The optimal hematocrit on CPB has not been defined, with large data-based investigations demonstrating that both severe hemodilution and transfusion of packed red blood cells increase the risk of adverse postoperative outcomes. Oxygen delivery is determined by the pump flow rate and the arterial oxygen content and organ injury may be prevented during more severe hemodilutional anemia by increasing pump flow rates. Furthermore, the optimal temperature during CPB likely varies with physiologic goals, and recent data suggest that aggressive rewarming practices may contribute to neurologic injury. The design of components of the CPB circuit may also influence tissue perfusion and outcomes. Although there are theoretical advantages to centrifugal blood pumps over roller pumps, it has been difficult to demonstrate that the use of centrifugal pumps improves clinical outcomes. Heparin coating of the CPB circuit may attenuate inflammatory and coagulation pathways, but has not been clearly demonstrated to reduce major morbidity and mortality. Similarly, no distinct clinical benefits have been observed when open venous reservoirs have been compared to closed systems. In conclusion, there are currently limited data upon which to confidently make strong recommendations regarding how to conduct optimal CPB. There is a critical need for randomized trials assessing clinically significant outcomes, particularly in high-risk patients.

 

 

使用旋转血栓弹力测定仪评估血小板输注的效果

The Effects of Platelet Transfusions Evaluated Using Rotational Thromboelastometry

Per Flisberg, MD, PhD*, Malin Rundgren, MD*, and Martin Engström, MD, PhD{dagger}

From the *Department of Anaesthesia and Intensive Care, Lund University Hospital, Lund, Sweden; and {dagger}Department of Anaesthesia and Intensive Care, Halmstad Central Hospital, Halmstad, Sweden.

Anesth Analg 2009 108: 1430-1432.

 

背景:此研究中,作者评估了血小板输注对全血凝固产生的即刻效应。

方法:10位血小板减少的患者输注一个单位200-300×109的血小板,并使用旋转血栓弹力测定仪测量输注前及输注时的凝血状态。

结果:输注使血小板计数的中位数从31.5×109上升至43.5×109。血凝块形成时间缩短了32%P=0.005),然而最大凝结强度却增加了47%P=0.005)。

结论:在这些患者中,输注血小板后血小板计数平均上升12×109与旋转血栓弹力测定仪的相关数据的提高的相关性在统计学上有意义。

(朱紫瑜 译 陈杰 校)

BACKGROUND: In this study, we assessed the immediate effects of platelet transfusion on whole blood coagulation.

METHODS: Ten thrombocytopenic patients given a single unit platelet transfusion of 200–300 x 109 platelets had their coagulation status assessed before and immediately after transfusion using rotational thromboelastometry.

RESULTS: Transfusion increased the median platelet count from 31.5 to 43.5 x 109/L. Clot formation time decreased by 32% (P = 0.005), whereas maximum clot strength increased by 47% (P = 0.005).

CONCLUSION: Statistically significant improvements in rotational thromboelastometry-measured parameters were observed in association with a mean increase of 12 x 109/L in platelet count after platelet transfusion in these patients.

 

 

经导管内主动脉瓣移植:麻醉学方面的思考

Transcatheter Aortic Valve Implantation: Anesthetic Considerations

Frederic T. Billings, IV, MD*, Susheel K. Kodali, MD{dagger}, and Jack S. Shanewise, MD*

From the Departments of *Anesthesiology, and {dagger}Internal Medicine, College of Physicians and Surgeons of Columbia University, New York, New York.

Anesth Analg 2009 108: 1453-1462.

 

主动脉瓣狭窄仍然是最常见的心脏瓣膜疾病。尽管主动脉瓣(AV)置换术对患者有益,但许多高危患者却不能耐受手术。AV移植术能够治疗主动脉狭窄,而患者不需行胸骨切开、体外循环(CPB)以及主动脉钳闭。这一经导管的操作是通过左心室(LV)尖穿刺或经皮股动脉或股静脉导管穿刺完成的。患者接受全身麻醉,术中需对其血流动力学进行严密调控,并接受经食管的心脏超声检查(TEE)。

作者通过回顾文献结合他们的经历探讨了在经导管内AV移植术中麻醉医生的角色,重点关注麻醉监护、术中特殊事件、TEE和围术期并发症。

目前有两种方法可以到达主动脉瓣口:经股动脉逆行和经心尖顺行。可根据每一位患者的髂动脉内径大小和迂曲度、主动脉弓内粥样板块的形成情况和心尖的病变情况选择不同的入路。

精心设计全身麻醉以便在操作结束后顺利拔管,而静脉通路和药物支持确保在紧急情况下实施胸骨切开并开始CPB。快速心室起搏和停止机械通气阻断心脏射血,并减少瓣膜成形术和假体移植过程中的心脏移位。尽管这些方法有利于操作者将假体放至受体的确切位置,但同时它们会引起低血压和心律失常。在起搏和心脏复律前应用血管加压药可恢复足够的血流动力学。

借助TEE可判断主动脉瓣口面积、主动脉病理变化、心室功能和二尖瓣返流情况。TEEX线荧光还可用于对主动脉瓣内的导引管进行定位。假体固定于瓣膜成形术的球囊导管上,通过充气后进行移植。TEE可迅速测量主动脉瓣的返流情况,同时评估是否存在主动脉夹层。缝合股血管或LV尖后,即可对患者实施复苏和拔管。

作者所观察到的以及文献报道的并发症包括主动脉瓣返流尽管那个表明、假体栓塞、二尖瓣破裂、出血、主动脉夹层、CPB、中风和死亡。

经导管内AV移植术的成功离不开术中的血流动力学调控。采用经股和经髂血管的入路时,需注意血流动力学管理方面的一些问题。但是总的来说两种入路都需要快速心室起搏、在不停跳心瓣膜移植期间处理好低血压和心律失常,以及实施TEE。麻醉医师应严密监测接受经导管AV移植的主动脉瓣狭窄的患者。

(周姝婧 译 陈杰 校)

Aortic valvular stenosis remains the most common debilitating valvular heart lesion. Despite the benefit of aortic valve (AV) replacement, many high-risk patients cannot tolerate surgery. AV implantation treats aortic stenosis without subjecting patients to sternotomy, cardiopulmonary bypass (CPB), and aorta cross-clamping. This transcatheter procedure is performed via puncture of the left ventricular (LV) apex or percutaneously, via the femoral artery or vein. Patients undergo general anesthesia, intense hemodynamic manipulation, and transesophageal echocardiography (TEE).

To elucidate the role of the anesthesiologist in the management of transcatheter AV implantation, we review the literature and provide our experience, focusing on anesthetic care, intraoperative events, TEE, and perioperative complications.

Two approaches to the aortic annulus are performed today: transfemoral retrograde and transapical antegrade. Iliac artery size and tortuosity, aortic arch atheroma, and pathology in the area of the (LV) apex help determine the preferred approach in each patient.

A general anesthetic is tailored to achieve extubation after procedure completion, whereas IV access and pharmacological support allow for emergent sternotomy and initiation of CPB. Rapid ventricular pacing and cessation of mechanical ventilation interrupts cardiac ejection and minimizes heart translocation during valvuloplasty and prosthesis implantation. Although these maneuvers facilitate exact prosthesis positioning within the native annulus, they promote hypotension and arrhythmia. Vasopressor administration before pacing and cardioversion may restore adequate hemodynamics.

TEE determines annulus size, aortic pathology, ventricular function, and mitral regurgitation. TEE and fluoroscopy are used for positioning the introducer catheter within the aortic annulus. The prosthesis, crimped on a valvuloplasty balloon catheter, is implanted by inflation. TEE immediately measures aortic regurgitation and assesses for aortic dissection. After repair of femoral vessels or LV apex, patients are allowed to emerge and assessed for extubation.

Observed and published complications include aortic regurgitation, prosthesis embolization, mitral valve disruption, hemorrhage, aortic dissection, CPB, stroke, and death.

Transcatheter AV implantation relies on intraoperative hemodynamic manipulation for success. Transfemoral and transapical approaches pose unique management challenges, but both require rapid ventricular pacing, the management of hypotension and arrhythmias during beating-heart valve implantation, and TEE. Anesthesiologists will care for debilitated patients with aortic stenosis receiving transcatheter AV implantation.


超声引导技术与体表标志定位技术用于小儿髂腹股沟-髂腹下神经阻滞:罗哌卡因血浆浓度的意义

Ultrasound Versus Landmark-Based Technique for Ilioinguinal-Iliohypogastric Nerve Blockade in Children: The Implications on Plasma Levels of Ropivacaine

Marion Weintraud, MD*, Märit Lundblad, MD{dagger}, Stephan C. Kettner, MD*, Harald Willschke, MD*, Stephan Kapral, MD*, Per-Arne Lönnqvist, MD{dagger}, Karl Koppatz{ddagger}, Klaus Turnheim, MD{ddagger}, Adrian Bsenberg, MD§, and Peter Marhofer, MD*

From the *Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria; {dagger}Department of Anesthesia and Intensive Care, Karolinska Hospital/Astrid Lindgren Hospital, Stockholm, Sweden; {ddagger}Department of Pharmacology, Medical University of Vienna, Vienna, Austria; and §Department of Anesthesia, University Cape Town, Red Cross Children Hospital, Cape Town, South Africa.

Anesth Analg 2009 108: 1488-1492.

 

背景:小儿髂腹股沟-髂腹下神经阻滞(INB)常见局部麻醉药(LAs)血浆浓度较高。超声引导可以在解剖上准确地注射局部麻醉药,其可能改变血药浓度。因此,作者比较了超声引导与体表标志定位下行髂腹股沟-髂腹下神经阻滞后的血浆罗哌卡因浓度。

方法: 全身麻醉下66名拟行腹股沟疝修补术的儿童(8-84个月)使用0.5%的罗哌卡因0.25ml/kg1.25mg/kg)行髂腹股沟-髂腹下神经阻滞。这些儿童接受体表标志定位技术(n=31)或超声引导技术(n=35)。在注射局部麻醉药之前(0)以及注射后5102030分钟后采用高效液相色谱法测量罗哌卡因的血药浓度。测定血浆峰浓度(Cmax),达到血浆峰浓度的时间(tmax),吸收速率常数(ka),血药浓度上升速率(dC0/dt)以及曲线下面积值(AUC)。  

 结果:与体表标志为基础的定位技术相比,超声引导技术导致了较高的Cmax (sd), ka, dC0/dt和曲线下面积值(AUC),以及较短的tmax(Cmax: 1.78 [0.62] vs 1.23 [0.70] µg/mL, P < 0.01; ka: 14.4 [10.7] vs 11.7 [11.4] h–1, P < 0.05; dC0/dt: 0.26 [0.12] vs 0.15 [0.03] µg/mL · min, P < 0.01; AUC: 42.4 [15.9] vs 27.2 [18.1] µg · 30 min/mL, P < 0.001; tmax: 20.4 [8.6] vs 25.3 [7.6] min, P < 0.05).

结论:药代动力学数据显示,与体表标志为基础的定位技术相比,使用超声引导技术行髂腹股沟-髂腹下神经阻滞后,局部麻醉药吸收更快,血药浓度更高。因此,超声引导下行髂腹股沟-髂腹下神经阻滞时,应考虑减少局部麻醉药的用量。

(黄丹 译 陈杰 校)

BACKGROUND: Ilioinguinal-iliohypogastric nerve blockade (INB) is associated with high plasma concentrations of local anesthetics (LAs) in children. Ultrasonographic guidance enables exact anatomical administration of LA, which may alter plasma levels. Accordingly, we compared plasma levels of ropivacaine after ultrasonographic versus landmark-based INB.

METHODS: After induction of general anesthesia, 66 children (8–84 mo) scheduled for inguinal hernia repair received INB with 0.25 mL/kg of ropivacaine 0.5% (1.25 mg/kg) either by a landmark-based (n = 31) or by an ultrasound-guided technique (n = 35). Ropivacaine plasma levels were measured before (0) and 5, 10, 20, and 30 min after the LA injection, using high-performance liquid chromatography. Maximum plasma concentrations (Cmax), time to Cmax (tmax), the absorption rate constant (ka), the speed of rise of the plasma concentration at Time 0 (dC0/dt), and area under the curve value (AUC) were determined.

RESULTS: The ultrasound-guided technique resulted in higher Cmax (sd), ka, dC0/dt, and AUC values and shorter tmax compared with the landmark-based technique (Cmax: 1.78 [0.62] vs 1.23 [0.70] µg/mL, P < 0.01; ka: 14.4 [10.7] vs 11.7 [11.4] h–1, P < 0.05; dC0/dt: 0.26 [0.12] vs 0.15 [0.03] µg/mL · min, P < 0.01; AUC: 42.4 [15.9] vs 27.2 [18.1] µg · 30 min/mL, P < 0.001; tmax: 20.4 [8.6] vs 25.3 [7.6] min, P < 0.05).

CONCLUSIONS: The pharmacokinetic data indicate faster absorption and higher maximal plasma concentration of LA when ultrasound was used as a guidance technique for INB compared with the landmark-based technique. Thus, a reduction of the volume of LA should be considered when using an ultrasound-guided technique for INB.


使用瑞芬太尼有利于插入Cobra喉周通气道(Cobra PLA)

The Use of Remifentanil to Facilitate the Insertion of the Cobra Perilaryngeal Airway

Woo Jae Jeon, MD, Kyoung Hun Kim, MD, Jung Kook Suh, MD, and Sang Yun Cho, MD

From the Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea.

Anesth Analg 2009 108: 1505-1509.

 

背景:在使用异丙酚前给瑞芬太尼利于喉罩插入。作者设计本研究以确定在给予异丙酚时瑞芬太尼是否也利于喉周通气道( CobraPLA )的插入。

方法:芬太尼和异丙酚都通过效应室靶控输注给予。实验分四组,25例。每组的异丙酚效应室浓度为6 μg / ml。在用异丙酚进行麻醉诱导前使R1组的瑞芬目标效应室浓度达到 1 ng / ml R2组达到2 ng / ml R3组达到3ng / mlR4组达到4 ng / ml。插入CobraPLA容易程度分级以下3个等级: 1级,良好,对CobraPLA的插入没有反应;2级,可接受,在CobraPLA 插入时出现恶心呕吐;3级,极差,无法打开口腔或咬住插入的CobraPLA
结果:大多数分级为良好的患者即被评为1级主要出现在R4组 ,人数明显高于R1组和R2 组( P < 0.01 ) ,但与R3组相比无显著差异。呼吸暂停时间有呈剂量依赖性增加( P <0.01 ) , R2组中位数为2.95minR3 组中位数为7.9min ,但在R3组和R4组间无显著差异。与R1组及R2组相比R4组在CobraPLA插入后一分钟内低血压的发生率更高( P <0.01 )。R3组与其他各组相比低血压的发生率没有明显差异。而在插入后1min内高血压的发生率在R1R2组比R3R4组更普遍 ( P <0.01 )。
结论:瑞芬太尼的效应室浓度在2
ng / ml时能提供最好的CobraPLA插入条件,在第一次尝试时血流动力学波动最小,呼吸暂停时间最短。

(潘钱玲 译 陈杰 校)

BACKGROUND: The use of remifentanil before propofol administration facilitates the insertion of the Laryngeal Mask Airway. We designed the present study to determine whether remifentanil would also create more suitable conditions for providing Cobra Perilaryngeal airway (CobraPLA) insertion when administered with propofol.

METHODS: Both remifentanil and propofol were given as effect-site target-controlled infusions. There were four groups of 25 patients each. The propofol effect-site concentration was set at 6 µg/mL in all groups. Group R1 received a target effect-site remifentanil concentration of 1 ng/mL, Group R2 received remifentanil at 2 ng/mL, Group R3 received remifentanil at 3 ng/mL, and Group R4 received remifentanil at 4 ng/mL before the induction of anesthesia with propofol. The ease of insertion of CobraPLA was graded by the following 3-point scale: Grade 1, excellent, no response to CobraPLA insertion; Grade 2, acceptable, gagging or swallowing with insertion of CobraPLA; Grade 3, poor, unable to open mouth or biting upon insertion of CobraPLA.

RESULTS: The most patients ranked as excellent for the first CobraPLA insertion (Grade 1) were found in Group R4, which was significantly higher than Groups R1 and R2 (P < 0.01), whereas no significant difference was found when compared with Group R3. The duration of apnea showed a significant dose-related increase (P < 0.01), especially between Group R2 (median 2.95 min) and R3 (median 7.9 min), but there was no significant difference between Groups R3 and R4. The incidence of hypotension in Group R4 within 1 min after insertion of CobraPLA was significantly more than for Groups R1 and R2 (P < 0.01). No significant differences could be found between the incidence of hypotension between Group R3 and the other groups. The incidence of hypertension at 1 min postinsertion was significantly more common in Groups R1 and R2 than Groups R3 and R4 (P < 0.01).

CONCLUSION: An effect-site concentration of remifentanil of 2 ng/mL provides excellent conditions for insertion of the CobraPLA on the first attempt with minimal hemodynamic perturbations and a shorter duration of apnea.


蝌蚪实验显示异戊酸、甲基丙二酸及丙酸能减少麻醉药物EC50值,调节甘氨酸受体功能以及与二棕榈酸磷脂酰胆碱相互作用

Isovaleric, Methylmalonic, and Propionic Acid Decrease Anesthetic EC50 in Tadpoles, Modulate Glycine Receptor Function, and Interact with the Lipid 1,2-Dipalmitoyl-Sn-Glycero-3-Phosphocholine

Yun Weng, PhD*, Tienyi Theresa Hsu, BS{dagger}, Jing Zhao, MD{ddagger}, Stefanie Nishimura, PhD{dagger}, Gerald G. Fuller, PhD{dagger}, and James M. Sonner, MD{ddagger}

From the *Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; {dagger}Department of Chemical Engineering, Stanford University, California; and {ddagger}Department of Anesthesia, Peking Union Medical College, Beijing, China.

Anesth Analg 2009 108: 1538-1545.

 

简介:在一些遗传性疾病中(有机酸血症),异戊酸、甲基丙二酸及丙酸浓度的升高与意识损伤有关。笔者推测在这些疾病中所见的这种部分中枢神经系统抑制是由于这些代谢物的麻醉作用。笔者检验了以下三种假设:第一,这些代谢物具有轻微的麻醉作用,很可能自身就是麻醉药物。第二,这些复合物能调节甘氨酸受体及γ-氨基丁酸GABAa)受体功能,如同临床吸入麻醉药物一样增加离子通道对氯离子的通透性。第三,这些复合物可能影响脂类的物理特性。

方法:测量爪蟾蝌蚪体内麻醉药物的EC50值。甘氨酸受体及γ-氨基丁酸GABAa)受体在蝌蚪卵母细胞内表达并通过双微电极电压测定。分别测定加或不加有机酸的情况下二棕榈酸磷脂酰胆碱(DPPC)的压力—面积等温线数据。

结果:在蝌蚪中异戊酸为一种麻醉药物,然而甲基丙二酸及丙酸只能部分减少异氟醚的EC50值。这三种有机酸都呈浓度依赖性地增加通过{alpha}1-甘氨酸受体的电流。对于{alpha}1β2{gamma}2sγ-氨基丁酸GABAa)受体的作用极小。这些有机酸增加单层二棕榈酸磷脂酰胆碱(DPPC)的总的侧向压力(表面压力),包括双分子层的平均分子面积。

结论:在蝌蚪体内,异戊酸、甲基丙二酸及丙酸具有麻醉作用,正相调节甘氨酸受体功能,以及影响单层二棕榈酸磷脂酰胆碱(DPPC)的物理特性。

(赵嫣红 译 陈杰 校)

INTRODUCTION: Elevated concentrations of isovaleric (IVA), methylmalonic (MMA), and propionic acid are associated with impaired consciousness in genetic diseases (organic acidemias). We conjectured that part of the central nervous system depression observed in these disorders was due to anesthetic effects of these metabolites. We tested three hypotheses. First, that these metabolites would have anesthetic-sparing effects, possibly being anesthetics by themselves. Second, that these compounds would modulate glycine and {gamma}-aminobutyric acid (GABAA) receptor function, increasing chloride currents through these channels as potent clinical inhaled anesthetics do. Third, that these compounds would affect physical properties of lipids.

METHODS: Anesthetic EC50s were measured in Xenopus laevis tadpoles. Glycine and GABAA receptors were expressed in Xenopus laevis oocytes and studied using two-electrode voltage clamping. Pressure-area isotherms of 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) monolayers were measured with and without added organic acids.

RESULTS: IVA acid was an anesthetic in tadpoles, whereas MMA and propionic acid decreased isoflurane’s EC50 by half. All three organic acids concentration-dependently increased current through {alpha}1 glycine receptors. There were minimal effects on {alpha}1β2{gamma}2s GABAA receptors. The organic acids increased total lateral pressure (surface pressure) of DPPC monolayers, including at mean molecular areas typical of bilayers.

CONCLUSION: IVA, MMA, and propionic acid have anesthetic effects in tadpoles, positively modulate glycine receptor function and affect physical properties of DPPC monolayers.


局部麻醉和监护下麻醉时的意识水平:患者的期望和体验

Levels of Consciousness During Regional Anesthesia and Monitored Anesthesia Care: Patient Expectations and Experiences

Roy K. Esaki, MS, and George A. Mashour, MD, PhD

From the Department of Anesthesiology, University of Michigan Medical School, Michigan.

Anesth Analg 2009 108: 1560-1563.

 

局部麻醉和监护下麻醉后术中知晓的投诉已有报道。作者假设其可能由于未能满足期望的意识水平或意识状态类似全身麻醉。作者对117例经历局部麻醉和监护下麻醉的患者实施访谈以评估其对意识水平的期望值和实际体验到的水平。完全无意识是大多数患者期望且实际体验的状态。此外,仅有58%的患者期望通过麻醉实施者设定意识水平。这些数据资料显示,从患者的角度看来,全麻与非全麻的界限并不清楚。

(张燕 译 陈杰 校)

Complaints of "intraoperative awareness" after regional anesthesia and monitored anesthesia care have been reported. We hypothesized that this may be due to either unmet expectations regarding levels of consciousness or states of consciousness resembling general anesthesia. A structured interview assessing expected and experienced levels of consciousness was given to 117 patients who underwent regional anesthesia or monitored anesthesia care. Complete unconsciousness was the state most often expected and subjectively experienced. Furthermore, only 58% of patients had expectations set by the anesthesia provider. These data indicate that, from the patient’s perspective, the boundary between general and nongeneral anesthesia is obscured.


在模拟未插管呼吸骤停患者的台式模型上研究气道阻塞时的通气策略

Ventilation Strategies in the Obstructed Airway in a Bench Model Simulating a Nonintubated Respiratory Arrest Patient

Holger Herff, MD, Peter Paal, MD, Achim von Goedecke, MD, MSc, Thomas Mitterlechner, MD, Christian A. Schmittinger, DVM, MD, and Volker Wenzel, MD, MSc

From the Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2009 108: 1585-1588.

 

背景The Smart Bag MO®是成年人气流限制袋瓣装置,用以降低无气道保护时胃膨胀的风险。在严重呼吸道阻塞时其特性仍不清楚。

方法:在这种台式模型中,气道阻力在4, 10和20 cm H2O · L–1 · s–1时,使用气流限制袋瓣装置和标准袋瓣装置来模拟无保护气道的呼吸骤停患者,评价其呼吸力学和潮气量。

结果:气流限制袋瓣装置的吸气时间比标准袋瓣装置长。模拟气道通畅的肺潮气量,气流限制袋瓣装置是750 ± 70毫升,标准袋瓣装置(生理盐水)是780 ± 30毫升;在模拟气道阻塞时它们潮气量分别是800 ± 70850 ± 20毫升( NS )的,在模拟严重气道阻塞时变为是210 ± 20170 ± 10毫升( P 0.01 ) 。在模拟气道通畅时,使用气流限制袋瓣装置的气道峰压是15 ± 2 cm H2O 而使用标准袋瓣装置的是22 ± 4 cm H2O P0.01 ;在模拟气道阻塞时气道峰压分别是22 ± 1 39 ± 7 cm H2O P 0.01 ) ,在模拟严重气道阻塞时分别是26 ± 161 ± 3 cm H2O P 0.01 ) 。模拟通畅气道时,这两种装置引起的胃胀气都为0 mL/min;在模拟气道阻塞时,流量限制袋瓣装置的胃胀气是0 mL/min而标准袋瓣装置为200 ± 20 mL/min P 0.01 ) ,在模拟严重气道阻塞分别是0 mL/min1240± 50 mL/min P 0.01 ) 。
结论:在模拟的无保护的严重阻塞气道
与标准袋瓣装置相比,使用流量限制袋瓣装置可导致更长的吸气时间,更高的潮气量,较低的吸气压力,且无胃胀气现象。

(张磊 译 陈杰 校)

BACKGROUND: The Smart Bag MO® is an adult flow-limited bag-valve device designed to reduce the risk of stomach inflation in an unprotected airway. Its properties in severe airway obstruction are as yet unknown.

METHODS: In a bench model, we evaluated respiratory mechanics and delivered tidal volumes although ventilating at airway resistances of 4, 10, and 20 cm H2O · L–1 · s–1 once with a flow-limited bag-valve device and once with a standard bag-valve device to simulate a respiratory arrest patient with an unprotected airway.

RESULTS: Inspiratory times were always longer with the flow-limited bag-valve device than with the standard bag-valve device. Lung tidal volume in the simulated unobstructed airway was 750 ± 70 mL using the flow-limited bag-valve device versus 780 ± 30 mL using the standard bag-valve device (n.s.); in the simulated medium obstructed airway it was 800 ± 70 versus 850 ± 20 mL (n.s.), and in the simulated severely obstructed airway it was 210 ± 20 versus 170 ± 10 mL (P < 0.01). Peak airway pressure in the simulated unobstructed airway was 15 ± 2 cm H2O using the flow-limited bag-valve device versus 22 ± 4 cm H2O using the standard bag-valve device (P < 0.01); in the simulated medium obstructed airway it was 22 ± 1 versus 39 ± 7 cm H2O (P < 0.01), and in the simulated severely obstructed airway it was 26 ± 1 versus 61 ± 3 cm H2O (P < 0.01). Stomach inflation in the simulated unobstructed airway was 0 mL/min using both bag-valve devices; in the simulated medium obstructed airway it was 0 mL/min for the flow-limited bag-valve device versus 200 ± 20 mL/min for the standard bag-valve device (P < 0.01), and in the simulated severely obstructed airway it was 0 versus 1240 ± 50 mL/min (P < 0.01).

CONCLUSION: In a simulated severely obstructed unprotected airway, the use of a flow-limited bag-valve device resulted in longer inspiratory times, higher tidal volumes, lower inspiratory pressures, and no stomach inflation compared with a standard bag-valve device.


儿科诊断成像和使用镇静的增长率
Growth Rates in Pediatric Diagnostic Imaging and Sedation

Ruth E. Wachtel, PhD, MBA*, Franklin Dexter, MD, PhD{dagger}, and Angella J. Dow, BS{ddagger}

From the *Department of Anesthesia, University of Iowa, Iowa City, Iowa; Departments of Anesthesia and Health Management and Policy, University of Iowa, Iowa City, Iowa; and {ddagger}Farrell Growth Group, LLC, Liberty, Missouri.

Anesth Analg 2009 108: 1616-1621.

背景:过去十年,麻醉实施者为小儿诊断成像实施全身麻醉和/或镇静的工作量大大增加。
方法:研究来自学术医学中心超过12年的数据。相对于接受MRICT检查的总人数的增加,麻醉实施者对017岁进行MRI/CT检查的儿童实施麻醉的数量也在日益增加。麻醉提供者包括麻醉医师,住院医生,认证注册的麻醉护士和认证注册麻醉护士的学生。研究结束时,一队镇静护士受雇于医院执行适度镇静。他们替代了管理全身麻醉的麻醉提供者。通过护士与麻醉医生给予镇静药,寻找扫描时间和病人年龄的关系,这一研究持续了六个多月。
结果:接受麻醉工作者提供麻醉进行MRICT检查的小儿的数量增长率与接受MRICT检查数量的增长率同为8 -9 % 。接受麻醉的儿童所占百分比12年来没有变化。建立一个护士镇静团队提供适度镇静并没有改变接受麻醉的儿童的数量,但是增加了接受催眠药的儿童总数。麻醉很少用于少于30分钟的扫描。扫描时间的延长与麻醉下接受MRI/CT检查人群的年龄分层成正相关。3-5岁年龄段接受麻醉的比例最高。
结论:今后麻醉工作者为儿科诊断成像提供全身麻醉和
/或镇静的工作量将取决于扫描总数。工作量也可能对扫描时间的增加或3-5年龄组患儿的比例改变比较敏感。它还可能与保险公司的赔偿有关。

(舒慧刚 译 陈杰 校)

BACKGROUND: Workload has increased greatly over the past decade for anesthesia providers administering general anesthesia and/or sedation for pediatric diagnostic imaging.

METHODS: Data from an academic medical center were studied over a 12-yr period. Growth in the number of children 0–17 yr of age undergoing magnetic resonance imaging (MRI) and/or computerized tomography (CT) scans who received care from anesthesia providers was compared with the increase in the total number of MRI and CT procedures performed in children. Anesthesia providers included anesthesiologists, residents, Certified Registered Nurse Anesthetists, and student Certified Registered Nurse Anesthetists. Toward the end of the study, a team of sedation nurses was employed by the hospital to administer moderate sedation. They provided an alternative to anesthesia providers from the anesthesia department, who usually administered general anesthesia. Use of sedation nurses versus anesthesia providers, and the relationship to scan duration and patient age, were studied over a 6-mo period.

RESULTS: The number of children receiving care from anesthesia providers for MRI and CT scans grew at the same 8%–9% annual rate as the number of scans performed. The percentage of children receiving anesthesia care did not change over the 12 yr. Creation of a nurse sedation team that provided moderate sedation did not alter the number of children receiving care from anesthesia providers but did increase the total number of children receiving hypnotics. Anesthesia was rarely used for scans shorter than 30 min in duration. Increases in scan duration were associated with increased utilization of anesthesia providers for both MRI and CT after stratifying by age. An age of 3–5 yr was associated with the highest rates of anesthesia care.

CONCLUSIONS: Future workload for anesthesia providers administering general anesthesia and/or sedation for pediatric diagnostic imaging will depend on trends in the total number of scans performed. Workload may also be sensitive to factors that increase scan duration or alter the percentage of patients in the 3–5 yr age group. It may additionally depend on reimbursements from insurance companies.


引导或可曲纤维支气管镜引导经口气管插管对颈椎移动影响的比较
A Comparison of Cervical Spine Motion During Orotracheal Intubation with the Trachlight® or the Flexible Fiberoptic Bronchoscope

Bryan J. Houde, MD*, Stephan R. Williams, MD, PhD*, Alexandre Cadrin-Chênevert, MD{dagger}, François Guilbert, MD, FRCPC{dagger}, and Pierre Drolet, MD, FRCPC{ddagger}

From the Departements of *Anesthesiology, and {dagger}Radiology, Centre hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Montréal, Canada; and {ddagger}Departement of Anesthesiology, Hôpital Maisonneuve-Rosemont, Montréal, Canada.
Anesth Analg 2009 108: 1638-1643.

 

背景:对于颈椎不稳定患者的气管插管,纤维支气管镜 (FOB) 常被认为可减少病人的颈椎运动,但对于某些病人可能存在技术上的困难。使用发光引导插管,如Trachlight ® 光索(TL) ,也能使颈椎运动达到最低限度,对于颈椎不稳定患者的气管插管这可能是一个有价值的替代技术。本研究中,作者比较了用TL和FOB插管对颈椎运动的影响。

方法: 在这一前瞻性、随机、对照、 非盲 、交叉试验中,包含了20例颈椎活动正常的在接受应用肌松剂的全身麻醉下行神经放射学的干预的患者。每个病人按次序随机应用TL和FOB进行气管插管。整个插管过程中由一名助理使颈椎维持线形稳定。用持续的影像学技术来记录插管过程中枕骨到颈5在矢状面上的活动情况。颈椎运动的分析方面,记录分为四个阶段: “基线水平”插管前制动, “置入阶段”的气管插管装置放入; “插管阶段” (导管通过声门) ;和“撤除阶段”气管插管的撤离。对于每个插管设备,计算平均颈椎最大活动度并利用标准t检验比较。同时比较应用不同插管装置所需的插管时间。

结果:平均颈椎最大活动度在用TL和FOB插管之间无显著差异(12° ± 6° 比11° ± 5°; P = 0.5)。节段性运动主要发生在C0 - 1和C1 - 2水平,两组设备插管过程中观察到的的患者(18/20)颈椎活动度最大的时刻发生在“插管”阶段,而使用TL进行气管插管所需的时间较短( 34 ± 17比60 ± 15s,P < 0.001)) 。

结论:在使用肌松并人为固定颈椎在一条线上实施全身麻醉的患者中,使用FOB和TL进行气管插管对节段性的颈椎运动的影响无差异。

(丁俊云 译 陈杰 校)

BACKGROUND: Tracheal intubation of an unstable cervical spine (c-spine) patient with the flexible fiberoptic bronchoscope (FOB) is thought to minimize c-spine movement but may be technically difficult in certain patients. Intubation using a luminous stylet, such as the Trachlight® (TL), also produces minimal motion of the c-spine and may be an interesting alternative technique for patients with an unstable c-spine. In this study, we compared the cervical motion caused by the TL and the FOB during intubation.

METHODS: Twenty patients with a normal c-spine undergoing general anesthesia, including neuromuscular blockade, for a neuroradiologic intervention were included in a prospective, randomized, controlled, nonblinded, crossover trial. Each patient was tracheally intubated sequentially with the TL and the FOB in a randomized order. Manual in-line stabilization was applied by an assistant during intubation. The motions produced by intubation from the occiput (C0) to C5 were recorded in the sagittal plane using continuous cinefluoroscopy. For movement analysis, the recordings were divided into four stages: "baseline" before intubation began; "introduction" of the intubation device; "intubation" (passage of the tube through the vocal cords); and "removal" of the device. For each intubating device, the average maximal segmental motion observed in every patient at any stage or cervical segment was calculated and compared using Student’s t-test. The time required to intubate with each device was also compared.

RESULTS: There was no significant difference in the mean maximum segmental motion produced during intubation with the TL versus the FOB (12° ± 6° vs 11° ± 5°; P = 0.5). Segmental movements occurred predominantly at the C0–1 and C1–2 levels, and maximal movements were observed during the introduction stage in 18/20 patients for both devices. Intubation took less time with the TL (34 ± 17 vs 60 ± 15 s, P < 0.001).

CONCLUSION: In patients under general anesthesia with neuromuscular blockade and manual in-line stabilization, we found no difference in the segmental c-spine motion produced during endotracheal intubation using the FOB and the TL.


 透视引导下正中入路颈段硬膜外注射:硬膜外腔造影图分析

Fluoroscopically Guided Cervical Interlaminar Epidural Injections Using the Midline Approach: An Analysis of Epidurography Contrast Patterns

Kwang Su Kim, MD*, Sung Sik Shin, MD*, Tae Sam Kim, MD*, Chang Young Jeong, MD{dagger}, Myung Ha Yoon, MD{dagger}, and Jeong Il Choi, MD{dagger}

From the *Department of Anesthesiology and Pain Medicine, Gwangju Saewoori Spine Hospital, Gwangju, Korea; and {dagger}Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea.

Anesth Analg 2009 108: 1658-1661. [

 

背景:本研究的目的是评估透视引导下正中入路颈段硬膜外注射造影剂的造影图.

方法:所有的硬膜外注射取侧卧位,于C6 - 7节段间实施。 硬膜外造影使用一定量的碘曲仑 240mg/ml( 1 , 2 , 3毫升) 。

结果:A组( 1毫升)硬膜外侧腔扩散速率为 56.7 %, B组( 2毫升)90 % ,和C组( 3毫升)93.3 %

结论:两毫升的造影剂可以在硬膜外腔腹侧和纵向扩散达到最佳。

(叶乐 译 陈杰 校)

BACKGROUND: The purpose of this study was to evaluate epidurography contrast patterns in fluoroscopically guided cervical interlaminar epidural injections using the midline approach.

METHODS: All epidural injections were performed at the C6-7 level in the prone position. Epidurography was performed using a fixed amount of iotrolan 240 mg I/mL (1, 2, 3 mL).

RESULTS: The rate of ventral epidural spread was 56.7% in Group A (1 mL), 90% in Group B (2 mL), and 93.3% in Group C (3 mL).

CONCLUSIONS: Two milliliters of contrast solution can provide optimal dispersion of contrast in a ventral and longitudinal spread.



急性炎性疼痛模型中外周给予胞二磷胆碱(CDP-胆碱)的效应:{alpha}7烟碱乙酰胆碱受体的作用

The Effect of Peripherally Administered CDP-Choline in an Acute Inflammatory Pain Model: The Role of {alpha}7 Nicotinic Acetylcholine Receptor

Mine Sibel Gurun, MD, PhD*, Renee Parker, BS{dagger}, James C. Eisenach, MD, PhD{dagger}, and Michelle Vincler, PhD{dagger}

From the *Department of Pharmacology and Clinical Pharmacology, Uludag University, Bursa, Turkey; and {dagger}Department of Anesthesiology, Wake Forest University, School of Medicine, Winston-Salem, North Carolina.

Anesth Analg 2009 108: 1680-1687.

 

背景:胞二磷胆碱(citicholine5'胞苷-二磷酸胆碱)是一种内源性核苷酸,当注入侧脑室时,在急性疼痛模型中可通过中枢类胆碱能机制和{alpha}7烟碱型乙酰胆碱受体(7nAChR)介导发挥止痛作用。以往的报告表明周围胆碱能系统在巨噬细胞上可通过的7nAChRs介导抗炎作用。

方法:雄性Sprague-Dawley大鼠脚掌内注射角叉菜聚糖(100μL2%)来 评估胞二磷胆碱的抗过敏和抗炎作用。爪机械性撤回阈值和爪的厚度分别由Randall-Selitto测试和千分尺测量。所有注入脚掌内的药品均为50 μL

结果:角叉菜聚糖注入后肢,胞二磷胆碱(12.55μmol;脚掌内注射)呈剂量和时间依赖性地增加爪机械性撤回阈值并降低爪的水肿程度。在对侧后肢注射胞二磷胆碱,不能改变同侧的炎症反应。甲基牛扁碱(100nmol),是选择性的7nAChR拮抗剂,给予发炎后肢可以完全阻断胞二磷胆碱的作用。然而,在对侧后肢注射甲基牛扁碱,不能阻止胞二磷胆碱在同侧爪的作用。在同侧后肢注射角叉菜聚糖,10分钟后再注射胞二磷胆碱(5μmol)并未减少肿胀和水肿,但大大降低了过敏。卡拉胶注射后再注射胞二磷胆碱可以减少肿瘤坏死因子在大鼠后爪组织的产生。

结论:本研究结果表明,在角叉菜聚糖诱导的炎症性疼痛模型中,脚掌内注射胞二磷胆碱可通过7nAChRs介导抗过敏和抗炎作用。

(宋翠侠 译 陈杰 校)

BACKGROUND: CDP-choline (citicholine; cytidine-5'-diphosphate choline) is an endogenously produced nucleotide which, when injected intracerebroventricularly, exerts an antinociceptive effect in acute pain models mediated by central cholinergic mechanisms and {alpha}7 nicotinic acetylcholine receptors ({alpha}7nAChR). Previous reports also suggest that the peripheral cholinergic system has an antiinflammatory role mediated by {alpha}7nAChRs on macrophages.

METHODS: We used male Sprague-Dawley rats to assess the antihypersensitivity and antiinflammatory effect of CDP-choline after intraplantar injection of carrageenan (100 µL, 2%). Mechanical paw withdrawal thresholds and paw thickness were measured by Randall-Selitto testing and microcallipers, respectively. All drugs were administered intraplantarly in a volume 50 µL.

RESULTS: CDP-choline (1, 2.5, 5 µmol; intraplantar) increased the mechanical paw withdrawal threshold and decreased paw edema in a dose- and time-dependent manner in the carrageenan-injected hindpaw. CDP-choline administration to the noninflamed contralateral hindpaw did not alter ipsilateral inflammation. Methyllycaconitine (100 nmol), a selective {alpha}7nAChR antagonist, completely blocked the effects of CDP-choline when administered to the inflamed hindpaw. However, the administration of methyllycaconitine to the contralateral hindpaw did not block the effects of CDP-choline in the ipsilateral paw. The administration of CDP-choline (5 µmol) 10 min after carrageenan administration to the ipsilateral hindpaw did not reduce swelling and edema but did significantly reduce hypersensitivity. Treatment with CDP-choline decreased tumor necrosis factor-{alpha} production in the rat paw tissue after carrageenan.

CONCLUSIONS: The results of this study suggest that intraplantar CDP-choline has antihypersensitivity and antiinflammatory effects mediated via {alpha}7nAChRs in the carrageenan-induced inflammatory pain model.


大鼠侧路经皮星状神经节阻滞技术

A Lateral Percutaneous Technique for Stellate Ganglion Blockade in Rats

Nebahat Gulcu, MD*, Ersoz Gonca, PhD{dagger}, and Hasan Kocoglu, MD*

From the Departments of *Anesthesiology, and {dagger}Biology, Bolu, Turkey.

Anesth Analg 2009 108: 1701-1704.

 

背景:本研究中,作者描述并展示

大鼠侧路星状神经节阻滞(SGB)方法的有效性。

方法:21只大鼠随机分为三组:后路组(n =7),侧路组(n =7)和对照组(n =7)。在实验中,按照大鼠体重,每100g腹腔注射5mg的硫喷妥钠镇静。后路组, 按照以前描述的方法行后路经皮SGB。在侧路组和对照组,以左手的第一和第三指固定颈椎,第二指触诊第七颈椎。研究的药物:治疗组为0.25%纯布比卡因0.2ml,对照组为0.2ml生理盐水。 
结果:后路组,在局部麻醉药注射后,2只动物立即死亡(P < 0.01)。侧路组和对照组没有死亡。在后路组,上睑下垂出现在300 ± 120 秒,而侧路组当注射针头撤回后, 上睑下垂几乎立即出现(6 ± 4秒)(P <0.001)。对照组未见上睑下垂。组间心率差异无统计学意义(P >0.069)。 
结论:侧路法SGB不需要全身麻醉诱导。该方法与早期上睑下垂有关, 死亡率低于传统的后路法。

(张燕 译 陈杰 校) 

BACKGROUND: In the present study, we describe and show the efficacy of a lateral approach to stellate ganglion block (SGB) in rats.

METHODS: Twenty-one rats were randomized into three groups: the posterior technique group (n = 7), the lateral technique group (n = 7), and the control group (n = 7). Thiopental was administered intraperitonally as 5 mg per 100 g of each rat's weight for sedation during the procedure. In the posterior technique group, SGB was performed by a posterior percutaneous approach as described previously. In the lateral technique and control groups, the cervical vertebrae was fixed between the left first and third fingers of the physician's left hand while palpating the C7 process with the second finger. The study drug was 0.2 mL 0.25% plain bupivacaine for the two percutaneous treatment groups, and 0.2 mL saline in the controls.

RESULTS: Two animals in the posterior technique group died immediately after local anesthetic injection (P < 0.01). There were no deaths in the new technique group or in the controls. Ptosis appeared at 300 ± 120 s in the posterior group, whereas it was seen almost immediately after withdrawing the needle in the lateral technique group (6 ± 4 s) (P < 0.001). Ptosis did not occur in the control group. There was no statistically significant difference in heart rate among groups (P > 0.069).

CONCLUSION: The lateral approach to SGB does not require the induction of general anesthesia. The approach is associated with early development of ptosis and may be associated with a lower mortality rate compared to the conventional posterior approach.