Anesthesia & Analgesia

June 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

心血管手术围手术期输注红细胞与术后长期生存率降低的关系

单嘉琪译 薛张纲校

The Association of Perioperative Red Blood Cell Transfusions and Decreased Long-Term Survival After Cardiac Surgery

Stephen D. Surgenor, Robert S. Kramer, Elaine M. Olmstead, Cathy S. Ross, Frank W. Sellke, Donald S. Likosky, Charles A. S. Marrin, Robert E. Helm, Jr, Bruce J. Leavitt, Jeremy R. Morton, David C. Charlesworth, Robert A. Clough, Felix Hernandez, Carmine Frumiento, Arnold Benak, Christian DioData, Gerald T. O’Connor For the Northern New England Cardiovascular Disease Study Group

Anesth Analg 2009 108: 1741-1746.

使用全血及经典的光导集合测定法评估体外循环导致的血小板功能改变的初步研究结果

裘毅敏译，马皓琳、李士通校

An Assessment of Cardiopulmonary Bypass-Induced Changes in Platelet Function Using Whole Blood and Classical Light Transmission Aggregometry: The Results of a Pilot Study

Corinna Velik-Salchner, Stephan Maier, Petra Innerhofer, Christian Kolbitsch, Werner Streif, Markus Mittermayr, Michael Praxmarer, and Dietmar Fries

Anesth Analg 2009 108: 1747-1754.

PEDIATRIC ANESTHESIOLOGY:

术前口服咪达唑仑对儿童呼吸功能的影响

刘世文　译　陈杰　校

The Impact of Oral Premedication with Midazolam on Respiratory Function in Children

Britta S. von Ungern-Sternberg, Thomas O. Erb, Walid Habre, Peter D. Sly, and Zoltan Hantos

Anesth Analg 2009 108: 1771-1776.

预测儿童患者的术前焦虑:谁最为准确？

范羽译 薛张纲校

Prediction of Preoperative Anxiety in Children: Who Is Most Accurate?

Jill E. MacLaren, Caitlin Thompson, Megan Weinberg, Michelle A. Fortier, Debra E. Morrison, Danielle Perret, and Zeev N. Kain

Anesth Analg 2009 108: 1777-1782.

Storz  Miller 1电视喉镜对模拟婴儿困难插管的效果

朱 慧译 马皓琳 李士通校

The Efficacy of the Storz Miller 1 Video Laryngoscope in a Simulated Infant Difficult Intubation

John E. Fiadjoe, Paul A. Stricker, Rebecca S. Hackell, Abdul Salam, Harshad Gurnaney, Mohamed A. Rehman, and Ronald S. Litman

Anesth Analg 2009 108: 1783-1786.

ANESTHETIC PHARMACOLOGY:

七氟醚制剂中水含量影响蒸发罐内路易斯酸引起的七氟醚降解

叶乐　译　陈杰　校

Sevoflurane Formulation Water Content Influences Degradation by Lewis Acids in Vaporizers

Evan D. Kharasch, Gowdahalli N. Subbarao, Keith R. Cromack, Dennis A. Stephens, and Mario D. Saltarelli

Anesth Analg 2009 108: 1796-1802.

糖尿病的新疗法：对于麻醉管理的意义(综述)

黄剑译 薛张纲校

New Therapeutic Agents for Diabetes Mellitus: Implications for Anesthetic Management (Review Article)

Daniel Chen, Stephanie L. Lee, and Robert A. Peterfreund [Abstract] [Full Text] [PDF] [CME]  

作用于外周的mu-阿片类受体拮抗剂与术后肠梗阻：作用机制及临床可应用性

吴进 译  马皓琳 李士通 校

Peripherally Acting Mu-Opioid Receptor Antagonists and Postoperative Ileus: Mechanisms of Action and Clinical Applicability (Review Article)

Eugene R. Viscusi, Tong J. Gan, John B. Leslie, Joseph F. Foss, Mark D. Talon, Wei Du, and Gay Owens

Anesth Analg 2009 108: 1811-1822.

TECHNOLOGY, COMPUTING, AND SIMULATION:

自动运算监测收缩压变异和脉压变化的差异

张磊　译　陈杰　校

Automatic Algorithm for Monitoring Systolic Pressure Variation and Difference in Pulse Pressure

Gunther Pestel, Kimiko Fukui, Volker Hartwich, Peter M. Schumacher, Andreas Vogt, Luzius B. Hiltebrand, Andrea Kurz, Yoshihisa Fujita, Daniel Inderbitzin, and Daniel Leibundgut

Anesth Analg 2009 108: 1823-1829.

同一患者状态熵的可重复性：全身麻醉状态下两侧电极同时测量的比较

李莹译 薛张纲校

Same-Patient Reproducibility of State Entropy: A Comparison of Simultaneous Bilateral Measurements During General Anesthesia

Mehmet S. Ozcan, David M. Thompson, Jorge Cure, J. Randal Hine, and Pamela R. Roberts

Anesth Analg 2009 108: 1830-1835.

CRITICAL CARE AND TRAUMA:

235名患败血症外科重症监护病人的肉眼可见尸检结果

王宏 译，马皓琳，李士通 校

Macroscopic Postmortem Findings in 235 Surgical Intensive Care Patients with Sepsis

Christian Torgersen, Patrizia Moser, Günter Luckner, Viktoria Mayr, Stefan Jochberger, Walter R. Hasibeder, and Martin W. Dünser

Anesth Analg 2009 108: 1841-1847.

一项七氟醚吸入（使用ICU中应用的麻醉装置）镇静与静注异丙酚镇静对肾功能完整性影响的比较研究

丁俊云　译　陈杰　校

Renal Integrity in Sevoflurane Sedation in the Intensive Care Unit with the Anesthetic-Conserving Device: A Comparison with Intravenous Propofol Sedation

Kerstin D. Röhm, Andinet Mengistu, Joachim Boldt, Jochen Mayer, Grietje Beck, and Swen N. Piper

Anesth Analg 2009 108: 1848-1854.

啮齿类创伤出血模型中血红素氧合酶-1的上调对于sirtinol介导的减弱肺损伤有重要作用

姚敏敏译 薛张纲校

Hemeoxygenase-1 Upregulation Is Critical for Sirtinol-Mediated Attenuation of Lung Injury After Trauma-Hemorrhage in a Rodent Model

Fu-Chao Liu, Yuan-Ji Day, Chang-Hui Liao, Jiin-Tarng Liou, Chih-Chieh Mao, and Huang-Ping Yu

Anesth Analg 2009 108: 1855-1861.

球囊扩张气管造口术：使用Ciaglia蓝海豚方法的初体验

唐李隽  译   马皓琳  李士通  校

Balloon Dilatational Tracheostomy: Initial Experience with the Ciaglia Blue Dolphin Method

Tom W. Gromann, Oliver Birkelbach, and Roland Hetzer

Anesth Analg 2009 108: 1862-1866.

OBSTETRIC ANESTHESIOLOGY:

产科围麻醉期监护病房标准的调查

舒慧刚　译　陈杰　校

A Survey of Obstetric Perianesthesia Care Unit Standards

Karen K. Wilkins, Mary Lou V. H. Greenfield, Linda S. Polley, and Jill M. Mhyre

Anesth Analg 2009 108: 1869-1875.

腰椎横断面的超声成像：肥胖产妇硬膜外腔深度估计值和实际值的相互关系

俞佳译 薛张纲校

Ultrasound Imaging of the Lumbar Spine in the Transverse Plane: The Correlation Between Estimated and Actual Depth to the Epidural Space in Obese Parturients

Mrinalini Balki, Yung Lee, Stephen Halpern, and Jose C. A. Carvalho

Anesth Analg 2009 108: 1876-1881.

XI因子缺乏和产科麻醉

黄丽娜 译 马皓琳 李士通 校

Factor XI Deficiency and Obstetrical Anesthesia (Brief Report)

Amarjeet Singh, Miriam J. Harnett, Jean M. Connors, and William R. Camann

Anesth Analg 2009 108: 1882-1885.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

严重蛛网膜下腔出血相关的钠及血容量调节的内分泌反应

赵嫣红　译　陈杰　校

Endocrine Response After Severe Subarachnoid Hemorrhage Related to Sodium and Blood Volume Regulation

Gérard Audibert, Gaëlle Steinmann, Nicole de Talancé, Marie-Hélène Laurens, Pierre Dao, Antoine Baumann, Dan Longrois, and Paul-Michel Mertes

Anesth Analg 2009 108: 1922-1928.

颈动脉内膜切除术的麻醉:第三种选择,患者合作下的全身麻醉

张玥琪译，薛张纲校

Anesthesia for Carotid Endarterectomy: The Third Option. Patient Cooperation During General Anesthesia

Sergio Bevilacqua, Stefano Romagnoli, Francesco Ciappi, Chiara Lazzeri, Sandro Gelsomino, Carlo Pratesi, and Gian Franco Gensini

Anesth Analg 2009 108: 1929-1936.

ANALGESIA:

病人自控镇痛的镇痛测量及其问题

江继宏 译  马皓琳 李士通 校

Patient-Controlled-Analgesia Analgesimetry and Its Problems (Medical Intelligence)

Igor Kissin

Anesth Analg 2009 108: 1945-1949.

利多卡因贴片用于前列腺癌根治术术后镇痛

周姝婧　译　陈杰　校

Lidocaine Patch for Postoperative Analgesia After Radical Retropubic Prostatectomy (Brief Report)

Ashraf S. Habib, Thomas J. Polascik, Alon Z. Weizer, William D. White, Judd W. Moul, Magdi A. ElGasim, and Tong J. Gan

Anesth Analg 2009 108: 1950-1953.

鞘内单独应用吗啡或联合可乐定对于根治性前列腺切除患者的术后镇痛效果

张钊译 薛张纲校

The Efficacy of Intrathecal Morphine With or Without Clonidine for Postoperative Analgesia After Radical Prostatectomy (Brief Report)

Grégoire Andrieu, Benjamin Roth, Laoual Ousmane, Michel Castaner, Patrice Petillot, Benoit Vallet, Arnauld Villers, and Gilles Lebuffe

Anesth Analg 2009 108: 1954-1957.

银杏提取物EGb 761对大鼠神经性疼痛模型机械性和冷性异常疼痛的作用

张莹译  马皓琳 李士通校

The Effects of Ginkgo Biloba Extract EGb 761 on Mechanical and Cold Allodynia in a Rat Model of Neuropathic Pain

Yee Suk Kim, Hue Jung Park, Tae Kwan Kim, Dong Eon Moon, and Hae Jin Lee

Anesth Analg 2009 108: 1958-1963.

U50,488和氟比洛芬对清醒大鼠的内脏痛的单独及联合效应

唐亮 译  马皓琳 李士通 校

The Individual and Combined Effects of U50,488, and Flurbiprofen Axetil on Visceral Pain in Conscious Rats (Brief Report)

Takayuki Kitamura, Makoto Ogawa, and Yoshitsugu Yamada

Anesth Analg 2009 108: 1964-1966.

与神经刺激相比，超声引导能提高桡侧畸形手儿童的锁骨下臂丛神经阻滞的成功率？

黄丹　译　陈杰　校

Does Ultrasound Guidance Improve the Success Rate of Infraclavicular Brachial Plexus Block When Compared with Nerve Stimulation in Children with Radial Club Hands?

Vrushali C. Ponde and Sandeep Diwan

Anesth Analg 2009 108: 1967-1970.

罗哌卡因用于上腹部大手术中硬膜外镇痛的浓度：一项前瞻性随机双盲安慰剂对照试验

朱兰芳译，薛张纲校

Epidural Ropivacaine Concentrations for Intraoperative Analgesia During Major Upper Abdominal Surgery: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study

Periklis Panousis, Axel R. Heller, Thea Koch, and Rainer J. Litz

Anesth Analg 2009 108: 1971-1976. [Abstract] [Full Text] [PDF]  

用骶骨旁进路在超声引导下定位骶丛神经

姜旭晖译，马皓琳，李士通校

Ultrasound Localization of the Sacral Plexus Using a Parasacral Approach (Technical Communication)

Alon Y. Ben-Ari, Rama Joshi, Anna Uskova, and Jacques E. Chelly

Anesth Analg 2009 108: 1977-1980.

 

术前口服咪达唑仑对儿童呼吸功能的影响

The Impact of Oral Premedication with Midazolam on Respiratory Function in Children

Britta S. von Ungern-Sternberg, MD^*, Thomas O. Erb, MD, MHS, Walid Habre, MD, PhD, Peter D. Sly, MD, PhD, and Zoltan Hantos, PhD^||

From the *Department of Anesthesia, Princess Margaret Hospital for Children; Division of Clinical Sciences, Telethon Institute for Child Health Research, and Centre for Child Health Research, University of Western Australia, Perth, Australia; Division of Paediatric Anesthesia, University Children’s Hospital Basel, Basel, Switzerland; Paediatric Anesthesia Unit, University Hospitals Geneva, Geneva, Switzerland; and ||Department of Medical Informatics and Engineering, University of Szeged, Szeged, Hungary.

Anesth Analg 2009 108: 1771-1776.

 

背景：咪达唑仑作为术前用药常用于儿童以减轻患儿的焦虑，促进其麻醉前的合作。但是，由于咪达唑仑的肌松作用，可能影响儿童的呼吸功能。研究者分别评估了清醒状态下和口服咪达唑仑（0.3mg/kg）20分钟后功能残气量(FRC)、通气均匀性和呼吸力学三项指标。其中，通气均匀性通过肺清除指数(LCI)进行评价。

方法：功能残气量和肺清除指数通过六氟化硫多次呼吸-洗出技术测定，而呼吸道的阻力和弹性回缩力则通过用力震荡技术中阻抗变化测定。研究共测定了18名儿童（3-8岁）使用咪唑安定前后的上述指标。

结果：麻醉前给予咪达唑仑导致患儿FRC均值降低6.5%，从25.0 ml/kg降低到23.4 ml/kg，差异具有统计学意义。LCI增加7.8%，从6.4 (0.4) 增加到 6.9 (0.4)，这些都显示患儿的通气不均匀性（ventilation inhomogeneity）增加。此外，咪达唑仑导致患儿呼吸阻力增加7.4%，从3.38 (0.6)到 3.62 (0.6) cm H₂O s/L（P<0.001），呼吸弹性回缩力增加9.2%，从48.8 到 52.9 cm H₂O s/L（P<0.001）。FRC、LCI的变化与呼吸阻力、弹性回缩力的变化具有显著的相关性。

结论：在肺正常的儿童，在给予相对小剂量的咪达唑仑后，可致呼吸器官微小的变化。麻醉医生应该意识到在具有肺部并发症高风险的儿童使用咪唑安定可能导致肺功能下降较大。

（刘世文　译　陈杰　校）

BACKGROUND: Premedication with midazolam is commonly used in children to reduce anxiety and improve cooperation before anesthesia. However, it has the potential to alter respiratory function because of its muscle relaxant properties. We assessed functional residual capacity (FRC), ventilation homogeneity, using a lung clearance index (LCI), and respiratory mechanics in children awake and 20 min after oral premedication with midazolam (0.3 mg/kg).

METHODS: FRC and LCI were measured using a SF₆ multibreath washout technique while respiratory resistance and elastance were extracted from the input impedance obtained by forced oscillation technique in 18 children (3–8 yr) before and after oral premedication with midazolam.

RESULTS: Premedication led to a small (6.5%) but statistically significant decrease in group mean FRC from 25.0 (sd 1.4) to 23.4 (1.9) mL/kg and an associated increase in LCI by 7.8% from 6.4 (0.4) to 6.9 (0.4), indicating increased ventilation inhomogeneities. Furthermore, midazolam resulted in a statistically significant increase in respiratory resistance by 7.4% from 3.38 (0.6) to 3.62 (0.6) cm H₂O s/L (P < 0.001) and in respiratory elastance by 9.2% from 48.8 to 52.9 cm H₂O s/L (P < 0.001). The changes in FRC, LCI, resistance and elastance were significantly correlated (P < 0.001).

CONCLUSIONS: In children with normal lungs, premedication with a relatively small-dose of midazolam led to mild changes in respiratory variables shortly after its administration. However, the anesthesiologist should be aware that using midazolam in children at high risk of respiratory complications under anesthesia might lead to a greater decrease in respiratory function.

七氟醚制剂中水含量影响蒸发罐内路易斯酸引起的七氟醚降解

Sevoflurane Formulation Water Content Influences Degradation by Lewis Acids in Vaporizers

Evan D. Kharasch, MD, PhD^*, Gowdahalli N. Subbarao, PhD, Keith R. Cromack, PhD, Dennis A. Stephens, PhD, and Mario D. Saltarelli, MD, PhD^||

From the *Department of Anesthesiology, Division of Clinical and Translational Research, WA University, St. Louis, Missouri; Global Aerosol Development; Department of Cardiovascular Research; Global Analytical Research and Development; and ||GPRD, Neuroscience and Anesthesia Development, Abbott, Abbott Park, Illinois.

Anesth Analg 2009 108: 1796-1802.

 

背景：许多制造商生产七氟醚。目前市售的七氟醚在合成方法，纯度，销售时的容器及含水量等方面各有不同。七氟醚易于受到各种化学降解的影响，最主要是被路易斯酸（如金属氧化物和金属卤化物）降解成氢氟酸和其他有毒化合物。水抑制这种降解。该观察研究测定了存储在三种类型的蒸发罐中的三种配方的七氟醚（二种低水配方和一种高水配方）的降解。

方法：低水配方七氟醚(Eraldin®, Laboratorios Richmond/Minrad, Argentina [19 ppm water]、美国百特产普通七氟醚[57 ppm water]以及高水配方七氟醚(Ultane®, Abbott, US [352 ppm water])，储存于三个不同的蒸发罐 (Draeger Vapor 2000, GE/Datex-Ohmeda Tec 7, Penlon Sigma Delta)，贮藏于 40 ℃ 环境下 。装入七氟醚后立即以及装入后的第1 、2和3周，从各蒸发罐取样，并分析水含量、pH值、氟化物以及总的降解产物。

结果：存放在Penlon Sigma Delta蒸发罐的低水配方七氟醚，其氢氟酸含量（ pH值降低至3 ，氟化物浓度达600PPM ）和总的降解产物（大于600PPM）呈时间相关性增加。Penlon Sigma Delta蒸发罐在存储3周后，从玻璃观察孔的刻蚀线观察显示金属容器内充满低水七氟醚。然而高水配方七氟醚（ Ultane ，雅培，美国[ 352PPM] ）氟化物和降解产物的含量微乎其微， pH值下降很小。存储于Draeger Vapor 2000 and GE/Datex-Ohmeda Tec 7蒸发罐的七氟醚pH值，氟化物浓度和降解产物的变化几乎可以忽略不计。 
结论：低水配方七氟醚在Penlon Sigma Delta蒸发罐内的储存期间产生大量氢氟酸和其他降解产物。七氟醚制剂水分含量的差异以及潜在的降解产物对患者具有潜在的安全问题。

（叶乐　译　陈杰　校）

BACKGROUND: Sevoflurane is produced by several manufacturers. Currently marketed sevoflurane formulations differ in their method of synthesis, impurities, containers in which they are sold, and water content. Of the various types of chemical degradation to which sevoflurane is susceptible, the most pertinent is degradation by Lewis acids (such as metal oxides and metal halides) to hydrofluoric acid and other toxic compounds. Water inhibits such degradation. This observational study determined the degradation profile of three formulations of sevoflurane (two lower-water and one higher-water formulation) when stored in three types of vaporizers.

METHODS: Lower-water sevoflurane (Eraldin®, Laboratorios Richmond/Minrad, Argentina [19 ppm water] and generic sevoflurane, Baxter, US [57 ppm water]) and higher-water sevoflurane formulations (Ultane®, Abbott, US [352 ppm water]) were stored in three different vaporizers (Draeger Vapor 2000, GE/Datex-Ohmeda Tec 7, Penlon Sigma Delta) under accelerated storage conditions (40°C). Sevoflurane was sampled from each vaporizer immediately following filling and after 1, 2, and 3 wk, and analyzed for water content, pH, fluoride, and total degradants.

RESULTS: Lower-water sevoflurane formulations stored in the Penlon Sigma Delta vaporizers contained time dependent increases in hydrofluoric acid (pH decreased as low as 3, fluoride concentration as high as 600 ppm), and total degradants (>68,000 ppm). Penlon Sigma Delta vaporizers filled with lower-water sevoflurane formulations showed substantial etching of the sight glass and metal filler shoe after 3 wk of storage. The higher-water sevoflurane formulation (Ultane, Abbott, US [352 ppm water]) contained negligible amounts of fluoride or degradants, and small decreases in pH. Sevoflurane stored in Draeger Vapor 2000 and GE/Datex-Ohmeda Tec 7 showed negligible changes in pH, fluoride concentration, and degradants.

CONCLUSIONS: Lower-water sevoflurane underwent substantial degradation to hydrofluoric acid and other degradants during storage in the Penlon Sigma Delta vaporizer. Differences in water content of sevoflurane formulations and potential for degradation present a potential patient safety issue.

自动运算监测收缩压变异和脉压变化的差异

Automatic Algorithm for Monitoring Systolic Pressure Variation and Difference in Pulse Pressure

Gunther Pestel, MD^*, Kimiko Fukui, MD^*, Volker Hartwich, CRNA, Peter M. Schumacher, MSc, PhD, Andreas Vogt, MD, Luzius B. Hiltebrand, MD, Andrea Kurz, MD, PhD, Yoshihisa Fujita, MD, PhD, Daniel Inderbitzin, MD^||, and Daniel Leibundgut, MEng

From the *Department of Anesthesiology, Johannes Gutenberg-University, Mainz, Germany; Department of Anesthesiology, Bern University Hospital (Inselspital), Bern, Switzerland; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Kurashiki, Okayama, Japan; and ||Department of Visceral and Transplantation Surgery, Bern University Hospital (Inselspital), Bern, Switzerland.

Anesth Analg 2009 108: 1823-1829.

 

背景：脉压变异(dPP)能可靠预测患者对液体的反应性。作者研制了呼吸变异性监测装置，能够持续记录气道压力和动脉血压 。研究者比较了呼吸变异监测仪和dPP两种测量方法的差异。
方法：记录24名患者动脉血压及气道压。数据提供给呼吸变异检测仪并用两种方法计算脉压变化和收缩压的变异：（a）同时考虑动脉血压和气道压(RV 算法)和（ b ）只考虑动脉血压(RV_slim 算法) 。此外，术中每隔10分钟记录一次动脉血压和气道压以便于人工计算脉压变化。 监测观察者之间的差异性，并将人工脉压变化测量与自动测量相比较。为了评估气道压的重要性，将RVslim测量法与RV测量法做比较。

结果： 24位患者共记录174个测量结果（ 每名患者6-10个）。 6名观察者人工评测前8位患者脉压变化（间隔10分钟， 53个测量结果）; 使用电脑辅助方法未发生观察者间的变异。布兰德-奥特曼分析表明了 与人工法相比，2种自动化测量方法的偏差和置信区间是可接受的（RV： -0.33 ％ ± 8.72 ％和RVslim ： -1.74 ％ ± 7.97 ％ ） 。RV的测量法和RVslim测量法之间的差别很小（偏差-1.05 ％ ，置信区间5.67 ％ ） 。

结论：自动测量结果与使用电脑辅助人工测定获得的监测结果相当。气道压信号的重要性值得怀疑。

（张磊　译　陈杰　校）

BACKGROUND: Difference in pulse pressure (dPP) reliably predicts fluid responsiveness in patients. We have developed a respiratory variation (RV) monitoring device (RV monitor), which continuously records both airway pressure and arterial blood pressure (ABP). We compared the RV monitor measurements with manual dPP measurements.

METHODS: ABP and airway pressure (PAW) from 24 patients were recorded. Data were fed to the RV monitor to calculate dPP and systolic pressure variation in two different ways: (a) considering both ABP and PAW (RV algorithm) and (b) ABP only (RV_slim algorithm). Additionally, ABP and PAW were recorded intraoperatively in 10-min intervals for later calculation of dPP by manual assessment. Interobserver variability was determined. Manual dPP assessments were used for comparison with automated measurements. To estimate the importance of the PAW signal, RV_slim measurements were compared with RV measurements.

RESULTS: For the 24 patients, 174 measurements (6–10 per patient) were recorded. Six observers assessed dPP manually in the first 8 patients (10-min interval, 53 measurements); no interobserver variability occurred using a computer-assisted method. Bland-Altman analysis showed acceptable bias and limits of agreement of the 2 automated methods compared with the manual method (RV: –0.33% ± 8.72% and RV_slim: –1.74% ± 7.97%). The difference between RV measurements and RV_slim measurements is small (bias –1.05%, limits of agreement 5.67%).

CONCLUSIONS: Measurements of the automated device are comparable with measurements obtained by human observers, who use a computer-assisted method. The importance of the PAW signal is questionable.

 

一项七氟醚吸入（使用ICU中应用的麻醉装置）镇静与静注异丙酚镇静对肾功能完整性影响的比较研究

Renal Integrity in Sevoflurane Sedation in the Intensive Care Unit with the Anesthetic-Conserving Device: A Comparison with Intravenous Propofol Sedation

Kerstin D. Röhm, MD^*, Andinet Mengistu, MD^*, Joachim Boldt, MD^*, Jochen Mayer, MD^*, Grietje Beck, MD, and Swen N. Piper, MD^*

From the *Department of Anesthesiology and Critical Care Medicine, Klinikum Ludwigshafen; and University Hospital Mannheim, Ruprecht-Karls-University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Germany.

Anesth Analg 2009 108: 1848-1854.

 

背景：上世纪70年代使用的甲氧氟烷能导致机体无机氟化物水平的增加和术中长时间使用七氟醚被认为具有潜在的肾毒性。研究者评估了ICU中术后短期吸入七氟醚镇静（使用ICU麻醉装置）和异丙酚镇静对肾功能完整性的影响。
方法：在这项前瞻性，随机，单盲的研究中，研究者选取了腹部大血管或胸外科手术后的125例患者，分别接受通过ACD（呼末气体浓度为0.5-1 ％ ）吸入七氟醚（ 64例）或静注异丙酚（ 61例）术后镇静24小时。在术前，术毕，术后24h和48 h分别测量作为主要结局变量的尿-谷胱甘肽- S -谷胱甘肽转移酶，尿N -乙酰氨基葡萄糖苷酶，血肌酐，无机氟化物浓度，尿量及液体管理。

结果：七氟醚（ 9.2 ± 4.3 h ）组和异丙酚（ 9.3 ± 4.7h）组在ICU的镇静时间上具有可比性。 两组中术后24h和48 h的α -谷胱甘肽- S -转移酶水平较术前值相比均明显增加，组间无显著差异。组间 N -乙酰氨基葡萄糖苷酶和血清肌酐无明显变化。研究期间两组尿量和肌酐清除率相当。术后24h无机氟化物水平七氟醚吸入组（ 39 ± 25 μmol / L）较异丙酚组（ 3 ± 6 μmol / L）显着增加（ P<0.001 ），且持续至术后48h（ 33 ± 26比3 ± 5 μmol / L ）。住院期间每组均有一名患者出现肾功能不全，需要接受强效利尿剂治疗，但不需要透析。
结论：使用麻醉保留装置吸入七氟醚或静注异丙酚行短期镇静对术后肾功能无不利影响。尽管使用七氟醚后机体无机氟含量升高，但住院期间肾小球和肾小管完整性未受影响。

（丁俊云　译　陈杰　校）

BACKGROUND: Increased inorganic fluoride levels after methoxyflurane exposure in the 1970s and prolonged intraoperative sevoflurane use have been suggested to be potentially nephrotoxic. In the intensive care unit we evaluated the effect on renal integrity of short-term inhaled postoperative sedation with sevoflurane using the Anesthetic Conserving Device (ACD) compared with propofol.

METHODS: In this prospective, randomized, single-blinded study, after major abdominal, vascular or thoracic surgery 125 patients were allocated to receive either sevoflurane (n = 64) via the ACD (end-tidal 0.5–1 vol%) or IV propofol (n = 61) for postoperative sedation up to 24 h. Urinary -glutathione-s-transferase as primary outcome variable, urinary N-acetyl-glucosaminidase, serum creatinine, and inorganic fluoride concentrations, urine output and fluid management were measured preoperatively, at the end of surgery, and at 24 and 48 h postoperatively.

RESULTS: The sedation time in the intensive care unit was comparable between the sevoflurane (9.2 ± 4.3 h) and the propofol (9.3 ± 4.7 h) group. Alpha-glutathione-s-transferase levels were significantly increased at 24 and 48 h postoperatively compared with preoperative values in both groups, without significant differences between the groups. N-acetyl-glucosaminidase and serum creatinine remained unchanged in both study groups, and urine output and creatinine clearance were comparable between the groups throughout the study period. Inorganic fluoride levels increased significantly (P < 0.001) at 24 h after sevoflurane exposure (39 ± 25 µmol/L) compared with propofol (3 ± 6 µmol/L) and remained elevated 48 h later (33 ± 26 vs 3 ± 5 µmol/L). One patient in each group suffered from renal insufficiency, requiring intensive diuretic therapy, but not dialysis, during hospital stay.

CONCLUSIONS: Short-term sedation with either sevoflurane using ACD or propofol did not negatively affect renal function postoperatively. Although inorganic fluoride levels were elevated after sevoflurane exposure, glomerular and tubular renal integrity were preserved throughout the hospital stay.

 

产科围麻醉期监护病房标准的调查

A Survey of Obstetric Perianesthesia Care Unit Standards

Karen K. Wilkins, MD, Mary Lou V. H. Greenfield, MPH, MS, Linda S. Polley, MD, and Jill M. Mhyre, MD

From the Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan.

Anesth Analg 2009 108: 1869-1875.

 

背景：虽然产科患者大多健康，但是由于高龄、肥胖、多胎妊娠增多，以及术后即刻并发症的发生，其总体风险正在增加。本研究评估了在北美专业机构中，目前接受全麻或神经阻滞麻醉的剖宫产患者的复苏护理水平。
方法：2007年6月至10月，针对产科麻醉复苏实践的调查电邮给北美专业医疗机构的135名产科麻醉主任。该研究完全通过匿名发送。
结果：调查的回收率为54.8 ％ （ 74/135份）。受访者报告的中位数为2550次分娩/年（四分位数间距[ IQR ] 2000 ， 4000 ） ，其中30 ％为剖宫产（ IQR 25.5 ％ ， 32.5 ％ ），5 ％的剖宫产在全身麻醉下进行（ IQR 4 ％ ， 8 ％ ）。多数医疗机构中，产妇的剖宫产后复苏在产科围麻醉期监护病房、产房或复苏室进行，复苏人员则完全由围产期护士担任，而不是专门的围麻醉期产科护士。对于那些护理全麻或神经阻滞麻醉剖宫产后患者的围产期护士，45%的医疗机构（28/62）没有提供专门的围手术期培训。 43%的受访者（29/67）认为在剖宫产后，产妇接受的护理质量低于普通外科患者。那些由完全围产期护士提供麻醉护理的受访者，认为剖宫产后的麻醉后护理质量低于普通外科患者（ P = 0.008 ）。
结论：关于麻醉后护理的指南由美国麻醉医师学会及美国麻醉护士协会制定，适用于所有患者术后恢复，而不论其复苏地点。这一研究结果表明，北美学术机构提供的剖宫产术后一级护理未能达到指南的要求。
（舒慧刚　译　陈杰　校）

BACKGROUND: Although obstetric patients are generally healthy, population risk is increasing because of increases in maternal age, obesity, and rates of multifetal pregnancies, and complications may occur in the immediate postoperative period. In this study, we sought to identify the current level of recovery care for obstetric patients in North American academic institutions after either general or major neuraxial anesthesia for cesarean delivery.

METHODS: A survey of obstetric anesthesia recovery practices was delivered electronically to 135 obstetric anesthesiology directors of North American academic institutions from June to October, 2007. Surveys were completed electronically and anonymously.

RESULTS: The response rate was 54.8% (74 of 135). Respondents reported a median of 2550 deliveries per year (interquartile range [IQR] 2000, 4000), with 30% delivered by cesarean delivery (IQR 25.5%, 32.5%) and 5% of cesarean deliveries performed under general anesthesia (IQR 4%, 8%). Most institutions recovered postcesarean patients in either an obstetric perianesthesia care unit or a labor, delivery, and recovery room. Recovery care was staffed solely by perinatal nurses, rather than dedicated perianesthesia care unit nurses in most institutions. Forty-five percent (28 of 62) of institutions had no specific postanesthesia recovery training for nursing staff providing postcesarean care for patients recovering from neuraxial or general anesthesia. Forty-three percent (29 of 67) of respondents rated the recovery care provided to cesarean delivery patients as lower quality than care given to general surgical patients. Respondents who relied solely on perinatal nurses to provide postanesthesia care were most likely to perceive that postanesthetic care for cesarean delivery was of lower quality than that given to general surgery patients (P = 0.008).

CONCLUSIONS: Guidelines put forth by the American Society of Anesthesiologists Task Force on Postanesthetic Care and the American Society of PeriAnesthesia Nurses apply to all postoperative patients regardless of their recovery locations. Results from this survey suggest that the level of care provided for postanesthesia recovery from cesarean delivery in North American academic institutions may not meet these guidelines.

严重蛛网膜下腔出血相关的钠及血容量调节的内分泌反应

Endocrine Response After Severe Subarachnoid Hemorrhage Related to Sodium and Blood Volume Regulation

Gérard Audibert, MD, PhD^*, Gaëlle Steinmann, MD^*, Nicole de Talancé, MD, PhD, Marie-Hélène Laurens, MD, PhD, Pierre Dao, MD^*, Antoine Baumann, MD^*, Dan Longrois, MD, PhD^*, and Paul-Michel Mertes, MD, PhD^*

From the Departments of *Anaesthesia and Critical Care, Hôpital Central, Biochemistry, and Nuclear Medicine, University Hospital of Nancy, Nancy, France.

Anesth Analg 2009 108: 1922-1928.

 

背景：低钠血症通常与严重的动脉瘤性蛛网膜下腔出血（SAH）相关，或者被SAH所加重。已经有研究表明动脉瘤性蛛网膜下腔出血（SAH）通常可能引起不同程度的水钠潴留并引起一些内分泌紊乱。然而，对参与水钠平衡以及循环血容量调节的不同激素系统进行广泛研究仍然是需要的。在控制钠的摄入来防止高钠血症的背景下，研究者的目的是通过研究血容量及不同激素调节系统来评估在严重SAH后水钠的调节机制。

方法：本前瞻性研究的对象为19位严重SAH的机械通气患者。通过调节尿钠排泄控制血钠大于4.5 mmol · kg^–1 · d^–1。控制水电解质平衡的激素因子：抗利尿激素、肾素、血管紧张素、醛固酮以及利钠肽，每3天评估一次共12天。并在入院48小时内及第7天通过同位素法（锝标血细胞法）测量血红细胞量。使用心电图，经胸超声心动图以及肌钙蛋白(cTnI)评估心功能。3个月时评估结局。

结果：严重的动脉瘤性蛛网膜下腔出血（SAH）发生后，高钠和输水以适应肾排泄可防止低钠血症而不降低循环血容量。激素的特点为肾素，血管紧张素II的增加，利钠肽的浓度与肌钙蛋白的增加，抗利尿激素的低水平和缺少醛固酮有关。激素水平与尿钠排泄无相关性。

结论：严重的SAH发生后，在多种临床治疗干预的情况下，血钠的增高及低血容量的发生与脑性盐耗综合症一致，可能与SAH引起的交感神经兴奋，血管紧张素增加，醛固酮减少和增加利钠肽的释放有关。

（赵嫣红　译　陈杰　校）

BACKGROUND: Hyponatremia is often associated with, and worsens, the prognosis of severe aneurysmal subarachnoid hemorrhage (SAH). Several possible endocrine perturbations of variable severity and variable sodium and water intake have been described in SAH. However, a comprehensive study of the different hormonal systems involved in sodium and water homeostasis and circulating blood volume modifications is still needed. Our aim was to assess water and sodium regulation after severe SAH by investigating blood volume and several hormonal regulatory systems in the context of hyponatremia prevention by controlled sodium intake.

METHODS: Nineteen mechanically ventilated patients with severe SAH, were prospectively studied. Replacement of sodium was at least 4.5 mmol · kg^–1 · d^–1 and adjusted on natriuresis. Hormones involved in electrolyte and water homeostasis: vasopressin, renin, angiotensin, aldosterone, and natriuretic peptides were assessed every 3 days for 12 days. Red blood cell volume was measured by the isotopic method (technetium–labeled red blood cells), in the first 48 h after admission and at day 7. Cardiac function was assessed using electrocardiogram, transthoracic echocardiography, and troponin Ic (cTnI). Outcome was assessed at 3 mo.

RESULTS: After SAH onset, hyponatremia, but not decreased circulating blood volume, was prevented by high sodium and water infusion adapted to renal excretion. The hormonal profiles were characterized by an increase in renin, angiotensin II, natriuretic peptide concentrations associated with increased troponin Ic, stable low levels of vasopressin, and the absence of increased aldosterone concentrations. There were no correlations between hormone concentrations and natriuresis.

CONCLUSION: After severe SAH, in the context of multiple clinical interventions, increased natriuresis and low blood volume are consistent with cerebral salt wasting syndrome, probably related to the sequence of severe SAH, highly increased sympathetic tone, hyperreninemic hypoaldosteronism syndrome, and increased natriuretic peptides release.

 

利多卡因贴片用于前列腺癌根治术术后镇痛

Lidocaine Patch for Postoperative Analgesia After Radical Retropubic Prostatectomy

Ashraf S. Habib, MBBCh, MSc, FRCA^*, Thomas J. Polascik, MD, Alon Z. Weizer, MD, William D. White, MPH^*, Judd W. Moul, MD, Magdi A. ElGasim, MD^*, and Tong J. Gan, MB, FRCA^*

From the *Department of Anesthesiology, and Division of Urologic Surgery and Duke Prostate Center, Department of Surgery, Duke University Medical System, Durham, North Carolina.

Anesth Analg 2009 108: 1950-1953.

 

在本项前瞻性、双盲、安慰剂对照的研究中，全身麻醉下接受前列腺癌根治术的患者被随机分配术毕在伤口两侧使用利多卡因贴片或安慰剂。收集术后24小时的数据。共有70位患者完成了本次研究（ 36位为利多卡因组，34位为对照组）。两组间人口统计学和患者术后吗啡用量方面无差异。但利多卡因组患者各个阶段咳嗽是疼痛显著减轻（下降19%–33%），治疗组和对照组间P<0.0001，疼痛需要治疗的次数两组比较P=0.3056；前6个小时静息时的疼痛明显减轻（下降17%–32%），治疗组和对照组间P=0.0003，疼痛需要治疗的次数两组比较P=0.0130。

（周姝婧　译　陈杰　校）

In a prospective, double-blind, placebo-controlled study, patients undergoing radical retropubic prostatectomy under general anesthesia were randomly assigned to receive a lidocaine patch or placebo applied on each side of the wound at the end of surgery. Data were collected for 24 h after surgery. Seventy patients completed the study (36 lidocaine group, 34 placebo group). Demographics and postoperative morphine consumption were not different between the groups. However, the lidocaine patch group reported significantly less pain on coughing (19%–33% reduction) over all time periods (treatment vs placebo P < 0.0001, time x treatment P = 0.3056) and at rest (17%–32% reduction) for up to 6 h (treatment vs placebo P = 0.0003, time x treatment P = 0.0130).

与神经刺激相比，超声引导能提高桡侧畸形手儿童的锁骨下臂丛神经阻滞的成功率？

Does Ultrasound Guidance Improve the Success Rate of Infraclavicular Brachial Plexus Block When Compared with Nerve Stimulation in Children with Radial Club Hands?

Vrushali C. Ponde, MD, and Sandeep Diwan, MD

From the Department of Anesthesiology, All India institute of physical Medicine and Rehabilitation, Mumbai, Maharashtra, India.

Anesth Analg 2009 108: 1967-1970.

 

背景：对于桡侧畸形手，神经刺激的典型反应可能会发生变化。这种情况下，超声引导可能是一种有用的方法。本研究中，研究者对比了儿童桡侧畸形手修复术时，超声引导法和神经刺激法行锁骨下臂丛神经阻滞的成功率。

方法：50名年龄为1-2岁，进行桡侧畸形手修复的儿童，被随机分配接受神经刺激法（NS组）或者超声引导法（U组）锁骨下臂丛神经阻滞，这两组均联合使用少量全身麻醉药。两组均给予0.5%的布比卡因0.5ml/kg。外科刺激时出现疼痛反应则被认为阻滞失败。根据东安大略儿童医院疼痛评分，在手术后1，4，6，8，10小时分别进行疼痛评分。

结果：在NS组中，25名患者中有16名阻滞成功（64%），而在U组中，25名患者有24名阻滞成功(P = 0.0053)。在术后10小时的研究期间，第一次出现痛觉消失的时间和止痛剂消耗量没有差异。

结论：桡侧畸形手患者进行修复术时，神经刺激法相比，超声引导法能够提高锁骨下臂丛神经阻滞的成功率。

（黄丹　译　陈杰　校）

BACKGROUND: The classical response to nerve stimulation may be altered in cases of radial club hand. Ultrasound guidance may prove to be a useful tool in such situations. In this study, we compared the success rate of ultrasound-guided infraclavicular brachial plexus block with nerve stimulation for children undergoing radial club hand repair.

METHODS: Fifty children, aged 1-2 yr, undergoing radial club hand repair were randomly assigned to receive infraclavicular brachial plexus block guided by nerve stimulator (Group NS) or ultrasound (Group U) in combination with light general anesthetic. Bupivacaine 0.5 mL/kg of 0.5% was injected in both groups. Pain response to surgical stimulus was considered as block failure. The Children’s Hospital Eastern Ontario Pain Scale pain score was recorded at 1, 4, 6, 8, and 10 postoperative hours.

RESULTS: In Group NS, the blocks were successful in 16 of 25 patients (64%), whereas in Group U, 24 of 25 patients had successful blocks (P = 0.0053). There was no difference in the time to first analgesia or analgesic consumption in the 10-h study period.

CONCLUSION: Ultrasound-guided infraclavicular brachial plexus block improves the success rate in patients with radial club hands when compared with nerve stimulation in patients undergoing radial club hand correction.

心血管手术围手术期输注红细胞与术后长期生存率降低的关系

The Association of Perioperative Red Blood Cell Transfusions and Decreased Long-Term Survival After Cardiac Surgery

Stephen D. Surgenor, Robert S. Kramer, Elaine M. Olmstead, Cathy S. Ross, Frank W. Sellke, Donald S. Likosky, Charles A. S. Marrin, Robert E. Helm, Jr, Bruce J. Leavitt, Jeremy R. Morton, David C. Charlesworth, Robert A. Clough, Felix Hernandez, Carmine Frumiento, Arnold Benak, Christian DioData, Gerald T. O’Connor

From the *Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Maine Medical Center, Portland, Maine; Dartmouth Medical School, Hanover, New Hampshire; Beth Israel Deaconess Medical Center, Boston, Massachusetts; ||Portsmouth Regional Hospital, Portsmouth, New Hampshire; ¶Fletcher Allen Health Care, Burlington, Vermont; #New England Heart Institute, Catholic Medical Center, Manchester, New Hampshire; **Eastern Maine Medical Center, Bangor, Maine; Central Maine Medical Center, Lewiston, Maine; and Concord Hospital, Concord, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.

Anesth Analg 2009 108: 1741-1746.

 

背景：为研究红细胞（RBC）输注与心血管手术术后死亡率的升高有关与否，我们对住院期间接受过一到两个单位红细胞输注的心血管手术病人的长期生存率进行了随访。

方法：9079位于2001至2004年在北新英格兰18个中心行冠状动脉旁路移植术，瓣膜或者冠状动脉瓣膜旁路移植/瓣膜手术的患者经过筛选后被长期连续性随访研究。2006年6月30日，将地区登记的与社会安全保障属的死亡认证文件进行匹配概率比较从而确认死亡率。并应用Cox概率风险与倾向的方法来计算和调整风险比率。

结果：有36%的患者（n=3254）曾输注过一到两个单位的红细胞，其中有43%是在术中输注的，56%在术后输注，1%是在术前输注的。接受红细胞输注的大多是那些贫血，高龄，低体重，女性或者有多种合并症的患者。与那些未输注过红细胞的患者相比，住院期间输注过一到两个单位红细胞的所有心血管手术患者，其生存率都明显下降（P< 0.001）。根据患者和疾病的特性对观察数据进行统计学分析调整后得出，输注过一到两个单位红细胞的患者，其长期死亡风险率将增加16%（调整风险比率=1.16，CI：1.01-1.34, P = 0.035）。

结论：输注一到两个单位的红细胞与心血管手术术后生存率降低有关，据研究结果其风险将增高16%。

（单嘉琪译 薛张纲校）

BACKGROUND: Exposure to red blood cell (RBC) transfusions has been associated with increased mortality after cardiac surgery. We examined long-term survival for cardiac surgical patients who received one or two RBC units during index hospitalization.

METHODS: Nine thousand seventy-nine consecutive patients undergoing coronary artery bypass graft, valve, or coronary artery bypass graft/valve surgery at eight centers in northern New England during 2001-2004 were examined after exclusions. A probabilistic match between the regional registry and the Social Security Administration's Death Master File determined mortality through June 30, 2006. Cox Proportional Hazard and propensity methods were used to calculate adjusted hazard ratios.

RESULTS: Thirty-six percent of patients (n = 3254) were exposed to one or two RBC units. Forty-three percent of RBCs were given intraoperatively, 56% in the postoperative period and 1% were preoperative. Patients transfused were more likely to be anemic, older, smaller, female and with more comorbid illness. Survival was significantly decreased for all patients exposed to 1 or 2 U of RBCs during hospitalization for cardiac surgery compared with those who received none (P < 0.001). After adjustment for patient and disease characteristics, patients exposed to 1 or 2 U of RBCs had a 16% higher long-term mortality risk (adjusted hazard ratios = 1.16, 95% CI: 1.01-1.34, P = 0.035).

CONCLUSIONS: Exposure to 1 or 2 U of RBCs was associated with a 16% increased hazard of decreased survival after cardiac surgery.

 

预测儿童患者的术前焦虑:谁最为准确？

Prediction of preoperative anxiety in children: who is most accurate?

MacLaren JE, Thompson C, Weinberg M, Fortier MA, Morrison DE, Perret D, Kain ZN

From the *Center for the Advancement of Perioperative Health, University of California, Irvine, California; Department of Anesthesiology and Perioperative Care, University of California, Irvine, California; Department of Pediatric Psychology, Children’s Hospital Orange County, Orange, California; and Departments of Child Psychiatry and ¶Anesthesiology, Yale University School of Medicine, New Haven, Connecticut.

Anesth Analg 2009 Jun; 108(6):1777-82.

 

背景：此次研究设法评价全麻诱导期间小儿麻醉主治医师、住院医师及患儿母亲三者预测2至16岁儿童(n=125)术前焦虑的能力。

方法：麻醉医师及患儿母亲运用视觉模拟量表对患儿的术前焦虑提供预测，患儿的客观焦虑状况则使用有效行为观察工具——改良耶鲁术前焦虑量表进行评估。所有患儿母亲在全麻诱导期间均在场，所有患儿均不接受术前镇静用药。采集数据后进行相关性分析。

结果：125名2至16岁的小儿病患、患者母亲及实施麻醉的主治和住院医师共同参与了此项研究。相关性分析显示全麻诱导期间麻醉主治医师对患儿术前焦虑的预测与患儿客观焦虑状况之间存在显著性关联（r(s) = 0.38, P < 0.001）。而诱导期间麻醉住院医师和患儿母亲的预测与患儿客观焦虑状况之间无显著性联系。就预测的准确性而言，在麻醉主治医师所提供的预测中，有47.2%与患儿的客观焦虑状况在一个标准差误差范围内，有70.4%在两个标准差误差范围内。

结论：相比患儿母亲，参与实施儿科麻醉的主治医师在全麻诱导期间更能准确地预测儿童患者的术前焦虑。虽然这一结论具有重要的临床意义，但是否可将其推广至其他较少从事儿科麻醉的麻醉主治

（范羽译 薛张纲校）

BACKGROUND: In this investigation, we sought to assess the ability of pediatric attending anesthesiologists, resident anesthesiologists, and mothers to predict anxiety during induction of anesthesia in 2 to 16-yr-old children (n = 125).
METHODS: Anesthesiologists and mothers provided predictions using a visual analog scale and children's anxiety was assessed using a valid behavior observation tool the Modified Yale Preoperative Anxiety Scale. All mothers were present during anesthetic induction and no child received sedative premedication. Correlational analyses were conducted.
RESULTS: A total of 125 children aged 2-16 yr, their mothers, and their attending pediatric anesthesiologists and resident anesthesiologists were studied. Correlational analyses revealed significant associations between attending predictions and child anxiety at induction (r(s) = 0.38, P < 0.001). Resident anesthesiologist and mother predictions were not significantly related to children's anxiety during induction (r(s) = 0.01 and 0.001, respectively). In terms of accuracy of prediction, 47.2% of predictions made by attending anesthesiologists were within one standard deviation of the observed anxiety exhibited by the child, and 70.4% of predictions were within two standard deviations.
CONCLUSIONS: We conclude that attending anesthesiologists who practice in pediatric settings are better than mothers in predicting the anxiety of children during induction of anesthesia. Although this finding has significant clinical implications, it is unclear if it can be extended to attending anesthesiologists whose practice is not mostly pediatric anesthesia.

 

糖尿病的新疗法：对于麻醉管理的意义(综述)

New Therapeutic Agents for Diabetes Mellitus: Implications for Anesthetic Management (Review Article)

Daniel Chen, Stephanie L. Lee, and Robert A. Peterfreund.

From the *Department of Anesthesiology, Hospital for Special Surgery, New York, New York; Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School; and Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.

Anesth Analg 2009 108: 1803-1810.

 

多种激素和信号转导系统在糖代谢平衡中发挥作用。近来发现，胃肠肽激素，高血糖样肽1和淀粉不溶素也在这一复杂的生理过程中具有重要作用。这些新发现为糖尿病的新治疗方法提供了基础。基于高血糖样肽1和淀粉不溶素的治疗方法现已进入临床实践。在欧洲多国选择性内源性大麻素受体拮抗剂(利莫大班)已经用于肥胖症的治疗，近来研究也将其归因于此。此种药物疗法显示出了在代谢病和2型糖尿病治疗方面的优势。作为麻醉实施者应该关心糖尿病人的情况，而必须理解这些围手术期的新疗法的意义，尤其是注意其副作用及和其它因素的相互作用。

（黄剑译 薛张纲校）

Multiple hormones and transmitter systems contribute to glucose homeostasis and the control of metabolism. Recently, the gastrointestinal peptide hormones glucagon-like peptide 1 and amylin have been shown to significantly contribute to this complex physiology. These advances provide the foundation for new treatments for diabetes mellitus. Therapies based on glucagon-like peptide 1 and amylin have now been introduced into clinical practice. Rimonabant, the selective endo cannabinoid receptor antagonist, had been used in European countries for the treatment of obesity; it has recently been withdrawn for this indication. This drug exhibited therapeutic benefits for metabolic variables and for type 2 diabetes mellitus. Anesthesia providers caring for patients with diabetes mellitus will need to understand the implications of these new therapies in perioperative settings, particularly with respect to side effects and interactions.

 

同一患者状态熵的可重复性：全身麻醉状态下两侧电极同时测量的比较

Same-patient reproducibility of state entropy: a comparison of simultaneous bilateral measurements during general anesthesia.

Mehmet S. Ozcan, David M. Thompson, Jorge Cure, J. Randal Hine, and Pamela R. Roberts

From the Departments of *Anesthesiology, and Biostatistics, University of Oklahoma Health Sciences Center, College of Medicine, Oklahoma City, Oklahoma; and Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Anesth Analg 2009 108: 1830-1835.

 

背景： 状态熵(SE)是类似于双频指数的反映麻醉深度的指标。 两个指标都通过记录在前额的一个单向电极得到的脑电图作为他们的输入。 双频指数对病人内在状况的再现能力在最近的一项研究中受到了质疑。在这个研究中，对同一病人应用两个电极并同时测量，得到了不一致的麻醉深度。我们的目的是确定状态熵是否是同样地可重复性，即使它的估计使用的是不同于双频指数的算法。在这次研究中，我们通过测量应用于同一患者两侧的不同电极同时获得的状态熵来研究其可重复性。

方法：熵电极并应用于21名处于吸入麻醉状态下的患者的两侧。每10秒对每名患者两侧的电极同时测量一次状态熵并记录。然后应用Bland-Altman统计学对得到的数据进行分析。

结果：我们得到了14379对状态熵测量值。4%的个体测量值显示的麻醉深度在数值上有大于10分的差异。差异不具有临床意义（-0.3）。95%的分布区间是-11.7到+11.6。

结论：当探针应用于同一名患者的前额两边时状态熵显示出了有临床意义的分歧。Bland-Altman分析显示在相似的研究中状态熵比双频指数具有更好地可重复性。然而，4%同时测量的状态熵对显示了不同的麻醉深度并且数值上有大于10点。因此应用状态熵来作为判断麻醉深度的指标应更加谨慎。

（李莹译 薛张纲校）

BACKGROUND: State Entropy (SE) is an index of anesthetic depth similar to Bispectral Index (BIS). Both indices use a single-channel electroencephalogram, recorded from a unilaterally applied electrode on the forehead, as their input. Intrapatient reproducibility of BIS was questioned in a recent study in which simultaneous measurements from two electrodes applied to the same patient showed conflicting anesthetic depths. Our purpose was to determine whether SE results are similarly reproducible, even though their computation uses a different algorithm than BIS. In this study, we investigated the reproducibility of SE measurements simultaneously obtained from bilaterally applied electrodes in the same patient.

METHODS: Entropy electrodes were applied bilaterally on 21 patients under general inhaled anesthesia. Simultaneous SE measurements from both electrodes were recorded every 10 s from each patient. Data were analyzed with Bland-Altman statistics.

RESULTS: We obtained 14,379 pairs of SE measurements. Four percent of the individual measurements suggested conflicting anesthetic depth along with a numeric difference more than 10 points. Bias was not clinically significant (-0.3). Ninety-five percent limits of agreement were -11.7 and +11.6.

CONCLUSIONS: SE showed a clinically significant degree of disagreement when probes were applied on both sides of the forehead in the same patient. Bland-Altman statistics showed better same-patient reproducibility in SE than did a similar study on BIS. Nevertheless, 4% of the simultaneously measured pairs of SE suggested different anesthetic depths and differed by more than 10 points. Caution is advised when using SE as a clinical index of anesthetic depth.

 

啮齿类创伤出血模型中血红素氧合酶-1的上调对于sirtinol介导的减弱肺损伤有重要作用

Hemeoxygenase-1 Upregulation Is Critical for Sirtinol-Mediated Attenuation of Lung Injury After Trauma-Hemorrhage in a Rodent Model

Fu-Chao Liu, MD^*, Yuan-Ji Day, MD, PhD^*, Chang-Hui Liao, PhD, Jiin-Tarng Liou, MD^*, Chih-Chieh Mao, MD, PhD^*, and Huang-Ping Yu, MD, PhD^*||

From the *Department of Anesthesiology, Chang Gung Memorial Hospital; College of Medicine; Graduate Institute of Clinical Medical Sciences; Institution of Natural Products; and ||Aging Healthy Center, Chang Gung University, Taoyuan, Taiwan.

Anesth Analg 2009 108:1855-1861.

 

背景：不良循环条件下血红素氧合酶-1的表达具有保护作用。我们最近的实验显示在创伤出血后的雄性SD大鼠中注入sirtinol减弱肝损伤。然而，sirtinol产生有益作用的机制是未知的。我们假设在创伤出血后的雄性SD大鼠注入sirtinol通过血红素氧合酶-1相关的途径减少细胞因子产生从而减弱肺损伤。

方法：雄性SD大鼠（每组n=8）经历创伤出血（平均动脉压保持在40mmHg90分钟，然后复苏）。单剂量sirtinol（1毫克每公斤体重）加或不加血红素氧合酶抑制剂（铬间卟啉）或是赋形剂在复苏时通过静脉注入。24小时后，对肺内髓过氧化物酶活性（中性粒细胞聚集的标志）和α肿瘤坏死因子、白细胞介素6、白细胞介素10，以及支气管肺泡灌洗液中蛋白浓度进行测定，肺脏组织学观察。肺脏血红素氧合酶-1蛋白浓度也进行测定。

结果：在用sirtinol治疗的创伤出血后大鼠中，肺过氧化物酶活性（4.68 ± 0.31 vs 9.36 ± 1.03 单位/毫克 蛋白, P < 0.05）、肿瘤坏死因子α水平（710.7 ± 28 vs 1288 ± 40.69皮克/毫克 蛋白, P < 0.05）、白介素6水平（343.6 ± 18.41 vs 592.7 ± 22.3皮克/毫克 蛋白, P < 0.05）和蛋白浓度（303.8 ± 24.54 vs 569.6 ± 34.82 微克/毫升, P < 0.05）有很大改善。组织学损伤减小。在sirtinol治疗组和赋形剂治疗组间肺内白介素10水平（分别为842.5 ± 54.18 vs 756.2 ± 41.34皮克/毫克 蛋白,）无统计学差异。sirtinol治疗组同赋形剂治疗组相比，肺内血红素氧合酶-1浓度升高(5.18 ± 0.25 vs 2.70 ± 0.16, P < 0.05)。注入血红素氧合酶抑制剂抑制了sirtinol介导的休克肺损伤的减弱作用。

结论：创伤出血后注入sirtinol后减弱肺脏炎症的有益作用通过血红素氧合酶-1表达的上调介导的。

（姚敏敏译 薛张纲校）

BACKGROUND: Hemeoxygenase-1 induction in response to adverse circulatory conditions is protective. Our recent study has shown that administration of sirtinol attenuates hepatic injury in male Sprague-Dawley rats after trauma-hemorrhage; however, the mechanism by which sirtinol produces the salutary effects remains unknown. We hypothesized that sirtinol administration in male Sprague-Dawley rats after trauma-hemorrhage decreases cytokine production and protects against lung injury through a hemeoxygenase-1 related pathway.

METHODS: Male Sprague-Dawley rats (n = 8 per group) underwent trauma-hemorrhage (mean arterial blood pressure 40 mm Hg for 90 min, then resuscitation). A single dose of sirtinol (1 mg/kg of body weight) with or without a hemeoxygenase enzyme inhibitor (chromium-mesoporphyrin) or vehicle was administered IV during resuscitation. Twenty-four hours thereafter, myeloperoxidase activity (a marker of neutrophil sequestration) and tumor necrosis factor , interleukin-6, and interleukin-10 levels in the lung, protein concentrations in bronchoalveolar lavage fluid and tissue histology were measured. Lung hemeoxygenase-1 protein level was also determined.

RESULTS: In the sirtinol-treated rats subjected to trauma-hemorrhage, there were significant improvements in lung myeloperoxidase activity (4.68 ± 0.31 vs 9.36 ± 1.03 U/mg protein, P < 0.05), tumor necrosis factor levels (710.7 ± 28 vs 1288 ± 40.69 pg/mg protein, P < 0.05), interleukin-6 levels (343.6 ± 18.41 vs 592.7 ± 22.3 pg/mg protein, P < 0.05), and protein concentrations (303.8 ± 24.54 vs 569.6 ± 34.82 µg/mL, P < 0.05) and lesser damage in histology. There was no statistically significant difference in interleukin-10 levels in the lung between sirtinol-treated trauma-hemorrhaged rats and vehicle-treated trauma-hemorrhaged rats (842.5 ± 54.18 vs 756.2 ± 41.34 pg/mg protein, respectively). Lung hemeoxygenase-1 protein levels were increased in rats receiving sirtinol treatment as compared with vehicle-treated trauma-hemorrhaged rats (5.18 ± 0.25 vs 2.70 ± 0.16, P < 0.05). Administration of the hemeoxygenase inhibitor chromium-mesoporphyrin prevented the sirtinol-induced attenuation of shock-induced lung damage.

CONCLUSION: The salutary effects of sirtinol administration on attenuation of lung inflammation after trauma-hemorrhage are mediated via upregulation of hemeoxygenase-1 expression.

 

腰椎横断面的超声成像：肥胖产妇硬膜外腔深度估计值和实际值的相互关系

Ultrasound Imaging of the Lumbar Spine in the Transverse Plane: The Correlation Between Estimated and Actual Depth to the Epidural Space in Obese Parturients

Mrinalini Balki, MBBS, MD*, Yung Lee, MD*, Stephen Halpern, MD, MSc, FRCPC, and Jose C. A. Carvalho, MD, PhD, FANZCA, FRCPC*

From the *Department of Anesthesia and Pain Management, Mount Sinai Hospital, and Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2009 108: 1876-1881.

 

背景：在穿刺前腰椎的超声扫描是一项可靠的工具。它使在不肥胖的产妇身上放置硬膜外针变得容易。在这项研究中，我们评估穿刺前腰椎超声扫描作为一项估计硬膜外腔深度的工具以确定最佳的穿刺点，研究对象是肥胖临产妇。

方法：我们研究了46名肥胖的临产妇，她们在怀孕前的BMI〉30 kg/m2,要求分娩过程中实施硬膜外麻醉。超声成像由其中一名研究者来完成，在腰3-4的水平确定中线，椎间隙，皮肤到硬膜外间隙的距离(ultrasound depth, UD)。然后，一位对超声定位皮肤到硬膜外间隙距离不知晓的麻醉科医生通过预定的穿刺点，在穿刺针上对实际的皮肤到硬膜外腔的距离(needle depth, ND)作无菌的标记。ND和UD的一致程度通过皮尔森相关系数和配对t检验进行计算。Bland-Altman检验被用来确定UD和ND一致程度的95%的界限。

结果：怀孕前BMI的范围从30到79 kg/m2,分娩时BMI范围从33-86 kg/m2。UD和ND之间的皮尔森相关系数是0.85（95%的可信区间：0.75-0.91），一致性相关系数是0.79（95%的可信区间：0.71-0.88）。平均值（±标准差）UD和ND分别是6.6 ± 1.0 cm and 6.3 ± 0.8 cm（差值为0.3cm， P = 0.002）。UD和ND一致程度的95%的界限是1.3 cm to –0.7 cm。在76.1%的产妇身上用预定的穿刺点硬膜外穿刺针放置完成无需在不同的穿刺点重新插入，67.4%无需重新定向。

结论：我们发现在肥胖的临产妇身上，超声估计的硬膜外腔距离和实际测量的距离有很强的相互关系。我们建议在肥胖的产妇中，穿刺前的腰椎超声可能是一种有用的引导来更好的放置硬膜外穿刺针。

（俞佳译 薛张纲校）

BACKGROUND: Pre puncture lumbar ultrasound scanning is a reliable tool to facilitate labor epidural needle placement in nonobese  parturients. In this study, we assessed prepuncture lumbar ultrasound scanning as a tool for estimating the depth to the epidural space and determining the optimal insertion point in obese parturients.

METHODS: We studied 46 obese parturients, with prepregnancy body mass index (BMI) >30 kg/m2, requesting labor epidural analgesia. Ultrasound imaging was done by one of the investigators to identify the midline, the intervertebral space, and the distance from the skin to the epidural space (ultrasound depth, UD) at the level of L3–4. Subsequently, an anesthesiologist blinded to the UD located the epidural space through the predetermined insertion point and marked the actual distance from the skin to the epidural space (needle depth, ND) on the needle with a sterile marker. The agreement between the UD and the ND was calculated using the Pearson correlation coefficient and a paired t-test. Bland-Altman analysis was used to determine the 95% limits of agreement between the UD and the ND.

RESULTS: The prepregnancy BMI ranged from 30 to 79 kg/m2, and the BMI at delivery was 33–86 kg/m2. The Pearson correlation coefficient between the UD and the ND was 0.85 (95% confidence interval: 0.75–0.91), and the concordance correlation coefficient was 0.79 (95% confidence interval: 0.71–0.88). The mean (±sd) ND and UD were 6.6 ± 1.0 cm and 6.3 ± 0.8 cm, respectively (difference = 0.3 cm, P = 0.002). The 95% limits of agreement were 1.3 cm to –0.7 cm. Epidural needle placement using the predetermined insertion point was done without reinsertion at a different puncture site  in 76.1% of parturients and without redirection in 67.4%.

CONCLUSIONS: We found a strong correlation between the ultrasound-estimated distance to the epidural space and the actual measured needle distance in obese parturients. We suggest that prepuncture lumbar ultrasound may be a useful guide to facilitate the placement of epidural needles in obese parturients.

 

颈动脉内膜切除术的麻醉:第三种选择,患者合作下的全身麻醉

Anesthesia for Carotid Endarterectomy: The Third Option. Patient Cooperation During General Anesthesia
Sergio Bevilacqua, Stefano Romagnoli, Francesco Ciappi, Chiara Lazzeri, Sandro Gelsomino, Carlo Pratesi, and Gian Franco Gensini

From the Heart and Vessels Department, *Anesthesia and Postsurgical Intensive Care Unit, Cardiology Unit, Cardiac Surgery Unit, and Vascular Surgery Unit, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy.

Anesth Analg 2009 108: 1929-1936.

 

背景：颈动脉内膜切除术是通常在区域阻滞或全身麻醉下施行，两者显示出几处不同,特别是患者手术过程中的神经检测。此研究中，我们介绍了一种全身麻醉技术（患者合作全身麻醉），这个技术允许手术中监测清醒患者的神经系统。

方法：我们前瞻性入组了181名有颈动脉内膜切除术安排的成年患者。患者都接受了全静脉麻醉。在颈动脉阻断期间，麻醉减浅并且仅维持高剂量的瑞芬太尼，这样患者可以口头表达且神经监测可以施行。此技术描述详尽。可以检测患者的神经系统和心血管系统。患者和外科医生对该技术的满意度也提高了。

结果：179名患者接受了患者合作下的全身麻醉。没有观察到术后神经系统事件。两名患者在术后早期阶段发生了致命性的心肌梗死（1.1%）。81%的患者可以大致描述手术持续时间，而19.3%的患者可以精确地说出他们保持清醒的时间。患者和外科医生都对该技术高度满意。

结论：在我们的研究中，患者合作下的全麻技术证明是一个对患者和外科医生来说安全满意的麻醉技术。该技术的特点是血流动力学稳定，通气模式可控性佳，持续神经监测，需要时可即刻安全地转换为全麻。进一步的研究需要突出该技术相较于标准全麻和局麻所显示出的优势。

（张玥琪译，薛张纲校）

BACKGROUND: Carotid endarterectomy is typically performed using either regional or general anesthesia techniques, which exhibit several differences, especially regarding the intraoperative neurological monitoring of patients. In this study, we introduce a technique of general anesthesia (cooperative patient general anesthesia), which allows neurological monitoring of the awake patient during surgery.

METHODS: We prospectively enrolled 181 consecutive adult patients scheduled for carotid endarterectomy. Patients were anesthetized with a total i.v. anesthesia technique. During carotid clamping, anesthesia was reduced and maintained only with high-dose remifentanil, such that the patient was able to respond to verbal statements and neurological monitoring could be performed. The technique is described in detail. Patient neurological and cardiac outcomes were investigated. Patient and surgeon satisfaction with the technique were also evaluated.

RESULTS: General anesthesia with a cooperative patient was achieved in 179 patients. No postoperative neurological events were observed. Two (1.1%) nonfatal myocardial infarctions occurred in the early postoperative period in two patients. Eighty-one percent of patients described the operation duration as brief, whereas 19.3% accurately perceived the time they were conscious. Both patients and surgeons were highly satisfied with the technique.

CONCLUSIONS: In our series, cooperative patient general anesthesia proved to be a safe and satisfactory anesthetic technique for both the patient and surgeon. The technique was characterized by hemodynamic stability, excellent control of ventilatory pattern, continuous neurological monitoring, and immediate and safe conversion to general anesthesia whenever required. Further studies are needed to highlight the advantages of this technique compared with standard general and local anesthesia.

                                                                         

 

鞘内单独应用吗啡或联合可乐定对于根治性前列腺切除患者的术后镇痛效果

The efficacy of intrathecal morphine with or without clonidine for postoperative analgesia after radical prostatectomy.

Andrieu G, Roth B, Ousmane L, Castaner M, Petillot P, Vallet B, Villers A, Lebuffe G.

From the Departments of *Anesthesiology and Intensive Care, and Urology, Lille University Hospital, rue Michel Polonovski, 59000 Lille. France.

Anesth Analg 2009 108: 1954-1957.

 

背景：在这项随机研究中，我们将鞘内(i.t.)单独应用吗啡或联合可乐定与静脉（i.v）以病人自控镇痛（PCA）应用吗啡对行耻骨后根治性前列腺切除患者的术后镇痛作比较。

方法：50例患者被随机分配至三组。他们分别接受鞘内应用吗啡(4 microg/kg) (M 组)，鞘内联合应用吗啡及可乐定(1 microg/kg) (MC 组)或PCA(PCA 组)。每位患者均给予吗啡PCA进行术后镇痛。首要目标是术后48小时内的吗啡需要量。同时记录对吗啡的首次需要时间，安静及咳嗽时的疼痛级别评分，拔管时间和吗啡的副作用（瘙痒，术后恶心呕吐，呼吸抑制）。

结果：术后48小时内的吗啡需要量在M组和MC组减少。安静及咳嗽时的疼痛等级评分在M组降低直至术后18小时，在MC组降低直至术后24小时。在这两组患者对PCA的首次需要时间延迟。在MC组术中对舒芬太尼的需要量显著减少。

结论：对行根治性前列腺切除的患者，鞘内应用吗啡可显著减少术后48小时内吗啡的需要量。鞘内联合应用吗啡和可乐定可减少术中舒芬太尼的使用量，延长术后对PCA的首次需要时间，而且无论安静状态或咳嗽时都能显著延长镇痛时间。

 （张钊译 薛张纲校）

BACKGROUND: In this randomized study, we compared intrathecal (i.t.) morphine with or without clonidine and i.v. postoperative patient-controlled analgesia (PCA) morphine for analgesia after radical retropubic prostatectomy.

METHODS: Fifty patients were randomly divided into three groups. They were allocated to receive i.t. morphine (4 microg/kg) (M group), i.t. morphine and clonidine (1 microg/kg) (MC group), or PCA (PCA group). Each patient was given morphine PCA for postoperative analgesia. The primary objective was the quantity of morphine required during the first 48 postoperative hours. The first request for morphine, numeric pain score at rest and on coughing, the time of tracheal decannulation and adverse effects (pruritus, postoperative nausea and vomiting, respiratory depression) were recorded.

RESULTS: Morphine consumption in the first 48 h was decreased in the M and MC groups. The numeric pain score at rest and on coughing were lower in the M group until the 18th postoperative hour and until the 24th postoperative hour in the MC group. The first requests for PCA were delayed in these two groups. The need for intraoperative sufentanil was significantly lower in the MC group.

CONCLUSION: IT morphine provided a significant reduction in morphine requirement during the first 48 postoperative hours after a radical prostatectomy. The addition of clonidine to i.t. morphine reduced intraoperative sufentanil use, prolonged time until first request for PCA rescue, and further prolonged analgesia at rest and with coughing.

 

罗哌卡因用于上腹部大手术中硬膜外镇痛的浓度：一项前瞻性随机双盲安慰剂对照试验

Epidural Ropivacaine Concentrations for Intraoperative Analgesia During Major Upper Abdominal Surgery: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study
Periklis Panousis, Axel R. Heller, Thea Koch, and Rainer J. Litz

From the Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl-Gustav-Carus, University of Technology, Dresden, Germany.

Anesth Analg 2009 108: 1971-1976.

 

背景：有较多来源于不同临床试验的资料证明术后硬膜外镇痛的益处，但是，仍缺乏有关术中不同硬膜外局麻药给药浓度对吸入麻醉药、补液和缩血管药物用量以及血流动力学改变的影响方面的数据资料。因此，我们在联合麻醉下行上腹部大手术的患者中进行了这项研究。

方法：45例行上腹部大手术的患者随机分为三组，第一组和第二组硬膜外每60分钟分别使用10ml 0.5%和0.2%的罗哌卡因，同时合并使用0.5µg/mL的舒芬太尼，第三组硬膜外每60分钟给予10ml 生理盐水。麻醉以地氟醚和60%的笑气维持，以与年龄相应的1MAC开始至切片。随后调整地氟醚剂量维持麻醉深度在50-55之间，由连续的BIS监测及常用的临床体征（PRST评分）进行评估。术中镇痛不足定义为：心率增加，出汗，流泪(PRST)评分＞2分，或者平均动脉压较基础血压增加＞20%，由调整呼气末地氟醚的浓度至1MAC，和在此水平上静脉追加瑞芬太尼治疗。低血压定义为平均动脉压较基础血压降低＞20%，并通过降低呼气末地氟醚浓度至 BIS为50-55治疗，血压仍低将根据中心静脉压输注晶体液或使用去甲肾上腺素。

结果：第一组和第二组呼气末地氟醚浓度明显降低（0.7 ± 0.1 MAC ，P < 0.001和 0.8 ± 0.1 MAC ，P < 0.001)，第三组无此改变。第一组和第二组所有患者在给药后20分钟内出现明显的低血压（MAP由80 ± 10 降至56 ± 5 mm Hg, 78 ± 18 降至58 ± 7 mm Hg, P < 0.01）,而第三组平均动脉压无改变(74 ± 12 至 83 ± 15 mm Hg, P = 0.42)。三组患者术中心率均未发生明显变化。并且，三组间补液量和去甲肾上腺素使用量无明显差别。与第二组比较第三组患者术中需要输注更多瑞芬太尼(1.6 ± 2.2 mg · kg–1 · h–1 和7.2 ± 4.9 mg · kg–1 · h–1， P < 0.01)。而接受0.5%罗哌卡因输注的患者术中不需要使用瑞芬太尼。

结论：在相同升压药支持和补液需求情况下，为达到足够的麻醉深度，硬膜外使用0.5%的罗哌卡因较0.2%的罗哌卡因更显著降低地氟醚使用浓度。

（朱兰芳译，薛张纲校）

BACKGROUND: The postoperative beneficial effects of thoracic epidural analgesia (TEA) within various clinical pathways are well documented. However, intraoperative data are lacking on the effect of different epidurally administered concentrations of local anesthetics on inhaled anesthetic, fluid and vasopressor requirement, and hemodynamic changes. We performed this study among patients undergoing major upper abdominal surgery under combined TEA and general anesthesia.

METHODS: Forty-five patients undergoing major upper abdominal surgery were randomly assigned to one of three treatment groups receiving intraoperative TEA with either 10 mL of 0.5% (Group 1) or 0.2% (Group 2) ropivacaine (both with 0.5 µg/mL sufentanil supplement), or 10 mL saline (Group 3) every 60 min. Anesthesia was maintained with desflurane in nitrous oxide (60%) initiated at an age-adapted 1 minimum alveolar concentration (MAC) until incision. Desflurane administration was then titrated to maintain an anesthetic level between 50 and 55, as assessed by continuous Bispectral Index monitoring and the common clinical signs (PRST score). Lack of intraoperative analgesia, as defined by an increase in pulse rate, sweating, and tearing (PRST) score >2 or an increase of mean arterial blood pressure (MAP) >20% of baseline, was treated by readjusting the end-tidal concentration of desflurane toward 1 MAC, and above this level by additional rescue IV remifentanil infusion. Hypotension, as defined as a decrease in MAP >20% of baseline, was treated by reducing the end-tidal desflurane concentration to a Bispectral Index level of 50–55 and below that with crystalloid or norepinephrine infusion, depending on central venous pressure.

RESULTS: End-tidal desflurane concentration could be significantly reduced in Group 1 to 0.7 ± 0.1 MAC (P < 0.001) and to 0.8 ± 0.1 MAC (P < 0.001) in Group 2, but not in Group 3. Significant hypotension occurred within 20 min in all patients of Groups 1 and 2 (MAP from 80 ± 10 to 56 ± 5) (Group 1), 78 ± 18 to 58 ± 7 mm Hg (Group 2), P < 0.01, whereas MAP remained unchanged in Group 3 (74 ± 12 to 83 ± 15 mm Hg, P = 0.42). Heart rate did not change significantly over time within any of the groups. Furthermore, groups did not differ significantly regarding IV fluid and norepinephrine requirement. Patients in Group 3 received more remifentanil throughout the surgical procedure (7.2 ± 4.9 mg · kg^–1 · h^–1) when compared with Group 2 (1.6 ± 2.2 mg · kg^–1 · h^–1), P < 0.01. Remifentanil infusion among patients receiving ropivacaine 0.5% was not necessary at any time.

CONCLUSION: Epidural administration of 0.5% ropivacaine leads to a more pronounced sparing effect on desflurane concentration for an adequate anesthetic depth when compared with a 0.2% concentration of ropivacaine at comparable levels of vasopressor support and IV fluid requirement.

使用全血及经典的光导集合测定法评估体外循环导致的血小板功能改变的初步研究结果

An Assessment of Cardiopulmonary Bypass-Induced Changes in Platelet Function Using Whole Blood and Classical Light Transmission Aggregometry: The Results of a Pilot Study

Corinna Velik-Salchner, MD^*, Stephan Maier, MD^*, Petra Innerhofer, MD^*, Christian Kolbitsch, MD^*, Werner Streif, MD, Markus Mittermayr, MD^*, Michael Praxmarer, MSc, and Dietmar Fries, MD

From the Departments of *Anesthesiology and Intensive Care Medicine, Pediatrics, Innsbruck Medical University; Assign Data Management and Biostatistics, Innsbruck Austria; and Department of General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2009; 108:1747-1754

背景：本研究将阻抗集合测定与经典的光导集合测定法（LTA）比较，探究抗血小板药物是否会破坏心脏手术及体外循环（CPB）后全血的血小板聚集功能。

方法：连续选择70位择期行冠脉搭桥术的患者，Multiplate® (M)检验法监测了以电阻作为聚集单位随时间而发生的变化，而LTA检验法（%聚集）则通过胶原（COL）、二磷酸腺苷（ADP）或花生四烯酸来检测，两种方法同时使用麻醉诱导前、中和肝素后15分钟及3小时获得的动脉血样。A组患者(n = 48)至少停用抗血小板药7天，作为对照组，B组患者(n = 11)接受阿司匹林治疗100 mg/天，C组患者(n = 11) 接受阿司匹林治疗100 mg/天及氯吡格雷75 mg/天（双重的抗血小板治疗）直到手术前一天。

结果：未接受抗血小板治疗的患者，用三个激动剂和两种聚集法都观察到使用鱼精蛋白后15分钟及3小时血小板聚集明显下降。在单独接受阿司匹林治疗的患者，LTA-COL, LTA-ADP 及 M-ADP随着时间明显改变，在接受双重抗血小板治疗的患者，两种聚集法通过ADP检验均显示出使用鱼精蛋白15分钟后血小板聚集明显下降。当我们计算受试者操作特征曲线下面积来区别两种抗血小板药物时，LTA-COL能够区分CPB后15分钟及3小时对照组及接受阿司匹林组或接受双重抗血小板治疗组不同的血小板聚集功能，M-ADP检验法能够区分使用鱼精蛋白后3小时对照组及接受双重抗血小板治疗组不同的血小板聚集功能。

结论：使用所有的常规使用的激动剂进行的全血及经典的LTA法能够检测出未经抗血小板治疗的患者中CPB引起的血小板聚集的改变，而在接受抗血小板治疗的患者，ADP诱导的抗血小板检验法能更好地用于检测CPB引起的血小板聚集功能的损害。

（裘毅敏译，马皓琳、李士通校）

BACKGROUND: In this study, we explored whether antiplatelet medications impair whole blood impedance aggregometry after cardiac surgery and cardiopulmonary bypass (CPB) compared with classical light transmission aggregometry (LTA).

METHODS: Multiplate® (M) assays measuring changes in electrical resistance as aggregation units over time, and LTA assays (% aggregation) induced by collagen (COL), adenosine diphosphate (ADP), or arachidonic acid were performed simultaneously using arterial blood samples obtained before induction of anesthesia, 15 min and 3 h after neutralization of heparin in 70 consecutive patients scheduled for elective coronary artery bypass grafting. Patients in Group A (n = 48) discontinued intake of antiplatelet drugs for at least 7 days and served as controls, patients in Group B (n = 11) received aspirin 100 mg/d and those in Group C (n = 11) aspirin 100 mg/d and clopidogrel 75 mg/d (dual antiplatelet therapy) until the day before surgery.

RESULTS: In patients without antiplatelet therapy, 15 min and 3 h after protamine a significant decrease in platelet aggregation was observed with all three agonists and both aggregation methods. In patients receiving aspirin alone, LTA-COL, LTA-ADP and M-ADP changed significantly over time, and ADP assays of both aggregation methods showed a significant decrease in platelet aggregation 15 min after protamine in patients receiving dual antiplatelet therapy. When calculating the areas under the receiver-operating characteristic curves for discrimination of antiplatelet agents, LTA-COL was able to discriminate between controls and patients receiving aspirin or dual antiplatelet therapy 15 min and 3 h after CPB and the M-ADP assay was able to discriminate between controls and patients receiving dual antiplatelet therapy 3 h after protamine.

CONCLUSION: Whole blood and classical LTA performed with all commonly used agonists enable detection of CPB-induced changes in platelet aggregation in patients not taking antiplatelet medication, whereas in patients receiving antiplatelet therapy, ADP-induced antiplatelet assays are preferable for detecting CPB-induced impairment of platelet aggregation.

 

Storz  Miller 1电视喉镜对模拟婴儿困难插管的效果

The Efficacy of the Storz Miller 1 Video Laryngoscope in a Simulated Infant Difficult Intubation

John E. Fiadjoe, MD^*, Paul A. Stricker, MD^*, Rebecca S. Hackell, AB^*, Abdul Salam, MS, Harshad Gurnaney, MD^*, Mohamed A. Rehman, MD^*, and Ronald S. Litman, DO^*

From the Departments of *Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine; and Department of Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.

Anesth Analg 2009; 108:1783-1786

背景：一些研究显示电视喉镜对于用直接喉镜会厌暴露声门困难的患者的处理来说是一项有用的技术。本实验作为一个初步研究在模拟直接喉镜插管困难的婴儿人体模型中比较Storz DCI Miller 1电视喉镜（VL，Karl Storz GmbH, Tuttlingen,德国）和使用Miller1 喉镜的直接喉镜检查（DL）。假设与DL相比，VL会提供更好的声门视野，但使插管时间更长，因为使用电视喉镜插管时需要的技术不同。

方法：Laerdal®婴儿气道管理训练模型（Laerdal Medical, Wappingers Falls, 纽约州）用布带限制颈椎活动度。32位儿科麻醉主治医师尝试以随机次序用VL和DL对婴儿模型进行气管插管。记录每次喉镜最佳喉部视野暴露和插管所需时间。

结果：VL和DL喉镜检查分级的分布有显著性差异(P < 0.001)，VL能提供更好的喉部视野。40%麻醉医生报告使用DL时的视野等级为3或4级，而所有的这些患者使用VL等级会变成1和2级。四分位距的中位等级是DL 2级（2-3），VL 1级（1-2）(P < 0.001)。78%参与者报告VL与DL相比喉部视野等级至少提高1级。DL组中有2例插管失败，而VL组没有。插管所需时间两组相似。

结论：与标准Miller 1的直接喉镜相比，Storz Miller 1 VL改善模拟的婴儿困难喉镜检查时的声门暴露，且不延长插管所需时间。

（朱 慧译 马皓琳 李士通校）

BACKGROUND: Several studies have shown video laryngoscopy to be a useful technique in the management of patients in whom glottic exposure by direct laryngoscopy is difficult. We conducted this study as a preliminary investigation comparing the Storz DCI Miller 1 video laryngoscope (VL, Karl Storz GmbH, Tuttlingen, Germany) and direct laryngoscopy with a Miller 1 laryngoscope (DL) in an infant manikin model simulating difficult direct laryngoscopy. We hypothesized that compared with DL, VL would provide a better glottic view but would be associated with a longer time to intubation because of the different skill set required when using video intubation.

METHODS: A Laerdal® infant airway management training manikin (Laerdal Medical, Wappingers Falls, NY) was adapted using cloth tape to limit cervical spine mobility. Thirty-two attending pediatric anesthesiologists attempted tracheal intubation of the infant manikin using VL and DL in randomized order. The best laryngeal view with each laryngoscope and time to intubation were documented.

RESULTS: There was a significant difference in the distributions of laryngoscopy grades between VL and DL (P < 0.001), with the VL giving a better laryngeal view. Forty percent of anesthesiologists reported a Grade 3 or 4 view with DL; all of which were converted to Grades 1 and 2 with VL. The median grade with interquartile range was two (2-3) for DL and one (1-2) for VL (P < 0.001). Seventy-eight percent of participants reported an improvement of at least one grade in laryngeal view with VL compared with DL. There were two failed intubations using DL and none using VL. Time to intubation was similar between the two techniques.

CONCLUSIONS: The Storz Miller 1 VL blade improved glottic exposure in a simulated difficult laryngoscopy compared with direct laryngoscopy with a standard Miller 1 blade without increasing the time to intubation.

作用于外周的mu-阿片类受体拮抗剂与术后肠梗阻：作用机制及临床可应用性

Peripherally Acting Mu-Opioid Receptor Antagonists and Postoperative Ileus: Mechanisms of Action and Clinical Applicability

Eugene R. Viscusi, MD^*, Tong J. Gan, MD, John B. Leslie, MD, MBA, Joseph F. Foss, MD, Mark D. Talon, CRNA^||, Wei Du, PhD^¶, and Gay Owens, PharmD^¶

From the *Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota; Cleveland Clinic, Cleveland, Ohio; ||Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas; and ¶Adolor Corporation, Exton, Pennsylvania.

Anesth Analg 2009; 108:1811-1822

术后肠梗阻(POI)――即手术后协调的肠功能的暂时丧失，是医疗中的一个重要难题。POI的病因是多方面的，与手术和选择的麻醉途径都有关。用于术后镇痛的阿片类药物会加剧POI，进而延迟胃肠道(GI)的恢复。作用于外周的mu-阿片类受体(PAM-OR)拮抗剂被研制出来以减轻阿片类药物对胃肠蠕动的不良效应。调查研究显示这类新药可用于治疗POI，目标是加快肠切除后上GI和下GI的恢复。在本综述中，我们总结了POI发生的机制以及阿片类药物和阿片类受体对肠道神经系统的作用，讨论了PAM-OR拮抗剂的作用机制，回顾了methylnaltrexone和爱维莫潘这两种药物的临床药理作用以及其II/III期POI临床试验的结果。最后，讨论了麻醉医师在多模式方法背景下的POI治疗中的作用。

（吴进 译  马皓琳 李士通 校）

Postoperative ileus (POI), a transient cessation of coordinated bowel function after surgery, is an important health care problem. The etiology of POI is multifactorial and related to both the surgical and anesthetic pathways chosen. Opioids used to manage surgical pain can exacerbate POI, delaying gastrointestinal (GI) recovery. Peripherally acting mu-opioid receptor (PAM-OR) antagonists are designed to mitigate the deleterious effects of opioids on GI motility. This new class is investigational for POI management with the goal of accelerating the recovery of upper and lower GI tract function after bowel resection. In this review, we summarize the mechanisms by which POI occurs and the role of opioids and opioid receptors in the enteric nervous system, discuss the mechanism of action of PAM-OR antagonists, and review clinical pharmacology and Phase II/III POI trial results of methylnaltrexone and alvimopan. Finally, the role of anesthesiologists in managing POI in the context of a multimodal approach is discussed.

235名患败血症外科重症监护病人的肉眼可见尸检结果

Macroscopic Postmortem Findings in 235 Surgical Intensive Care Patients with Sepsis

Christian Torgersen, MD^*, Patrizia Moser, MD, Günter Luckner, MD^*, Viktoria Mayr, MD^*, Stefan Jochberger, MD^*, Walter R. Hasibeder, MD, and Martin W. Dünser, MD^*

From the *Department of Anesthesiology and Critical Care Medicine, Institute of Pathology, Innsbruck Medical University, Austria; and Department of Anesthesiology and Critical Care Medicine, Krankenhaus der Barmherzigen Schwestern, Austria.

Anesth Analg 2009; 108:1841-1847

背景：虽然已经公布了各种严重疾病病人尸检的详细分析，但是没有进行过对败血症病人的相关研究。在本回顾性队列性研究中，我们回顾在外科重症监护病房（ICU）死于败血症或感染性休克病人的肉眼可见尸检。

方法:在1997和2006年之间，回顾ICU资料库和尸检登记中因为败血症/感染性休克而进入ICU，或者在ICU期间形成败血症/感染性休克后期并随后死于败血症/感染性休克的病人。记录所有的临床资料和尸检结果。

结果：235个病人(84.8%)的尸检结果可用于统计学分析。病史报告中主要的死因是难治性多脏器功能紊乱综合症（51.5%）和不能控制的心血管衰竭（35.3%）。在肺(89.8%)、肾/泌尿道(60%)、胃肠道(54%)、心血管系统(53.6%)、肝(47.7%)、脾(33.2%)、中枢神经系统(18.7%)和胰腺(8.5%)中发现有病理学改变。在180个病人(76.6%)，尸检揭示有持续性的脓毒性病灶。最常见的持续性病灶是肺炎(41.3%)、气管支气管炎(28.9%)、腹膜炎(23.4%)、子宫/卵巢坏死(9.8%的女性病人)、腹内脓肿(9.1%)和肾盂肾炎(6%)。因为败血症/感染性休克而进入ICU且治疗时间超过7天的71个病人中63个病人(88.7%)有持续性脓毒性病灶。

结论：解释死于败血症/感染性休克的外科ICU病人死亡的有关尸检所见是持续性病灶的约占80%，心脏病占50%。最常受影响的脏器是肺、腹和泌尿生殖道。更多的诊断、治疗和科学的努力应该放在发现和控制败血症和感染性休克病人的感染性病灶。

（王宏 译，马皓琳，李士通 校）

BACKGROUND: Although detailed analyses of the postmortem findings of various critically ill patient groups have been published, no such study has been performed in patients with sepsis. In this retrospective cohort study, we reviewed macroscopic postmortem examinations of surgical intensive care unit (ICU) patients who died from sepsis or septic shock.

METHODS: Between 1997 and 2006, the ICU database and autopsy register were reviewed for patients who were admitted to the ICU because of sepsis/septic shock, or who developed sepsis/septic shock at a later stage during their ICU stay and subsequently died from of sepsis/septic shock. Clinical data and postmortem findings were documented in all patients.

RESULTS: Postmortem results of 235 patients (84.8%) were available for statistical analysis. The main causes of death as reported in the patient history were refractory multiple organ dysfunction syndrome (51.5%) and uncontrollable cardiovascular failure (35.3%). Pathologies were detected in the lungs (89.8%), kidneys/urinary tract (60%), gastrointestinal tract (54%), cardiovascular system (53.6%), liver (47.7%), spleen (33.2%), central nervous system (18.7%), and pancreas (8.5%). In 180 patients (76.6%), the autopsy revealed a continuous septic focus. The most common continuous foci were pneumonia (41.3%), tracheobronchitis (28.9%), peritonitis (23.4%), uterine/ovarial necrosis (9.8% of female patients), intraabdominal abscesses (9.1%), and pyelonephritis (6%). A continuous septic focus was observed in 63 of the 71 patients (88.7%) who were admitted to the ICU because of sepsis/septic shock and treated for longer than 7 days.

CONCLUSIONS: Relevant postmortem findings explaining death in surgical ICU patients who died because of sepsis/septic shock were a continuous septic focus in approximately 80% and cardiac pathologies in 50%. The most frequently affected organs were the lungs, abdomen, and urogenital tract. More diagnostic, therapeutic and scientific efforts should be launched to identify and control the infectious focus in patients with sepsis and septic shock.

球囊扩张气管造口术：使用Ciaglia蓝海豚方法的初体验

Balloon Dilatational Tracheostomy: Initial Experience with the Ciaglia Blue Dolphin Method

Tom W. Gromann, MD, Oliver Birkelbach, MD, and Roland Hetzer, MD, PhD

From the Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Germany.

Anesth Analg 2009; 108:1862-1866

背景：经皮扩张气管造口术已成为一项确定的技术，用于保证行长期插管患者的呼吸系统安全和不繁琐的方法。我们研究了一项新的经皮球囊扩张气管插管技术，它最初是使用径向力来增宽气管造口，即Ciaglia蓝海豚系统。

方法：我们报道的该方法的初次临床试验的病例来自心外科监护室的20名患者。结果分析既关注球囊扩张实践的可行性，也包括可能的并发症。

结果：气管造口手术时间平均3.3 ± 1.9分钟。这项新技术未引发需要治疗的出血或气管后壁的损伤。常规的支气管镜检查显示了一例单一气管软骨环的骨折(5%)。一例患者在球囊扩张时出现皮下气肿，但未经治疗自行消退。未发现气管造口的伤口感染或伤口延期愈合。分析不同长度的皮肤切口后发现实践可行性和出血并发症没有差异。

结论：球囊扩张气管造口术是一项可行、简单、成功的技术。其主要使用径向力可减少典型的并发症，如气管软骨环的骨折或气管后壁的损伤。

（唐李隽  译   马皓琳  李士通  校）

BACKGROUND: Percutaneous dilational tracheostomy has become an established technique for ensuring safe and uncomplicated access to the respiratory systems of patients undergoing prolonged intubation. We studied a new balloon dilation percutaneous dilational tracheostomy technique which primarily uses radial force to widen the tracheostoma, the Ciaglia Blue Dolphin system.

METHODS: We report our initial clinical experience with this method in 20 patients from a cardiosurgical intensive care unit. We analyzed the results with regard to the practical feasibility of balloon dilation as well as possible complications.

RESULTS: Tracheostomy surgery time averaged 3.3 ± 1.9 min. The new technique caused neither bleeding requiring treatment nor injuries of the posterior tracheal wall. Routine bronchoscopic checks revealed one fracture of a single tracheal cartilage ring (5%). One patient developed subcutaneous emphysema during the balloon dilation, but this regressed spontaneously without treatment. No wound infections or prolonged wound healing of the tracheostoma were observed in any patient. There were no differences in terms of practical feasibility or bleeding complications when skin incisions of different lengths were analyzed.

CONCLUSIONS: The balloon dilational tracheostomy proved to be a feasible, easy, and successful technique. Its use of mainly radial force may reduce typical complications such as fractures of tracheal cartilage rings or injuries of the posterior tracheal wall.

XI因子缺乏和产科麻醉

Factor XI Deficiency and Obstetrical Anesthesia

Amarjeet Singh, MBBS, DA, FRCA^*, Miriam J. Harnett, MB, FFARCSI^*, Jean M. Connors, MD, and William R. Camann, MD^*

From the *Division of Obstetric Anesthesiology, Department of Anesthesiology, Harvard Medical School, and Division of Hematology, Department of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts.

Anesth Analg 2009; 108:1882-1885

XI因子（FXI）缺乏是一种与激活部分促凝血酶原激酶时间延长有关的罕见的遗产性凝血功能紊乱性疾病。出血的严重性并不经常与血浆因子水平有关。我们综述了13名FXI缺乏的经历了分娩的产妇的医学和麻醉记录。9例进行了椎管内麻醉（其中，7例为硬膜外麻醉，1例脊麻，1例腰­—硬联合麻醉）。3例全身麻醉进行了剖腹产手术，1例未采取医疗手段完成了阴道分娩。因子水平的基础值范围从严重缺乏(<15%)到轻度缺乏(接近50%)。大部分病人而不是全部病人输注了新鲜冰冻血浆以矫正激活部分促凝血酶原激酶时间。所有病人都进行了血液科会诊。没有记录到任何血液学或麻醉并发症。只要进行了合适的血液科会诊，在临床和实验室止血评估的指导下进行因子替代治疗，FXI缺乏并不是椎管内麻醉的绝对禁忌证。

（黄丽娜 译 马皓琳 李士通 校）

Factor XI (FXI) deficiency is a rare inherited coagulation disorder associated with prolonged activated partial thromboplastin time. The severity of bleeding often does not correlate with plasma factor levels. We reviewed the medical and anesthetic records of 13 parturients with FXI deficiency that presented for delivery. Nine cases were managed with neuraxial anesthesia. (epidural, seven; spinal, one; combined spinal-epidural, one). Three received general anesthesia for cesarean delivery, and one had an unmedicated vaginal delivery. Baseline factor levels ranged from severe (<15%) to mild (near 50%) deficiency. Fresh frozen plasma was administered to correct activated partial thromboplastin time in most, but not all, cases. Hematology consultation was obtained for all. No hematological or anesthetic complications were noted. FXI deficiency is not an absolute contraindication to neuraxial anesthesia, provided appropriate hematology consultation has been obtained, and factor replacement is provided as guided by clinical and laboratory hemostatic evaluation.

病人自控镇痛的镇痛测量及其问题

Patient-Controlled-Analgesia Analgesimetry and Its Problems

Igor Kissin, MD, PhD

From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2009; 108:1945-1949

病人自控镇痛法(PCA)除用于缓解疼痛外, 也在临床研究中广泛用于新药及疼痛治疗方法的镇痛效能的评定。PCA镇痛测量的主要研究结果是，对照（安慰剂）组与新药（或方法）组之间阿片类药物需要量的差异。本文分析了PCA镇痛测量的如下潜在问题：1) 疼痛强度与阿片药物需要量之间的弱相关性；2) 阿片类药物非镇痛效应的干预作用；3) 对阿片类镇痛效应的急性耐受作用；4) 病人的训练问题；5) 主要测量结果之间的相互影响；以及6) 样本量大小和阴性结果问题。了解PCA镇痛测量的缺陷应该可降低使用过程中误差的风险。

(江继宏 译  马皓琳 李士通 校）

In addition to providing pain relief, patient-controlled-analgesia (PCA) is also extensively used in clinical research for the assay of analgesic effectiveness of new drugs and methods of pain treatment. The main outcome measure of PCA analgesimetry is the difference in opioid requirements between the control (placebo) group and the new drug (or treatment) group. The following potential problems of PCA analgesimetry are analyzed: 1) weak correlation between pain intensity and opioid consumption, 2) interference of nonanalgesic effects of opioids, 3) role of acute tolerance to the analgesic effect of opioids, 4) problems of the patient's training, 5) interaction between main outcome measures, and 6) sample size and negative outcome problems. Knowledge of the pitfalls of PCA analgesimetry should decrease the risk of errors in its use.

银杏提取物EGb 761对大鼠神经性疼痛模型机械性和冷性异常疼痛的作用

The Effects of Ginkgo Biloba Extract EGb 761 on Mechanical and Cold Allodynia in a Rat Model of Neuropathic Pain

Yee Suk Kim, MD, Hue Jung Park, MD, Tae Kwan Kim, MD, Dong Eon Moon, MD, FIPP, and Hae Jin Lee, MD

From the Department of Anesthesiology and Pain Medicine, School of Medicine, The Catholic University of Korea, Seoul, Korea.

Anesth Analg 2009; 108:1958-1963

背景：神经性疼痛是对外周或中枢神经系统的损伤引起的慢性疼痛。神经性疼痛的症状包括：持续性疼痛、痛觉过敏和异常性疼痛。银杏提取物是一种具有多种药理学活性的东方草药。我们研究了银杏提取物EGb 761对大鼠神经性疼痛模型机械性和冷性异常疼痛的作用。

方法：选择雄性SD大鼠，结扎L5和L6脊神经。所有大鼠在术后7天均出现机械性和冷性异常疼痛。采用双盲法，将50只神经性疼痛大鼠分为5组，腹膜腔内给予药物，给药持续随机化。各组分别给予生理盐水、EGb 761(50、100、150和200 mg/kg)。我们研究了给药前和腹膜腔内给药后15、30、60、90、120、150和180分钟，大鼠的机械性和冷性异常疼痛。通过测定对von Frey探针(1.0、1.4、2.0、4.0、6.0、8.0、10.0、12.0、15.0和 26.0 g)刺激的缩爪阈值来定量机械性异常疼痛。通过测定给予100%丙酮后大鼠抬腿的频率来定量冷性异常疼痛。我们使用旋转试验测定神经性模型大鼠的运动功能，以揭示银杏提取物EGb 761是否存在不良反应，例如镇静或运动协调功能减退。

结果：对照组中，大鼠机械性和冷性异常疼痛没有差别。EGb 761组中，大鼠对机械性刺激的缩爪阈值和缩爪频率，明显小于给药前和对照组。抗异常性疼痛的作用时间呈剂量依赖性延长，在最高剂量组可以持续120分钟(P < 0.05)。只有在最高剂量组(200 mg/kg)，EGb 761会降低大鼠旋转运动时间。

结论：我们认为银杏提取物EGb 761降低大鼠神经性疼痛模型机械性和冷性异常疼痛，这可能对神经性疼痛的治疗有用。

（张莹译  马皓琳 李士通校）

BACKGROUND: Neuropathic pain is chronic pain that is caused by an injury to the peripheral or central nervous system. The symptoms of neuropathic pain are continuing pain, hyperalgesia, and allodynia. Ginkgo biloba extract is an oriental herbal medicine that has various pharmacological actions. We examined the effect of Ginkgo biloba extract, EGb 761, on the mechanical and cold allodynia in a rat model of neuropathic pain.

METHODS: Male Sprague-Dawley rats were prepared by tightly ligating the left L5 and L6 spinal nerves. All the rats developed mechanical and cold allodynia 7 days after surgery. Fifty neuropathic rats were assigned into five groups for the intraperitoneal administration of drugs. The study was double-blind and the order of the treatments was randomized. Normal saline and EGb 761 (50, 100, 150, and 200 mg/kg) were administered, respectively, to the individual groups. We examined mechanical and cold allodynia at preadministration and at 15, 30, 60, 90, 120, 150, and 180 min after intraperitoneal drug administration. Mechanical allodynia was quantified by measuring the paw withdrawal threshold to stimuli with von Frey filaments of 1.0, 1.4, 2.0, 4.0, 6.0, 8.0, 10.0, 12.0, 15.0, and 26.0 g. Cold allodynia was quantified by measuring the frequency of foot lift with applying 100% acetone. We measured the locomotor function of the neuropathic rats by using the rotarod test to reveal if EGb 761 has side effects, such as sedation or reduced motor coordination.

RESULTS: The control group showed no differences for mechanical and cold allodynia. For the EGb 761 groups, the paw withdrawal thresholds to mechanical stimuli and withdrawal frequencies to cold stimuli were significantly reduced versus the preadministration values and versus the control group. The duration of antiallodynic effects increased in a dose-dependent fashion, and these were maintained for 120 min at the highest dose (P < 0.05). Only at the highest dose (200 mg/kg) did EGb 761 reduce the rotarod performance time.

CONCLUSION: We conclude that Ginkgo biloba extract, EGb 761, attenuates mechanical and cold allodynia in a rat model of neuropathic pain, and it may be useful for the management of neuropathic pain.

U50,488和氟比洛芬对清醒大鼠的内脏痛的单独及联合效应

The Individual and Combined Effects of U50,488, and Flurbiprofen Axetil on Visceral Pain in Conscious Rats

Takayuki Kitamura, MD, Makoto Ogawa, MD, and Yoshitsugu Yamada, MD, PhD

From the Department of Anesthesiology, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan.

Anesth Analg 2009; 108:1964-1966

我们检查了U50,488（一种κ阿片受体激动剂）和氟比洛芬（一种非甾体类抗炎药）对清醒大鼠内脏痛模型的效应。U50,488产生内脏镇痛效应，但是用量在0.9 mg/kg或更多时，中枢神经系统(CNS)的副作用明显增加。纳洛酮可以完全拮抗这种效应。氟比洛芬产生内脏镇痛效应，但是用量在80 mg/kg时，CNS的副作用明显增加。同时给予U50,488(0.27 mg/kg)和氟比洛芬(50 mg/kg)可以产生强效的内脏镇痛作用，而不会产生CNS的副作用，意味着联合运用κ阿片受体激动剂和非甾体类抗炎药对内脏疼痛有治疗效果。

（唐亮 译  马皓琳 李士通 校）  

We examined the effects of U50,488, a kappa-opioid receptor agonist, and flurbiprofen axetil, a nonsteroidal antiinflammatory drug, in a visceral pain model using conscious rats. U50,488 produced visceral antinociception, but exaggerated the adverse effects on the central nervous system (CNS) at 0.9 mg/kg or more. Naloxone completely antagonized these effects. Flurbiprofen axetil produced visceral antinociception, but exaggerated the adverse effects on the CNS at 80 mg/kg. Coadministration of U50,488 (0.27 mg/kg) and flurbiprofen axetil (50 mg/kg) produced intense visceral antinociception without adverse effects on the CNS, implying therapeutic efficacies of coadministration of kappa-opioid receptor-agonists and nonsteroidal antiinflammatory drugs on visceral pain.

用骶骨旁进路在超声引导下定位骶丛神经

Ultrasound Localization of the Sacral Plexus Using a Parasacral Approach

Alon Y. Ben-Ari, MD, Rama Joshi, MD, Anna Uskova, MD, and Jacques E. Chelly, MD, PhD, MBA

From the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Anesth Analg 2009; 108:1977-1980

在本报告里，我们描绘了用骶骨旁进路和超声引导方法定位骶丛神经的可行性。我们在17位病人身上用2–5 MHz的弯探针在骶骨旁区域进行超声探测，寻找坐骨内侧缘和骶骨外侧缘，从而划出坐骨大孔的区域。另外我们试着辨别梨状肌和臀动脉的位置。在坐骨孔水平找到了圆形高回声结构的骶丛神经。17例病人中有10例辨别出了臀动脉，但是所有病人身上我们都没能确定地辨别出梨状肌。为了确定骶丛的定位，进针绝缘，并连接一个神经刺激器，且对每个病人身上在电流为0.2~0.5mA时引出了骶丛神经运动反应（足石屈-12，背屈-1，腱肌刺激-3，腓肠肌刺激-1-没有记录）。没有观察到任何并发症。本报告肯定了超声引导下用骶骨旁路径定位骶丛神经的可行性。

（姜旭晖译，马皓琳，李士通校）

In this report, we describe the feasibility of locating the sacral plexus nerve using a parasacral approach and an ultrasound-guided technique. The parasacral region using a curved probe (2–5 MHz) was scanned in 17 patients in search of the medial border of the ischial bone and the lateral border of the sacrum, which represent the limit of the greater sciatic foramen. In addition, attempts were made to identify the piriformis muscles and the gluteal arteries. The sacral plexus was identified at the level of the sciatic foramen as a round hyperechoic structure. The gluteal arteries were identified in 10 of 17 patients, but we failed to positively identify the piriformis muscle in any patient. To confirm localization of the sacral plexus, an insulated needle attached to a nerve stimulator was advanced and, in each case, a sacral plexus motor response was elicited (plantar flexion—12, dorsal flexion—1, hamstring muscle stimulation—3, gastrocnemius muscle stimulation-1-not recorded) at a current between 0.2 and 0.5 mA. No complications were observed. This report confirms the feasibility of using ultrasound to locate the sacral plexus using a parasacral approach.