Anesthesia & Analgesia

July 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

ε-氨基己酸和抑肽酶应用于行初次冠状动脉旁路分离手术患者后在纤维蛋白溶解和血液流失方面的效果:一个随机双盲,安慰剂控制的无差别试验

单嘉琪译 薛张纲校

The Effect of Epsilon-Aminocaproic Acid and Aprotinin on Fibrinolysis and Blood Loss in Patients Undergoing Primary, Isolated Coronary Artery Bypass Surgery: A Randomized, Double-Blind, Placebo-Controlled, Noninferiority Trial

Philip E. Greilich, Michael E. Jessen, Neeraj Satyanarayana, Charles W. Whitten, Gregory A. Nuttall, Joseph M. Beckham, Michael H. Wall, and John F. Butterworth

Anesth Analg 2009 109: 15-24.

全血多极凝集测定仪是一种可靠的阿司匹林诱导的血小板功能障碍的床边检验方法

刘世文 译 陈杰 校

Whole Blood Multiple Electrode Aggregometry Is a Reliable Point-of-Care Test of Aspirin-Induced Platelet Dysfunction

Csilla Jámbor, Christian F. Weber, Konstanze Gerhardt, Wulf Dietrich, Michael Spannagl, Bernhard Heindl, and Bernhard Zwissler

Anesth Analg 2009 109: 25-31.

PEDIATRIC ANESTHESIOLOGY:

在体外循环下行先天性心脏病手术的病人使用抑肽酶与肾功能不全的关系

颜涛译, 马皓琳 李士通

The Association of Renal Dysfunction and the Use of Aprotinin in Patients Undergoing Congenital Cardiac Surgery Requiring Cardiopulmonary Bypass

Ana Manrique, Edmund H. Jooste, Bradley A. Kuch, Steven E. Lichtenstein, Victor Morell, Ricardo Munoz, Demetrius Ellis, and Peter J. Davis

Anesth Analg 2009 109: 45-52.

Narcotrend指数提示儿童丙泊酚诱导期间的年龄相关性变化

范羽译 薛张纲校

The Narcotrend Index Indicates Age-Related Changes During Propofol Induction in Children

Sinikka Münte, Jaakko Klockars, Mark van Gils, Arja Hiller, Michael Winterhalter, Christina Quandt, Matthias Gross, and Tomi Taivainen

Anesth Analg 2009 109: 53-59.

儿童阻塞性睡眠呼吸暂停的围手术期处理

叶乐 译 陈杰 校

Perioperative Management of Children with Obstructive Sleep Apnea (Review Article)

Deborah A. Schwengel, Laura M. Sterni, David E. Tunkel, and Eugenie S. Heitmiller

Anesth Analg 2009 109: 60-75.

AMBULATORY ANESTHESIOLOGY:

评估用甘草漱口减少术后咽喉痛的有效性:一个前瞻性、随机、单盲研究

彭中美   马皓琳 李士通 \

An Evaluation of the Efficacy of Licorice Gargle for Attenuating Postoperative Sore Throat: A Prospective, Randomized, Single-Blind Study

Anil Agarwal, Devendra Gupta, Ghanshyam Yadav, Puneet Goyal, Prabhat K. Singh, and Uttam Singh

Anesth Analg 2009 109: 77-81.

ANESTHETIC PHARMACOLOGY:

七氟烷麻醉状态下右美托咪定,异丙酚和咪达唑仑对兔子呼吸CO2反应性,动脉压及心率影响的比较。

黄剑译 薛张纲校

A Comparison of the Effects on Respiratory Carbon Dioxide Response, Arterial Blood Pressure, and Heart Rate of Dexmedetomidine, Propofol, and Midazolam in Sevoflurane-Anesthetized Rabbits

Cheng Chang, Akinori Uchiyama, Ling Ma, Takashi Mashimo, and Yuji Fujino

Anesth Analg 2009 109: 84-89.

妊娠早期异丙酚诱导和恢复麻醉的效应室浓度的预测

张磊 译 陈杰 校

Predicted Propofol Effect-Site Concentration for Induction and Emergence of Anesthesia During Early Pregnancy

Nicolas Mongardon, Frédérique Servin, Mathilde Perrin, Ennoufous Bedairia, Sylvie Retout, Chadi Yazbeck, Philippe Faucher, Philippe Montravers, Jean-Marie Desmonts, and Jean Guglielminotti

Anesth Analg 2009 109: 90-95.

家兔给予新型苯二氮卓受体激动剂JM-1232(–)后的寒战阈值

周雅春 马皓琳 李士通

The Shivering Threshold in Rabbits with JM-1232(–), a New Benzodiazepine Receptor Agonist

Taishi Masamune, Hiroaki Sato, Katsumi Okuyama, Yusuke Imai, Hironobu Iwashita, Tadahiko Ishiyama, Takeshi Oguchi, Daniel I. Sessler, and Takashi Matsukawa

Anesth Analg 2009 109: 96-100.

活体适度的氦气吸入可降低炎性反应,但不能防止缺血再灌注时的内皮损伤

李莹译 薛张纲校

Helium Breathing Provides Modest Antiinflammatory, but No Endothelial Protection Against Ischemia-Reperfusion Injury in Humans In Vivo

Eliana Lucchinetti, Johannes Wacker, Christian Maurer, Marius Keel, Luc Härter, Kathrin Zaugg, and Michael Zaugg

Anesth Analg 2009 109: 101-108.

硫喷妥钠抑制脂多糖诱导的组织因子的表达

丁俊云 译 陈杰 校

Thiopental Inhibits Lipopolysaccharide-Induced Tissue Factor Expression

Matthias Hartmann, Priv Doz D, Semih Özlügedik, and Juergen Peters

Anesth Analg 2009 109: 109-113.

TECHNOLOGY, COMPUTING, AND SIMULATION:

脉搏波形分析和经食管超声心动图:两种方法在腹腔镜结肠手术中测定心输出量的比较

姚敏敏译 薛张纲校

Pulse Contour Analysis and Transesophageal Echocardiography: A Comparison of Measurements of Cardiac Output During Laparoscopic Colon Surgery

Mario R. Concha, Verónica F. Mertz, Luis I. Cortínez, Katya A. González, and Jean M. Butte

Anesth Analg 2009 109: 114-118.

NICO监护仪能估测混合静脉血红蛋白氧饱和度吗?
舒慧刚 译 陈杰 校

Can Mixed Venous Hemoglobin Oxygen Saturation Be Estimated Using a NICO Monitor? (Technical Communication)

Yoshifumi Kotake, Takashige Yamada, Hiromasa Nagata, Takeshi Suzuki, and Junzo Takeda

Anesth Analg 2009 109: 119-123.

PATIENT SAFETY:

关于外周静脉和动脉置管的医疗责任:一项终审索赔分析 

江继宏   马皓琳 李士通

Liability Related to Peripheral Venous and Arterial Catheterization: A Closed Claims Analysis

Sanjay M. Bhananker, Derek W. Liau, Preetma K. Kooner, Karen L. Posner, Robert A. Caplan, and Karen B. Domino

Anesth Analg 2009 109: 124-129.

中心静脉置管期间使用测压法减少动脉损伤

俞佳译 薛张纲校

Eliminating Arterial Injury During Central Venous Catheterization Using Manometry

Catalin S. Ezaru, Michael P. Mangione, Todd M. Oravitz, James W. Ibinson, and Richard J. Bjerke

Anesth Analg 2009 109: 130-134.

CRITICAL CARE AND TRAUMA:

非诺特罗的吸入对酸吸入性肺损伤的影响

怀晓蓉 译 陈杰 校

The Effects of Fenoterol Inhalation After Acid Aspiration-Induced Lung Injury

Michael T. Pawlik, Thomas Schubert, Susanne Hopf, Matthias Lubnow, Michael Gruber, Christoph Selig, Kai Taeger, and Karl P. Ittner

Anesth Analg 2009 109: 143-150.

 

肺募集反应对病态肥胖病人容积性二氧化碳描记图III相斜率的影响

王宏翻译,李士通,马皓琳校正

The Effects of Lung Recruitment on the Phase III Slope of Volumetric Capnography in Morbidly Obese Patients

Stephan H. Böhm, Stefan Maisch, Alexandra von Sandersleben, Oliver Thamm, Isabel Passoni, Jorge Martinez Arca, and Gerardo Tusman

Anesth Analg 2009 109: 151-159.

肺泡复张及高PEEP措施应用于有血管内容量负荷的病态肥胖病人后,并不对血流动力学产生影响

陈珺珺译,薛张纲校

Alveolar Recruitment Strategy and High Positive End-Expiratory Pressure Levels Do Not Affect Hemodynamics in Morbidly Obese Intravascular Volume-Loaded Patients (Brief Report)

Stephan H. Bohm, Oliver C. Thamm, Alexandra von Sandersleben, Katrin Bangert, Thomas E. Langwieler, Gerardo Tusman, Tim G. Strate, and Thomas G. Standl

Anesth Analg 2009 109: 160-163.

OBSTETRIC ANESTHESIOLOGY:

硬膜外注射2-氯普鲁卡因与吗啡的相互作用——一项关于吗啡镇痛时效的随机对照试验

赵嫣红 译 陈杰 校

The Interaction Between Epidural 2-Chloroprocaine and Morphine: A Randomized Controlled Trial of the Effect of Drug Administration Timing on the Efficacy of Morphine Analgesia

Paloma Toledo, Robert J. McCarthy, Mary Jane Ebarvia, Christopher J. Huser, and Cynthia A. Wong

Anesth Analg 2009 109: 168-173.

5-羟色胺拮抗剂对剖宫产中接受鞘内吗啡的产妇瘙痒、恶心呕吐的预防和治疗作用:系统性回顾和Meta分析

黄佳佳译,马皓琳 李士通校

Serotonin Receptor Antagonists for the Prevention and Treatment of Pruritus, Nausea, and Vomiting in Women Undergoing Cesarean Delivery with Intrathecal Morphine: A Systematic Review and Meta-Analysis

Ronald B. George, Terrence K. Allen, and Ashraf S. Habib

Anesth Analg 2009 109: 174-182.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

镇静对颅内占位的病人的颅内压的作用:瑞芬太尼与异丙酚

张玥琪译,薛张纲校

The Effect of Sedation on Intracranial Pressure in Patients with an Intracranial Space-Occupying Lesion: Remifentanil Versus Propofol

Francois Girard, Robert Moumdjian, Daniel Boudreault, Philippe Chouinard, Alain Bouthilier, and Monique Ruel

Anesth Analg 2009 109: 194-198.

开颅手术中动脉血二氧化碳分压与七氟醚对脑毛细静脉血流、脑血流及血氧饱和度的影响

朱紫瑜 译 陈杰 校

The Effects of Arterial Carbon Dioxide Partial Pressure and Sevoflurane on Capillary Venous Cerebral Blood Flow and Oxygen Saturation During Craniotomy

Klaus Ulrich Klein, Martin Glaser, Robert Reisch, Achim Tresch, Christian Werner, and Kristin Engelhard

Anesth Analg 2009 109: 199-204.

发育中大鼠脑的器官型海马脑片模型中氧和葡萄糖缺失:对N-甲基-d-天门冬氨酸亚单位组成的影响

黄施伟 译,马皓琳 李士通

Oxygen and Glucose Deprivation in an Organotypic Hippocampal Slice Model of the Developing Rat Brain: The Effects on N-Methyl-d-Aspartate Subunit Composition

Lisa Wise-Faberowski, Prairie Neeley Robinson, Sarah Rich, and David S. Warner

Anesth Analg 2009 109: 205-210.

GENERAL ARTICLES:

腹部外科手术期间体液平衡的影响:一个数学模型

张钊译 薛张纲校

The Effect of Duration of Surgery on Fluid Balance During Abdominal Surgery: A Mathematical Model

Tsuneo Tatara, Yoshiaki Nagao, and Chikara Tashiro

Anesth Analg 2009 109: 211-216.

ANALGESIA:

经椎孔硬膜外注射的血管内扩散方式:颈椎和腰椎的对比研究

周姝婧 译 陈杰 校

Intravascular Flow Patterns in Transforaminal Epidural Injections: A Comparative Study of the Cervical and Lumbar Vertebral Segments

Do Wan Kim, Kyung Ream Han, Chan Kim, and Yun Jeong Chae

Anesth Analg 2009 109: 233-239.

颅内肿瘤切除术后罗哌卡因头皮浸润的镇痛作用

唐亮   马皓琳 李士通

The Analgesic Properties of Scalp Infiltrations with Ropivacaine After Intracranial Tumoral Resection

Hélène Batoz, Olivier Verdonck, Christelle Pellerin, Gaëlle Roux, and Pierre Maurette

Anesth Analg 2009 109: 240-244.

滴注或注射提纯的天然辣椒碱对大鼠后肢感觉-运动行为或截骨修复术无有害影响

朱兰芳译 薛张纲校

Instilled or Injected Purified Natural Capsaicin Has No Adverse Effects on Rat Hindlimb Sensory-Motor Behavior or Osteotomy Repair

Susan M. Kramer, Jonelle R. May, Daniel J. Patrick, Luc Chouinard, Marilyne Boyer, Nancy Doyle, Aurore Varela, Susan Y. Smith, and Eric Longstaff

Anesth Analg 2009 109: 249-257.

美西律和利多卡因对后角神经元兴奋性的抑制作用

黄丹 译 陈杰 校

Mexiletine and Lidocaine Suppress the Excitability of Dorsal Horn Neurons

Andrea Olschewski, Rose Schnoebel-Ehehalt, Yingji Li, Bi Tang, Michael E. Bräu, and Matthias Wolff

Anesth Analg 2009 109: 258-264.

比较超声和神经刺激仪引导肌间沟法臂丛神经阻滞用于肩关节门诊手术后神经症状的前瞻性随机对照试验

慧译 马皓琳 李士通校

A Prospective, Randomized, Controlled Trial Comparing Ultrasound Versus Nerve Stimulator Guidance for Interscalene Block for Ambulatory Shoulder Surgery for Postoperative Neurological Symptoms

Spencer S. Liu, Victor M. Zayas, Michael A. Gordon, Jonathan C. Beathe, Daniel B. Maalouf, Leonardo Paroli, Gregory A. Liguori, Jaime Ortiz, Valeria Buschiazzo, Justin Ngeow, Teena Shetty, and Jacques T. Ya Deau

Anesth Analg 2009 109: 265-271.

有癫痫病史的病人行区域阻滞

陈珺珺译 薛张纲校

Regional Blockade in Patients with a History of a Seizure Disorder

Sandra L. Kopp, Kimberly P. Wynd, Terese T. Horlocker, James R. Hebl, and Jack L. Wilson

Anesth Analg 2009 109: 272-278.

超声引导下腋路臂丛神经阻滞(局部麻醉药混合液20ml)与全麻在上肢外伤手术中的比较:一项单盲、前瞻、随机、对照试验

张燕 译 陈杰 校

Ultrasound-Guided Axillary Brachial Plexus Block with 20 Milliliters Local Anesthetic Mixture Versus General Anesthesia for Upper Limb Trauma Surgery: An Observer-Blinded, Prospective, Randomized, Controlled Trial (Brief Report)

Brian D. O’Donnell, Helen Ryan, Owen O’Sullivan, and Gabrielle Iohom

Anesth Analg 2009 109: 279-283.

在体外循环下行先天性心脏病手术的病人使用抑肽酶与肾功能不全的关系

The Association of Renal Dysfunction and the Use of Aprotinin in Patients Undergoing Congenital Cardiac Surgery Requiring Cardiopulmonary Bypass

Ana Manrique, MD*, Edmund H. Jooste, MB, ChB{dagger}, Bradley A. Kuch, BS, RRT-NPS{ddagger}, Steven E. Lichtenstein, MD{dagger}, Victor Morell, MD*, Ricardo Munoz, MD§, Demetrius Ellis, MD||, and Peter J. Davis, MD{dagger}

From the Departments of *Cardiovascular Surgery, {dagger}Anesthesiology, {ddagger}Critical Care Medicine, §Pediatric Cardiac Critical Care, and ||Nephrology, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Anesth Analg 2009; 109:45-52

背景:在成人体外循环(CPB)期间使用大剂量抑肽酶与术后肾功能不全有关,但对接受复杂先天性心脏病手术的儿童的作用并未确定。

方法:我们采用回顾性群组分析方法研究了在20047月至20067月间需要体外循环行先天性心脏病手术的病儿。患儿的人口统计学资料和按Aristotle外科复杂性分级划分的手术风险都作为协变量。按照RIFLE标准(一种根据血清肌酐值将急性肾损伤按严重程度分为R-风险,I-损伤,F-衰竭的国际公认的分类法)确定肾功能不全。采用单因素、多因素逻辑回归分析和倾向性评分方法分析资料。使用与使用抑肽酶相关的预处理协变量进行倾向性评分。接着采用对倾向性评分和术中测定值作为协变量进行多因素逻辑回归分析。认为P<0.05有统计学显著性。

结果:395例进行心脏手术的病儿中,55%使用了抑肽酶,而45%未用。组群中31%曾接受过心脏手术,17%为新生儿。按照RIFLE标准,80例病儿(20.3%)术后有急性肾功能损伤;其中53(13.4%)有肾功能不全风险,23(5.8%)存在肾损伤,4(0.7%)为肾衰竭。使用抑肽酶的病儿在既往心脏手术(54.1% vs 5%)、败血症(6.9% vs.0.0%),心力衰竭(24.8% vs 12.4%)、机械通气(25.2% vs 2.8%)或机械循环支持(6.0% vs.0.6%)的发生率更高。使用抑肽酶的患儿,Aristotle外科分级4(26.6% vs 2.8%)者更多,使用利尿药(63.8% vs 26.6%)、血管紧张素转换酶抑制剂(21.1% vs 7.9%)、米力农(25.7% vs 4.5%)和强心剂(16.1% vs 2.3%)治疗者也更多。尽管未调整的肾功能不全风险存在明显差异,根据术前倾向性评分调整后却显示使用抑肽酶与肾功能不全没有相关性 (OR 1.32; 95% CI 0.55–3.19)。体外循环时间是唯一与肾功能不全产生有关的独立因素 (OR 1.0; 95% CI 1.009–1.014)

结论:使用抑肽酶的患儿同时伴有产生术后肾功能不全的术前危险因素的可能性更大。然而,当恰当地考虑了相关危险因素时,使用抑肽酶看来与儿童术后即时的产生肾功能不全高危险性不相关。

(颜涛译, 马皓琳 李士通 校)

BACKGROUND: The use of large-dose aprotinin during cardiopulmonary bypass (CPB) in adult patients has been linked to postoperative renal dysfunction, but its effect on the pediatric population undergoing complex congenital cardiac operations is not well defined.

METHODS: We used a retrospective cohort analysis to evaluate children undergoing cardiac surgery requiring CPB between July 2004 and July 2006. Demographic data and surgical risk quantified by the Aristotle surgical complexity level were analyzed as covariates. Renal dysfunction was defined according to the RIFLE criteria, an international consensus classification which defines three grades of increasing severity of acute kidney injury: risk (Class R), injury (Class I), and failure (Class F) based on serum creatinine values. A univariate and multivariate logistic regression analysis and a propensity score were used to analyze the data. The propensity score was developed using pretreatment covariates associated with the administration of aprotinin. A multivariate logistic regression was then used with the propensity score and intraoperative measures as covariates. A P value <0.05 was considered statistically significant.

RESULTS: Among 395 patients who underwent cardiac surgery, 55% received aprotinin and 45% did not. Thirty-one percent of the cohort had previous cardiac surgery; 17% were neonates. According to the RIFLE criteria, 80 of the patients (20.3%) had acute kidney injury in the postoperative period; 53 (13.4%) had risk of renal dysfunction with 23 (5.8%) having injury and four patients (0.7%) having failure. Those receiving aprotinin had a higher incidence of previous cardiac surgery (54.1% vs 5%), sepsis (6.9% vs.0.0%), heart failure (24.8% vs 12.4%), mechanical ventilation (25.2% vs 2.8%), or mechanical circulatory support (6.0% vs.0.6%). More patients had an Aristotle level of 4 (26.6% vs 2.8%) and were treated with diuretics (63.8% vs 26.6%), angiotensin converting enzyme inhibitors (21.1% vs 7.9%), milrinone (25.7% vs 4.5%), and inotropic support (16.1% vs 2.3%). Although there was a significant difference in the unadjusted risk of renal dysfunction, adjustment with the preoperative propensity score revealed that there was no association between aprotinin and renal dysfunction (OR 1.32; 95% CI 0.55–3.19). The duration of CPB was the only independent variable associated with the development of renal dysfunction (OR 1.0; 95% CI 1.009–1.014).

CONCLUSIONS: Patients who receive aprotinin are more likely to present with preoperative risk factors for the development of postoperative renal dysfunction. However, when associated risk factors are properly considered, the use of aprotinin does not seem to be associated with a higher risk of developing renal dysfunction in the immediate postoperative period in children.


评估用甘草漱口减少术后咽喉痛的有效性:一个前瞻性、随机、单盲研究

An Evaluation of the Efficacy of Licorice Gargle for Attenuating Postoperative Sore Throat: A Prospective, Randomized, Single-Blind Study

Anil Agarwal, MD*, Devendra Gupta, MD*, Ghanshyam Yadav, MD*, Puneet Goyal, MD, DM*, Prabhat K. Singh, MD*, and Uttam Singh, PhD{dagger}

From the *Department of Anesthesiology and {dagger}Biostatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Anesth Analg 2009; 109:77-81

背景:术后咽喉痛(POST)是主要的术后并发症。甘草作为一个祛痰药可用来治疗咳嗽和感冒。在本研究中,我们评估可甘草漱口来减少术后喉痛的效果。

方法:40个成年人(18-60岁),ASA分级III,行择期腰椎板切除术,随机分为两组,每组20例。C组:用水;L组加0.5 g甘草在水里。使两组标准化地都在麻醉前5分钟,用30毫升混合液漱口。在术后024、和24小时,监测休息和吞咽时术后咽喉痛的发生率和严重度及术后副作用。用直观类比标度(在0-100之间;0表示没有咽喉痛,100表示可想像的最严重的咽喉痛)评估术后咽喉痛的严重度。气管导管拔后立即评估拔管后咳嗽。用Z试验和Fisher’s精确试验分析资料。P < 0.05表示有显著性意义。

结果:L组与C组在休息和吞咽的所有时间点相比,术后咽喉痛(发生率和严重度)减少(P < 0.05),只有在24小时休息状态时的术后喉痛严重度两组相似(P > 0.05)。拔管后咳嗽在L组比C组明显减少(P < 0.05)。两组间副作用没有明显差异(P > 0.05)。

结论:麻醉前5分钟用甘草漱口可有效地减少术后咽喉痛的发生率和严重度。

(彭中美   马皓琳 李士通 校)

BACKGROUND: Postoperative sore throat (POST) contributes to postoperative morbidity. Licorice has been used as an expectorant in cough and cold preparations. In this study, we evaluated the efficacy of licorice gargle for attenuating POST.

METHODS: Forty adults (18-60 yr), ASA physical status I and II of either sex, undergoing elective lumber laminectomy were randomized into two groups of 20 each. Group C: received water; Group L: received 0.5 g licorice in water. Both groups received a 30 mL mixture for 30 s, 5 min before anesthesia which was standardized. The incidence and severity of POST at rest and on swallowing and side effects were assessed at 0, 2, 4, and 24 h, postoperatively. Severity of POST was assessed by visual analog scale (between 0 and 100 mm; where 0 means no sore throat and 100 means worst imaginable sore throat). Postextubation cough was assessed immediately after tracheal extubation. Data were analyzed by Z test and Fisher’s exact test. P < 0.05 was considered as significant.

RESULTS: POST (incidence and severity) was reduced in the Group L compared with Group C at rest and on swallowing for all time points (P < 0.05), except that the severity of POST at rest, at 24 h, was similar in both groups (P > 0.05). Postextubation cough was reduced in Group L compared with Group C (P < 0.05). There was no difference in side effects between groups (P > 0.05).

CONCLUSION: Licorice gargle performed 5 min before anesthesia is effective in attenuating the incidence and severity of POST.


家兔给予新型苯二氮卓受体激动剂JM-1232(–)后的寒战阈值

The Shivering Threshold in Rabbits with JM-1232(–), a New Benzodiazepine Receptor Agonist

Taishi Masamune, MD*, Hiroaki Sato, MD*, Katsumi Okuyama, MD, PhD{dagger}, Yusuke Imai, MD{ddagger}, Hironobu Iwashita, MD, PhD*, Tadahiko Ishiyama, MD, PhD*, Takeshi Oguchi, MD, PhD{dagger}, Daniel I. Sessler, MD§, and Takashi Matsukawa, MD, PhD{dagger}

From the *Operating Theater, Yamanashi University Hospital, Yamanashi, Japan; {dagger}Department of Anesthesiology, University of Yamanashi, Japan; {ddagger}Department of Anesthesia, Kanoiwa General Hospital, Yamanashi, Japan; and §Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio.

Anesth Analg 2009; 109:96-100

背景:JM-1232(–) 是一种新型异二氢吲哚衍生物,通过作用于{gamma}-氨基丁酸A型(GABAA)受体的苯二氮卓位点显示出镇静催眠活性。另一GABAA受体激动剂咪达唑仑的标准剂量可轻度降低人的寒战阈值。本研究旨在确定JM-1232(–)可降低寒战阈值到何种程度。

方法: 给予0.2最小肺泡麻醉浓度(MAC)异氟醚后处于浅麻醉状态的18只家兔随机分为三组,分别静脉输注1)生理盐水(对照组), 2) 0.01 mg · kg–1 · min–1 JM-1232(–)3) 0.1 mg · kg–1 · min–1 JM-1232(–)。通过置于结肠内的U形塑料管灌注10°C的水使得家兔体温以2-3°C/h的速度下降。当不知分组情况的观察者观察到家兔寒战或家兔中心体温降至34°C时,停止降温。记录经由食道远端测得的中心体温,寒战开始时的中心体温定义为寒战阈值。数据分析采用单因素方差分析和Student-Newman-Keuls检验。结果表示为平均值 ± 标准差; P < 0.05 认为有统计学意义。

结果:静脉输注生理盐水的家兔在体温36.5 ± 0.3°C时发生寒战。以0.01 mg · kg–1 · min–1速度静脉输注JM-1232(–) 6个家兔中有5个在体温35.7 ± 0.8°C时发生寒战,并有一个家兔在体温降到34.0°C时也没发生寒战。以0.1 mg · kg–1 · min–1速度静脉输注JM-1232(–)的家兔在体温达到34°C中止降温之前都未发生寒战。

结论:低剂量JM-1232(–)可使家兔寒战阈值降低约0.8°C,这一结果与给予人术前用药剂量咪达唑仑后的效果相似。相对而言,10倍剂量的JM-1232(–)可使寒战阈值降低2.5°C以上。这个阈值降低幅度很大且可能利于治疗性降温的实施。

(周雅春 马皓琳 李士通 校)

BACKGROUND: JM-1232(–) is a novel isoindoline derivative which shows sedative and hypnotic activities through the benzodiazepine site of {gamma}-aminobutyric acid type A (GABAA) receptors. Typical doses of midazolam, another GABAA receptor agonist, slightly reduce the shivering threshold in humans. We thus determined the extent to which JM-1232(–) decreases the shivering threshold.

METHODS: Eighteen rabbits, lightly anesthetized with isoflurane 0.2 minimum alveolar anesthetic concentration (MAC), were randomly assigned to infusions of 1) saline (control), 2) 0.01 mg · kg–1 · min–1 JM-1232(–), or 3) 0.1 mg · kg–1 · min–1 JM-1232(–). Body temperature was reduced at a rate of 2-3°C/h by perfusing water at 10°C though a U-shaped plastic tube positioned in the colon. Cooling continued until shivering was observed by an investigator blinded to treatment, or until core temperature reached 34°C. Core temperatures were recorded from the distal esophagus, and core temperature at the onset of shivering defined the threshold. Data were analyzed by one-way analysis of variance with Student-Newman-Keuls tests. Results are presented as means ± sd; P < 0.05 was considered statistically significant.

RESULTS: The rabbits given a saline infusion shivered at 36.5 ± 0.3°C. Five of the six rabbits given JM-1232(–) at a rate of 0.01 mg · kg–1 · min–1 shivered at 35.7 ± 0.8°C, and one of these rabbits failed to shiver at 34.0°C. None of the rabbits given JM-1232(–) at a rate of 0.1 mg · kg–1 · min–1 shivered before reaching the 34.0°C cutoff temperature.

CONCLUSION: A low dose of JM-1232(–) reduced the shivering threshold in rabbits approximately 0.8°C which is similar to the effects in humans given premedication doses of midazolam. In contrast, a 10-fold larger dose reduced the threshold more than 2.5°C. This is a substantial decrement and might facilitate induction of therapeutic hypothermia.


关于外周静脉和动脉置管的医疗责任:一项终审索赔分析 

Liability Related to Peripheral Venous and Arterial Catheterization: A Closed Claims Analysis

Sanjay M. Bhananker, MD, FRCA, Derek W. Liau, MD, Preetma K. Kooner, BA, BS, Karen L. Posner, PhD, Robert A. Caplan, MD, and Karen B. Domino, MD, MPH

From the Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington.

Anesth Analg 2009; 109:124-129

背景:外周静脉和动脉置管后严重并发症已有很多报导。为了评估麻醉医生在外周血管置管中的责任,我们回顾了国麻醉医师协会索赔终审数据库。

方法:把外周血管置管相关的索赔归为与静脉内或动脉导管有关。与静脉内导管有关的并发症按并发症的类型加以分类。我们比较了数据库中与因静脉内导管有关的索赔和所有的其他(非外周置管)索赔之间的病人和病例特征、损伤严重度和赔偿金额。赔偿金额用日用品价格指数调整到2007年的美金金额。

结果:与外周血管置管相关的索赔占数据库中总索赔的2% (n = 140/6894例索赔),其中大多数(91%)与静脉内导管相关(n = 127)。最常见的并发症包括:皮肤坏死(28%)、隆起/感染(17%)、神经损伤(17%)、筋膜切开后疤痕(16%)以及空气栓塞(8%)。大约一半(55%)的并发症发生于药物或液体渗出血管后。与其他索赔相比,静脉内置管相关索赔涉及的心脏外科手术病例部分较大(25%相比其他2%, P < 0.001),急诊手术病例部分较小(8%相比其他22%, P < 0.001)。与动脉导管有关的索赔较少(n = 13, 8%),其中只有7例与桡动脉置管有关。

结论:与静脉内导管相关的索赔是麻醉医生的一个重要责任根源,其中大约一半是因为药物或液体渗出血管。桡动脉置管相关的索赔比较少见。

(江继宏   马皓琳 李士通 校)

BACKGROUND: Serious complications after peripheral IV and arterial vascular cannulations have been reported. To assess liability associated with these peripheral vascular catheters for anesthesiologists, we reviewed claims in the American Society of Anesthesiologists Closed Claims database.

METHODS: Claims related to peripheral vascular catheterization were categorized as related to IV or arterial catheters. Complications related to IV catheters were categorized as to type of complication. Patient and case characteristics, severity of injury, and payments were compared between claims related to IV catheters and all other (nonperipheral catheter) claims in the database. Payment amounts were adjusted to 2007-dollar amounts using the consumer price index.

RESULTS: Claims related to peripheral vascular catheterization accounted for 2% of claims in the database (n = 140 of 6894 claims), most (91%) associated with IV catheters (n = 127). The most common complications were skin slough (28%), swelling/infection (17%), nerve damage (17%), fasciotomy scars (16%), and air embolism (8%). Approximately half of these complications (55%) occurred after extravasation of drugs or fluids. Compared with other claims, IV claims involved a larger proportion of cardiac surgery (25% vs 2% for other, P < 0.001) and smaller proportion of emergency procedures (8% vs 22% for other, P < 0.001). Claims related to arterial catheters were few (n = 13, 8%), with only seven associated with radial artery catheterization.

CONCLUSIONS: Claims related to IV catheters were an important source of liability for anesthesiologists, approximately half of which resulted from extravasation of drugs or fluid. Claims related to radial arterial catheterization were uncommon.


肺募集反应对病态肥胖病人容积性二氧化碳描记图III相斜率的影响

The Effects of Lung Recruitment on the Phase III Slope of Volumetric Capnography in Morbidly Obese Patients

Stephan H. Böhm, MD*, Stefan Maisch, MD*, Alexandra von Sandersleben, MD*, Oliver Thamm, MD*{dagger}, Isabel Passoni, PhD{ddagger}, Jorge Martinez Arca, MSc{ddagger}, and Gerardo Tusman, MD§

From the *Clinic of Anesthesiology, University Hospital, Hamburg-Eppendorf, Hamburg, Germany; {dagger}currently at Clinic of Plastic and Reconstructive Surgery, Burn Care Center, Hospital Cologne-Merheim, University of Witten/Herdecke, Germany; {ddagger}Department of Bioengineering, University of Mar del Plata, Argentina; and §Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina.

Anesth Analg 2009; 109:151-159

背景:在本研究中,我们分析肺泡复原(ARS)和呼气末正压(PEEP)选择对病态肥胖病人容积性二氧化碳描记图(VC)III相斜率(SIII)的影响。

方法:十一个麻醉的病态肥胖病人是研究对象。肺以潮气量10 mL·kg–1、呼吸频率12-14/分钟、吸呼比1:2及吸入气氧含量 0.4的方式通气。通过5步将呼气末压从0增加到15 cm H2O完成ARS。在肺征募期间,限制平台压在50 cm H2O范围内,而增加潮气量到呼吸机的最大值1400mlPEEP增加到20 cm H2O 持续2分钟。此后,把PEEP每步减少5 cm H2O地从15 cm H2O减少到0。在PEEP每个阶段,测定容积二氧化碳描记图、动脉血气和肺的力学资料。

结果:呼气末正压为0时与ARSPEEP 15 cm H2O 时比较,SIII0.014 ± 0.006 减少到 0.005 ± 0.005 mm Hg/mL(15ARS, P < 0.05)。比较ARS前后的值,我们发现SIII减少伴随着动脉氧分压(27%, P < 0.002)和顺应性(32%, P < 0.001)的增加,然而,动脉二氧化碳分压减少8(P < 0.038)。接受者操作特征曲线分析(曲线下面积:0.81,敏感性:0.75,特异性:0.74P < 0.001)显示SIII可以很好的预测肺募集反应。

结论VCSIII对麻醉的病态肥胖病人肺募集反应后发现最优的PEEP水平是有用的。

(王宏翻译,李士通,马皓琳校正)

BACKGROUND: In this study, we analyzed the effect of the alveolar recruitment strategy (ARS) and positive end-expiratory pressure (PEEP) titration on Phase III slope (SIII) of volumetric capnography (VC) in morbidly obese patients.

METHODS: Eleven anesthetized morbidly obese patients were studied. Lungs were ventilated with tidal volumes of 10 mL · kg–1, respiratory rates of 12–14 bpm, inspiration:expiration ratio of 1:2, and Fio2 of 0.4. ARS was performed by increasing PEEP in steps of five from 0 end-expiratory pressure to 15 cm H2O. During lung recruitment, plateau pressure was limited to 50 cm H2O, whereas tidal volume was increased to the ventilator’s maximum value of 1400 mL, and PEEP was increased to 20 cm H2O for 2 min. Thereafter, PEEP was reduced in steps of 5 cm H2O, from 15 to 0. VC, arterial blood gases, and lung mechanics data were determined for each PEEP step.

RESULTS: SIII decreased from 0.014 ± 0.006 to 0.005 ± 0.005 mm Hg/mL when 0 end-expiratory pressure was compared against 15 cm H2O of PEEP after ARS (15ARS, P < 0.05). This decrement in SIII was accompanied by increases in Pao2 (27%, P < 0.002) and compliance (32%, P < 0.001), whereas Paco2 decreased by 8% (P < 0.038) when comparing values before and after ARS. A good prediction of the lung recruitment effect by SIII was derived from the receiver operating characteristic curve analysis (area under the curve of 0.81, sensitivity of 0.75, and specificity of 0.74; P < 0.001).

CONCLUSION: The SIII in VC was useful to detect the optimal level of PEEP after lung recruitment in anesthetized morbidly obese patients.


5-羟色胺拮抗剂对剖宫产中接受鞘内吗啡的产妇瘙痒、恶心呕吐的预防和治疗作用:系统性回顾和Meta分析

Serotonin Receptor Antagonists for the Prevention and Treatment of Pruritus, Nausea, and Vomiting in Women Undergoing Cesarean Delivery with Intrathecal Morphine: A Systematic Review and Meta-Analysis

Ronald B. George, MD, FRCPC*, Terrence K. Allen, MBBS, FRCA{dagger}, and Ashraf S. Habib, MBBCh, MSc, FRCA{dagger}

From the *Department of Women’s and Obstetric Anesthesia, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada; and {dagger}Department of Anesthesiology, Division of Women’s Anesthesia, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2009; 109:174-182

背景:我们完成了一个系统性回顾以决定5-羟色胺(5-HT3)受体拮抗剂对剖宫产中接受腰麻及鞘内吗啡的产妇瘙痒、恶心呕吐的预防和治疗作用。

方法:我们回顾了比较5-HT3受体拮抗剂和安慰剂对产妇瘙痒和/或恶心呕吐预防和治疗作用的随机对照试验的报道。这些文章根据其有效度进行评分,由作者独立地提取数据资料,并且用相关危险度(RR)和95%可信区间(CI)进行总结分析。

结果:本系统性回顾包括了九例随机对照试验。九例实验中共有1152例病人,其中539例接受5-HT3受体拮抗剂,413例接受安慰剂,200例接受其他止吐药的产妇没有包括在分析中。预防性使用5-HT3受体拮抗剂并没有比安慰剂减少瘙痒的发生率(80.7%85.8%, RR [95% CI] = 0.94 [0.81–1.09])。然而,它们的使用减少了剧烈瘙痒的发生率及其需要治疗的概率(需要治疗的病例数分别为1215)。他们的使用对于顽固性瘙痒的治疗效力比安慰剂要高,其需要治疗的病例数为3。使用5-HT3受体拮抗剂组较安慰剂组术后恶心(22.0%33.6%, RR [95% CI] = 0.75[0.58–0.96])和呕吐的发生率(7.7%16.8%, RR [95% CI] = 0.49 [0.30–0.81])显著降低,术后需要止吐治疗的概率也显著降低(9%23%, RR [95% CI] = 0.38 [0.21–0.68])

结论:虽然在剖宫产使用鞘内吗啡的产妇中,预防性使用5-HT3受体拮抗剂并不能有效地减少瘙痒的发生率,但是它们可以显著降低瘙痒的严重性及其需要治疗的概率,也可以减少术后恶心呕吐的发生率及需要止吐治疗的概率。它们对于顽固性瘙痒也有有效的治疗作用。虽然仍需要进行更多的研究,但是现有的数据表明,对于剖宫产使用鞘内吗啡的产妇来说,应该考虑常规预防性使用这些药物。

(黄佳佳译,马皓琳 李士通校)

BACKGROUND: We performed a systematic review to determine the overall efficacy of serotonin (5-HT3) receptor antagonists for the prevention and treatment of pruritus, nausea, and vomiting in women receiving spinal anesthesia with intrathecal morphine for cesarean delivery.

METHODS: Reports of randomized, controlled trials that compared prophylaxis or treatment of pruritus and/or nausea, and vomiting using one of the 5-HT3 receptor antagonists or placebo in women undergoing cesarean delivery were reviewed. The articles were scored for validity and data were extracted by the authors independently and summarized using relative risks (RR) with 95% confidence intervals (CI).

RESULTS: Nine randomized, controlled trials were included in the systematic review. The nine trials had a total of 1152 patients enrolled; 539 received 5-HT3 receptor antagonists, 413 received placebo, and 200 received other antiemetics and were not included in the analysis. The incidence of pruritus was not reduced with 5-HT3 receptor antagonists prophylaxis compared with placebo (80.7% vs 85.8%, RR [95% CI] = 0.94 [0.81–1.09]). However, their use reduced the incidence of severe pruritus and the need for treatment of pruritus (number-needed-to-treat = 12 and 15, respectively). Their use for the treatment of established pruritus showed improved efficacy compared with placebo with a number-needed-to-treat of three. There was a significant reduction in the incidence of postoperative nausea (22.0% vs 33.6%, RR [95% CI] = 0.75[0.58–0.96]) and vomiting (7.7% vs 16.8%, RR [95% CI] = 0.49 [0.30–0.81]), and the need for postoperative rescue antiemetic treatment with the use of 5-HT3 receptor antagonists when compared with placebo (9% vs 23%, RR [95% CI] = 0.38 [0.21–0.68]).

CONCLUSIONS: Although prophylactic 5-HT3 receptor antagonists were ineffective in reducing the incidence of pruritus, they significantly reduced the severity and the need for treatment of pruritus, the incidence of postoperative nausea and vomiting, and the need for rescue antiemetic therapy in parturients who received intrathecal morphine for cesarean delivery. They were also effective for the treatment of established pruritus. Although more studies are warranted, the current data suggest that the routine prophylactic use of those drugs should be considered in this patient population.




发育中大鼠脑的器官型海马脑片模型中氧和葡萄糖缺失:对N-甲基-d-天门冬氨酸亚单位组成的影响

Oxygen and Glucose Deprivation in an Organotypic Hippocampal Slice Model of the Developing Rat Brain: The Effects on N-Methyl-d-Aspartate Subunit Composition

Lisa Wise-Faberowski, MD*, Prairie Neeley Robinson, MD*, Sarah Rich, BS*, and David S. Warner, MD{dagger}

From the *The Children’s Hospital Pediatric Anesthesia Laboratory, Department of Anesthesiology, University of Colorado Health Sciences Center, Aurora, Colorado; and {dagger}Departments of Anesthesiology, Neurobiology, and Surgery, Multidisciplinary Neuroprotection Laboratories, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2009; 109:205-210

背景:器官型海马脑片(OHS)常用于小儿脑损伤相关药物的神经保护效应的筛选。供体新生大鼠的日龄的重要性和N-甲基-d-天门冬氨酸(NMDA)受体亚单位组成尚未被阐明。本研究中,我们评估了氧-葡萄糖缺失(OGD)在发育中大鼠脑中的日龄依赖效应并判断OGD是否调制NMDA受体亚单位的组成。

方法:分别制备出生后(PND471421天新生大鼠的OHS并在体外培养7天。脑片接触OGD的时间为5-60 min2472 h之后,测定OHS的存活以及NMDA亚单位的组成。

结果:PND1421新生大鼠制备的OHS中细胞死亡明显(P < 0.001)OGD时间分别为5min10min。由PND7新生大鼠制备的OHS中,OGD时间直至20 min才出现明显的神经变性(P < 0.001)。在由PND4PND7新生大鼠制备的OHS中,OGD接触与NMDA受体亚单位组成从NR2B占主导向NR2A占主导的转变相关。

结论:本次新生大鼠OHS的离体研究结果,支持OGD和神经细胞死亡之间存在日龄及NMDA受体亚单位组成依赖性的关系。

(黄施伟 译,马皓琳 李士通 校)

BACKGROUND: Oganotypic hippocampal slices (OHS) are commonly used to screen for neuroprotective effects of pharmacological agents relevant to pediatric brain injury. The importance of donor rat pup age and N-methyl-d-aspartate (NMDA) receptor subunit composition have not been addressed. In this study, we evaluated the age-dependent effect of oxygen-glucose deprivation (OGD) in the developing rat brain and determined whether OGD modulates the NMDA receptor subunit composition.

METHODS: OHS were prepared from rat pups on postnatal days (PND) 4, 7, 14, and 21 and cultured 7 days in vitro. The slices were exposed to OGD for durations of 5–60 min. After 24 and 72 h, OHS survival and NMDA subunit composition were assessed.

RESULTS: Cell death was evident in OHS prepared from PND 14 and 21 rat pups (P < 0.001) with OGD durations of 5 and 10 min, respectively. In OHS prepared from PND7 rat pups, neurodegeneration was not evident until 20 min OGD (P < 0.001). Exposure to OGD in OHS prepared from PND4 and PND7 rat pups was associated with a transition in the NMDA receptor subunit composition from NR2B predominant to NR2A predominant subunit composition.

CONCLUSIONS: This in vitro neonatal rat pup investigation using OHS supports both an age and an NMDA receptor subunit composition-dependent relationship between OGD and neuronal cell death.


颅内肿瘤切除术后罗哌卡因头皮浸润的镇痛作用

The Analgesic Properties of Scalp Infiltrations with Ropivacaine After Intracranial Tumoral Resection

Hélène Batoz, MD, Olivier Verdonck, MD, Christelle Pellerin, MD, Gaëlle Roux, MD, and Pierre Maurette, PhD

From the Department of Anesthesiology and Intensive Care Unit III, Pellegrin Hospital, Bordeaux, France.

Anesth Analg 2009; 109:240-244

背景神经外科手术后的疼痛是一个有争议的问题。这种疼痛为轻到中度,对其治疗往往是不足够的。手术部位进行局麻药的浸润麻醉对颅骨切开术后的疼痛是有短暂的帮助,但是对于慢性疼痛的治疗还没有进行过评估。因此我们设计了这个研究,来证实罗哌卡因头皮浸润麻醉能减轻颅内肿瘤切除术后急性和持续性疼痛的假设。

方法这是一个前瞻性的、单盲研究。选择标准为颅内肿瘤切除术患者,年龄1880岁,有能力理解和使用视觉模拟评价标尺(VAS)。排除标准为有颅骨切除手术史、长期吸毒和神经系统疾病。所有入选的患者随机分成I组(浸润组)和C组(对照组)。术后镇痛为对乙酰氨基酚联合纳布啡静脉注射。手术结束时,I组在手术部位用0.75%的罗哌卡因20ml进行浸润麻醉。在第一个24小时每小时进行急性疼痛的VAS评估。罗哌卡因的镇痛效果通过纳布啡的用量和VAS的分数来评估。持续性疼痛的发生率和神经性疼痛在手术后2个月进行评估。我们用Student’s t检验比较纳布啡的总用量,反复测量并分别用post hoc Bonferronit检验和Fisher确切检验法对VAS分数和慢性及神经性疼痛进行方差分析。。

结果:共有52名患者入选,I25名、C27名。两组人口统计学和手术中的数据相似。I组结果显示在术后第一天对于减少纳布啡的用量没有显著变化趋势,11.2 ± 9.2 mgC16.6 ± 11.0 mg (平均值±标准差, P = 0.054)VAS评分C组明显较高。术后2个月,持续性疼痛在I组明显较低,2/24 (8%)14/25 (56%), P = 0.0003I1名患者(4.1%)C6名患者(25%)(P = 0.04)出现有神经性疼痛。

结论由于颅内肿瘤切除术的疼痛为中度,所以在术后急性期对于罗哌卡因的头皮浸润麻醉有限制的影响。尽管如此,这些浸润麻醉对于限制延迟持续性疼痛尤其是神经性疼痛的作用可能有利于神经外科手术患者的康复以及他们的生活质量。

(唐亮   马皓琳 李士通 校)      

BACKGROUND: The issue of postoperative pain after neurosurgery is controversial. It has been reported as mild to moderate and its treatment may be inadequate. Infiltration of the surgical site with local anesthetics has provided transient benefit after craniotomy, but its effect on chronic pain has not been evaluated. Accordingly, we designed the present study to test the hypothesis that ropivacaine infiltration of the scalp reduces acute and persistent postoperative pain after intracranial tumor resection.

METHODS: This was a prospective, single-blinded study. Inclusion criteria were intracranial tumor resection, age ≥18 or ≤80 yr, and ability to understand and use a visual analog scale (VAS). Exclusion criteria were history of craniotomy, chronic drug abuse, and neurologic disorders. All eligible patients were randomly included in Group I (infiltration) or C (control). Postoperative analgesia was IV acetaminophen combined with nalbuphine. At the end of the surgery, Group I received an infiltration of the surgical site with 20 mL of ropivacaine 0.75%. Acute pain was evaluated hourly by VAS during the first 24 h. The analgesic effect of ropivacaine was evaluated based on total consumption of nalbuphine and VAS scores. The incidence of persistent pain and neuropathic pain was assessed at the 2-mo postoperative evaluation. We used the Student’s t-test to compare total nalbuphine consumption, repeated measures analysis of variance with post hoc Bonferroni t-test for VAS score and the Fisher’s exact test for chronic and neuropathic pain.

RESULTS: Fifty-two patients were enrolled, 25 in Group I and 27 in Group C. Demographic and intraoperative data were similar between groups. Group I showed a nonsignificant trend toward reduced nalbuphine consumption during the first postoperative day, 11.2 ± 9.2 mg vs 16.6 ± 11.0 mg for Group C (mean ± sd, P = 0.054). VAS scores were significantly higher in Group C. Two months after surgery, persistent pain was significantly lower in Group I, 2/24 (8%) vs 14/25 (56%), P = 0.0003. One patient (4.1%) in Group I versus six (25%) patients in Group C (P = 0.04) experienced neuropathic pain.

CONCLUSIONS: Because pain is moderate after intracranial tumor resection, there is limited interest in scalp infiltrations with ropivacaine in the acute postoperative period. Nevertheless, these infiltrations may be relevant for the rehabilitation of neurosurgical patients and their quality of life by limiting the development of persistent pain and particularly neuropathic pain.


比较超声和神经刺激仪引导肌间沟法臂丛神经阻滞用于肩关节门诊手术后神经症状的前瞻性随机对照试验

A Prospective, Randomized, Controlled Trial Comparing Ultrasound Versus Nerve Stimulator Guidance for Interscalene Block for Ambulatory Shoulder Surgery for Postoperative Neurological Symptoms

Spencer S. Liu, MD*, Victor M. Zayas, MD*, Michael A. Gordon, MD*, Jonathan C. Beathe, MD*, Daniel B. Maalouf, MD*, Leonardo Paroli, MD*, Gregory A. Liguori, MD*, Jaime Ortiz, MD*, Valeria Buschiazzo*, Justin Ngeow, BA*, Teena Shetty, MD{dagger}, and Jacques T. Ya Deau, MD, PhD*

From the Departments of *Anesthesiology, and {dagger}Neurology, Hospital for Special Surgery, Weill College of Medicine of Cornell University, New York.

Anesth Analg 2009; 109:265271

背景:区域麻醉中超声可视性能减少神经内注射和并发神经症状的风险,但还未进行正式评估。因此,我们进行这个随机临床试验来比较超声和神经刺激仪引导的肌间沟法臂丛神经阻滞用于肩关节镜检查来判断超声是否能减少术后神经症状的发生率。

方法:230例患者随机分为两组施行标准化肌间沟法臂丛阻滞(超声或神经刺激仪辅助下),使用5cm长的22g Stimuplex®绝缘针注射1.5%盐酸甲哌卡因(含1:300,000肾上腺素及NaCO3 1 meq/10 mL)。在术前(用问卷和体检)、术后约1周(用问卷)和术后4-6周(问卷和体检)用一项神经学家设计的标准化神经学评价方法进行评价。术后神经症状的诊断由一位不知阻滞方法的神经专家确定。

结果:219例患者进行了评估。超声的应用降低了阻滞操作时针穿过神经的数量(13, 中位数, P < 0.001),提高了5分钟时评估的运动神经阻滞效果(P = 0.04),但未减少神经阻滞施行的时间(两组均为5分钟)。没有患者因阻滞失败改上全麻,而且两组患者满意度相似(神经刺激仪组96%,超声组92%)。术后1周随访时和后期随访时的神经症状的发生率相似,术后1周随访时神经刺激仪组为11%(95% CI 5%–17%),超声组为8% (95% CI 3%–13%),后期随访时神经刺激仪组为7% (95% CI 3%–12%),超声组为6% (95% CI 2%–11%)。术后神经症状的严重程度两组相似,分级中位数为重度。症状主要是感觉的,包括疼痛,麻刺或感觉异常。

结论:超声减少肌间沟法臂丛阻滞操作时针穿过神经的数量,提高5分钟时的运动神经阻滞效果。然而,我们并未观察到在阻滞失败、患者满意度及术后神经症状发生率和严重程度上有明显差异。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Visualization with ultrasound during regional anesthesia may reduce the risk of intraneural injection and subsequent neurological symptoms but has not been formally assessed. Thus, we performed this randomized clinical trial comparing ultrasound versus nerve stimulator-guided interscalene blocks for shoulder arthroscopy to determine whether ultrasound could reduce the incidence of postoperative neurological symptoms.

METHODS: Two hundred thirty patients were randomized to a standardized interscalene block with either ultrasound or nerve stimulator with a 5 cm, 22 g Stimuplex® insulated needle with 1.5% mepivacaine with 1:300,000 epinephrine and NaCO3 (1 meq/10 mL). A standardized neurological assessment tool (questionnaire and physical examination) designed by a neurologist was administered before surgery (both components), at approximately 1 wk after surgery (questionnaire), and at approximately 4–6 weeks after surgery (both components). Diagnosis of postoperative neurological symptoms was determined by a neurologist blinded to block technique.

RESULTS: Two hundred nineteen patients were evaluated. Use of ultrasound decreased the number of needle passes for block performance (1 vs 3, median, P < 0.001), enhanced motor block at the 5-min assessment (P = 0.04) but did not decrease block performance time (5 min for both). No patient required conversion to general anesthesia for failed block, and patient satisfaction was similar in both groups (96% nerve stimulator and 92% ultrasound). The incidence of postoperative neurological symptoms was similar at 1 wk follow-up with 11% (95% CI of 5%–17%) for nerve stimulator and 8% (95% CI of 3%–13%) for ultrasound and was similar at late follow-up with 7% (95% CI of 3%–12%) for nerve stimulator and 6% (95% CI of 2%–11%) for ultrasound. The severity of postoperative neurological symptoms was similar between groups with a median patient rating of moderate. Symptoms were primarily sensory and consisted of pain, tingling, or paresthesias.

CONCLUSIONS: Ultrasound reduced the number of needle passes needed to perform interscalene block and enhanced motor block at the 5 min assessment; however, we did not observe significant differences in block failures, patient satisfaction or incidence, and severity of postoperative neurological symptoms.

 

全血多极凝集测定仪是一种可靠的阿司匹林诱导的血小板功能障碍的床边检验方法

Whole Blood Multiple Electrode Aggregometry Is a Reliable Point-of-Care Test of Aspirin-Induced Platelet Dysfunction

Csilla Jámbor, MD*, Christian F. Weber, MD{ddagger}, Konstanze Gerhardt{ddagger}, Wulf Dietrich, PhD*, Michael Spannagl, PhD*{dagger}, Bernhard Heindl, PhD*, and Bernhard Zwissler, PhD*

From the *Clinic for Anesthesiology, {dagger}Department of Transfusion Medicine and Hemostaseology, University of Munich, Germany; and {ddagger}Department of Anesthesiology, Intensive Care and Pain Medicine, Goethe-University Frankfurt am Main, Germany.

Anesth Analg 2009 109: 25-31.

 

背景:阿司匹林是最常用的非处方药,除镇痛和抗炎作用之外,还有潜在的抗血小板凝集作用。阿司匹林诱导的血小板功能障碍与不同的临床条件有关,包括复杂的外科手术同时服用阿司匹林致出血风险高的患者。在这项研究中,作者评估了单次口服阿司匹林500mg后血小板的凝集功能。应用多极凝集测定仪(MEA)测定凝血功能,通过比较采集血液样本的不同时间间隔的测试结果来确定这种方法在床边检验的可用性。

方法:研究包括24名健康志愿者。在基础状态时取血后所有志愿者接受阿司匹林500mg。在应用阿司匹林后4, 24, 56, 80, 124 h 时采血。每个取血时点即刻或取血后30min60min行凝血功能检查。在用凝血酶受体激活肽(TRAPtest, 32 µM)或花生四烯酸(ASPItest, 0.5 mM)刺激后检测全血MEA。用Bonferroni 相关重复方差分析检测时点间差异。通过计算变异系数确定不精确性。P < 0.05为统计学差异有意义。

结果:摄入阿司匹林4h后血小板聚集的ASPItest明显降低,摄入阿司匹林第二天,ASPItest恢复,但个体差异显著。阿司匹林摄入五天后,ASPItest回到基础值。TRAPtest无显著差异。样本测试时间并不影响TRAPtestASPItest值。ASPItest的变异系数为10 %和TRAPtest的变异系数为7 %。

结论:MEA 能可靠检测阿司匹林对凝血功能的影响。值得注意的是所有健康志愿者服用阿司匹林500mg后导致花生四烯酸致血小板凝集的作用完全逆转。5天内随着时间延长血小板聚集功能逐渐恢复但有个体差异。血液标本存放时间对ASPItest TRAPtest检测无影响。测试均能床边完成。本研究测试的可重复性在现代床边分析仪要求的范围内。

(刘世文 译 陈杰 校)

BACKGROUND: Aspirin is one of the most commonly ingested over-the-counter drugs. In addition to its analgesic and antiinflammatory actions, it also potently inhibits platelet aggregation. Evaluation of aspirin-induced platelet dysfunction is relevant in various clinical situations, including during complex surgeries with high bleeding risk in individuals who have ingested aspirin. In this study, we examined the suitability of multiple electrode aggregometry (MEA) for time course assessment of the antiplatelet effects of a single oral dose of 500 mg aspirin. We also determined the applicability of this method in the point-of-care (POC) setting by comparing the results of the test after different time intervals after blood sampling.

METHOD: Twenty-four adult volunteers were enrolled in the study. After blood drawing at baseline, 500 mg aspirin was administered to all volunteers. Blood samples were taken at 4, 24, 56, 80, and 124 h after aspirin ingestion. At each time point, measurements were performed immediately and 30 and 60 min after drawing blood. Whole blood MEA was performed after stimulation with thrombin receptor activating peptide (TRAPtest, 32 µM) and arachidonic acid (ASPItest, 0.5 mM). Repeated measurement analysis of variance with a Bonferroni correction for multiple comparisons was performed to detect differences between time points. Assay imprecision was determined by calculating the coefficient of variation. The level of statistical significance was set to P < 0.05.

RESULTS: Platelet aggregation by ASPItest was markedly decreased 4 h after aspirin intake. From the second day after aspirin intake, ASPItest values recovered with high interindividual variability, and 5 days after aspirin intake, ASPItest values did not differ significantly from baseline. TRAP-induced platelet aggregation (TRAPtest) showed no systematic changes during the study period. The resting time of the sample did not affect TRAPtest or ASPItest values. The coefficients of variation were 10% for the ASPItest and 7% for the TRAPtest.

CONCLUSIONS: MEA reliably detected the effects of aspirin. Notably, 500 mg aspirin caused complete inhibition of arachidonic acid-induced platelet aggregation for 2 days in all volunteers. Aggregation returned to baseline values with a wide interindividual variation in time course by day 5. No resting time for the blood sample was required for ASPItest or TRAPtest. These assays can be implemented as real POC tests. The reproducibility of the assays studied here is within the range of modern POC analyzers.

 

儿童阻塞性睡眠呼吸暂停的围手术期处理

Perioperative Management of Children with Obstructive Sleep Apnea

Deborah A. Schwengel, MD*{dagger}, Laura M. Sterni, MD{dagger}, David E. Tunkel, MD*{dagger}{ddagger}, and Eugenie S. Heitmiller, MD*{dagger}

From the Departments of *Anesthesiology/Critical Care Medicine, {dagger}Pediatrics, and {ddagger}Otolaryngology Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Anesth Analg 2009 109: 60-75.

 

1 -3 %的儿童受到阻塞性睡眠呼吸暂停综合征(OSA)的影响。所有需要麻醉的外科手术和诊断性治疗中常可碰见OSA的患儿。小儿,扁桃腺切除术是最常见的外科治疗OSA的方法。因此,麻醉医生的当务之急是熟悉OSA患儿潜在的麻醉并发症和术后相关问题。国家专业医疗协会认识并提出对于OSA患儿应加强围手术期护理。2002年美国儿科学会发表儿科OSA临床实践的指南。指南指出麻醉并发症风险呈现上升趋势,尽管未曾提及具体的麻醉事件。2006年,美国麻醉医师学会出版了一本关于OSA病人围术期管理的实践指南,指出儿科相关的危险因子是肥胖,3岁以下儿童围术期手术风险增加与扁桃体切除术有关。然而,1岁以下OSA儿童的围术期管理则未在指南中提及。因此,关于围术期OSA儿童的护理仍有许多问题。
在这篇综述中作者复习了儿童OSA相关的文献,探讨了其病理生理及目前的治疗方案,以及这些年幼及潜在高风险的患儿围手术期处理方法。

(叶乐 译 陈杰 校)

Obstructive sleep apnea syndrome (OSA) affects 1%-3% of children. Children with OSA can present for all types of surgical and diagnostic procedures requiring anesthesia, with adenotonsillectomy being the most common surgical treatment for OSA in the pediatric age group. Thus, it is imperative that the anesthesiologist be familiar with the potential anesthetic complications and immediate postoperative problems associated with OSA. The significant implications that the presence of OSA imposes on perioperative care have been recognized by national medical professional societies. The American Academy of Pediatrics published a clinical practice guideline for pediatric OSA in 2002, and cited an increased risk of anesthetic complications, though specific anesthetic issues were not addressed. In 2006, the American Society of Anesthesiologists published a practice guideline for perioperative management of patients with OSA that noted the pediatric-related risk factor of obesity, and the increased perioperative risk associated with adenotonsillectomy in children younger than 3 yr. However, management of OSA in children younger than 1 yr-of-age was excluded from the guideline, as were other issues related specifically to the pediatric patient. Hence, many questions remain regarding the perioperative care of the child with OSA.

In this review, we examine the literature on pediatric OSA, discuss its pathophysiology, current treatment options, and recognized approaches to perioperative management of these young and potentially high-risk patients.


妊娠早期异丙酚诱导和恢复麻醉的效应室浓度的预测
Predicted Propofol Effect-Site Concentration for Induction and Emergence of Anesthesia During Early Pregnancy

Nicolas Mongardon, MD*, Frédérique Servin, MD, PhD*, Mathilde Perrin, MD*, Ennoufous Bedairia, MD*, Sylvie Retout, PhD{dagger}, Chadi Yazbeck, MD, PhD{ddagger}, Philippe Faucher, MD{ddagger}, Philippe Montravers, MD, PhD*, Jean-Marie Desmonts, MD*, and Jean Guglielminotti, MD*

From the *Département d’Anesthésie et de Réanimation Chirurgicale; {dagger}Département d’Epidémiologie, Biostatistique et Recherche Clinique; and {ddagger}Service de Gynécologie et d’Obstétrique, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France.

Anesth Analg 2009 109: 90-95.

 

背景:据称由于孕酮的原因,妊娠降低了对催眠药的要求。然而,妊娠和黄体酮对异丙酚的用量的影响未完全阐明。作者进行这项研究,以确定麻醉诱导使意识丧失时异丙酚的剂量和预测效应室的浓度,以及妊娠早期麻醉过程中麻醉药用量是否减少。并验证血孕酮是否与异丙酚剂量和效应室浓度在意识丧失方面相关。
方法: 57ASA I-II级的妇女选择终止妊娠和55位妇女进行阴道穿刺卵母细胞体外受精。用1 %异丙酚以200ml/min?的速度麻醉诱导。诱导过程中记录在意识丧失时异丙酚剂量和计算的效应室浓度( Schnider模型)。另计算麻醉时患者能睁眼时的效应室浓度。手术后测定血孕酮浓度。
结果:与未孕对照组相比,怀孕组意识丧失时异丙酚平均( ± 1SD )剂量较少(108.57 ± 20.04 vs 117.59 ± 17.98 mg, respectively; P = 0.014) 。同样,怀孕组所计算的异丙酚效应室浓度明显低于对照组(分别为 4.59 ± 0.725.01 ± 0.64 μg / ml时, P=0.0014 。这两组在麻醉过程中能睁眼时的效应室浓度无差异。意识丧失时所观察的血孕酮和异丙酚剂量或异丙酚效应室浓度的关系无显着相关性。
结论:在妊娠早期意识丧失时异丙酚剂量和预测异丙酚效应室浓度减少。但不能用黄体酮浓度变化来解释。

(张磊 译 陈杰 校)

BACKGROUND: Pregnancy is associated with decreased hypnotic requirement, allegedly related to progesterone. However, the effects of pregnancy and progesterone on propofol requirement have not been thoroughly investigated. We conducted this study to determine whether propofol dose and predicted effect-site concentration for loss of consciousness (LOC) during induction of anesthesia, and eye opening during emergence from anesthesia, are decreased during early pregnancy. We also investigated whether blood progesterone was correlated with propofol dose and effect-site concentration for LOC.

METHODS: We studied 57 ASA I-II women patients undergoing elective termination of pregnancy and 55 control patients undergoing transvaginal oocyte puncture for in vitro fertilization. Anesthesia was induced by administration of a 1% propofol infusion at 200 mL/min. Propofol dose and calculated effect-site concentration (Schnider model) were recorded at the time of LOC during induction. We also calculated effect-site concentration at the time of eye opening upon emergence from anesthesia. Blood progesterone was measured after surgery.

RESULTS: Mean (±1 sd) propofol dose at LOC was significantly reduced in the pregnant patients compared with the nonpregnant control patients (108.57 ± 20.04 vs 117.59 ± 17.98 mg, respectively; P = 0.014). Similarly, the calculated propofol effect-site concentration at LOC was significantly lower in the pregnant patients than the nonpregnant control patients (4.59 ± 0.72 vs 5.01 ± 0.64 µg/mL, respectively; P = 0.0014). There was no difference in the calculated effect-site concentration on eye opening upon emergence. No significant relationship was observed between blood progesterone and propofol dose or calculated propofol effect-site concentration at LOC.

CONCLUSION: Propofol dose and predicted propofol effect-site concentration at LOC are decreased during early pregnancy. Progesterone does not explain this result.

 

硫喷妥钠抑制脂多糖诱导的组织因子的表达
Thiopental Inhibits Lipopolysaccharide-Induced Tissue Factor Expression

Matthias Hartmann, Priv Doz Dr med*, Semih Özlügedik, Dr med{dagger}, and Juergen Peters, Prof Dr med*

From the *Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Universitätsklinikum Essen, Essen, Germany; and {dagger}Klinik für Anästhesiologie, Universität Düsseldorf, Universitätsklinikum Düsseldorf, Düsseldorf, Germany.

Anesth Analg 2009 109: 109-113.

 

背景:在革兰氏阴性菌引起败血症时,脂多糖( LPS )刺激Toll样受体4 ,从而激活免疫系统,并在单核细胞上表达组织因子,进而可能发生血管内凝血,心肌缺血,多器官功能障碍。因为硫喷妥钠已被证实具有调节免疫系统的作用,作者假设硫喷妥钠能改变LPS诱导组织因子的表达。
方法: 1. 用硫喷妥钠( 0 0.250.5 1mg/ml)和脂多糖( 100µg/mL)枸橼酸化全血样本4小时。再钙化后,凝血时间( CT )是由ROTEM来测定 2. LPS诱导缩短CT的机制通过使用组织因子受体阻滞剂活性位点抑制因子VIIA和蛋白质合成抑制剂放线菌酮来确定。3. 制定组织因子影响CT的浓度反应曲线。
结果:脂多糖缩短了CT,由618 ± 122 s192 ± 33秒( n = 6; P < 0.05 CT的缩短通过组织因子的合成媒介,因为蛋白质合成抑制和组织因子的阻断影响消除了LPS作用。硫喷妥钠明显抑制LPS诱导的CT缩短(372 ± 86 s; n = 6; P < 0.001 。通过CT与组织因子标准曲线比较后表明,硫喷妥钠降低了LPS诱导组织因子活性达86 。排除硫喷妥钠对凝血的直接影响,因为组织因子诱导的CT没有受到巴比妥酸盐的影响。
结论:在全血样本中硫喷妥钠明显抑制LPS诱导组织因子的表达。

(丁俊云 译 陈杰 校)

BACKGROUND: During Gram-negative sepsis, lipopolysaccharide (LPS) stimulates toll-like receptor 4, resulting in an activation of the immune system and the expression of tissue factor on monocytes. As a consequence, intravascular coagulation, ischemia, and multiorgan dysfunction may occur. Because thiopental has been described to modulate the immune system, we tested the hypothesis that thiopental alters the LPS-induced tissue factor expression.

METHODS: (i) Citrated whole blood samples were incubated with thiopental (0, 0.25, 0.5, 1 mg/mL) and LPS (100 µg/mL) for 4 h. After recalcification, clotting time (CT) was determined by rotational thrombelastometry. (ii) The mechanism of the LPS-induced shortening of CT was investigated using the tissue factor blocker active-site inhibited factor VIIa and the protein synthesis inhibitor cycloheximide. (iii) A concentration response curve for the effect of tissue factor on CT was generated.

RESULTS: LPS shortened CT from 618 ± 122 s to 192 ± 33 s (n = 6; P < 0.05). Shortening of CT was mediated by synthesis of tissue factor, because both inhibition of protein synthesis and blockade of tissue factor effects abolished this effect of LPS. Thiopental markedly inhibited the LPS-induced shortening of CT (372 ± 86 s; n = 6; P < 0.001). Comparison of CT with a tissue factor standard curve demonstrated that thiopental reduced the LPS-induced tissue factor activity up to 86%. A direct effect of thiopental on coagulation was excluded, because tissue factor-induced CT was not affected by the barbiturate.

CONCLUSIONS: Thiopental markedly inhibits the LPS-induced tissue factor expression in whole blood samples.

 

NICO监护仪能估测混合静脉血红蛋白氧饱和度吗?
Can Mixed Venous Hemoglobin Oxygen Saturation Be Estimated Using a NICO Monitor?

Yoshifumi Kotake, MD, PhD*, Takashige Yamada, MD{dagger}, Hiromasa Nagata, MD{dagger}, Takeshi Suzuki, MD, PhD{dagger}, and Junzo Takeda, MD, PhD{dagger}

From the *Department of Anesthesiology, Toho University Medical Center Ohmori Hospital; and {dagger}Department of Anesthesiology, School of Medicine, Keio University, Tokyo, Japan.

Anesth Analg 2009 109: 119-123.

 

背景:作者假设,混合静脉血红蛋白氧饱和度( SvO2 )可通过无创心输出量(NICO)监测以计算二氧化碳产生、心输出量和动脉血氧饱和度来估测。
方法: 23名进行主动脉瘤修复的患者使用肺动脉导管监测SvO2NICO监测心输出量。通过NICO计算出的SvO2值与使用肺动脉导管实测的SvO2值进行比较。这一估测的准确性由Bland-Altman方法进行分析。另利用相关分析评估SvO2估测值和SvO2值的变化。
结果: SvO2估测值与实测值的偏倚及范围-2.1 ± 11.2 SvO2估测值与实测值的变化相关。
结论:来自NICOSvO2估测值不能与肺动脉导管的实测值互换使用。还需更完善的方法以便获得更可靠的SvO2值。然而,在未作中心静脉导管插管时,SvO2值变化较大时这方法可用来作为氧供需失衡而的预警信号。

(舒慧刚 译 陈杰 校)

BACKGROUND: We hypothesized that mixed venous hemoglobin oxygen saturation (SvO2) can be estimated by calculation from CO2 production, cardiac output, and arterial oxygen saturation measured using a noninvasive cardiac output (NICO) monitor (Novametrix-Respironics, Wallingford, CT).

METHODS: Twenty-three patients undergoing aortic aneurysm repair underwent SvO2 monitoring using a pulmonary artery catheter and cardiac output monitoring using a NICO monitor. The estimated SvO2 value calculated from NICO monitor-derived values was compared with the SvO2 value measured using a pulmonary artery catheter. The accuracy of this estimation was analyzed with Bland-Altman method. The ability of this estimation to track the change of SvO2 was also evaluated using correlation analysis to compare the changes of estimated SvO2 and measured SvO2.

RESULTS: The bias ± limits of agreement of the estimated SvO2 against measured SvO2 was –2.1% ± 11.2%. The change of estimated SvO2 was modestly correlated with the change of measured SvO2.

CONCLUSIONS: SvO2 derived from the values measured by the NICO monitor cannot be used interchangeably with the values measured spectrophotometrically using the pulmonary artery catheter. More refinement is required to obtain more reliable estimate of SvO2 less invasively. However, large changes of SvO2 may be detected with this method and can be used as a precautionary sign when the balance between oxygen supply and demand is compromised without inserting a central venous catheter.


非诺特罗的吸入对酸吸入性肺损伤的影响

The Effects of Fenoterol Inhalation After Acid Aspiration-Induced Lung Injury

Michael T. Pawlik, MD*, Thomas Schubert, MD{dagger}, Susanne Hopf, MD*, Matthias Lubnow, MD{ddagger}, Michael Gruber, PhD*, Christoph Selig, MD§, Kai Taeger, MD, PhD*, and Karl P. Ittner, MD*

From the Departments of *Anesthesiology, {dagger}Pathology, {ddagger}Cardiology, Pulmonology and Intensive Care, University Hospital, Regensburg, Germany; and §Department of Anesthesiology, University Hospital Ulm, Ulm, Germany.

Anesth Analg 2009 109: 143-150.

BACKGROUND: Acid aspiration is a serious complication that can occur during general anesthesia.背景:酸吸入是一个可能在全身麻醉发生的严重并发症。 Studies show that β-agonists have beneficial effects on lung injury.研究表明, β -激动剂对于肺损伤有有益的影响。 Therefore, we tested the effect of the nebulized β-agonist fenoterol on lung variables in a rodent model of acid-induced lung injury.因此,作者测试了雾化吸入β -受体激动剂非诺特罗对酸诱导肺损伤啮鼠动物模式肺变量的影响。

METHODS: In a prospective, randomized, and controlled study, we evaluated the effects of fenoterol inhalation on lung oxygenation, inflammation, and pulmonary histology in a rat model of acid-induced lung injury.方法:在这项前瞻性,随机,对照研究中,作者评估了吸入非诺特罗对于酸诱导肺损伤大鼠模型的肺氧合、炎症、以及肺组织的影响。 Sprague-Dawley rats underwent sevoflurane anesthesia with tracheotomy and carotid catheter insertion.七氟醚麻醉的Sprague - Dawley大鼠进行了气管切开术和置入颈内动脉导管。 Lung injury was induced by instillation of 0.4 mL/kg 0.1 M hydrochloric acid.通过滴注0.4ml/kg 0.1M的盐酸诱导肺损伤。The lungs were ventilated for 6 h and randomized to receive either fenoterol inhalation 10 µg or saline inhalation, both at 15 and 180 min after acid aspiration.肺进行6 h的通气后,吸入酸15min180 min后随机吸入10ug非诺特罗或吸入生理盐水。记录Mean arterial blood pressures and peak airway pressures were documented, arterial blood gases were determined at 30, 90, 180, 270, and 360 min, and postmortem histology was subsequently examined.平均动脉压力和气道峰压力,测定3090180 270以及360min时的动脉血气,随后处死并行组织病理检查。Additionally, fenoterol concentrations in bronchoalveolar lavage fluid (BALF) and plasma were determined by liquid chromatography/tandem mass spectroscopy.此外,用液相色谱/ 质谱法来测定支气管肺泡灌洗液( BALF )和血浆中非诺特罗的浓度。360min后,测定支气管肺泡灌洗液中肿瘤坏死因子(TNF)和白细胞介素(IL -6),且测定湿/干比。

RESULTS: Inhalation treatment with 10 µg fenoterol significantly increased oxygenation after 270 and 360 min when compared with placebo.结果:与安慰剂相比,10ug非诺特罗的吸入治疗后270360min显著增加了氧合作用。 Fenoterol-treated rats showed a significant decrease in IL-6 and TNF- levels and in the wet/dry weight ratio of the lungs.非诺特罗治疗的大鼠显示出了 IL - 6TNF 水平以及肺部湿/干比的显著降低。 在非诺特罗组The histologic appearance showed significantly less interstitial edema and leukocyte infiltration in the fenoterol group.组织学表现展现了明显减少的间质水肿及白细胞浸润。 支气管肺泡灌洗液中The concentration of fenoterol was 10.3 µg/L (median) in the BALF and <1 µg/L in the plasma.非诺特罗的浓度为10.3ug/l(中位数)在和 血浆中浓度< 1ug/l

CONCLUSIONS: Fenoterol inhalation improved oxygenation after 270 and 360 min, attenuated the release of TNF- and IL-6, and diminished the lung edema and infiltration of polymorphonuclear leukocytes.结论:吸入非诺特罗270360min氧合改善,降低TNFIL6的释放 ,且减少肺水肿和多形核细胞浸润。

(怀晓蓉 译 陈杰 校)

BACKGROUND: Acid aspiration is a serious complication that can occur during general anesthesia. Studies show that β-agonists have beneficial effects on lung injury. Therefore, we tested the effect of the nebulized β-agonist fenoterol on lung variables in a rodent model of acid-induced lung injury.

METHODS: In a prospective, randomized, and controlled study, we evaluated the effects of fenoterol inhalation on lung oxygenation, inflammation, and pulmonary histology in a rat model of acid-induced lung injury. Sprague-Dawley rats underwent sevoflurane anesthesia with tracheotomy and carotid catheter insertion. Lung injury was induced by instillation of 0.4 mL/kg 0.1 M hydrochloric acid. The lungs were ventilated for 6 h and randomized to receive either fenoterol inhalation 10 µg or saline inhalation, both at 15 and 180 min after acid aspiration. Mean arterial blood pressures and peak airway pressures were documented, arterial blood gases were determined at 30, 90, 180, 270, and 360 min, and postmortem histology was subsequently examined. Additionally, fenoterol concentrations in bronchoalveolar lavage fluid (BALF) and plasma were determined by liquid chromatography/tandem mass spectroscopy. After 360 min tumor necrosis factor (TNF)-{alpha} and interleukin (IL)-6 were determined in the BALF, and lungs were dried for determination of the wet/dry ratio.

RESULTS: Inhalation treatment with 10 µg fenoterol significantly increased oxygenation after 270 and 360 min when compared with placebo. Fenoterol-treated rats showed a significant decrease in IL-6 and TNF-{alpha} levels and in the wet/dry weight ratio of the lungs. The histologic appearance showed significantly less interstitial edema and leukocyte infiltration in the fenoterol group. The concentration of fenoterol was 10.3 µg/L (median) in the BALF and <1 µg/L in the plasma.

CONCLUSIONS: Fenoterol inhalation improved oxygenation after 270 and 360 min, attenuated the release of TNF-{alpha} and IL-6, and diminished the lung edema and infiltration of polymorphonuclear leukocytes.


硬膜外注射2-氯普鲁卡因与吗啡的相互作用——一项关于吗啡镇痛时效的随机对照试验

The Interaction Between Epidural 2-Chloroprocaine and Morphine: A Randomized Controlled Trial of the Effect of Drug Administration Timing on the Efficacy of Morphine Analgesia

Paloma Toledo, MD, Robert J. McCarthy, PharmD, Mary Jane Ebarvia, BS, RN, Christopher J. Huser, MD, and Cynthia A. Wong, MD

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

Anesth Analg 2009 109: 168-173.

 

背景:与利多卡因相比,硬膜外吗啡伍用2-氯普鲁卡因镇痛作用降低已不常用。2-氯普鲁卡因与吗啡之间的相互作用机制至今未明。可能的机制包括两种药物之间药物反应时间及作用时程的不同以及阿片受体对抗性。本实验中作者选取了产后输卵管结扎的病人,假设在硬膜外注射2-氯普鲁卡因前30分钟注射吗啡会导致的术后镇痛的时程及效果与硬膜外给予利多卡因后注射吗啡是一致的。

方法:实验选取阴道分娩后行双侧输卵管结扎并实施硬膜外镇痛的患者,随机分为三组,其中一组在实施硬膜外给予3%2-氯普鲁卡因镇痛前30分钟预注吗啡,另一组则预注生理盐水,第三组则硬膜外给予2%利多卡因术后镇痛,并且在手术切皮后,三组硬膜外不输注任何药物包括吗啡及生理盐水。镇痛时效定义为从吗啡输注到患者要求追加镇痛剂量的时间。硬膜外吗啡的作用时程采用Kaplan-Meier组间分析及log-rank检验。

结果:在硬膜外注射2-氯普鲁卡因前30分钟注射吗啡(n=29)导致较长的镇痛时程(28.6 h [95% CI 4.4–52.7])。而在2-氯普鲁卡因后注射吗啡(n = 30)其作用时程为(2.2 h [95% CI 0–4.8]) (P = 0.006)。硬膜外注射2-氯普鲁卡因前注射吗啡与注射利多卡因后注射吗啡两者的作用时程相似(n = 28) (25.8 h [95% CI 10.7–40.9]) (P = 0.83)。在麻醉术后复苏室内对两组进行疼痛评分也无明显差异。而该疼痛评分在产后恢复室内硬膜外注射2-氯普鲁卡因后注射吗啡这组中评分较高。在48小时内吗啡的追加量相似,并且在阿片类药物相关副作用中无明显差异。

结论:这项研究证实在硬膜外输注2-氯普鲁卡因前30分钟输注吗啡其作用时程与输注利多卡因后输注吗啡的镇痛时程是相似的。这提示硬膜外吗啡与2-氯普鲁卡因的相互作用是由于两种药物的作用时程,在2-氯普鲁卡因前输注吗啡能有效的阻滞阿片类药物受体对抗性。

(赵嫣红 译 陈杰 校)

BACKGROUND: The efficacy and duration of epidural morphine analgesia is diminished when administered after 2-chloroprocaine compared with lidocaine. The mechanism of the interaction between 2-chloroprocaine and morphine is unknown. Possible explanations include differences in the latency and duration of action of the two drugs or opioid receptor antagonism. We hypothesized that administration of epidural morphine 30 min before the initiation of 2-chloroprocaine anesthesia would result in postoperative analgesia of similar duration and quality to that achieved by epidural morphine after the initiation of lidocaine anesthesia in patients undergoing postpartum tubal ligation.

METHODS: Subjects undergoing bilateral postpartum tubal ligation after vaginal delivery with epidural analgesia were randomized to one of three groups. Subjects received epidural morphine or saline 30 min before the initiation of analgesia with 3% 2-chloroprocaine (two groups) or 2% lidocaine (one group), and at the time of surgical incision, they received either epidural saline or morphine. The duration of analgesia was defined as the time from morphine administration until the first request for supplemental analgesia. Duration of epidural morphine analgesia was compared among groups using Kaplan–Meier survival analysis and the log-rank test.

RESULTS: Administration of epidural morphine 30 min before the initiation of 2-chloroprocaine anesthesia (n = 29) resulted in a longer median duration of analgesia (28.6 h [95% CI 4.4–52.7]) compared with the administration of morphine after 2-chloroprocaine anesthesia (n = 30) (2.2 h [95% CI 0–4.8]) (P = 0.006). The median duration of analgesia observed when morphine was administered before 2-chloroprocaine was similar to that observed when morphine was administered after initiation of lidocaine anesthesia (n = 28) (25.8 h [95% CI 10.7–40.9]) (P = 0.83). Pain scores were not different in the postanesthesia care unit, but were higher on admission to the postpartum unit in the subjects receiving morphine after 2-chloroprocaine. Supplemental morphine equivalents administered in the first 48 h were similar among groups and there were no differences in opioid-related side effects.

DISCUSSION: This study demonstrates that administration of epidural morphine 30 min before epidural anesthesia with 2-chloroprocaine provides a similar duration of analgesia as epidural morphine after epidural lidocaine anesthesia. This suggests that the observed interaction between epidural morphine and 2-chloroprocaine is a result of differences in latency and duration of action of the two drugs, or that the administration of morphine before 2-chloroprocaine effectively blocks a receptor site antagonism.

 

 

开颅手术中动脉血二氧化碳分压与七氟醚对脑毛细静脉血流、脑血流及血氧饱和度的影响

The Effects of Arterial Carbon Dioxide Partial Pressure and Sevoflurane on Capillary Venous Cerebral Blood Flow and Oxygen Saturation During Craniotomy

Klaus Ulrich Klein, MD*, Martin Glaser, MD{dagger}, Robert Reisch, MD, PhD{dagger}, Achim Tresch, MSc{ddagger}, Christian Werner, MD, PhD*, and Kristin Engelhard, MD, PhD*

From the Departments of *Anesthesiology, {dagger}Neurosurgery, Johannes Gutenberg-University, Mainz, Germany; and {ddagger}Department of Chemistry and Biochemistry, Gene Center Munich, Ludwig-Maximilians-University, Munich, Germany.

Anesth Analg 2009 109: 199-204.

 

背景:术中常规监测脑血流及氧合是一项技术挑战。通过二氧化碳对脑血管产生的生理反应,作者旨在研究一先进的神经监测装置(oxygen-to-see, O2CTM device),在毛细静脉水平,对开颅手术病人的区域脑血流(rvCBF),流速(rvVelo),氧饱和度(srvO2)以及血色素(rvHb)的同步监测意义。

方法: 26名神经外科病人随机分配接受呼气末浓度为1.4%或者2%七氟醚。开颅后,在手术侧,在肉眼可见正常的脑组织表面放置一光纤探头。每位病人同步监测低动脉二氧化碳分压(35mmHg)或高动脉二氧化碳分压(45mmHg)时脑深度为2mm8mm的组织脑血流。应用激光多普勒血流计(rvCBF, rvVelo)和分光光度计(srvO2, rvHb)测量。使用线性模型检验低动脉二氧化碳分压和高动脉二氧化碳分压,1.4%2%呼气末七氟醚浓度,2mm8mm脑深度时rvCBF, rvVelo, srvO2, rvHb数值变化的线性关系。

结果:在脑组织深度2mm8mm处,RvCBF rvVelo随动脉二氧化碳分压升高而增加,而与七氟醚浓度无关(P < 0.001)。高二氧化碳分压使平均氧饱和度从50%上升至68%P < 0.001)。脑深度8mm处较脑深度2mm处的血流流速(P < 0.001)和氧饱和度(P=0.007)快和高。RvHb不受二氧化碳变化影响,但是和七氟醚浓度呈正相关(P=0.005)。

结论:二氧化碳分压造成的脑血流和流速增加提示在呼气末浓度1.4%2%七氟醚麻醉下,高二氧化碳可造成保护性血管扩张。氧饱和度连续升高提示高二氧化碳分压导致脑动静脉中氧降低存在差异。血色素量不变表示,监测中没有血液丢失。数据显示,此装置可以监测脑微血管主要静脉在不同二氧化碳分压水平的血流和氧饱和度。

(朱紫瑜 译 陈杰 校)

BACKGROUND: Intraoperative routine monitoring of cerebral blood flow and oxygenation remains a technological challenge. Using the physiological principle of carbon dioxide reactivity of cerebral vasculature, we investigated a recently developed neuromonitoring device (oxygen-to-see, O2CTM device) for simultaneous measurements of regional cerebral blood flow (rvCBF), blood flow velocity (rvVelo), oxygen saturation (srvO2), and hemoglobin amount (rvHb) at the capillary venous level in patients subjected to craniotomy.

METHODS: Twenty-six neurosurgical patients were randomly assigned to anesthesia with 1.4% or 2.0% sevoflurane end-tidal concentration. After craniotomy, a fiberoptic probe was applied on a macroscopically healthy surface of cerebral tissue next to the site of surgery. Simultaneous measurements in 2 and 8 mm cerebral depth were performed in each patient during lower (35 mm Hg) and higher (45 mm Hg) levels (random order) of arterial carbon dioxide partial pressure (Paco2). The principle of these measurements relies on the combination of laser-Doppler flowmetry (rvCBF, rvVelo) and photo-spectrometry (srvO2, rvHb). Linear models were fitted to test changes of end points (rvCBF, rvVelo, srvO2, rvHb) in response to lower and higher levels of Paco2, 1.4% and 2.0% sevoflurane end-tidal concentration, and 2 and 8 mm cerebral depth.

RESULTS: RvCBF and rvVelo were elevated by Paco2 independent of sevoflurane concentration in 2 and 8 mm depth of cerebral tissue (P < 0.001). Higher Paco2 induced an increase in mean srvO2 from 50% to 68% (P < 0.001). RvVelo (P < 0.001) and srvO2 (P = 0.007) were higher in 8 compared with 2 mm cerebral depth. RvHb was not influenced by alterations in Paco2 but positively correlated to sevoflurane concentration (P = 0.005).

CONCLUSIONS: Increases in rvCBF and rvVelo by Paco2 suggest preserved hypercapnic vasodilation under anesthesia with sevoflurane 1.4% and 2.0% end-tidal concentration. A consecutive increase in srvO2 implies that cerebral arteriovenous difference in oxygen was decreased by elevated Paco2. Unchanged levels of rvHb signify that there was no blood loss during measurements. Data suggest that the device allows detection of local changes in blood flow and oxygen saturation in response to different Paco2 levels in predominant venous cerebral microvessels.

 

经椎孔硬膜外注射的血管内扩散方式:颈椎和腰椎的对比研究

Intravascular Flow Patterns in Transforaminal Epidural Injections: A Comparative Study of the Cervical and Lumbar Vertebral Segments

Do Wan Kim, MD, Kyung Ream Han, MD, Chan Kim, MD, and Yun Jeong Chae, MD

From the Department of Anesthesiology and Pain Medicine, Pain Clinic, College of Medicine, Ajou University, Suwon, Korea.

Anesth Analg 2009 109: 233-239.

 

背景:经椎孔硬膜外注射(transforaminal epidural injectionTEI)通常用于神经根性疼痛的治疗。然而,许多已发表的研究表明,TEI的实施经常伴有严重的并发症,其中大多发生在颈椎水平。对该并发症的一种解释是操作者不慎将药物注入了血管内。作者拟鉴别在实施TEI时颈椎和腰椎水平血管内注射的发生率。

方法:将伴有根性疼痛症状或者有带状疱疹相关疼痛的患者前瞻性地分为2组,各由一位作者对其实施颈椎或腰椎TEIlumbar TEIsLTEIs)。以双平面X线透视确认了穿刺针的理想位置后,操作者在X线透视下以0.3-0.5ml/s的速度持续注入由非离子型造影剂和生理盐水组成的混合液3ml的实时显影。

结果:研究共实施了182TEI56例(30.8%)的注射液扩散至血管内,其中45例发生在颈段TEIcervical TEICTEI),11例为LTEI。其中,52.1%CTEI9%LTEI注射液同时扩散至神经周围和血管内,11.3%CTEI0.9%LTEI病例的注射液仅扩散至血管内。

结论:实施CTEILTEI时,注射液误入血管的发生率前者明显高于后者,表明操作者应更加谨慎地实施CTEI。此外,与之前的报道相比,实施CTEI时注射液误入血管的发生率明显偏高。这一发现提示在实施操作时,需要加入适量的造影剂(3ml)以探测注射液是否注入了血管内,注射液同时扩散至血管内和神经周围的情况尤为突出。

(周姝婧 译 陈杰 校)

BACKGROUND: Transforaminal epidural injection (TEI) is commonly used in the treatment of radicular pain. However, there have been many published cases of serious complications after a TEI, occurring most often in cervical levels. One of the presumptive reasons for this complication is inadvertent intravascular injection. We sought to identify the incidence of intravascular injections in cervical and lumbar spinal segments during TEI.

METHODS: All patients with radicular symptoms or herpes zoster-associated pain underwent cervical and lumbar TEIs (LTEIs) prospectively by one of the authors. After an ideal needle position was confirmed by biplanar fluoroscopy, 3 mL of a mixture containing nonionic contrast and normal saline was continuously injected at the rate of 0.3–0.5 mL/s with real-time fluoroscopic visualization.

RESULTS: One hundred eighty-two TEIs were performed. Fifty-six cases (30.8%) showed intravascular spreading patterns, 45 cases occurring during a cervical TEI (CTEI) and 11 during a LTEI. The incidences of simultaneous perineural and vascular injection in cervical and LTEIs were 52.1% and 9%, respectively, and pure vascular flow pattern rates in cervical and LTEIs were 11.3% and 0.9%, respectively.

CONCLUSION: The incidence of vascular injection in CTEIs is significantly higher than in LTEIs, suggesting that CTEIs should be performed more cautiously. Furthermore, the vascular injection rate of CTEIs is much higher than that previously reported. This finding suggests the need for a proper volume of contrast injection (3 mL) to detect vascular flow, especially in simultaneous perineural and vascular injections.

 

美西律和利多卡因对后角神经元兴奋性的抑制作用

Mexiletine and Lidocaine Suppress the Excitability of Dorsal Horn Neurons

Andrea Olschewski, MD, PhD*{dagger}, Rose Schnoebel-Ehehalt, MD*, Yingji Li, MD, PhD{ddagger}§, Bi Tang, MD{ddagger}§, Michael E. Bräu, MD, PhD*, and Matthias Wolff, MD, PhD*

From the *Departments of Anaesthesiology, Intensive Care Medicine, Pain Therapy, University Clinic Giessen and Marburg GmbH, Giessen, Germany; {dagger}Experimental Anaesthesiology, University Clinic of Anaesthesia and Intensive Care Medicine, Medical University of Graz, Austria; {ddagger}Department of Pulmonology, University Clinic of Internal Medicine, Medical University of Graz, Austria; and §Department of Physiology, Justus-Liebig-University, Giessen, Germany.

Anesth Analg 2009 109: 258-264.

 

背景:神经受损后,后角神经元的敏化作用和痛觉异化路径改变了脊髓信号输出,导致痛觉提高及慢性疼痛综合症。临床上使用剂量不足以阻滞传导的Na+通道阻滞剂可缓解这种慢性疼痛。尽管对这些药对传入的影响作用关注备至,很少有研究关注他们对中央感觉神经的兴奋作用。因此作者研究了Na+阻滞剂美西律和利多卡因对感觉神经后角神经元的作用。

方法:用膜片钳技术记录美西律和利多卡因对年轻大鼠不同种类的后角神经元(强化发热、适应发热和单峰神经元)的作用。

结果:所有三种不同神经元对美西律和利多卡因的反应呈剂量依赖性。两种局部麻醉药可逆性抑制Na+ K+电流。对Na+传导阻滞的最大半数抑制浓度为89± 2 54 ± 6 µM,对K+传导阻滞的延迟整流浓度分别为利多卡因582 ± 36 及美西律398 ± 14 µM。对Na+ K+ 连续电流的抑制改变了单个动作电位的特性并降低强直发放和适应发放神经元的发放频率。

结论:在与临床相关的浓度中,通过阻滞Na+ K+通道降低感觉神经后角神经元的兴奋性。研究证实利多卡因和美西律除了其周围神经作用外,它们对中枢神经系统中电压门控离子通道的调节作用在疼痛治疗中的抗伤害作用中有重要意义。

(黄丹 译 陈杰 校)

BACKGROUND: Spinal sensitization and facilitatory processes in dorsal horn neurons after nerve injury alter spinal outflow leading to enhanced pain perception and chronic pain syndromes. Clinically used Na+ channel blockers at doses which do not block conduction can relieve such chronic pain. Although much attention has been paid to their effect upon afferents, less work has been done with their effect on the excitability of central sensory neurons. Thus, we investigated the effects of the Na+ channel blockers mexiletine and lidocaine on sensory spinal dorsal horn neurons.

METHODS: Patch-clamp recordings were directly performed in visualized neurons of the substantia gelatinosa in the spinal cord of young rats to investigate the effect of mexiletine and lidocaine in different types of dorsal horn neurons (tonically firing, adapting-firing, and single spike neurons).

RESULTS: All three different types of neurons responded dose-dependently to mexiletine and lidocaine. Both local anesthetics reversibly inhibited Na+ and K+ currents. The half-maximal inhibitory concentration for Na+ conductance block was 89 ± 2 or 54 ± 6 µM and for delayed-rectifier K+ conductance block was 582 ± 36 or 398 ± 14 µM for lidocaine and mexiletine, respectively. The inhibition of Na+ and K+ currents consecutively altered the properties of single action potentials and reduced the firing rate of tonically firing and adapting-firing neurons.

CONCLUSIONS: In clinically relevant concentrations, lidocaine and mexiletine reduced the excitability of sensory dorsal horn neurons via a blockade of Na+ and K+ channels. Our work confirms that, in addition to the peripheral effects of lidocaine and mexiletine, modulation of voltage-gated ion channels in the central nervous system contributes to the antinociceptive effects of these drugs used in pain therapy.

 

超声引导下腋路臂丛神经阻滞(局部麻醉药混合液20ml)与全麻在上肢外伤手术中的比较:一项单盲、前瞻、随机、对照试验

Ultrasound-Guided Axillary Brachial Plexus Block with 20 Milliliters Local Anesthetic Mixture Versus General Anesthesia for Upper Limb Trauma Surgery: An Observer-Blinded, Prospective, Randomized, Controlled Trial

Brian D. O’Donnell, MB, FCARCSI, MSc, Helen Ryan, MB, BCh, BAO, Owen O’Sullivan, MB, FCARCSI, and Gabrielle Iohom, FCARCSI, MD, PhD

From the Department of Anesthesia, Cork University Hospital, Wilton, Cork, Ireland.

Anesth Analg 2009 109: 279-283.

 

目的:作者随机、对照研究低剂量超声引导腋路臂丛神经阻滞与全身麻醉的麻醉效果及预后。

方法:患者随机接受超声引导腋路臂丛神经阻滞或全身麻醉。超声引导腋路臂丛神经阻滞使用一种针面朝外进路的方法。超声引导定位正中神经、尺神经、桡神经、和肌皮神经后,分别注射至多5毫升的局麻药(等份混合2%利多卡因与加入7.5mg/mL可乐定的0.5%布比卡因并加入1200000肾上腺素)。局麻药注射总量不超过20毫升。全身麻醉标准包括用芬太尼和异丙酚诱导,使用七氟醚和N2O的混合气体来维持。疼痛评分分别在在恢复室术后2 6 24 48小时和7天获得。并评估不需入恢复室人次和出院时间。

结果:所有超声引导腋路臂丛神经阻滞的患者取得了令人满意的麻醉效果。超声引导腋路臂丛神经阻滞组患者在恢复室、术后2小时、6小时,视觉模拟疼痛评分较低(分别为:0.3[1.3]55.8 [36.5]P<0.0010.3[1.3]45[29.6]P< 0.00,;1.1[2.7]4[2.8]P<0.01)。所有超声引导腋路臂丛神经阻滞患者无需在恢复室进行观察,且较接受全麻的病人更早出院( 30min120min30/240 P<0.0001  

结论:与全身麻醉相比,在上肢外伤手术,超声引导腋路臂丛神经阻滞(使用20ml局部麻醉药混合液)提供了令人满意的麻醉和镇痛效果。
(
张燕 译 陈杰 校)

OBJECTIVE: We performed a randomized, controlled trial comparing low-dose ultrasound-guided axillary block with general anesthesia evaluating anesthetic and perioperative analgesic outcomes.

METHODS: Patients were randomized to either ultrasound-guided axillary block or general anesthesia. Ultrasound-guided axillary block was performed using a needle-out-of-plane approach. Up to 5 mL of local anesthetic injectate (equal parts 2% lidocaine with 1:200,000 epinephrine and 0.5% bupivacaine with 7.5 mg/mL clonidine) was injected after identifying the median, ulnar, radial, and musculocutaneous nerves. A maximum of 20 mL local anesthetic injectate was used. General anesthesia was standardized to include induction with fentanyl and propofol, maintenance with sevoflurane in an oxygen/nitrous oxide mixture. Pain scores were measured in the recovery room and at 2, 6, 24, 48 h, and 7 days. Ability to bypass the recovery room and time to achieve hospital discharge criteria were also assessed.

RESULTS: All ultrasound-guided axillary block patients achieved satisfactory anesthesia. The ultrasound-guided axillary block group had lower visual analog scale pain scores in the recovery room (0.3 [1.3] vs 55.8 [36.5], P < 0.001), and visual rating scale pain scores at 2 h (0.3 [1.3] vs 45 [29.6], P < 0.001), and at 6 h (1.1 [2.7] vs 4 [2.8], P < 0.01). All ultrasound-guided axillary block patients bypassed the recovery room and attained earlier hospital discharge criteria (30 min vs 120 min 30/240 P < 0.0001 median [range]).

CONCLUSIONS: Ultrasound-guided axillary brachial plexus block with 20 mL local anesthetic mixture provided satisfactory anesthesia and superior analgesia after upper limb trauma surgery when compared with general anesthesia.

 

ε-氨基己酸和抑肽酶应用于行初次冠状动脉旁路分离手术患者后在纤维蛋白溶解和血液流失方面的效果:一个随机双盲,安慰剂控制的无差别试验

The Effect of Epsilon-Aminocaproic Acid and Aprotinin on Fibrinolysis and Blood Loss in Patients Undergoing Primary, Isolated Coronary Artery Bypass Surgery: A Randomized, Double-Blind, Placebo-Controlled, Noninferiority Trial. Philip E. Greilich, MD, FAHA*, Michael E. Jessen, MD{dagger}, Neeraj Satyanarayana, BS*, Charles W. Whitten, MD*, Gregory A. Nuttall, MD{ddagger}, Joseph M. Beckham, MD*, Michael H. Wall, MD§, and John F. Butterworth, MD||

From the Departments of *Anesthesiology and Pain Management, and {dagger}Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas; {ddagger}Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota; §Department of Anesthesiology, Washington University, St. Louis, Missouri; and ||Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana.

Anesth Analg 2009 109: 15-24.

 

背景:直到现在,抑肽酶仍是唯一一个美国法定认可的可应用于心血管手术的抗纤维蛋白溶解的药物。而最有可能替代抑肽酶的ε-氨基己酸(EACA)还未被充分地与抑肽酶比较。我们所要进行的研究正是要测试这一假说成立与否,即合理剂量地应用ε-氨基己酸,其在减少纤维蛋白溶解和血液流失方面的效果与抑肽酶并无差别。

方法78位择期行初次冠状动脉旁路分离手术的患者被随机地分为三组进行双盲实验:一组应用Hammersmith剂量的抑肽酶,一组应用大剂量的ε-氨基己酸(以100mg/kg为初始符合剂量,另将含ε-氨基己酸5g的溶液以30mg/kg·h的速度进行泵控维持给药),另一组给予等容量生理盐水作为安慰剂。ε-氨基己酸与抑肽酶的无差别性通过两个主要的终检值来测定——D-二聚体形成的峰值的降低(纤维蛋白溶解的一个测试指标)以及24小时胸管引流量(CTD)。与抑肽酶比较,无差别的可信区间被设定在D-二聚体形成的峰值增加30%(相差250ug/ml)以及24小时胸管引流量(相差350ml)。

结果:组间比较ε-氨基己酸与抑肽酶,两者的D-二聚体形成的峰值(-3.58 ug/L95% 可信区间: -203~195ug/L)和24小时胸管引流量(67 mL95% 可信区间:-90~230 mL)的差别均在预先设定的无差被可信区间范围内(分别为250ug/mL 350 mL),完全符合两者无差别的标准。生理盐水安慰剂组与ε-氨基己酸组和抑肽酶组比较,后两者D-二聚体形成的峰值均明显降低(ε-氨基己酸组 589ug/L95%可信区间为399~788ug/LP<0.0001抑肽酶组 585ug/L95%可信区间为393~778ug/LP<0.0001)。同样的,与生理盐水安慰剂比较,应用ε-氨基己酸组和抑肽酶组的24小时胸管引流量也明显减少(ε-氨基己酸组 239 mL95%可信区间为50~415 mLP<0.05;抑肽酶组 323 mL95%可信区间为105~485 mLP<0.05)。血浆ε-氨基己酸的水平可以很好地维持在靶浓度260ug/mL以上。

结论:行初次冠状动脉旁路分离手术的患者应用ε-氨基己酸,如按用药指南合理剂量给予,则其在减少纤维蛋白溶解和血液流失方面的效果与抑肽酶无差别。

(单嘉琪译 薛张纲校)

BACKGROUND: Until recently, aprotinin was the only antifibrinolytic drug with a licensed indication in cardiac surgery in the United States. The most popular alternative, [epsilon]-aminocaproic acid (EACA), has not been adequately compared with aprotinin. We undertook this study to test the hypothesis that EACA, when dosed appropriately, is not inferior to aprotinin at reducing fibrinolysis and blood loss.

METHODS: Seventy-eight patients scheduled for primary, isolated coronary artery bypass graft surgery were randomly assigned to receive "full Hammersmith" dose aprotinin, high dose EACA (100 mg/kg initial loading dose, 5 g in the pump prime solution, 30 mg [middle dot] kg-1 [middle dot] h-1 maintenance infusion) or equal volumes of a saline-placebo in a double-blind trial. Reductions in peak d-dimer formation (a measure of fibrinolysis) and 24-h chest tube drainage (CTD) were the primary end points by which noninferiority of EACA was tested. The noninferiority limit was set at a 30% increase in peak d-dimer formation (a difference of 250 [mu]g/mL) and 24-h CTD (a difference of 350 mL) relative to aprotinin.

RESULTS: The between-group differences (EACA versus aprotinin) in peak d-dimer formation (-3.58 [mu]g/L, 95% CI -203 to 195 [mu]g/L) and 24-h CTD (67 mL, 95% CI -90 to 230 mL) were within the predetermined noninferiority margins (250 [mu]g/mL and 350 mL, respectively) and satisfied the criteria for noninferiority. Compared with saline, significant between-group reductions in peak d-dimer formation were observed using EACA (589 [mu]g/L, 95% CI 399-788 [mu]g/L; P < 0.0001) and aprotinin (585 [mu]g/L, 95% CI 393-778 [mu]g/L; P < 0.0001). Similar reductions in 24 h CTD were also seen using EACA (239 mL, 95% CI 50-415 mL; P < 0.05) and aprotinin (323 mL, 95% CI 105-485 mL; P < 0.05) compared with saline. Plasma EACA levels were maintained well above a target of 260 [mu]g/mL.

CONCLUSIONS: When dosed in a pharmacologically guided manner, EACA is not inferior to aprotinin in reducing fibrinolysis and blood loss in patients undergoing primary, isolated coronary artery bypass surgery.

 

Narcotrend指数提示儿童丙泊酚诱导期间的年龄相关性变化

The Narcotrend index indicates age-related changes during propofol induction in children.

Sinikka Münte, MD, PhD*, Jaakko Klockars, MD*, Mark van Gils, PhD{dagger}, Arja Hiller, MD, PhD*, Michael Winterhalter, MD, PhD{ddagger}, Christina Quandt, MD{ddagger}, Matthias Gross, MD{ddagger}, and Tomi Taivainen, MD, PhD*

From the *Department of Anesthesiology and Intensive Care Medicine, Children’s Hospital, Helsinki University Clinics; {dagger}VTT Technical Research Centre of Finland, Finland; and {ddagger}Department of Anesthesiology, Hanover Medical School, Hannover, Germany.

Anesth Analg 2009 109:53-9.

 

背景Narcotrend脑电监护仪适用于麻醉期间催眠状态的监测。此研究通过儿童丙泊酚麻醉诱导期间Narcotrend监护仪对催眠状态和意识丧失(LOC)的判定来评估其使用的效力和可信度。

方法:选取62名年龄跨度分别为1-5岁(n=17)、6-12岁(n=23)、13-16岁(n=21)的择期手术患儿入组研究。所有病患均需于术前口服咪唑安定0.5 mg/kg。开放静脉通路后,设定0.5 microg/mL为初始剂量靶控输注丙泊酚,并以每两分钟提高0.5 microg/mL为增量持续输注,直至患儿对任何口头命令或物理刺激均无应答。体重<15 kg的患儿应对照指南方案进行给药。运用密歇根大学镇静评分系统(UMSS)自丙泊酚输注开始后每分钟对催眠状态进行判定,并定义UMSS评分2-3分为意识丧失。Narcotrend指数(NI)需从诱导开始至研究终点全程记录,同时还需记录独立于镇静状态测量结论的NI值。预测概率(PK)用于评估NIUMSS的一致性。计算NI在区分意识状态中的敏感性与特异性。比较不同年龄组别间特定UMSS水平的NI值,并运用相关性分析评价丙泊酚靶控输注浓度与镇静程度间的关系。

结果:将评测意识丧失所获取的数据计算NIPK值为0.8495%可信区间[0.80-0.88])。类似地,UMSSPK值为0.8295%可信区间[0.78-0.86]),提示NIUMSS具有一致性。UMSS连续镇静评分0-1分与1-2分所对应的NI平均值具有统计学差异(P < 0.01)。对于三组不同年龄组,NI可分别区分UMSS23分、UMSS12分、23分以及UMSS01分。此外,不同组别中UMSS评分1-4分的患儿其NI值也具有显著的统计学差异(P < 0.005),年少组患儿其NI值相比年长组更高。意识丧失水平的NI值为68。从评测意识状态所获取的数据中可得到NI的敏感性为0.67、特异性为0.79。斯皮尔曼相关系数提示,相比NIUMSS间的联系(-0.68),丙泊酚靶控输注浓度与UMSS间有着更紧密的关联(0.96)

结论:在儿童丙泊酚诱导期间,Narcotrend脑电监护仪能在一定程度上描述儿童镇静状态的变化,但其也会在预测意识状态改变时出现相对较高的错误机率(0.18)。因此,该监护仪不应单独用于指导镇静与麻醉。NI具有年龄相关性,就同一镇静级别而言,年少儿童比年长儿童拥有更高的NI值。

(范羽译 薛张纲校)

BACKGROUND: The Narcotrend electroencephalogram monitor is designed to measure hypnotic state during anesthesia. We performed this study to evaluate the effectiveness and reliability of the Narcotrend monitor in assessing hypnotic state and loss of consciousness (LOC) during propofol anesthesia induction in children.

METHODS: Sixty-two children, aged 1-5 (n = 17), 6-12 (n = 23), and 13-16 (n = 21) yr, scheduled for elective surgery were studied. The patients were premedicated with oral midazolam 0.5 mg/kg. After IV access, propofol target controlled infusion (TCI) was started with 0.5 microg/mL and increased by 0.5 microg/mL increments every 2 min until the child did not respond to any verbal command or physical stimuli. A manual scheme was used for children weighing <15 kg. Hypnotic state was measured every minute from the start of the propofol infusion using the University of Michigan Sedation Scale (UMSS). LOC was defined as a transition of UMSS scale value 2 to 3. The Narcotrend index (NI) was recorded before the start of induction and during the whole study period. NI values were noted simultaneously, yet independently of the sedation measurements. Prediction probability (PK) was used to assess the correspondence between NI and UMSS. Sensitivity and specificity of NI for differentiating between consciousness and unconsciousness were calculated. NI values at specific UMSS levels were compared between the different age groups and the relationships between TCI propofol concentrations and sedation levels were assessed using correlation analysis.

RESULTS: A PK-value of 0.84 (95% CI [0.80-0.88]) of NI was calculated from the data for the detection of LOC. Similarly, a PK value of 0.82 (95% CI [0.78-0.86]) indicated agreement between NI and UMSS values. The average NI values differed between successive UMSS sedation levels 0 and 1 and levels 1 and 2 (P < 0.01). In the youngest age group, the NI discriminated between UMSS levels 2 and 3, in the second age group between levels 1 and 2 and 2 and 3, and in the oldest age group between 0 and 1. Furthermore, the NI values differed significantly between age groups at UMSS levels 1-4 (P < 0.005), with the NI values being higher in younger compared with older children. The average NI value at LOC was 68. For the detection of consciousness, a sensitivity of 0.67 and specificity of 0.79 were achieved. Spearman correlation coefficients indicated higher association between TCI propofol concentrations and UMSS (0.96) than between NI and UMSS (-0.68).

CONCLUSIONS: During propofol induction in children, the Narcotrend electroencephalogram monitor was capable of following changes in the sedation level of children to some extent, but also had a relatively high probability (0.18) of incorrectly predicting changes in conscious state. Therefore, the monitor should not solely be used to guide sedation and anesthesia. NI was age-dependent and younger children had higher NI-values than older children at the same level of sedation.

 

七氟烷麻醉状态下右美托咪定,异丙酚和咪达唑仑对兔子呼吸CO2反应性,动脉压及心率影响的比较。

A Comparison of the Effects on Respiratory Carbon Dioxide Response, Arterial Blood Pressure, and Heart Rate of Dexmedetomidine, Propofol, and Midazolam in Sevoflurane-Anesthetized Rabbits

Chang C, Uchiyama A, Ma L, Mashimo T, Fujino Y.

Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Osaka, Japan.

Anesth Analg. 2009 Jul;109(1):84-9.

 

背景:右美托咪定,异丙酚和咪达唑仑均为常用镇静剂。我们使用稳定状态下的七氟烷麻醉的兔子,分别监测这三种药物作用下CO2呼吸的反应性、平均动脉压和心率。

方法:选用新西兰白兔,体重2.9+/-0.2kg(平均值+/-标准差)。麻醉诱导和气管造口术后,吸入2%七氟烷以保持试验过程中稳定的镇静状态。准备完毕后,将兔子随机分为4(n=10X4),并分别给予以下药物:C组为对照组(Control)D组为右美托咪定(Dexmedetomidine)2ug/kg/h的速率输注;P组为异丙酚(Propofol)TCI Plasa浓度15ug/ml.M组为咪达唑仑(Midazolam)首剂0.3mg/kg静推,然后1.86mg/kg/h的速率输注。首次静脉给药15分钟后开始每隔20分钟,随机的顺序给予每只兔子C02浓度为0%, 1%, 2%, 3%, 4%, 或者5%的气体。吸入氧浓度保持在90%。比较不同吸入C02浓度下最后一分钟里组间的分钟通气量,呼吸频率,平均动脉压和心率。

结果:由分钟通气量-吸入C02浓度曲线可见,与C组相比P组和M组的曲线右移,提示存在明显的呼吸抑制,同时也显著高于D组,但P组和M组之间,C组和D组之间均无显著性差异。四组间呼吸频率无显著性差异。由不同吸入CO2浓度下的平均分钟通气量和平均动脉二氧化碳分压的数据进行线性回归分析得到动脉二氧化碳分压-分钟通气量曲线,以计算发生呼吸暂停CO2的阈值来评价对CO2敏感性。P组和M组发生呼吸暂停的CO2阈值明显高于C组和D组。D组对CO2的敏感性略低于C组。其余组间CO2敏感性均无明显差别。D组平均动脉压低于C组和M组。D组心率低于C组,P组和M组。

结论:在七氟烷麻醉下的兔子中,右美托咪定轻度影响呼吸对CO2的反应性,但引起平均动脉压下降较为明显。异丙酚和咪达唑仑对于呼吸抑制较明显,而循环影响较轻。

(黄剑译 薛张纲校)

BACKGROUND: Dexmedetomidine, propofol, and midazolam are commonly used sedative-hypnotic drugs. Using a steady-state method, we examined the CO2 ventilatory response, mean arterial blood pressure (MAP) and heart rate (HR) effects of these three drugs in sevoflurane-anesthetized rabbits.

METHODS: New Zealand white rabbits weighing 2.9 +/- 0.2 kg (mean +/- SD) were used. After anesthetic induction and tracheostomy, the animals inhaled 2% sevoflurane to ensure a stable level of sedation throughout the experiment. After preparation, the rabbits were randomly assigned to four groups (n = 10 x 4) and received the following drugs: Group C, control; Group D, dexmedetomidine infused at 2 microg x kg(-1) x h(-1); Group P, propofol with the plasma concentration maintained at 15 microg/mL; Group M, midazolam initial IV 0.3 mg/kg bolus dose, followed by infusion at 1.86 mg x kg(-1) x h(-1). At 15 minutes after the start of infusion, for 20 min periods, in random sequences, gas including 0%, 1%, 2%, 3%, 4%, or 5% of CO2 was delivered to each animal. Fraction of inspired oxygen was maintained at 0.9. We did intergroup comparisons of minute ventilation (MV), respiratory rate, MAP, and HR during the final minute of each inspiratory carbon dioxide concentration (FiCO2) period.

RESULTS: For Groups P and M, the rightward shift of plots for MV against FiCO2 indicated significant respiratory depression compared with Group C. There was also significantly more depression than in Group D. We found no significant differences between Groups P and M or between Groups C and D in the plots of MV against FiCO2. No significant differences among the four groups were apparent for respiratory rate. PaCO2-MV response plots were derived from linear regression analysis of data for mean MV and mean PaCO2 at each FiCO2 to compute apneic CO2 thresholds and CO2 sensitivities. The apneic CO2 thresholds of Groups P and M were larger than those of Groups C and D. The CO2 sensitivities of Group D were slightly lower than in Group C. No similar significant difference between the CO2 sensitivities of other group pairs was apparent. MAP in Group D was lower than in Groups C and M. In Group D, HR was lower than in Groups C, P, and M.

CONCLUSIONS: The major finding is that, during sevoflurane anesthesia in rabbits, dexmedetomidine slightly altered the ventilatory response to CO2. It decreased MAP more than propofol and midazolam, which both significantly depressed the ventilatory response to CO2.

 

 

活体适度的氦气吸入可降低炎性反应,但不能防止缺血再灌注时的内皮损伤

Helium Breathing Provides Modest Antiinflammatory, but No Endothelial Protection Against Ischemia-Reperfusion Injury in Humans In Vivo

Eliana Lucchinetti, PhD*, Johannes Wacker, MD{dagger}, Christian Maurer, MD{dagger}, Marius Keel, MD{ddagger}, Luc Härter, PhD{ddagger}, Kathrin Zaugg, MD, PhD§, and Michael Zaugg, MD||

From the *Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Canada; {dagger}Institute of Anesthesiology, {ddagger}Department of Trauma Surgery, §Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland; and ||Department of Anesthesiology and Pain Medicine, University of Alberta and Perioperative Translational Medicine, Mazankowski Alberta Heart Institute, Edmonton, Canada.

Anesth Analg 2009 109: 101-108.

 

背景:惰性气体氦气并没有麻醉效果,但能引起强心预反应。我们假定吸入氦气提供预防性的保护,防止前臂血管内皮缺血再灌注时的损伤。

方法 8名健康男性受试者参加这项配对设计的研究。每个志愿者随机吸入或不吸入氦气接收15分钟的前臂缺血。吸入氦气是从缺血前15分钟开始直到灌注后5分钟( 氦调节 ),呼气末浓度为50% 。充血反应可标志一氧化氮的生物利用度和血管内皮的功能,通过对前臂在1530分钟再灌注时使用静脉闭塞容积描记来记录。应用流式细胞仪来测定灌注期间表达的促炎性反应标记因子,包括白细胞上的CD11b, ICAM-1, PSGL-1, and L-selectin (CD62L)和血小板上的P-selectin (CD62P), PSGL-1, and CD42b

结果:在灌注1530分钟时缺血再灌注持续减少内皮依赖的闭塞后充血反应。吸入浓度为50%的氦气不会改善闭塞后充血反应。氦气可减少白细胞上炎性标记CD11bICAM - 1和血小板上凝血因子CD42bPSGL-1的表达。

结论:虽然吸入氦气减少了缺血后炎症反应,我们的数据表明,活体吸入浓度为50%的氦气并不能保护人体所有重要器官内的血管内皮细胞。这与七氟醚不同,七氟烷在低麻醉浓度下即可保护人类内皮细胞。

(李莹译 薛张纲校)

BACKGROUND: The noble gas helium is devoid of anesthetic effects, and it elicits cardiac preconditioning. We hypothesized that inhalation of helium provides protection against postocclusive endothelial dysfunction after ischemia-reperfusion of the forearm in humans.

METHODS: Eight healthy male subjects were enrolled in this study with a crossover design. Each volunteer was randomly exposed to 15 min of forearm ischemia in the presence or absence of helium inhalation. Helium was inhaled at an end-tidal concentration of 50 vol% from 15 min before ischemia until 5 min after the onset of reperfusion ("helium conditioning"). Hyperemic reaction, a marker of nitric oxide bioavailability and endothelial function, was determined at 15 and 30 min of reperfusion on the forearm using venous occlusion plethysmography. Expression of the proinflammatory markers CD11b, ICAM-1, PSGL-1, and L-selectin (CD62L) on leukocytes and P-selectin (CD62P), PSGL-1, and CD42b on platelets were measured by flow cytometry during reperfusion.

RESULTS: Ischemia-reperfusion consistently reduced the postocclusive endothelium-dependent hyperemic reaction at 15 and 30 min of reperfusion. Periischemic inhalation of helium at 50 vol% did not improve postocclusive hyperemic reaction. Helium decreased expression of the proinflammatory marker CD11b and ICAM-1 on leukocytes and attenuated the expression of the procoagulant markers CD42b and PSGL-1 on platelets.

CONCLUSIONS: Although inhalation of helium diminished the postischemic inflammatory reaction, our data indicate that human endothelium, which is a component of all vital organs, is not amenable to protection by helium at 50 vol% in vivo. This is in contrast to sevoflurane, which protects human endothelium at low subanesthetic concentrations.

 

 

脉搏波形分析和经食管超声心动图:两种方法在腹腔镜结肠手术中测定心输出量的比较

Pulse Contour Analysis and Transesophageal Echocardiography: A Comparison of Measurements of Cardiac Output During Laparoscopic Colon Surgery

Mario R. Concha, MD, Verónica F. Mertz, MD, Luis I. Cortínez, MD, Katya A. González, MD, and Jean M. Butte, MD

From the Departments of Anesthesiology and Digestive Surgery, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.

Anesth Analg 2009 109: 114-118.

 

背景:脉搏波形分析(PWA)在经肺热稀释法校准后能测定心输出量。FloTrac/Vigileo (FTV)仪器最近被开发,这个脉搏波形分析系统并不需要提前校准。我们比较FTV测定的心输出量及同步经食管超声心动图(TEE)测定的心输出量。

方法:我们对10名将进行腹腔镜结直肠手术的ASA I-II病人进行了研究。桡动脉20号套管针被连接至血流动力学的监测和FTV仪器进行脉搏波形分析测定心输出量(COPWA)。经食管超声心动图测定心输出量(COTEE)就如之前所述方法进行测定。数据测定在插管后、摆好截石体位后5分钟、建立气腹后5分钟、之后每30分钟或在每当平均动脉压低于基线水平时进行。数据分析运用了Bland-Altman法。

结果:我们对88组数据进行了比较。经食管超声心动图测定的心输出量(COTEE)值从3.23 12 /分钟不等(均数 6.21 ± 1.85)。经脉搏波形分析测定的心输出量(COPWA)值从2.9 8.5 /分钟不等。(均数 4.84 ± 1.14)。偏差为1.17,一致性范围为–2.02 4.37。所有经食管超声心动图测定的心输出量(COTEE)值和经脉搏波形分析测定的心输出量(COPWA)值之间的百分误差均值为40% (27%50%不等)

结论:在腹腔镜结肠手术中,经食管超声心动图和脉搏波形分析测定的心输出量临床上有显著的差异。

(姚敏敏译 薛张纲校)

BACKGROUND: Pulse wave analysis (PWA) allows cardiac output (CO) measurement after calibration by transpulmonary thermodilution. A PWA system that does not require previous calibration, the FloTrac/Vigileo (FTV), has been recently developed. We compared determinations of CO made with the FTV to simultaneous measurements using transesophageal echocardiography (TEE).

METHOD: Ten ASA I-II patients scheduled for laparoscopic colorectal surgery were studied. A radial 20-gauge cannula was inserted and connected to a hemodynamic monitor and a FTV system for PWA and determination of CO (COPWA). TEE CO (COTEE) was determined as previously described. Measurements were made after intubation, 5 min after establishing the lithotomy position, 5 min after establishing pneumoperitoneum, every 30 min, or each time mean arterial blood pressure decreased below basal values. Statistical analysis was made with the Bland and Altman method.

RESULTS: Eighty-eight measurements were compared. The COTEE values ranged from 3.23 to 12 Lt/min (mean 6.21 ± 1.85). Values for COPWA ranged from 2.9 to 8.5 Lt/min (mean 4.84 ± 1.14). Bias was 1.17 and limits of agreement –2.02 and 4.37. The percentage error between all COTEE and COPWA measurements was 40% (27%-50%) mean (range).

CONCLUSION: During laparoscopic colon surgery, clinically important differences were observed between CO determinations made with TEE and FTV.

 

中心静脉置管期间使用测压法减少动脉损伤

Eliminating Arterial Injury During Central Venous Catheterization Using Manometry

Catalin S. Ezaru, MD, Michael P. Mangione, MD, Todd M. Oravitz, MD, James W. Ibinson, MD, and Richard J. Bjerke, MD

From the Department of Anesthesiology, Veterans Affairs Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Anesth Analg 2009 109: 130-134

 

背景:2%-4.5%的中心静脉置管会误穿到动脉,造成0.1%-0.5%的病人动脉损伤。置管过程中常规使用测压法也许可以成功辨别动脉,避免动脉置管和损伤。

方法:我们进行了一项回顾性调查包括15年期间在实施要求强制使用测压法来证实静脉通路的安全计划后,实现中心静脉置管的病例。动脉损伤被定义为非故意的动脉置管,使用7-French或者更大的导管或扩张器。动脉穿刺被定义为非故意的18G导管的放置或者针误入动脉。15年期间所有的动脉损伤数据都被回顾。而且在最后一年的分析中,估计了动脉穿刺和其后动脉损伤的数据。

结果:在观察期间共放置了9348个中心静脉导管。在15年的观察中,没有动脉损伤的发生。在最后一年的评估中,放置了511个中心静脉导管,动脉穿刺发生了28例(5%)。在没有使用测压法的情况下24例动脉穿刺被辨认出来,4例动脉穿刺在使用测压法的情况下才被发现,没有伴随动脉损伤的发生。

结论15年的评估表明,在中心静脉置管中使用测压法验证静脉放置,有效地减少了非故意的动脉置管造成的动脉损伤。

(俞佳译 薛张纲校)

BACKGROUND: Unintended arterial puncture occurs in 2%-4.5% of central venous catheterizations, resulting in arterial injury in 0.1%-0.5% of patients. Routine performance of manometry during catheterization may successfully identify unintended arterial puncture and avoid arterial cannulation and injury.

METHODS: We conducted a retrospective review of all cases of central venous catheter placement during a 15-yr period after  implementation of a safety program requiring mandatory use of manometry to verify venous access. Arterial injuries were defined as unintended arterial cannulations with a 7-French or larger catheter or dilator. Arterial punctures were defined as the unintended placement of an 18-gauge catheter or needle into the artery. Data were reviewed for all arterial injuries during the entire 15-yr period. In addition, data on both arterial puncture and subsequent arterial injury were evaluated during the final year of analysis.

RESULTS: A total of 9348 central venous catheters were placed during the observation period. During the full 15 yr of observation, there were no cases of arterial injury. During the final year of assessment, 511 central venous catheters were placed, with arterial punctures in 28 patients (5%). Arterial puncture was recognized without manometry in 24 cases. Arterial puncture was identified only with manometry in 4 cases, with no incidents of arterial injury.

CONCLUSIONS: Consistent use of manometry, to verify venous placement, during central venous catheterization effectively eliminated arterial injury from unintended arterial cannulation during the 15-yr assessment.

 

肺泡复张及高PEEP措施应用于有血管内容量负荷的病态肥胖病人后,并不对血流动力学产生影响

Alveolar Recruitment Strategy and High Positive End-Expiratory Pressure Levels Do Not Affect Hemodynamics in Morbidly Obese Intravascular Volume-Loaded Patients

Stephan H. Bohm, MD*, Oliver C. Thamm, MD*, Alexandra von Sandersleben, MD*, Katrin Bangert, MD*, Thomas E. Langwieler, MD{dagger}, Gerardo Tusman, MD{ddagger}, Tim G. Strate, MD, PhD{dagger}, and Thomas G. Standl, MD, PhD*

From the Clinics of *Anesthesiology, {dagger}General Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany; and {ddagger}Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina.

Anesth Analg 2009 109: 160-163

 

我们评估了肺泡复张和高呼气末正压(PEEP)通气在20名行腔镜手术的容量负荷的病态肥胖病人(BMI 50 ± 9 kg/m2)中应用的效果。肺泡复张合并PEEP试验措施在二氧化碳气腹建立前后连续进行,由前PEEP试验,平台压力为50–60 cm H2O的复张10次,及后PEEP组成。肺泡复张及高PEEP并不会显著造成病人血流动力学紊乱,该项指标由肺动脉导管测定。经食管超声并不能揭示舒张末容积的差异及心脏异常活动。

(陈珺珺译,薛张纲校)

We evaluated the effect of the alveolar recruitment strategy and high positive end-expiratory pressure (PEEP) on hemodynamics in 20 morbidly obese (body mass index 50 ± 9 kg/m2), intravascular volume-loaded patients undergoing laparoscopic surgery. The alveolar recruitment strategy was sequentially performed with and without capnoperitoneum and consisted of an upward PEEP trial, recruitment with 50–60 cm H2O of plateau pressure for 10 breaths, and a downward PEEP trial. Recruitment and high PEEP did not cause significant disturbances in any hemodynamic variable measured by systemic and pulmonary artery catheters. Transesophageal echocardiography revealed no differences in end-diastolic areas or evidence of segmental abnormalities in wall motion.

 

镇静对颅内占位的病人的颅内压的作用:瑞芬太尼与异丙酚

The Effect of Sedation on Intracranial Pressure in Patients with an Intracranial Space-Occupying Lesion: Remifentanil Versus Propofol

lFrancois Girard, MD, FRCPC*, Robert Moumdjian, MD, FRCSC{dagger}, Daniel Boudreault, MD, FRCPC*, Philippe Chouinard, MD, FRCPC*, Alain Bouthilier, MD, FRCSC{dagger}, and Monique Ruel, RN*

From the *Department of Anesthesiology, and {dagger}Neurosurgery Division, Centre Hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Montreal, Canada.

Anesth Analg 2009 109: 194-198.

 

背景:在此研究中,我们比较了轻度镇静作用的瑞芬太尼和异丙酚在患者于区域麻醉下行立体定向脑肿瘤活检术时颅内压和颅内灌注压的影响。

方法:这是一个前瞻性、开放式、随机对照研究。40名于区域麻醉下行立体定向脑肿瘤活检术的患者被随机分为两组分别接受瑞芬太尼和异丙酚的滴定直至到达清醒/镇静量表四级的程度。颅内压通过活检针测定。

结果:达到目标镇静程度时,瑞芬太尼和异丙酚的注射速度分别为4.2 +/- 1.8 microg x kg(-1) x h(-1) 4.3 +/- 2.5 mg x kg(-1) x h(-1)。测量颅内压时,瑞芬太尼组的病人比异丙酚组的病人有更慢的呼吸频率(11/min +/- 3 vs 15 per min +/- 3, P = 0.0001)和更高的二氧化碳分压(48.3 +/- 6.2 mm Hg vs 43.1 +/- 5.5 mm Hg, P = 0.009)。两组的平均值相似,瑞芬太尼组和异丙酚组分别为19.0 +/- 11.9 mm Hg vs 16.4 +/- 11.1 mm Hg(P = 0.48)。瑞芬太尼组的平均动脉压相对于异丙酚组的更高(101.1 +/- 13.7 mm Hg vs 85.8 +/- 12.7 mm Hg, P = 0.0008),导致较高的颅内灌注压2.0 +/- 19.0 mm Hg vs 69.5 +/- 17.0 +/- 19.0 mm Hg (P = 0.03)

结论:轻度镇静的瑞芬太尼在行立体定向脑肿瘤活检术的患者中相对于异丙酚不会导致更高颅内压,而颅内灌注压可能保持得更好。

(张玥琪译,薛张纲校)

BACKGROUND: In this study, we compared the effect of light sedation with remifentanil versus propofol on intracranial (ICP) and cerebral perfusion pressure (CPP) of patients undergoing stereotactic brain tumor biopsy under regional anesthesia.

METHODS: This was a prospective, open-label, randomized, and controlled study. Forty patients undergoing stereotactic brain tumor biopsy under regional anesthesia were randomized into two groups to receive remifentanil or propofol titrated to a level of four on the modified Assessment of Alertness/Sedation Scale. ICP was measured via the biopsy needle.

RESULTS: At the targeted level of sedation, the rates of infusion for remifentanil and propofol were, respectively, 4.2 +/- 1.8 microg x kg(-1) x h(-1) and 4.3 +/- 2.5 mg x kg(-1) x h(-1). At the time of ICP measurement, patients in the remifentanil group had a slower respiratory rate (11/min +/- 3 vs 15 per min +/- 3, P = 0.0001) and a higher PCO2 (48.3 +/- 6.2 mm Hg vs 43.1 +/- 5.5 mm Hg, P = 0.009) than patients in the propofol group. The mean was similar for both groups, 19.0 +/- 11.9 mm Hg vs 16.4 +/- 11.1 mm Hg for remifentanil and propofol, respectively (P = 0.48). Higher mean arterial blood pressure in the remifentanil group (101.1 +/- 13.7 mm Hg vs 85.8 +/- 12.7 mm Hg, P = 0.0008) resulted in a higher CPP than the propofol group: 82.0 +/- 19.0 mm Hg vs 69.5 +/- 17.0 +/- 19.0 mm Hg (P = 0.03).

CONCLUSION: Light sedation with remifentanil does not result in a higher ICP than propofol in patients undergoing stereotactic brain tumor biopsy. CPP might be better preserved with remifentanil.

 

腹部外科手术期间体液平衡的影响:一个数学模型

The effect of duration of surgery on fluid balance during abdominal surgery: a mathematical model.

Tatara T, Nagao Y, Tashiro C.

Department of Anesthesiology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan.

Anesth Analg. 2009 109:211-6.

 

背景:关于术中液体管理制度是否可以带来好的术后结果一直存在争论。组织间隙液体积聚会带来术后不良结果,但是术中体液平衡管理的影响尚不清楚。在此项研究中,我们运用一个数学模型来描述体液分布。

方法:以前发表的关于进行腹部手术患者的生物阻抗分析数据常被用来估算损伤和未损伤组织间隙的容量变化(DeltaV(IT),相对基线的变化百分比)。比较手术时间小于3h(n = 5)和手术时间大于等于3h(n = 25),手术结束时非损伤组织和损伤组织的间隙容量变化比值,和术中总的输注液体量(V(INF), mL/kg)。可导致不良结果的血浆容量变化(DeltaV(PL), 相对基线值得百分比)和间隙容量变化的临界值,可以从健康志愿者接受不影响生理的静脉液体容量而得到的数据估算出来。最后,模拟一个70 kg的患者进行1-8 h的腹部外科手术,根据DeltaV(PL) DeltaV(IT)来决定晶体从2 mL x kg(-1) x h(-1) 30 mL x kg(-1) x h(-1)的输注速率。维持未损伤组织间隙DeltaV(PL) DeltaV(IT)在临界值内的液体输注速率可作为手术期间的一项功能。

结果:生物阻抗数据显示非损伤组织和损伤组织DeltaV(IT)/V(INF)比率的不同仅在大于等于3小时的手术中有显著意义(0.30 +/- 0.17% x kg/mL vs 1.55 +/- 0.73% x kg/mL, P < 0.0001)。手术时间小于3小时和大于等于3小时的DeltaV(IT)/V(INF)比率的不同仅在损伤组织中有意义(0.45 +/- 0.35% x kg/mL vs 1.55 +/- 0.73% x kg/mL, P = 0.003)。维持DeltaV(PL) DeltaV(IT)在临界值(分别>-15% <20%)所需的液体输注比率在短时手术的范围很大(对于2小时的手术需2-18.5 mL x kg(-1) x h(-1)),但对于长时手术来说较狭窄(对于6小时的手术需5-8 mL x kg(-1) x h(-1))

结论:基于我们的模型,对于小于3小时的腹部手术,在没有明显组织间隙水肿的情况下应尽可能的增加液体的输注速率。然而,从我们的模型可预测在大于6小时的腹部手术需限制不也量来避免过度的组织间隙水肿。

 (张钊译 薛张纲校)

BACKGROUND: There is controversy regarding which fluid management regimen provides the best postoperative outcome. Interstitial fluid accumulation may adversely affect postoperative outcome, but the effect of surgical duration on fluid balance is unknown. In this study, we used a mathematical model to describe fluid distribution.

METHODS: Previously published data from bioimpedance analysis in patients undergoing abdominal surgery were used to calculate changes to interstitial volume (DeltaV(IT), percent change relative to baseline) in uninjured and injured tissues. Ratios of DeltaV(IT) in uninjured and injured tissues at the end of surgery to total fluid volume infused during surgery (V(INF), mL/kg) were compared between surgeries of duration <3 h (n = 5) and > or = 3 h (n = 25). Critical values for change in plasma volume (DeltaV(PL), percent change relative to baseline) and DeltaV(IT), which give rise to adverse outcome, were calculated from previously published data on the physiological effects of IV fluid administration in healthy volunteers. Finally, simulated abdominal surgery in a 70 kg man for 1-8 h was used to determine the effect of crystalloid infusion rate between 2 and 30 mL x kg(-1) x h(-1) on DeltaV(PL) and DeltaV(IT). Fluid infusion rates that maintained DeltaV(PL) and DeltaV(IT) in uninjured tissue within critical values were then computationally determined as a function of duration of surgery.

RESULTS: Bioimpedance data showed that the differences in DeltaV(IT)/V(INF) ratios between uninjured and injured tissues were significant only for surgical duration > or = 3 h (0.30 +/- 0.17% x kg/mL vs 1.55 +/- 0.73% x kg/mL, P < 0.0001). Differences of DeltaV(IT)/V(INF) ratios between surgical durations <3 and > or = 3 h were found only for injured tissue (0.45 +/- 0.35% x kg/mL vs 1.55 +/- 0.73% x kg/mL, P = 0.003). The range of fluid infusion rates required to maintain DeltaV(PL) and DeltaV(IT) within the critical values (>-15% and <20%, respectively) was wide for short-duration surgery (2-18.5 mL x kg(-1) x h(-1) for a 2 h-surgery), whereas it was narrow for long-duration surgery (5-8 mL x kg(-1) x h(-1) for a 6 h-surgery).

CONCLUSIONS: Based on our model, it should be possible to increase the fluid infusion rate without significant interstitial edema for abdominal surgery of <3 h duration. However, our model predicts that restrictive fluid management should be used in abdominal surgery of >6 h duration to avoid excessive interstitial edema.

 

滴注或注射提纯的天然辣椒碱对大鼠后肢感觉-运动行为或截骨修复术无有害影响

Instilled or Injected Purified Natural Capsaicin Has No Adverse Effects on Rat Hindlimb Sensory-Motor Behavior or Osteotomy Repair
\
Susan M. Kramer, DrPH*, Jonelle R. May, MS{dagger}, Daniel J. Patrick, DVM, DACVP{dagger}, Luc Chouinard, DVM, DES{ddagger}, Marilyne Boyer, BSc{ddagger}, Nancy Doyle, BSc{ddagger}, Aurore Varela, DVM, IPSAV, MSc{ddagger}, Susan Y. Smith, MSc{ddagger}, and Eric Longstaff, PhD§

From the *Anesiva, Inc., South San Francisco, California; {dagger}MPI Research, Inc., Mattawan, Michigan; {ddagger}Charles River Laboratories Preclinical Services Montreal Inc., Senneville, Quebec, Canada; and §Preclinical Development Services Ltd., Bramhall, Stockport, Cheshire, UK.

Anesth Analg 2009 109: 249-257.

 

背景:一种新型的纯度为98%的辣椒素成分(4975)正在接受临床观察,通过新的方式提供选择性镇痛,单次给药即能维持数周至数月的镇痛效果。我们进行这项研究来评价在大鼠截骨修复术创伤愈合和感觉-运动神经功能模型中滴注或注射4975的安全性和效应。

方法:选用成年雌雄SD大鼠。第一组评价4975对神经或肌肉的效应。0.00830.025 mg 4975或载体(25%的聚乙二醇300)用于暴露的坐骨神经,或0.1 mg 4975或载体注入周围的肌肉。第二组评价4975对骨头愈合的影响,对一侧股骨实行截骨术,将0.5 mg 4975或载体滴入创伤处。对两组大鼠均进行行动测试和股神经的组织学评估,周围的软组织和骨头于术后31428天进行测试。实行截骨术的大鼠股骨通过外周定量计算机摄影和生物机械测试法进行评估。用标准统计检验比较两组结果。

结果:直接股神经使用和周围肌肉使用4975的大鼠在控制伤害性感受反应(F = 0.910, P = 0.454),握力(F = 0.550, P = 0.654),肌肉或股神经的组织学方面没有差别。在截骨术的大鼠中,使用4975和载体治疗在骨面积(H = 2.858, P = 0.414)、骨矿物质含量(F = 0.945, P = 0.425)、骨矿物质密度(F = 0.87, P = 0.462)以及软组织愈合方面没有差别。对照组和4975治疗组不仅骨的强度没有差别,从大体和微观上看右侧股骨截骨术愈合处和周围软组织也没有明显的差别。

结论:单次临床相关滴注或注射4975对截骨术后伤口和骨头愈合或暴露的肌肉和神经的结构完整性无明显有害影响。

(朱兰芳译 薛张纲校)

BACKGROUND: A novel formulation of ≥98% pure capsaicin (4975) is currently undergoing clinical investigation using novel routes of delivery to provide selective analgesia lasting weeks to months with a single dose. We conducted this study to assess the safety and effects of instilled and injected 4975 in rat models of wound healing osteotomy repair and sensory-motor nerve function.

METHODS: Adult male and female Sprague-Dawley rats were used. To assess the effects of 4975 on nerve or muscle, 0.0083 or 0.025 mg 4975 or vehicle (25% polyethylene glycol-300) was applied to exposed sciatic nerve, or 0.1 mg 4975 or vehicle was injected into the surrounding muscle (Group 1). To assess the effect of 4975 on bone healing, an osteotomy was made in one femur and 0.5 mg of 4975 or vehicle was instilled into the site (Group 2). Behavioral testing was performed on both groups of rats and histological evaluation of the sciatic nerve, and surrounding soft tissue and bone was done at days 3, 14, and 28 after surgery. Femurs from osteotomy rats were assessed using peripheral quantitative computed tomography and biomechanical testing. Standard statistical tests were used to compare groups.

RESULTS: Rats with direct application of 4975 to the sciatic nerve and surrounding muscle were no different from the controls in nociceptive sensory responses (F = 0.910, P = 0.454), grip strength (F = 0.550, P = 0.654), or histology of the muscle or sciatic nerve. In osteotomy rats, there were no statistical differences between 4975 and vehicle-treated rats for bone area (H = 2.858, P = 0.414), bone mineral content (F = 0.945, P = 0.425), or bone mineral density (F = 0.87, P = 0.462) and no difference in soft tissue healing. There were neither differences in bone stiffness (F = 1.369, P = 0.268) nor were there noticeable differences in the macro- or microscopic appearance of the right femur osteotomy healing site and surrounding soft tissues between the control group and the 4975-treated animals.

CONCLUSION: A single, clinically relevant application of instilled or injected 4975 has no observable adverse effect on wound and bone healing after osteotomy or on the structural integrity of exposed muscle and nerve.

有癫痫病史的病人行区域阻滞

Regional Blockade in Patients with a History of a Seizure Disorder

Sandra L. Kopp, MD, Kimberly P. Wynd, MBBCh, Terese T. Horlocker, MD, James R. Hebl, MD, and Jack L. Wilson, MD

From the Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota.

Anesth Analg 2009 109: 272-278.

 

背景:行区域阻滞的病人在使用局麻药药时会出现局麻药的全身毒性作用,特别是大剂量使用时,例如硬膜外阻滞,骶麻或周围神经阻滞。但是对于既往有癫痫病史的病人,使用局麻药是否会增加局麻药的神经毒性尚不清楚。

方法:我们研究了从19881120011231期间行硬膜外阻滞,骶麻及外周神经阻滞的既往有癫痫病史的病人进行回顾性研究。我们调查了病人的人口统计学,癫痫发作的类型,区域阻滞的详细情况,及是否有癫痫发作的资料。我们将研究的结果与由于局麻药的神经毒性所致癫痫在人群中的发生率10000分之一相比较,并比较了95%的置信区间。

结果:在这14年中,共记录了335名病人411人次的手术过程。24名病人术后出现了癫痫发作。术前最近一次癫痫发作的时间与术后发作与否相关(P < 0.001)。基于间断及之后注射局麻药的时间间隔,我们认为其中24名病人中的19人,局麻药并不能作为癫痫发作的病因及相关因素。其他5名病人,围手术期癫痫的发作特性与既往相类似。尽管我们不能证实局麻药是造成癫痫的主要因素,但是我们不能忽视这5名病人局麻药的神经毒性作用.假定没有一次癫痫发作与局麻药的神经毒性有关,估计癫痫的发生率是10000分之0 95% CI 0–89/10,000)。反之,如果癫痫的发作与局麻药有关,其发生率增加至10000分之12095% CI 40–280/10,000)

结论:我们得出的结论是围手术期癫痫的发作与患者既往癫痫的种类及基本状况相关,这些病人并不是区域阻滞的禁忌症。进一步讲,近期有过癫痫发作病史的病人围手术期出现癫痫的可能性增高,因此无论是行何种麻醉或镇痛手段都应准备好应对癫痫发作。

(陈珺珺译 薛张纲校)

BACKGROUND: Systemic local anesthetic toxicity is a potential complication in patients undergoing regional anesthesia, particularly during procedures requiring large doses of local anesthetic, such as epidurals, caudal, and peripheral nerve blocks. It is unknown whether patients with a history of a seizure disorder are at an increased risk of central nervous system toxicity (seizures) after local anesthetic administration.

METHODS: We retrospectively reviewed the medical records of all patients with documented history of a seizure disorder who underwent epidural, caudal, or peripheral nerve block from January 1, 1988 to December 31, 2001. Patient demographics, character of the seizure disorder, details of the regional procedure, and seizure activity in the perioperative period were recorded. The rate of seizure due to local anesthetic toxicity per 10,000 anesthetics was estimated using a point estimate and corresponding 95% confidence interval (CI).

RESULTS: During the 14-yr study period, 411 procedures in 335 patients with a seizure disorder were identified. Twenty-four patients experienced postoperative seizure activity. The timing of the most recent (preoperative) seizure was found to be significantly related to the likelihood of experiencing a postoperative seizure (P < 0.001). Based on the extended time interval between local anesthetic injection and/or termination of the infusion and the event, it was determined that the regional anesthetic was neither the primary etiology nor a contributing factor for the seizure in 19 of the 24 patients. In the remaining five patients, perioperative seizure activity was characteristic of their usual seizures. Although unlikely to be the cause of the seizure, local anesthetic toxicity could not be absolutely excluded as a contributing factor to the event in these five patients. Assuming that none of the seizures was related to local anesthetic toxicity the estimated incidence is 0 per 10,000 (95% CI 0–89 per 10,000). Conversely, if the seizures were related to local anesthetic toxicity in the five cases, the incidence is increased to 120 per 10,000 (95% CI 40–280 per 10,000).

CONCLUSIONS: We conclude that majority of seizures occurring in the perioperative period in patients with a preexisting seizure disorder are likely related to the patient’s underlying condition and that regional anesthesia in these patients is not contraindicated. Furthermore, because the likelihood of a postoperative seizure is increased in patients with a recent seizure, it is essential to be prepared to treat seizure activity, regardless of the anesthetic and analgesic technique.