Anesthesia & Analgesia

July 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

ε-氨基己酸和抑肽酶應用於行初次冠狀動脈旁路分離手術患者後在纖維蛋白溶解和血液流失方面的效果:一個隨機雙盲,安慰劑控制的無差別試驗

單嘉琪譯 薛張綱校

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.

全血多極凝集測定儀是一種可靠的阿司匹林誘導的血小板功能障礙的床邊檢驗方法

劉世文 譯 陳傑 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:

在體外迴圈下行先天性心臟病手術的病人使用抑肽酶與腎功能不全的關係

顏濤譯, 馬皓琳 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指數提示兒童丙泊酚誘導期間的年齡相關性變化

范羽譯 薛張綱校

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.

兒童阻塞性睡眠呼吸暫停的圍手術期處理

葉樂 譯 陳傑 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:

評估用甘草漱口減少術後咽喉痛的有效性:一個前瞻性、隨機、單盲研究

彭中美   馬皓琳 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:

七氟烷麻醉狀態下右美托咪定,異丙酚和咪達唑侖對兔子呼吸CO2反應性,動脈壓及心率影響的比較。

黃劍譯 薛張綱校

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.

妊娠早期異丙酚誘導和恢復麻醉的效應室濃度的預測

張磊 譯 陳傑 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.

家兔給予新型苯二氮卓受體激動劑JM-1232(–)後的寒戰閾值

周雅春 馬皓琳 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.

活體適度的氦氣吸入可降低炎性反應,但不能防止缺血再灌注時的內皮損傷

李瑩譯 薛張綱校

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.

硫噴妥鈉抑制脂多糖誘導的組織因數的表達

丁俊雲 譯 陳傑 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:

脈搏波形分析和經食管超聲心動圖:兩種方法在腹腔鏡結腸手術中測定心輸出量的比較

姚敏敏譯 薛張綱校

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監護儀能估測混合靜脈血紅蛋白氧飽和度嗎?
舒慧剛 譯 陳傑 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:

關於外周靜脈和動脈置管的醫療責任:一項終審索賠分析 

江繼宏   馬皓琳 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.

中心靜脈置管期間使用測壓法減少動脈損傷

俞佳譯 薛張綱校

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:

非諾特羅的吸入對酸吸入性肺損傷的影響

懷曉蓉 譯 陳傑 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.

 

肺募集反應對病態肥胖病人容積性二氧化碳描記圖III相斜率的影響

王宏翻譯,李士通,馬皓琳校正

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.

肺泡複張及高PEEP措施應用於有血管內容量負荷的病態肥胖病人後,並不對血流動力學產生影響

陳珺珺譯,薛張綱校

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-氯普魯卡因與嗎啡的相互作用——一項關於嗎啡鎮痛時效的隨機對照試驗

趙嫣紅 譯 陳傑 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-羥色胺拮抗劑對剖宮產中接受鞘內嗎啡的產婦瘙癢、噁心嘔吐的預防和治療作用:系統性回顧和Meta分析

黃佳佳譯,馬皓琳 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:

鎮靜對顱內占位的病人的顱內壓的作用:瑞芬太尼與異丙酚

張玥琪譯,薛張綱校

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.

開顱手術中動脈血二氧化碳分壓與七氟醚對腦毛細靜脈血流、腦血流及血氧飽和度的影響

朱紫瑜 譯 陳傑 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.

發育中大鼠腦的器官型海馬腦片模型中氧和葡萄糖缺失:對N-甲基-d-天門冬氨酸亞單位組成的影響

黃施偉 譯,馬皓琳 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:

腹部外科手術期間體液平衡的影響:一個數學模型

張釗譯 薛張綱校

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:

經椎孔硬膜外注射的血管內擴散方式:頸椎和腰椎的對比研究

周姝婧 譯 陳傑 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.

顱內腫瘤切除術後羅呱卡因頭皮浸潤的鎮痛作用

唐亮   馬皓琳 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.

滴注或注射提純的天然辣椒堿對大鼠後肢感覺-運動行為或截骨修復術無有害影響

朱蘭芳譯 薛張綱校

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.

美西律和利多卡因對後角神經元興奮性的抑制作用

黃丹 譯 陳傑 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.

比較超聲和神經刺激儀引導肌間溝法臂叢神經阻滯用於肩關節門診手術後神經症狀的前瞻性隨機對照試驗

慧譯 馬皓琳 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.

有癲癇病史的病人行區域阻滯

陳珺珺譯 薛張綱校

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.

超聲引導下腋路臂叢神經阻滯(局部麻醉藥混合液20ml)與全麻在上肢外傷手術中的比較:一項單盲、前瞻、隨機、對照試驗

張燕 譯 陳傑 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.

在體外迴圈下行先天性心臟病手術的病人使用抑肽酶與腎功能不全的關係

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:在成人體外迴圈(CPB)期間使用大劑量抑肽酶與術後腎功能不全有關,但對接受複雜先天性心臟病手術的兒童的作用並未確定。

方法:我們採用回顧性群組分析方法研究了在20047月至20067月間需要體外迴圈行先天性心臟病手術的病兒。患兒的人口統計學資料和按Aristotle外科複雜性分級劃分的手術風險都作為協變數。按照RIFLE標準(一種根據血清肌酐值將急性腎損傷按嚴重程度分為R-風險,I-損傷,F-衰竭的國際公認的分類法)確定腎功能不全。採用單因素、多因素邏輯回歸分析和傾向性評分方法分析資料。使用與使用抑肽酶相關的預處理協變數進行傾向性評分。接著採用對傾向性評分和術中測定值作為協變數進行多因素邏輯回歸分析。認為P<0.05有統計學顯著性。

結果:395例進行心臟手術的病兒中,55%使用了抑肽酶,而45%未用。組群中31%曾接受過心臟手術,17%為新生兒。按照RIFLE標準,80例病兒(20.3%)術後有急性腎功能損傷;其中53(13.4%)有腎功能不全風險,23(5.8%)存在腎損傷,4(0.7%)為腎衰竭。使用抑肽酶的病兒在既往心臟手術(54.1% vs 5%)、敗血症(6.9% vs.0.0%),心力衰竭(24.8% vs 12.4%)、機械通氣(25.2% vs 2.8%)或機械迴圈支持(6.0% vs.0.6%)的發生率更高。使用抑肽酶的患兒,Aristotle外科分級4(26.6% vs 2.8%)者更多,使用利尿藥(63.8% vs 26.6%)、血管緊張素轉換酶抑制劑(21.1% vs 7.9%)、米力農(25.7% vs 4.5%)和強心劑(16.1% vs 2.3%)治療者也更多。儘管未調整的腎功能不全風險存在明顯差異,根據術前傾向性評分調整後卻顯示使用抑肽酶與腎功能不全沒有相關性 (OR 1.32; 95% CI 0.55–3.19)。體外迴圈時間是唯一與腎功能不全產生有關的獨立因素 (OR 1.0; 95% CI 1.009–1.014)

結論:使用抑肽酶的患兒同時伴有產生術後腎功能不全的術前危險因素的可能性更大。然而,當恰當地考慮了相關危險因素時,使用抑肽酶看來與兒童術後即時的產生腎功能不全高危險性不相關。

(顏濤譯, 馬皓琳 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.


評估用甘草漱口減少術後咽喉痛的有效性:一個前瞻性、隨機、單盲研究

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:術後咽喉痛(POST)是主要的術後併發症。甘草作為一個祛痰藥可用來治療咳嗽和感冒。在本研究中,我們評估可甘草漱口來減少術後喉痛的效果。

方法:40個成年人(18-60歲),ASA分級III,行擇期腰椎板切除術,隨機分為兩組,每組20例。C組:用水;L組加0.5 g甘草在水裏。使兩組標準化地都在麻醉前5分鐘,用30毫升混合液漱口。在術後024、和24小時,監測休息和吞咽時術後咽喉痛的發生率和嚴重度及術後副作用。用直觀類比標度(在0-100之間;0表示沒有咽喉痛,100表示可想像的最嚴重的咽喉痛)評估術後咽喉痛的嚴重度。氣管導管拔後立即評估拔管後咳嗽。用Z試驗和Fisher’s精確試驗分析資料。P < 0.05表示有顯著性意義。

結果:L組與C組在休息和吞咽的所有時間點相比,術後咽喉痛(發生率和嚴重度)減少(P < 0.05),只有在24小時休息狀態時的術後喉痛嚴重度兩組相似(P > 0.05)。拔管後咳嗽在L組比C組明顯減少(P < 0.05)。兩組間副作用沒有明顯差異(P > 0.05)。

結論:麻醉前5分鐘用甘草漱口可有效地減少術後咽喉痛的發生率和嚴重度。

(彭中美   馬皓琳 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.


家兔給予新型苯二氮卓受體激動劑JM-1232(–)後的寒戰閾值

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(–) 是一種新型異二氫吲哚衍生物,通過作用於{gamma}-氨基丁酸A型(GABAA)受體的苯二氮卓位元點顯示出鎮靜催眠活性。另一GABAA受體激動劑咪達唑侖的標準劑量可輕度降低人的寒戰閾值。本研究旨在確定JM-1232(–)可降低寒戰閾值到何種程度。

方法: 給予0.2最小肺泡麻醉濃度(MAC)異氟醚後處於淺麻醉狀態的18只家兔隨機分為三組,分別靜脈輸注1)生理鹽水(對照組), 2) 0.01 mg · kg–1 · min–1 JM-1232(–)3) 0.1 mg · kg–1 · min–1 JM-1232(–)。通過置於結腸內的U形塑膠管灌注10°C的水使得家兔體溫以2-3°C/h的速度下降。當不知分組情況的觀察者觀察到家兔寒戰或家兔中心體溫降至34°C時,停止降溫。記錄經由食道遠端測得的中心體溫,寒戰開始時的中心體溫定義為寒戰閾值。資料分析採用單因素方差分析和Student-Newman-Keuls檢驗。結果表示為平均值 ± 標準差; P < 0.05 認為有統計學意義。

結果:靜脈輸注生理鹽水的家兔在體溫36.5 ± 0.3°C時發生寒戰。以0.01 mg · kg–1 · min–1速度靜脈輸注JM-1232(–) 6個家兔中有5個在體溫35.7 ± 0.8°C時發生寒戰,並有一個家兔在體溫降到34.0°C時也沒發生寒戰。以0.1 mg · kg–1 · min–1速度靜脈輸注JM-1232(–)的家兔在體溫達到34°C中止降溫之前都未發生寒戰。

結論:低劑量JM-1232(–)可使家兔寒戰閾值降低約0.8°C,這一結果與給予人術前用藥劑量咪達唑侖後的效果相似。相對而言,10倍劑量的JM-1232(–)可使寒戰閾值降低2.5°C以上。這個閾值降低幅度很大且可能利於治療性降溫的實施。

(周雅春 馬皓琳 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.


關於外周靜脈和動脈置管的醫療責任:一項終審索賠分析 

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:外周靜脈和動脈置管後嚴重併發症已有很多報導。為了評估麻醉醫生在外周血管置管中的責任,我們回顧了美國麻醉醫師協會索賠終審資料庫。

方法:把外周血管置管相關的索賠歸為與靜脈內或動脈導管有關。與靜脈內導管有關的併發症按併發症的類型加以分類。我們比較了資料庫中與因靜脈內導管有關的索賠和所有的其他(非外周置管)索賠之間的病人和病例特徵、損傷嚴重度和賠償金額。賠償金額用日用品價格指數調整到2007年的美金金額。

結果:與外周血管置管相關的索賠占資料庫中總索賠的2% (n = 140/6894例索賠),其中大多數(91%)與靜脈內導管相關(n = 127)。最常見的併發症包括:皮膚壞死(28%)、隆起/感染(17%)、神經損傷(17%)、筋膜切開後疤痕(16%)以及空氣栓塞(8%)。大約一半(55%)的併發症發生於藥物或液體滲出血管後。與其他索賠相比,靜脈內置管相關索賠涉及的心臟外科手術病例部分較大(25%相比其他2%, P < 0.001),急診手術病例部分較小(8%相比其他22%, P < 0.001)。與動脈導管有關的索賠較少(n = 13, 8%),其中只有7例與橈動脈置管有關。

結論:與靜脈內導管相關的索賠是麻醉醫生的一個重要責任根源,其中大約一半是因為藥物或液體滲出血管。橈動脈置管相關的索賠比較少見。

(江繼宏   馬皓琳 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.


肺募集反應對病態肥胖病人容積性二氧化碳描記圖III相斜率的影響

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,我們分析肺泡復原(ARS)和呼氣末正壓(PEEP)選擇對病態肥胖病人容積性二氧化碳描記圖(VC)III相斜率(SIII)的影響。

方法:十一個麻醉的病態肥胖病人是研究物件。肺以潮氣量10 mL·kg–1、呼吸頻率12-14/分鐘、吸呼比1:2及吸入氣氧含量 0.4的方式通氣。通過5步將呼氣末壓從0增加到15 cm H2O完成ARS。在肺徵募期間,限制平臺壓在50 cm H2O範圍內,而增加潮氣量到呼吸機的最大值1400mlPEEP增加到20 cm H2O 持續2分鐘。此後,把PEEP每步減少5 cm H2O地從15 cm H2O減少到0。在PEEP每個階段,測定容積二氧化碳描記圖、動脈血氣和肺的力學資料。

結果:呼氣末正壓為0時與ARSPEEP 15 cm H2O 時比較,SIII0.014 ± 0.006 減少到 0.005 ± 0.005 mm Hg/mL(15ARS, P < 0.05)。比較ARS前後的值,我們發現SIII減少伴隨著動脈氧分壓(27%, P < 0.002)和順應性(32%, P < 0.001)的增加,然而,動脈二氧化碳分壓減少8(P < 0.038)。接受者操作特徵曲線分析(曲線下面積:0.81,敏感性:0.75,特異性:0.74P < 0.001)顯示SIII可以很好的預測肺募集反應。

結論VCSIII對麻醉的病態肥胖病人肺募集反應後發現最優的PEEP水平是有用的。

(王宏翻譯,李士通,馬皓琳校正)

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-羥色胺拮抗劑對剖宮產中接受鞘內嗎啡的產婦瘙癢、噁心嘔吐的預防和治療作用:系統性回顧和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:我們完成了一個系統性回顧以決定5-羥色胺(5-HT3)受體拮抗劑對剖宮產中接受腰麻及鞘內嗎啡的產婦瘙癢、噁心嘔吐的預防和治療作用。

方法:我們回顧了比較5-HT3受體拮抗劑和安慰劑對產婦瘙癢和/或噁心嘔吐預防和治療作用的隨機對照試驗的報導。這些文章根據其有效度進行評分,由作者獨立地提取資料資料,並且用相關危險度(RR)和95%可信區間(CI)進行總結分析。

結果:本系統性回顧包括了九例隨機對照試驗。九例實驗中共有1152例病人,其中539例接受5-HT3受體拮抗劑,413例接受安慰劑,200例接受其他止吐藥的產婦沒有包括在分析中。預防性使用5-HT3受體拮抗劑並沒有比安慰劑減少瘙癢的發生率(80.7%85.8%, RR [95% CI] = 0.94 [0.81–1.09])。然而,它們的使用減少了劇烈瘙癢的發生率及其需要治療的概率(需要治療的病例數分別為1215)。他們的使用對於頑固性瘙癢的治療效力比安慰劑要高,其需要治療的病例數為3。使用5-HT3受體拮抗劑組較安慰劑組術後噁心(22.0%33.6%, RR [95% CI] = 0.75[0.58–0.96])和嘔吐的發生率(7.7%16.8%, RR [95% CI] = 0.49 [0.30–0.81])顯著降低,術後需要止吐治療的概率也顯著降低(9%23%, RR [95% CI] = 0.38 [0.21–0.68])

結論:雖然在剖宮產使用鞘內嗎啡的產婦中,預防性使用5-HT3受體拮抗劑並不能有效地減少瘙癢的發生率,但是它們可以顯著降低瘙癢的嚴重性及其需要治療的概率,也可以減少術後噁心嘔吐的發生率及需要止吐治療的概率。它們對於頑固性瘙癢也有有效的治療作用。雖然仍需要進行更多的研究,但是現有的資料表明,對於剖宮產使用鞘內嗎啡的產婦來說,應該考慮常規預防性使用這些藥物。

(黃佳佳譯,馬皓琳 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.




發育中大鼠腦的器官型海馬腦片模型中氧和葡萄糖缺失:對N-甲基-d-天門冬氨酸亞單位組成的影響

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:器官型海馬腦片(OHS)常用于小兒腦損傷相關藥物的神經保護效應的篩選。供體新生大鼠的日齡的重要性和N-甲基-d-天門冬氨酸(NMDA)受體亞單位組成尚未被闡明。本研究中,我們評估了氧-葡萄糖缺失(OGD)在發育中大鼠腦中的日齡依賴效應並判斷OGD是否調製NMDA受體亞單位的組成。

方法:分別製備出生後(PND471421天新生大鼠的OHS並在體外培養7天。腦片接觸OGD的時間為5-60 min2472 h之後,測定OHS的存活以及NMDA亞單位的組成。

結果:PND1421新生大鼠製備的OHS中細胞死亡明顯(P < 0.001)OGD時間分別為5min10min。由PND7新生大鼠製備的OHS中,OGD時間直至20 min才出現明顯的神經變性(P < 0.001)。在由PND4PND7新生大鼠製備的OHS中,OGD接觸與NMDA受體亞單位組成從NR2B占主導向NR2A占主導的轉變相關。

結論:本次新生大鼠OHS的離體研究結果,支持OGD和神經細胞死亡之間存在日齡及NMDA受體亞單位組成依賴性的關係。

(黃施偉 譯,馬皓琳 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.


顱內腫瘤切除術後羅呱卡因頭皮浸潤的鎮痛作用

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

背景神經外科手術後的疼痛是一個有爭議的問題。這種疼痛為輕到中度,對其治療往往是不足夠的。手術部位進行局麻藥的浸潤麻醉對顱骨切開術後的疼痛是有短暫的幫助,但是對於慢性疼痛的治療還沒有進行過評估。因此我們設計了這個研究,來證實羅呱卡因頭皮浸潤麻醉能減輕顱內腫瘤切除術後急性和持續性疼痛的假設。

方法這是一個前瞻性的、單盲研究。選擇標準為顱內腫瘤切除術患者,年齡1880歲,有能力理解和使用視覺類比評價尺規(VAS)。排除標準為有顱骨切除手術史、長期吸毒和神經系統疾病。所有入選的患者隨機分成I組(浸潤組)和C組(對照組)。術後鎮痛為對乙酰氨基酚聯合納布啡靜脈注射。手術結束時,I組在手術部位用0.75%的羅呱卡因20ml進行浸潤麻醉。在第一個24小時每小時進行急性疼痛的VAS評估。羅呱卡因的鎮痛效果通過納布啡的用量和VAS的分數來評估。持續性疼痛的發生率和神經性疼痛在手術後2個月進行評估。我們用Student’s t檢驗比較納布啡的總用量,反復測量並分別用post hoc Bonferronit核對總和Fisher確切檢驗法對VAS分數和慢性及神經性疼痛進行方差分析。。

結果:共有52名患者入選,I25名、C27名。兩組人口統計學和手術中的資料相似。I組結果顯示在術後第一天對於減少納布啡的用量沒有顯著變化趨勢,11.2 ± 9.2 mgC16.6 ± 11.0 mg (平均值±標準差, P = 0.054)VAS評分C組明顯較高。術後2個月,持續性疼痛在I組明顯較低,2/24 (8%)14/25 (56%), P = 0.0003I1名患者(4.1%)C6名患者(25%)(P = 0.04)出現有神經性疼痛。

結論由於顱內腫瘤切除術的疼痛為中度,所以在術後急性期對於羅呱卡因的頭皮浸潤麻醉有限制的影響。儘管如此,這些浸潤麻醉對於限制延遲持續性疼痛尤其是神經性疼痛的作用可能有利於神經外科手術患者的康復以及他們的生活質量。

(唐亮   馬皓琳 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.


比較超聲和神經刺激儀引導肌間溝法臂叢神經阻滯用於肩關節門診手術後神經症狀的前瞻性隨機對照試驗

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:區域麻醉中超聲可視性能減少神經內注射和併發神經症狀的風險,但還未進行正式評估。因此,我們進行這個隨機臨床試驗來比較超聲和神經刺激儀引導的肌間溝法臂叢神經阻滯用於肩關節鏡檢查來判斷超聲是否能減少術後神經症狀的發生率。

方法:230例患者隨機分為兩組施行標準化肌間溝法臂叢阻滯(超聲或神經刺激儀輔助下),使用5cm長的22g Stimuplex®絕緣針注射1.5%鹽酸甲呱卡因(含1:300,000腎上腺素及NaCO3 1 meq/10 mL)。在術前(用問卷和體檢)、術後約1周(用問卷)和術後4-6周(問卷和體檢)用一項神經學家設計的標準化神經學評價方法進行評價。術後神經症狀的診斷由一位不知阻滯方法的神經專家確定。

結果:219例患者進行了評估。超聲的應用降低了阻滯操作時針穿過神經的數量(13, 中位數, P < 0.001),提高了5分鐘時評估的運動神經阻滯效果(P = 0.04),但未減少神經阻滯施行的時間(兩組均為5分鐘)。沒有患者因阻滯失敗改上全麻,而且兩組患者滿意度相似(神經刺激儀組96%,超聲組92%)。術後1周隨訪時和後期隨訪時的神經症狀的發生率相似,術後1周隨訪時神經刺激儀組為11%(95% CI 5%–17%),超聲組為8% (95% CI 3%–13%),後期隨訪時神經刺激儀組為7% (95% CI 3%–12%),超聲組為6% (95% CI 2%–11%)。術後神經症狀的嚴重程度兩組相似,分級中位數為重度。症狀主要是感覺的,包括疼痛,麻刺或感覺異常。

結論:超聲減少肌間溝法臂叢阻滯操作時針穿過神經的數量,提高5分鐘時的運動神經阻滯效果。然而,我們並未觀察到在阻滯失敗、患者滿意度及術後神經症狀發生率和嚴重程度上有明顯差異。

(朱 慧譯 馬皓琳 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.

 

全血多極凝集測定儀是一種可靠的阿司匹林誘導的血小板功能障礙的床邊檢驗方法

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處方藥,除鎮痛和抗炎作用之外,還有潛在的抗血小板凝集作用。阿司匹林誘導的血小板功能障礙與不同的臨床條件有關,包括複雜的外科手術同時服用阿司匹林致出血風險高的患者。在這項研究中,作者評估了單次口服阿司匹林500mg後血小板的凝集功能。應用多極凝集測定儀(MEA)測定凝血功能,通過比較採集血液樣本的不同時間間隔的測試結果來確定這種方法在床邊檢驗的可用性。

方法:研究包括24名健康志願者。在基礎狀態時取血後所有志願者接受阿司匹林500mg。在應用阿司匹林後4, 24, 56, 80, 124 h 時采血。每個取血時點即刻或取血後30min60min行凝血功能檢查。在用凝血酶受體啟動肽(TRAPtest, 32 µM)或花生四烯酸(ASPItest, 0.5 mM)刺激後檢測全血MEA。用Bonferroni 相關重複方差分析檢測時點間差異。通過計算變異係數確定不精確性。P < 0.05為統計學差異有意義。

結果:攝入阿司匹林4h後血小板聚集的ASPItest明顯降低,攝入阿司匹林第二天,ASPItest恢復,但個體差異顯著。阿司匹林攝入五天後,ASPItest回到基礎值。TRAPtest無顯著差異。樣本測試時間並不影響TRAPtestASPItest值。ASPItest的變異係數為10 %和TRAPtest的變異係數為7 %。

結論:MEA 能可靠檢測阿司匹林對凝血功能的影響。值得注意的是所有健康志願者服用阿司匹林500mg後導致花生四烯酸致血小板凝集的作用完全逆轉。5天內隨著時間延長血小板聚集功能逐漸恢復但有個體差異。血液標本存放時間對ASPItest TRAPtest檢測無影響。測試均能床邊完成。本研究測試的可重複性在現代床邊分析儀要求的範圍內。

(劉世文 譯 陳傑 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.

 

兒童阻塞性睡眠呼吸暫停的圍手術期處理

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 %的兒童受到阻塞性睡眠呼吸暫停綜合征(OSA)的影響。所有需要麻醉的外科手術和診斷性治療中常可碰見OSA的患兒。小兒,扁桃腺切除術是最常見的外科治療OSA的方法。因此,麻醉醫生的當務之急是熟悉OSA患兒潛在的麻醉併發症和術後相關問題。國家專業醫療協會認識並提出對於OSA患兒應加強圍手術期護理。2002年美國兒科學會發表兒科OSA臨床實踐的指南。指南指出麻醉併發症風險呈現上升趨勢,儘管未曾提及具體的麻醉事件。2006年,美國麻醉醫師學會出版了一本關於OSA病人圍術期管理的實踐指南,指出兒科相關的危險因數是肥胖,3歲以下兒童圍術期手術風險增加與扁桃體切除術有關。然而,1歲以下OSA兒童的圍術期管理則未在指南中提及。因此,關於圍術期OSA兒童的護理仍有許多問題。
在這篇綜述中作者復習了兒童OSA相關的文獻,探討了其病理生理及目前的治療方案,以及這些年幼及潛在高風險的患兒圍手術期處理方法。

(葉樂 譯 陳傑 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.


妊娠早期異丙酚誘導和恢復麻醉的效應室濃度的預測
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:據稱由於孕酮的原因,妊娠降低了對催眠藥的要求。然而,妊娠和黃體酮對異丙酚的用量的影響未完全闡明。作者進行這項研究,以確定麻醉誘導使意識喪失時異丙酚的劑量和預測效應室的濃度,以及妊娠早期麻醉過程中麻醉藥用量是否減少。並驗證血孕酮是否與異丙酚劑量和效應室濃度在意識喪失方面相關。
方法: 57ASA I-II級的婦女選擇終止妊娠和55位婦女進行陰道穿刺卵母細胞體外受精。用1 %異丙酚以200ml/min?的速度麻醉誘導。誘導過程中記錄在意識喪失時異丙酚劑量和計算的效應室濃度( Schnider模型)。另計算麻醉時患者能睜眼時的效應室濃度。手術後測定血孕酮濃度。
結果:與未孕對照組相比,懷孕組意識喪失時異丙酚平均( ± 1SD )劑量較少(108.57 ± 20.04 vs 117.59 ± 17.98 mg, respectively; P = 0.014) 。同樣,懷孕組所計算的異丙酚效應室濃度明顯低於對照組(分別為 4.59 ± 0.725.01 ± 0.64 μg / ml時, P=0.0014 。這兩組在麻醉過程中能睜眼時的效應室濃度無差異。意識喪失時所觀察的血孕酮和異丙酚劑量或異丙酚效應室濃度的關係無顯著相關性。
結論:在妊娠早期意識喪失時異丙酚劑量和預測異丙酚效應室濃度減少。但不能用黃體酮濃度變化來解釋。

(張磊 譯 陳傑 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.

 

硫噴妥鈉抑制脂多糖誘導的組織因數的表達
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:在革蘭氏陰性菌引起敗血症時,脂多糖( LPS )刺激Toll樣受體4 ,從而啟動免疫系統,並在單核細胞上表達組織因數,進而可能發生血管內凝血,心肌缺血,多器官功能障礙。因為硫噴妥鈉已被證實具有調節免疫系統的作用,作者假設硫噴妥鈉能改變LPS誘導組織因數的表達。
方法: 1. 用硫噴妥鈉( 0 0.250.5 1mg/ml)和脂多糖( 100µg/mL)枸櫞酸化全血樣本4小時。再鈣化後,凝血時間( CT )是由ROTEM來測定 2. LPS誘導縮短CT的機制通過使用組織因數受體阻滯劑活性位點抑制因數VIIA和蛋白質合成抑制劑放線菌酮來確定。3. 制定組織因數影響CT的濃度反應曲線。
結果:脂多糖縮短了CT,由618 ± 122 s192 ± 33秒( n = 6; P < 0.05 CT的縮短通過組織因數的合成媒介,因為蛋白質合成抑制和組織因數的阻斷影響消除了LPS作用。硫噴妥鈉明顯抑制LPS誘導的CT縮短(372 ± 86 s; n = 6; P < 0.001 。通過CT與組織因數標準曲線比較後表明,硫噴妥鈉降低了LPS誘導組織因數活性達86 。排除硫噴妥鈉對凝血的直接影響,因為組織因數誘導的CT沒有受到巴比妥酸鹽的影響。
結論:在全血樣本中硫噴妥鈉明顯抑制LPS誘導組織因數的表達。

(丁俊雲 譯 陳傑 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監護儀能估測混合靜脈血紅蛋白氧飽和度嗎?
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:作者假設,混合靜脈血紅蛋白氧飽和度( SvO2 )可通過無創心輸出量(NICO)監測以計算二氧化碳產生、心輸出量和動脈血氧飽和度來估測。
方法: 23名進行主動脈瘤修復的患者使用肺動脈導管監測SvO2NICO監測心輸出量。通過NICO計算出的SvO2值與使用肺動脈導管實測的SvO2值進行比較。這一估測的準確性由Bland-Altman方法進行分析。另利用相關分析評估SvO2估測值和SvO2值的變化。
結果: SvO2估測值與實測值的偏倚及範圍-2.1 ± 11.2 SvO2估測值與實測值的變化相關。
結論:來自NICOSvO2估測值不能與肺動脈導管的實測值互換使用。還需更完善的方法以便獲得更可靠的SvO2值。然而,在未作中心靜脈導管插管時,SvO2值變化較大時這方法可用來作為氧供需失衡而的預警信號。

(舒慧剛 譯 陳傑 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.


非諾特羅的吸入對酸吸入性肺損傷的影響

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:酸吸入是一個可能在全身麻醉發生的嚴重併發症。 Studies show that β-agonists have beneficial effects on lung injury.研究表明, β -激動劑對於肺損傷有有益的影響。 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,作者測試了霧化吸入β -受體激動劑非諾特羅對酸誘導肺損傷齧鼠動物模式肺變數的影響。

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:在這項前瞻性,隨機,對照研究中,作者評估了吸入非諾特羅對於酸誘導肺損傷大鼠模型的肺氧合、炎症、以及肺組織的影響。 Sprague-Dawley rats underwent sevoflurane anesthesia with tracheotomy and carotid catheter insertion.七氟醚麻醉的Sprague - Dawley大鼠進行了氣管切開術和置入頸內動脈導管。 Lung injury was induced by instillation of 0.4 mL/kg 0.1 M hydrochloric acid.通過滴注0.4ml/kg 0.1M的鹽酸誘導肺損傷。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.肺進行6 h的通氣後,吸入酸15min180 min後隨機吸入10ug非諾特羅或吸入生理鹽水。記錄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.平均動脈壓力和氣道峰壓力,測定3090180 270以及360min時的動脈血氣,隨後處死並行組織病理檢查。Additionally, fenoterol concentrations in bronchoalveolar lavage fluid (BALF) and plasma were determined by liquid chromatography/tandem mass spectroscopy.此外,用液相色譜/ 質譜法來測定支氣管肺泡灌洗液( BALF )和血漿中非諾特羅的濃度。360min後,測定支氣管肺泡灌洗液中腫瘤壞死因數(TNF)和白細胞介素(IL -6),且測定濕/幹比。

RESULTS: Inhalation treatment with 10 µg fenoterol significantly increased oxygenation after 270 and 360 min when compared with placebo.結果:與安慰劑相比,10ug非諾特羅的吸入治療後270360min顯著增加了氧合作用。 Fenoterol-treated rats showed a significant decrease in IL-6 and TNF- levels and in the wet/dry weight ratio of the lungs.非諾特羅治療的大鼠顯示出了 IL - 6TNF 水平以及肺部濕/幹比的顯著降低。 在非諾特羅組The histologic appearance showed significantly less interstitial edema and leukocyte infiltration in the fenoterol group.組織學表現展現了明顯減少的間質水腫及白細胞浸潤。 支氣管肺泡灌洗液中The concentration of fenoterol was 10.3 µg/L (median) in the BALF and <1 µg/L in the plasma.非諾特羅的濃度為10.3ug/l(中位數)在和 血漿中濃度< 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.結論:吸入非諾特羅270360min氧合改善,降低TNFIL6的釋放 ,且減少肺水腫和多形核細胞浸潤。

(懷曉蓉 譯 陳傑 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-氯普魯卡因與嗎啡的相互作用——一項關於嗎啡鎮痛時效的隨機對照試驗

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:與利多卡因相比,硬膜外嗎啡伍用2-氯普魯卡因鎮痛作用降低已不常用。2-氯普魯卡因與嗎啡之間的相互作用機制至今未明。可能的機制包括兩種藥物之間藥物反應時間及作用時程的不同以及阿片受體對抗性。本實驗中作者選取了產後輸卵管結紮的病人,假設在硬膜外注射2-氯普魯卡因前30分鐘注射嗎啡會導致的術後鎮痛的時程及效果與硬膜外給予利多卡因後注射嗎啡是一致的。

方法:實驗選取陰道分娩後行雙側輸卵管結紮並實施硬膜外鎮痛的患者,隨機分為三組,其中一組在實施硬膜外給予3%2-氯普魯卡因鎮痛前30分鐘預注嗎啡,另一組則預注生理鹽水,第三組則硬膜外給予2%利多卡因術後鎮痛,並且在手術切皮後,三組硬膜外不輸注任何藥物包括嗎啡及生理鹽水。鎮痛時效定義為從嗎啡輸注到患者要求追加鎮痛劑量的時間。硬膜外嗎啡的作用時程採用Kaplan-Meier組間分析及log-rank檢驗。

結果:在硬膜外注射2-氯普魯卡因前30分鐘注射嗎啡(n=29)導致較長的鎮痛時程(28.6 h [95% CI 4.4–52.7])。而在2-氯普魯卡因後注射嗎啡(n = 30)其作用時程為(2.2 h [95% CI 0–4.8]) (P = 0.006)。硬膜外注射2-氯普魯卡因前注射嗎啡與注射利多卡因後注射嗎啡兩者的作用時程相似(n = 28) (25.8 h [95% CI 10.7–40.9]) (P = 0.83)。在麻醉術後復蘇室內對兩組進行疼痛評分也無明顯差異。而該疼痛評分在產後恢復室內硬膜外注射2-氯普魯卡因後注射嗎啡這組中評分較高。在48小時內嗎啡的追加量相似,並且在阿片類藥物相關副作用中無明顯差異。

結論:這項研究證實在硬膜外輸注2-氯普魯卡因前30分鐘輸注嗎啡其作用時程與輸注利多卡因後輸注嗎啡的鎮痛時程是相似的。這提示硬膜外嗎啡與2-氯普魯卡因的相互作用是由於兩種藥物的作用時程,在2-氯普魯卡因前輸注嗎啡能有效的阻滯阿片類藥物受體對抗性。

(趙嫣紅 譯 陳傑 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.

 

 

開顱手術中動脈血二氧化碳分壓與七氟醚對腦毛細靜脈血流、腦血流及血氧飽和度的影響

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:術中常規監測腦血流及氧合是一項技術挑戰。通過二氧化碳對腦血管產生的生理反應,作者旨在研究一先進的神經監測裝置(oxygen-to-see, O2CTM device),在毛細靜脈水平,對開顱手術病人的區域腦血流(rvCBF),流速(rvVelo),氧飽和度(srvO2)以及血色素(rvHb)的同步監測意義。

方法: 26名神經外科病人隨機分配接受呼氣末濃度為1.4%或者2%七氟醚。開顱後,在手術側,在肉眼可見正常的腦組織表面放置一光纖探頭。每位病人同步監測低動脈二氧化碳分壓(35mmHg)或高動脈二氧化碳分壓(45mmHg)時腦深度為2mm8mm的組織腦血流。應用鐳射多普勒血流計(rvCBF, rvVelo)和分光光度計(srvO2, rvHb)測量。使用線性模型檢驗低動脈二氧化碳分壓和高動脈二氧化碳分壓,1.4%2%呼氣末七氟醚濃度,2mm8mm腦深度時rvCBF, rvVelo, srvO2, rvHb數值變化的線性關係。

結果:在腦組織深度2mm8mm處,RvCBF rvVelo隨動脈二氧化碳分壓升高而增加,而與七氟醚濃度無關(P < 0.001)。高二氧化碳分壓使平均氧飽和度從50%上升至68%P < 0.001)。腦深度8mm處較腦深度2mm處的血流流速(P < 0.001)和氧飽和度(P=0.007)快和高。RvHb不受二氧化碳變化影響,但是和七氟醚濃度呈正相關(P=0.005)。

結論:二氧化碳分壓造成的腦血流和流速增加提示在呼氣末濃度1.4%2%七氟醚麻醉下,高二氧化碳可造成保護性血管擴張。氧飽和度連續升高提示高二氧化碳分壓導致腦動靜脈中氧降低存在差異。血色素量不變表示,監測中沒有血液丟失。資料顯示,此裝置可以監測腦微血管主要靜脈在不同二氧化碳分壓水平的血流和氧飽和度。

(朱紫瑜 譯 陳傑 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.

 

經椎孔硬膜外注射的血管內擴散方式:頸椎和腰椎的對比研究

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:經椎孔硬膜外注射(transforaminal epidural injectionTEI)通常用於神經根性疼痛的治療。然而,許多已發表的研究表明,TEI的實施經常伴有嚴重的併發症,其中大多發生在頸椎水平。對該併發症的一種解釋是操作者不慎將藥物注入了血管內。作者擬鑒別在實施TEI時頸椎和腰椎水平血管內注射的發生率。

方法:將伴有根性疼痛症狀或者有帶狀皰疹相關疼痛的患者前瞻性地分為2組,各由一位作者對其實施頸椎或腰椎TEIlumbar TEIsLTEIs)。以雙平面X線透視確認了穿刺針的理想位置後,操作者在X線透視下以0.3-0.5ml/s的速度持續注入由非離子型造影劑和生理鹽水組成的混合液3ml的即時顯影。

結果:研究共實施了182TEI56例(30.8%)的注射液擴散至血管內,其中45例發生在頸段TEIcervical TEICTEI),11例為LTEI。其中,52.1%CTEI9%LTEI注射液同時擴散至神經周圍和血管內,11.3%CTEI0.9%LTEI病例的注射液僅擴散至血管內。

結論:實施CTEILTEI時,注射液誤入血管的發生率前者明顯高於後者,表明操作者應更加謹慎地實施CTEI。此外,與之前的報導相比,實施CTEI時注射液誤入血管的發生率明顯偏高。這一發現提示在實施操作時,需要加入適量的造影劑(3ml)以探測注射液是否注入了血管內,注射液同時擴散至血管內和神經周圍的情況尤為突出。

(周姝婧 譯 陳傑 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.

 

美西律和利多卡因對後角神經元興奮性的抑制作用

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:神經受損後,後角神經元的敏化作用和痛覺異化路徑改變了脊髓信號輸出,導致痛覺提高及慢性疼痛綜合症。臨床上使用劑量不足以阻滯傳導的Na+通道阻滯劑可緩解這種慢性疼痛。儘管對這些藥對傳入的影響作用關注備至,很少有研究關注他們對中央感覺神經的興奮作用。因此作者研究了Na+阻滯劑美西律和利多卡因對感覺神經後角神經元的作用。

方法:用膜片鉗技術記錄美西律和利多卡因對年輕大鼠不同種類的後角神經元(強化發熱、適應發熱和單峰神經元)的作用。

結果:所有三種不同神經元對美西律和利多卡因的反應呈劑量依賴性。兩種局部麻醉藥可逆性抑制Na+ K+電流。對Na+傳導阻滯的最大半數抑制濃度為89± 2 54 ± 6 µM,對K+傳導阻滯的延遲整流濃度分別為利多卡因582 ± 36 及美西律398 ± 14 µM。對Na+ K+ 連續電流的抑制改變了單個動作電位的特性並降低強直發放和適應發放神經元的發放頻率。

結論:在與臨床相關的濃度中,通過阻滯Na+ K+通道降低感覺神經後角神經元的興奮性。研究證實利多卡因和美西律除了其周圍神經作用外,它們對中樞神經系統中電壓門控離子通道的調節作用在疼痛治療中的抗傷害作用中有重要意義。

(黃丹 譯 陳傑 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.

 

超聲引導下腋路臂叢神經阻滯(局部麻醉藥混合液20ml)與全麻在上肢外傷手術中的比較:一項單盲、前瞻、隨機、對照試驗

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:作者隨機、對照研究低劑量超聲引導腋路臂叢神經阻滯與全身麻醉的麻醉效果及預後。

方法:患者隨機接受超聲引導腋路臂叢神經阻滯或全身麻醉。超聲引導腋路臂叢神經阻滯使用一種針面朝外進路的方法。超聲引導定位正中神經、尺神經、橈神經、和肌皮神經後,分別注射至多5毫升的局麻藥(等份混合2%利多卡因與加入7.5mg/mL可樂定的0.5%布比卡因並加入1200000腎上腺素)。局麻藥注射總量不超過20毫升。全身麻醉標準包括用芬太尼和異丙酚誘導,使用七氟醚和N2O的混合氣體來維持。疼痛評分分別在在恢復室術後2 6 24 48小時和7天獲得。並評估不需入恢復室人次和出院時間。

結果:所有超聲引導腋路臂叢神經阻滯的患者取得了令人滿意的麻醉效果。超聲引導腋路臂叢神經阻滯組患者在恢復室、術後2小時、6小時,視覺類比疼痛評分較低(分別為: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)。所有超聲引導腋路臂叢神經阻滯患者無需在恢復室進行觀察,且較接受全麻的病人更早出院( 30min120min30/240 P<0.0001 

結論:與全身麻醉相比,在上肢外傷手術,超聲引導腋路臂叢神經阻滯(使用20ml局部麻醉藥混合液)提供了令人滿意的麻醉和鎮痛效果。
(張燕 譯 陳傑 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-氨基己酸和抑肽酶應用於行初次冠狀動脈旁路分離手術患者後在纖維蛋白溶解和血液流失方面的效果:一個隨機雙盲,安慰劑控制的無差別試驗

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:直到現在,抑肽酶仍是唯一一個美國法定認可的可應用於心血管手術的抗纖維蛋白溶解的藥物。而最有可能替代抑肽酶的ε-氨基己酸(EACA)還未被充分地與抑肽酶比較。我們所要進行的研究正是要測試這一假說成立與否,即合理劑量地應用ε-氨基己酸,其在減少纖維蛋白溶解和血液流失方面的效果與抑肽酶並無差別。

方法78位擇期行初次冠狀動脈旁路分離手術的患者被隨機地分為三組進行雙盲實驗:一組應用Hammersmith劑量的抑肽酶,一組應用大劑量的ε-氨基己酸(以100mg/kg為初始符合劑量,另將含ε-氨基己酸5g的溶液以30mg/kg·h的速度進行泵控維持給藥),另一組給予等容量生理鹽水作為安慰劑。ε-氨基己酸與抑肽酶的無差別性通過兩個主要的終檢值來測定——D-二聚體形成的峰值的降低(纖維蛋白溶解的一個測試指標)以及24小時胸管引流量(CTD)。與抑肽酶比較,無差別的可信區間被設定在D-二聚體形成的峰值增加30%(相差250ug/ml)以及24小時胸管引流量(相差350ml)。

結果:組間比較ε-氨基己酸與抑肽酶,兩者的D-二聚體形成的峰值(-3.58 ug/L95% 可信區間: -203~195ug/L)和24小時胸管引流量(67 mL95% 可信區間:-90~230 mL)的差別均在預先設定的無差被可信區間範圍內(分別為250ug/mL 350 mL),完全符合兩者無差別的標準。生理鹽水安慰劑組與ε-氨基己酸組和抑肽酶組比較,後兩者D-二聚體形成的峰值均明顯降低(ε-氨基己酸組 589ug/L95%可信區間為399~788ug/LP<0.0001抑肽酶組 585ug/L95%可信區間為393~778ug/LP<0.0001)。同樣的,與生理鹽水安慰劑比較,應用ε-氨基己酸組和抑肽酶組的24小時胸管引流量也明顯減少(ε-氨基己酸組 239 mL95%可信區間為50~415 mLP<0.05;抑肽酶組 323 mL95%可信區間為105~485 mLP<0.05)。血漿ε-氨基己酸的水平可以很好地維持在靶濃度260ug/mL以上。

結論:行初次冠狀動脈旁路分離手術的患者應用ε-氨基己酸,如按用藥指南合理劑量給予,則其在減少纖維蛋白溶解和血液流失方面的效果與抑肽酶無差別。

(單嘉琪譯 薛張綱校)

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指數提示兒童丙泊酚誘導期間的年齡相關性變化

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腦電監護儀適用於麻醉期間催眠狀態的監測。此研究通過兒童丙泊酚麻醉誘導期間Narcotrend監護儀對催眠狀態和意識喪失(LOC)的判定來評估其使用的效力和可信度。

方法:選取62名年齡跨度分別為1-5歲(n=17)、6-12歲(n=23)、13-16歲(n=21)的擇期手術患兒入組研究。所有病患均需於術前口服咪唑安定0.5 mg/kg。開放靜脈通路後,設定0.5 microg/mL為初始劑量靶控輸注丙泊酚,並以每兩分鐘提高0.5 microg/mL為增量持續輸注,直至患兒對任何口頭命令或物理刺激均無應答。體重<15 kg的患兒應對照指南方案進行給藥。運用密歇根大學鎮靜評分系統(UMSS)自丙泊酚輸注開始後每分鐘對催眠狀態進行判定,並定義UMSS評分2-3分為意識喪失。Narcotrend指數(NI)需從誘導開始至研究終點全程記錄,同時還需記錄獨立于鎮靜狀態測量結論的NI值。預測概率(PK)用於評估NIUMSS的一致性。計算NI在區分意識狀態中的敏感性與特異性。比較不同年齡組別間特定UMSS水平的NI值,並運用相關性分析評價丙泊酚靶控輸注濃度與鎮靜程度間的關係。

結果:將評測意識喪失所獲取的資料計算NIPK值為0.8495%可信區間[0.80-0.88])。類似地,UMSSPK值為0.8295%可信區間[0.78-0.86]),提示NIUMSS具有一致性。UMSS連續鎮靜評分0-1分與1-2分所對應的NI平均值具有統計學差異(P < 0.01)。對於三組不同年齡組,NI可分別區分UMSS23分、UMSS12分、23分以及UMSS01分。此外,不同組別中UMSS評分1-4分的患兒其NI值也具有顯著的統計學差異(P < 0.005),年少組患兒其NI值相比年長組更高。意識喪失水平的NI值為68。從評測意識狀態所獲取的資料中可得到NI的敏感性為0.67、特異性為0.79。斯皮爾曼相關係數提示,相比NIUMSS間的聯繫(-0.68),丙泊酚靶控輸注濃度與UMSS間有著更緊密的關聯(0.96)

結論:在兒童丙泊酚誘導期間,Narcotrend腦電監護儀能在一定程度上描述兒童鎮靜狀態的變化,但其也會在預測意識狀態改變時出現相對較高的錯誤機率(0.18)。因此,該監護儀不應單獨用於指導鎮靜與麻醉。NI具有年齡相關性,就同一鎮靜級別而言,年少兒童比年長兒童擁有更高的NI值。

(范羽譯 薛張綱校)

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.

 

七氟烷麻醉狀態下右美托咪定,異丙酚和咪達唑侖對兔子呼吸CO2反應性,動脈壓及心率影響的比較。

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,異丙酚和咪達唑侖均為常用鎮靜劑。我們使用穩定狀態下的七氟烷麻醉的兔子,分別監測這三種藥物作用下CO2呼吸的反應性、平均動脈壓和心率。

方法:選用新西蘭白兔,體重2.9+/-0.2kg(平均值+/-標準差)。麻醉誘導和氣管造口術後,吸入2%七氟烷以保持試驗過程中穩定的鎮靜狀態。準備完畢後,將兔子隨機分為4(n=10X4),並分別給予以下藥物:C組為對照組(Control)D組為右美托咪定(Dexmedetomidine)2ug/kg/h的速率輸注;P組為異丙酚(Propofol)TCI Plasa濃度15ug/ml.M組為咪達唑侖(Midazolam)首劑0.3mg/kg靜推,然後1.86mg/kg/h的速率輸注。首次靜脈給藥15分鐘後開始每隔20分鐘,隨機的順序給予每只兔子C02濃度為0%, 1%, 2%, 3%, 4%, 或者5%的氣體。吸入氧濃度保持在90%。比較不同吸入C02濃度下最後一分鐘裏組間的分鐘通氣量,呼吸頻率,平均動脈壓和心率。

結果:由分鐘通氣量-吸入C02濃度曲線可見,與C組相比P組和M組的曲線右移,提示存在明顯的呼吸抑制,同時也顯著高於D組,但P組和M組之間,C組和D組之間均無顯著性差異。四組間呼吸頻率無顯著性差異。由不同吸入CO2濃度下的平均分鐘通氣量和平均動脈二氧化碳分壓的資料進行線性回歸分析得到動脈二氧化碳分壓-分鐘通氣量曲線,以計算發生呼吸暫停CO2的閾值來評價對CO2敏感性。P組和M組發生呼吸暫停的CO2閾值明顯高於C組和D組。D組對CO2的敏感性略低於C組。其餘組間CO2敏感性均無明顯差別。D組平均動脈壓低於C組和M組。D組心率低於C組,P組和M組。

結論:在七氟烷麻醉下的兔子中,右美托咪定輕度影響呼吸對CO2的反應性,但引起平均動脈壓下降較為明顯。異丙酚和咪達唑侖對於呼吸抑制較明顯,而迴圈影響較輕。

(黃劍譯 薛張綱校)

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.

 

 

活體適度的氦氣吸入可降低炎性反應,但不能防止缺血再灌注時的內皮損傷

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:惰性氣體氦氣並沒有麻醉效果,但能引起強心預反應。我們假定吸入氦氣提供預防性的保護,防止前臂血管內皮缺血再灌注時的損傷。

方法 8名健康男性受試者參加這項配對設計的研究。每個志願者隨機吸入或不吸入氦氣接收15分鐘的前臂缺血。吸入氦氣是從缺血前15分鐘開始直到灌注後5分鐘( 氦調節 ),呼氣末濃度為50% 。充血反應可標誌一氧化氮的生物利用度和血管內皮的功能,通過對前臂在1530分鐘再灌注時使用靜脈閉塞容積描記來記錄。應用流式細胞儀來測定灌注期間表達的促炎性反應標記因數,包括白細胞上的CD11b, ICAM-1, PSGL-1, and L-selectin (CD62L)和血小板上的P-selectin (CD62P), PSGL-1, and CD42b

結果:在灌注1530分鐘時缺血再灌注持續減少內皮依賴的閉塞後充血反應。吸入濃度為50%的氦氣不會改善閉塞後充血反應。氦氣可減少白細胞上炎性標記CD11bICAM - 1和血小板上凝血因數CD42bPSGL-1的表達。

結論:雖然吸入氦氣減少了缺血後炎症反應,我們的資料表明,活體吸入濃度為50%的氦氣並不能保護人體所有重要器官內的血管內皮細胞。這與七氟醚不同,七氟烷在低麻醉濃度下即可保護人類內皮細胞。

(李瑩譯 薛張綱校)

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.

 

 

脈搏波形分析和經食管超聲心動圖:兩種方法在腹腔鏡結腸手術中測定心輸出量的比較

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:脈搏波形分析(PWA)在經肺熱稀釋法校準後能測定心輸出量。FloTrac/Vigileo (FTV)儀器最近被開發,這個脈搏波形分析系統並不需要提前校準。我們比較FTV測定的心輸出量及同步經食管超聲心動圖(TEE)測定的心輸出量。

方法:我們對10名將進行腹腔鏡結直腸手術的ASA I-II病人進行了研究。橈動脈20號套管針被連接至血流動力學的監測和FTV儀器進行脈搏波形分析測定心輸出量(COPWA)。經食管超聲心動圖測定心輸出量(COTEE)就如之前所述方法進行測定。資料測定在插管後、擺好截石體位後5分鐘、建立氣腹後5分鐘、之後每30分鐘或在每當平均動脈壓低于基線水平時進行。資料分析運用了Bland-Altman法。

結果:我們對88組資料進行了比較。經食管超聲心動圖測定的心輸出量(COTEE)值從3.23 12 /分鐘不等(均數 6.21 ± 1.85)。經脈搏波形分析測定的心輸出量(COPWA)值從2.9 8.5 /分鐘不等。(均數 4.84 ± 1.14)。偏差為1.17,一致性範圍為–2.02 4.37。所有經食管超聲心動圖測定的心輸出量(COTEE)值和經脈搏波形分析測定的心輸出量(COPWA)值之間的百分誤差均值為40% (27%50%不等)

結論:在腹腔鏡結腸手術中,經食管超聲心動圖和脈搏波形分析測定的心輸出量臨床上有顯著的差異。

(姚敏敏譯 薛張綱校)

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.

 

中心靜脈置管期間使用測壓法減少動脈損傷

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%的中心靜脈置管會誤穿到動脈,造成0.1%-0.5%的病人動脈損傷。置管過程中常規使用測壓法也許可以成功辨別動脈,避免動脈置管和損傷。

方法:我們進行了一項回顧性調查包括15年期間在實施要求強制使用測壓法來證實靜脈通路的安全計畫後,實現中心靜脈置管的病例。動脈損傷被定義為非故意的動脈置管,使用7-French或者更大的導管或擴張器。動脈穿刺被定義為非故意的18G導管的放置或者針誤入動脈。15年期間所有的動脈損傷資料都被回顧。而且在最後一年的分析中,估計了動脈穿刺和其後動脈損傷的資料。

結果:在觀察期間共放置了9348個中心靜脈導管。在15年的觀察中,沒有動脈損傷的發生。在最後一年的評估中,放置了511個中心靜脈導管,動脈穿刺發生了28例(5%)。在沒有使用測壓法的情況下24例動脈穿刺被辨認出來,4例動脈穿刺在使用測壓法的情況下才被發現,沒有伴隨動脈損傷的發生。

結論15年的評估表明,在中心靜脈置管中使用測壓法驗證靜脈放置,有效地減少了非故意的動脈置管造成的動脈損傷。

(俞佳譯 薛張綱校)

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.

 

肺泡複張及高PEEP措施應用於有血管內容量負荷的病態肥胖病人後,並不對血流動力學產生影響

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

 

我們評估了肺泡複張和高呼氣末正壓(PEEP)通氣在20名行腔鏡手術的容量負荷的病態肥胖病人(BMI 50 ± 9 kg/m2)中應用的效果。肺泡複張合併PEEP試驗措施在二氧化碳氣腹建立前後連續進行,由前PEEP試驗,平臺壓力為50–60 cm H2O的複張10次,及後PEEP組成。肺泡複張及高PEEP並不會顯著造成病人血流動力學紊亂,該項指標由肺動脈導管測定。經食管超聲並不能揭示舒張末容積的差異及心臟異常活動。

(陳珺珺譯,薛張綱校)

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.

 

鎮靜對顱內占位的病人的顱內壓的作用:瑞芬太尼與異丙酚

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,我們比較了輕度鎮靜作用的瑞芬太尼和異丙酚在患者于區域麻醉下行立體定向腦腫瘤活檢術時顱內壓和顱內灌注壓的影響。

方法:這是一個前瞻性、開放式、隨機對照研究。40名於區域麻醉下行立體定向腦腫瘤活檢術的患者被隨機分為兩組分別接受瑞芬太尼和異丙酚的滴定直至到達清醒/鎮靜量表四級的程度。顱內壓通過活檢針測定。

結果:達到目標鎮靜程度時,瑞芬太尼和異丙酚的注射速度分別為4.2 +/- 1.8 microg x kg(-1) x h(-1) 4.3 +/- 2.5 mg x kg(-1) x h(-1)。測量顱內壓時,瑞芬太尼組的病人比異丙酚組的病人有更慢的呼吸頻率(11/min +/- 3 vs 15 per min +/- 3, P = 0.0001)和更高的二氧化碳分壓(48.3 +/- 6.2 mm Hg vs 43.1 +/- 5.5 mm Hg, P = 0.009)。兩組的平均值相似,瑞芬太尼組和異丙酚組分別為19.0 +/- 11.9 mm Hg vs 16.4 +/- 11.1 mm Hg(P = 0.48)。瑞芬太尼組的平均動脈壓相對於異丙酚組的更高(101.1 +/- 13.7 mm Hg vs 85.8 +/- 12.7 mm Hg, P = 0.0008),導致較高的顱內灌注壓2.0 +/- 19.0 mm Hg vs 69.5 +/- 17.0 +/- 19.0 mm Hg (P = 0.03)

結論:輕度鎮靜的瑞芬太尼在行立體定向腦腫瘤活檢術的患者中相對于異丙酚不會導致更高顱內壓,而顱內灌注壓可能保持得更好。

(張玥琪譯,薛張綱校)

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.

 

腹部外科手術期間體液平衡的影響:一個數學模型

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:關於術中液體管理制度是否可以帶來好的術後結果一直存在爭論。組織間隙液體積聚會帶來術後不良結果,但是術中體液平衡管理的影響尚不清楚。在此項研究中,我們運用一個數學模型來描述體液分佈。

方法:以前發表的關於進行腹部手術患者的生物阻抗分析資料常被用來估算損傷和未損傷組織間隙的容量變化(DeltaV(IT),相對基線的變化百分比)。比較手術時間小於3h(n = 5)和手術時間大於等於3h(n = 25),手術結束時非損傷組織和損傷組織的間隙容量變化比值,和術中總的輸注液體量(V(INF), mL/kg)。可導致不良結果的血漿容量變化(DeltaV(PL), 相對基線值得百分比)和間隙容量變化的臨界值,可以從健康志願者接受不影響生理的靜脈液體容量而得到的資料估算出來。最後,模擬一個70 kg的患者進行1-8 h的腹部外科手術,根據DeltaV(PL) DeltaV(IT)來決定晶體從2 mL x kg(-1) x h(-1) 30 mL x kg(-1) x h(-1)的輸注速率。維持未損傷組織間隙DeltaV(PL) DeltaV(IT)在臨界值內的液體輸注速率可作為手術期間的一項功能。

結果:生物阻抗資料顯示非損傷組織和損傷組織DeltaV(IT)/V(INF)比率的不同僅在大於等於3小時的手術中有顯著意義(0.30 +/- 0.17% x kg/mL vs 1.55 +/- 0.73% x kg/mL, P < 0.0001)。手術時間小於3小時和大於等於3小時的DeltaV(IT)/V(INF)比率的不同僅在損傷組織中有意義(0.45 +/- 0.35% x kg/mL vs 1.55 +/- 0.73% x kg/mL, P = 0.003)。維持DeltaV(PL) DeltaV(IT)在臨界值(分別>-15% <20%)所需的液體輸注比率在短時手術的範圍很大(對於2小時的手術需2-18.5 mL x kg(-1) x h(-1)),但對於長時手術來說較狹窄(對於6小時的手術需5-8 mL x kg(-1) x h(-1))

結論:基於我們的模型,對於小於3小時的腹部手術,在沒有明顯組織間隙水腫的情況下應盡可能的增加液體的輸注速率。然而,從我們的模型可預測在大於6小時的腹部手術需限制不也量來避免過度的組織間隙水腫。

 (張釗譯 薛張綱校)

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.

 

滴注或注射提純的天然辣椒堿對大鼠後肢感覺-運動行為或截骨修復術無有害影響

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:一種新型的純度為98%的辣椒素成分(4975)正在接受臨床觀察,通過新的方式提供選擇性鎮痛,單次給藥即能維持數周至數月的鎮痛效果。我們進行這項研究來評價在大鼠截骨修復術創傷癒合和感覺-運動神經功能模型中滴注或注射4975的安全性和效應。

方法:選用成年雌雄SD大鼠。第一組評價4975對神經或肌肉的效應。0.00830.025 mg 4975或載體(25%的聚乙二醇300)用於暴露的坐骨神經,或0.1 mg 4975或載體注入周圍的肌肉。第二組評價4975對骨頭癒合的影響,對一側股骨實行截骨術,將0.5 mg 4975或載體滴入創傷處。對兩組大鼠均進行行動測試和股神經的組織學評估,周圍的軟組織和骨頭於術後31428天進行測試。實行截骨術的大鼠股骨通過外周定量電腦攝影和生物機械測試法進行評估。用標準統計檢驗比較兩組結果。

結果:直接股神經使用和周圍肌肉使用4975的大鼠在控制傷害性感受反應(F = 0.910, P = 0.454),握力(F = 0.550, P = 0.654),肌肉或股神經的組織學方面沒有差別。在截骨術的大鼠中,使用4975和載體治療在骨面積(H = 2.858, P = 0.414)、骨礦物質含量(F = 0.945, P = 0.425)、骨礦物質密度(F = 0.87, P = 0.462)以及軟組織癒合方面沒有差別。對照組和4975治療組不僅骨的強度沒有差別,從大體和微觀上看右側股骨截骨術癒合處和周圍軟組織也沒有明顯的差別。

結論:單次臨床相關滴注或注射4975對截骨術後傷口和骨頭癒合或暴露的肌肉和神經的結構完整性無明顯有害影響。

(朱蘭芳譯 薛張綱校)

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.

有癲癇病史的病人行區域阻滯

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:行區域阻滯的病人在使用局麻藥藥時會出現局麻藥的全身毒性作用,特別是大劑量使用時,例如硬膜外阻滯,骶麻或周圍神經阻滯。但是對於既往有癲癇病史的病人,使用局麻藥是否會增加局麻藥的神經毒性尚不清楚。

方法:我們研究了從198811日至20011231日期間行硬膜外阻滯,骶麻及外周神經阻滯的既往有癲癇病史的病人進行回顧性研究。我們調查了病人的人口統計學,癲癇發作的類型,區域阻滯的詳細情況,及是否有癲癇發作的資料。我們將研究的結果與由於局麻藥的神經毒性所致癲癇在人群中的發生率10000分之一相比較,並比較了95%的置信區間。

結果:在這14年中,共記錄了335名病人411人次的手術過程。24名病人術後出現了癲癇發作。術前最近一次癲癇發作的時間與術後發作與否相關(P < 0.001)。基於間斷及之後注射局麻藥的時間間隔,我們認為其中24名病人中的19人,局麻藥並不能作為癲癇發作的病因及相關因素。其他5名病人,圍手術期癲癇的發作特性與既往相類似。儘管我們不能證實局麻藥是造成癲癇的主要因素,但是我們不能忽視這5名病人局麻藥的神經毒性作用.假定沒有一次癲癇發作與局麻藥的神經毒性有關,估計癲癇的發生率是10000分之0 95% CI 0–89/10,000)。反之,如果癲癇的發作與局麻藥有關,其發生率增加至10000分之12095% CI 40–280/10,000)

結論:我們得出的結論是圍手術期癲癇的發作與患者既往癲癇的種類及基本狀況相關,這些病人並不是區域阻滯的禁忌症。進一步講,近期有過癲癇發作病史的病人圍手術期出現癲癇的可能性增高,因此無論是行何種麻醉或鎮痛手段都應準備好應對癲癇發作。

(陳珺珺譯 薛張綱校)

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.