Anesthesia & Analgesia

June 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

心血管手術圍手術期輸注紅細胞與術後長期生存率降低的關係

單嘉琪譯 薛張綱校

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

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

Anesth Analg 2009 108: 1741-1746.

使用全血及經典的光導集合測定法評估體外迴圈導致的血小板功能改變的初步研究結果

裘毅敏譯，馬皓琳、李士通校

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

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

Anesth Analg 2009 108: 1747-1754.

PEDIATRIC ANESTHESIOLOGY:

術前口服咪達唑侖對兒童呼吸功能的影響

劉世文　譯　陳傑　校

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

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

Anesth Analg 2009 108: 1771-1776.

預測兒童患者的術前焦慮:誰最為準確？

范羽譯 薛張綱校

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

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

Anesth Analg 2009 108: 1777-1782.

Storz  Miller 1電視喉鏡對類比嬰兒困難插管的效果

朱 慧譯 馬皓琳 李士通校

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

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

Anesth Analg 2009 108: 1783-1786.

ANESTHETIC PHARMACOLOGY:

七氟醚製劑中水含量影響蒸發罐內路易斯酸引起的七氟醚降解

葉樂　譯　陳傑　校

Sevoflurane Formulation Water Content Influences Degradation by Lewis Acids in Vaporizers

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

Anesth Analg 2009 108: 1796-1802.

糖尿病的新療法：對於麻醉管理的意義(綜述)

黃劍譯 薛張綱校

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

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

作用于外周的mu-阿片類受體拮抗劑與術後腸梗阻：作用機制及臨床可應用性

吳進 譯  馬皓琳 李士通 校

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

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

Anesth Analg 2009 108: 1811-1822.

TECHNOLOGY, COMPUTING, AND SIMULATION:

自動運算監測收縮壓變異和脈壓變化的差異

張磊　譯　陳傑　校

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

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

Anesth Analg 2009 108: 1823-1829.

同一患者狀態熵的可重複性：全身麻醉狀態下兩側電極同時測量的比較

李瑩譯 薛張綱校

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

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

Anesth Analg 2009 108: 1830-1835.

CRITICAL CARE AND TRAUMA:

235名患敗血症外科重症監護病人的肉眼可見屍檢結果

王宏 譯，馬皓琳，李士通 校

Macroscopic Postmortem Findings in 235 Surgical Intensive Care Patients with Sepsis

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

Anesth Analg 2009 108: 1841-1847.

一項七氟醚吸入（使用ICU中應用的麻醉裝置）鎮靜與靜注異丙酚鎮靜對腎功能完整性影響的比較研究

丁俊雲　譯　陳傑　校

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

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

Anesth Analg 2009 108: 1848-1854.

齧齒類創傷出血模型中血紅素氧合酶-1的上調對於sirtinol介導的減弱肺損傷有重要作用

姚敏敏譯 薛張綱校

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

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

Anesth Analg 2009 108: 1855-1861.

球囊擴張氣管造口術：使用Ciaglia藍海豚方法的初體驗

唐李雋  譯   馬皓琳  李士通  校

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

Tom W. Gromann, Oliver Birkelbach, and Roland Hetzer

Anesth Analg 2009 108: 1862-1866.

OBSTETRIC ANESTHESIOLOGY:

產科圍麻醉期監護病房標準的調查

舒慧剛　譯　陳傑　校

A Survey of Obstetric Perianesthesia Care Unit Standards

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

Anesth Analg 2009 108: 1869-1875.

腰椎橫斷面的超聲成像：肥胖產婦硬膜外腔深度估計值和實際值的相互關係

俞佳譯 薛張綱校

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

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

Anesth Analg 2009 108: 1876-1881.

XI因數缺乏和產科麻醉

黃麗娜 譯 馬皓琳 李士通 校

Factor XI Deficiency and Obstetrical Anesthesia (Brief Report)

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

Anesth Analg 2009 108: 1882-1885.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

嚴重蛛網膜下腔出血相關的鈉及血容量調節的內分泌反應

趙嫣紅　譯　陳傑　校

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

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

Anesth Analg 2009 108: 1922-1928.

頸動脈內膜切除術的麻醉:第三種選擇,患者合作下的全身麻醉

張玥琪譯，薛張綱校

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

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

Anesth Analg 2009 108: 1929-1936.

ANALGESIA:

病人自控鎮痛的鎮痛測量及其問題

江繼宏 譯  馬皓琳 李士通 校

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

Igor Kissin

Anesth Analg 2009 108: 1945-1949.

利多卡因貼片用於前列腺癌根治術術後鎮痛

周姝婧　譯　陳傑　校

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

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

Anesth Analg 2009 108: 1950-1953.

鞘內單獨應用嗎啡或聯合可樂定對於根治性前列腺切除患者的術後鎮痛效果

張釗譯 薛張綱校

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

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

Anesth Analg 2009 108: 1954-1957.

銀杏提取物EGb 761對大鼠神經性疼痛模型機械性和冷性異常疼痛的作用

張瑩譯  馬皓琳 李士通校

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

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

Anesth Analg 2009 108: 1958-1963.

U50,488和氟比洛芬對清醒大鼠的內臟痛的單獨及聯合效應

唐亮 譯  馬皓琳 李士通 校

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

Takayuki Kitamura, Makoto Ogawa, and Yoshitsugu Yamada

Anesth Analg 2009 108: 1964-1966.

與神經刺激相比，超聲引導能提高橈側畸形手兒童的鎖骨下臂叢神經阻滯的成功率？

黃丹　譯　陳傑　校

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

Vrushali C. Ponde and Sandeep Diwan

Anesth Analg 2009 108: 1967-1970.

羅呱卡因用於上腹部大手術中硬膜外鎮痛的濃度：一項前瞻性隨機雙盲安慰劑對照試驗

朱蘭芳譯，薛張綱校

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

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

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

用骶骨旁進路在超聲引導下定位骶叢神經

姜旭暉譯，馬皓琳，李士通校

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

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

Anesth Analg 2009 108: 1977-1980.

 

術前口服咪達唑侖對兒童呼吸功能的影響

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

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

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

Anesth Analg 2009 108: 1771-1776.

 

背景：咪達唑侖作為術前用藥常用于兒童以減輕患兒的焦慮，促進其麻醉前的合作。但是，由於咪達唑侖的肌松作用，可能影響兒童的呼吸功能。研究者分別評估了清醒狀態下和口服咪達唑侖（0.3mg/kg）20分鐘後功能殘氣量(FRC)、通氣均勻性和呼吸力學三項指標。其中，通氣均勻性通過肺清除指數(LCI)進行評價。

方法：功能殘氣量和肺清除指數通過六氟化硫多次呼吸-洗出技術測定，而呼吸道的阻力和彈性回縮力則通過用力震盪技術中阻抗變化測定。研究共測定了18名兒童（3-8歲）使用咪唑安定前後的上述指標。

結果：麻醉前給予咪達唑侖導致患兒FRC均值降低6.5%，從25.0 ml/kg降低到23.4 ml/kg，差異具有統計學意義。LCI增加7.8%，從6.4 (0.4) 增加到 6.9 (0.4)，這些都顯示患兒的通氣不均勻性（ventilation inhomogeneity）增加。此外，咪達唑侖導致患兒呼吸阻力增加7.4%，從3.38 (0.6)到 3.62 (0.6) cm H₂O s/L（P<0.001），呼吸彈性回縮力增加9.2%，從48.8 到 52.9 cm H₂O s/L（P<0.001）。FRC、LCI的變化與呼吸阻力、彈性回縮力的變化具有顯著的相關性。

結論：在肺正常的兒童，在給予相對小劑量的咪達唑侖後，可致呼吸器官微小的變化。麻醉醫生應該意識到在具有肺部併發症高風險的兒童使用咪唑安定可能導致肺功能下降較大。

（劉世文　譯　陳傑　校）

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

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

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

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

七氟醚製劑中水含量影響蒸發罐內路易斯酸引起的七氟醚降解

Sevoflurane Formulation Water Content Influences Degradation by Lewis Acids in Vaporizers

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

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

Anesth Analg 2009 108: 1796-1802.

 

背景：許多製造商生產七氟醚。目前市售的七氟醚在合成方法，純度，銷售時的容器及含水量等方面各有不同。七氟醚易於受到各種化學降解的影響，最主要是被路易斯酸（如金屬氧化物和金屬鹵化物）降解成氫氟酸和其他有毒化合物。水抑制這種降解。該觀察研究測定了存儲在三種類型的蒸發罐中的三種配方的七氟醚（二種低水配方和一種高水配方）的降解。

方法：低水配方七氟醚(Eraldin®, Laboratorios Richmond/Minrad, Argentina [19 ppm water]、美國百特產普通七氟醚[57 ppm water]以及高水配方七氟醚(Ultane®, Abbott, US [352 ppm water])，儲存於三個不同的蒸發罐 (Draeger Vapor 2000, GE/Datex-Ohmeda Tec 7, Penlon Sigma Delta)，貯藏於 40 ℃ 環境下 。裝入七氟醚後立即以及裝入後的第1 、2和3周，從各蒸發罐取樣，並分析水含量、pH值、氟化物以及總的降解產物。

結果：存放在Penlon Sigma Delta蒸發罐的低水配方七氟醚，其氫氟酸含量（ pH值降低至3 ，氟化物濃度達600PPM ）和總的降解產物（大於600PPM）呈時間相關性增加。Penlon Sigma Delta蒸發罐在存儲3周後，從玻璃觀察孔的刻蝕線觀察顯示金屬容器內充滿低水七氟醚。然而高水配方七氟醚（ Ultane ，雅培，美國[ 352PPM] ）氟化物和降解產物的含量微乎其微， pH值下降很小。存儲於Draeger Vapor 2000 and GE/Datex-Ohmeda Tec 7蒸發罐的七氟醚pH值，氟化物濃度和降解產物的變化幾乎可以忽略不計。 
結論：低水配方七氟醚在Penlon Sigma Delta蒸發罐內的儲存期間產生大量氫氟酸和其他降解產物。七氟醚製劑水分含量的差異以及潛在的降解產物對患者具有潛在的安全問題。

（葉樂　譯　陳傑　校）

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

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

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

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

自動運算監測收縮壓變異和脈壓變化的差異

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

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

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

Anesth Analg 2009 108: 1823-1829.

 

背景：脈壓變異(dPP)能可靠預測患者對液體的反應性。作者研製了呼吸變異性監測裝置，能夠持續記錄氣道壓力和動脈血壓 。研究者比較了呼吸變異監測儀和dPP兩種測量方法的差異。
方法：記錄24名患者動脈血壓及氣道壓。資料提供給呼吸變異檢測儀並用兩種方法計算脈壓變化和收縮壓的變異：（a）同時考慮動脈血壓和氣道壓(RV 演算法)和（ b ）只考慮動脈血壓(RV_slim 演算法) 。此外，術中每隔10分鐘記錄一次動脈血壓和氣道壓以便於人工計算脈壓變化。 監測觀察者之間的差異性，並將人工脈壓變化測量與自動測量相比較。為了評估氣道壓的重要性，將RVslim測量法與RV測量法做比較。

結果： 24位元患者共記錄174個測量結果（ 每名患者6-10個）。 6名觀察者人工評測前8位元患者脈壓變化（間隔10分鐘， 53個測量結果）; 使用電腦輔助方法未發生觀察者間的變異。布蘭德-奧特曼分析表明了 與人工法相比，2種自動化測量方法的偏差和置信區間是可接受的（RV： -0.33 ％ ± 8.72 ％和RVslim ： -1.74 ％ ± 7.97 ％ ） 。RV的測量法和RVslim測量法之間的差別很小（偏差-1.05 ％ ，置信區間5.67 ％ ） 。

結論：自動測量結果與使用電腦輔助人工測定獲得的監測結果相當。氣道壓信號的重要性值得懷疑。

（張磊　譯　陳傑　校）

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

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

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

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

 

一項七氟醚吸入（使用ICU中應用的麻醉裝置）鎮靜與靜注異丙酚鎮靜對腎功能完整性影響的比較研究

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

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

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

Anesth Analg 2009 108: 1848-1854.

 

背景：上世紀70年代使用的甲氧氟烷能導致機體無機氟化物水準的增加和術中長時間使用七氟醚被認為具有潛在的腎毒性。研究者評估了ICU中術後短期吸入七氟醚鎮靜（使用ICU麻醉裝置）和異丙酚鎮靜對腎功能完整性的影響。
方法：在這項前瞻性，隨機，單盲的研究中，研究者選取了腹部大血管或胸外科手術後的125例患者，分別接受通過ACD（呼末氣體濃度為0.5-1 ％ ）吸入七氟醚（ 64例）或靜注異丙酚（ 61例）術後鎮靜24小時。在術前，術畢，術後24h和48 h分別測量作為主要結局變數的尿-谷胱甘肽- S -谷胱甘肽轉移酶，尿N -乙醯氨基葡萄糖苷酶，血肌酐，無機氟化物濃度，尿量及液體管理。

結果：七氟醚（ 9.2 ± 4.3 h ）組和異丙酚（ 9.3 ± 4.7h）組在ICU的鎮靜時間上具有可比性。 兩組中術後24h和48 h的α -谷胱甘肽- S -轉移酶水準較術前值相比均明顯增加，組間無顯著差異。組間 N -乙醯氨基葡萄糖苷酶和血清肌酐無明顯變化。研究期間兩組尿量和肌酐清除率相當。術後24h無機氟化物水準七氟醚吸入組（ 39 ± 25 μmol / L）較異丙酚組（ 3 ± 6 μmol / L）顯著增加（ P<0.001 ），且持續至術後48h（ 33 ± 26比3 ± 5 μmol / L ）。住院期間每組均有一名患者出現腎功能不全，需要接受強效利尿劑治療，但不需要透析。
結論：使用麻醉保留裝置吸入七氟醚或靜注異丙酚行短期鎮靜對術後腎功能無不利影響。儘管使用七氟醚後機體無機氟含量升高，但住院期間腎小球和腎小管完整性未受影響。

（丁俊雲　譯　陳傑　校）

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

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

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

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

 

產科圍麻醉期監護病房標準的調查

A Survey of Obstetric Perianesthesia Care Unit Standards

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

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

Anesth Analg 2009 108: 1869-1875.

 

背景：雖然產科患者大多健康，但是由於高齡、肥胖、多胎妊娠增多，以及術後即刻併發症的發生，其總體風險正在增加。本研究評估了在北美專業機構中，目前接受全麻或神經阻滯麻醉的剖宮產患者的復蘇護理水準。
方法：2007年6月至10月，針對產科麻醉復蘇實踐的調查電郵給北美專業醫療機構的135名產科麻醉主任。該研究完全通過匿名發送。
結果：調查的回收率為54.8 ％ （ 74/135份）。受訪者報告的中位數為2550次分娩/年（四分位數間距[ IQR ] 2000 ， 4000 ） ，其中30 ％為剖宮產（ IQR 25.5 ％ ， 32.5 ％ ），5 ％的剖宮產在全身麻醉下進行（ IQR 4 ％ ， 8 ％ ）。多數醫療機構中，產婦的剖宮產後復蘇在產科圍麻醉期監護病房、產房或復蘇室進行，復蘇人員則完全由圍產期護士擔任，而不是專門的圍麻醉期產科護士。對於那些護理全麻或神經阻滯麻醉剖宮產後患者的圍產期護士，45%的醫療機構（28/62）沒有提供專門的圍手術期培訓。 43%的受訪者（29/67）認為在剖宮產後，產婦接受的護理品質低於普通外科患者。那些由完全圍產期護士提供麻醉護理的受訪者，認為剖宮產後的麻醉後護理品質低於普通外科患者（ P = 0.008 ）。
結論：關於麻醉後護理的指南由美國麻醉醫師學會及美國麻醉護士協會制定，適用于所有患者術後恢復，而不論其復蘇地點。這一研究結果表明，北美學術機構提供的剖宮產術後一級護理未能達到指南的要求。
（舒慧剛　譯　陳傑　校）

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

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

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

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

嚴重蛛網膜下腔出血相關的鈉及血容量調節的內分泌反應

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

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

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

Anesth Analg 2009 108: 1922-1928.

 

背景：低鈉血症通常與嚴重的動脈瘤性蛛網膜下腔出血（SAH）相關，或者被SAH所加重。已經有研究表明動脈瘤性蛛網膜下腔出血（SAH）通常可能引起不同程度的水鈉瀦留並引起一些內分泌紊亂。然而，對參與水鈉平衡以及迴圈血容量調節的不同激素系統進行廣泛研究仍然是需要的。在控制鈉的攝入來防止高鈉血症的背景下，研究者的目的是通過研究血容量及不同激素調節系統來評估在嚴重SAH後水鈉的調節機制。

方法：本前瞻性研究的物件為19位元嚴重SAH的機械通氣患者。通過調節尿鈉排泄控制血鈉大於4.5 mmol · kg^–1 · d^–1。控制水電解質平衡的激素因數：抗利尿激素、腎素、血管緊張素、醛固酮以及利鈉肽，每3天評估一次共12天。並在入院48小時內及第7天通過同位素法（鍀標血細胞法）測量血紅細胞量。使用心電圖，經胸超聲心動圖以及肌鈣蛋白(cTnI)評估心功能。3個月時評估結局。

結果：嚴重的動脈瘤性蛛網膜下腔出血（SAH）發生後，高鈉和輸水以適應腎排泄可防止低鈉血症而不降低迴圈血容量。激素的特點為腎素，血管緊張素II的增加，利鈉肽的濃度與肌鈣蛋白的增加，抗利尿激素的低水準和缺少醛固酮有關。激素水準與尿鈉排泄無相關性。

結論：嚴重的SAH發生後，在多種臨床治療干預的情況下，血鈉的增高及低血容量的發生與腦性鹽耗綜合症一致，可能與SAH引起的交感神經興奮，血管緊張素增加，醛固酮減少和增加利鈉肽的釋放有關。

（趙嫣紅　譯　陳傑　校）

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

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

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

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

 

利多卡因貼片用於前列腺癌根治術術後鎮痛

Lidocaine Patch for Postoperative Analgesia After Radical Retropubic Prostatectomy

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

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

Anesth Analg 2009 108: 1950-1953.

 

在本項前瞻性、雙盲、安慰劑對照的研究中，全身麻醉下接受前列腺癌根治術的患者被隨機分配術畢在傷口兩側使用利多卡因貼片或安慰劑。收集術後24小時的資料。共有70位患者完成了本次研究（ 36位為利多卡因組，34位為對照組）。兩組間人口統計學和患者術後嗎啡用量方面無差異。但利多卡因組患者各個階段咳嗽是疼痛顯著減輕（下降19%–33%），治療組和對照組間P<0.0001，疼痛需要治療的次數兩組比較P=0.3056；前6個小時靜息時的疼痛明顯減輕（下降17%–32%），治療組和對照組間P=0.0003，疼痛需要治療的次數兩組比較P=0.0130。

（周姝婧　譯　陳傑　校）

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

與神經刺激相比，超聲引導能提高橈側畸形手兒童的鎖骨下臂叢神經阻滯的成功率？

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

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

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

Anesth Analg 2009 108: 1967-1970.

 

背景：對於橈側畸形手，神經刺激的典型反應可能會發生變化。這種情況下，超聲引導可能是一種有用的方法。本研究中，研究者對比了兒童橈側畸形手修復術時，超聲引導法和神經刺激法行鎖骨下臂叢神經阻滯的成功率。

方法：50名年齡為1-2歲，進行橈側畸形手修復的兒童，被隨機分配接受神經刺激法（NS組）或者超聲引導法（U組）鎖骨下臂叢神經阻滯，這兩組均聯合使用少量全身麻醉藥。兩組均給予0.5%的布比卡因0.5ml/kg。外科刺激時出現疼痛反應則被認為阻滯失敗。根據東安大略兒童醫院疼痛評分，在手術後1，4，6，8，10小時分別進行疼痛評分。

結果：在NS組中，25名患者中有16名阻滯成功（64%），而在U組中，25名患者有24名阻滯成功(P = 0.0053)。在術後10小時的研究期間，第一次出現痛覺消失的時間和止痛劑消耗量沒有差異。

結論：橈側畸形手患者進行修復術時，神經刺激法相比，超聲引導法能夠提高鎖骨下臂叢神經阻滯的成功率。

（黃丹　譯　陳傑　校）

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

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

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

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

心血管手術圍手術期輸注紅細胞與術後長期生存率降低的關係

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

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

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

Anesth Analg 2009 108: 1741-1746.

 

背景：為研究紅細胞（RBC）輸注與心血管手術術後死亡率的升高有關與否，我們對住院期間接受過一到兩個單位紅細胞輸注的心血管手術病人的長期生存率進行了隨訪。

方法：9079位於2001至2004年在北新英格蘭18個中心行冠狀動脈旁路移植術，瓣膜或者冠狀動脈瓣膜旁路移植/瓣膜手術的患者經過篩選後被長期連續性隨訪研究。2006年6月30日，將地區登記的與社會安全保障屬的死亡認證檔進行匹配概率比較從而確認死亡率。並應用Cox概率風險與傾向的方法來計算和調整風險比率。

結果：有36%的患者（n=3254）曾輸注過一到兩個單位的紅細胞，其中有43%是在術中輸注的，56%在術後輸注，1%是在術前輸注的。接受紅細胞輸注的大多是那些貧血，高齡，低體重，女性或者有多種合併症的患者。與那些未輸注過紅細胞的患者相比，住院期間輸注過一到兩個單位紅細胞的所有心血管手術患者，其生存率都明顯下降（P< 0.001）。根據患者和疾病的特性對觀察資料進行統計學分析調整後得出，輸注過一到兩個單位紅細胞的患者，其長期死亡風險率將增加16%（調整風險比率=1.16，CI：1.01-1.34, P = 0.035）。

結論：輸注一到兩個單位的紅細胞與心血管手術術後生存率降低有關，據研究結果其風險將增高16%。

（單嘉琪譯 薛張綱校）

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

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

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

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

 

預測兒童患者的術前焦慮:誰最為準確？

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

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

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

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

 

背景：此次研究設法評價全麻誘導期間小兒麻醉主治醫師、住院醫師及患兒母親三者預測2至16歲兒童(n=125)術前焦慮的能力。

方法：麻醉醫師及患兒母親運用視覺類比量表對患兒的術前焦慮提供預測，患兒的客觀焦慮狀況則使用有效行為觀察工具——改良耶魯術前焦慮量表進行評估。所有患兒母親在全麻誘導期間均在場，所有患兒均不接受術前鎮靜用藥。採集資料後進行相關性分析。

結果：125名2至16歲的小兒病患、患者母親及實施麻醉的主治和住院醫師共同參與了此項研究。相關性分析顯示全麻誘導期間麻醉主治醫師對患兒術前焦慮的預測與患兒客觀焦慮狀況之間存在顯著性關聯（r(s) = 0.38, P < 0.001）。而誘導期間麻醉住院醫師和患兒母親的預測與患兒客觀焦慮狀況之間無顯著性聯繫。就預測的準確性而言，在麻醉主治醫師所提供的預測中，有47.2%與患兒的客觀焦慮狀況在一個標準差誤差範圍內，有70.4%在兩個標準差誤差範圍內。

結論：相比患兒母親，參與實施兒科麻醉的主治醫師在全麻誘導期間更能準確地預測兒童患者的術前焦慮。雖然這一結論具有重要的臨床意義，但是否可將其推廣至其他較少從事兒科麻醉的麻醉主治

（范羽譯 薛張綱校）

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

 

糖尿病的新療法：對於麻醉管理的意義(綜述)

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

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

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

Anesth Analg 2009 108: 1803-1810.

 

多種激素和信號轉導系統在糖代謝平衡中發揮作用。近來發現，胃腸肽激素，高血糖樣肽1和澱粉不溶素也在這一複雜的生理過程中具有重要作用。這些新發現為糖尿病的新治療方法提供了基礎。基於高血糖樣肽1和澱粉不溶素的治療方法現已進入臨床實踐。在歐洲多國選擇性內源性大麻素受體拮抗劑(利莫大班)已經用於肥胖症的治療，近來研究也將其歸因於此。此種藥物療法顯示出了在代謝病和2型糖尿病治療方面的優勢。作為麻醉實施者應該關心糖尿病人的情況，而必須理解這些圍手術期的新療法的意義，尤其是注意其副作用及和其他因素的相互作用。

（黃劍譯 薛張綱校）

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

 

同一患者狀態熵的可重複性：全身麻醉狀態下兩側電極同時測量的比較

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

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

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

Anesth Analg 2009 108: 1830-1835.

 

背景： 狀態熵(SE)是類似於雙頻指數的反映麻醉深度的指標。 兩個指標都通過記錄在前額的一個單向電極得到的腦電圖作為他們的輸入。 雙頻指數對病人內在狀況的再現能力在最近的一項研究中受到了質疑。在這個研究中，對同一病人應用兩個電極並同時測量，得到了不一致的麻醉深度。我們的目的是確定狀態熵是否是同樣地可重複性，即使它的估計使用的是不同於雙頻指數的演算法。在這次研究中，我們通過測量應用于同一患者兩側的不同電極同時獲得的狀態熵來研究其可重複性。

方法：熵電極並應用於21名處於吸入麻醉狀態下的患者的兩側。每10秒對每名患者兩側的電極同時測量一次狀態熵並記錄。然後應用Bland-Altman統計學對得到的資料進行分析。

結果：我們得到了14379對狀態熵測量值。4%的個體測量值顯示的麻醉深度在數值上有大於10分的差異。差異不具有臨床意義（-0.3）。95%的分佈區間是-11.7到+11.6。

結論：當探針應用于同一名患者的前額兩邊時狀態熵顯示出了有臨床意義的分歧。Bland-Altman分析顯示在相似的研究中狀態熵比雙頻指數具有更好地可重複性。然而，4%同時測量的狀態熵對顯示了不同的麻醉深度並且數值上有大於10點。因此應用狀態熵來作為判斷麻醉深度的指標應更加謹慎。

（李瑩譯 薛張綱校）

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

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

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

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

 

齧齒類創傷出血模型中血紅素氧合酶-1的上調對於sirtinol介導的減弱肺損傷有重要作用

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

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

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

Anesth Analg 2009 108:1855-1861.

 

背景：不良迴圈條件下血紅素氧合酶-1的表達具有保護作用。我們最近的實驗顯示在創傷出血後的雄性SD大鼠中注入sirtinol減弱肝損傷。然而，sirtinol產生有益作用的機制是未知的。我們假設在創傷出血後的雄性SD大鼠注入sirtinol通過血紅素氧合酶-1相關的途徑減少細胞因數產生從而減弱肺損傷。

方法：雄性SD大鼠（每組n=8）經歷創傷出血（平均動脈壓保持在40mmHg90分鐘，然後復蘇）。單劑量sirtinol（1毫克每公斤體重）加或不加血紅素氧合酶抑制劑（鉻間卟啉）或是賦形劑在復蘇時通過靜脈注入。24小時後，對肺內髓過氧化物酶活性（中性粒細胞聚集的標誌）和α腫瘤壞死因數、白細胞介素6、白細胞介素10，以及支氣管肺泡灌洗液中蛋白濃度進行測定，肺臟組織學觀察。肺臟血紅素氧合酶-1蛋白濃度也進行測定。

結果：在用sirtinol治療的創傷出血後大鼠中，肺過氧化物酶活性（4.68 ± 0.31 vs 9.36 ± 1.03 單位/毫克 蛋白, P < 0.05）、腫瘤壞死因數α水準（710.7 ± 28 vs 1288 ± 40.69皮克/毫克 蛋白, P < 0.05）、白介素6水準（343.6 ± 18.41 vs 592.7 ± 22.3皮克/毫克 蛋白, P < 0.05）和蛋白濃度（303.8 ± 24.54 vs 569.6 ± 34.82 微克/毫升, P < 0.05）有很大改善。組織學損傷減小。在sirtinol治療組和賦形劑治療組間肺內白介素10水準（分別為842.5 ± 54.18 vs 756.2 ± 41.34皮克/毫克 蛋白,）無統計學差異。sirtinol治療組同賦形劑治療組相比，肺內血紅素氧合酶-1濃度升高(5.18 ± 0.25 vs 2.70 ± 0.16, P < 0.05)。注入血紅素氧合酶抑制劑抑制了sirtinol介導的休克肺損傷的減弱作用。

結論：創傷出血後注入sirtinol後減弱肺臟炎症的有益作用通過血紅素氧合酶-1表達的上調介導的。

（姚敏敏譯 薛張綱校）

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

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

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

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

 

腰椎橫斷面的超聲成像：肥胖產婦硬膜外腔深度估計值和實際值的相互關係

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

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

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

Anesth Analg 2009 108: 1876-1881.

 

背景：在穿刺前腰椎的超聲掃描是一項可靠的工具。它使在不肥胖的產婦身上放置硬膜外針變得容易。在這項研究中，我們評估穿刺前腰椎超聲掃描作為一項估計硬膜外腔深度的工具以確定最佳的穿刺點，研究物件是肥胖臨產婦。

方法：我們研究了46名肥胖的臨產婦，她們在懷孕前的BMI〉30 kg/m2,要求分娩過程中實施硬膜外麻醉。超聲成像由其中一名研究者來完成，在腰3-4的水準確定中線，椎間隙，皮膚到硬膜外間隙的距離(ultrasound depth, UD)。然後，一位對超聲定位皮膚到硬膜外間隙距離不知曉的麻醉科醫生通過預定的穿刺點，在穿刺針上對實際的皮膚到硬膜外腔的距離(needle depth, ND)作無菌的標記。ND和UD的一致程度通過皮爾森相關係數和配對t檢驗進行計算。Bland-Altman檢驗被用來確定UD和ND一致程度的95%的界限。

結果：懷孕前BMI的範圍從30到79 kg/m2,分娩時BMI範圍從33-86 kg/m2。UD和ND之間的皮爾森相關係數是0.85（95%的可信區間：0.75-0.91），一致性相關係數是0.79（95%的可信區間：0.71-0.88）。平均值（±標準差）UD和ND分別是6.6 ± 1.0 cm and 6.3 ± 0.8 cm（差值為0.3cm， P = 0.002）。UD和ND一致程度的95%的界限是1.3 cm to –0.7 cm。在76.1%的產婦身上用預定的穿刺點硬膜外穿刺針放置完成無需在不同的穿刺點重新插入，67.4%無需重新定向。

結論：我們發現在肥胖的臨產婦身上，超聲估計的硬膜外腔距離和實際測量的距離有很強的相互關係。我們建議在肥胖的產婦中，穿刺前的腰椎超聲可能是一種有用的引導來更好的放置硬膜外穿刺針。

（俞佳譯 薛張綱校）

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

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

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

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

 

頸動脈內膜切除術的麻醉:第三種選擇,患者合作下的全身麻醉

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

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

Anesth Analg 2009 108: 1929-1936.

 

背景：頸動脈內膜切除術是通常在區域阻滯或全身麻醉下施行，兩者顯示出幾處不同,特別是患者手術過程中的神經檢測。此研究中，我們介紹了一種全身麻醉技術（患者合作全身麻醉），這個技術允許手術中監測清醒患者的神經系統。

方法：我們前瞻性入組了181名有頸動脈內膜切除術安排的成年患者。患者都接受了全靜脈麻醉。在頸動脈阻斷期間，麻醉減淺並且僅維持高劑量的瑞芬太尼，這樣患者可以口頭表達且神經監測可以施行。此技術描述詳盡。可以檢測患者的神經系統和心血管系統。患者和外科醫生對該技術的滿意度也提高了。

結果：179名患者接受了患者合作下的全身麻醉。沒有觀察到術後神經系統事件。兩名患者在術後早期階段發生了致命性的心肌梗死（1.1%）。81%的患者可以大致描述手術持續時間，而19.3%的患者可以精確地說出他們保持清醒的時間。患者和外科醫生都對該技術高度滿意。

結論：在我們的研究中，患者合作下的全麻技術證明是一個對患者和外科醫生來說安全滿意的麻醉技術。該技術的特點是血流動力學穩定，通氣模式可控性佳，持續神經監測，需要時可即刻安全地轉換為全麻。進一步的研究需要突出該技術相較于標準全麻和局麻所顯示出的優勢。

（張玥琪譯，薛張綱校）

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

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

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

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

                                                                         

 

鞘內單獨應用嗎啡或聯合可樂定對於根治性前列腺切除患者的術後鎮痛效果

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

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

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

Anesth Analg 2009 108: 1954-1957.

 

背景：在這項隨機研究中，我們將鞘內(i.t.)單獨應用嗎啡或聯合可樂定與靜脈（i.v）以病人自控鎮痛（PCA）應用嗎啡對行恥骨後根治性前列腺切除患者的術後鎮痛作比較。

方法：50例患者被隨機分配至三組。他們分別接受鞘內應用嗎啡(4 microg/kg) (M 組)，鞘內聯合應用嗎啡及可樂定(1 microg/kg) (MC 組)或PCA(PCA 組)。每位患者均給予嗎啡PCA進行術後鎮痛。首要目標是術後48小時內的嗎啡需要量。同時記錄對嗎啡的首次需要時間，安靜及咳嗽時的疼痛級別評分，拔管時間和嗎啡的副作用（瘙癢，術後噁心嘔吐，呼吸抑制）。

結果：術後48小時內的嗎啡需要量在M組和MC組減少。安靜及咳嗽時的疼痛等級評分在M組降低直至術後18小時，在MC組降低直至術後24小時。在這兩組患者對PCA的首次需要時間延遲。在MC組術中對舒芬太尼的需要量顯著減少。

結論：對行根治性前列腺切除的患者，鞘內應用嗎啡可顯著減少術後48小時內嗎啡的需要量。鞘內聯合應用嗎啡和可樂定可減少術中舒芬太尼的使用量，延長術後對PCA的首次需要時間，而且無論安靜狀態或咳嗽時都能顯著延長鎮痛時間。

 （張釗譯 薛張綱校）

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

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

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

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

 

羅呱卡因用於上腹部大手術中硬膜外鎮痛的濃度：一項前瞻性隨機雙盲安慰劑對照試驗

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

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

Anesth Analg 2009 108: 1971-1976.

 

背景：有較多來源於不同臨床試驗的資料證明術後硬膜外鎮痛的益處，但是，仍缺乏有關術中不同硬膜外局麻藥給藥濃度對吸入麻醉藥、補液和縮血管藥物用量以及血流動力學改變的影響方面的資料資料。因此，我們在聯合麻醉下行上腹部大手術的患者中進行了這項研究。

方法：45例行上腹部大手術的患者隨機分為三組，第一組和第二組硬膜外每60分鐘分別使用10ml 0.5%和0.2%的羅呱卡因，同時合併使用0.5µg/mL的舒芬太尼，第三組硬膜外每60分鐘給予10ml 生理鹽水。麻醉以地氟醚和60%的笑氣維持，以與年齡相應的1MAC開始至切片。隨後調整地氟醚劑量維持麻醉深度在50-55之間，由連續的BIS監測及常用的臨床體征（PRST評分）進行評估。術中鎮痛不足定義為：心率增加，出汗，流淚(PRST)評分＞2分，或者平均動脈壓較基礎血壓增加＞20%，由調整呼氣末地氟醚的濃度至1MAC，和在此水準上靜脈追加瑞芬太尼治療。低血壓定義為平均動脈壓較基礎血壓降低＞20%，並通過降低呼氣末地氟醚濃度至 BIS為50-55治療，血壓仍低將根據中心靜脈壓輸注晶體液或使用去甲腎上腺素。

結果：第一組和第二組呼氣末地氟醚濃度明顯降低（0.7 ± 0.1 MAC ，P < 0.001和 0.8 ± 0.1 MAC ，P < 0.001)，第三組無此改變。第一組和第二組所有患者在給藥後20分鐘內出現明顯的低血壓（MAP由80 ± 10 降至56 ± 5 mm Hg, 78 ± 18 降至58 ± 7 mm Hg, P < 0.01）,而第三組平均動脈壓無改變(74 ± 12 至 83 ± 15 mm Hg, P = 0.42)。三組患者術中心率均未發生明顯變化。並且，三組間補液量和去甲腎上腺素使用量無明顯差別。與第二組比較第三組患者術中需要輸注更多瑞芬太尼(1.6 ± 2.2 mg · kg–1 · h–1 和7.2 ± 4.9 mg · kg–1 · h–1， P < 0.01)。而接受0.5%羅呱卡因輸注的患者術中不需要使用瑞芬太尼。

結論：在相同升壓藥支援和補液需求情況下，為達到足夠的麻醉深度，硬膜外使用0.5%的羅呱卡因較0.2%的羅呱卡因更顯著降低地氟醚使用濃度。

（朱蘭芳譯，薛張綱校）

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

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

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

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

使用全血及經典的光導集合測定法評估體外迴圈導致的血小板功能改變的初步研究結果

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

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

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

Anesth Analg 2009; 108:1747-1754

背景：本研究將阻抗集合測定與經典的光導集合測定法（LTA）比較，探究抗血小板藥物是否會破壞心臟手術及體外迴圈（CPB）後全血的血小板聚集功能。

方法：連續選擇70位擇期行冠脈搭橋術的患者，Multiplate® (M)檢驗法監測了以電阻作為聚集單位隨時間而發生的變化，而LTA檢驗法（%聚集）則通過膠原（COL）、二磷酸腺苷（ADP）或花生四烯酸來檢測，兩種方法同時使用麻醉誘導前、中和肝素後15分鐘及3小時獲得的動脈血樣。A組患者(n = 48)至少停用抗血小板藥7天，作為對照組，B組患者(n = 11)接受阿司匹林治療100 mg/天，C組患者(n = 11) 接受阿司匹林治療100 mg/天及氯吡格雷75 mg/天（雙重的抗血小板治療）直到手術前一天。

結果：未接受抗血小板治療的患者，用三個激動劑和兩種聚集法都觀察到使用魚精蛋白後15分鐘及3小時血小板聚集明顯下降。在單獨接受阿司匹林治療的患者，LTA-COL, LTA-ADP 及 M-ADP隨著時間明顯改變，在接受雙重抗血小板治療的患者，兩種聚集法通過ADP檢驗均顯示出使用魚精蛋白15分鐘後血小板聚集明顯下降。當我們計算受試者操作特徵曲線下面積來區別兩種抗血小板藥物時，LTA-COL能夠區分CPB後15分鐘及3小時對照組及接受阿司匹林組或接受雙重抗血小板治療組不同的血小板聚集功能，M-ADP檢驗法能夠區分使用魚精蛋白後3小時對照組及接受雙重抗血小板治療組不同的血小板聚集功能。

結論：使用所有的常規使用的激動劑進行的全血及經典的LTA法能夠檢測出未經抗血小板治療的患者中CPB引起的血小板聚集的改變，而在接受抗血小板治療的患者，ADP誘導的抗血小板檢驗法能更好地用於檢測CPB引起的血小板聚集功能的損害。

（裘毅敏譯，馬皓琳、李士通校）

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

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

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

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

 

Storz  Miller 1電視喉鏡對類比嬰兒困難插管的效果

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

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

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

Anesth Analg 2009; 108:1783-1786

背景：一些研究顯示電視喉鏡對於用直接喉鏡會厭暴露聲門困難的患者的處理來說是一項有用的技術。本實驗作為一個初步研究在模擬直接喉鏡插管困難的嬰兒人體模型中比較Storz DCI Miller 1電視喉鏡（VL，Karl Storz GmbH, Tuttlingen,德國）和使用Miller1 喉鏡的直接喉鏡檢查（DL）。假設與DL相比，VL會提供更好的聲門視野，但使插管時間更長，因為使用電視喉鏡插管時需要的技術不同。

方法：Laerdal®嬰兒氣道管理訓練模型（Laerdal Medical, Wappingers Falls, 紐約州）用布帶限制頸椎活動度。32位兒科麻醉主治醫師嘗試以隨機次序用VL和DL對嬰兒模型進行氣管插管。記錄每次喉鏡最佳喉部視野暴露和插管所需時間。

結果：VL和DL喉鏡檢查分級的分佈有顯著性差異(P < 0.001)，VL能提供更好的喉部視野。40%麻醉醫生報告使用DL時的視野等級為3或4級，而所有的這些患者使用VL等級會變成1和2級。四分位元距的中位元等級是DL 2級（2-3），VL 1級（1-2）(P < 0.001)。78%參與者報告VL與DL相比喉部視野等級至少提高1級。DL組中有2例插管失敗，而VL組沒有。插管所需時間兩組相似。

結論：與標準Miller 1的直接喉鏡相比，Storz Miller 1 VL改善模擬的嬰兒困難喉鏡檢查時的聲門暴露，且不延長插管所需時間。

（朱 慧譯 馬皓琳 李士通校）

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

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

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

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

作用于外周的mu-阿片類受體拮抗劑與術後腸梗阻：作用機制及臨床可應用性

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

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

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

Anesth Analg 2009; 108:1811-1822

術後腸梗阻(POI)――即手術後協調的腸功能的暫時喪失，是醫療中的一個重要難題。POI的病因是多方面的，與手術和選擇的麻醉途徑都有關。用於術後鎮痛的阿片類藥物會加劇POI，進而延遲胃腸道(GI)的恢復。作用于外周的mu-阿片類受體(PAM-OR)拮抗劑被研製出來以減輕阿片類藥物對胃腸蠕動的不良效應。調查研究顯示這類新藥可用於治療POI，目標是加快腸切除後上GI和下GI的恢復。在本綜述中，我們總結了POI發生的機制以及阿片類藥物和阿片類受體對腸道神經系統的作用，討論了PAM-OR拮抗劑的作用機制，回顧了methylnaltrexone和愛維莫潘這兩種藥物的臨床藥理作用以及其II/III期POI臨床試驗的結果。最後，討論了麻醉醫師在多模式方法背景下的POI治療中的作用。

（吳進 譯  馬皓琳 李士通 校）

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

235名患敗血症外科重症監護病人的肉眼可見屍檢結果

Macroscopic Postmortem Findings in 235 Surgical Intensive Care Patients with Sepsis

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

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

Anesth Analg 2009; 108:1841-1847

背景：雖然已經公佈了各種嚴重疾病病人屍檢的詳細分析，但是沒有進行過對敗血症病人的相關研究。在本回顧性佇列性研究中，我們回顧在外科重症監護病房（ICU）死於敗血症或感染性休克病人的肉眼可見屍檢。

方法:在1997和2006年之間，回顧ICU資料庫和屍檢登記中因為敗血症/感染性休克而進入ICU，或者在ICU期間形成敗血症/感染性休克後期並隨後死於敗血症/感染性休克的病人。記錄所有的臨床資料和屍檢結果。

結果：235個病人(84.8%)的屍檢結果可用於統計學分析。病史報告中主要的死因是難治性多臟器功能紊亂綜合症（51.5%）和不能控制的心血管衰竭（35.3%）。在肺(89.8%)、腎/泌尿道(60%)、胃腸道(54%)、心血管系統(53.6%)、肝(47.7%)、脾(33.2%)、中樞神經系統(18.7%)和胰腺(8.5%)中發現有病理學改變。在180個病人(76.6%)，屍檢揭示有持續性的膿毒性病灶。最常見的持續性病灶是肺炎(41.3%)、氣管支氣管炎(28.9%)、腹膜炎(23.4%)、子宮/卵巢壞死(9.8%的女性病人)、腹內膿腫(9.1%)和腎盂腎炎(6%)。因為敗血症/感染性休克而進入ICU且治療時間超過7天的71個病人中63個病人(88.7%)有持續性膿毒性病灶。

結論：解釋死於敗血症/感染性休克的外科ICU病人死亡的有關屍檢所見是持續性病灶的約占80%，心臟病占50%。最常受影響的臟器是肺、腹和泌尿生殖道。更多的診斷、治療和科學的努力應該放在發現和控制敗血症和感染性休克病人的感染性病灶。

（王宏 譯，馬皓琳，李士通 校）

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

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

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

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

球囊擴張氣管造口術：使用Ciaglia藍海豚方法的初體驗

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

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

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

Anesth Analg 2009; 108:1862-1866

背景：經皮擴張氣管造口術已成為一項確定的技術，用於保證行長期插管患者的呼吸系統安全和不繁瑣的方法。我們研究了一項新的經皮球囊擴張氣管插管技術，它最初是使用徑向力來增寬氣管造口，即Ciaglia藍海豚系統。

方法：我們報導的該方法的初次臨床試驗的病例來自心外科監護室的20名患者。結果分析既關注球囊擴張實踐的可行性，也包括可能的併發症。

結果：氣管造口手術時間平均3.3 ± 1.9分鐘。這項新技術未引發需要治療的出血或氣管後壁的損傷。常規的支氣管鏡檢查顯示了一例單一氣管軟骨環的骨折(5%)。一例患者在球囊擴張時出現皮下氣腫，但未經治療自行消退。未發現氣管造口的傷口感染或傷口延期癒合。分析不同長度的皮膚切口後發現實踐可行性和出血併發症沒有差異。

結論：球囊擴張氣管造口術是一項可行、簡單、成功的技術。其主要使用徑向力可減少典型的併發症，如氣管軟骨環的骨折或氣管後壁的損傷。

（唐李雋  譯   馬皓琳  李士通  校）

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

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

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

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

XI因數缺乏和產科麻醉

Factor XI Deficiency and Obstetrical Anesthesia

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

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

Anesth Analg 2009; 108:1882-1885

XI因數（FXI）缺乏是一種與啟動部分促凝血酶原激酶時間延長有關的罕見的遺產性凝血功能紊亂性疾病。出血的嚴重性並不經常與血漿因數水準有關。我們綜述了13名FXI缺乏的經歷了分娩的產婦的醫學和麻醉記錄。9例進行了椎管內麻醉（其中，7例為硬膜外麻醉，1例脊麻，1例腰­—硬聯合麻醉）。3例全身麻醉進行了剖腹產手術，1例未採取醫療手段完成了陰道分娩。因數水準的基礎值範圍從嚴重缺乏(<15%)到輕度缺乏(接近50%)。大部分病人而不是全部病人輸注了新鮮冰凍血漿以矯正啟動部分促凝血酶原激酶時間。所有病人都進行了血液科會診。沒有記錄到任何血液學或麻醉併發症。只要進行了合適的血液科會診，在臨床和實驗室止血評估的指導下進行因數替代治療，FXI缺乏並不是椎管內麻醉的絕對禁忌證。

（黃麗娜 譯 馬皓琳 李士通 校）

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

病人自控鎮痛的鎮痛測量及其問題

Patient-Controlled-Analgesia Analgesimetry and Its Problems

Igor Kissin, MD, PhD

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

Anesth Analg 2009; 108:1945-1949

病人自控鎮痛法(PCA)除用於緩解疼痛外, 也在臨床研究中廣泛用於新藥及疼痛治療方法的鎮痛效能的評定。PCA鎮痛測量的主要研究結果是，對照（安慰劑）組與新藥（或方法）組之間阿片類藥物需要量的差異。本文分析了PCA鎮痛測量的如下潛在問題：1) 疼痛強度與阿片藥物需要量之間的弱相關性；2) 阿片類藥物非鎮痛效應的干預作用；3) 對阿片類鎮痛效應的急性耐受作用；4) 病人的訓練問題；5) 主要測量結果之間的相互影響；以及6) 樣本量大小和陰性結果問題。瞭解PCA鎮痛測量的缺陷應該可降低使用過程中誤差的風險。

(江繼宏 譯  馬皓琳 李士通 校）

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

銀杏提取物EGb 761對大鼠神經性疼痛模型機械性和冷性異常疼痛的作用

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

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

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

Anesth Analg 2009; 108:1958-1963

背景：神經性疼痛是對外周或中樞神經系統的損傷引起的慢性疼痛。神經性疼痛的症狀包括：持續性疼痛、痛覺過敏和異常性疼痛。銀杏提取物是一種具有多種藥理學活性的東方草藥。我們研究了銀杏提取物EGb 761對大鼠神經性疼痛模型機械性和冷性異常疼痛的作用。

方法：選擇雄性SD大鼠，結紮L5和L6脊神經。所有大鼠在術後7天均出現機械性和冷性異常疼痛。採用雙盲法，將50只神經性疼痛大鼠分為5組，腹膜腔內給予藥物，給藥持續隨機化。各組分別給予生理鹽水、EGb 761(50、100、150和200 mg/kg)。我們研究了給藥前和腹膜腔內給藥後15、30、60、90、120、150和180分鐘，大鼠的機械性和冷性異常疼痛。通過測定對von Frey探針(1.0、1.4、2.0、4.0、6.0、8.0、10.0、12.0、15.0和 26.0 g)刺激的縮爪閾值來定量機械性異常疼痛。通過測定給予100%丙酮後大鼠抬腿的頻率來定量冷性異常疼痛。我們使用旋轉試驗測定神經性模型大鼠的運動功能，以揭示銀杏提取物EGb 761是否存在不良反應，例如鎮靜或運動協調功能減退。

結果：對照組中，大鼠機械性和冷性異常疼痛沒有差別。EGb 761組中，大鼠對機械性刺激的縮爪閾值和縮爪頻率，明顯小於給藥前和對照組。抗異常性疼痛的作用時間呈劑量依賴性延長，在最高劑量組可以持續120分鐘(P < 0.05)。只有在最高劑量組(200 mg/kg)，EGb 761會降低大鼠旋轉運動時間。

結論：我們認為銀杏提取物EGb 761降低大鼠神經性疼痛模型機械性和冷性異常疼痛，這可能對神經性疼痛的治療有用。

（張瑩譯  馬皓琳 李士通校）

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

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

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

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

U50,488和氟比洛芬對清醒大鼠的內臟痛的單獨及聯合效應

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

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

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

Anesth Analg 2009; 108:1964-1966

我們檢查了U50,488（一種κ阿片受體激動劑）和氟比洛芬（一種非甾體類抗炎藥）對清醒大鼠內臟痛模型的效應。U50,488產生內臟鎮痛效應，但是用量在0.9 mg/kg或更多時，中樞神經系統(CNS)的副作用明顯增加。納洛酮可以完全拮抗這種效應。氟比洛芬產生內臟鎮痛效應，但是用量在80 mg/kg時，CNS的副作用明顯增加。同時給予U50,488(0.27 mg/kg)和氟比洛芬(50 mg/kg)可以產生強效的內臟鎮痛作用，而不會產生CNS的副作用，意味著聯合運用κ阿片受體激動劑和非甾體類抗炎藥對內臟疼痛有治療效果。

（唐亮 譯  馬皓琳 李士通 校）  

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

用骶骨旁進路在超聲引導下定位骶叢神經

Ultrasound Localization of the Sacral Plexus Using a Parasacral Approach

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

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

Anesth Analg 2009; 108:1977-1980

在本報告裏，我們描繪了用骶骨旁進路和超聲引導方法定位骶叢神經的可行性。我們在17位病人身上用2–5 MHz的彎探針在骶骨旁區域進行超聲探測，尋找坐骨內側緣和骶骨外側緣，從而劃出坐骨大孔的區域。另外我們試著辨別梨狀肌和臀動脈的位置。在坐骨孔水準找到了圓形高回聲結構的骶叢神經。17例病人中有10例辨別出了臀動脈，但是所有病人身上我們都沒能確定地辨別出梨狀肌。為了確定骶叢的定位，進針絕緣，並連接一個神經刺激器，且對每個病人身上在電流為0.2~0.5mA時引出了骶叢神經運動反應（足石屈-12，背屈-1，腱肌刺激-3，腓腸肌刺激-1-沒有記錄）。沒有觀察到任何併發症。本報告肯定了超聲引導下用骶骨旁路徑定位骶叢神經的可行性。

（姜旭暉譯，馬皓琳，李士通校）

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