A&A -- Table of Contents (98 [3])

Anesthesia & Analgesia

March 2004

Table of Content

CARDIOVASCULAR ANESTHESIA:

(方芳譯薛張綱校）

The Incidence and Prediction of Automatically Detected Intraoperative Cardiovascular Events in Noncardiac Surgery

Rainer Röhrig, Axel Junger, Bernd Hartmann, Joachim Klasen, Lorenzo Quinzio, Andreas Jost, Matthias Benson, and Gunter Hempelmann

Anesth Analg 2004 98: 569-577.

術前服用阿斯匹林病人預防性應用去氨加壓素並能不減少冠脈手術後出血量

(王立中譯　李士通校）

Prophylactic Treatment with Desmopressin Does Not Reduce Postoperative Bleeding After Coronary Surgery in Patients Treated with Aspirin Before Surgery

Hilde Pleym, Roar Stenseth, Alexander Wahba, Lise Bjella, Arve Tromsdal, Asbjørn Karevold, and Ola Dale

Anesth Analg 2004 98: 578-584.

CABG術後卵圓孔未閉和心房顫動的相關性

(齊波　譯　　王祥瑞　校）

The Association of Patent Foramen Ovale and Atrial Fibrillation After Coronary Artery Bypass Graft Surgery

George Djaiani, Barbara Phillips-Bute, Mihai Podgoreanu, Robert H. Messier, Joseph P. Mathew, Fiona Clements, and Mark F. Newman

Anesth Analg 2004 98: 585-589.

靜脈使用烯丙呱三嗪治療單肺通氣的低氧血症

(方芳譯薛張綱校）

Treatment of Hypoxemia During One-Lung Ventilation Using Intravenous Almitrine

Nicolas Dalibon, Marc Moutafis, Ngai Liu, Jean-Dominique Law-Koune, Stéphanie Monsel, and Marc Fischler

Anesth Analg 2004 98: 590-594.

高氧增強異丙酚舒張冠狀動脈的作用

(馬皓琳譯　李士通校）

Amplification by Hyperoxia of Coronary Vasodilation Induced by Propofol

Alexandre Ouattara, Gilles Boccara, Patrick Lecomte, Rachid Souktani, Philippe Le Cosquer, Stéphane Mouren, Pierre Coriat, and Bruno Riou

Anesth Analg 2004 98: 595-603.

家兔應用牛源性聚合血紅蛋白對動脈的血栓形成和出血的作用

(齊波　譯　王祥瑞　校）

The Effects of a Polymerized Bovine-Derived Hemoglobin Solution in a Rabbit Model of Arterial Thrombosis and Bleeding

Emmanuel Marret, Philippe Bonnin, Elisabeth Mazoyer, Bruno Riou, Ted Jacobs, Pierre Coriat, and Charles-Marc Samama

Anesth Analg 2004 98: 604-610.

PEDIATRIC ANESTHESIA:

小兒使用Masimo SET® and Nellcor N-395血氧計的信號整合和飽和度的資料準確性和有效性的臨床評價

(方芳譯薛張綱校）

Clinical Evaluation of the Effects of Signal Integrity and Saturation on Data Availability and Accuracy of Masimo SET® and Nellcor N-395 Oximeters in Children

Frederick A. Robertson and George M. Hoffman

Anesth Analg 2004 98: 617-622.

兒童矯形大手術術後持續腰肌間室阻滯鎮痛：一項前瞻性CT掃描及臨床試驗

(周志堅譯李士通校）

Continuous Psoas Compartment Blocks After Major Orthopedic Surgery in Children: A Prospective Computed Tomographic Scan and Clinical Studies

C. Dadure, O. Raux, P. Gaudard, M. Sagintaah, R. Troncin, A. Rochette, and X. Capdevila

Anesth Analg 2004 98: 623-628.

AMBULATORY ANESTHESIA:

丙泊酚、異氟醚、七氟醚和地氟醚非住院麻醉後復蘇情況的比較：一項系統性回顧研究

(殷文淵　譯　王祥瑞　校）

Comparison of Recovery Profile After Ambulatory Anesthesia with Propofol, Isoflurane, Sevoflurane and Desflurane: A Systematic Review

Anil Gupta, Tracey Stierer, Rhonda Zuckerman, Neal Sakima, Stephen D. Parker, and Lee A. Fleisher

Anesth Analg 2004 98: 632-641.

行走時間對利多卡因脊麻後一過性神經症狀發生的影響

(鍾鳴譯薛張綱校）

The Influence of Ambulation Time on the Incidence of Transient Neurologic Symptoms After Lidocaine Spinal Anesthesia

Martti Silvanto, Pekka Tarkkila, Marja-Leena Mäkelä, and Per H. Rosenberg

Anesth Analg 2004 98: 642-646.

ANESTHETIC PHARMACOLOGY:

減弱縫隙連接介導的信號傳導促進七氟醚在大鼠中樞神經系統的麻醉效應

(周雅春譯　李士通校）

Attenuation of Gap-Junction-Mediated Signaling Facilitated Anesthetic Effect of Sevoflurane in the Central Nervous System of Rats

Eiji Masaki, Masahito Kawamura, and Fusao Kato

Anesth Analg 2004 98: 647-652.

美沙酮功能性抑制N－甲基D－天冬氨酸受體在爪蟾蜍卵母細胞中的表達：立體異構體和亞單位的效應

(殷文淵　譯　王祥瑞　校）

Functional Inhibition by Methadone of N-Methyl-D-Aspartate Receptors Expressed in Xenopus Oocytes: Stereospecific and Subunit Effects

Robert J. Callahan, John D. Au, Matthias Paul, Canhui Liu, and C. Spencer Yost

Anesth Analg 2004 98: 653-659.

己醇對異三聚體G蛋白質 G_i亞基的影響

(鍾鳴譯薛張綱校）

The Effects of Hexanol on G ${alpha}$ _i Subunits of Heterotrimeric G Proteins

John Streiff, David O. Warner, Elena Klimtchuk, William J. Perkins, Kristofer Jones, and Keith A. Jones

Anesth Analg 2004 98: 660-7.

過氧化亞硝酸鹽降低離體兔組織因數活性

（沈浩譯，李士通校）

Peroxynitrite Decreases Rabbit Tissue Factor Activity In Vitro

Vance G. Nielsen and John P. Crow

Anesth Analg 2004 98: 668-671.

新衍生物N-甲基多慮平與多慮平和布比卡因作為局部麻醉藥特性的比較

(朱輝　譯　王祥瑞　校）

Local Anesthetic Properties of a Novel Derivative, N-Methyl Doxepin, Versus Doxepin and Bupivacaine

Yukari Sudoh, Elaine Elliott Cahoon, Umberto De Girolami, and Ging Kuo Wang

Anesth Analg 2004 98: 672-676.

血管擴張提高大鼠布比卡因誘發驚厥的域值

(鍾鳴譯薛張綱校）

Vasodilation Increases the Threshold for Bupivacaine-Induced Convulsions in Rats

Yutaka Oda, Tomoharu Funao, Katsuaki Tanaka, and Akira Asada

Anesth Analg 2004 98: 677-682.

預注硫噴妥鈉防止丙泊酚注射痛

(軒泓　譯　李士通　校）

Pretreatment with Thiopental for Prevention of Pain Associated with Propofol Injection

Anil Agarwal, Mohammad F. Ansari, Devendra Gupta, Ravindra Pandey, Mehdi Raza, Prabhat K. Singh, Shiopriye, Sanjay Dhiraj, and Uttam Singh

Anesth Analg 2004 98: 683-686.

低脂異丙酚乳劑與標準的異丙酚乳劑的藥效比較

(朱輝　譯　王祥瑞　校）

The Pharmacodynamic Effects of a Lower-Lipid Emulsion of Propofol: A Comparison with the Standard Propofol Emulsion

Dajun Song, Mohamed Hamza, Paul F. White, Kevin Klein, Alejandro Recart, and Omeed Khodaparast

Anesth Analg 2004 98: 687-691.

TECHNOLOGY, COMPUTING, AND SIMULATION:

丙泊芬麻醉中應用腦電圖監測麻醉藥物作用的Narcotrend指數與雙頻指數比較

(周曉敏譯薛張綱校）

Narcotrend Index Versus Bispectral Index as Electroencephalogram Measures of Anesthetic Drug Effect During Propofol Anesthesia

Sascha Kreuer, Wolfram Wilhelm, Ulrich Grundmann, Reinhard Larsen, and Jörgen Bruhn

Anesth Analg 2004 98: 692-697.

麻醉期間體動形式的頻譜分析

(黃施偉譯，李士通校）

Spectral Analysis of Movement Patterns During Anesthesia (Technical Communication)

Steven L. Jinks, Joseph F. Antognini, and Earl Carstens

Anesth Analg 2004 98: 698-702.

PAIN MEDICINE:

大手術後病人硬膜外自控鎮痛（PCEA）治療術後疼痛的費用比較

(忻紀華　譯　王祥瑞　校）

Cost Drivers in Patient-Controlled Epidural Analgesia for Postoperative Pain Management After Major Surgery

Martin Schuster, André Gottschalk, Marc Freitag, and Thomas Standl

Anesth Analg 2004 98: 708-713.

惡性骨腫瘤切除術病人中應用Dextromethorphan聯合硬膜外PCA較聯合靜脈PCA提供更好的鎮痛效果——一項隨機、雙盲、安慰劑對照研究

(周曉敏譯薛張綱校）

Dextromethorphan-Associated Epidural Patient-Controlled Analgesia Provides Better Pain- and Analgesics-Sparing Effects than Dextromethorphan-Associated Intravenous Patient-Controlled Analgesia After Bone-Malignancy Resection: A Randomized, Placebo-Controlled, Double-Blinded Study

Avi A. Weinbroum, Benjamin Bender, Alexander Nirkin, Shoshana Chazan, Isaac Meller, and Yehuda Kollender

Anesth Analg 2004 98: 714-722.

大鼠爪炎症組織中含有β內啡肽的免疫細胞減少與免疫源性抗傷害作用有關：輸入啟動淋巴細胞可逆轉之

(周雅春譯　李士通校）

Reduction of ß-Endorphin-Containing Immune Cells in Inflamed Paw Tissue Corresponds with a Reduction in Immune-Derived Antinociception: Reversible by Donor Activated Lymphocytes

Siobhan Hermanussen, MyHong Do, and Peter John Cabot

Anesth Analg 2004 98: 723-729.

自由活動大鼠聯合應用直流和交流電進行經顱電刺激的抗傷害作用

(忻紀華　譯　王祥瑞　校）

The Antinociceptive Effect of Transcranial Electrostimulation with Combined Direct and Alternating Current in Freely Moving Rats

Vladimir Nekhendzy, Christo P. Fender, M. Frances Davies, Hendrikus J. M. Lemmens, Michael S. Kim, Donna M. Bouley, and Mervyn Maze

Anesth Analg 2004 98: 730-737.

鞘內或口服可樂定預防術後酒精戒斷綜合征——一項隨機、雙盲對照研究

(周曉敏譯薛張綱校）

Intrathecal and Oral Clonidine as Prophylaxis for Postoperative Alcohol Withdrawal Syndrome: A Randomized Double-Blinded Study

I. Dobrydnjov, K. Axelsson, L. Berggren, J. Samarütel, and B. Holmström

Anesth Analg 2004 98: 738-744.

糖尿病病人行脊髓刺激能減少胰島素需要量

(趙雪蓮　譯　　　李士通　校）

Decreased Insulin Requirements with Spinal Cord Stimulation in a Patient with Diabetes (Case Report)

Leonardo Kapural, Salim M. Hayek, Michael Stanton-Hicks, and Nagy Mekhail

Anesth Analg 2004 98: 745-746.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

醫師麻醉的成本效益問題

(朱慧琛　譯　王祥瑞　校）

Is Physician Anesthesia Cost-Effective?

J. P. Abenstein, Kirsten Hall Long, Brian P. McGlinch, and Niki M. Dietz

Anesth Analg 2004 98: 750-757.

NEUROSURGICAL ANESTHESIA:

異氟醚對局灶性腦缺血大鼠神經元凋亡的影響

(陸旭偉譯薛張綱校）

Effect of Isoflurane on Neuronal Apoptosis in Rats Subjected to Focal Cerebral Ischemia

Masahiko Kawaguchi, John C. Drummond, Daniel J. Cole, Paul J. Kelly, Mark P. Spurlock, and Piyush M. Patel

Anesth Analg 2004 98: 798-805.

OBSTETRIC ANESTHESIA:

用硬膜外容量擴充的脊－硬聯合麻醉使擇期剖宮產後運動恢復較快：一項前瞻性、隨機、雙盲研究

(馬皓琳譯　李士通校）

Combined Spinal-Epidural Anesthesia Using Epidural Volume Extension Leads to Faster Motor Recovery After Elective Cesarean Delivery: A Prospective, Randomized, Double-Blind Study

Eileen Lew, Seow-Woon Yeo, and Easaw Thomas

Anesth Analg 2004 98: 810-814.

預防性使用苯腎上腺素可防止剖腹產手術中因脊麻引起的低血壓

(朱慧琛　譯　王祥瑞　校）

Prophylactic Phenylephrine Infusion for Preventing Hypotension During Spinal Anesthesia for Cesarean Delivery

Warwick D. Ngan Kee, Kim S. Khaw, Floria F. Ng, and Bee B. Lee

Anesth Analg 2004 98: 815-821.

REGIONAL ANESTHESIA:

持續性骶周和坐骨神經阻滯：一項X線片研究

(陸旭偉譯薛張綱校）

Continuous Parasacral Sciatic Block: A Radiographic Study

Elisabeth Gaertner, Pablo Lascurain, Cyrille Venet, Xavier Maschino, Alina Zamfir, Radu Lupescu, and Admir Hadzic

Anesth Analg 2004 98: 831-834.

利多卡因靜脈局部麻醉中加入dexmedetomidine

(趙雪蓮　譯李士通校）

Adding Dexmedetomidine to Lidocaine for Intravenous Regional Anesthesia

Dilek Memis, Alparslan Turan, Beyhan Karamanlioglu, Zafer Pamukçu, and Imran Kurt

Anesth Analg 2004 98: 835-840.

地卡因增加神經生長錐細胞內鈣離子

(陳潔　譯　王祥瑞　校）

Intracellular Calcium Increases in Growth Cones Exposed to Tetracaine

Shigeru Saito, Inas A. M. Radwan, Koichi Nishikawa, Hideaki Obata, Tomonori Okamoto, Toshio Kanno, and Fumio Goto

Anesth Analg 2004 98: 841-845.

短期硬膜外阻滯對間質性膀胱炎的尿液P物質水平的影響

(陸旭偉譯薛張綱校）

The Effect of Short-Term Epidural Local Anesthetic Blockade on Urinary Levels of Substance P in Interstitial Cystitis

Andrew Sukiennik, Daniel B. Carr, Iwona Bonney, James E. Marchand, Heinrich Wurm, and Grannum R. Sant

Anesth Analg 2004 98: 846-850.

GENERAL ARTICLES:

使用加速度儀評價術後清醒病人的神經肌肉傳導阻滯殘餘的結果可能不準確

(顏濤譯，李士通校）

Assessing Residual Neuromuscular Blockade Using Acceleromyography Can Be Deceptive in Postoperative Awake Patients

Christophe Baillard, Sylvie Bourdiau, Philippe Le Toumelin, Farid Ait Kaci, Bruno Riou, Michel Cupa, and C. Marc Samama

Anesth Analg 2004 98: 854-7.

喉罩有助於側臥位氣管插管

(陳潔　譯　王祥瑞　校）

The Intubating Laryngeal Mask Airway Facilitates Tracheal Intubation in the Lateral Position

Ryu Komatsu, Osamu Nagata, Daniel I. Sessler, and Makoto Ozaki

Anesth Analg 2004 98: 858-861.

使用加速度儀評價術後清醒病人的神經肌肉傳導阻滯殘餘的結果可能不準確

Assessing Residual Neuromuscular Blockade Using Acceleromyography Can Be Deceptive in Postoperative Awake Patients

Christophe Baillard, MD PhD^*, Sylvie Bourdiau, MD^*, Philippe Le Toumelin, MD^*, Farid Ait Kaci, MD^*, Bruno Riou, MD PhD, Michel Cupa, MD^*, and C. Marc Samama, MD PhD^*

*Department of Anesthesiology and Intensive Care, Avicenne Hospital, Bobigny; and Department of Emergency Medicine and Surgery, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University, Paris, France

Anesth Analg 2004;98:854-7

術後清醒病人可能存在明顯的神經肌肉傳導阻滯殘留。在清醒的病人，由於牽扯到拇指的活動可能影響加速度儀監測的結果。在本研究中，我們評價了253例麻醉後復蘇病人進行四個成串刺激（TOF）比值監測結果的重複性。在病人到達麻醉後監護室即刻對尺神經進行TOF刺激，激發的反應通過加速度儀加以評定。電流強度是30mA。每個病人進行兩次TOF刺激，間隔30s。使用Bland-Altman檢驗。根據TOF< 0.9判斷是否存在神經肌肉傳導阻滯殘留。兩次監測結果的臨床一致性採用κ檢驗。按是否存在神經肌肉傳導阻滯殘留分析，61例（24%；95%可信區間，21%-27%）病人的兩次TOF監測結果不符合。κ檢驗表明其符合度中等（κ= 0.47）。我們證實本研究中使用加速度儀並非總是準確。兩次孤立的使用加速度儀監測的TOF比值不能準確反映麻醉恢復期病人神經肌肉傳導阻滯狀態。

（顏濤譯，李士通校）

Postoperative awake patients may have significant residual neuromuscularblock. In awake patients, the results of accelerometry are affectedby extra movements to which the thumb may be subject. In thisstudy, we evaluated the repeatability of train-of-four (TOF)ratio using acceleromyography in 253 patients recovering fromanesthesia. Immediately after arrival in the postanesthesiacare unit, the ulnar nerve was stimulated with TOF stimulation.The evoked response at the thumb was measured by the TOF-Watchapparatus. The current intensity was 30 mA. Two TOF stimulationswere applied and recorded at 30-s intervals. A Bland-Altmantest was used. The Kappa () test for clinical agreement betweenthe two measurements was also calculated according to the presenceor absence of a residual neuromuscular blockade, defined asa TOF ratio <0.9. According to the presence of a residualneuromuscular blockade, the paired TOF ratios were discordantin 61 patients (24%; 95% confidence interval, 21%–27%).The test indicated a moderate agreement (k = 0.47). We demonstratedthat accelerometry as used in this study is not always accurate.Two isolated acceleromyograph TOF ratios are not an accuraterepresentation of the neuromuscular status of the patient recoveringfrom anesthesia.

麻醉期間體動形式的頻譜分析

Spectral Analysis of Movement Patterns During Anesthesia

Steven L. Jinks, PhD, Joseph F. Antognini, MD, and Earl Carstens, PhD Department of Anesthesiology and Pain Medicine and the Section of Neurobiology, Physiology and Behavior, University of California, Davis, Davis, California

Anesth Analg 2004;98:698-702

動形式中的高頻和低頻部分的頻譜分析有助於了解體動（對傷害性刺激的反應）是如何被麻醉藥消除的。因此我們對以前已發表的關於使用0.6、0.9和1.1MAC的異氟醚和氟烷麻醉的大鼠的體動資料進行了頻譜分析。我們記錄了由後爪受傷害性機械刺激引出的後肢等長收縮力。體動形式經過頻譜分析來判定每一頻率部分的力的幅度。當氟烷從0.6增加到0.9MAC時，僅在最低頻部分（<1Hz）力的幅度有降低，與0.6MAC時高頻部分力幅普遍較低有部分關係。在0.6到0.9MAC的異氟醚時，0－10Hz範圍內的大多數頻率的力幅降低。當異氟醚和氟烷均為1.1MAC時，和預期的一樣，所有頻率的力幅大幅下降。我們得出結論：頻譜分析有利於描述和定量麻醉藥對傷害性刺激引起的複合體動形式的影響。

（黃施偉譯，李士通校）

It remains unclear how anesthetics produce immobility, an end-pointused in determining anesthetic potency. Understanding how movement(in response to noxious stimulation) is ablated by anestheticscould be aided by using spectral analysis of the high and lowfrequency components of complex movement patterns. We thereforeapplied a spectral analysis to previously published movementdata from rats anesthetized with isoflurane and halothane at0.6, 0.9, and 1.1 minimum alveolar concentration (MAC). We recordedisometric forces of hindlimb movement elicited by noxious mechanicalstimulation of the hindpaw. The movement patterns were subjectedto spectral analysis to determine force amplitude for each frequencycomponent. When halothane was increased from 0.6 to 0.9 MAC,force amplitude decreased only for the lowest-frequency (<1Hz) components, in part related to the generally lower high-frequencyforces at 0.6 MAC. Between 0.6 and 0.9 MAC isoflurane amplitudewas reduced for most frequencies in the 0–10 Hz range.For both halothane and isoflurane at 1.1 MAC, as expected, forceamplitude substantially decreased at all frequencies. We concludethat spectral analysis is useful to describe and quantify theeffects of anesthetics on complex movement patterns resultingfrom noxious stimuli applied during anesthesia.

兒童矯形大手術術後持續腰肌間室阻滯鎮痛：一項前瞻性CT掃描及臨床試驗

Continuous Psoas Compartment Blocks After Major Orthopedic Surgery in Children: A Prospective Computed Tomographic Scan and Clinical Studies

C. Dadure, MD*, O. Raux, MD*, P. Gaudard, MD*, M. Sagintaah, MD , R. Troncin, MD*, A. Rochette, MD*, and X. Capdevila, MD PhD*

Departments of *Anesthesia and Critical Care Medicine and　 Pediatric Radiology, Lapeyronie University Hospital, Montpellier, France

Address correspondence and reprint requests to Christophe Dadure, MD, Département d’Anesthésie Réanimation A, Hôpital Lapeyronie, 371 Avenue du Doyen G. Giraud, 34295 Montpellier, France.

Anesth Analg 2004 98: 623-628.

股骨幹或髖部手術的疼痛程度對兒童來說相當嚴重。我們用CT掃描方法，同時進行臨床前瞻性試驗，來確定兒童腰肌間室阻滯的新標記方法，並評價用一次性彈性泵進行持續腰肌間室阻滯（CPCB）的有效性。通過預先對20名病人進行CT掃描，發現神經叢的深度與病人年齡相關，CPCB最佳穿刺點位於從L4棘突至經過髂後上棘的脊柱平行線之間的距離的3/4處。隨後的前瞻性研究系列中，在患兒接受股骨和髂骨截骨手術之前，給予CPCB，用以緩解術後疼痛。全麻後，通過CPCB置管給負荷量1%利多卡因（含1/200.000腎上腺素）和0.5%羅呱卡因混合液0.5ml/kg。經過造影劑確定置管位置後，連接一次性泵（Infusor LV®; Baxter, Paris, France），藥液配成0.2%的羅呱卡因，根據體重調整輸注速度(0.2 mg/ kg/h)。術後疼痛評分採用視覺類比評分（visual analog scale）或嬰幼兒術後疼痛評分（Children and Infants Postoperative Pain Score）法，評分時間為術後1, 6, 12, 18, 24, 36及48小時，並評價追加補充鎮痛情況、副作用和運動阻滯。手術過程中所有阻滯都有效果，術後鎮痛良好。疼痛評分中位值1小時時為1分， 6小時後皆為0分。術後24小時內有輕微運動阻滯，之後便消失。未發現嚴重的副作用。93%患兒的父母滿意。結論：兒童下肢近端矯形大手術後用CPCB鎮痛，是一項非常有效的技術。與文獻所提的傳統穿刺標記法相比，本研究所描述的CT掃描定位法，則更為客觀。

（周志堅譯李士通校）

Femoral shaft or hip surgeries are very painful for children. We conducted both computed tomographic (CT) and clinical prospective studies to define new landmarks in children and to evaluate the effectiveness of continuous psoas compartment blocks (CPCBs) using disposable elastomeric pumps. In a preliminary CT scan study of 20 patients, the plexus depth was correlated to patient age and the optimal point of puncture for CPCB was three-quarters of the distance from the spinous process of L4 to a line parallel to the spinal column passing through the posterior superior iliac spine. In a subsequent prospective series, a CPCB was administered before surgery to 15 children for pain relief after femoral and hip osteotomies. After general anesthesia, a 0.5 mL/kg bolus of a mixture of 1% lidocaine with epinephrine (1/200.000) and 0.5% ropivacaine was injected through the CPCB catheter. After contrast media assessment of the catheter location, a disposable pump (Infusor LV®; Baxter, Paris, France) with 0.2% ropivacaine was connected and pump flow was adjusted to the patient’s weight (0.2 mg /kg/ h). Postoperative pain was evaluated using a visual analog scale or the Children and Infants Postoperative Pain Score at hour H1, H6, H12, H18, H24, H36, and H48, and in terms of rescue analgesia, adverse events, and motor blocks. All blocks were effective during surgery. Postoperative analgesia was excellent. The median pain scores were 1 for H1 and 0 beginning H6. The motor blockade was minimal before 24 h and absent thereafter. No major adverse event was noted. Parents of 93% of the children were satisfied. We conclude that postoperative analgesia with CPCB is a very effective technique in children after major proximal lower limb orthopedic surgery. The CT scan landmarks described in this study were more medial than the conventional landmarks used in the literature .

減弱縫隙連接介導的信號傳導促進七氟醚在大鼠中樞神經系統的麻醉效應

Attenuation of Gap-Junction-Mediated Signaling Facilitated Anesthetic Effect of Sevoflurane in the Central Nervous System of Rats

Eiji Masaki, MD PhD^*, Masahito Kawamura, MD, and Fusao Kato, PhD Section Editor

Departments of *Anesthesiology, Pharmacology, and Neuroscience, Jikei University School of Medicine, Tokyo, Japan

Address correspondence and reprint requests to Eiji Masaki, Department of Anesthesiology, Jikei University School of Medicine, 3–25–8, Nishishinbashi Minato-ku, Tokyo 105–8461, Japan.

Anesth Analg 2004;98:647-652

越來越多的證據提示減少內在興奮性或突觸興奮和/或增強突觸抑制是全身麻醉狀態的基礎。除了化學性突觸，神經元之間還能通過縫隙連接的電耦聯進行信號傳導。我們假設吸入麻醉藥的麻醉機制中包括在中樞神經系統（CNS）中抑制通過縫隙連接的細胞至細胞的信號傳導。活體試驗中在腦室內（ICV）或鞘內（IT）給予縫隙連接抑制劑甘珀酸（CBX）後測定七氟醚的最低肺泡濃度（MAC）。同時在離體試驗中用膜片鉗方法記錄年輕大鼠腦橋腦片藍斑神經元由於神經元間電傳導而產生的自發膜電流震盪，並且記錄七氟醚對此種震盪的作用。腦室內給予CBX（125和250ug/個大鼠）可劑量依賴地減少七氟醚的MAC，而鞘內給予CBX並不能減少MAC。臨床相關濃度（0.1-0.5mM）的七氟醚可劑量依賴地抑制自發膜電流震盪，七氟醚在0.5mM濃度時對電流幅度及頻率的抑制有顯著性。此研究提示七氟醚麻醉作用涉及中樞神經系統內縫隙連接介導的信號傳導的抑制。

（周雅春譯　李士通校）

Accumulating evidence suggests that reduction of intrinsic excitability or synaptic excitation and/or an enhancement of synaptic inhibition underlie the general anesthetic condition. Besides chemical synapse, neurons could communicate with each other by electrical coupling via gap-junctions. We hypothesized that inhibition of cell-to-cell signaling through gap-junction in the central nervous system (CNS) is involved in the anesthetic mechanism of volatile anesthetics. The minimum alveolar concentration (MAC) of sevoflurane was measured after the intracerebroventricular (ICV) or intrathecal (IT) administration of carbenoxolone (CBX), a gap-junction inhibitor, in vivo. The spontaneous oscillation in membrane currents of locus coeruleus neurons that results from electrical coupling between neurons was also recorded from young rat pontine slices by the patch clamp method, and the effect of sevoflurane on this oscillation was examined in vitro. The ICV administration of CBX (125 and 250 µg/rat)

significantly reduced the MAC of sevoflurane dose-dependently, whereas IT injection failed to inhibit the MAC. Sevoflurane at clinically relevant concentrations (0.1–0.5 mM) suppressed the spontaneous oscillation in membrane current concentration-dependently. These suppressions were significant at 0.5 mM with both amplitude and frequency. We suggest that suppression of gap-junction-mediated signaling in the CNS is involved in the anesthetic-induced immobilization by sevoflurane.

大鼠爪炎症組織中含有β內啡肽的免疫細胞減少與免疫源性抗傷害作用有關：輸入啟動淋巴細胞可逆轉之

Reduction of ß-Endorphin-Containing Immune Cells in Inflamed Paw Tissue Corresponds with a Reduction in Immune-Derived Antinociception: Reversible by Donor Activated Lymphocytes

Siobhan Hermanussen, BSc Hons, MyHong Do, BPharm Hons, and Peter John Cabot, PhD

The School of Pharmacy, The University of Queensland, Queensland, Australia

Address correspondence and reprint requests to Peter J. Cabot, PhD, The School of Pharmacy, The University of Queensland, 4072, Queensland, Australia.

Anesth Analg 2004;98:723-729

免疫系統功能完整是產生外周抗傷害感受作用的必要條件。以前的研究表明免疫細胞可在炎症組織中引發強效的抗傷害作用。在接受過環孢素A（CsA）產生免疫抑制的動物中，促腎上腺皮質激素釋放因數誘導的抗傷害作用受到明顯的抑制。我們此項研究檢驗了單次劑量CsA對炎症傷害感受的作用。接受CsA的大鼠較沒有產生免疫抑制的大鼠傷害性作用明顯增加，同時迴圈中和組織中淋巴細胞減少。此外，CsA抑制大鼠促腎上腺皮質激素釋放因數誘導的免疫源性抗傷害作用，靜脈注射外源性經刀豆素A啟動的淋巴細胞（1.0－7.0x10⁶細胞/0.1毫升）可逆轉此種效應，且具有劑量依賴性。結論：該發現提供進一步證據證明含阿片的免疫細胞是外周鎮痛的必要條件。這些發現還表明炎性疼痛的控制很大部分依賴於功能良好的免疫系統。

（周雅春譯　李士通校）

The functional integrity of the immune system is essential forperipheral antinociception. Previous studies have demonstratedthat immune cells elicit potent antinociception in inflamedtissues and that corticotropin-releasing factor-induced antinociceptionis significantly inhibited in animals that have undergone cyclosporinA (CsA)-induced immunosuppression. In this study, we examinedthe effect of a single bolus of CsA on inflammatory nociception.CsA-treated rats had substantially increased nociception comparedwith nonimmunosuppressed rats, consistent with a reduction incirculating and infiltrating lymphocytes. Furthermore, CsA-treatedrats had inhibition of corticotropin-releasing factor-inducedimmune-derived antinociception, which was dose-dependently reversedby IV injection of concanavalin A-activated donor lymphocytes(1.0–7.0 x 10⁶ cells/0.1 mL). In conclusion, our findingsprovided further evidence that opioid-containing immune cellsare essential for peripheral analgesia. It is evident from thesefindings that control of inflammatory pain relies heavily ona functioning immune system.

用硬膜外容量擴充的脊－硬聯合麻醉使擇期剖宮產後運動恢復較快：一項前瞻性、隨機、雙盲研究

Combined Spinal-Epidural Anesthesia Using Epidural Volume Extension Leads to Faster Motor Recovery After Elective Cesarean Delivery: A Prospective, Randomized, Double-Blind Study

Eileen Lew, MBBS MMed, Seow-Woon Yeo, MBBS MMed, FAMS, and Easaw Thomas, MBBS FANZCA, FAMS Section Editor

From the Department of Anaesthesia (Obstetrics and Gynaecology), KK Women’s and Children’s Hospital, Singapore

Anesth Analg 2004;98:810-814

在脊麻－硬膜外阻滯聯合麻醉（CSE）時，採用硬膜外容量擴充（EVE）技術是通過硬膜外腔注射生理鹽水使小劑量鞘內阻滯增強的方法。在此項前瞻性、隨機、雙盲的研究中，我們比較了EVE方法與單次注射脊麻的感覺和運動阻滯特性及血流動力學穩定性。62例進行擇期剖宮產的臨產婦（各組n＝31）給予重比重0.5%布比卡因9mg＋芬太尼10 µg脊麻；或CES即重比重0.5%布比卡因5mg＋芬太尼10 µg脊麻後5 min通過硬膜外導管注射0.9%鹽水6.0 ml。每隔2.5 min記錄各組的最低收縮血壓（SBP）、針刺無痛的感覺阻滯平面和改良Bromage評分。比較兩組的視覺類比疼痛評分（VAS）、最高感覺阻滯平面、最高改良Bromage運動評分、感覺阻滯消退到第10胸段脊髓皮區（T10）所需的時間和運動阻滯的恢復。兩組病人的一般資料、VAS評分、最高感覺阻滯平面、感覺阻滯消退到T10所需的時間及記錄的最低SBP均相似。EVE組的病人顯示運動恢復到改良Bromage 0水平的時間顯著較快(73 ± 33 min vs. 136 ± 32 min, P < 0.05)。提示：與傳統的單次注射脊麻相比，小劑量脊椎阻滯的硬膜外容量擴充只需55%的布比卡因劑量就能提供滿意的剖宮產麻醉，且下肢運動恢復較快。

（馬皓琳譯　李士通校）

Epidural volume extension (EVE) via a combined spinal-epidural (CSE) technique is the enhancement of a small-dose intrathecal block by epidural saline boluses. In this prospective, randomized, double-blind study, we compared the EVE technique with single-shot spinal anesthesia with respect to its sensory and motor block profile and hemodynamic stability. Sixty-two parturients (n = 31 in each group) undergoing elective cesarean deliveries were administered either spinal anesthesia with hyperbaric 0.5% bupivacaine 9 mg and fentanyl 10 µg or CSE comprising intrathecal hyperbaric 0.5% bupivacaine 5 mg with fentanyl 10 µg, followed by 0.9% saline 6.0 mL through the epidural catheter 5 min thereafter. In each group, the lowest systolic blood pressure (SBP), sensory block level to loss of pain from pinprick, and modified Bromage scores were recorded at 2.5-min intervals. The visual analog pain score (VAS), peak sensory block height, highest modified Bromage motor score, time for sensory regression to the tenth thoracic dermatome (T10), and motor block recovery were compared between groups. Both groups were comparable in demographic data, VAS scores, peak sensory block height, time for sensory regression to T10, and lowest SBP recorded. Patients in the EVE group demonstrated significantly faster motor recovery to modified Bromage 0 (73 ± 33 min versus 136 ± 32 min, P < 0.05).

高氧增強異丙酚舒張冠狀動脈的作用

Amplification by Hyperoxia of Coronary Vasodilation Induced by Propofol

Alexandre Ouattara, MD^*,, Gilles Boccara, MD PhD^*,, Patrick Lecomte, MD^*,, Rachid Souktani, PhD^*,, Philippe Le Cosquer, MD^*,, Stéphane Mouren, MD PhD^*,, Pierre Coriat, MD^*,, and Bruno Riou, MD PhD^*,

*Laboratory of Anesthesiology, Université Pierre et Marie Curie, Paris; Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris; Department of Emergency Medicine and Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France

Anesth Analg 2004;98:595-603

我們在離體、紅細胞灌注的兔心模型中檢驗了這樣一個假設：在無高氧(PaO2 = 137 ± 16 mm Hg, n = 12)和有高氧(PaO2 = 541 ± 138 mm Hg, n = 12)的情況下，異丙酚(10–300 µM)對離體冠狀動脈和心肌作用顯著不同。高氧誘導冠狀動脈顯著收縮(-13% ± 7%)。高氧時異丙酚舒張冠狀動脈的作用增強。因為已有報導氧分壓高通過關閉ATP敏感的鉀通道使冠狀動脈收縮，我們研究了在無高氧和有高氧情況下用格列本脲（glibenclamide ）0.6 µM和cromakalim 0.5 µM預處理的另外兩組（各組n=6）心臟中異丙酚的作用。格列本脲預處理使冠狀動脈收縮(-16% ± 7%)，但不影響異丙酚的冠狀動脈舒張作用。Cromakalim預處理去除了高氧時異丙酚冠狀動脈舒張作用的增強。在無高氧和有高氧情況下，異丙酚濃度>100 µM均顯著降低心肌性能。我們得出結論：高氧增強異丙酚舒張冠狀動脈的作用。此現象不能用格列本脲引起的冠狀動脈收縮的現象解釋。但是，Cromakalim心臟預處理去除了高氧時異丙酚冠狀動脈舒張作用的增強。高氧不影響異丙酚的心肌作用。

（馬皓琳譯　李士通校）

　We tested the hypothesis that in vitro coronary and myocardial effects of propofol (10–300 µM) should be significantly modified in an isolated and erythrocyte-perfused rabbit heart model in the absence (PaO2 = 137 ± 16 mm Hg, n = 12) or in the presence (PaO2 = 541 ± 138 mm Hg, n = 12) of hyperoxia. The induction of hyperoxia provoked a significant coronary vasoconstriction (-13% ± 7%). Propofol induced increased coronary vasodilation in the presence of hyperoxia. Because high oxygen tension has been reported to induce a coronary vasoconstriction mediated by the closure of adenosine triphosphate-sensitive potassium channels, we studied the effects of propofol in 2 additional groups of hearts (n = 6 in each group) pretreated by glibenclamide (0.6 µM) and cromakalim (0.5 µM) in the absence and presence of hyperoxia, respectively. The pretreatment by glibenclamide induced a coronary vasoconstriction (-16% ± 7%) which did not affect propofol coronary vasodilation. The pretreatment by cromakalim abolished the amplification of propofol coronary vasodilation in the presence of hyperoxia. Propofol induced a significant decrease in myocardial performance for a concentration >100 µM both in the absence and presence of hyperoxia. We conclude that propofol coronary vasodilation is amplified in the presence of hyperoxia. This phenomenon is not explained by the previous coronary vasoconstriction induced by glibenclamide. However, the pretreatment of hearts by cromakalim abolished the amplification of propofol coronary vasodilation in the presence of hyperoxia. The myocardial effects of propofol were not affected by the presence of hyperoxia.

術前服用阿斯匹林病人預防性應用去氨加壓素並能不減少冠脈手術後出血量Prophylactic Treatment with Desmopressin Does Not Reduce Postoperative Bleeding After Coronary Surgery in Patients Treated with Aspirin Before Surgery

Hilde Pleym, MD^*, Roar Stenseth, MD PhD^*, Alexander Wahba, MD PhD, Lise Bjella, MD^*, Arve Tromsdal, MD, Asbjørn Karevold, MD, and Ola Dale, MD PhD^*,

Departments of *Anesthesiology and Cardiothoracic Surgery, St. Olav University Hospital; and Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway

Anesth Analg 2004;98:578-584

人工合成的血管加壓素－去氨加壓素具有止血特性，可能減少冠狀動脈搭橋術（CABG）後出血量。一項關於近期服用阿斯匹林在心臟手術中對血小板功能影響的研究顯示，術前2日內服用阿斯匹林對血小板功能有較大的損害。我們在服用阿斯匹林75或160 mg至術前一天而行CABG術的病人中評估去氨加壓素對術後出血量的影響。本研究為前瞻性、隨機、雙盲、安慰劑對照、平行分組試驗。100例病人分成二組。一組在硫酸魚精蛋白拮抗肝素後給予去氨加壓素0.3 µg/kg，另一組則給予安慰劑（0.9%生理鹽水）。記錄術後16小時內出血量。去氨加壓素組平均出血量（標準差）為606（237）mL，對照組為601 (301) mL(P = 0.93)，無明顯差異（95%可信區間為107—117 mL）。結論：去氨加壓素並不減少服用阿斯匹林至術前一天病人CABG術後出血量。

（王立中譯　李士通校）

The synthetic vasopressin analog desmopressin has hemostaticproperties and may reduce postoperative bleeding after coronaryartery bypass grafting (CABG). A study on the effects of recentaspirin ingestion on platelet function in cardiac surgery showeda greater impairment of platelet function in patients treatedwith aspirin <2 days before the operation. We evaluated theeffects of desmopressin on postoperative bleeding in CABG patientswho were treated with aspirin 75 or 160 mg until the day beforesurgery. The study was a prospective, randomized, double-blinded,placebo-controlled, parallel group trial. One-hundred patientswere included and divided into two groups. One group receiveddesmopressin 0.3 µg/kg and the other received placebo(0.9% NaCl) after the neutralization of heparin with protaminesulfate. Postoperative blood loss was recorded for 16 h. Themean (SD) bleeding was 606 (237) mL in the desmopressin groupand 601 (301) mL in the placebo group (P = 0.93), representingno significant difference (95% confidence interval, -107 to117 mL). We conclude that desmopressin does not reduce postoperativebleeding in CABG patients treated with aspirin until the daybefore surgery.

過氧化亞硝酸鹽降低離體兔組織因數活性

Peroxynitrite Decreases Rabbit Tissue Factor Activity In Vitro

Vance G,Nielsen,MD,*and John P.Crow,PhD*.

Department of *Anesthesiology . Pharmacology/Toxicology, Biochemistry and Molecular Genetics,The Center for Free Radical Biology, The University of Alabama at Birmingham

Anesth Analg 2004;98:668-671.

組織因數是機體內引起生理性凝集反應的一種重要物質。過氧化亞硝酸鹽（OONO^-）分子能產生氧化氮(NO)和超氧化物(O₂^-)，可以在體外降低人組織因數的活性。在肝小腸局部缺血再灌注所導致的凝血病中，也涉及到過氧化亞硝酸鹽的形成。而且，兔肝小腸局部缺血再灌注後迴圈中的組織因數活性顯著降低。我們推測兔組織因數暴露在過氧化亞硝酸鹽後可使其活性降低。過氧化亞硝酸鹽可以由SIN－1（3-morpholinosydnonimine）產生， SIN－1可以形成氧化氮和超氧化物。兔腦組織因數分別在下列溶液中以37℃孵育90分鐘(每組n=8 )：①0mM SIN-1, ②5mM SIN-1, ③ 5mM SIN-1 和 2000 U/mL人重組超氧化物歧化酶（hSOD1），④2000 U/mL人重組超氧化物歧化酶（hSOD1）。然後將這些組織因數樣本加入人血漿中，用血栓彈性描記圖測定血凝塊形成動力學，評定組織因數的活性。組織因數暴露在SIN－1中其活性降低了48％。與其他三組比較有顯著性差異(P<0.01)。其他幾組間結果無顯著性差異。我們的結論是，兔組織因數被過氧化亞硝酸鹽所抑制，揭示過氧化亞硝酸鹽在肝臟小腸局部缺血再灌注所導致的凝血病所起到的作用仍需繼續研究。

（沈浩譯，李士通校）

Tissue factor (TF) is a primary initiator of physiological coagulation in vivo.Peroxynitrite (OONO^-),a molecule formed nitric oxide (NO) and superoxide (O₂^-),decreases human TF activity in vitro. Coagulopathy has been associated with hepatoenteric ischemia-reperfusion　 known to involve formation of OONO^-. Further , circulating TF activity decreases in rabbits after hepatoenteric ischemia-reperfusion.We hypothesized that exposure of rabbit TF to OONO^- would result in a decrease in activity. OONO^- generation was performed with 3-morpholinosydnonimine(SIN-1),a molecule that produces both nitric oxide and superoxide .Rabbit brain TF was incubated at 37C for 90 min with 1)0mM SIN-1, 2)5mM SIN-1, 3) 5mM SIN-1 and 2000 U/mL recombinant human superoxide　 dismutase (hSOD1),or 4)2000 U/mL hSOD1(n=8 per condition ) .TF activity was assessed by addition of TF samples to human plasma and measuring clot formation kinetics with a thrombelastograph. TF exposure to SIN-1 resulted in a 48%decrease in activity that was significantly different from the other three conditions (P<0.01). There were no significantly differences between the other conditions .We conclude that rabbit TF is inhibited by OONO^-,and further investigation to determine the role of OONO^- in coagulopathies associated with hepatoenteric ischemia-reperfusion is warranted.

預注硫噴妥鈉防止丙泊酚注射痛

Pretreatment with Thiopental for Prevention of Pain Associated with Propofol Injection

Anil Agarwal, MD, Mohammad F. Ansari, MD, Devendra Gupta, MD, Ravindra Pandey, MD, Mehdi Raza, MD, Prabhat K. Singh, MD, Shiopriye, MBBS, Sanjay Dhiraj, MD, and Uttam Singh, PhD^*

Departments of Anesthesia and *Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Anesth Analg 2004;98:683-686

丙泊酚注射痛的發生率約為28%–90%，為減少疼痛所試用的方法很多，效果各異。我們比較了阻斷靜脈後，預先注射硫噴妥鈉0.25 mg/kg，0.5 mg/kg或利多卡因40 mg預防丙泊酚注射痛的效果。124例成年患者，ASA I–II級，行擇期手術，隨機分為四組，每組31人。組I預注生理鹽水，組II 2%利多卡因40 mg，組III硫噴妥鈉0.25 mg/kg，組IV硫噴妥鈉0.5 mg/kg。各預注藥均稀釋至2 mL，同時手法阻斷靜脈回流1分鐘。靜脈開放後注射丙泊酚。疼痛評分採用四分法，注射時無痛為0分，輕微痛為1分，中度痛為2分，重度痛為3分。生理鹽水組 24例患者（77%）主訴注射痛，組II、組III、組IV分別為12 例（39%）、10例（32%）和 1 例（3%）（P < 0.05）。硫噴妥鈉0.5 mg/kg預防丙泊酚注射痛最有效。我們推薦常規預注硫噴妥鈉0.5 mg/kg，同時手法阻斷靜脈回流1分鐘，來預防丙泊酚注射痛。

（軒泓　譯　李士通　校）

Propofol causes pain on IV injection in 28%–90% of patients.A number of techniques have been tried to minimize propofol-inducedpain, with variable results. We compared the efficacy of pretreatmentwith thiopental 0.25 mg/kg and 0.5 mg/kg and lidocaine 40 mgafter venous occlusion for prevention of propofol-induced pain.One-hundred-twenty-four adult patients, ASA physical statusI–II, undergoing elective surgery were randomly assignedinto 4 groups of 31 each. Group I received normal saline, groupII received lidocaine 2% (40 mg), and groups III and IV receivedthiopental 0.25 mg/kg and 0.5 mg/kg, respectively. All pretreatmentdrugs were made in 2 mL and were accompanied by manual venousocclusion for 1 min. Propofol was administered after releaseof venous occlusion. Pain was assessed with a four-point scale:0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severepain at the time of propofol injection. Twenty-four patients(77%) complained of pain in the group pretreated with normalsaline as compared with 12 (39%), 10 (32%), and 1 (3%) in thegroups pretreated with lidocaine 40 mg, thiopental 0.25 mg/kg,and thiopental 0.5 mg/kg, respectively (P < 0.05). Thiopental0.5 mg/kg was the most effective treatment. We therefore suggestroutine pretreatment with thiopental 0.5 mg/kg along with venousocclusion for 1 min for prevention of pain associated with propofolinjection.

利多卡因靜脈局部麻醉中加入dexmedetomidine

Adding Dexmedetomidine to Lidocaine for Intravenous Regional Anesthesia

Dilek Memi, MD^*, Alparslan Turan, MD^*, Beyhan Karamanlolu, MD^*, Zafer Pamukçu, MD^*, and Imran Kurt, MD

Departments of *Anaesthesiology and Biostatistics, Trakya University Medical Faculty, Edirne, Turkey

Anesth Analg 2004;98:835-840

Dexmedetomidine對-2腎上腺素能受體的選擇性是可樂定的8倍多。具有鎮痛效應並能減少達90%的麻醉藥用量。本實驗評估利多卡因靜脈局部麻醉加入Dexmedetomidine的效能。實驗觀察運動和感覺阻滯的起效和維持時間，麻醉質量，術中和術後血流動力學參數以及術中和術後疼痛和鎮靜情況。30例手部手術患者隨機分為2組行靜脈局部麻醉。對照組為0.5%利多卡因40 mL加1 mL 等張鹽水 ( L組,n = 15). 實驗組為0.5%利多卡因40 mL加0.5 µg/kg dexmedetomidine (LD組, n = 15)。記錄感覺和運動阻滯起效和恢復時間及麻醉質量。應用止血帶前和應用後　 5, 10, 15, 20, 和40 min記錄血流動力學參數、止血帶疼痛、鎮靜和鎮痛藥物使用情況。松止血帶後30 min, 和2, 4, 6, 12, 24 h記錄血流動力學參數、疼痛和鎮靜數值、要求第一次鎮痛藥的時間、鎮痛藥的使用情況及不良反應。在LD組感覺和運動阻滯起效時間縮短，感覺和運動恢復時間延長，對止血帶的耐受時間延長，麻醉質量提高。術中和松止血帶後30 min, 和2, 4, and 6 h，LD組的VAS評分顯著低於L組。LD組術中和術後鎮痛藥的要求量明顯低於L組。第一次要求鎮痛藥的時間LD組顯著延遲。結論：行IVRA時在利多卡因中加入dexmedetomidine能提高麻醉質量和術中鎮痛效果卻不會引起不良反應

（趙雪蓮　譯李士通校）

　Dexmedetomidine is approximately 8 times more selective towardthe -2-adrenoceptors than clonidine. It decreases anestheticrequirements by up to 90% and induces analgesia in patients.We designed this study to evaluate the effect of dexmedetomidinewhen added to lidocaine in IV regional anesthesia (IVRA). Weinvestigated onset and duration of sensory and motor blocks,the quality of the anesthesia, intraoperative-postoperativehemodynamic variables, and intraoperative-postoperative painand sedation. Thirty patients undergoing hand surgery were randomlyassigned to 2 groups to receive IVRA They received 40 mL of0.5% lidocaine and either 1 mL of isotonic saline (group L,n = 15) or 0.5 µg/kg dexmedetomidine (group LD, n = 15).Sensory and motor block onset and recovery times and anesthesiaquality were noted. Before and after the tourniquet applicationat 5, 10, 15, 20, and 40 min, hemodynamic variables, tourniquetpain and sedation, and analgesic use were recorded. After thetourniquet deflation, at 30 min, and 2, 4, 6, 12, and 24 h,hemodynamic variables, pain and sedation values, time to firstanalgesic requirement, analgesic use, and side effects werenoted. Shortened sensory and motor block onset times, prolongedsensory and motor block recovery times, prolonged tolerancefor the tourniquet, and improved quality of anesthesia werefound in group LD. Visual analog scale scores were significantlyless in group LD in the intraoperative period and 30 min, and2, 4, and 6 h after tourniquet release. Intra-postoperativeanalgesic requirements were significantly less in group LD.Time to first analgesic requirements was significantly longerin group LD in the postoperative period. We conclude that theaddition of 0.5 µg/kg dexmedetomidine to lidocaine forIVRA improves quality of anesthesia and perioperative analgesiawithout causing side effects.

糖尿病病人行脊髓刺激能減少胰島素需要量

Decreased Insulin Requirements with Spinal Cord Stimulation in a Patient with Diabetes

Leonardo Kapural, MD PhD, Salim M. Hayek, MD PhD, Michael Stanton-Hicks, MB BS, and Nagy Mekhail, MD PhD

Department of Pain Management, The Cleveland Clinic Foundation, Cleveland, Ohio

Address correspondence and reprint requests to Leonardo Kapural, MD, PhD, Pain Management Center, The Cleveland Clinic Foundation, 9500 Euclid Ave. Desk C25, Cleveland, OH 44195.

Anesth Analg 2004;98:745-746

我們介紹一例II型糖尿病患者在行脊髓刺激後血糖控制得到顯著改善和明顯降低胰島素的需要量。我們相信脊髓刺激更有益於長期疼痛的糖尿病人。

（趙雪蓮　譯　　　李士通　校）

We describe a case of type-2 diabetes mellitus with significantimprovement in blood glucose control and significant decreasein insulin requirements after initiation of spinal cord stimulation.We believe that spinal cord stimulation may provide additionalbeneficial effects in patients with chronic pain and diabetes.

（

CABG術後卵圓孔未閉和心房顫動的相關性

The Association of Patent Foramen Ovale and Atrial Fibrillation After Coronary Artery

Bypass Graft Surgery

George Djaiani, MD DEAA, FRCA^*, Barbara Phillips-Bute, PhD^*, Mihai Podgoreanu, MD^*, Robert H. Messier, MD, Joseph P. Mathew, MD^*, Fiona Clements, MD^*, and Mark F. Newman, MD^*

Departments of *Anesthesiology and Cardiac Surgery, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2004;98:585-589

CABG術後房顫(AF)的發病率高，增加了醫療資源消耗。本文研究了CABG病人卵圓孔未閉(PFO)和房間隔動脈瘤與術後AF發病率的關係。1008例CABG手術病人，術中通過經食道超聲心動圖明確是否有房間隔缺損，監測手術結束到出院期間AF發生情況。結果顯示：術後124例(12.3%)併發AF。AF病人多為年老的病人，術前常伴有充血性心力衰竭史，術中夾閉時間長，術後住院時間延長。PFO72例 (7.1%)，房間隔動脈瘤23例(2.3%)。術後AF病人併發PFO 14例(19.4%)，併發房間隔動脈瘤8例(34.8%)。用Logistic回歸分析顯示PFO (幾率[OR], 1.95; 1.007–3.778; P = 0.047), 年齡(OR, 1.03; 1.015–1.053; P = 0.0004)及充血性心衰史(OR, 2.55; 1.671–3.900; P < 0.0001)是術後發生AF的先兆。

（齊波　譯　　王祥瑞　校）

Atrial fibrillation (AF) is associated with considerable morbidityand increased resource utilization after coronary artery bypassgraft surgery. In this study, we sought to determine whetherpatent foramen ovale (PFO) and atrial septal aneurysm are associatedwith an increased risk of postoperative AF in this patient population.We performed a database study on 1008 patients undergoing primarycoronary artery bypass graft surgery. All patients were assessedfor the development of postoperative AF from the day of surgeryto hospital discharge. Atrial septal defects were identifiedduring comprehensive intraoperative transesophageal echocardiographicexamination. Postoperative AF was present in 124 (12.3%) patients.Patients with AF were significantly older and had a more frequentincidence of preoperative congestive heart failure, longer cross-clamptime, and prolonged hospital length of stay. PFO was presentin 72 (7.1%) and atrial septal aneurysm in 23 (2.3%) patients.In these patients, postoperative AF was present in 14 (19.4%)patients with PFO and 8 (34.8%) patients with atrial septalaneurysm. Multivariate logistic regression analysis identifiedthat PFO (odds ratio [OR], 1.95; 1.007–3.778; P = 0.047),age (OR, 1.03; 1.015–1.053; P = 0.0004), and history ofcongestive heart failure (OR, 2.55; 1.671–3.900; P <0.0001) were predictive of postoperative AF.

家兔應用牛源性聚合血紅蛋白對動脈的血栓形成和出血的作用

The Effects of a Polymerized Bovine-Derived Hemoglobin Solution in a Rabbit Model of Arterial Thrombosis and Bleeding

Emmanuel Marret, MD^*, Philippe Bonnin, MD PhD, Elisabeth Mazoyer, MD, Bruno Riou, MD PhD^*,, Ted Jacobs, MD^||, Pierre Coriat, MD^*, and Charles-Marc Samama, MD PhD^¶

Departments of *Anesthesiology and Critical Care and Emergency Medicine and Surgery, Hôpital Pitié-Salpêtrière, Paris, France; Department of Functional Investigations and Laboratory of Hematology, Hôpital Lariboisière, Paris, France; ||Biopure Corporation, Cambridge, Massachusetts; and ¶Department of Anesthesiology, Hôpital Avicenne, Bobigny, France

Anesth Analg 2004;98:604-610

以血紅蛋白為基礎的氧載體(HBOCs)具有氧合功能常用於術中或創傷後紅細胞代用品，然而其對止血方面的影響未深入研究。本研究比較牛源聚合血紅蛋白(HBOC-201)，明膠溶液和生理鹽水對動脈血栓形成和出血的影響。全麻後，30只Folts模型家兔，暴露頸總動脈並製備60%的狹窄，並建立動脈擠壓性損傷，後者觸發週期性血栓形成（週期性血流減少 [CFRs])，在計數CFRs基礎值後，動物隨機分三組，每組10只(n = 10)：生理鹽水(對照組)，明膠，和HBOC-201組。通過以下指標來反映藥物的作用：不同時期CFRs次數和耳朵的出血時間。結果顯示：明膠和HBOC-201的作用相似，CFRs減低時 (分別從中7到1，6到1)出血時間顯著延長(從88到98s和81到102s； P < 0.05)。生理鹽水對CFRs或出血時間無顯著影響。結論：HBOC-201和明膠的作用相似，可減少動脈血栓形成率並延長出血時間。

（齊波　譯　王祥瑞　校）

Hemoglobin-based oxygen carriers (HBOCs) have been developedprimarily for their oxygenating function and possible use asan alternative to red blood cells during surgery or after majortrauma. However, their effect on hemostasis has not been studiedextensively. We compared the effects on hemostasis of bovine-derivedhemoglobin solution (HBOC-201) with gelatin solution and salineinfusion in an experimental model of arterial thrombosis andbleeding. After anesthesia, the Folts model was constructedin 30 rabbits. The common carotid artery was exposed, and a60% stenosis was induced. A compression injury of the arterywas then produced, which triggered a series of cyclic episodesof thrombosis (cyclic flow reductions [CFRs]). After the numberof baseline CFRs was counted, animals were assigned randomlyto one of three groups (n = 10 each): saline (control), gelatin,or HBOC-201 solution. The effect of studied solutions was observedby recording the number of CFRs during another period and wascompared with that of saline. Ear immersion bleeding time wasrecorded after each CFR period. Gelatin and HBOC-201 had similareffects, manifested by significantly decreased CFRs (from medianof 7 to 1 and 6 to 1, respectively) and significantly lengthenedbleeding time (from 88 to 98 s and 81 to 102 s, respectively;P < 0.05). Saline infusion had no significant effect on CFRsor bleeding time. HBOC-201 and gelatin had similar effects markedby a reduction in the arterial thrombosis rate and increasedbleeding time in rabbits.

丙泊酚、異氟醚、七氟醚和地氟醚非住院麻醉後復蘇情況的比較：一項系統性回顧研究

Comparison of Recovery Profile After Ambulatory Anesthesia with Propofol, Isoflurane, Sevoflurane and Desflurane: A Systematic Review

Anil Gupta, MD FRCA, PhD^*,, Tracey Stierer, MD^*, Rhonda Zuckerman, MD^*, Neal Sakima, MD^*, Stephen D. Parker, MD^*, and Lee A. Fleisher, MD^* Section Editor

*Department of Anesthesiology and Critical Care, and the Division of Ambulatory Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland and the Division for Ambulatory Surgery, Department of Anesthesiology, University Hospital, Örebro, Sweden

Anesth Analg 2004;98:632-641

本文系統性回顧研究四種麻醉技術的術後復蘇和併發症。使用搜索詞“anesthesia”和短小手術，並且局限于成人（>19歲）的隨機對照實驗，語言為英語，通過PubMed（1966至2002年6月）檢索MEDLINE上的資料庫。第二步檢索使用 “丙泊酚”、“地氟醚”、“七氟醚”和“地氟醚”的任意兩個詞。篩選後共58篇論文進行最後分析。結果顯示：在早期復蘇中，丙泊酚和異氟醚沒有差異；地氟醚的早期復蘇要快於丙泊酚和異氟醚，而七氟醚又快於異氟醚。異氟醚和七氟醚之間的5分鐘定向力有微小差異，而其他麻醉劑之間沒有差異。在噁心、嘔吐、頭痛和出院後噁心、嘔吐發生率方面丙泊酚優於異氟醚（P<0.05）。許多吸入麻醉劑組的病人與丙泊酚組相比需要止吐藥。結論：不同麻醉劑間的早期復蘇時間差異不大，而吸入性麻醉劑占優。副反應發生率方面丙泊酚較少，尤其是出院後噁心和嘔吐。

（殷文淵　譯　王祥瑞　校）

In this systematic review we focused on postoperative recoveryand complications using four different anesthetic techniques.The database MEDLINE was searched via PubMed (1966 to June 2002)using the search words "anesthesia" and with ambulatory surgicalprocedures limited to randomized controlled trials in adults(>19 yr), in the English language, and in humans. A secondsearch strategy was used combining two of the words "propofol,""isoflurane," "sevoflurane," or "desflurane". Screening anddata extraction produced 58 articles that were included in thefinal meta-analysis. No differences were found between propofoland isoflurane in early recovery. However, early recovery wasfaster with desflurane compared with propofol and isofluraneand with sevoflurane compared with isoflurane. A minor differencewas found in home readiness between sevoflurane and isoflurane(5 min) but not among the other anesthetics. Nausea, vomiting,headache, and postdischarge nausea and vomiting incidence werein favor of propofol compared with isoflurane (P < 0.05).A larger number of patients in the inhaled anesthesia groupsrequired antiemetics compared with the propofol group. We concludethat the differences in early recovery times among the differentanesthetics were small and in favor of the inhaled anesthetics.The incidence of side effects, specifically postoperative nauseaand vomiting, was less frequent with propofol.

美沙酮功能性抑制N－甲基D－天冬氨酸受體在爪蟾蜍卵母細胞中的表達：立體異構體和亞單位的效應

Functional Inhibition by Methadone of N-Methyl-D-Aspartate Receptors Expressed in Xenopus Oocytes: Stereospecific and Subunit Effects

Robert J. Callahan, BS^*, John D. Au, BS^*, Matthias Paul, MD DEAA, Canhui Liu, PhD^*, and C. Spencer Yost, MD^*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; and Department of Anesthesiology and Intensive Care, University of Cologne, Cologne, Germany

Anesth Analg 2004;98:653-659

美沙酮（Methadone）是一種在慢性疼痛治療中使用越來越多的強效阿片類鎮痛藥。作者在一項電生理試驗（爪蟾蜍光滑卵母細胞）中證明其具有抑制N－甲基D－天冬氨酸受體表達。外消旋美沙酮在微摩爾濃度範圍抑制所有鼠NMDA受體亞型。這濃度與藥物動力學研究中報導的臨床有效濃度相一致。相比較而言，嗎啡抑制這些功能性離子通道所需濃度是臨床使用濃度8-16倍。NR1/2A和NR1/2B亞型複合體對美沙酮和嗎啡的抑制作用較NR1/2C和NR1/2D亞型複合體更為敏感。在外消旋美沙酮存在的情況下，最大NMDA刺激電流顯著增大，但產生50%最大活動的NMDA濃度改變不大，這說明美沙酮通過非競爭機制抑制。雖然美沙酮的立體異構體在許多亞型中顯示了最小的立體選擇性，但R(-)美沙酮對抑制NR1/2A複合體有高度選擇性。這些結果提供了美沙酮抑制NMDA受體活動的進一步資料，其藥理作用是通過阿片類受體和NMDA受體共同起作用。

（殷文淵　譯　王祥瑞　校）

Methadone is a strong opioid analgesic that is finding increasinguse in chronic pain therapeutics. We explored its reported efficacyfor inhibiting N-methyl-D-aspartate (NMDA) receptors in a functionalelectrophysiologic assay (Xenopus laevis oocyte expression).Racemic methadone inhibited all subtypes of rat NMDA receptorswith derived 50% inhibitory concentrations in the low micromolarrange. These concentrations overlap with clinically achievableconcentrations reported in pharmacokinetic studies. In contrast,morphine inhibited these functional ion channels only at 8–16times larger concentrations. The NR1/2A and NR1/2B subtype combinationswere in general significantly more sensitive to inhibition bymethadone and morphine compared with the NR1/2C and NR1/2D subtypes.In the presence of racemic methadone, the maximum NMDA-stimulatedcurrents were markedly decreased, but the NMDA concentrationproducing 50% of maximal activation was altered only slightly,indicating that methadone blocks by a noncompetitive mechanism.Although stereoisomers of methadone showed minimal stereoselectivityin most subtypes, R(-) methadone was highly selective in itsinhibition of the NR1/2A combination. These results providefurther functional data describing the NMDA receptor inhibitoryactions of methadone and support the hypothesis that methadoneacts through both opioid and NMDA receptor mechanisms.

新衍生物N-甲基多慮平與多慮平和布比卡因作為局部麻醉藥特性的比較

Local Anesthetic Properties of a Novel Derivative, N-Methyl Doxepin, Versus Doxepin and Bupivacaine

Yukari Sudoh, MD^*, Elaine Elliott Cahoon, BS^*, Umberto De Girolami, MD, and Ging Kuo Wang, PhD^*

*Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital; and Department of Pathology, Brigham and Women’s Hospital and Children’s Hospital and Harvard Medical School, Boston, Massachusetts

Anesth Analg 2004;98:672-676

在各種三環類抗抑鬱藥中，多慮平和阿米替林也是長效的局麻藥。作者合成了一新的化合物N-甲基多慮平並研究其局部麻醉的作用特性。取大鼠的坐骨神經，測試2.5，5.0，10mM N-甲基多慮平和多慮平對本體感覺，運動以及痛覺阻滯的效果並與0.5%的布比卡因作對比；通過電壓鉗制術下測試培養垂體瘤細胞來評估N-甲基多慮平和多慮平對Na離子通道的阻滯情況。結果顯示：N-甲基多慮平引起完全的神經阻滯時間長於多慮平（例如，在10mM時分別是7.4小時和5.3小時）。作者發現在各種濃度情況下的功能完全恢復時間有顯著差異，除了2.5mM濃度外完全阻滯時間也有顯著差異。0.5%布比卡因（15.4mM）完全阻滯時間（約1.5小時）少於N-甲基多慮平和多慮平。N-甲基多慮平和多慮平是潛在的Na離子通道阻滯劑，但N-甲基多慮平清除率慢于多慮平。結論：N-甲基多慮平是一潛在的Na離子通道阻滯劑且是一長效局部麻醉劑。

（朱輝　譯　王祥瑞　校）

Among various tricyclic antidepressants, doxepin and amitriptylineare also long-acting local anesthetics. We synthesized a newcompound, N-methyl doxepin, and investigated whether this derivativepossesses local anesthetic properties. N-methyl doxepin anddoxepin were tested in a rat sciatic nerve model at 2.5, 5.0,and 10 mM. Proprioceptive, motor, and nociceptive blockade wereevaluated and compared with those induced by 0.5% bupivacaine.Block of Na⁺ channels by N-methyl doxepin and doxepin was assessedin cultured pituitary tumor cells under voltage clamp conditions.N-methyl doxepin elicited complete nociceptive blockade thatgenerally lasted longer than that caused by doxepin (e.g., approximately7.4 h versus 5.3 h at 10 mM). Significant differences were observedfor full recovery of function at all concentrations and forthe duration of complete blockade except at 2.5 mM. Bupivacaineat 0.5% (15.4 mM) was less effective in producing complete blockade(approximately 1.5 h) than N-methyl doxepin and doxepin. Bothdoxepin and N-methyl doxepin were potent Na⁺ channel blockers,although N-methyl doxepin displayed a slower wash-in rate. Nomorphological alterations were detected in cross-sectioned sciaticnerve specimens with these three drugs. We conclude that N-methyldoxepin is a potent Na⁺ channel blocker and a long-acting localanesthetic for rat sciatic nerve blockade.

低脂異丙酚乳劑與標準的異丙酚乳劑的藥效比較

The Pharmacodynamic Effects of a Lower-Lipid Emulsion of Propofol: A Comparison with the Standard Propofol Emulsion

Dajun Song, MD PhD, Mohamed Hamza, MD, Paul F. White, PhD MD, Kevin Klein, MD, Alejandro Recart, MD, and Omeed Khodaparast, MS

From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

Anesth Analg 2004;98:687-691

新藥物——低脂異丙酚乳劑（Ampofol），它含有1%的異丙酚，5%的豆油以及0.6%的卵磷脂。作者隨機、雙盲研究63名健康的門診病人“平衡”麻醉時應用低脂異丙酚乳劑或異丙酚乳劑(Diprivan)比較其起效時間、誘導和維持時的作用效果。靜脈注射舒芬太尼0.1μg/kg（或芬太尼1μg/kg）和異丙酚2mg/kg，使用一可調節異丙酚速率的推注泵靜脈維持，速率在120-200μg‧kg^-1‧min^-1。記錄下睫毛反射消失時間和停止注射的時間，並且評估注射時疼痛的程度，誘導速度，術中血流動力學的變化以及雙頻指數，睜眼時間和定位恢復時間。結果顯示Ampofol和Diprivan在起效時間，誘導速度，麻醉所需的劑量，雙頻指數，血流動力學指標，恢復指標以及患者的滿意度都沒有明顯的差異。注射時疼痛的發生率Ampofol組高於Diprivan組（26%和6%，P〈0.05〉。結論：Ampofol在麻醉性能與Diprivan相同，但注射疼痛發生率高於後者。

（朱輝　譯　王祥瑞　校）

Using a randomized, double-blind protocol design, we compareda new lower-lipid emulsion of propofol (Ampofol®) containingpropofol 1%, soybean oil 5%, and egg lecithin 0.6% with themost commonly used formulation of propofol (Diprivan®) withrespect to onset of action and recovery profiles, as well asintraoperative efficacy, when administered for induction andmaintenance of general anesthesia as part of a "balanced" anesthetictechnique in 63 healthy outpatients. Anesthesia was inducedwith sufentanil 0.1 µg/kg (or fentanyl 1 µg/kg)and propofol 2 mg/kg IV and maintained with a variable-ratepropofol infusion, 120–200 µg ‧ kg^-1 ‧min^-1. Onset times to loss of the eyelash reflex and droppinga syringe were recorded. Severity of pain on injection, speedof induction, intraoperative hemodynamic variables, and electroencephalographicbispectral index values were assessed. Recovery times to openingeyes and orientation were noted. The results demonstrated thatthere were no significant differences between Ampofol® andDiprivan® with respect to onset times, speed of induction,anesthetic dose requirements, bispectral index values, hemodynamicvariables, recovery variables, or patient satisfaction. However,the incidence of pain on injection was more frequent in theAmpofol® group (26% versus 6%, P < 0.05). We concludethat Ampofol® is equipotent to Diprivan® with respectto its anesthetic properties but was associated with a morefrequent incidence of mild pain on injection.

大手術後病人硬膜外自控鎮痛（PCEA）治療術後疼痛的費用比較

Cost Drivers in Patient-Controlled Epidural Analgesia for Postoperative Pain Management After Major Surgery

Martin Schuster, MD, MA, André Gottschalk, MD, Marc Freitag, MD, and Thomas Standl, MD Section Editor

Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

Anesth Analg 2004;98:708-713

作者回顧性研究了350例大手術後應用PCEA治療術後疼痛（包括腹部、胸部、手術、婦產科和整形外科手術病人）的療效、療程和方法。術後第一天和第三天的平均疼痛評分分別為16±23和9±16（視覺類比評分範圍，0-100）。全麻病人平均療程為4.9±2.2天，婦產科病人為5.2±3.1天，整形外科病人為4.5±2.8天。硬膜外腔注射局麻藥和阿片類藥物混合液的總量在全麻病人為707±507ml，婦產科病人為770±576ml，整形外科病人為593±456ml。所有PCEA治療過程中的總費用為447±218/例（1個單位約為1美元）。其中51%為醫務人員的花費，20%為藥費，15%為PCEA泵和泵材料費，13%為原先導管置入的費用。根據這些費用和減少費用的可行性，建議使用PCEA後計算費用。由於使用PCEA的費用主要是藥費和醫務人員的支出，所以應該考慮停止PCEA後期監測並預先確定其他途徑。

（忻紀華　譯　王祥瑞　校）

In this retrospective study, we determined efficiency, treatmentlength, and resource use for postoperative pain management withpatient-controlled epidural analgesia (PCEA) in 350 consecutivepatients undergoing major abdominal, thoracic, gynecological,or orthopedic surgery. Average pain scores on a visual analogscale were 16 ± 23 and 9 ± 16 (visual analog scalerange, 0 to 100) on postoperative Days 1 and 3, respectively,and were similar among groups. The treatment length was 4.9± 2.2 days in general surgical, 5.2 ± 3.1 daysin gynecological, and 4.5 ± 2.8 days in orthopedic patients.The total volumes of the mixture of local anesthetic and opioidreceived epidurally were 707 ± 507 mL, 770 ± 576mL, and 593 ± 456 mL in the general surgical, gynecological,and orthopedic groups, respectively. The average total costsfor all groups for the full treatment course with PCEA were447 ±218 percase (1 equals approximately US$1). Fifty-onepercent of these costs were staff costs, 20% were costs forthe applied drugs, 15% were costs for PCEA pumps and pump material,and 13% were costs for the initial catheter insertion. In thelight of these costs and the availability of less costly alternatives,measurements for cost containment by using PCEA are recommended.Because treatment length is the main cost driver both for drugand staff costs, close monitoring of treatment length and apredefined migration path to alternative techniques after PCEAshould be considered.

自由活動大鼠聯合應用直流和交流電進行經顱電刺激的抗傷害作用

The Antinociceptive Effect of Transcranial Electrostimulation with Combined Direct and Alternating Current in Freely Moving Rats

Vladimir Nekhendzy, MD^*, Christo P. Fender, BA^*, M. Frances Davies, PhD^*, Hendrikus J. M. Lemmens, MD, PhD^*, Michael S. Kim, MD^*, Donna M. Bouley, DVM, PhD, and Mervyn Maze, MBChB, FRCP, FRCA

Departments of *Anesthesiology and Comparative Medicine, Stanford University School of Medicine, Stanford, California, and the Department of Anaesthetics and Intensive Care, Imperial College, London and Chelsea and Westminster NHS Hospital Trust, London, UK

Anesth Analg 2004;98:730-737

據報導經顱電刺激（TES）可以誘發明顯的鎮痛作用，使術前阿片類藥物的用量減少。由於缺少臨床對照實驗和TES鎮痛作用的動物實驗，TES臨床應用受阻。這些非決定性的資料可以部分解釋為TES電極置於皮膚時，在人類應用的各種刺激無法用於小鼠。本實驗中，作者採用刺激形式與臨床相似新的動物模型，證實TES的抗傷害作用。抗傷害作用通過測量清醒、自由活動雄鼠對夾尾、熱板試驗傷害刺激閾值來評估。應用2.25mA的TES產生快速、持續、頻率依賴性（40-60Hz）的抗傷害作用,可達最大值50%。結論：大鼠經皮TES具有抗傷害作用。這種作用的特點提示大鼠頭皮中的感覺神經在經TES介導的抗傷害作用中起重要作用。

（忻紀華　譯　王祥瑞　校）

Transcranial electrostimulation (TES) has been reported to elicitsignificant analgesia, allowing a substantial reduction of intraoperativeopioids. Acceptance of TES into clinical practice is hamperedby lack of controlled clinical trials and inconclusive animaldata regarding the TES antinociceptive action. This inconclusivedata may be explained, in part, by failure in rat experimentsto simulate the variables used in humans when TES electrodesare positioned on the skin. In this study we validated the TESantinociceptive effect in a novel animal model of cutaneouslyadministered TES, when the stimulating conditions mimic theones used in clinical practice. The antinociceptive effect wasassessed by measuring nociceptive thresholds in the tail-flickand hot-plate latency tests in awake, unrestrained male rats.Data were analyzed by analysis of variance and mixed-effectspopulation modeling. The administration of TES at 2.25 mA producedan almost immediate, sustained, frequency-dependent (40–60Hz) antinociceptive effect, reaching approximately 50% of themaximal possible value. We conclude that an antinociceptiveeffect of cutaneously administered TES can be demonstrated inthe rat. Some characteristics of the effect suggest an importantrole of the sensory nerves of the rat’s scalp in mediatingthe TES antinociceptive response.

醫師麻醉的成本效益問題

Is Physician Anesthesia Cost-Effective?

J. P. Abenstein, MSEE MD^*, Kirsten Hall Long, PhD, Brian P. McGlinch, MD^*, and Niki M. Dietz, MD^* Section Editor

*Department of Anesthesiology and Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota

Anesth Analg 2004;98:750-757

麻醉中一個最有爭議的問題是：在麻醉工作中是否非醫學專業的麻醉師比醫師麻醉更具有成本效益？作者調查美國麻醉支付費用來評估其成本。利用支付麻醉費用的調查資料和研究結果，建立起一種特定的模式來比較醫師麻醉與非醫師麻醉哪一種更經濟。成本效益率定義為：麻醉醫師的成本比上這種模式帶來的預期壽命增加（即費用/壽命增加[$/YLS]）。結果表明醫師麻醉可以降低成本，加入保險的青年患者成本效益率為-$2,601/YLS，加入保險的老年患者預期成本效益率為-$4,410/YLS。一元或多元敏感分析表明成本效益率範圍在-$4,410 － $38,778/YLS之間。結果對反映假定的支付差別和假定的死亡率非常精確。這種分析為支援醫師麻醉模式提供了經濟學的證據。

（朱慧琛　譯　王祥瑞　校）

One of the most controversial issues in anesthesia is whethernonmedically directed nurse anesthetists are relatively morecost-effective than anesthesiologists in the provision of anesthesiacare. We electronically surveyed anesthesia practices throughoutthe United States to estimate the range in anesthesia professionalcosts from the payer perspective. Using this survey data onanesthesia reimbursement and published outcomes studies, wedeveloped an ad hoc model to estimate the cost-effectivenessof physician-directed anesthesia relative to a nonmedicallydirected nurse anesthetist model of care from the payer perspective.Cost-effectiveness ratios were defined as the ratio of incrementalcosts associated with physician anesthesia relative to the estimatedincremental life expectancy gains with this model of care (i.e.,dollars per year of life saved [$/YLS]). Reference case resultssuggest that physician anesthesia is cost saving with an estimatedincremental cost-effectiveness ratio of -$2,601/YLS for a youngerprivately insured patient and an estimated cost-effectivenessratio of -$4,410/YLS for an elderly Medicare insured patient.Cost-effectiveness ratios ranged from -$4,410 to $38,778/YLSin univariate and multivariate sensitivity analyses across payertypes. Results were most sensitive to assumed differences inreimbursement (commercial conversion factors) and to mortalityrate assumptions by provider type. This analysis offers economicevidence in support of the physician anesthesia model of care.

預防性使用苯腎上腺素可防止剖腹產手術中因脊麻引起的低血壓

Prophylactic Phenylephrine Infusion for Preventing Hypotension During Spinal Anesthesia for Cesarean Delivery

Warwick D. Ngan Kee, MBChB MD, FANZCA, Kim S. Khaw, MBBS FRCA, Floria F. Ng, RN BASc, and Bee B. Lee, MBBS FANZCA

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China

Anesth Analg 2004;98:815-821

在一次隨機的對照實驗中，作者研究了剖腹產手術中預防性使用苯腎上腺素對避免脊髓麻醉引起的低血壓的作用。在鞘內注藥後隨即使用苯腎上腺素100μg/min（n=26）持續3分鐘。在胎兒取出之前每分鐘測量一次血壓，若動脈收縮壓（SAP）低於正常水平便給予苯腎上腺素100μg/min。對照組（n=24）在SAP小於正常水平的80%時給予苯腎上腺素100μg。與對照組相比持續注射苯腎上腺素能減少低血壓的發生率（6/26（23%）；對照組為21/24（88%）；P<0.0001），同時也能減輕血壓下降的程度（平均最低的SAP為106mmHg,波動幅度為95—111mmHg;對照組為80mmHg,73—93mmHg；P<0.0001）。心率也較對照組慢（P<0.0001）。實驗組苯腎上腺素劑量（1260μg±; 1010--1640μg）大於對照組（450μg，300--750μg；P<0.0001），但臍帶血氣和Apgar評分相似。每組均有一個胎兒的臍帶血PH<7.2。結論：脊髓麻醉下剖腹產病人預防性使用苯腎上腺素可簡單、安全、有效地控制術中血壓。

（朱慧琛　譯　王祥瑞　校）

In a randomized, double-blinded, controlled trial, we investigatedthe prophylactic infusion of IV phenylephrine for the preventionof hypotension during spinal anesthesia for cesarean delivery.Immediately after intrathecal injection, phenylephrine was infusedat 100 µg/min (n = 26) for 3 min. From that point untildelivery, phenylephrine was infused at 100 µg/min wheneversystolic arterial blood pressure (SAP), measured each minute,was less than baseline. A control group (n = 24) received IVbolus phenylephrine 100 µg after each measurement of SAP<80% of baseline. Phenylephrine infusion decreased the incidence(6 [23%] of 26 versus 21 [88%] of 24; P < 0.0001), frequency,and magnitude (median minimum SAP, 106 mm Hg; interquartilerange, 95–111 mm Hg; versus median, 80 mm Hg; range, 73–93mm Hg; P < 0.0001) of hypotension compared with control.Heart rate was significantly slower over time in the infusiongroup compared with the control group (P < 0.0001). Despitea large total dose of phenylephrine administered to the infusiongroup compared with the control group (median, 1260 µg;interquartile range, 1010–1640 µg; versus median,450 µg; interquartile range, 300–750 µg; P< 0.0001), umbilical cord blood gases and Apgar scores weresimilar. One patient in each group had umbilical arterial pH<7.2. Prophylactic phenylephrine infusion is a simple, safe,and effective method of maintaining arterial blood pressureduring spinal anesthesia for cesarean delivery.

地卡因增加神經生長錐細胞內鈣離子

Intracellular Calcium Increases in Growth Cones Exposed to Tetracaine

Shigeru Saito, MD, Inas A. M. Radwan, MD, Koichi Nishikawa, MD, Hideaki Obata, MD, Tomonori Okamoto, MD, Toshio Kanno, MD, and Fumio Goto, MD

From the Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, Japan

Anesth Analg 2004;98:841-845

局麻藥對成熟和正在生長的神經元的毒性作用均已有報導。本實驗作者研究地卡因在生長錐衰退的過程中是否引起Ca²⁺濃度升高。生長錐暴露於地卡因之後，通過fura2/AM測定Ca²⁺濃度，發現地卡因（1－2mM）引起生長錐細胞內的Ca²⁺濃度升高（P<0.01）. Ca²⁺的熱點布從外周向細胞體分佈直至神經突。在無Ca²⁺的培養基中，地卡因作用於生長錐，Ca²⁺濃度的增加很小，但導致了生長錐的衰退。Ni²⁺(100Um;一種Ca²⁺阻滯劑)和BAPTA-AM(5Um; 細胞內Ca²⁺螯合劑)不能抑制1－2mM地卡因導致生長錐衰退。結論：地卡因（>1Mm）同時引起生長錐衰退和Ca²⁺濃度增加，這兩種現象可能是獨立發生的。

（陳潔　譯　王祥瑞　校）

Neurotoxicity of local anesthetics has been reported for bothmatured and growing neurons. In the present study, we examinedif tetracaine increases Ca²⁺ concentration during growth conecollapse. Intracellular Ca²⁺ concentration was measured by fura2/AM after exposure to tetracaine. Tetracaine (1–2 mM)induced increases in intra-growth cone Ca²⁺ concentration (P< 0.01). The Ca²⁺ hot spot was expanded into the neuritefrom the periphery towards the cell body. When tetracaine wasapplied to growth cones in Ca²⁺ free media, the increase wasminor. However, tetracaine induced growth cone collapse evenin the culture media, which did not contain Ca²⁺. Ni²⁺ (100µM; a general Ca²⁺ channel inhibitor) and BAPTA-AM (5µM; intracellular Ca²⁺ chelator) could not inhibit growthcone collapse induced by 1–2 mM tetracaine. Tetracaine(>1 mM) induces collapse and Ca²⁺ increase at growth conessimultaneously; however, these two

phenomena might be provokedindependently.

喉罩有助於側臥位氣管插管

The Intubating Laryngeal Mask Airway Facilitates Tracheal Intubation in the Lateral Position

Ryu Komatsu, MD^*, Osamu Nagata, MD^*, Daniel I. Sessler, MD, and Makoto Ozaki, MD^*

*Department of Anesthesiology, Tokyo Women’s Medical University, Tokyo, Japan, and the Outcomes Research^TM Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2004;98:858-861

雖然側臥位氣管插管的困難程度沒有經過系統的評價，但側臥位元手術時氣道顯示困難會引起危險的結果。作者調查喉罩置入（ILMA）是否能幫助氣道解剖正常的患者的氣管插管，側臥位時Mallampati評分≤3，仰頭距離≥5cm。通過成功率和插管時間來評價這種技術是否能作為手術中側臥位患者困難插管時的補救措施。選擇為50，例接受腰椎間盤突出手術（側臥位）和50例其他手術（仰臥位），麻醉誘導用藥為異丙酚和芬太尼。腰椎手術患者麻醉誘導前取左側或右側臥位，插管也採用同樣的體位，對照組誘導和插管均採用仰臥位。兩組均使用LIMA盲插，記錄插管的時間和需要調整插管例數和方式等。使用Mann-Whitney U , Fisher’s exact test,X²或非成對Student’s t 統計分析。結果：兩組病人一般情況和氣道測量情況相似；側臥位組張口程度稍大（5.1：4.6cm）；兩組氣管插管時間相近（25s），插管成功率也一樣（96％）。結論：即使在側臥位，ILMA提供了滿意的插管成功率和插管時間（<1min）。

（陳潔　譯　王祥瑞　校）

Although the difficulty of tracheal intubation in the lateralposition has not been systematically evaluated, airway lossduring surgery in a laterally positioned patient may have hazardousconsequences. We explored whether the intubating laryngeal maskairway (ILMA) facilitates tracheal intubation in patients withnormal airway anatomy, i.e., Mallampati grade 3 and thyromentaldistance 5 cm, positioned in the lateral position.We evaluated whether this technique can be used as a rescuewhen the airway is lost during the middle of surgery in laterallypositioned patients with respect to success rate and intubationtime. Anesthesia was induced with propofol, fentanyl, and vecuroniumin 50 patients undergoing spine surgery for lumbar disk herniation(Lateral) and 50 undergoing other surgical procedures (Supine).Patients having disk surgery (Lateral) were positioned on theirright or left sides before induction of general anesthesia,and intubation was performed in that position. Patients in thecontrol group (Supine) were anesthetized in supine position,and intubation was performed in that position. Intubation wasperformed blindly via an ILMA in both groups. The time requiredfor intubation and number and types of adjusting maneuvers usedwere recorded. Data were compared by the Mann-Whitney U test,Fisher’s exact test, ² test, or unpaired Student’st-test, as appropriate. Data presented as mean (SD). Demographicand airway measures were similar in the two groups, except formouth opening, which was slightly wider in patients in the lateralposition: 5.1 (0.9) versus 4.6 (0.7) cm. The time required forintubation was similar in each group (25 s), as was intubationsuccess (96%). We conclude that blind intubation via an ILMAoffers a frequent success rate and a clinically acceptable intubationtime (<1 min) even in the lateral position.

非心臟手術術中心血管事件的發生率及自動檢出率

The Incidence and Prediction of Automatically Detected Intraoperative Cardiovascular Events in Noncardiac Surgery

Rainer Röhrig, Dr. med., Axel Junger, PD Dr. med., MBA (FIT), Bernd Hartmann, Dr. med., Joachim Klasen, Dr. med., Lorenzo Quinzio, Dr. med., Andreas Jost, Matthias Benson, Dr. med. habil., and Gunter Hempelmann, Prof. Dr. med. Dr. h.c. Section Editor

Anesth Analg 2004;98:569-577
　

此研究是出於質量保證的目的來評價術中自動檢出心血管事件(CVE)的58，458名進行非心臟手術患者的預後模型。我們使用修訂後的心臟危險指數(RCRI)以及ASA分級來評估麻醉危險。以此我們建立了兩種新的模型。通過電子麻醉持續記錄系統來發現CVEs。使用邏輯回歸來建立一個複雜和一個簡單的模型。使用校準和辨別的分析來評價預後模型的準確性。在評估(n = 29,437)的5249名患者(17.8%)和證實的(n = 29,021) 5031名患者(17.3%)中至少有一項CVE。CVE和醫院病死率顯著相關(2.1% 比1.0%; P < 0.01)。新的模型顯示了很好的辨別力，受試者工作特徵曲線(AUC)下面積分別為0.709 和 0.707。而ASA分類(AUC 0.647)和 RCRI (AUC 0.620)的解析度差一些。但是兩種新的模型和ASA ，RCRI的辨別率都還不夠。單純的ASA分級和 RCRI都不適合用於預見術中CVE的發生。

（方芳譯薛張綱校）

The objective of this study was to evaluate prognostic modelsfor quality assurance purposes in predicting automatically detectedintraoperative cardiovascular events (CVE) in 58,458 patientsundergoing noncardiac surgery. To this end, we assessed theperformance of two established models for risk assessment inanesthesia, the Revised Cardiac Risk Index (RCRI) and the ASAphysical status classification. We then developed two new models.CVEs were detected from the database of an electronic anesthesiarecord-keeping system. Logistic regression was used to builda complex and a simple predictive model. Performance of theprognostic models was assessed using analysis of discriminationand calibration. In 5249 patients (17.8%) of the evaluation(n = 29,437) and 5031 patients (17.3%) of the validation cohorts(n = 29,021), a minimum of one CVE was detected. CVEs were associatedwith significantly more frequent hospital mortality (2.1% versus1.0%; P < 0.01). The new models demonstrated good discriminativepower, with an area under the receiver operating characteristiccurve (AUC) of 0.709 and 0.707 respectively. Discriminationof the ASA classification (AUC 0.647) and the RCRI (AUC 0.620)were less. Neither the two new models nor ASA classificationnor the RCRI showed acceptable calibration. ASA classificationand the RCRI alone both proved unsuitable for the predictionof intraoperative CVEs.

靜脈使用烯丙呱三嗪治療單肺通氣的低氧血症

Treatment of Hypoxemia During One-Lung Ventilation Using Intravenous Almitrine

Nicolas Dalibon, MD, Marc Moutafis, MD, Ngai Liu, MD, Jean-Dominique Law-Koune, MD, Stéphanie Monsel, MD, and Marc Fischler, MD

From the Department of Anesthesiology, Hôpital Foch, Université Paris-Ouest, Suresnes, France

Anesth Analg 2004;98:590-594

我們使用這個隨機雙盲的前瞻性研究來評價靜脈使用烯丙呱三嗪來治療單肺通氣(OLV) 時的低氧血症的效果。28名患者使用異丙酚，舒芬太尼，阿曲庫安，使用雙腔管進行肺隔離術。使用食道超聲探頭來評價心臟指數。OLV 期間SpO₂等於或小於95%（吸入氧0.6）的患者被納入本研究。使用安慰劑，烯丙呱三嗪 (12 µg ‧ kg^-1 ‧min^-1 持續10 min 接著 4 µg ‧ kg^-1 ‧min^-1)直到 SpO₂達到90%或低於90%（排除在研究之外）。28名患者中18人被納入研究範圍，其中9人接受烯丙呱三嗪，8人接受安慰劑治療。烯丙呱三嗪組中有一個，安慰劑組中有6人終止治療(P < 0.05)。烯丙呱三嗪組中8人，安慰劑組中1人治療有效(SpO₂ 保持 95% 在 OLV期間) (P < 0.01)。研究中心率，動脈壓，心臟指數都沒有明顯改變。但是我們只在一半的患者中發現足夠的主動脈血流。烯丙呱三嗪可以用來治療單肺通氣時的低氧血症。

（方芳譯薛張綱校）

We performed this prospective randomized double-blinded studyto assess the ability of almitrine to treat hypoxemia duringone-lung ventilation (OLV). Twenty-

eight patients were anesthetizedwith propofol, sufentanil, and atracurium; lung separation wasachieved with a double-lumen tube. A transesophageal Dopplerprobe was inserted to evaluate cardiac index. If SpO₂ was equalto or decreased to <95% during OLV (inspired fraction ofoxygen of 0.6), patients were included in the study and receiveda placebo or almit- rine (12 µg ‧ kg^-1 ‧min^-1 for 10 min followed by 4 µg ‧ kg^-1 ‧min^-1) infusion until SpO₂ reached 90% or decreased to <90%(exclusion from the study). Eighteen of the 28 patients wereincluded and received either almitrine (n = 9) or a placebo(n = 9). Treatment was discontinued in 1 patient in the almitrinegroup and 6 in the placebo group (P < 0.05). Treatment wassuccessful (SpO₂ remaining 95% during OLV) in8 patients in the almitrine group and 1 in the placebo group(P < 0.01). Heart rate, arterial blood pressure, and cardiacindex did not change throughout the study, but we could obtainan adequate aortic blood flow signal in only half of the patients.Almitrine could be used to treat hypoxemia during OLV.

小兒使用Masimo SET® and Nellcor N-395血氧計的信號整合和飽和度的資料準確性和有效性的臨床評價

Clinical Evaluation of the Effects of Signal Integrity and Saturation on Data Availability and Accuracy of Masimo SET® and Nellcor N-395 Oximeters in Children

Frederick A. Robertson, MD, and George M. Hoffman, MD Section Editor

From the Department of Pediatric Anesthesiology, Children’s Hospital of Wisconsin, and the Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin

Anesth Analg 2004;98:617-622
　

脈搏血氧計製造商介紹了技術，聲稱可以提高低氧的檢出率。由於提高信號的處理和資料的演算法對最終資料有不同的作用，我們比較了在不同的信號整合和血氧飽和度下Nellcor N-395,Masimo SET®, and GE Solar 8000血氧計的資料報告，信號啟發和協定。在27位患者中一對一進行技術比較，分析時間和資料的關係，檢測協定和信號啟發，通過信號整合和 SpO₂來進行報警分層。Solar 8000比其他兩個新的機器更少有資料逃脫。Masimo’sLoSIQ（信號質量）啟發比Nellcor’sMOT/PS（運動/脈搏檢測）反應了更少的資料。當沒有信號啟發被顯示的時候，兩者之間在精確性和偏差方面沒有差別。然而，兩種儀器之間的協定在SIQ, MOT, 或低氧血症的情況下會惡化。兩種儀器都可以衰減有問題的信號，但是他們不同的演算法造成了不同的結果。因此，在低SIQ和低氧下Nellcor N-395 和 Masimo血氧儀在臨床上是不同的，和老的GE Solar 8000血氧計也不同。

（方芳譯薛張綱校）

Pulse oximetry manufacturers have introduced technologies thatclaim improved detection of hypoxemic events. Because improvementsin signal processing and data rejection algorithms may differentiallyaffect data reporting, we compared the data reporting and signalheuristic performance and agreement among the Nellcor N-395,Masimo SET®, and GE Solar 8000 oximeters under a spectrumof conditions of signal integrity and arterial oxygen saturations.A blinded side-by-side comparison of technologies was performedin 27 patients, and data were analyzed for time of data availability,measures of agreement and signal heuristics, and warnings stratifiedby signal integrity and SpO₂. The Solar 8000 had less totaldata dropout than either of the new technologies. Masimo’sLoSIQ (signal quality) heuristic rejected less data than Nellcor’sMOT/PS (motion/pulse search) flag. When no signal heuristicwas displayed, there was little difference in precision andbias between the two newer technologies; however, agreementbetween devices deteriorated in the presence of SIQ, MOT, orhypoxemia. Both newer devices flagged questionable data, buttheir use of different rejection algorithms resulted in differentprobabilities of presenting data. Therefore, with poor SIQ orduring hypoxemia, the Nellcor N-395 and Masimo oximeters arenot clinically equivalent to each other or to the older Solar8000 oximeter

行走時間對利多卡因脊麻後一過性神經症狀發生的影響

The Influence of Ambulation Time on the Incidence of Transient Neurologic Symptoms After Lidocaine Spinal Anesthesia

Martti Silvanto, MD^*, Pekka Tarkkila, MD, PhD, Marja-Leena Mäkelä, MD, and Per H. Rosenberg, MD, PhD

Research Institute of Military Medicine and Department of Anaesthesia, Central Military Hospital, Helsinki; Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital

Anesth Analg 2004;98:642-646

利多卡因脊麻後一過性神經綜合症（TNS）尚不清楚。已有的假設認為脊麻後早期行走可能導致TNS的發展。我們假設2％等比重的利多卡因50mg用於膝關節鏡手術後，行走時間能TNS的發生。120位行膝關節鏡手術（ASA分級1~2）的病人被隨機分成3組，如早期行走組（GroupE），6小時後行走組（Group6－h）和晚期行走組（GroupL）。在GroupE，病人被允許在脊麻恢復後儘早行走（平均229+/-21分鐘，範圍135－247分鐘）。在Group6－h，病人在脊麻後臥床大約6消失，而在GroupL病人臥床至第二天早上。所有病人在統計學、麻醉和外科學的指標均類似。總的TNS發生率為16％。其中GroupE有3例（7.5％），Group6－h有11例（28％），GroupL有5例（13％）。在有或無TNS的病人間未發現明顯差異。2％利多卡因50mg脊麻後早期行走並非TNS的危險因素。

（鍾鳴譯薛張綱校）

The cause of transient neurologic symptoms (TNSs) after lidocainespinal anesthesia remains unclear. It has been proposed thatearly ambulation after spinal anesthesia contributes to thedevelopment of TNSs. We evaluated the influence of ambulationtime on the occurrence of TNSs after spinal anesthesia with50 mg of 2% plain lidocaine for knee arthroscopy. One-hundred-twentypatients undergoing knee arthroscopy (ASA physical status 1–2)were randomized into 3 groups, i.e., early (Group E), 6-h (Group6-h), or late ambulation (Group L) groups. In Group E, ambulationwas allowed as early as possible after regression of spinalblock (on average 229 ± 21 min; range, 135–247min). In Group 6-h, the patients remained in bed for approximately6 h after the block and in Group L until the next morning. Thepatient groups were comparable with respect to demographic,anesthetic, and surgical variables. The overall incidence ofTNSs was 16%. TNSs occurred in 3 patients of Group E (7.5%),in 11 patients of Group 6-h (28%), and in 5 patients of GroupL (13%). No significant differences were detected between thepatients with and without TNSs. Early ambulation was not foundto be a risk factor for TNSs after spinal anesthesia with 50mg of 2% lidocaine.

己醇對異三聚體G蛋白質 G_i亞基的影響

The Effects of Hexanol on G_i Subunits of Heterotrimeric G Proteins

John Streiff, PhD^*, David O. Warner, MD^*, Elena Klimtchuk, PhD, William J. Perkins, MD^*, Kristofer Jones, BS, and Keith A. Jones, MD^*

Departments of *Anesthesiology and Physiology and Biophysics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

Anesth Analg 2004;98:660-7

乙醇和其他麻醉藥能干擾由三磷酸鳥嘌呤（GTP）結合蛋白（G蛋白）調節的一系列系統的功能。我們檢驗了己醇對異三聚體G蛋白質 G_i亞基活性的作用。GTP水解再結合G_I活性是0.029摩爾*Pi/摩爾G_I*min，被己醇在大於10mM、平均為22mM的濃度所抑制。圓形二色性光譜法揭示了己醇將G_I的變性溫度從47.2^oC降到42.5^oC，而在10^oC不改變其二級結構。通過尺寸－排除的套色版法檢驗得出己醇（30mM）能降低水溶液中G_I單聚體的數量，這提示了己醇導致了蛋白的聚合。然而，GTP結合到從氣道平滑肌膜免疫沉澱而得G_I的速度並不被己醇（30mM）所影響。除外由聚合誘導的假像產生的再結合G_I的明顯抑制，我們並沒有發現在完整的氣道平滑肌，由於內源性[³⁵S]GTPS結合到G_I速度的直接抑制而導致的己醇誘導的受體啟動的G_I耦聯途徑的抑制。

（鍾鳴譯薛張綱校）

Alcohols and other anesthetics interfere with the function ofa variety of systems regulated by guanosine triphosphate (GTP)-bindingproteins (G proteins). We examined the effect of hexanol onthe activity of the subunit (G_i1) of heterotrimeric G proteins.The GTP hydrolysis activity of recombinant G_i1 was 0.029 molePi ‧ mole G_i1^-1 ‧ min^-1 and was inhibited by hexanolat concentrations larger than 10 mM, with a 50% inhibitory concentrationof 22 mM. Circular dichroism spectroscopy revealed that hexanoldecreased the denaturation temperature of G_i1 from 47.2°Cto 42.5°C without altering its secondary structure at 10°C.Hexanol (30 mM) reduced the amount of monomeric G_i1 in solutionmeasured by size-exclusion chromatography, indicating that hexanolcaused protein aggregation. However, the rate of GTPS bindingto G_i immunoprecipitated from airway smooth muscle membraneswas not affected by 30 mM hexanol. Excluding the apparent inhibitionof recombinant G_i1 resulting from aggregation-induced artifact,we found no evidence that the hexanol-induced inhibition ofreceptor-activated G_i-coupled pathways in intact airway smoothmuscle resulted from direct inhibition of the intrinsic rateof [³⁵S]GTPS binding to G_i.

血管擴張提高大鼠布比卡因誘發驚厥的域值

Vasodilation Increases the Threshold for Bupivacaine-Induced Convulsions in Rats

Yutaka Oda, MD PhD, Tomoharu Funao, MD, Katsuaki Tanaka, MD, and Akira Asada, MD PhD

From the Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan

Anesth Analg 2004 98: 677-682

布比卡因通過外周和中樞神經系統的機制影響了血管阻力。因為血管收縮藥增加了靜脈注射布比卡因的中樞神經系統毒性，故血管擴張藥可能降低這種毒性。我們檢驗了該假設，即血管擴張藥降低了清醒、自主呼吸的老鼠中布比卡因的中樞毒性。雄性Sprague-Dawley老鼠被隨機分成對照組（C）、尼卡地平組（N）和酚妥拉明組（P）（每組12例）。以1mg/kg/min的速度給予消旋布比卡因直至出現緊張/陣攣性驚厥。3組隨布比卡因同時分別給予生理鹽水、尼卡地平（0.4ug/min）和酚妥拉明（最初5分鐘10ug/min，隨後50ug/min）。C組注射布比卡因後平均動脈壓明顯升高而N組、P組在驚厥發作前維持在基線水平。C組布比卡因的驚厥劑量為5.8+/-1.5mg/kg，而在N組和P組顯著升高（分別為7.6+/-1.5mg/kg,p=0.02和8.1+/-1.1mg/kg）。然而，在3組中發作驚厥時血漿中總的或非蛋白結合的布比卡因濃度或腦內布比卡因濃度沒有差異。我們得出結論，尼卡地平和酚妥拉明提高了布比卡因的累積劑量，但並不影響由布比卡因誘導的驚厥所需的血漿或腦內的域濃度。

（鍾鳴譯薛張綱校）

Bupivacaine affects the vascular resistance by peripheral andcentral nervous system (CNS) mechanisms. As vasoconstrictorsincrease the CNS toxicity of IV bupivacaine, vasodilators maydecrease its CNS toxicity. We examined the hypothesis that vasodilatorsdecrease the CNS toxicity of bupivacaine in awake, spontaneouslybreathing rats. Male Sprague-Dawley rats were randomly dividedinto control (C), nicardipine (N), and phentolamine (P) groups(n = 12 in each group). Racemic bupivacaine was administeredIV at 1 mg/kg/min until tonic/clonic convulsions occurred. Saline,nicardipine (0.4 µg/min), and phentolamine (10 µg/minwithin 5 min, 50 µg/min thereafter) were simultaneouslyadministered with bupivacaine in groups C, N, and P, respectively.Mean arterial blood pressure was significantly increased byinfusion of bupivacaine in group C and was maintained at baselinelevels before the onset of convulsions in groups N and P. Theconvulsive dose of bupivacaine in group C was 5.8 ± 1.5mg/kg, but was significantly larger in groups N and P (7.6 ±1.5 and 8.1 ± 1.1 mg/kg, P = 0.02 and 0.001, respectively).However, there were no differences in total or protein-unboundplasma concentration of bupivacaine or in concentration of bupivacainein the brain at the onset of convulsions among the 3 groups.We conclude that nicardipine and phentolamine increase the cumulativedose but do not affect the threshold plasma or brain concentrationsrequired for bupivacaine-induced convulsions.

丙泊芬麻醉中應用腦電圖監測麻醉藥物作用的Narcotrend指數與雙頻指數比較

Narcotrend Index Versus Bispectral Index as Electroencephalogram Measures of Anesthetic Drug Effect During Propofol Anesthesia

Sascha Kreuer, MD^*, Wolfram Wilhelm, MD DEAA^*, Ulrich Grundmann, MD^*, Reinhard Larsen, MD^*, and Jörgen Bruhn, MD Section Editor

*Department of Anesthesiology and Intensive Care Medicine, University of Saarland, Homburg/Saar, Germany, and the Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany

Anesth Analg 2004 98: 692-697

Narcotrend監測儀(MonitorTechnik, Bad Bramstedt, Germany)能基於初始EEG的視覺評估對麻醉期間的EEG進行自動分析。它的最新軟體4.0版包括dimensionless指數（類似於BIS指數），範圍從100（蘇醒）至0。我們比較在丙泊芬麻醉中應用Narcotrend指數及BIS監測麻醉藥物作用。選取18位行擇期根治性前列腺切除術的病人。術前於腰椎間隙放置硬膜外導管，並按生產商的推薦位置放置BIS(version XP; Aspect Medical Systems,Natick, MA)及Narcotrend的電極。每5s記錄一次Narcotrend指數、BIS值、丙泊芬的血漿濃度及效應室濃度。以芬太尼及丙泊芬誘導，氣管插管後硬膜外予0.5%布比卡因15ml，45min後丙泊芬劑量依次增加、減少2次。在此種劑量調整中，丙泊芬效應室濃度在2.0 ± 0.4 µg/mL (最低)到 6.3 ± 1.3 µg/mL (最高)之間波動。用Narcotrend指數及BIS來預測丙泊芬效應室濃度（以P_K表示），兩者分別為0.88±0.03, 0.85±0.04。用Narcotrend指數及BIS監測藥物作用，平均k_e0分別為0.20±0.05 min^-1（Narcotrend指數）、0.16±0.07 min^-1（BIS）.在丙泊芬的波動範圍內，Narcotrend指數及BIS均能檢測到EEG的動態變化。

（周曉敏譯薛張綱校）

The Narcotrend monitor (MonitorTechnik, Bad Bramstedt, Germany)performs an automatic analysis of the electroencephalogram (EEG)during anesthesia based on a visual assessment of the raw EEG.Its newest software version 4.0 includes a dimensionless indexthat, similar to the bispectral index (BIS), ranges from 100(awake) to 0. We compared the performance of Narcotrend indexand BIS as EEG measures of anesthetic drug effect during propofolanesthesia. Eighteen adult patients scheduled for radical prostatectomywere investigated. An epidural catheter was placed in the lumbarspace and electrodes for BIS (version XP; Aspect Medical Systems,Natick, MA) and Narcotrend were positioned as recommended bythe manufacturers. Narcotrend index, BIS values, and propofolplasma and effect site concentrations as parallelly simulatedby Rugloop software (Department of Anesthesia, Ghent University,Belgium) were automatically recorded in intervals of 5 s. Inductionof anesthesia consisted of a fentanyl bolus and a propofol infusion.After endotracheal intubation, patients received 15 mL bupivacaine0.5% epidurally, and 45 min later propofol dosages were subsequentlyincreased and decreased twice. Simulated propofol effect siteconcentrations ranged from 2.0 ± 0.4 µg/mL (smallest)to 6.3 ± 1.3 µg/mL (largest) during these subsequentincreases and decreases of propofol. In terms of predictionprobability (P_K) the performance of the Narcotrend index (P_K= 0.88 ± 0.03) to predict propofol effect site concentrationswas comparable to the BIS (P_K = 0.85 ± 0.04). Using therespective EEG index as a measure of drug effect the mean k_e0was calculated as 0.20 ± 0.05 min^-1 for Narcotrend indexand 0.16 ± 0.07 min^-1 for BIS. In the observed propofolconcentration range Narcotrend index detected differences inEEG dynamics as well as BIS.

惡性骨腫瘤切除術病人中應用Dextromethorphan聯合硬膜外PCA較聯合靜脈PCA提供更好的鎮痛效果——一項隨機、雙盲、安慰劑對照研究

Avi A. Weinbroum, MD^*,, Benjamin Bender, MD, Alexander Nirkin, MD, Shoshana Chazan, RN, Isaac Meller, MD, and Yehuda Kollender, MD

*Postanesthesia Care Unit, the Acute Pain Service, and the National Orthopedic Oncology Unit, Tel Aviv Sourasky Medical Center and the Sackler Faculty Medicine, Tel Aviv University, Tel Aviv, Israel

Anesth Analg 2004 98: 714-722.

惡性骨腫瘤外科術後疼痛劇烈，需用大劑量的麻醉藥。Dextromethorphan（DM），N-甲基D-天冬氨酸受體拮抗劑，已被證明具有強大的鎮痛效果。惡性骨腫瘤病人在標準全麻複合硬膜外麻醉下（應用或不用DM）外科手術後，我們對其應用硬膜外PCA(PCEA)或靜脈PCA(IV-PCA)來評估其作用。隨機召集120位元病人，術後應用PCEA(羅派卡因3.2mg＋芬太尼8ug/單劑)或IV-PCA(嗎啡mg/單劑)，均在主觀視覺疼痛評分>=4時開始應用直至術後96h。每組中各取30位病人予安慰劑或DM 90mg口服（術前應用直至術後2天）作為雙盲對照。疼痛劇烈時予Diclofenac75mg IM作為補救。應用DM的病人PCA使用及疼痛評分較同組安慰劑對照病人減少50％，特別是術後2天內（P<0.01）。PCEA組的每小時及總疼痛強度均較IV-PCA組減小50％(P<0.01)。PCA-DM病人的Diclofenac用量較同組安慰劑對照病人減少42％(P<0.01)。PCEA-DM組7人、IV-PCA-DM組11人報告有副作用，而PCEA-安慰劑組及IV-PCA-安慰劑組共44人報告有副作用(P<0.01)。應用兩種不同鎮痛技術的病人最早下床活動時間相近，但應用DM的病人較安慰劑組下床時間短(1.5+-0.8 VS 2.1+-1.1d，P=0.02)。因此，DM能有效地控制疼痛並減少麻醉性藥物用量，此種增強作用在PCEA組較IV-PCA組更明顯。此外應用DM的病人下床活動時間較安慰劑應用者早。

（周曉敏譯薛張綱校）

Pain after bone malignancy surgery is intense and requires largeamounts of analgesics. The augmented antinociceptive effectsof dextromethorphan (DM), a N-methyl-D-aspartate receptor antagonist,were demonstrated previously. We assessed the use of postoperativepatient-controlled epidural analgesia (PCEA) or IV patient-controlledanalgesia (PCA) in patients undergoing surgery for bone malignancyunder standardized combined general and epidural anesthesiawith or without DM. Patients (n = 120) were randomly allocatedto receive PCEA (ropivacaine 3.2 mg plus fentanyl 8 µg/dose)or IV-PCA (morphine 2 mg/dose) postoperatively, starting atsubjective visual analog scale pain intensity 4of 10 for up to 96 h. Placebo or DM 90 mg orally (30 patients/group/set)was given in a double-blinded manner before surgery and for2 days afterwards. Diclofenac 75 mg IM was available as a rescuedrug. DM patients used PCA and rated their pain >50% lessthan their placebo counterparts in each set, especially duringthe first 2 postoperative days (P < 0.01). Hourly and overallmaximal pain intensity among PCEA patients was 50% less thanin the IV-PCA set (P < 0.01). Diclofenac was used 42% less(P < 0.01) by the PCA-DM patients compared with their placebocounterparts. Seven PCEA-DM and 11 IV-PCA-DM individuals reportedhaving side effects compared with 44 in the PCEA-placebo andthe IV-PCA-placebo groups (P < 0.01). Time to first ambulationwas similar with both analgesia techniques but shorter amongthe DM-treated patients compared with the placebo recipients(1.5 ± 0.8 versus 2.1 ± 1.1 days, P = 0.02). Thus,DM afforded better pain control and reduced the demand for analgesics,augmented the PCEA effect versus IV-PCA, and was associatedwith minimal untoward effects in each analgesia set. DM patientsambulated earlier than placebo recipients.

鞘內或口服可樂定預防術後酒精戒斷綜合征——一項隨機、雙盲對照研究

Intrathecal and Oral Clonidine as Prophylaxis for Postoperative Alcohol Withdrawal Syndrome: A Randomized Double-Blinded Study

I. Dobrydnjov, MD^*, K. Axelsson, MD PhD^*, L. Berggren, MD PhD^*, J. Samarütel, MD PhD, and B. Holmström, MD PhD^*

*Departments of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden; and Tartu University Hospital, Tartu, Estonia Anesth Analg 2004 98: 738-744

在此項研究中，我們評價了在具術後發生酒精戒斷綜合症(AWS)危險的脊麻病人中補充鞘內應用或口服可樂定的效果。我們假定可樂定對術後AWS有預防作用。45位酒精依賴病人(乙醇攝入>60g/d)，行擇期經尿道前列腺切除術(TURP)，隨機雙盲分為3組。所有病人予利多卡因100mg高比重液蛛網膜下腔注射。地西泮組(DiazG)予術前地西泮10mg口服，鞘內可樂定組(Clon^i/tG)予口服安慰劑並鞘內應用可樂定150ug，口服可樂定組(Clon^p/oG)予可樂定150ug口服。按酒精戒斷臨床評估委員會制定的評分標準診斷AWS病人。DiazG組12位病人出現戒斷症狀，而Clon^i/tG組2位、Clon^p/oG組1位病人出現症狀。按酒精戒斷臨床評估委員會制定的評分標準進行評分，DiazG組平均12分而可樂定組平均1分。DiazG組有2位病人出現嚴重譫妄。Clon^p/oG組病人脊麻後6－12h平均動脈壓輕度下降(P<0.05), DiazG組病人術後24－72h出現高動力性迴圈反應。總之，術前鞘內應用或口服可樂定150ug可預防酒精依賴病人發生嚴重術後AWS。

（周曉敏譯薛張綱校）

　In this study, we evaluated the effect of intrathecal and oralclonidine as supplements to spinal anesthesia with lidocainein patients at risk of postoperative alcohol withdrawal syndrome(AWS). We hypothesized that clonidine would have a prophylacticeffect on postoperative AWS. Forty-five alcohol-dependent patients(daily ethanol intake >60 g) scheduled for transurethralresection of the prostate were double-blindly randomized intothree groups. All patients received hyperbaric lidocaine 100mg intrathecally. The diazepam group (DiazG) was premedicatedwith diazepam 10 mg orally; the intrathecal clonidine group(Clon^i/tG) received a placebo (saline) tablet and clonidine150 µg intrathecally; and the oral clonidine group (Clon^p/oG)received clonidine 150 µg orally. For patients diagnosedwith AWS, the Clinical Institute Withdrawal Assessment for Alcohol,revised scale, was used. Twelve patients in the DiazG had symptomsof AWS, compared with two in the Clon^i/tG and one in the Clon^p/oG.The median Clinical Institute Withdrawal Assessment for Alcohol,revised scale, score was 12 in the DiazG versus 1 in the clonidine-treatedgroups. Two patients in the DiazG had severe delirium. Patientsreceiving oral clonidine had a slightly decreased mean arterialblood pressure 6–12 h after spinal anesthesia (P <0.05); patients in the DiazG had a hyperdynamic circulatoryreaction 24–72 h after surgery. In conclusion, preoperativeclonidine 150 µg, intrathecally or orally, prevented significantpostoperative AWS in ethanol-dependent patients.

Anesth Analg 2004 98: 738-744

異氟醚對局灶性腦缺血大鼠神經元凋亡的影響

Effect of isoflurane on neuronal apoptosis in rats subjected to focal cerebral ischemia.

Kawaguchi M, Drummond JC, Cole DJ, Kelly PJ, Spurlock MP, Patel PM.

Department of Anesthesiology, VA Medical Center and University of California, San Diego, California, USA.

Anesth Analg 2004 98： 798-805

雖然異氟醚可以減少短暫缺血後恢復期的缺血性神經元損傷，但是這一腦保護效力並非是持續不變的。神經元的凋亡可歸因於缺血後梗塞面積的逐步擴大。這提示儘管異氟醚可減少早期神經元的死亡，但可能無法抑制缺血引起的神經元凋亡。我們研究了異氟醚對局灶性缺血大鼠的標記細胞凋亡的影響。使用異氟醚麻醉Wistar-Kyoto大鼠並隨機分為清醒組(n = 40)和異氟醚組(n = 40)，兩組大鼠均通過結紮大腦中動脈70分鐘來形成局灶性缺血。實驗過程中頭部溫度控制在37+/- 0.2℃。在清醒組異氟醚停止使用，大鼠可蘇醒;在異氟醚組，異氟醚麻醉維持在1.5 MAC。大鼠在再灌注後第7小時、第1、第4或第7天處死（n=10/組/時點）。腦梗塞面積通過蘇紅染色切片的圖像分析來進行計算。在三個相鄰切片中，通過TUNEL染色和免疫染色法證實了凋亡細胞中有活性的caspase-9和caspase-3。再灌注後7小時、1天和4天異氟醚組的梗塞面積小於清醒組(P < 0.05)，然而再灌注後7天兩組並無差別。缺血1天後清醒組的凋亡細胞(TUNEL, caspase-3, 和 caspase-9 陽性)數量明顯多於異氟醚組，經過4天或7天的恢復期，異氟醚組的凋亡細胞多於清醒組。7天後，caspase-3 和 -9陽性的神經元數量在異氟醚組中較多(P < 0.05)。這些資料表明異氟醚是延遲而不是阻止了缺血導致的腦梗塞的發展。異氟醚減少了缺血後早期的凋亡的發展，但是並沒有阻止缺血後恢復後期的凋亡的發展。結論：我們研究了異氟醚對局灶性腦缺血大鼠的神經元凋亡的影響。在異氟醚麻醉的大鼠，缺血引起的凋亡發生於缺血後恢復的晚期階段，異氟醚並不抑制缺血後的神經元凋亡。

（陸旭偉譯薛張綱校）

Although isoflurane can reduce ischemic neuronal injury after short postischemic recovery intervals, this neuroprotective efficacy is not sustained. Neuronal apoptosis can contribute to the gradual increase in infarct size after ischemia. This suggests that isoflurane, although capable of reducing early neuronal death, may not inhibit ischemia-induced apoptosis. We investigated the effects of isoflurane on markers of apoptosis in rats subjected to focal ischemia. Fasted Wistar-Kyoto rats were anesthetized with isoflurane and randomly allocated to awake (n = 40) or isoflurane (n = 40) groups. Animals in both groups were subjected to focal ischemia by filament occlusion of the middle cerebral artery for 70 min. Pericranial temperature was servo-controlled at 37 degrees C +/- 0.2 degrees C throughout the experiment. In the awake group, isoflurane was discontinued and the animals were allowed to awaken. In the isoflurane group, isoflurane anesthesia was maintained at 1.5 MAC (minimum alveolar anesthetic concentration). Animals were killed 7 h, 1 day, 4 days, or 7 days after reperfusion (n = 10/group/time point). The area of cerebral infarction was measured by image analysis in a hematoxylin and eosin stained section. In three adjacent sections, apoptotic neurons were identified by TUNEL staining and immunostaining for active caspase-9 and caspase-3. Infarct size was smaller in the isoflurane group than the awake group 7 h, 1 day, and 4 days after reperfusion (P < 0.05). However, this difference was absent 7 days after reperfusion. The number of apoptotic (TUNEL, caspase-3, and caspase-9 positive) cells 1 day after ischemia was significantly more in the awake versus isoflurane group. After a recovery period of 4 or 7 days, the number of apoptotic cells in the isoflurane group was more than in the awake group. After 7 days, the number of caspase-3 and -9 positive neurons was more in the isoflurane group (P < 0.05). The data indicate that isoflurane delays but does not prevent the development of cerebral infarction caused by ischemia. Isoflurane reduced the development of apoptosis early after ischemia but did not prevent it at later stages of postischemic recovery. IMPLICATIONS: The effect of isoflurane on neuronal apoptosis was investigated in rats subjected to focal cerebral ischemia. In isoflurane-anesthetized animals, ischemia-induced apoptosis occurred during the later stages of postischemic recovery. Isoflurane did not inhibit postischemic neuronal apoptosis.

持續性骶周和坐骨神經阻滯：一項X線片研究

Continuous parasacral sciatic block: a radiographic study.

Gaertner E, Lascurain P, Venet C, Maschino X, Zamfir A, Lupescu R, Hadzic A.

*Service d’Anesthésie Réanimation Chirurgicale Hôpital de Hautepierre, Strasbourg, France; Service d’Anesthésie, Clinique des Eaux Claires, Grenoble, France; and Department of Anesthesiology, St. Luke’s-Roosevelt Hospital, New York, New York

Anesth Analg 2004 98: 831-834.

完全性的骶叢麻醉導致了骶周和坐骨神經阻滯。在這項研究中，我們觀察了經骶管注入的局麻藥的擴散的決定因素，骶管注入點的解剖位置和阻滯的範圍及強度。我們記錄了87名主要行下肢手術的病人，置管後注入8 mL的不透射線的對比染料，使用X線片分析注入液的散佈情況，同時進行感覺和運動的分析。注入液的X線片分析顯示幾乎所有的導管(86 根導管, 占99%)都在正確的解剖位置。局麻藥注入的平均容量為21 +/- 3 mL。所有病人的骶叢的全部三個主要組成部分（脛神經、腓總神經和股後皮神經）都達到了感覺阻滯。我們得出結論：骶叢的全部三個主要組成部分的成功阻滯導致骶周和坐骨神經阻滯，它有發生併發症的微小風險。對比性X線片可用於證實導管的位置。結論：骶叢的全部三個主要組成部分（脛神經、腓總神經和股後皮神經）的成功阻滯導致骶周和坐骨神經阻滯。對比性X線片可用於證實導管的正確位置。

（陸旭偉譯薛張綱校）

Parasacral sciatic blockade results in anesthesia of the entire sacral plexus. In this study we sought to determine the spread of the local anesthetic injected through a parasacral catheter, the anatomical location of the inserted catheters, and the extent and reliability of the blockade. In this study, 87 consecutive patients undergoing major lower limb surgery were enrolled. After placement of the catheter and injection of 8 mL of radio-opaque contrast dye, radiographic images were evaluated for dispersion of the injectate. Sensory and motor evaluations were also performed. Radiographic analysis of the injectates revealed that nearly all catheters (86 catheters, 99%) were in the correct anatomical position. The mean volume of local anesthetic injection was 21 +/- 3 mL. All patients developed a full sensory block of all three major components of the sciatic plexus (tibial, common peroneal, and posterior cutaneous nerve of the thigh). We conclude that the parasacral sciatic block results in frequent success of blockade of all three major components of the sciatic plexus and it has a small risk of complications. Contrast radiography can be used to document the catheter placement.

短期硬膜外阻滯對間質性膀胱炎的尿液P物質水平的影響

The effect of short-term epidural local anesthetic blockade on urinary levels of substance P in interstitial cystitis.

Sukiennik A, Carr DB, Bonney I, Marchand JE, Wurm H, Sant GR.

Departments of Anesthesia and Urology, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA.

Anesth Analg 2004 98: 846-850.

我們研究了硬膜外阻滯對五個突發性疼痛的間質性膀胱炎病人的尿液P物質水平的影響。硬膜外首先使用0.25%的布比卡因，然後用0.05%的布比卡因維持，收集24小時的尿液，使用放射免疫法測量P物質含量。在硬膜外注藥開始後，所有的病人尿液中P物質水平先升高然後下降。所有的病人主述疼痛程度減輕。我們考慮在3天的硬膜外給藥期間膀胱感覺神經末梢的P物質的急性釋放和損耗導致尿液肽水平的短暫升高和疼痛強度的減輕。結論：在5個使用硬膜外給藥達到鎮痛的急性發作的間質性膀胱炎病人中，尿液中的P物質水平先升高然後下降。

（陸旭偉譯薛張綱校）

We investigated the effect of epidural local anesthetic blockade on urinary substance P levels in five patients suffering from painful flare-ups of interstitial cystitis. Urine was collected in 24-h intervals commencing at the onset of an epidural bolus of 0.25% bupivacaine followed by maintenance epidural infusions of 0.05% bupivacaine. Substance P was measured by radioimmunoassay. After initiation of the epidural infusion, urinary substance P levels increased and then declined in all patients. All patients reported a decrease in pain intensity. We hypothesize that acute release, followed by depletion, of substance P from bladder sensory nerve endings accounts for the transient increase of peptide levels in urine and may contribute to the decrease in pain intensity during a 3-day epidural infusion.