Anesthesia & Analgesia

July 2004

Table of Content

CARDIOVASCULAR ANESTHESIA:

比較心臟手術後輸注異體紅細胞或100%純氧通氣對全身氧傳輸和骨骼肌氧分壓的影響

黃施偉 譯　　　 李士通

The Influence of Allogeneic Red Blood Cell Transfusion Compared with 100% Oxygen Ventilation on Systemic Oxygen Transport and Skeletal Muscle Oxygen Tension After Cardiac Surgery
Stefan Suttner, Swen N. Piper, Bernhard Kumle, Katrin Lang, Kerstin D. Röhm, Frank Isgro, and Joachim Boldt

Anesth Analg 2004 99: 2-11

利用術中經食管超聲確診肺栓塞

葛寧花 譯

Utility of Intraoperative Transesophageal Echocardiography for Diagnosis of Pulmonary Embolism

Peter Rosenberger, Stanton K. Shernan, Simon C. Body, and Holger K. Eltzschig

Anesth Analg 2004 99: 12-16.

清洗後的血小板活性

殷文淵　譯　陳傑　校

Platelet Activity in Washed Platelet Concentrates

Helge Schoenfeld, Manfred Muhm, Ulrich Doepfmer, Aristomenis Exadaktylos, and Hartmut Radtke

Anesth Analg 2004 99: 17-20.

過氧亞硝基陰離子減低人類血漿止血效應的體外實驗

王立中 譯　　　 李士通 校

Peroxynitrite Decreases Hemostasis in Human Plasma In Vitro
Vance G. Nielsen, John P. Crow, Ashish Mogal, Fen Zhou, and Dale A. Parks

Anesth Analg 2004 99: 21-26.

PEDIATRIC ANESTHESIA:

比較硬膜外布比卡因、左旋布比卡因和羅呱卡因對術後鎮痛和運動阻滯的作用

葛寧花 譯

A Comparison of Epidural Bupivacaine, Levobupivacaine, and Ropivacaine on Postoperative Analgesia and Motor Blockade
Pasquale De Negri, Giorgio Ivani, Tiziana Tirri, Pasqualina Modano, Cesare Reato, Staffan Eksborg, and Per-Arne Lonnqvist

Anesth Analg 2004 99: 45-48.

丙泊酚導致新生大鼠中樞性呼吸抑制的神經機制

殷文淵　譯　陳傑　校

A Neuronal Mechanism of Propofol-Induced Central Respiratory Depression in Newborn Rats

Masanori Kashiwagi, Yasumasa Okada, Shun-ichi Kuwana, Shigeki Sakuraba, Ryoichi Ochiai, and Junzo Takeda

Anesth Analg 2004 99: 49-55

兒童雙側呼吸音聽診不能排除支氣管內插管

軒　　　 泓 譯　　　 李士通 校

Auscultation of Bilateral Breath Sounds Does Not Rule Out Endobronchial Intubation in Children

Susan T. Verghese, Raafat S. Hannallah, Michael C. Slack, Russell R. Cross, and Kantilal M. Patel

Anesth Analg 2004 99: 56-58.

AMBULATORY ANESTHESIA:

評估住院醫生麻醉前諮詢能力的方法的發展及應用

陸續偉 譯 葛寧花 校

The Development and Application of an Instrument for Assessing Resident Competence During Preanesthesia Consultation
Getúlio Rodrigues de Oliveira Filho and Leonardo Schonhorst

Anesth Analg 2004 99: 62-69

門診手術後夜間動脈去氧飽和和間歇性氣道阻塞

殷文淵　譯　陳傑　校

Nocturnal Arterial Oxygen Desaturation and Episodic Airway Obstruction After Ambulatory Surgery

T. Andrew Bowdle

Anesth Analg 2004 99: 70-76.

ANESTHETIC PHARMACOLOGY:

隨機比較綜合處理策略和複合應用止吐劑預防術後噁心嘔吐

張俊傑 譯　　　 李士通 校

A Randomized Comparison of a Multimodal Management Strategy Versus Combination Antiemetics for the Prevention of Postoperative Nausea and Vomiting

Ashraf S. Habib, William D. White, Steve Eubanks, Theodore N. Pappas, and Tong J. Gan

Anesth Analg 2004 99: 77-81.

抑制脊髓蛋白激酶C-ε或 同工酶不影響鼠吸入氟烷最低肺泡濃度

葛寧花 譯

Inhibition of Spinal Protein Kinase C- or - Isozymes Does Not Affect Halothane Minimum Alveolar Anesthetic Concentration in Rats
Jennifer A. Shumilla, Sarah M. Sweitzer, Edmond I Eger, II, Michael J. Laster, and Joan J. Kendig

Anesth Analg 2004 99: 82-84.

GABA_A受體不介導異氟醚所致的制動作用

顧漪聞　譯　陳傑　校

Gamma-Aminobutyric Acid_A Receptors Do Not Mediate the Immobility Produced by Isoflurane

Yi Zhang, James M. Sonner, Edmond I Eger, II, Caroline R. Stabernack, Michael J. Laster, Douglas E. Raines, and R. Adron Harris

Anesth Analg 2004 99: 85-90.

異丙酚的非麻醉性類似物2,6－雙叔丁基酚（2,6 Di-tert-butylphenol）調整a₁ß甘氨酸受體功能的方式有別於異丙酚

裘毅敏 譯　　　 李士通 校

2,6 Di-tert-butylphenol, a Nonanesthetic Propofol Analog, Modulates ₁ß Glycine Receptor Function in a Manner Distinct from Propofol

Jörg Ahrens, Gertrud Haeseler, Martin Leuwer, Bahram Mohammadi, Klaus Krampfl, Reinhard Dengler, and Johannes Bufler

Anesth Analg 2004 99: 91-96.

布比卡因抑制大鼠胸主動脈血栓烷A₂誘導的血管收縮

鍾鳴 譯 葛寧花 校

Bupivacaine Inhibits Thromboxane A₂-Induced Vasoconstriction in Rat Thoracic Aorta

Klaus Hahnenkamp, Joke Nollet, Danja Strümper, Tobias Halene, Pia Rathman, Eike Mortier, Hugo Van Aken, Joerg Knapp, Marcel E. Durieux, and Christian W. Hoenemann

Anesth Analg 2004 99: 97-102.

惡性高熱易感者的選擇性微創診斷試驗中四氯甲酚不能檢測惡性高熱可疑細胞

蘇殿三　譯　陳傑　校

4-Chloro-m-Cresol Cannot Detect Malignant Hyperthermia Equivocal Cells in an Alternative Minimally Invasive Diagnostic Test of Malignant Hyperthermia Susceptibility
Lukas G. Weigl, Carmen Ludwig-Papst, and Hans G. Kress

Anesth Analg 2004 99: 103-107.

志願者靜注嗎啡、可待因和曲馬多對瞳孔的影響

沈　　　 浩 譯　　 李士通 校

The Pupillary Effects of Intravenous Morphine, Codeine, and Tramadol in Volunteers

Roger D. Knaggs, Isla M. Crighton, Timothy F. Cobby, Anthony J. P. Fletcher, and Gregory J. Hobbs

Anesth Analg 2004 99: 108-112.

犬異丙酚蘇醒期引起膈肌收縮減少的研究

方芳 譯 葛寧花 校

The Recovery Profile of Reduced Diaphragmatic Contractility Induced by Propofol in Dogs

Yoshitaka Fujii, Aki Uemura, and Hidenori Toyooka

Anesth Analg 2004 99: 113-116.

預注布托非諾對丙泊酚注射疼痛的效果

齊波　譯　陳傑　校

Pain During Injection of Propofol: The Effect of Prior Administration of Butorphanol

Anil Agarwal, Mehdi Raza, Sanjay Dhiraaj, Ravinder Pandey, Devendra Gupta, Chandra Kant Pandey, Prabhat K Singh, and Uttam Singh

Anesth Analg 2004 99: 117-119

TECHNOLOGY, COMPUTING, AND SIMULATION:

用血栓彈性描記圖研究XIII因數對凝血過程和血塊強度的作用

趙雪蓮　 譯　　　 李士通 校

The Impact of Factor XIII on Coagulation Kinetics and Clot Strength Determined by Thrombelastography

Vance G. Nielsen, William Q. Gurley, Jr, and Thomas M. Burch

Anesth Analg 2004 99: 120-123.

老年病人鞘內注射可樂定行術後鎮痛：比重對血流動力學和鎮痛效果的影響

忻紀華　譯　陳傑　校

Intrathecal Clonidine for Postoperative Analgesia in Elderly Patients: The Influence of Baricity on Hemodynamic and Analgesic Effects
Amir Baker, Walter Klimscha, James C. Eisenach, Xin-Hui Li, Eckart Wildling, Wolfgang A. Menth-Chiari, and Astrid I. Chiari

Anesth Analg 2004 99: 128-134.

幼鼠術前坐骨神經阻滯更多地降低機械性痛覺超敏：預先鎮痛是否隨發育不同而調整？

馬皓琳　 譯　　　 李士通　 校

Preoperative Sciatic Nerve Block Decreases Mechanical Allodynia More in Young Rats: Is Preemptive Analgesia Developmentally Modulated?

Douglas G. Ririe, David Barclay, Heather Prout, Chuanyo Tong, Joseph R. Tobin, and James C. Eisenach

Anesth Analg 2004 99: 140-145.

大鼠關節腔內預注氯胺酮或美金剛有助於減少關節痛及脊髓 c- Fos 表達

周潔　譯　陳傑　校

Intraarticular Pretreatment with Ketamine and Memantine Could Prevent Arthritic Pain: Relevance to the Decrease of Spinal c-Fos Expression in Rats
Guo Hua Zhang, Sun Seek Min, Kyu Sang Lee, Seung Keun Back, Seong Jun Yoon, Young Wook Yoon, Yang In Kim, Heung Sik Na, Seung Kil Hong, and Hee Chul Han

Anesth Analg 2004 99: 152-158.

CRITICAL CARE AND TRAUMA:

單腔和多腔中心靜脈導管置管的細菌定植和血液感染：一項定量的系統評估

彭中美 譯 李士通 校

Colonization and Bloodstream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review

Mathias Zürcher, Martin R. Tramèr, and Bernhard Walder

Anesth Analg 2004 99: 177-182

經胸部超聲引導腋靜脈置管：標準鎖骨下靜脈置管的另一選擇

葛寧花 譯

Transpectoral Ultrasound-Guided Catheterization of the Axillary Vein: An Alternative to Standard Catheterization of the Subclavian Vein
NavParkash S. Sandhu

Anesth Analg 2004 99: 183-187.

二十個月常規使用新的帶可控旋轉擴張器的經皮氣管造瘻套管

張　 曦　　 譯　　　 李士通　 校

Twenty Months’ Routine Use of a New Percutaneous Tracheostomy Set Using Controlled Rotating Dilation

Neel Sengupta, Keng Leong Ang, Doraiswamy Prakash, Vivien Ng, and Shane J. George

Anesth Analg 2004 99: 188-192.

較小潮氣量通氣：隨機對照定量系統回顧

Ventilation with Smaller Tidal Volumes: A Quantitative Systematic Review of Randomized Controlled Trials

Nicola Petrucci and Walter Iacovelli

Anesth Analg 2004 99: 193-200.

在伴有嚴重多器官功能障礙綜合征的晚期血管擴張性休克病人中應用精氨酸抗利尿激素會影響凝血系統嗎?

朱 慧譯 李士通校

Does Arginine Vasopressin Influence the Coagulation System in Advanced Vasodilatory Shock with Severe Multiorgan Dysfunction Syndrome?

Martin W. Dünser, Dietmar R. Fries, Wolfgang Schobersberger, Hanno Ulmer, Volker Wenzel, Barbara Friesenecker, Walter R. Hasibeder, and Andreas J. Mayr

Anesth Analg 2004 99: 201-206.

增加氧和二氧化碳均能增加皮下和腸粘膜的氧合。

葛寧花 譯

Supplemental Oxygen and Carbon Dioxide Each Increase Subcutaneous and Intestinal Intramural Oxygenation

Jebadurai Ratnaraj, Barbara Kabon, Michael R. Talcott, Daniel I. Sessler, and Andrea Kurz

Anesth Analg 2004 99: 207-211

　

NEUROSURGICAL ANESTHESIA:

動脈-頸內靜脈血氧含量差與顱腦外傷病人預後

周雅春 譯　 李士通 校

Arterio-Jugular Difference of Oxygen Content and Outcome After Head Injury

Nino Stocchetti, Katia Canavesi, Sandra Magnoni, Valerio Valeriani, Valeria Conte, Sandra Rossi, Luca Longhi, Elisa Roncati Zanier, and Angelo Colombo

Anesth Analg 2004 99: 230-234

阿片受體激動劑SNC80對脊髓缺血後大鼠後肢運動功能和神經元損傷的影響

王柯 譯 葛寧花 校

The Effects of the -Opioid Agonist SNC80 on Hind-Limb Motor Function and Neuronal Injury After Spinal Cord Ischemia in Rats

Toshinori Horiuchi, Masahiko Kawaguchi, Takanori Sakamoto, Naoko Kurita, Satoki Inoue, Mitsutoshi Nakamura, Noboru Konishi, and Hitoshi Furuya

Anesth Analg 2004 99: 235-240

OBSTETRIC ANESTHESIA:

連硬下剖腹産時下肢加壓包紮預防低血壓而不能預防低溫或寒戰

　陳潔 譯　　 陳傑 校

Lower Limb Wrapping Prevents Hypotension, but Not Hypothermia or Shivering, After the Introduction of Epidural Anesthesia for Cesarean Delivery
Hsiao Lun Sun, Qing Dong Ling, Wei Zen Sun, Rick Sai-Chuen Wu, Tzong Jeng Wu, Shih Chieh Wang, and Chih Cheng Chien

Anesth Analg 2004 99: 241-244.

REGIONAL ANESTHESIA:

判斷進入硬脊膜外腔：分別用空氣、利多卡因或複合空氣和利多卡因阻力消失法

陳瑋譯 李士通 校

Identification of the Epidural Space: Loss of Resistance with Air, Lidocaine, or the Combination of Air and Lidocaine

Samuel Evron, Daniel Sessler, Oscar Sadan, Mona Boaz, Marek Glezerman, and Tiberiu Ezri

Anesth Analg 2004 99: 245-250.

全膝置換術後鎮痛：閉孔神經阻滯加股神經3合1神經阻滯

葛寧花 譯

Postoperative Analgesia After Total Knee Replacement: The Effect of an Obturator Nerve Block Added to the Femoral 3-in-1 Nerve Block

D. Macalou, S. Trueck, P. Meuret, M. Heck, F. Vial, S. Ouologuem, X. Capdevila, J. -M. Virion, and H. Bouaziz

Anesth Analg 2004 99: 251-254.

GENERAL ARTICLES:

全髖或全膝關節成形術病人限制用重組人血紅細胞生成素和自體血回輸是有效對策

肖潔　譯　陳傑　校

A Restrictive Use of Both Autologous Donation and Recombinant Human Erythropoietin Is an Efficient Policy for Primary Total Hip or Knee Arthroplasty
Claude Couvret, Marc Laffon, Annick Baud, Valérie Payen, Philippe Burdin, and Jacques Fusciardi

Anesth Analg 2004 99: 262-271.

新型喉周通氣道(CobraPLA^TM)與喉罩通氣道(LMA^TM)相比同樣有效，且提供更好的氣道密閉性

周志堅 譯　 李士通 校)

The New Perilaryngeal Airway (CobraPLA^TM) Is as Efficient as the Laryngeal Mask Airway (LMA^TM) but Provides Better Airway Sealing Pressures
Ozan Akça, Anupama Wadhwa, Papiya Sengupta, Jaleel Durrani, Keith Hanni, Mary Wenke, Yüksel Yücel, Rainer Lenhardt, Anthony G. Doufas, and Daniel I. Sessler

Anesth Analg 2004 99: 272-278

光導輔助插管在側臥位患者中的應用

葛寧花 譯

Lightwand-Assisted Intubation of Patients in the Lateral Decubitus Position
Kuang-I Cheng, Koung-Shing Chu, Siu-Wah Chau, Soo-Lee Ying, Hong-Te Hsu, Yin-Lung Chang, and Chao-Shun Tang

Anesth Analg 2004 99: 279-283.

輕度體溫增高可下調受體依賴的噬中性粒細胞功能

朱輝　譯　陳傑　校

Mild Hyperthermia Down-Regulates Receptor-Dependent Neutrophil Function

Dieter Fröhlich, Sigrid Wittmann, Gregor Rothe, Daniel I. Sessler, Peter Vogel, and Kai Taeger

Anesth Analg 2004 99: 284-292.

清洗後的血小板活性

Platelet Activity in Washed Platelet Concentrates

Helge Schoenfeld, MD^*,, Manfred Muhm, MD^*,, Ulrich Doepfmer, MD FRCA, Aristomenis Exadaktylos, MD^*, and Hartmut Radtke, MD

*Department of Anesthesiology, University Hospital of Bern, Inselspital, Switzerland, the Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Berlin, Germany, the Department of Anesthesiology and Intensive Care Medicine, Hospital of Oberpullendorf and Department of Cardiothoracic Anesthesia and Intensive Care Medicine, University of Vienna, Austria, and the Institute of Transfusion Medicine, University Hospital Charité Berlin, Germany

Anesth Analg 2004;99:17-20

輸注血小板濃縮液（PCs）後發生的威脅生命的過敏和非溶血性發熱輸血反應是一個很嚴重的臨床問題，這是由所接受的血漿成分過敏而引起的，例如免疫球蛋白A、細胞因數等。血小板減少病人可能是使用清洗過的血小板濃縮液的指征。可是，只有在生理刺激下血小板功能啟動才是有用的。作者測定了清洗前和清洗後的血小板自主和誘導啟動功能。11份連續採集的血液經部分成分清除的血小板濃縮液。在採集和去除白細胞後，PCs在15%右旋檸檬酸溶液中清洗。通過流式細胞計量儀測定自主和二磷酸腺苷誘導以及膠原質誘導的血小板啟動。此外，測定ADP和膠原誘導的聚集反應。結果：未經清洗的血小板16%自主啟動，清洗血小板濃縮液導致血小板自主啟動提高三倍（47.4%）。因爲清洗後會增加自主啟動，所以洗滌後血小板的誘導活性下降。因此，作者認爲應減少濃縮血小板清洗的使用頻率，使用清洗血小板的唯一指征是有嚴重的非溶血性輸血反應史的病人。

(殷文淵　譯　陳傑　校)

Life-threatening anaphylaxis or febrile nonhemolytic transfusion reactions after transfusion of platelet concentrates (PCs) is a serious clinical problem caused by the sensitizing of recipients to plasma components, such as immunoglobulin A, or by cytokines. There is a possible indication for washing of PCs in these thrombocytopenic patients. However, only platelets that show activation after physiological stimulation are useful. We determined the spontaneous and induced activation of platelets before and after washing. We investigated 11 consecutive single-donor-apheresis PCs. After production and leukocyte-depletion the PCs were washed in 15% acid-citrate-dextrose-solution. The spontaneous and the adenosine diphosphate (ADP)-induced, as well as collagen-induced activation, were determined by flow cytometry. Additionally, ADP- and collagen-induced aggregation were measured. Unwashed platelets (16.1%) were activated spontaneously. The washing of PCs led to a threefold increase of spontaneous activation of platelets (47.4%). Because of increased spontaneous activation after washing we could demonstrate cytometrically a loss of induced activation of washed platelets. Furthermore, washing resulted in an impaired ADP-induced aggregability of platelets. These results have led us to reduce the frequency of washing of PCs in our institution, where the only current indication for washing of PCs is in patients with a history of severe nonhemolytic transfusion reactions.

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丙泊酚導致新生大鼠中樞性呼吸抑制的神經機制

A Neuronal Mechanism of Propofol-Induced Central Respiratory Depression in Newborn Rats

Masanori Kashiwagi, MD^*, Yasumasa Okada, MD, Shun-ichi Kuwana, PhD, Shigeki Sakuraba, MD^*, Ryoichi Ochiai, MD^*, and Junzo Takeda, MD^*

*Department of Anesthesiology, School of Medicine, Keio University; Department of Physiology, Teikyo University School of Medicine, Tokyo; and Department of Medicine, Keio University Tsukigase Rehabilitation Center, Shizuoka-ken, Japan

Anesth Analg 2004;99:49-55

丙泊酚導致的中樞性呼吸抑制的神經機制至今仍不很明確。作者研究了γ-羥基丁酸(GABA_A)受體在丙泊酚導致的中樞性呼吸抑制中的作用。分離出1-4天幼鼠的腦幹和脊髓並保存在氧合人工腦脊液中備用。記錄來自C4脊神經前根的節律性吸氣衝動。使用一種打孔膜片鉗技術記錄位於延髓腹外側區神經元的活動。作者發現丙泊酚降低C4脊神經前根的節律性吸氣衝動頻率，並可以通過使用GABA_A拮抗劑，荷包牡丹堿而逆轉。丙泊酚會使吸氣前和呼氣神經元靜息膜電位超極化從而抑制動作電位的激發。相比較而言，丙泊酚對吸氣神經元靜息膜電位超極化和動作電位的激發影響較小。結果顯示丙泊酚的抑制作用至少部分通過拮抗GABA_A受體起作用。GABA_A受體介導的吸氣前神經元超極化可能是丙泊酚引起的新生幼鼠呼吸抑制的神經基礎。

(殷文淵　譯　陳傑　校)

The neural mechanisms of propofol-induced central respiratory depression remain poorly understood. In the present study, we studied these mechanisms and the involvement of -aminobutyric acid (GABA)_A receptors in propofol-induced central respiratory depression. The brainstem and the cervical spinal cord of 1- to 4-day-old rats were isolated, and preparations were maintained in vitro with oxygenated artificial cerebrospinal fluid. Rhythmic inspiratory burst activity was recorded from the C4 spinal ventral root. The activity of respiratory neurons in the ventrolateral medulla was recorded using a perforated patch-clamp technique. We found that bath-applied propofol decreased C4 inspiratory burst rate, which could be reversed by the administration of a GABA_A antagonist, bicuculline. Propofol caused resting membrane potentials to hyperpolarize and suppressed the firing of action potentials in preinspiratory and expiratory neurons. In contrast, propofol had little effect on resting membrane potentials and action potential firing in inspiratory neurons. Our findings suggest that the depressive effects of propofol are, at least in part, mediated by the agonistic action of propofol on GABA_A receptors. It is likely that the GABA_A receptor-mediated hyperpolarization of preinspiratory neurons serves as the neuronal basis of propofol-induced respiratory depression in the newborn rat.

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門診手術後夜間動脈去氧飽和和間歇性氣道阻塞

Nocturnal Arterial Oxygen Desaturation and Episodic Airway Obstruction After Ambulatory Surgery

T. Andrew Bowdle, MD PhD

Departments of Anesthesiology and Pharmaceutics, University of Washington, Seattle, Washington

Anesth Analg 2004;99:70-76

一些住院病人在重大手術後常有睡眠時呼吸不規則和動脈去氧飽和的經歷。作者研究了門診手術後是否也有相類似的事件發生。45名不限量使用麻醉藥的門診手術病人，連續記錄手術前和手術後回家後的第一、二個晚上病人的呼吸和氧飽和度。結果：9名病人呼吸干擾指數>10和/或至少一個晚上1%的記錄時間氧飽和度<90%。這9名病人年齡和體表指數均顯著大於均值，術後第一天夜間呼吸干擾指數均數和氧飽和度<90%時間百分比的均數顯著高於術前夜間。

(殷文淵　譯　陳傑　校)

Some patients experience disordered breathing during sleep and arterial oxygen desaturation after major inpatient surgery. We performed this study to determine whether similar events occur after ambulatory surgery. Forty-five ambulatory surgery patients received an unrestricted anesthetic. Continuous unattended nocturnal recordings of breathing pattern and oxygen saturation were made in the patients’ homes before surgery and during the first and second postoperative nights. Nine patients had a respiratory disturbance index >10 and/or >1% of recording time with oxygen saturation <90% on at least one study night. These nine patients had a significantly older median age and a significantly larger median body mass index. Their median respiratory disturbance index and median percentage of time with oxygen saturation <90% were significantly higher on the first postoperative night than on the preoperative night.

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GABA_A受體不介導異氟醚所致的制動作用

Gamma-Aminobutyric Acid_A Receptors Do Not Mediate the Immobility Produced by Isoflurane

Yi Zhang, MD^*, James M. Sonner, MD, Edmond I Eger, II, MD^*, Caroline R. Stabernack, MD^*, Michael J. Laster, DVM^*, Douglas E. Raines, MD, and R. Adron Harris, PhD

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, Harvard Medical School, Boston, Massachusetts, and the University of Texas, Austin, Texas

Anesth Analg 2004;99:85-90

許多吸入性麻醉藥可以增強抑制性神經遞質GABA作用，支援GABA_A受體介導吸入性麻醉藥物在對傷害刺激時所産生制動作用（例如：MAC是指在傷害性刺激時，50%的人可以達到沒有反應的最小肺泡濃度）。但是，只有很有限的證據支援GABA_A和MAC之間有關聯。因此，作者根據兩個研究結果來檢驗此受體和異氟醚的制動作用之間的關係：1）不同的麻醉藥物在增加GABA系統的受體表達上是不同的。例如：異氟醚是大量的增加;環丙烷是輕度增加；氙也是輕度增加。2）研究顯示：脊髓介導異氟醚的MAC。如果GABA_A受體介導異氟醚的MAC，那麽抑制脊髓GABA_A受體，就可以提高異氟醚的MAC，其提高的幅度要大於環丙烷和氙的 MAC的提高，而且在體外試驗中，MAC的提高與GABA_A受體的增強是成比例的。爲了驗證這一假設，作者做了以下試驗：異氟醚，環丙烷，氙分別麻醉小鼠，這些小鼠事先都已通過埋入的連續導管，在鞘內注射了人造的αCSF液（人造腦脊液），然後檢測三者的MAC。然後，再分別以含有印防己毒素（一種非競爭性的GABA受體阻滯劑）0.6或2.4mg/ml的αCSF液(以1μL/min的速度)注入小鼠，同時檢測其異氟醚，環丙烷，氙三者的MAC。結果發現：印防己毒素的濃度從0.6μg/min提高到2.4μg/min，異氟醚，環丙烷，氙三者的MAC並沒有相應的增加，說明此時在脊髓中已達到了對GABA_A受體的最大的阻滯。印防己毒素可以增加所有麻醉藥的MAC大約40%。說明GABA在脊髓的釋放影響了對麻醉藥的需求。但是，這種增加在不同的麻醉藥中是不同的，而且在體外試驗中，這些麻醉藥對GABA_A受體的增強作用並不相關。此結果支援了GABA_A受體並不能增強異氟醚的制動作用的假設。

(顧漪聞　譯　陳傑　校)

Many inhaled anesthetics enhance the effect of the inhibitory neurotransmitter gamma aminobutyric acid (GABA), supporting the view that the GABA_A receptor could mediate the capacity of inhaled anesthetics to produce immobility in the face of noxious stimulation (i.e., MAC, the minimum alveolar concentration required to suppress movement in response to a noxious stimulus in 50% of subjects). However, only limited in vivo data support the relevance of the GABA_A receptor to MAC. In the present study we used two findings to test for the relevance of this receptor to immobilization for isoflurane: 1) differences among anesthetics in their capacity to enhance the response of receptor expression systems to GABA: isoflurane (considerable enhancement), xenon (minimal enhancement), and cyclopropane (minimal enhancement); and 2) studies showing that the spinal cord mediates MAC for isoflurane. If GABA_A receptors mediate isoflurane MAC, then their blockade in the spinal cord should increase isoflurane MAC more than cyclopropane or xenon MAC and the MAC increase should be proportional to the in vitro enhancement of the GABA_A receptor. To test this thesis, isoflurane, cyclopropane, or xenon MAC was determined in rats during intrathecal infusion of artificial cerebrospinal fluid (aCSF) via chronically implanted catheters. Then MAC was redetermined during infusion of 1 µL/min aCSF containing either 0.6 or 2.4 mg/mL picrotoxin, which noncompetitively blocks GABA_A receptors. There was no consistent increase in MAC consequent to increasing the picrotoxin dose from 0.6 to 2.4 µg/min, which suggests that maximal blockade of GABA_A receptors in the spinal cord had been achieved. Picrotoxin infusion increased MAC approximately 40% with all anesthetics. This indicates that GABA release in the spinal cord influences anesthetic requirement. However, the increase did not consistently differ among anesthetics and did not correlate with in vitro enhancement of GABA_A receptors by these anesthetics. This supports the view that GABA_A receptors do not mediate immobilization for isoflurane.

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惡性高熱易感者的選擇性微創診斷試驗中四氯甲酚不能檢測惡性高熱可疑細胞

4-Chloro-m-Cresol Cannot Detect Malignant Hyperthermia Equivocal Cells in an Alternative Minimally Invasive Diagnostic Test of Malignant Hyperthermia Susceptibility

Lukas G. Weigl, PhD^*, Carmen Ludwig-Papst, PhD, and Hans G. Kress, MD PhD^*

Departments of *Anesthesiology and Intensive Care Medicine (B) and Surgery, Medical University Vienna, Vienna, Austria

Anesth Analg 2004;99:103-107

惡性高熱（MH）是一種遺傳性的骨骼肌病變，可以被麻醉藥物觸發。斯里蘭卡肉桂堿受體突變被認爲是MH的分子基礎。臨床上一般首先將患者的骨骼肌標本進行體外攣縮實驗，根據實驗結果分成MH易感患者（MHS）、正常人（MHN）和疑似患者（MHEH）。然後進一步應用促進鈣離子釋放的藥物四氯甲酚（4-CmC）和咖啡因進行刺激觀察鈣離子釋放情況，以期進一步評估肌管的敏感度。在本研究中，作者研究了是否可以通過4-CmC促進鈣離子釋放的作用對MHEH患者做出明確的診斷。以Fura2作爲染料，應用光度鏡檢測細胞內的鈣離子濃度。斯里蘭卡肉桂堿受體1基因含有大部分的MH基因突變。在一名MHS患者發現一種MH突變(Gly2434Arg)。咖啡因誘導的鈣離子釋放在MHS和MHN患者與體外攣縮實驗具有良好的相關性。MHS患者的細胞表現出對咖啡因的敏感性比4-CmC高。MHEH患者的細胞對於咖啡因和4-CmC的敏感性均較低。因此，用肌管，咖啡因可鑒別MHS和MHN細胞，但是咖啡因和4-CMC都不能鑒別MHEH細胞。

(蘇殿三　譯　陳傑　校)

Malignant hyperthermia (MH) is an inherited skeletal muscle disorder triggered by commonly used anesthetics. Mutated ryanodine receptors have been identified as molecular targets. The sensitivity of myotubes from individuals classified by the in vitro contracture test as MH susceptible (MHS), normal (MHN), and equivocal (MHEH) was assessed for the Ca²⁺-releasing activity of 4-chloro-m-cresol (4-CmC) and caffeine. In this study, we sought to determine whether 4-CmC can differentiate the MH status of an individual on the basis of the release of intracellular Ca²⁺, particularly in regard to MHEH diagnosis. Intracellular Ca²⁺ concentration was determined photometrically with Fura2. Regions of the ryanodine receptor 1 harboring most of the described MH mutations were sequenced from MHS and MHEH cells. One MH mutation (Gly2434Arg) was found in one MHS individual. Results of the caffeine-induced Ca²⁺ release in MHS and MHN cells correlated well with the in vitro contracture test results. MHS cells showed a higher sensitivity against caffeine and, to a lesser extent, against 4-CmC. Cells of MHEH individuals showed low sensitivities against both caffeine and 4-CmC, comparable to those of the MHN group. Therefore, with myotubes, caffeine was able to discriminate between MHS and MHN cells, but both caffeine and 4-CmC failed to detect MHEH cells.

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預注布托非諾對丙泊酚注射疼痛的效果

Pain During Injection of Propofol: The Effect of Prior Administration of Butorphanol

Anil Agarwal, MD, Mehdi Raza, MD, Sanjay Dhiraaj, MD, Ravinder Pandey, MD, Devendra Gupta, MD, Chandra Kant Pandey, MD, Prabhat K Singh, MD, and Uttam Singh, PhD

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

Anesth Analg 2004;99:117-119

靜脈注射丙泊酚可使28%－90%的病人感到疼痛或不適。目前，有許多方法用於減輕注射丙泊酚而引起的疼痛，但效果參差不齊。本實驗比較布托非諾和利多卡因預防丙泊酚注射疼痛的效果。選擇150名ASA　I－II 擇期手術的成年病人，並隨機分爲三組，每組50名病人。組I（NS）預注生理鹽水，組II預注2%利多卡因40mg，組III預注布托非諾2mg。預注藥物用生理鹽水稀釋至2ml，注射時間超過5秒。1分鐘後注射病人所需丙泊酚總量（2.5mg/Kg）的1/4，時間超過5秒。採用4分制疼痛評分法評估病人的疼痛：0＝無疼痛，1＝輕度疼痛，2＝中度疼痛，3＝嚴重疼痛。結果發現在對照組有39個（78%）病人在注射丙泊酚時感到疼痛；而利多卡因組和布托非諾組分別只有21個（42%）和10個（20%）病人感到疼痛（P＜0.05），布托非諾是最有效的。因此靜脈預先注射布托非諾2mg可減輕因注射丙泊酚而引起的疼痛。

(齊波　譯　陳傑　校)

Propofol causes pain or discomfort on injection in 28%–90% of patients. A number of techniques have been tried for minimizing propofol-induced pain with variable results. We compared the efficacy of butorphanol and lidocaine for prevention of propofol-induced pain. One-hundred-fifty ASA I–II adults, undergoing elective surgery were randomly assigned into 3 groups of 50 each. Group I (NS) received normal saline, Group II (L) received lidocaine 2% (40 mg), and Group III (B) received butorphanol 2 mg. All patients received pretreatment solutions made in 2 mL with normal saline administered over 5 s. One min after pretreatment patients received one-fourth of the total calculated dose of propofol (2.5 mg/kg) over 5 s. Assessment of pain with IV propofol was done by using a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain and 3 = severe pain at the time of propofol injection. In the control Group 39 (78%) patients had pain during propofol injection as compared to 21 (42%) and 10 (20%) in the lidocaine and butorphanol groups, respectively (P < 0.05). Butorphanol was the most effective. We therefore suggest the IV pretreatment with butorphanol 2 mg for attenuation of pain associated with propofol injection.

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老年病人鞘內注射可樂定行術後鎮痛：比重對血流動力學和鎮痛效果的影響

Intrathecal Clonidine for Postoperative Analgesia in Elderly Patients: The Influence of Baricity on Hemodynamic and Analgesic Effects

Amir Baker, MD^*, Walter Klimscha, MD^*, James C. Eisenach, MD, Xin-Hui Li, PhD, Eckart Wildling, MD^*, Wolfgang A. Menth-Chiari, MD, and Astrid I. Chiari, MD^*

*Department of Anesthesiology and General Intensive Care, University of Vienna, Vienna, Austria; Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina; and Department of Traumatology, University of Vienna, Vienna, Austria

Anesth Analg 2004;99:128-134

鞘內注射可樂定是一種有效的鎮痛方式，但可能抑制血流動力學和産生鎮靜，可能與鞘內注射可樂定後在腦脊液內向頭端擴散有關。作者假設鞘內用可樂定的不良作用可通過使用高比重可樂定液和擡高軀幹的方法而減少，同時不影響鎮痛時間和效果。隨機選擇30例老年病人接受150ug重比重（HYPER）或等比重(ISO)的可樂定用於外傷性髖骨骨折修補術後鎮痛。選擇時段記錄血流動力學、靜脈補液、視覺鎮痛類比評分、鎮靜評分和可樂定在腦脊液中的濃度。ISO組病人需要的晶體液明顯多於HYPER組（ISO組爲：1500ml－3000ml，平均2500ml；HYPER組500ml－3000ml，平均1500ml）以維持有效動脈血壓（p<0.01）。同樣，ISO組心率下降較HYPER組顯著（p<0.01）。鎮痛時間ISO組（115－400min，平均400min）較HYPER組（205－400min，平均265min）增加顯著（p<0.05），鎮痛評分兩組無差異。結論：增加鞘內注射可樂定溶液的比重可減少血流動力學的不利影響同時産生鎮痛作用。

(忻紀華　譯　陳傑　校)

Intrathecal (IT) clonidine is an effective analgesic, but it also produces hemodynamic depression and sedation which are likely to be related to IT clonidine’s cephalad spread within the cerebrospinal fluid. We hypothesized that IT clonidine’s side effects could be reduced without compromising the duration and quality of analgesia by injecting clonidine IT in a hyperbaric solution and elevating the patient’s trunk. We prospectively randomized 30 elderly patients to receive IT 150 µg of either isobaric (ISO) or hyperbaric (HYPER) clonidine for postoperative analgesia after surgical repair of traumatic hip fracture. Hemodynamics, IV fluid administration, visual analog pain scores, sedation scores, and clonidine cerebrospinal fluid levels were recorded at fixed intervals. Patients in the ISO group required significantly more crystalloid fluid administration (median, 2500 mL; range, 1500–3000 mL) than those in the HYPER group (median, 1500; range, 500–3000 mL) to maintain adequate arterial blood pressure (P < 0.01). Also, the decrease in heart rate was significantly more pronounced in the ISO than in the HYPER group (P < 0.01). The duration of analgesia was significantly larger in the ISO (median, 400 min; range, 115–400 min) than in the HYPER (median, 265 min; range, 205–400 min) group (P < 0.05). Sedation scores did not differ between groups. We conclude that increasing the baricity of IT clonidine solution in the conditions of our experiment reduces hemodynamic side effects but also analgesia from IT administered clonidine.

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大鼠關節腔內預注氯胺酮或美金剛有助於減少關節痛及脊髓 c- Fos 表達

Intraarticular Pretreatment with Ketamine and Memantine Could Prevent Arthritic Pain: Relevance to the Decrease of Spinal c-Fos Expression in Rats

Guo Hua Zhang, MD PhD^*, Sun Seek Min, PhD^*, Kyu Sang Lee, MS^*, Seung Keun Back, MS^*, Seong Jun Yoon, MD PhD, Young Wook Yoon, MD PhD^*, Yang In Kim, PhD, Heung Sik Na, MD PhD^*, Seung Kil Hong, MD PhD^*, and Hee Chul Han, MD PhD^*

*Department of Physiology, College of Medicine and Neuroscience Research Institute, Medical Science Research Center, Korea University, Seoul; and Department of Obstetrics & Gynecology, Gil Medical Center, Gachon Medical School, Inchon, South Korea

Anesth Analg 2004;99:152-158

爲了確定人體關節內使用N-甲基-D天冬氨酸受體拮抗劑氯胺酮或美金剛預注射是否可以預防關節疼痛，作者用大鼠研究膝關節內注射角叉膠之前注入上述藥物對疼痛相關行爲和脊髓c-Fos受體的表達程度。在膝關節內注入角叉膠（2%，40μL）之前注入氯胺酮（0.2mg或1mg）或美金剛（0.1mg,0.2mg或1mg），而不是注入腹腔，可以明顯改善疼痛相關行爲。關節內注入氯胺酮（1mg）或美金剛（0.2mg）還可以抑制c-Fos受體在L3-4脊髓水平的表達。隨後的統計學分析顯示，脊髓c-Fos受體表達程度與疼痛相關行爲的程度呈正相關。上述結果提示在外周神經末梢給予NMDA受體拮抗劑對於關節痛有預防性鎮痛作用，這可能與中樞疼痛信號減弱有關。由於目前認爲氯胺酮與美金剛用於臨床病人是安全的，其對關節痛有一定治療價值。

(周潔　譯　陳傑　校)

To determine whether intraarticular pretreatment with N-methyl-D-aspartic (NMDA) receptor antagonist ketamine or memantine currently used in humans has prophylactic analgesia in arthritic pain, we examined the effects of their intraarticular injection before carrageenan injection into the knee joint on pain-related behavior and spinal c-Fos expression in rats. Injection of ketamine (0.2 mg and 1 mg) or memantine (0.1 mg, 0.2 mg, and 1 mg) into the knee joint, but not the abdominal cavity, immediately before carrageenan injection (2%, 40 µL) significantly prevented pain-related behavior. The intraarticular injection of ketamine (1 mg) or memantine (0.2 mg) also suppressed c-Fos expression in the laminae I-II and laminae V-VI at the L3-4 spinal level. Subsequent statistical analyses revealed that the degree of the spinal c-Fos expression was correlated with the extent of the pain-related behavior. These results suggest that peripheral administration of NMDA receptor antagonists has prophylactic analgesic effects in arthritic pain, which might be associated with the decrease of central nociceptive signaling. Because ketamine and memantine are currently used in humans and considered clinically safe, they may have therapeutic value in the treatment of joint pain.

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連硬下剖腹産時下肢加壓包紮預防低血壓而不能預防低溫或寒戰

Lower Limb Wrapping Prevents Hypotension, but Not Hypothermia or Shivering, After the Introduction of Epidural Anesthesia for Cesarean Delivery

Hsiao Lun Sun, MD^*, Qing Dong Ling, PhD, Wei Zen Sun, MD, Rick Sai-Chuen Wu, MD, Tzong Jeng Wu, MD^*, Shih Chieh Wang, MD^*, and Chih Cheng Chien, MD PhD

*Department of Anesthesiology and Cathay Medical Research Institute, Cathay General Hospital, Taipei, Taiwan; Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan; and Department of Anesthesiology, Pain Service and Critical Care Medicine, China Medical College Hospital, Taipei, Taiwan

Anesth Analg 2004;99:241-244

連硬和蛛網膜下腔麻醉後體溫和血壓降低被認爲是交感神經阻滯，血流重新分佈下肢所致。研究證實下肢用彈力繃帶加壓包紮可以減少脊麻後低血壓的發生率，我們在此基礎上進一步研究，驗證下肢使用彈力繃帶加壓包紮是否可以減少硬膜外麻醉後低血壓的發生，同時評價此措施對低溫和寒戰的效果。60例臨産婦隨機分爲下肢加壓包紮組和不加壓對照組，記錄５個階段的舌下溫度：基礎值,麻醉後,皮膚消毒後,開皮和分娩時。觀察期間，同時記錄患者低溫和寒戰的情況。包紮組低血壓的發生率(23%)顯著低於對照組(50%) (p=0.03)；兩組寒戰的發生率近似(70%比70%)；兩組的舌下溫度均顯著降低(p<0.001)，但溫度降低的程度沒有顯著差異。結論：下肢加壓包紮顯著降低了産婦連硬麻醉後低血壓的發生率，但沒有減少寒戰和低溫的數量和程度。

( 陳潔 譯　　 陳傑 校)

The decrease of arterial blood pressure and body temperature after epidural or spinal anesthesia is thought to be the result of sympathetic block, which could cause pooling and redistribution of blood into the lower extremities. Studies have demonstrated that leg wrapping with elastic bandages may reduce the incidence of hypotension after spinal anesthesia. We tried to extend these previous observations to epidural anesthesia by testing the hypothesis that leg wrapping with elastic bandages should decrease the incidence of hypotension in patients receiving epidural anesthesia. Moreover, we evaluated the effect of this maneuver as regards hypothermia and shivering. Sixty parturients were randomly allocated to receive either leg wrapping with tight elastic bandages (leg-wrapped group) or not (control group) before anesthesia. Sublingual temperature was observed at five periods: baseline, immediately after epidural anesthesia, abdominal skin disinfection, skin incision, and delivery. Hypotension and shivering during the observation periods were also recorded. The incidence of hypotension was significantly less frequent (P = 0.03) in the leg-wrapped group (23%) compared with the control group (50%). Shivering incidences were similar in both groups (70% versus 70%). Sublingual temperature decreased significantly (P < 0.001) throughout the procedure in each group. However, no differences were found between the two groups at each designated observation, even if compared by the magnitude of temperature decrease. We conclude that although leg wrapping with elastic bandages prevents maternal hypotension after epidural anesthesia, it does not reduce the incidence or magnitude of hypothermia or prevent shivering.

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全髖或全膝關節成形術病人限制用重組人血紅細胞生成素和自體血回輸是有效對策

A Restrictive Use of Both Autologous Donation and Recombinant Human Erythropoietin Is an Efficient Policy for Primary Total Hip or Knee Arthroplasty

Claude Couvret, MD^*, Marc Laffon, MD^*, Annick Baud, MD^*, Valérie Payen, MD^*, Philippe Burdin, MD, and Jacques Fusciardi^*

Departments of *Anesthesiology and Critical Care and Orthopedic Surgery, Trousseau University Hospital, Tours, France

Anesth Analg 2004;99:262-271

在全髖（THA）或全膝（TKA）關節成形術前，非貧血病人限制使用自體血回輸（PABD），貧血病人（血球壓迹〔Hct〕≤39％）限制使用重組人血紅細胞生成素（EPO），可以有效的改善輸血的花費－受益比。根據這兩種不同的輸血方案，我們評價了THA或TKA手術中需要輸血的病人的比率和花費情況。本研究爲保證質量，病人的治療和護理均由同一醫療小組完成，並前瞻性的觀察了連續性的一個時間段。在研究1中（n＝182），當醫師們認爲紅細胞儲備不足且預期生命≥10年時，就採用PABD，不使用EPO，也不使用常規的輸血標準。因爲，常規的標準可導致異體輸血率50%以上（Hct≤37％）和非貧血患者自體血的浪費(Hct≤39％)。在研究2中(n=708)，又分爲兩種情況，當Hct≤37％，預期生命≥10年使用EPO，而不用PABD；非貧血病人不用PABD。結果發現輸血比率明顯下降(在非貧血病人中，從41%降到7%，P<0.0002；在貧血病人中，從58%降到27%，P<0.003；總輸血率，從43%降到12%，P<0.0001)， 異體輸血比率(10%)和Hct沒有明顯改變，節約經濟花費39%。經濟節約主要原因是限制了非貧血病人PABD的使用（常規75%的手術病人使用PABD）。雖然促紅細胞生成素很貴，但它可以節省部分病人輸血的費用，減少總費用。

(肖潔　譯　陳傑　校)

A limitation of preoperative autologous blood donation (PABD) in nonanemics and the use of recombinant human erythropoietin (EPO) in anemics (baseline hematocrit [Hct] 39%) could be an efficient approach of the cost-benefit ratio of transfusion during primary total hip (THA) or knee (TKA) arthroplasties. We evaluated the consequences on transfusion rates and costs of two different applications of a transfusion policy based on personal requirements during primary THA or TKA. This quality assurance observational study compared two prospective successive time periods; each included successive patients treated by the same medical team and standardized care. In Study 1 (n = 182), PABD was indicated if there were insufficient estimated red blood cell reserve and a life expectancy 10 yr, no use of EPO, and identical criteria for any transfusion. Because this policy led to a 50% allogeneic transfusion rate when baseline Hct 37% and autologous blood wastage in the nonanemics (baseline Hct > 39%), 2 refinements were introduced in Study 2 (n = 708): EPO without PABD when baseline Hct 37%, and life expectancy 10 yr, and avoidance of PABD in nonanemics. This novel care induced a marked decrease in transfusion rates (respectively, from 41% to 7%, P < 0.0002, in nonanemics; from 58% to 27%, P < 0.003, in anemics; and from 43% to 12%, P < 0.0001, overall), with no change in allogeneic transfusion (10%) and discharge Hct, and a 39% financial savings. This saving effect is a result of the suppression of PABD in nonanemics, who represent 75% of this surgical population. Although erythropoietin is expensive, it can be used with cost savings in selected patients because the overall cost of transfusion is reduced.

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輕度體溫增高可下調受體依賴的噬中性粒細胞功能

Mild Hyperthermia Down-Regulates Receptor-Dependent Neutrophil Function

Dieter Fröhlich, MD^*, Sigrid Wittmann, MD^*, Gregor Rothe, MD, Daniel I. Sessler, MD, Peter Vogel, MD, and Kai Taeger, MD^*

Departments of *Anesthesia, Clinical Chemistry and Laboratory Medicine, and Surgery, University of Regensburg, Regensburg, Germany; and Outcomes Research^TM Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2004;99:284-292

輕度體溫降低可削弱噬中性粒細胞對感染的抵抗力，還可削弱其噬菌作用和對非調理素作用細菌的氧化毒殺作用。我們從志願者身上提取噬中性粒細胞並放在33°－41°C的溫度環境下評估其各種功能。我們通過光學顯微鏡判斷其黏附內皮細胞的作用，通過流式細胞分析來測定粘附分子的表達，受體，噬菌作用和活性氧化劑的釋放。休眠的嗜中性粒細胞中粘附蛋白CD11b的表達是溫度無關的。然而，CD11b與腫瘤壞死因數TNF-α的上調作用在體溫過低溫時增強而在體溫過高時下降。噬中性粒細胞粘附休眠或啟動的噬中性粒細胞不是溫度依賴的。細菌的攝取作用與溫度反相關，這一點大腸桿菌比金黃色葡萄球菌更明顯。溫度依賴的噬菌作用僅發生在受調理素作用的細菌。低溫可輕微增加噬中性粒細胞中的N－甲酰甲硫亮氨酸苯丙氨酰基受體，高溫則降低表達，尤其在伴有TNF-α的情況下。N－甲酰甲硫亮氨酸苯丙氨酰基引起的過氧化氫的産生與溫度呈反相關，尤其當TNF-α存在的情況下。相反地，phorbol-13-myristate-12-acetate,蛋白酶C的啟動物，當溫度升高時可過度地釋放同源的活性氧化劑。與非受體依賴的噬菌作用以及氧化毒殺作用相比，許多重要的受體依賴的噬中性粒細胞活性作用需溫度依賴的調節，低溫可增強其功能。溫度依賴的噬中性粒細胞功能遠比先前預料的複雜。

(朱輝　譯　陳傑　校)

Mild hypothermia impairs resistance to infection and, reportedly, impairs phagocytosis and oxidative killing of un-opsonized bacteria. We evaluated various functions at 33°–41°C in neutrophils taken from volunteers. Adhesion on endothelial cells was determined using light microscopy. Adhesion molecule expression and receptors, phagocytosis, and release of reactive oxidants were assessed using flow cytometric assays. Adhesion protein CD11b expression on resting neutrophils was temperature-independent. However, up-regulation of CD11b with tumor necrosis factor (TNF)- was increased by hypothermia and decreased with hyperthermia. Neutrophil adhesion to either resting or activated endothelial cells was not temperature-dependent. Bacterial uptake was inversely related to temperature, more so with Escherichia coli than Staphylococcus aureus. Temperature dependence of phagocytosis occurred only with opsonized bacteria. Hypothermia slightly increased N-formyl-L-methionyl-L-leucyl-phenylalanine receptors on neutrophils: hyperthermia decreased expression, especially with TNF-. N-formyl-L-methionyl-L-leucyl-phenylalanine-induced H₂O₂ production was inversely related to temperature, especially in the presence of TNF-. Conversely, phorbol-13-myristate-12-acetate, an activator of protein kinase C, induced an extreme and homogenous release of reactive oxidants that increased with temperature. In contrast to nonreceptor-dependent phagocytosis and oxidative killing, several crucial receptor-dependent neutrophil activities show temperature-dependent regulation, with hypothermia increasing function. The temperature dependence of neutrophil function is thus more complicated than previously appreciated.

抑制脊髓蛋白激酶C-ε或 同工酶不影響鼠吸入氟烷最低肺泡濃度

Inhibition of Spinal Protein Kinase C- or - Isozymes Does Not Affect Halothane Minimum Alveolar Anesthetic Concentration in Rats

Jennifer A. Shumilla, PhD^*, Sarah M. Sweitzer, PhD^*, Edmond I Eger, II, MD, Michael J. Laster, DVM, and Joan J. Kendig, PhD^*

*Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and Department of Anesthesia and Perioperative Care, University of California, San Francisco, California

Anesth Analg 2004;99:82-84

麻醉劑通過酶如蛋白激酶 C （PKC）作用於受體或離子通道磷酸化的假設能解釋麻醉某些方面的作用。離體試驗顯示麻醉劑對一些受體的作用受PKC的調節。爲驗證PKC在吸入麻醉藥後抑制體動中的重要性，我們在出生7天和21天的Sprague-Dawley鼠的椎管內注入PKC-ε和PKC-的抑制劑，觀察其對氟烷最低肺泡濃度的影響。抑制劑的規格：溶液，100 pmol/5µL。7天鼠給予5µL（P7），21天鼠給予10µL（P21）。對照組給予同樣濃度和容積的鹽水或多肽載體，每組有6只實驗鼠。在P7中，生理鹽水對照組的MAC：1.63±0.0727 （ 均數±標準差），載體組的MAC：1.55±0.141，PKC-組的MAC：1.54±0.0800，PKC-組的MAC：1.69 ± 0.0554。在P21中，各組的MAC 分別爲1.20 ± 0.0490, 1.31 ± 0.0124, 1.27 ± 0.0367, and 1.15 ± 0.0483。注射抑制劑，並不改變各年齡組的MAC。這些結果，並不支援麻醉劑對磷酸化的作用作爲一種機制來解釋吸入麻醉藥後抑制軀體對傷害性刺激反應的體動，不直接支援對受體或離子通道的直接作用。

(葛寧花 譯)

Anesthetic effects on receptor or ion channel phosphorylation by enzymes such as protein kinase C (PKC) have been postulated to underlie some aspects of anesthesia. In vitro studies show that anesthetic effects on several receptors are mediated by PKC. To test the importance of PKC for the immobility produced by inhaled anesthetics, we measured the effect of intrathecal injections of PKC- and - inhibitors on halothane minimum alveolar anesthetic concentration (MAC) in 7-day-old and 21-day-old Sprague-Dawley rats. The inhibitors were made as solutions of 100 pmol/5 µL and were given in a volume of 5 µL (7-day-old [P7] rats) or 10 µL (21-day-old [P21] rats). Controls were saline injections or injections of the peptide carrier at the same concentration and volumes; there were six animals in each group. In P7 rats, MAC values (in percentage of an atmosphere) were 1.63 ± 0.0727 (mean ± SEM) in saline controls, 1.55 ± 0.141 in carrier controls, 1.54 ± 0.0800 in rats given PKC-, and 1.69 ± 0.0554 in rats given PKC-. In P21 animals, the values were 1.20 ± 0.0490, 1.31 ± 0.0124, 1.27 ± 0.0367, and 1.15 ± 0.0483, respectively. Injection of the inhibitors did not change MAC in either age group. These results do not support an anesthetic effect on phosphorylation as a mechanism underlying the capacity of inhaled anesthetics to prevent movement in response to noxious stimulation, and they indirectly support a direct action on receptors or ion channels.

經胸部超聲引導腋靜脈置管：標準鎖骨下靜脈置管的另一選擇

Transpectoral Ultrasound-Guided Catheterization of the Axillary Vein: An Alternative to Standard Catheterization of the Subclavian Vein

NavParkash S. Sandhu, MD

Department of Anesthesiology, New York University School of Medicine, New York, New York

Anesth Analg 2004;99:183-187

鎖骨下靜脈置管常因損傷肺和鎖骨下動脈而失敗或産生並發症。鎖骨下靜脈位於鎖骨和第一肋之間，使得超聲顯像困難。在超聲探頭中點穿刺，通過針尖顯示整個穿刺針有一定的難度。腋靜脈位於胸廓外，容易在縱切位元確切顯示穿刺針、導引鋼絲、擴張器和導管的位置。所有用超聲定位靜脈的技術，均顯示靜脈的橫切面，而穿刺針並不能完全顯像。本文描述5例腋靜脈置管，通過超聲在縱切面的靜脈定位，隨後穿刺，放置導引鋼絲和導管，圖像顯示和真實操作一致。建議使用較長的穿刺針和引導鞘。同時需要更多的實踐來評價這種技術的可能性。

(葛寧花 譯)

Subclavian vein catheterization is associated with failure and complications because of injury to the nearby lung and subclavian artery. Its position, sandwiched between the clavicle and the first rib, makes sonographic imaging difficult. The medially pointed sonography probe makes it difficult to align the needle as well as image the entire needle. The axillary vein lies outside of the thoracic cage and can be easily imaged in its longitudinal view along with the entire needle, guidewire, dilator, and catheter in real-time. All described techniques of venous access using sonography have used transverse images of veins, and the needle is not completely visualized. Five cases of axillary vein catheterization using longitudinal section images of the vein, and following the needle, guidewire, and line with real-time sonography, are described. The use of longer puncture needles and introducer sheaths is suggested. A larger study is required to assess the potential of this technique.

利用術中經食管超聲確診肺栓塞

Utility of Intraoperative Transesophageal Echocardiography for Diagnosis of Pulmonary Embolism

Peter Rosenberger, MD^*, Stanton K. Shernan, MD^*, Simon C. Body, MBChB^*, and Holger K. Eltzschig, MD

*Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts; and Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany

Anesth Analg 2004;99:12-16

圍術期的肺栓塞（PE）與死亡率和發病率有密切關係。經食管超聲能直接顯示肺栓塞，或肺動脈阻塞的繼發症狀。但是，用於術中診斷肺栓塞尚有待於明確。我們對46位在肺葉切除前一刻進行術中TEE檢查。主要檢查左肺動脈、右肺動脈和肺動脈主幹有無栓塞、急性肺動脈阻塞的繼發症狀（右心衰竭、中度到重度的三尖瓣反流、房間隔左移）。栓塞的確切部位由手術確定。超聲診斷PE的正確率是46%（n = 21 / 46)。但是，即使栓塞在某一特殊部位，敏感率也只有26%。TEE診斷左肺動脈栓塞最不敏感（17%）。在檢查過程中，TEE能觀察到96%的右心功能不全，50%的三尖瓣反流，98%的房間隔左移。因此，與直接手術診斷PE比較，術中TEE診斷急性PE有局限性。TEE對間接症狀肺動脈阻塞的證據有助於PE的診斷。

(葛寧花 譯)

Pulmonary embolism (PE) is associated with significant perioperative morbidity and mortality. Transesophageal echocardiography (TEE) may permit direct visualization of PE or secondary signs of pulmonary artery (PA) obstruction. However, its utility in diagnosing PE in the intraoperative setting has yet to be defined. Therefore, we performed intraoperative TEE examinations in 46 patients immediately before pulmonary embolectomy. TEE examinations were reviewed for signs of thromboemboli within the right, left, and main PA, and secondary signs of acute PA obstruction (right ventricular dysfunction, moderate-to-severe tricuspid regurgitation, leftward bowing of the interatrial septum). The definitive location of thromboemboli was determined from the surgical record. Echocardiographic evidence for the presence of PE was correctly demonstrated in 46% of all patients (n = 21 of 46). However, the sensitivity for direct visualization of thromboemboli at any specific location was only 26%. TEE was least sensitive for thromboemboli in the left PA (17%). TEE evidence of right ventricular dysfunction was observed in 96%, tricuspid regurgitation in 50%, and leftward interatrial septal bowing in 98% of examinations. Therefore, the use of intraoperative TEE to diagnose acute PE via direct visualization is limited. Indirect TEE evidence of PA obstruction may be helpful in supporting a diagnosis of PE.

增加氧和二氧化碳均能增加皮下和腸粘膜的氧合。

Supplemental Oxygen and Carbon Dioxide Each Increase Subcutaneous and Intestinal Intramural Oxygenation

Jebadurai Ratnaraj, MD^*, Barbara Kabon, MD^*, Michael R. Talcott, DVM, Daniel I. Sessler, MD, and Andrea Kurz, MD

Departments of *Anesthesiology and Veterinary Surgical Services, Washington University, St. Louis, MO; the Outcomes Research Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, KY; and the Department of Anesthesiology, University of Bern, Switzerland and the Department of Anesthesiology and Intensive Care Medicine, University of Vienna, Vienna, Austria

Anesth Analg 2004;99:207-211

中性粒細胞的氧化滅菌是防禦手術病菌的主要手段，直接與組織的氧供有關。我們驗證這一理論：增加吸入氧濃度或輕度高碳酸血症（呼氣末PCO₂ 保持在50 mmHg）能增加腸道組織的氧供。實驗豬（重量25 ± 2.5 kg）隨機分爲以下兩類：1 氧供研究：在保持呼氣末PCO₂ 40 mmHg的前提下，吸入30%的氧與吸入100%的氧對照；2 二氧化碳研究：在吸入30%氧的條件下，呼氣末PCO₂ 30 mmHg與50 mmHg對照。各組研究中，治療順序隨機，持續1.5小時；檢測資料平均延續至實驗的最後一小時。在左側大腿的皮下放置壓力器測量皮下氧張力，在腸壁放置壓力器，測量小腸和大腸黏膜下的氧張力。100%的氧供能使皮下氧分壓(PO₂)(57 ± 10 至 107 ± 48 mm Hg, P = 0.006)和大腸黏膜下氧分壓(PO₂) (53 ± 14 to 118 ± 72 mm Hg, P = 0.014)增加一倍，能使小腸黏膜下氧分壓增加40%。呼氣末PCO₂ 50 mm Hg組，大腸黏膜下PO₂增加 16%(49 ± 10 至 57 ± 12 mm Hg, P = 0.039)，小腸黏膜下PO₂增加45% (31 ± 12 to 44 ± 16 mm Hg, P = 0.002).增加氧供和輕度的高碳酸血症均能增加皮下和腸黏膜下組織的氧分壓，而增加氧供的效果更有效。

(葛寧花 譯)

Oxidative killing by neutrophils, a primary defense against surgical pathogens, is directly related to tissue oxygenation. We tested the hypothesis that supplemental inspired oxygen or mild hypercapnia (end-tidal PCO₂ of 50 mm Hg) improves intestinal oxygenation. Pigs (25 ± 2.5 kg) were used in 2 studies in random order: 1) Oxygen Study: 30% versus 100% inspired oxygen concentration at an end-tidal PCO₂ of 40 mm Hg, and 2) Carbon Dioxide Study: end-tidal PCO₂ of 30 mm Hg versus 50 mm Hg with 30% oxygen. Within each study, treatment order was randomized. Treatments were maintained for 1.5 h; measurements were averaged over the final hour. A tonometer inserted in the subcutaneous tissue of the left upper foreleg measured subcutaneous oxygen tension. Tonometers inserted into the intestinal wall measured intestinal intramural oxygen tension from the small and large intestines. Oxygen 100% administration doubled subcutaneous oxygen partial pressure (PO₂) (57 ± 10 to 107 ± 48 mm Hg, P = 0.006) and large intestine intramural PO₂ (53 ± 14 to 118 ± 72 mm Hg, P = 0.014); intramural PO₂ increased 40% in the small intestine (37 ± 10 to 52 ± 25 mm Hg, P = 0.004). An end-tidal PCO₂ of 50 mm Hg increased large intestinal PO₂ approximately 16% (49 ± 10 to 57 ± 12 mm Hg, P = 0.039), whereas intramural PO₂ increased by 45% in the small intestine (31 ± 12 to 44 ± 16 mm Hg, P = 0.002). Supplemental oxygen and mild hypercapnia each increased subcutaneous and intramural tissue PO₂, with supplemental oxygen being most effective.

比較硬膜外布比卡因、左旋布比卡因和羅呱卡因對術後鎮痛和運動阻滯的作用

A Comparison of Epidural Bupivacaine, Levobupivacaine, and Ropivacaine on Postoperative Analgesia and Motor Blockade

Pasquale De Negri, MD^*, Giorgio Ivani, MD, Tiziana Tirri, MD^*, Pasqualina Modano, MD^*, Cesare Reato, MD^*, Staffan Eksborg, PhD, and Per-Arne Lonnqvist, MD PhD

*Department of Anesthesia, ICU and Pain Management, Centro di Riferimento Oncologico della Basilicata-Cancer Center, Rionero in Vulture, Potenza, Italy; Department of Pediatric Anesthesia and Intensive Care Unit, "Regina Margherita" Children’s Hospital, Turin, Italy; and Department of Women and Child Health and Department of Surgical Sciences, Karolinska Institute, Stockholm, Sweden

Anesth Analg 2004;99:45-48

在前瞻性、隨機性和觀察者不知情的臨床試驗中，我們在小兒尿道下裂修補術後硬膜外腔分別注射小劑量(0.125%， 0.2 mg • kg^–1 • h^–1)的布比卡因（B組，n = 26)，左旋布比卡因（L組，n = 27)和羅呱卡因（R組，n = 26)，比較下肢出現運動阻滯與鎮痛的效果。術後48小時，在事先固定的時間，用改良的Bromage評分法評估運動阻滯的程度，用兒童和嬰兒術後疼痛評分法（CHIPPS）評估疼痛的程度。三組患者術後鎮痛效果幾乎一致(CHIPPS評分 0–3)，沒有任何患者需要另外增加鎮痛藥。但是，在觀察期間，B組出現運動阻滯的人數 (n = 6) 與L組(n = 0)和R組(n = 0)比較明顯增加，差異有顯著性（P = 0.03）。結論，小兒尿道下裂修補術後在硬膜外腔連續注射0.125%的左旋布比卡因和羅呱卡因，與注射相同劑量的布比卡因比較，運動阻滯發生率明顯減少；但三組的鎮痛效果無顯著性差異。

(葛寧花 譯)

In this prospective, randomized, observer-blinded clinical trial, we compared the incidence of unwanted lower extremity motor blockade and the analgesic efficacy between small-dose (0.125%; 0.2 mg • kg^–1 • h^–1) postoperative epidural infusions of bupivacaine (Group B; n = 28), levobupivacaine (Group L; n = 27), and ropivacaine (Group R; n = 26) in children after hypospadias repair. Motor blockade and pain were assessed at predetermined time points during 48 h by using a modified Bromage scale and the Children’s and Infant’s Postoperative Pain Scale (CHIPPS). Postoperative analgesia was almost identical in all three study groups (CHIPPS range, 0–3), with no need for the administration of supplemental analgesia in any patient. However, significantly more patients in Group B (n = 6; P = 0.03) displayed signs of unwanted motor blockade during the observation period compared with Group L (n = 0) and Group R (n = 0). In conclusion, significantly less unwanted motor blockade was associated with postoperative epidural infusions of 0.125% levobupivacaine or ropivacaine in children after hypospadias repair as compared with a similar infusion of bupivacaine. However, no difference with regard to postoperative analgesia could be detected among the three different local anesthetics studied.

全膝置換術後鎮痛：閉孔神經阻滯加股神經3合1神經阻滯

Postoperative Analgesia After Total Knee Replacement: The Effect of an Obturator Nerve Block Added to the Femoral 3-in-1 Nerve Block

D. Macalou, MD^*, S. Trueck, MD^*, P. Meuret, MD^*, M. Heck, MD^*, F. Vial, MD^*, S. Ouologuem, MD^*, X. Capdevila, MD PhD, J. -M. Virion, and H. Bouaziz, MD PhD^*

*Department of Anesthesiology and Intensive Care, Central University Hospital, Nancy, France, the Department of Anesthesiology and Intensive Care, Lapeyronie University Hospital, Montpellier, France, and the Department of Epidemiology & Clinical Evaluation and Centre of Clinical Investigation, University Hospital, Nancy, France

Anesth Analg 2004;99:251-254
　

股神經阻滯並不包括閉孔神經。在這單盲、隨機和對照研究中，我們在阻滯股神經的基礎上，選擇閉孔神經阻滯，分析其在全膝置換術後鎮痛中的作用。在全身麻醉前，90位行全膝置換術的患者隨機分爲股神經阻滯組（組1），股神經加選擇性閉孔神經阻滯組（組2）和安慰劑股神經阻滯組（組3）。此外由病人自控靜脈嗎啡注射鎮痛。記錄術後最初6小時內鎮痛效果和副作用。在組1中，內收肌肌力減弱是18% ± 9%，而在組2，是78% ± 22%(P < 0.0001)。與組1和組3比較，組2的嗎啡總用量減少(P 0.0001)。組2的疼痛評分比組1和組3低(P = 0.0003)。噁心的發生率在組1和組3高(P = 0.01)。結論，只有股神經阻滯而沒有閉孔神經的阻滯，並不能産生完全的鎮痛作用。在術後的早期，單次股神經阻滯對靜止時的鎮痛作用並不比靜脈鎮痛有優勢。在全膝置換術後增加閉孔神經的阻滯能增加術後鎮痛效果。

(葛寧花 譯)

Femoral nerve block (FNB) does not consistently produce anesthesia of the obturator nerve. In this single-blind, randomized, controlled study we added a selective obturator nerve block (ONB) to FNB to analyze its influence on postoperative analgesia after total knee replacement (TKR). Before general anesthesia, 90 patients undergoing TKR received FNB (Group 1), FNB and selective ONB (Group 2), or placebo FNB (Group 3). Postoperative analgesia was further provided by morphine IV via patient-controlled analgesia. Analgesic efficacy and side effects were recorded in the first 6 h after surgery. Adductor strength decreased by 18% ± 9% in Group 1 and by 78% ± 22% in Group 2 (P < 0.0001). Total morphine consumption was reduced in Group 2 compared with Groups 1 and 3 (P 0.0001). Patients in Group 2 reported lower pain scores than those in Groups 1 and 3 (P = 0.0003). The incidence of nausea was more frequent in Groups 1 and 3 (P = 0.01). We conclude that FNB does not produce complete anesthesia of the obturator nerve. Single-shot FNB does not provide additional benefits on pain at rest over opioids alone in the early postoperative period. The addition of an ONB to FNB improves postoperative analgesia after TKR.

.

較小潮氣量通氣：隨機對照定量系統回顧

Ventilation with Smaller Tidal Volumes: A Quantitative Systematic Review of Randomized Controlled Trials

Nicola Petrucci, MD MSc, and Walter Iacovelli, MD

Department of Anaesthesia & Intensive Care, Azienda Ospedaliera Desenzano, Desenzano, Italy

Anesth Analg 2004;99:193-200

在這一詳細的系統回顧中，我們評估用較小潮氣量通氣在16歲以上患有急性肺損傷和急性呼吸窘迫綜合征患者中的作用。5個隨機試驗（1202名患者），隨機比較用較小的VT和/或低氣道驅動壓力（平臺壓30cm H₂O或以下）通氣，保持Vt在 7 mL/kg 以下，和對照組Vt在10 - 15 mL/kg，結果由Cochrance中心註冊的對照試驗，MEDLINE，EMBASE，CINAHL，當代資料研究，參考目錄和“灰色文獻”等系統研究後確定。28天的死亡率在肺保護性通氣組有明顯降低（相對危險因素RR 0.74；CI0.61-0.88），而對死亡率的長期有利性作用不確切（RR，0.84，CI，0.68-1.05）。如果對照組的平臺壓力小於或等於31cm H₂O (RR, 1.13; CI, 0.88–1.45)，則小潮氣量組和常規潮氣量組無顯著性差異。臨床試驗的不均一性，如隨訪時間長短不同，對照組較高的平臺壓力，使得合理解釋結果有一定的困難。

In this quantitative systematic review we assessed the effects of ventilation with smaller tidal volume (VT) on morbidity and mortality in patients aged 16 yr or older affected by acute lung injury and acute respiratory distress syndrome. Five randomized trials (1202 patients) comparing ventilation using smaller VT and/or low airway driving pressure (plateau pressure 30 cm H₂O or less), resulting in VT of 7 mL/kg or less versus ventilation that uses VT in the range of 10 to 15 mL/kg, were identified after a systematic search of The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, databases of current research, reference lists, and "gray literature." Mortality at day 28 was significantly reduced by lung-protective ventilation (relative risk [RR], 0.74; confidence interval [CI], 0.61–0.88), whereas beneficial effect on long-term mortality was uncertain (RR, 0.84; CI, 0.68–1.05). The comparison between small and conventional VT was not significantly different if a plateau pressure less than or equal to 31 cm H₂O in the control group was used (RR, 1.13; CI, 0.88–1.45). Clinical heterogeneity, such as different lengths of follow-up and higher plateau pressures in control arms in two trials, make the interpretation of the combined results difficult.

犬異丙酚蘇醒期引起膈肌收縮減少的研究

The Recovery Profile of Reduced Diaphragmatic Contractility Induced by Propofol in Dogs

Yoshitaka Fujii, MD, Aki Uemura, MD, and Hidenori Toyooka, MD

Department of Anesthesiology, University of Tsukuba Institute of Clinical Medicine, Tsukuba City, Ibaraki, Japan

Anesth Analg 2004;99:113-116
　

異丙酚可以減少膈肌的收縮，但是尚無資料顯示其在蘇醒時的作用。我們在狗身上研究了蘇醒時異丙酚減少膈肌收縮的作用。動物分爲4組，每組7個。組1，不伴有膈肌疲勞，只接受維持7的補液；組2，不伴有膈肌疲勞，輸注異丙酚；組3，伴有膈肌疲勞，不接受任何藥物；組4，伴有膈肌疲勞，輸注異丙酚。麻醉劑量的異丙酚(初始0.1 mg/kg 持續6.0 mg • kg^–1 • h^–1)持續60分鐘。在組3和4中，使用20赫茲持續30分鐘超大的雙側電刺激達到膈肌疲勞的目的。我們通過測跨膈肌壓力(Pdi)來評價膈肌收縮力。組2中，低頻(20-Hz)時的 Pdi小於基礎值(P < 0.05)，高頻(100-Hz)刺激時沒有改變。停止異丙酚輸注後10分鐘，低頻(20-Hz)時的 Pdi恢復到基礎值。當出現疲勞時，組3和組4，低頻(20-Hz)時的 Pdi降到基礎值以下(P < 0.05)，高頻(100-Hz)刺激時沒有改變。組4中使用異丙酚以後低頻(20-Hz)時的 Pdi降到疲勞值以下(P < 0.05)。停止異丙酚輸注後20分鐘，低頻(20-Hz)時的 Pdi恢復到疲勞值。我們於是認爲在犬身上，由於異丙酚引起的膈肌收縮下降，無論是否伴有膈肌疲勞，在停止異丙酚輸注後20分鐘可以恢復。

(方芳 譯 葛寧花 校)

Propofol decreases contractility of the diaphragm, but no data are available for its effects on recovery. We studied the recovery profile of reduced diaphragmatic contractility induced by propofol in dogs. Animals were divided into 4 groups of 7 each. Group I, without fatigue, received only maintenance fluid; Group II, without fatigue, was infused with propofol; Group III, with fatigue, received no study drug; Group IV, with fatigue, was infused propofol. Propofol at an anesthetic dose (0.1 mg/kg initial dose plus 6.0 mg • kg^–1 • h^–1) was administered for 60 min. In Groups III and IV, diaphragmatic fatigue was induced by intermittent supramaximal bilateral electrophrenic stimulation at 20-Hz for 30 min. We assessed diaphragmatic contractility by transdiaphragmatic pressure (Pdi). In group II, Pdi at low-frequency (20-Hz) stimulation decreased to less than baseline (P < 0.05), whereas there was no change in Pdi at high-frequency (100-Hz) stimulation. At 10 min after the end of propofol administration, Pdi at 20-Hz stimulation returned to baseline. When

　fatigue was established, in Groups III and IV, Pdi at 20-Hz stimulation decreased to less than baseline (P < 0.05), whereas Pdi at 100-Hz stimulation did not change. After administering propofol in Group IV, Pdi at 20-Hz stimulation decreased from fatigued values (P < 0.05). At 20 min after the end of propofol administration, Pdi at 20-Hz stimulation returned to fatigued values. We conclude that reduced contractility in nonfatigued and fatigued canine diaphragm induced by propofol recovers within 20 min after the cessation of administration

評估住院醫生麻醉前諮詢能力的方法的發展及應用

The Development and Application of an Instrument for Assessing Resident Competence During Preanesthesia Consultation

Getúlio Rodrigues de Oliveira Filho, MD, and Leonardo Schonhorst, MD

Department of Anesthesiology, Hospital Governador Celso Ramos, Florianópolis-SC, Brazil

Anesth Analg 2004;99:62-69

在此項研究中，我們著眼于建立、驗證並應用評估住院醫生在門診病人麻醉前諮詢（PAC）方面能力的方法。Delphi專題專家組制定了門診病人PAC中應包含的幾個典型專案，這幾項的採用與否正是能力的體現。而由這幾項組成的方案在幾位受過鑒定的麻醉醫生的PAC中得到驗證。此項諮詢方案易於建立，評估準確性高，適中的內部連貫性，並在圈內得到高度認同，共37項歸結爲5個方面（醫患關係、醫療史、體檢、病人宣教、麻醉前記錄）。此項方案在7位第一年住院醫師進行的連續317次PAC中被應用於評估其能力。通過建立各個方面評分及總評分的指數變動均數表來分析資料。而後可通過統計資料顯著的區分能力水平，並且結果穩定。連續在專案列表評分方案中應用指數變動均數表可以可靠的評估住院醫師的能力。麻醉前諮詢評分列表在住院醫師的培訓期間包括門診病人麻醉前評估方面是一項非常有效的格式化及累積性的方法。

(陸續偉 譯 葛寧花 校)

In this study, we aimed to construct, validate, and apply an instrument for assessing resident performance at outpatient preanesthesia consultation (PAC). A focus group and a Delphi panel of experts defined component items of a typical outpatient PAC, which could be used as indicators of competence. Items were incorporated in a checklist, which was further validated in a sample of consultations performed by board-certified anesthesiologists. The resulting instrument contained 37 items, grouped into five domains (physician-patient relationship, medical history, physical examination, patient education, and preanesthesia records), with high construct validity, high discriminant validity, moderate internal consistency, and high probability of inter-raters agreement. The instrument was applied to evaluate the performance of seven first-year residents at 317 consecutive PAC. Data were analyzed by constructing exponentially weighted moving average charts for domain and total scores. Statistically significant differing levels of performance could be consistently detected. Applying exponentially weighted moving average charts to the sequential analysis of the developed checklist scores can reliably assess resident performance at the devised criteria. The Preanesthesia Consultation Scoring Checklist is a potentially useful instrument for both formative and summative assessment of residents during their training in processes involved in outpatient preanesthesia evaluation.

光導輔助插管在側臥位患者中的應用

Lightwand-Assisted Intubation of Patients in the Lateral Decubitus Position

Kuang-I Cheng, MD^*, Koung-Shing Chu, MD, Siu-Wah Chau, MD^*, Soo-Lee Ying, MD^*, Hong-Te Hsu, MD^*, Yin-Lung Chang, MD^*, and Chao-Shun Tang, PhD^*

*Department of Anesthesiology, Kaohsiung Medical University, Kaohsiung, Taiwan, and the Department of Anesthesiology, Kuo General Hospital, Tainan, Taiwan

Anesth Analg 2004;99:279-283

在某些情況下，側臥位元的手術患者需要氣管插管以維持呼吸道的通暢。在這一研究中，我們選擇120患者，隨機分配至平臥、左側臥位和右側臥位，比較光導輔助插管的可行性。S組患者首先平臥，氣管插管後改爲側臥位。R組患者右側臥位進行誘導和氣管插管。L組患者左側臥位進行誘導和氣管插管。記錄每次插管的時間，總的插管成功時間，與插管有關的口腔損傷，血流動力學變化，術後咽喉疼痛和聲音嘶啞等等。插管所需的時間相似，平臥位：14.5±13.4s，左側臥位：13.3 ± 10.2s，右側臥位：15.5 ± 13.0s；血流動力學變化的趨勢相似。患者在平臥和側臥位時，第一次插管的成功率、咽喉痛、聲音嘶啞、口腔黏膜損傷和心率失常等發生率均相似。與平臥位比較，第一次插管時，側臥位更容易誤入食管，但差異無顯著性意義。在重新插管後都能糾正。我們得出的結論是光導輔助插管簡單可行，不論是側臥位、俯臥位還是平臥位，技術方法相同。這種方法可用於臨床，並建議用於那些插管和手術時保持側臥位的患者。

(葛寧花 譯)

In some situations, patients need endotracheal intubation to maintain airway patency while they are constrained in the lateral position. In this study we compared lightwand-guided intubation of 120 randomly enrolled patients placed in the supine, right, or left lateral position. Group S patients were initially placed in the supine position, and subsequent to the artificial airway having been established they were turned to the lateral decubitus position. Group R patients were initially placed in a right decubitus position during induction and intubation. Group L patients were initially placed in a left decubitus position during induction and intubation. The duration of each intubation attempt, the total time to successful intubation, and the incidence of intubation-related intraoral injury, hemodynamic changes, and postoperative sore throat and hoarseness were recorded. Intubation took a similar length of time in the supine (14.5 ± 13.4 s), left lateral (13.3 ± 10.2 s), and right lateral positions (15.5 ± 13.0 s) and resulted in a similar trend in hemodynamic changes. Patients in the lateral and supine positions revealed a comparable incidence of successful first-attempt intubation, sore throat, hoarseness, oral mucosal injury, and dysrhythmia. Insignificantly more esophageal intubations were performed in the lateral position in the first attempt at intubation; however, all patients were correctly intubated shortly after reattempting intubation. We concluded that lightwand-assisted intubation is easily performed and a similar technique may be used whether the patient is in a lateral, recumbent, or a supine position. This alternative technique should be practiced and is recommended for patients who must remain in a lateral position during intubation and surgery.

－阿片受體激動劑SNC80對脊髓缺血後大鼠後肢運動功能和神經元損傷的影響

The Effects of the -Opioid Agonist SNC80 on Hind-Limb Motor Function and Neuronal Injury After Spinal Cord Ischemia in Rats

Toshinori Horiuchi, MD^*, Masahiko Kawaguchi, MD^*, Takanori Sakamoto, MD^*, Naoko Kurita, MD^*, Satoki Inoue, MD^*, Mitsutoshi Nakamura, MD, Noboru Konishi, MD, and Hitoshi Furuya, MD^*

Departments of *Anesthesiology and Pathology, Nara Medical University, Nara, Japan

Address correspondence and reprint requests to Masahiko Kawaguchi, MD, Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.

Anesth Analg 2004;99:235-240

最近的研究表明-阿片受體激動劑在大腦內具有神經保護作用，我們研究了椎管內使用-阿片受體激動劑（SNC80）對於脊髓缺血（SCI）大鼠的影響。我們放置主動脈內球囊導管以産生脊髓缺血。這些老鼠隨機分配到下面5組之一：（1）脊髓缺血前9分鐘使用SNC80 (SNC-9; n = 12)；（2）脊髓缺血前9分鐘使用安慰劑（V-9; n = 12）；（3）脊髓缺血前11分鐘使用SNC80(SNC-11; n = 10)；（4）脊髓缺血前11分鐘使用安慰劑（V-11; n = 12）；（5）類比組（n = 12），脊髓缺血前15分鐘給予SNC80(400 nmol)或者安慰劑。再灌注48小時後，我們使用Basso, Beattie, Bresnahan (BBB)評分法評估了後肢的運動功能，並且對L4和L5脊髓節段進行了組織學評分。SNC-9組的BBB評分要高於V-9(P < 0.05)，然而SNC-11組和V-11組的BBB評分沒有差異。SNC-9組和SNC-11組正常神經元的數目比V-9組和V-11組明顯要多(P < 0.05)。結果提示椎管內使用-阿片受體激動劑（SNC80）可以減輕脊髓缺血後大鼠的後肢運動障礙和神經元損傷。

（王柯 譯 葛寧花 校）

Recent investigation suggested neuroprotective efficacy of a -opioid agonist in the brain. We investigated the effects of intrathecal treatment with a -opioid agonist (SNC80) on spinal cord ischemia (SCI) in rats. SCI was induced with an intraaortic balloon catheter. The animals were randomly allocated to one of the following five groups: 1) SNC80 before 9 min of SCI (SNC-9; n = 12), 2) vehicle before 9 min of SCI (V-9; n = 12), 3) SNC80 before 11 min of SCI (SNC-11; n = 10), 4) vehicle before 11 min of SCI (V-11; n = 12), or 5) sham (n = 12). SNC80 (400 nmol) or vehicle was administered 15 min before SCI. Forty-eight hours after reperfusion, hind-limb motor function was assessed by using the Basso, Beattie, Bresnahan (BBB) scale (0 = paraplegia; 21 = normal) and histological assessment of the L4 and L5 spinal segments was performed. BBB scores in the SNC-9 group were higher compared with those in the V-9 group (P < 0.05), whereas there were no differences in BBB scores between the SNC-11 and V-11 groups. There were significantly more normal neurons in the SNC-9 and SNC-11 groups than in the V-9 and V-11 groups (P < 0.05). The results indicate that intrathecal treatment with the -opioid agonist SNC80 can attenuate hind-limb motor dysfunction and neuronal injury after SCI in rats.

布比卡因抑制大鼠胸主動脈血栓烷A₂誘導的血管收縮

Bupivacaine Inhibits Thromboxane A₂-Induced Vasoconstriction in Rat Thoracic Aorta

Klaus Hahnenkamp, , Joke Nollet, , Danja Strümper, , Tobias Halene, Pia Rathman^*, Eike Mortier, , Hugo Van Aken, , Joerg Knapp, , Marcel E. Durieux, , and Christian W. Hoenemann,

Department of Anesthesiology and Intensive Care, University Hospital, Münster, Germany, the Department of Anesthesiology, University Hospital, Gent, Belgium, the Institute of Pharmacology and Toxicology, Westfälische-Wilhelms-Universität, Münster, Germany, and the Department of Anesthesiology, Marienhospital, Vechta, Germany

Anesth Analg 2004;99:97-102

作爲一種誘導血小板聚集,支氣管收縮和血管收縮的炎性介質,血栓烷A₂(TXA₂)的血漿水平在圍手術期增高了.圍手術期血栓性和缺血性綜合症的發病機制主要歸因於這種前列腺素樣物質.在細胞模型中局麻藥(LA)抑制了TXA₂的信號表達.因此,我們假設LA能抑制大鼠胸主動脈由TXA₂類似物U46619誘導的血管收縮.大鼠胸主動脈圈(長度3-mm)架在器官浴器內並測量其等容收縮力.帶或不帶內皮的圈在布比卡因(10^–6 or 10^–5 M) 或Krebs-Henseleit溶液中孵化60分鐘,隨後暴露於累積濃度的U46619(10^-10至10^-6M).我們也研究了布比卡因所致的TXA₂誘導血管收縮的可逆性.用布比卡因對大鼠胸主動脈圈預處理能劑量依賴性減輕TXA₂誘導的胸主動脈圈的收縮.我們發現有或無內皮對布比卡因的舒張作用無顯著差異.由U46619所致的動脈圈收縮並不能被累積濃度的布比卡因所逆轉.布比卡因抑制卡巴膽鹼誘導的血管舒張作用.本研究給我們提供了實驗性證據,即對於TXA₂誘導的大鼠胸主動脈血管收縮,布比卡因是非內皮依賴的抑制劑.

(鍾鳴 譯 葛寧花 校)

Plasma levels of thromboxane A₂ (TXA₂), an inflammatory mediator inducing platelet aggregation, bronchoconstriction, and vasoconstriction, are increased in the perioperative period. A major role in the pathogenesis of perioperative thromboembolic and ischemic syndromes is attributed to this prostanoid. Local anesthetics (LA) inhibit signaling of TXA₂ receptors expressed in cell models. Therefore, we hypothesized that LA may inhibit vasoconstriction induced by the TXA₂ analog U46619 in rat thoracic aorta. Rings (3-mm length) of the rat thoracic aorta were mounted in organ baths and isometric contractile force was measured. Rings, with or without endothelium, were incubated for 60 min in bupivacaine (10^–6 or 10^–5 M) or Krebs-Henseleit solution (control group) and subsequently exposed to cumulative concentrations of U46619 (10^–10 to 10^–6 M). The reversibility of the TXA₂-induced vasoconstriction by bupivacaine was also studied. Pretreatment of rings with bupivacaine concentration-dependently diminished TXA₂-induced contraction in rat aortic rings. We found no significant differences in relaxing effect of bupivacaine between rings with and without endothelium. Contraction in rings established with U46619 could not be reversed by cumulative concentrations of bupivacaine. Bupivacaine inhibited carbachol-induced vascular relaxation. This study provides experimental evidence that bupivacaine is an endothelium-independent inhibitor of TXA₂-induced vasoconstriction of rat thoracic aorta.

比較心臟手術後輸注異體紅細胞或100%純氧通氣對全身氧傳輸和骨骼肌氧分壓的影響

The Influence of Allogeneic Red Blood Cell Transfusion Compared with 100% Oxygen Ventilation on Systemic Oxygen Transport and Skeletal Muscle Oxygen Tension After Cardiac Surgery

Stefan Suttner, MD^*, Swen N. Piper, MD^*, Bernhard Kumle, MD^*, Katrin Lang, MD^*, Kerstin D. Röhm, MD^*, Frank Isgro, MD, and Joachim Boldt, MD^*

Departments of *Anesthesiology and Intensive Care Medicine and Cardiac Surgery, Klinikum Ludwigshafen, Ludwigshafen, Germany

Anesth Analg 2004;99:2-11

本研究中我們使用全身氧傳輸參數和骨骼肌氧分壓（PtiO2）來比較異體紅細胞（RBC）輸注或100%純氧通氣對組織氧合的影響。51例擇期冠脈搭橋術後接受機械通氣的患者在容量補足後最低血紅蛋白濃度爲7.5至8.5之間者被隨機分配接受1個單位（輸注1；n = 17）或2個單位（輸注2；n = 17）異體紅細胞的同時吸入40%氧；或者不輸異體紅細胞而吸入純氧通氣（100%氧；n = 17）。3小時內每隔30min記錄有創動脈壓和肺動脈壓並計算氧的輸送（氧輸送指數）和消耗的指數（氧耗指數）。通過植入的極譜微探針可持續測量P_tiO₂。全身氧運輸參數和P_tiO₂的基礎值在組間相似。隨著異體紅細胞的輸入和100%氧的通氣，氧輸送指數顯著增加而氧耗指數則維持不變。100%氧的通氣顯著增加P_tiO₂（從24.0 ± 5.1 mm Hg 到 34.2 ± 6.2 mm Hg）而異體紅細胞輸注後則無變化。P_tiO₂的峰值在輸注1組和2組分別爲25.2 ± 5.2 mm Hg 和 26.3 ± 6.5 mm Hg。輸注庫存異體紅細胞只對改善全身氧輸送指數有效而100%氧通氣可同時改善全身氧輸送和P_tiO₂。這種氧合狀態的改善最有可能歸功於對流性氧輸送的增加伴巨大的驅動梯度使血漿內溶解的氧向組織彌散。

（黃施偉 譯　　　 李士通 校）

In this study we investigated the effects of allogeneic red blood cell (RBC) transfusion on tissue oxygenation compared with those of 100% oxygen ventilation by using systemic oxygen transport variables and skeletal muscle oxygen tension (P_tiO₂). Fifty-one volume-resuscitated, mechanically ventilated patients with a nadir hemoglobin concentration in the range from 7.5 to 8.5 g/dL after elective coronary artery bypass grafting were allocated randomly to receive 1 unit (transfusion 1; n = 17) or 2 units (transfusion 2; n = 17) of allogeneic RBCs and ventilation with 40% oxygen or pure oxygen ventilation (100% oxygen; n = 17) and no allogeneic blood for 3 hours. Invasive arterial and pulmonary artery pressures and calculations of oxygen delivery (oxygen delivery index) and consumption indices (oxygen consumption index) were documented at 30-min intervals. P_tiO₂ was measured continuously by using implantable polarographic microprobes. Systemic oxygen transport variables and P_tiO₂ were similar between groups at baseline. The oxygen delivery index increased significantly with transfusion of allogeneic RBCs and 100% oxygen ventilation, whereas the oxygen consumption index remained unchanged. Oxygen 100% ventilation increased P_tiO₂ significantly (from 24.0 ± 5.1 mm Hg to 34.2 ± 6.2 mm Hg), whereas no change was found after transfusion of allogeneic RBCs. Peak P_tiO₂ values were 25.2 ± 5.2 mm Hg and 26.3 ± 6.5 mm Hg in the transfusion 1 and 2 groups, respectively. Transfusion of stored allogeneic RBCs was effective only in improving systemic oxygen delivery index, whereas 100% oxygen ventilation improved systemic oxygen transport and P_tiO₂. This improved oxygenation status was most likely due to an increase in convective oxygen transport with a large driving gradient for diffusion of plasma-dissolved oxygen into the tissue.

過氧亞硝基陰離子減低人類血漿止血效應的體外實驗

Peroxynitrite Decreases Hemostasis in Human Plasma In Vitro

Vance G. Nielsen, MD^*, John P. Crow, PhD, Ashish Mogal, MD^*, Fen Zhou, MD^*, and Dale A. Parks, PhD^*,,

Departments of *Anesthesiology, Physiology and Biophysics, and Pediatrics, The Center for Free Radical Biology, The University of Alabama at Birmingham, Birmingham, Alabama, and the Departments of Pharmacology and Toxicology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas

Anesth Analg 2004;99:21-26

凝血紊亂與涉及活性氮如過氧亞硝基陰離子(OONO–) 等産生的臨床情況有關。此外體外實驗顯示OONO–能減少組織因數和纖維蛋白原功能。因此我們假設血漿與OONO–接觸能通過減低凝血蛋白活性而降低血漿止血功能，OONO–由3-morpholinosydnonimine (SIN-1)産生，它是能産生氧化氮和超氧陰離子的分子。 在超氧化物岐化酶（SOD）或OONO–清除劑存在或缺少的情況下，血漿暴露於SIN-1（37°C， 濃度分別0, 1, 5, 和10 mM ，時間60 min ）後利用血栓彈力描記圖、部分凝血活酶時間和凝血酶原時間來評估血漿凝血功能。SIN-1導致顯著(P < 0.05)及劑量相關的血漿凝血功能下降，同時伴有VII因數、 VIII 因數複合物及 X 因數活性下降(P < 0.05)，纖維蛋白原濃度並不受影響。抗凝血酶及C蛋白活性也明顯下降(P < 0.05)。超氧岐化酶（SOD）或OONO–清除劑明顯緩解SIN-1引起的止血及促凝/抗凝活性的改變(P < 0.05)。我們認爲OONO–能通過對關健促凝物質的硝基化而減低人類血漿止血功能,可能在出血狀況下起重要作用。

（王立中 譯　　　 李士通 校）

Coagulopathy has been associated with clinical scenarios that involve reactive nitrogen species such as peroxynitrite (OONO^–). Further, OONO^– decreases tissue factor and fibrinogen function in vitro. Thus, we hypothesized that exposure of plasma to the OONO^– generated with 3-morpholinosydnonimine (SIN-1), a molecule that produces both nitric oxide and superoxide, would result in a decrease in hemostatic function via diminished coagulation protein activity. Hemostatic function of plasma exposed to SIN-1 (0, 1, 5, and 10 mM for 60 min at 37°C) was assessed with thrombelastography, activated partial thromboplastin time, and prothrombin time in the presence or absence of superoxide dismutase (SOD) or an OONO^– scavenger. SIN-1 exposure resulted in a significant (P < 0.05), dose-dependent decrease in plasma hemostatic function and concurrent significant (P < 0.05) decreases in activities of factor VII, factor VIII complex, and factor X. Fibrinogen concentration was not affected by SIN-1. Antithrombin and protein C activity also decreased significantly (P < 0.05). Coincubation with SOD or an OONO^– scavenger significantly (P < 0.05) attenuated SIN-1 mediated changes in hemostasis and procoagulant/anticoagulant activity. We conclude that OONO^– may decrease hemostatic function in human plasma by nitration of key procoagulants and that OONO^– may play a significant role in hemorrhagic states.

兒童雙側呼吸音聽診不能排除支氣管內插管

Auscultation of Bilateral Breath Sounds Does Not Rule Out Endobronchial Intubation in Children

Susan T. Verghese, MD^*, Raafat S. Hannallah, MD^*, Michael C. Slack, MD, Russell R. Cross, MD, and Kantilal M. Patel, PhD

Departments of *Anesthesiology, Pediatric Cardiology, and Pediatrics, Children’s National Medical Center and George Washington University Medical Center, Washington, DC

Anesth Analg 2004;99:56-58

連續153例患兒在經口氣管插管全麻下行心導管術。聽診雙側呼吸音以確定導管位置。透視檢查發現18例患兒(11.8%)氣管導管(ETT)頂端位於右主支氣管，29例患兒(19.0%)插管偏深（即導管頂端距隆突1 cm以內）。18例管端位於右主支氣管內的患兒年齡均小於120個月，其中7例小於12個月 (Fisher’s exact test; P = 0.013)。支氣管內插管或插管偏深者的年齡、體重、ETT大小明顯小於管端位於氣管中段的患兒(P < 0.001)。單純聽診呼吸音未能發現支氣管內插管可能與有側孔的Murphy氏ETT的使用有關，其降低了聽診判斷支氣管內插管的可信度。預防支氣管內插管的建議方法有：對聽診的不確切性保持警惕，檢查導管刻度以確定置管深度，儘量減少插管後的頭頸活動。插管後頸部過曲或過伸會改變管端的位置，對此必須有預見性，並慎重考慮插管深度。本組起初插管過深的發生率是20%，使用上述措施後，最後98例患兒降爲7.1%。

（軒　　　 泓 譯　　　 李士通 校）

We performed orotracheal intubation in 153 consecutive pediatric patients undergoing cardiac catheterization. Auscultation of bilateral breath sounds was confirmed. By fluoroscopy, the tip of the endotracheal tube (ETT) was seen in the right mainstem bronchus in 18 patients (11.8%) and in a low position, defined as within 1 cm above the carina, in 29 patients (19.0%). All of the 18 patients with right mainstem intubation were children <120 mo of age, and 7 were infants <12 mo of age (Fisher’s exact test; P = 0.013). The age, weight, and ETT size for children who had endobronchial and low tracheal positions were significantly (P < 0.001) less than for those who had midtracheal positions. The failure to diagnose mainstem intubation by auscultation alone may be related to the use of the Murphy eye ETT, which reduces the reliability of chest auscultation in detecting endobronchial intubation. Suggested measures for preventing endobronchial intubation include maintaining increased awareness of the imperfection or lack of accuracy of the auscultatory method, assessing insertion depth by checking the length scale on the tube, and minimizing the patient’s head and neck movement after intubation. When extreme flexion or extension of the neck is expected after ETT insertion, the resultant change in ETT final position must be anticipated and taken into consideration when deciding on the depth of ETT insertion. This approach resulted in a decrease in improper tube positioning from 20% when the study was initiated to 7.1% in the last 98 patients.

隨機比較綜合處理策略和複合應用止吐劑預防術後噁心嘔吐

A Randomized Comparison of a Multimodal Management Strategy Versus Combination Antiemetics for the Prevention of Postoperative Nausea and Vomiting

Ashraf S. Habib, MBBCh MSc, FRCA^*, William D. White, MPH^*, Steve Eubanks, MD, Theodore N. Pappas, MD, and Tong J. Gan, MB FRCA, FFARCS(I)^*

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

Anesth Analg 2004;99:77-81

綜合處理策略在防止術後噁心和嘔吐方面（PONV）優於使用單個預防噁心和嘔吐的藥物。我們檢驗了以下假設：異丙酚全憑靜脈麻醉複合恩丹司瓊和氟呱利多的綜合處理預防PONV方案效果優於吸入麻醉時使用這些止吐劑。90例行腹腔鏡膽囊切除術的患者被隨機分爲3組。綜合處理組（組1）：異丙酚全憑靜脈麻醉複合恩丹司瓊，氟呱利多。複合止吐劑組（組2）：恩丹司瓊，氟呱利多，術中異氟醚、笑氣維持麻醉。全憑靜脈組（組3）：異丙酚誘導並維持麻醉。術後2小時組 1、2、3的完全有效率（未發生PONV和另外使用止吐劑）分別爲90%、63%、 66%，(組 1 與組2比較，P < 0.05)。24小時3組的有效率分別爲80%, 63%, 43%，(組 1 與組3比較，P < 0.05)。在麻醉復蘇室，綜合組的患者滿意度也優於其他兩組(P < 0.05)。總之，相對於吸入麻醉複合止吐劑或者異丙酚全憑靜脈麻醉這兩種方法，綜合處理策略在預防PONV的有效性和患者滿意度方面更好。

（張俊傑 譯　　　 李士通 校）

A multimodal management strategy for the prevention of postoperative nausea and vomiting (PONV) appears to be superior to single-drug prophylaxis. We tested the hypothesis that a multimodal PONV prophylaxis regimen incorporating total IV anesthesia (TIVA) with propofol and a combination of ondansetron and droperidol is more effective than a combination of these antiemetics in the presence of an inhaled anesthetic. Ninety patients undergoing laparoscopic cholecystectomy were randomized to one of three groups. Group 1 (multimodal group) received TIVA with propofol, droperidol, and ondansetron. Group 2 (combination group) received droperidol and ondansetron with isoflurane and nitrous oxide for the maintenance of anesthesia. Group 3 (TIVA group) received propofol for the induction and maintenance of anesthesia. The complete response rate (no PONV and no rescue antiemetic) at 2 h after surgery was 90%, 63%, and 66% in Groups 1, 2, and 3, respectively (P < 0.05, Group 1 versus Group 2). At 24 h, the complete response rate was 80%, 63%, and 43% in Groups 1, 2, and 3, respectively (P < 0.05, Group 1 versus Group 3). Patient satisfaction was also greater in the multimodal group than in the other two groups in the postanesthesia care unit (P < 0.05). In conclusion, the multimodal management strategy for PONV was associated with a higher complete response rate and greater patient satisfaction when compared with similar antiemetic prophylaxis with inhaled anesthesia or TIVA with propofol.

異丙酚的非麻醉性類似物2,6－雙叔丁基酚（2,6 Di-tert-butylphenol）調整a₁ß甘氨酸受體功能的方式有別於異丙酚

2,6 Di-tert-butylphenol, a Nonanesthetic Propofol Analog, Modulates ₁ß lycine Receptor Function in a Manner Distinct from Propofol

Jörg Ahrens, MD^*, Gertrud Haeseler, MD^*, Martin Leuwer, MD, Bahram Mohammadi, MD, Klaus Krampfl, MD, Reinhard Dengler, MD, and Johannes Bufler, MD

Departments of *Anaesthesiology and Neurology and Neurophysiology, Hannover Medical School, Hannover, Germany; and University Department of Anaesthesia, The University of Liverpool, Liverpool, United Kingdom

Anesth Analg 2004;99:91-96

麻醉藥異丙酚(2,6 diisopropylphenol)通過啟動腦幹較低部位及脊髓部位抑制性氯電流而起到部分麻醉作用。這些作用包括在沒有天然激動劑存在時對GABA-A受體及甘氨酸受體的直接興奮，也包括對亞最大激動濃度的激動劑的增強作用。用雙叔丁基替代異丙酚中的異丙基所産生的化合物在體內無麻醉作用。我們通過異種雜交方法在人胚腎細胞表達大鼠a1ß甘氨酸受體，研究異丙酚及2,6－雙叔丁基酚對內向氯電流的作用。異丙酚可直接活化甘氨酸受體，而2,6－雙叔丁基酚不能啟動之。異丙酚114 ± 27 µM時可觀察到半量最大電流活動。兩種化合物都可將亞最大激動濃度的甘氨酸（10 µM甘氨酸）的作用增強到最大值，異丙酚增強10 µM甘氨酸的作用136% ± 71%，2,6－雙叔丁基酚增強279% ± 109%。該作用50%的有效濃度：異丙酚爲12.5 ± 6.4 µM，2,6－雙叔丁基酚爲9.4 ± 10.2 µM。異丙酚及其非麻醉性類似物在對甘氨酸受體的天然激動劑的增強作用上無差別，但在無天然激動劑存在時直接啟動受體的能力上有差別。

（裘毅敏 譯　　　 李士通 校）

The anesthetic propofol (2,6 diisopropylphenol) mediates some of its effects by activating inhibitory chloride currents in the lower brainstem and spinal cord. The effects comprise direct activation of -aminobutyric acid-A and glycine receptors in the absence of the natural agonist, as well as potentiation of the effect of submaximal agonist concentrations. Replacement of propofol’s isopropyl groups by di-tert-butyl groups yields a compound without in vivo anesthetic effects. We have studied the effects of propofol and 2,6 di-tert-butylphenol on chloride inward currents via rat ₁ß glycine receptors heterologously expressed in human embryonic kidney cells. Propofol, but not 2,6 di-tert-butylphenol, directly activated glycine receptors; half-maximal current activation was observed with propofol 114 ± 27 µM. Both compounds potentiated the effect of a submaximal glycine concentration (10 µM) to a maximum value of 136% ± 71% (propofol) and 279% ± 109% (2,6 di-tert-butylphenol) of the response to glycine 10 µM. The 50% effective concentration for this effect was 12.5 ± 6.4 µM and 9.4 ± 10.2 µM for propofol and 2,6 di-tert-butylphenol, respectively. Propofol and its nonanesthetic structural analog do not differ in their ability to coactivate the glycine receptor but differ in their ability to directly activate the receptor in the absence of the natural agonist.

志願者靜注嗎啡、可待因和曲馬多對瞳孔的影響

The Pupillary Effects of Intravenous Morphine, Codeine, and Tramadol in Volunteers

Roger D. Knaggs, PhD MRPharmS, Isla M. Crighton, MBChB FRCA, Timothy F. Cobby, MBChB FRCA, Anthony J. P. Fletcher, BMBS FRCA, and Gregory J. Hobbs, BMBS FRCA

University Department of Anaesthesia, Queen’s Medical Centre, University Hospital, Nottingham, UK

Anesth Analg 2004;99:108-112

阿片類鎮痛藥有多個器官的藥理作用，其中也包括眼睛。由於嗎啡和可待因的代謝産物在其整個藥效中起一定作用，所以瞳孔測量持續6個小時。我們研究了10個健康志願者靜脈注射嗎啡（1.25mg/kg），可待因（1mg/kg），曲馬多（1.25mg/kg），安慰劑(10ml 0.9％生理鹽水)後瞳孔的變化。瞳孔直徑用瞳孔直徑測量器每隔30min進行測定並比較不同藥物對於瞳孔的影響。統計方法以方差分析法。安慰劑組瞳孔直徑前後沒有明顯的改變。靜脈注射嗎啡和可待因後瞳孔直徑縮小了26％（P<0.001）。在實驗中，所用志願者的瞳孔都漸漸的恢復到原來的大小。在注射了曲馬多後150min內瞳孔沒有明顯的改變，而其後剩餘的實驗時間中瞳孔縮小（P<0.01）。藥物對於瞳孔直徑的影響可能部分是由於所研究的阿片類藥物的藥代動力學不同所致。測定瞳孔直徑可以作爲一種監測阿片藥物中樞作用的參考方法。

（沈　　　 浩 譯 　　李士通 校）

Opioid analgesics have pharmacological effects in many organ systems, including the eye. Because the metabolites of morphine and codeine contribute to their overall pharmacological effect pupil diameter measurements were made over a 6-h period. We studied the pupillary effects of IV morphine (0.125 mg/kg), codeine (1 mg/kg), tramadol (1.25 mg/kg), or placebo (10 mL 0.9% w/v sodium chloride) in 10 healthy volunteers. Pupil diameter was measured every 30 min using a pupil densitometer. Comparisons of the change in pupil diameter for each drug were made using analysis of variance with repeated measures. No significant change in pupil diameter was observed after placebo. After IV morphine and codeine administration there was a 26% decrease in pupil diameter (P < 0.001). Over the course of the study period, pupil diameter gradually returned to baseline values. After administration of tramadol there were no significant changes in pupil diameter until 150 min after administration, after which there was a significant reduction for the remainder of the study period (P < 0.01). The changes in pupil diameter may be explained in part by the pharmacokinetic profiles of the opioids studied. Measurement of pupil diameter may have a place in monitoring the central effect of opioids.

用血栓彈性描記圖研究XIII因數對凝血過程和血塊強度的作用

The Impact of Factor XIII on Coagulation Kinetics and Clot Strength Determined by Thrombelastography

Vance G. Nielsen, MD, William Q. Gurley, Jr, MD, and Thomas M. Burch, MD

Department of Anesthesiology, The University of Alabama at Birmingham

Anesth Analg 2004;99:120-123

纖維蛋白原與血栓彈性描記圖記錄的許多由蛋白介導的血塊凝固強度有關。但是XIII因數(FXIII)的活性在血塊凝固進展過程中也起重要的作用。我們假設不同FXIII活性能顯著增強血塊的凝固。活性爲正常值0%、 1%、6.25%、 12.5%、 25%、 50% 和 100%的FXIII配製成相同容量，並將其與內含1%組織因數和CaCl₂的無FXIII的血漿混合並行血栓彈性描記圖測定10min。測定參數包括反應時間R（凝血開始時間）；α，血塊形成速率；幅度（A，血塊強度）；剪力彈性係數（G，血塊強度）。結果發現FXIII活性能顯著降低R，使其呈指數性衰減(R² = 0.77; P < 0.001)；FXIII活性以S形曲線模式明顯增加α(R² = 0.88; P < 0.001)； 增加FXIII活性能顯著提高A和G，也呈S形曲線模式(R² = 0.89; P < 0.001)。因此，我們認爲FXIII可顯著影響R，α，A，G。由蛋白介導的血栓彈性描記圖提供的輸血決策受纖維蛋白原和FXIII雙重影響。

（趙雪蓮　 譯　　　 李士通 校）

Fibrinogen has been shown to be responsible for most protein-mediated clot strength via thrombelastography. However, factor XIII (FXIII) activity also plays a prominent role in the development of clot strength. Thus, we hypothesized that changes in FXIII activity would significantly increase clot strength. FXIII (0%, 1%, 6.25%, 12.5%, 25%, 50%, and 100% normal activity) was placed in a fixed volume of citrated FXIII-deficient plasma with 1% tissue factor and calcium chloride and underwent thrombelastography for 10 min. We measured the variables reaction time (R; a measurement of clot initiation), (a measure of the rate of clot formation), amplitude (A; a measure of clot strength), and shear elastic modulus (G; a measure of clot strength). FXIII activity significantly decreased R in a pattern of exponential decay (R² = 0.77; P < 0.001). FXIII activity significantly increased , following a sigmoidal pattern (R² = 0.88; P < 0.001). Finally, increases in FXIII activity significantly increased A and G in a sigmoidal pattern (R² = 0.89; P < 0.001). We concluded that FXIII significantly affects R, alpha, A, and G. Thus, transfusion decision making with protein-mediated thrombelastographic patterns must account for the contribution of both fibrinogen and FXIII.

幼鼠術前坐骨神經阻滯更多地降低機械性痛覺超敏：預先鎮痛是否隨發育不同而調整？

Preoperative Sciatic Nerve Block Decreases Mechanical Allodynia More in Young Rats: Is Preemptive Analgesia Developmentally Modulated?

Douglas G. Ririe, MD, David Barclay, MD, Heather Prout, BA, Chuanyo Tong, MD, Joseph R. Tobin, MD, and James C. Eisenach, MD

Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth Analg 2004;99:140-145

術後對觸覺刺激的敏感性隨年齡而不同。在本研究中，我們假設幼鼠術前坐骨神經阻滯（SNB）通過提供預先鎮痛比術後SNB鎮痛效果好。用爪底切口的術後疼痛模型，2或4周齡的雄性Sprague-Dawley鼠接受全身麻醉，然後給予左側0.5%布比卡因5 µL/g或生理鹽水的SNB。SNB在術前或術後進行。在SNB和手術前後各時點用von Frey細絲評價機械性痛覺超敏。在2周齡大鼠，術前SNB顯著降低機械性痛覺超敏，該組的機械性痛覺超敏的閾值在術後2、5和24 h比生理鹽水組高（P<0.03）。在術後24 h時，術前SNB組的閾值爲4.0 ± 0.7 g，術後SNB組爲1.6 ± 0.3 g（P=0.004）。4周大小的鼠在任何時點，術前與術後SNB之間均無差異。這些結果提示年幼的動物術前SNB提供與年齡或發育相關的對機械性痛覺超敏的預先鎮痛作用。

（馬皓琳　 譯　　　 李士通　 校）

Postoperative sensitivity to tactile stimuli differs as a function of age. In this study, we hypothesized that preoperative sciatic nerve block (SNB), by providing preemptive analgesia, would result in better analgesia than postoperative SNB in the young rat. With the paw incision model of postoperative pain, male Sprague-Dawley rats, aged 2 or 4 wk, underwent general anesthesia and then received a left SNB with 5 µL/g of 0.5% bupivacaine or normal saline. SNB was performed either before or after surgery. Mechanical allodynia was assessed by using von Frey filaments before and at various times after SNB and surgery. In the 2-wk-old rats, preoperative SNB produced a significant reduction in mechanical allodynia, as reflected by a higher threshold at 2, 5, and 24 h when compared with saline control (P < 0.03). At 24 h, the threshold was 4.0 ± 0.7 g in the preoperative SNB group compared with 1.6 ± 0.3 g in the postoperative SNB group (P = 0.004). There was no difference at any time point between the preoperative and the postoperative SNB in the 4-wk-old animals. These results suggest that preoperative SNB in young animals provides a preemptive analgesic effect on mechanical allodynia that is age or developmentally dependent.

單腔和多腔中心靜脈導管置管的細菌定植和血液感染：一項定量的系統評估

Colonization and Bloodstream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review

Mathias Zürcher, MD, Martin R. Tramèr, MD DPhil, and Bernhard Walder, MD

Division of Surgical Intensive Care and the Center for Evidence-Based Critical Care, Anesthesia and Pain Treatment, Division of Anesthesiology, Geneva University Hospitals, Geneva, Switzerland

Anesth Analg 2004;99:177-182

中心靜脈導管的腔數是否會影響與置管相關的血液感染的發生率仍有爭論。我們對隨機地比較單腔中心靜脈導管和多腔導管的全部報告(截至到2003年4月的MEDLINE, PREMEDLINE, Cochrane Library, EMBASE, BIOSIS Previews, CINAHL, HealthSTAR/Ovid healthstar, bibliographies收錄的所有文字發表的文獻)進行了系統的研究。研究必須包括導管的細菌定植或者血液感染的資料。用固定效應模式進行Meta分析。資料用概率和95%可信區間的需要治療的病人數來表示。五個隨機試驗（1987-1995）納入分析，分析了255個單腔中心靜脈導管和275個多腔中心靜脈導管的資料。平均置管時間：多腔導管爲8至21天，單腔導管爲9至24天。在四個試驗中，多腔有23/176發生細菌定植，單腔有26/177（概率,0.92;95%可信區間,0.49-1.72）。在五個試驗中，多腔導管的血液感染發生率爲23/275（8.4%），單腔導管爲8/255（3.1%）（概率,2.58;95%可信區間1.24-5.37；需要治療的病人數19；95%可信區間11-75）。如果用單腔中心靜脈導管代替多腔導管，每20個病人可避免一個病人發生血液感染。導管細菌定植的危險性沒有下降。儘管這些結論是基於有限的資料，但是單腔中心靜脈導管應盡可能在可行的時候選用。

（彭中美 譯 李士通 校）

There is a controversy as to whether the number of lumens in the central venous catheters may impact the incidence of catheter-related bloodstream infection. We performed a systematic search (MEDLINE, PREMEDLINE, Cochrane Library, EMBASE, BIOSIS Previews, CINAHL, HealthSTAR/Ovid healthstar, bibliographies, any language, to April, 2003) for full reports on randomized comparisons of single-lumen and multi-lumen catheters. Trials had to report on dichotomous data of catheter colonization or bloodstream infection. Meta-analyses were performed using a fixed effect model. Data were expressed as odds ratio (OR) and number-needed-to-treat (NNT) with 95% confidence interval (CI). Five randomized trials (1987–1995) with data on 255 single-lumen and 275 multi-lumen catheters were analyzed. Average insertion times were 8 to 21 days with multi-lumen catheters and 9 to 24 days with single-lumen catheters. In 4 trials, 23 of 176 (13.1%) multi-lumen and 26 of 177 (14.7%) single-lumen catheters were colonized (OR, 0.92; 95% CI, 0.49–1.72). In 5 trials, bloodstream infection occurred with 23 of 275 (8.4%) multi-lumen and with 8 of 255 (3.1%) single-lumen catheters (OR, 2.58; 95% CI, 1.24–5.37; NNT, 19; 95% CI, 11–75). For every 20 single-lumen catheters inserted, one bloodstream infection will be avoided that would have occurred had multi-lumen catheters been used. The risk of catheter colonization is not decreased. Although these conclusions are based on limited data, single-lumen catheters should be used whenever feasible.

二十個月常規使用新的帶可控旋轉擴張器的經皮氣管造瘻套管

Twenty Months’ Routine Use of a New Percutaneous Tracheostomy Set Using Controlled Rotating Dilation

Neel Sengupta, BSc (Hons), MBBS, Keng Leong Ang, MBBCh BAO, MRCS, Doraiswamy Prakash, FRCA, Vivien Ng, BSc (Hons), MBBS, and Shane J. George, FRCP FRCA

Intensive Care Unit, Harefield Hospital, Royal Brompton & Harefield Hospitals NHS Trust, Middlesex, UK

Anesth Analg 2004;99:188-192

通過一個理想的試用期後，我們在2002年2月採用新的PercuTwist^TM經皮氣管造瘻套裝置做爲常規。接下來20個月，進行了90例此項操作，只有極小的並發症。爲了前瞻性評估此經歷，我們收集的資訊包括病人進入監護病房的原因、手術者先前的經驗、原先氣管插管的持續時間、操作所需要時間、困難分級、出血量和操作並發症。其中90個操作過程中22個(24.4%)由高年資的有經驗的醫生完成；90個操作中的68個(75.6%)由監護病房的住院醫生在床旁密切指導下安全完成。操作所需要的平均時間爲13分鐘7秒。在全部研究中只有一例在插入過程中覺得有困難，原因是最初的皮膚切口太小。沒有遇到大的出血和並發症。

（張　 曦　　 譯　　　 李士通　 校）

After a favorable trial period, we introduced the new percutaneous tracheostomy set, PercuTwist^TM, in February of 2002 for our routine procedures. Over the next 20 mo, 90 procedures were performed with minimal complications. To prospectively evaluate this experience, we collected information on reasons for unit admission, operators’ previous experience, the duration of prior tracheal intubation, the time needed for the procedure, the grading of the difficulty, the amount of bleeding, and the complications of the procedure. Twenty-two of 90 (24.4%) procedures were performed by senior consultants with experience; 68 of 90 (75.6%) were safely performed by intensive care residents under close bedside supervision. The mean time needed for the procedure was 13 min 7 s. In only one procedure during the entire study was any difficulty observed during the insertion process. This occurred because the initial skin incision was too small. However, no major bleeding or complications were encountered.

在伴有嚴重多器官功能障礙綜合征的晚期血管擴張性休克病人中應用精氨酸抗利尿激素會影響凝血系統嗎?

Does Arginine Vasopressin Influence the Coagulation System in Advanced Vasodilatory Shock with Severe Multiorgan Dysfunction Syndrome?

Martin W. Dünser, MD^*, Dietmar R. Fries, MD^*, Wolfgang Schobersberger, MD^*, Hanno Ulmer, PhD, Volker Wenzel, MD^*, Barbara Friesenecker, MD^*, Walter R. Hasibeder, MD^*, and Andreas J. Mayr, MD^*

*Division of General and Surgical Intensive Care Medicine, Department of Anesthesiology and Critical Care Medicine, and the Institute of Medical Biostatistics, The University of Innsbruck, Innsbruck, Austria

Anesth Analg 2004;99:201-206

精氨酸抗利尿激素(AVP) 對晚期血管擴張性休克是有效的強化性血管收縮藥，但是在　 AVP 治療期間已有關於血小板計數減少的報道。 在這項研究中，我們評估了晚期血管擴張性休克時AVP輸注對凝血系統的影響，並與單獨注入去甲腎上腺素相比較。42例血管擴張性休克的病人 （去甲腎上腺素需求 >0.5 μ g • kg– 1 • min– 1，平均動脈壓 <70 mmHg）隨機接受額外的AVP輸注 (4 U/h) 或單獨輸注去甲腎上腺素。大多數的病人應用了啟動凝血系統的治療 (新鮮冷凍血漿,濃縮血小板，凝血因數和肝素下持續靜-靜脈血液透析濾過)。在隨機化分組前和分組治療後 1、24、48 h 時，檢測凝血系統的實驗室指標和改良血栓彈力圖。組間血漿凝血物質沒有明顯差異。儘管組間比較沒有統計學差異，但血小板在使用AVP 的病人明顯減少 (P = 0.036)。 改良血栓彈力圖分析的結果在組間無明顯差異。 在伴有嚴重多器官功能障礙綜合征的晚期血管擴張性休克病人中應用精氨酸抗利尿激素不會影響血漿中VIII因數、von Willebrand因數抗原和 ristocetin 輔助因數的濃度，但可能促使血小板聚合而且引起血小板減少症。改良血栓彈力圖測定的總體凝血功能與單獨輸注去甲腎上腺素的病人比較沒有不同。

（朱 慧譯 李士通校）

Arginine vasopressin (AVP) is a potent supplementary vasopressor in advanced vasodilatory shock, but decreases in platelet count have been reported during AVP therapy. In this study we evaluated the effects of AVP infusion on the coagulation system in advanced vasodilatory shock when compared to norepinephrine (NE) infusion alone. Forty-two patients with advanced vasodilatory shock (NE requirements >0.5 µg • kg^–1 • min^–1, mean arterial blood pressure <70 mm Hg) were prospectively randomized to receive an additional AVP infusion (4 U/h) or NE infusion alone. Most patients received coagulation active treatment (fresh-frozen plasma, thrombocyte concentrates, coagulation factors, and continuous veno-venous hemofiltration with heparin). At baseline and 1, 24, and 48 h after randomization, coagulation laboratory variables and a modified thrombelastography were measured. There were no differences between groups in plasmatic coagulation variables. Although there was no significant difference between groups, platelet count significantly decreased in AVP patients (P = 0.036). There were no differences in results of modified thrombelastography analyses between groups. AVP infusion in advanced vasodilatory shock with severe multiorgan dysfunction syndrome does not increase plasma concentrations of Factor VIII, von Willebrand Factor antigen, and ristocetin Co-Factor but may stimulate platelet aggregation and induce thrombocytopenia. Global coagulation, assessed by modified thrombelastography, is not different from patients receiving NE infusion alone.

動脈-頸內靜脈血氧含量差與顱腦外傷病人預後

Arterio-Jugular Difference of Oxygen Content and Outcome After Head Injury

Nino Stocchetti, MD, Katia Canavesi, MD, Sandra Magnoni, MD, Valerio Valeriani, MD, Valeria Conte, MD, Sandra Rossi, MD, Luca Longhi, MD, Elisa Roncati Zanier, MD, and Angelo Colombo, MD

Istituto Anestesia e Rianimazione, Università di Milano, Terapia Intensiva Neuroscienze, Ospedale Maggiore Policlinico, Istituto Ricovero e Cura a Carattere Scientifico, Milan, Italy

Anesth Analg 2004;99:230-234

本研究通過調查大樣本嚴重顱腦外傷病人的AJDO₂（動脈－頸內靜脈血氧含量差），確定AJDO₂在外傷後最初幾天內的模式並描述其與急性神經功能障礙的嚴重程度和外傷後6個月預後的關係。229名昏迷狀態的顱腦外傷病人，監測顱內壓，腦灌注壓和AJDO₂。在外傷後六個月評價這些病人的預後。頸內靜脈血氧飽和度(SjO₂)平均值爲68％。AJDO₂平均值爲4.24 vol% (標準差, 1.3 vol%)。有80個測量值（4.6％）其SjO₂ <55%和304個測量值SjO₂ >75%。8個測量值AJDO₂高於8.7 vol% (0.4%)及718個測量值AJDO₂低於3.9 vol% (42%)。病人AJDO₂第一個測量值比較高，而在隨後的幾天裏其值逐步下降。預後良好的病人AJDO₂平均值(4.3 vol%; 標準差, 0.3 vol%)高於那些發生嚴重殘疾或陷入植物狀態(3.8 vol%; 標準差, 1.3 vol%)和死亡的病人(3.6 vol%; 標準差, 1 vol%)，且差別具有統計學意義(P < 0.001)。可以推斷低水平的AJDO₂與不良預後有關而正常或高水準的AJDO₂預示較好的預後。

（周雅春 譯　 李士通 校）

This study investigated AJDO₂ (arterio-jugular difference of oxygen content) in a large sample of severely head-injured patients to identify its pattern during the first days after injury and to describe the relationship of AJDO₂ with acute neurological severity and with outcome 6 mo after trauma. In 229 comatose head-injured patients, we monitored intracranial pressure, cerebral perfusion pressure, and AJDO₂. Outcome was defined 6 mo after injury. Jugular hemoglobin oxygen saturation (SjO₂) averaged 68%. The mean AJDO₂ was 4.24 vol% (SD, 1.3 vol%). There were 80 measurements (4.6%) with SjO₂ <55% and 304 (17.6%) with saturation >75%. AJDO₂ was higher than 8.7 vol% in 8 measurements (0.4%) and was lower than 3.9 vol% in 718 (42%) measurements. AJDO₂ was higher during the first tests and decreased steadily over the next few days. Cases with a favorable outcome had a higher mean AJDO₂ (4.3 vol%; SD, 0.3 vol%) than patients with severe disability or vegetative status (3.8 vol%; SD, 1.3 vol%) and patients who died (3.6 vol%; SD, 1 vol%). This difference was significant (P < 0.001). We conclude that low levels of AJDO₂ are correlated with a poor prognosis, whereas normal or high levels of AJDO₂ are predictive of better results.

判斷進入硬脊膜外腔：分別用空氣、利多卡因或複合空氣和利多卡因阻力消失法

Identification of the Epidural Space: Loss of Resistance with Air, Lidocaine, or the Combination of Air and Lidocaine

Samuel Evron, MD^*, Daniel Sessler, MD, Oscar Sadan, MD, Mona Boaz, Marek Glezerman, MD, and Tiberiu Ezri, MD^||

*Obstetric Anesthesia Unit, Department of Obstetrics and Gynecology, Epidemiology Unit, and ||Department of Anesthesia, The Edith Wolfson Medical Center, Holon, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Israel; and Outcomes Research^TM Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2004;99:245-250

判斷進入硬脊膜外腔的理想技術仍不清楚。547例需要硬脊膜外腔鎮痛的即將分娩的孕婦根據判斷進入硬脊膜外腔的技術隨機分成三組：1）空氣阻力消失法（空氣組，n=180）；2）利多卡因阻力消失法（利多卡因組，n=185）；3）空氣和利多卡因阻力消失法（空氣+利多卡因組，n=182）。評估硬脊膜外腔導管置入的難易程度、阻滯的特性、鎮痛的效果及並發症。不能置入硬脊膜外腔導管的發生率在空氣組是16%，利多卡因組是4%，空氣+利多卡因組是3%（P<0.001）；在空氣組有更多的患者阻滯不全（分別是6.6%，3.2%，2.2%；P<0.02）；意外的硬脊膜穿破的發生也是在空氣組較高（1.7%對另兩組的0%；P<0.02）。疼痛評分、鎮痛的起效時間、上面的感覺阻滯平面、運動阻滯、低血壓的發生、暫態的神經症狀、產後尿瀦留和硬脊膜刺破後的頭痛均相當。用空氣判斷進入硬脊膜外腔比用利多卡因或空氣+利多卡因更困難，刺破硬脊膜的發生更高。另外，按順序應用空氣和利多卡因與單獨應用利多卡因相比沒有優勢。

（陳瑋譯 李士通 校）

The ideal technique for identifying the epidural space remains unclear. Five-hundred-forty-seven women in labor who requested epidural analgesia were randomly allocated to three groups according to the technique by which the epidural space was identified: 1) loss-of-resistance with air (air; n = 180), 2) loss-of-resistance with lidocaine (lidocaine; n = 185), and 3) loss-of-resistance with both air and lidocaine (air-plus-lidocaine; n = 182). We assessed ease of epidural catheter insertion, characteristics of the blockade, quality of analgesia, and complications. The inability to thread the epidural catheter occurred in 16% of the air, 4% of the lidocaine, and 3% of the air-plus-lidocaine patients (P < 0.001). More patients from the air group had unblocked segments (6.6% versus 3.2% and 2.2%, respectively; P < 0.02). The incidence of accidental dural puncture was greater in the air group (1.7% versus 0% in the other two groups; P < 0.02). Pain scores, time to onset of analgesia, upper sensory level, motor blockade, and the incidence of hypotension, transient neurological deficits, postpartum urinary retention, and postdural puncture headache were comparable. Identification of the epidural space with air was more difficult and caused more dural punctures than with lidocaine or air plus lidocaine. Additionally, sequential use of air and lidocaine had no advantage over lidocaine alone.

新型喉周通氣道(CobraPLA^TM)與喉罩通氣道(LMA^TM)相比同樣有效，且提供更好的氣道密閉性

The New Perilaryngeal Airway (CobraPLA^TM) Is as Efficient as the Laryngeal Mask Airway (LMA^TM) but Provides Better Airway Sealing Pressures

Ozan Akça, MD, Anupama Wadhwa, MD, Papiya Sengupta, MD, Jaleel Durrani, MD, Keith Hanni, MD, Mary Wenke, CRNA, Yüksel Yücel, MD, Rainer Lenhardt, MD, Anthony G. Doufas, MD PhD, and Daniel I. Sessler, MD

OUTCOMES RESEARCH^TM Institute and the Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2004;99:272-278

喉罩通氣道(LMA)是一種常用的有效通氣裝置，然而其密閉性差，降低了正壓通氣的有效性。喉周通氣道(CobraPLA)是一種新型的通氣裝置，它帶有一個更大的喉部套囊（充氣時）。我們檢驗了這樣一個假設：CobraPLA在置入時間和氣道密閉壓力方面優於LMA，而氣道通暢性和術後恢復情況相同。81例ASA I–II級的擇期門診手術病人隨機分組，先給予咪唑安定、芬太尼，然後用丙泊酚2.5 mg/kg IV麻醉誘導，置入LMA 或 CobraPLA。我們觀測：1) 置入時間；2) 通氣的足夠性(在 15-cm-H₂O峰壓下或潮氣量達 5 mL/kg無漏氣)；3) 氣道密閉壓力；4)調整置管的次數；5) 密閉性(在潮氣量達8 mL/kg時無漏氣)。在手術結束之後，我們對胃脹氣、喉嚨痛、發音困難、吞咽困難進行評價。資料用非配對Student t檢驗、卡方檢驗或Fisher確切概率法進行統計分析，P < 0.05爲有顯著性差異。兩組病人在一般特性、通氣道置入時間、通氣足夠性、調整置管次數和術後恢復方面相似。而CobraPLA 組的氣道密閉壓顯著高於LMA組(23±6cm H₂O vs 18±5cm H₂O, P < 0.001)。因此，CobraPLA與LMA有相似的置入特性，而具有更好的氣道密閉性能。

(周志堅 譯　 李士通 校)

The Laryngeal Mask Airway (LMA) is a frequently used efficient airway device, yet it sometimes seals poorly, thus reducing the efficacy of positive-pressure ventilation. The Perilaryngeal Airway (CobraPLA) is a novel airway device with a larger pharyngeal cuff (when inflated). We tested the hypothesis that the CobraPLA was superior to the LMA with regard to insertion time and airway sealing pressure and comparable to the LMA in airway adequacy and recovery characteristics. After midazolam and fentanyl administration, 81 ASA physical status I–II outpatients having elective surgery were randomized to receive an LMA or CobraPLA. Anesthesia was induced with propofol (2.5 mg/kg IV), and the airway was inserted. We measured 1) insertion time; 2) adequacy of the airway (no leak at 15-cm-H₂O peak pressure or tidal volume of 5 mL/kg); 3) airway sealing pressure; 4) number of repositioning attempts; and 5) sealing quality (no leak at tidal volume of 8 mL/kg). At the end of surgery, gastric insufflation, postoperative sore throat, dysphonia, and dysphagia were evaluated. Data were compared with unpaired Student’s t-tests, ² tests, or Fisher’s exact tests; P < 0.05 was significant. Patient characteristics, insertion times, airway adequacy, number of repositioning attempts, and recovery were similar in each group. Airway sealing pressure was significantly greater with CobraPLA (23 ± 6 cm H₂O) than LMA (18 ± 5 cm H₂O, P < 0.001). The CobraPLA has insertion characteristics similar to the LMA but better airway sealing capabilities.

　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

IMPLICATIONS: The skilled anesthesiologist can easily and effectively perform a lightwand-assisted intubation for patients in a lateral position. This alternative technique should be practiced before attempting it for the first time, and it is recommended for patients who must remain in a lateral position.