Anesthesia & Analgesia

June 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

體外迴圈下心臟手術期間嗜中性粒細胞介導基質金屬蛋白酶-9的分泌和啟動

（殷文淵 譯 陳傑 校）

Neutrophil-Mediated Secretion and Activation of Matrix Metalloproteinase-9 During Cardiac Surgery with Cardiopulmonary Bypass

Tso-Chou Lin, Chi-Yuan Li, Chien-Sung Tsai, Chih-Hung Ku, Ching-Tang Wu, Chih-Shung Wong, and Shung-Tai Ho

Anesth Analg 2005 100: 1554-1560.

高位胸段硬膜外麻醉對冠心病病人左心室收縮及舒張功能的影響

（裘毅敏 譯 李士通 校）

The Effect of High Thoracic Epidural Anesthesia on Systolic and Diastolic Left Ventricular Function in Patients with Coronary Artery Disease

Christoph Schmidt, Frank Hinder, Hugo Van Aken, Gregor Theilmeier, Christian Bruch, Stefan P. Wirtz, Hartmut Bürkle, Tim Gühs, Markus Rothenburger, and Elmar Berendes

Anesth Analg 2005 100: 1561-1569.

馬體內血紅蛋白依賴性氧載體牛血紅蛋白－200的藥代動力學

(王麗珺譯 薛張綱校)

The Pharmacokinetics of Hemoglobin-Based Oxygen Carrier Hemoglobin Glutamer-200 Bovine in the Horse

Lawrence R. Soma, Cornelius E. Uboh, Fuyu Guan, Yi Luo, Peter J. Moate, Raymond C. Boston, and Bernd Driessen

Anesth Analg 2005 100: 1570-1575.

血栓彈性描記法的最大振幅預測包括心肌梗死的術後血栓性併發症

（殷文淵 譯 陳傑 校）

Thromboelastography Maximum Amplitude Predicts Postoperative Thrombotic Complications Including Myocardial Infarction

Douglas J. McCrath, Elisabetta Cerboni, Robert J. Frumento, Andrew L. Hirsh, and Elliott Bennett-Guerrero

Anesth Analg 2005 100: 1576-1583.

揮發性麻醉藥的心臟保護作用：機制和臨床意義

（馬皓琳 譯 李士通 校）

Cardioprotection with Volatile Anesthetics: Mechanisms and Clinical Implications (Review Article)

Stefan G. De Hert, Franco Turani, Sanjiv Mathur, and David F. Stowe

Anesth Analg 2005 100: 1584-1593.

PEDIATRIC ANESTHESIA:

瑞芬太尼在嬰兒氣管插管中的劑量效應

(王麗珺譯 薛張綱校)

Dose-Response of Remifentanil for Tracheal Intubation in Infants

Mark W. Crawford, Jason Hayes, and Juliana M. Tan

Anesth Analg 2005 100: 1599-1604.

兒科病人使用2 ProSeal^TM喉罩通氣與標準喉罩通氣的隨機交叉比較

（肖潔 譯 陳傑 校）

A Randomized Crossover Comparison of the Size 2 Laryngeal Mask Airway ProSeal^TM Versus Laryngeal Mask Airway-Classic^TM in Pediatric Patients

Kai Goldmann and Christian Jakob

Anesth Analg 2005 100: 1605-1610.

在豬動物模型使用電刺激來監測硬膜外穿刺進針位置

（張瑩 譯 李士通 校）

The Use of Electrical Stimulation to Monitor Epidural Needle Advancement in a Porcine Model

Ban C. H. Tsui, Derek Emery, Richard R. E. Uwiera, and Brendan Finucane

Anesth Analg 2005 100: 1611-1613.

達特茅斯手術條件標準的發展和確證

（金 路 譯 薛張綱 校）

Development and Validation of the Dartmouth Operative Conditions Scale

Joseph P. Cravero, George T. Blike, Stephen D. Surgenor, and Jens Jensen

Anesth Analg 2005 100: 1614-1621.

預防性使用地塞米松以減少兒科斜視手術後噁心嘔吐的發生：劑量範圍和安全性評價研究

（肖潔 譯 陳傑 校）

Prophylactic Dexamethasone for Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Dose Ranging and Safety Evaluation Study

Rashmi Madan, Anuj Bhatia, Sajith Chakithandy, Rajeshwari Subramaniam, Gurram Rammohan, Shrinivas Deshpande, Manorama Singh, and H. L. Kaul

Anesth Analg 2005 100: 1622-1626.

AMBULATORY ANESTHESIA:

愛荷華麻醉滿意量表是否可用于評價社區醫院白內障治療時局部麻醉和監護鎮靜下病人的滿意程度？

（周志堅 譯 李士通 校）

Can the Iowa Satisfaction with Anesthesia Scale Be Used to Measure Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation at a Community Hospital?
Donald Fung, Marsha Cohen, Susan Stewart, and Andy Davies

Anesth Analg 2005 100: 1637-1643.

在進行表面局部麻醉和監測下鎮靜時白內障護理的社區醫院中決定病人滿意度的是何種因素

(金 路 譯 薛張綱 校)

What Determines Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation in a Community Hospital Setting?

Donald Fung, Marsha M. Cohen, Susan Stewart, and Andy Davies

Anesth Analg 2005 100: 1644-1650.

ANESTHETIC PHARMACOLOGY:

異丙酚劑量依賴性地通過影響Bcl－2、BAX表達和NO產生減少腫瘤壞死因數（TNF－α）誘導的人臍靜脈內皮細胞凋亡

（顧漪聞 譯 陳傑 校）

Propofol Dose-Dependently Reduces Tumor Necrosis Factor--Induced Human Umbilical Vein Endothelial Cell Apoptosis: Effects on Bcl-2 and Bax Expression and Nitric Oxide Generation

Tao Luo, Zhengyuan Xia, David M. Ansley, Jingping Ouyang, David J. Granville, Yinping Li, Zhong-Yuan Xia, Qing-Shan Zhou, and Xian-Yi Liu

Anesth Analg 2005 100: 1653-1659.

氯胺酮立體選擇性抑制培養海馬神經元的自發性鈣振盪

（黃施偉 譯 李士通 校）

Ketamine Stereoselectively Inhibits Spontaneous Ca²⁺-Oscillations in Cultured Hippocampal Neurons

Barbara Sinner, Oliver Friedrich, Wolfgang Zink, Eike Martin, Rainer H. A. Fink, and Bernhard M. Graf

Anesth Analg 2005 100: 1660-1666.

非制動劑1，2-二氯己氟環丁烷（1,2-dichlorohexafluorocyclobutane（F6，2N））和異氟醚對突觸外γ-氨基丁酸受體的不同效應

（沈洪譯 薛張綱 校）

The Differential Effects of the Nonimmobilizer 1,2-Dichlorohexafluorocyclobutane (F6, 2N) and Isoflurane on Extrasynaptic Gamma-Aminobutyric Acid_A Receptors

Misha Perouansky, Mathew I. Banks, and Robert A. Pearce

Anesth Analg 2005 100: 1667-1673.

局麻藥n－丁基－ p－氨基苯甲酸酯可完全阻滯鼠感覺神經元的N－型鈣離子傳導

（顧漪聞 譯 陳傑 校）

The Block of Total and N-Type Calcium Conductance in Mouse Sensory Neurons by the Local Anesthetic n-Butyl-p-Aminobenzoate

Jeroen P. Beekwilder, Daniel L. B. Winkelman, Gertrudis Th. H. van Kempen, Rutgeris J. van den Berg, and Dirk L. Ypey

Anesth Analg 2005 100: 1674-1679.

異氟醚與肌膜上K_ATP通道蛋白激酶C啟動劑的關係

(趙雪蓮 譯 李士通 校)

The Interaction of Isoflurane and Protein Kinase C-Activators on Sarcolemmal K_ATP Channels

Lawrence A. Turner, Kazuhiro Fujimoto, Akihiro Suzuki, Anna Stadnicka, Zeljko J. Bosnjak, and Wai-Meng Kwok

Anesth Analg 2005 100: 1680-1686.

NR3B亞組不改變重組N-甲基D-門冬氨酸受體的麻醉敏感性

（孫敏莉譯，薛張綱校）

The NR3B Subunit Does Not Alter the Anesthetic Sensitivities of Recombinant N-Methyl-d-Aspartate Receptors
Tomohiro Yamakura, Ahmed R. Askalany, Andrey B. Petrenko, Tatsuro Kohno, Hiroshi Baba, and Kenji Sakimura

Anesth Analg 2005 100: 1687-1692

TECHNOLOGY, COMPUTING, AND SIMULATION:

硬膜外導管的電特性：神經刺激引導儀要求什麼?

（顧漪聞 譯 陳傑 校）

The Electrical Properties of Epidural Catheters: What Are the Requirements for Nerve Stimulation Guidance?

Hisayoshi Tamai, Shigehito Sawamura, Hidenao Atarashi, Kenji Takeda, Kazuhiko Ohe, and Kazuo Hanaoka

Anesth Analg 2005 100: 1704-1707.

體循環阻力對麻醉犬阻抗心動描記法測量值的影響

（周雅春 譯 李士通 校）

The Effect of Peripheral Resistance on Impedance Cardiography Measurements in the Anesthetized Dog

Lester A. H. Critchley, Zhi Y. Peng, Benny S. Fok, and Anthony E. James

Anesth Analg 2005 100: 1708-1712.

現場麻醉機機械通氣時的氧氣消耗

（陳瑋 譯 李士通 審校）

Oxygen Consumption with Mechanical Ventilation in a Field Anesthesia Machine (Technical Communication)

Dale F. Szpisjak, Charles L. Lamb, and Kenneth D. Klions

Anesth Analg 2005 100: 1713-1717.

頸外表面監測不能夠評估喉部神經肌肉阻滯作用（經驗交流）

（金琳 譯，薛張綱 校）

An External Monitoring Site at the Neck Cannot Be Used to Measure Neuromuscular Blockade of the Larynx (Technical Communication)
Thomas M. Hemmerling, Guillaume Michaud, Stéphane Deschamps, and Guillaume Trager

Anesth Analg 2005 100: 1718-1722.

通過改良壓力降低方式來檢測單向活瓣功能不全

（顧漪聞 譯 陳傑 校）

Detecting Unidirectional Valve Incompetence by the Modified Pressure Decline Method (Technical Communication)

Wade A. Weigel and W. Bosseau Murray

Anesth Analg 2005 100: 1723-1727

PAIN MEDICINE:

年齡對大鼠嗎啡耐藥性產生的影響

（邱鬱薇 譯 李士通 校）

Age-Dependent Morphine Tolerance Development in the Rat

Yan Wang, James Mitchell, Kumi Moriyama, Ki-jun Kim, Manohar Sharma, Guo-xi Xie, and Pamela Pierce Palmer

Anesth Analg 2005 100: 1733-1739.

慢性疼痛病人對阿片類鎮痛藥量的增加呈年齡依賴性

（吳德華 譯 薛張綱 校）

Age-Dependent Opioid Escalation in Chronic Pain Patients

Chante Buntin-Mushock, Lisa Phillip, Kumi Moriyama, and Pamela Pierce Palmer

Anesth Analg 2005 100: 1740-1745.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

麻醉前訪視後病人的滿意度和所獲的資訊：面對面會談，宣傳資料和錄影三種方法的比較

（朱輝 譯 陳傑 校）

Patient Satisfaction and Information Gain After the Preanesthetic Visit: A Comparison of Face-to-Face Interview, Brochure, and Video

Stephanie A. Snyder-Ramos, Henrik Seintsch, Bernd W. Böttiger, Johann Motsch, Eike Martin, and Martin Bauer

Anesth Analg 2005 100: 1753-1758.

主要麻醉學期刊中隨機對照試驗的質量

(黃麗娜 譯 李士通 校)

The Quality of Randomized Controlled Trials in Major Anesthesiology Journals

Mary Lou V. H. Greenfield, Andrew L. Rosenberg, Michael O’Reilly, Amy M. Shanks, Michelle J. Sliwinski, and Michael D. Nauss

Anesth Analg 2005 100: 1759-1764.

CRITICAL CARE AND TRAUMA:

高頻通氣相和傳統通氣對急性肺損傷和急性呼吸窘迫綜合征治療的比較:系統性回顧和cochrane分析

(孫志榮 譯,薛張綱 校)

High-Frequency Ventilation Versus Conventional Ventilation for the Treatment of Acute Lung Injury and Acute Respiratory Distress Syndrome: A Systematic Review and Cochrane Analysis

Hannah Wunsch, James Mapstone, and Jukka Takala

Anesth Analg 2005 100: 1765-1772

兩種不同羥乙基澱粉溶液（6％賀斯130/0.4和200/0.5）對血粘度的影響

（朱輝 譯 陳傑 校）

The Influence of Two Different Hydroxyethyl Starch Solutions (6% HES 130/0.4 and 200/0.5) on Blood Viscosity

Thomas A. Neff, Lukas Fischler, Michael Mark, Reto Stocker, and Walter H. Reinhart

Anesth Analg 2005 100: 1773-1780.

在血栓彈性描記法中血小板計數對血塊退縮和組織纖溶酶原活化劑介導的纖維蛋白溶解的影響

（張曦 譯 李士通 校）

The Effects of Platelet Count on Clot Retraction and Tissue Plasminogen Activator-Induced Fibrinolysis on Thrombelastography

Nobuyuki Katori, Kenichi A. Tanaka, Fania Szlam, and Jerrold H. Levy

Anesth Analg 2005 100: 1781-1785.

單磷酰脂質A預處理後:危急的局部缺血組織的存活率

(許文妍 譯 薛張綱 校)

Preconditioning with Monophosphoryl Lipid A Improves Survival of Critically Ischemic Tissue
Yves Harder, Claudio Contaldo, Joachim Klenk, Andrej Banic, Stephan M. Jakob, and Dominique Erni

Anesth Analg 2005 100: 1786-1792.

NEUROSURGICAL ANESTHESIA:

在兒科脊柱側彎手術中異氟醚和地氟醚逐步增加劑量腦雙頻指數維持在60時對皮層體感誘發電位的影響

（朱玫娟 譯 陳傑 校）

The Effects of Isoflurane and Desflurane Titrated to a Bispectral Index of 60 on the Cortical Somatosensory Evoked Potential During Pediatric Scoliosis Surgery

James E. Fletcher, Albert R. Hinn, Christopher M. Heard, Linda S. Georges, Eugene B. Freid, Ann Keifer, Sandra D. Brooks, Ann G. Bailey, and Robert D. Valley

Anesth Analg 2005 100: 1797-1803.

REGIONAL ANESTHESIA:

比較用利多卡因和其他局麻藥脊麻後的一過性神經症狀：對隨機對照試驗的一個系統性回顧

（朱慧 譯 李士通 校）

Transient Neurologic Symptoms After Spinal Anesthesia with Lidocaine Versus Other Local Anesthetics: A Systematic Review of Randomized, Controlled Trials

Dusanka Zaric, Christian Christiansen, Nathan L. Pace, and Yodying Punjasawadwong

Anesth Analg 2005 100: 1811-1816.

昂丹司瓊全身性給藥能拮抗椎管內利多卡因的感覺阻滯作用

（蔡美華 譯 薛張綱 校）

Systemic Ondansetron Antagonizes the Sensory Block Produced by Intrathecal Lidocaine
Argyro Fassoulaki, A. Melemeni, Marianna Zotou, and Constantine Sarantopoulos

Anesth Analg 2005 100: 1817-1821.

家庭持續周圍神經阻滯:綜述

（朱玫娟 譯 陳傑 校）

Continuous Peripheral Nerve Blocks at Home: A Review (Review Article)
Brian M. Ilfeld and F. Kayser Enneking

Anesth Analg 2005 100: 1822-1833.

GENERAL ARTICLES:

氣管導管拔除時的殘餘肌松

（馬皓琳 譯 李士通 校）

Residual Paralysis at the Time of Tracheal Extubation

Glenn S. Murphy, Joseph W. Szokol, Jesse H. Marymont, Mark Franklin, Michael J. Avram, and Jeffery S. Vender

Anesth Analg 2005 100: 1840-1845.

比較在整形外科大手術中大劑量10%羥乙基澱粉264/0.45與5%白蛋白對凝血功能的影響：一項三盲隨機試驗

（周曉敏 譯 薛張綱 校）

A Triple-Blinded Randomized Trial Comparing the Hemostatic Effects of Large-Dose 10% Hydroxyethyl Starch 264/0.45 Versus 5% Albumin During Major Reconstructive Surgery

Ramiro Arellano, Bing Siang Gan, Mary Jane Salpeter, Erik Yeo, Stuart McCluskey, Ruxandra Pinto, Jonathan Irish, Douglas C. Ross, D. John Doyle, John Parkin, Dale Brown, Lorne Rotstein, Ian Witterick, Wayne Matthews, John Yoo, Peter C. Neligan, Pat Gullane, and Howard Lampe

Anesth Analg 2005 100: 1846-1853.

馬體內血紅蛋白依賴性氧載體牛血紅蛋白－200的藥代動力學

The Pharmacokinetics of Hemoglobin-Based Oxygen Carrier Hemoglobin Glutamer-200 Bovine in the Horse

Lawrence R. Soma, VMD^*, Cornelius E. Uboh, PhD^*, Fuyu Guan, PhD^*, Yi Luo, PhD^*, Peter J. Moate, Magr, SC^*, Raymond C. Boston, PhD^*, and Bernd Driessen, DVM, PhD^*

Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania; Department of Chemistry, Pennsylvania Equine Toxicology & Research Center, West Chester University; and Department of Anesthesiology, David Geffen School of Medicine, University of California-Los Angeles

Anesth Analg 2005;100:1570-1575

小牛血紅蛋白－200(HBOC-200)是一種血紅蛋白依賴性氧載體(HBOC)。它包含了聚合戊二醛牛血紅蛋白。這項研究的目的在於研究在馬體內靜脈注入32.5克HBOC-200溶液後，第一代HBOC的藥代動力學。用我們實驗室最近得出的方法對馬血漿和尿中的HBOC-200進行定量。血漿清除以牛血紅蛋白的容積分佈為基礎。HBOC-200血漿濃度－時間曲線的減退期由非互換2區劃模型來描述，大小聚合物的消除半衰期分別為12和1.3小時，隨著HBOC-200的注入，47.0%象小分子量聚合物那樣消除，53%象大分子量聚合物那樣消除。血漿濃度－時間曲線下的面積是5143.1 µg · h^–1 · mL^–1.，大小聚合物的分配容積分別為86.9 和 63.9 mL/kg，清除率是42.1 和3.8 mL · kg^–1 · h^–1,總之，由於這些溶液的異質性，第一代HBOC的消除要比以往假定的複雜的多。哺乳動物用相同的機制去除血紅蛋白，這並不是馬體內唯一的代謝過程，這一研究的結論可以推廣。

(王麗珺譯 薛張綱校)

Hemoglobin-glutamer-200 (HBOC-200) is a hemoglobin (Hb)-based oxygen carrier (HBOC) comprising glutaraldehyde-polymerized bovine Hb. In this study, we sought to determine the pharmacokinetics of this first generation HBOC after IV infusion of 32.5 g of HBOC-200 solution in horses. Quantification of HBOC-200 in equine plasma and urine was performed using a method recently developed by our laboratory. The elimination from plasma was based on size distribution of the bovine Hb polymer. The decline of plasma concentration-time curve of HBOC-200 was described by a noninterchanging 2-compartmental model. The median elimination half-lives of the small and large aggregates were 1.3 and 12.0 h, respectively. Of the HBOC-200 infused, 47.0% was eliminated as the smaller molecular weight and 53% as the larger molecular weight polymers. The area under the plasma concentration-time curve was 5143.1 µg · h^–1 · mL^–1. The volumes of distribution of the small and large aggregates were 86.9 and 63.9 mL/kg and the clearances were 42.1 and 3.8 mL · kg^–1 · h^–1, respectively. In conclusion, elimination of first generation HBOCs was shown to be more complex than previously assumed because of the heterogeneous nature of these solutions. Mammalian species dispose of Hb using similar mechanisms, and there is no unique metabolic process in the horse that would not allow a logical extension of the general interpretation of this study.

瑞芬太尼在嬰兒氣管插管中的劑量效應

Dose-Response of Remifentanil for Tracheal Intubation in Infants

Mark W. Crawford, MBBS, FRCPC, Jason Hayes, MD, FRCPC, and Juliana M. Tan, MBBS, MMed (Anesth)

Department of Anaesthesia and the Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada

Anesth Analg 2005;100:1599-1604

為了比較瑞芬太尼在嬰兒和兒童氣管插管中的劑量效應，32名足月兒和32名兒童分別用10 µg/kg的格隆溴銨和4.0 mg/kg的異丙酚實施麻醉，並給予四種劑量的瑞芬太尼(1.25, 1.50, 1.75, or 2.00 µg/kg)促進插管。我們採用logistic回歸分析測定瑞芬太尼在50%和98％病人的有效劑量（ED₅₀和ED₉₈）。我們發現嬰兒和兒童的logistic回歸曲線是相似的(P = 0.38)。瑞芬太尼的ED₅₀和ED₉₈分別為1.70 ± 0.1 µg/kg and 2.88 ± 0.5 µg/kg。在第二項雙盲試驗中，24名嬰兒用異丙酚實施麻醉並隨機接受3.0 µg/kg瑞芬太尼或2.0 mg/kg琥珀膽鹼以促進氣管插管。測定呼吸暫停時間、氣管插管條件以及血流動力學改變。我們發現異丙酚/瑞芬太尼組和異丙酚/琥珀膽鹼組的呼吸暫停時間及插管條件是相似的。心動過緩、低血壓和胸壁強直並未發生。我們推斷在嬰兒和兒童的氣管插管過程中使用瑞芬太尼的劑量效應是相似的。相比在嬰兒中採用異丙酚/琥珀膽鹼，異丙酚/瑞芬太尼提供了臨床可接受的插管條件、穩定的血流動力學和一定時間的呼吸暫停。

(王麗珺譯 薛張綱校)

To compare the dose-response of remifentanil for tracheal intubation in infants and children, 32 healthy full-term infants and 32 children were anesthetized with 10 µg/kg glycopyrrolate and 4.0 mg/kg propofol and administered 1 of 4 doses of remifentanil (1.25, 1.50, 1.75, or 2.00 µg/kg) to facilitate tracheal intubation. We determined the effective doses of remifentanil in 50% (ED₅₀) and 98% (ED₉₈) of patients by using logistic regression analysis. We found that logistic regression curves were similar for infants and children (P = 0.38). ED₅₀ and ED₉₈ values for remifentanil were 1.70 ± 0.1 µg/kg and 2.88 ± 0.5 µg/kg, respectively. In a second double-blind study, 24 infants were anesthetized with propofol and randomized to receive either 3.0 µg/kg remifentanil or 2.0 mg/kg succinylcholine to facilitate tracheal intubation. The duration of apnea, tracheal intubating conditions and hemodynamic changes were determined. We found that the duration of apnea and intubating conditions after propofol/remifentanil were similar to those after propofol/succinylcholine. Bradycardia, hypotension, and chest wall rigidity did not occur. We conclude that the dose-response of remifentanil for tracheal intubation is similar in infants and children. Propofol/remifentanil provides clinically acceptable intubating conditions, stable hemodynamics, and a duration of apnea comparable to that with propofol/succinylcholine in infants.

達特茅斯手術條件標準的發展和確證

Development and Validation of the Dartmouth Operative Conditions Scale

Joseph P. Cravero, MD, George T. Blike, MD, Stephen D. Surgenor, MD, and Jens Jensen, MS

Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

Address correspondence and reprint requests to Joseph P. Cravero, Department of Anesthesiology, Dartmouth Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH 03756.

Anesth Analg 2005;100: 1614-1621

關於小兒科鎮靜實施的研究由於沒有客觀的衡量標準很難進行。該標準應允許就在不同的操作者及技術條件下實施鎮靜時的效果和安全性進行比較。我們推薦達特茅斯手術條件標準（DOCS），它被設計作為一種研究工具用來將不同的鎮靜實施者的操作條件的合理性進行標化。起先，人們採用人性因素方法學建立了一種兒科鎮靜方法的模型，並詳細說明了（DOCS）操作過程中衡量病人條件的標準。為了達到確證，從長達300小時的為測試或評級目的的操作過程錄影帶中選取70段錄影剪輯（各長30秒）。通過比較10位不同的評價者間對各剪輯的打分，證實了其內部評價的可靠性。內部評價的可靠性通過各評價者一年後的再次測試進行評價。測驗編制的正確性通過分析與時間相關的採取鎮靜操作的DOCS的評分改變得到證實。標準的有效性通過對比DOCS和一種修正的舒適度的評分得到驗證。經過10位具有不同背景的衛生保健提供者在為期一年的研究後，DOCS取得了極好的內部評價(kappa = 0.84)和外部評價(kappa = 0.91)一致性。標準的有效性由於從20個相互獨立的錄影剪輯獲得的DOCS和修正的舒適度評分之間密切的相關性（Spearman相關係數=0.98；P<0.001）而得到驗證。麻醉誘導20分鐘後DOCS評分的分佈顯著低於鎮靜開始之前的評分，而鎮靜剛出現時的評分始終高於20分鐘後的評分（p<0.001），因而確定了該標準的測驗編制的正確性。在用於通過影像資料比較兒科鎮靜服務的有效性和安全性方面，DOCS是一個有效的研究工具，而無需考慮為減少焦慮或疼痛在操作過程中所採取的是何種技術。

（金 路 譯 薛張綱 校）

Studies of pediatric sedation practice have suffered from the lack of an objective scale that would allow for a comparison of the effectiveness and safety of sedation provided by various providers and techniques. We present the Dartmouth Operative Conditions Scale (DOCS), which is designed as a research tool to codify the appropriateness of the procedural conditions provided by various sedation interventions. To begin, human factors methodology was used to develop a model of the pediatric sedation process and to define the criteria for measuring a patient’s condition during a procedure (DOCS). To accomplish validation, 70 video clips (30-s duration) were then selected from more than 300 h of procedural video tape for testing/grading purposes. Inter-rater reliability was tested by comparing the score for each video clip among 10 different raters. Intra-rater reliability was evaluated by retesting all of the raters 1 yr after their initial rating. Construct validity was confirmed by analyzing the change in DOCS score relative to the time that sedation intervention was undertaken. Criterion validity was tested by comparing the DOCS to a modified COMFORT® score. The DOCS was completed with excellent inter-rater (kappa = 0.84) and intra-rater (kappa = 0.91) agreement by 10 health care providers with various backgrounds during the 1-yr study period. Criterion validity was supported by the close correlation between the DOCS and the modified COMFORT® scores for 20 distinct video clips (Spearman correlation coefficient = 0.98; P < 0.001). The distribution of DOCS scores 20 min after the anesthetic induction was significantly lower than the scores before initiation of sedation, and scores after emergence were consistently higher than those 20 min after sedation (P < 0.001), thus confirming construct validity of the scale. The DOCS is a validated research tool when used with video data for comparing the effectiveness and safety of pediatric sedation service, regardless of technique used for decreasing anxiety or pain during a procedure.

在進行表面局部麻醉和監測下鎮靜時白內障護理的社區醫院中決定病人滿意度的是何種因素

What Determines Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation in a Community Hospital Setting?

Donald Fung, MD, MSc^*, Marsha M. Cohen, MSc, MD, Susan Stewart, BSc, MA, and Andy Davies, MD^*

*North Bay General Hospital, North Bay, and Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto; Centre for Research in Women’s Health, Sunnybrook & Women’s College Health Sciences Centre and the Department of Health Policy, Management & Evaluation, University of Toronto, Toronto; and North Shores District Health Council, North Bay, Ontario, Canada

Address correspondence and reprint requests to Donald Fung, North Bay General Hospital, 750 Scollard, North Bay, Ontario, Canada.

Anesth Analg 2005;100: 1644-1650.

愛荷華麻醉滿意度標準（ISAS）是一種用來評價監測下麻醉護理時病人滿意度的可靠而又有效的工具。我們用ISAS來探索在一所小規模社區醫院中進行表面局部麻醉和監測下鎮靜時白內障護理的病人滿意度決定因素。ISAS（評分1-6）在306例白內障手術後的病人中馬上進行。所有病人均接受由麻醉醫生實施的表面局麻和四級鎮靜。病人滿意度較高：平均ISAS為5.6（標準差：0.46；範圍：3.3-6.0）。術中和術後疼痛發生率分別為13%和37%；其他負反應發生率很低（<0.5%）。在多因素邏輯回歸分析中，有意義的滿意度預測因素為術後疼痛(優勢比 [OR]: 4.84; 99% 可信限 [CI]: 2.21, 10.60)，手術醫生(OR: 0.21; 99% CI: 0.05, 0.91),以及術前焦慮(OR: 1.17; 99% CI: 1.03, 1.34)。ISAS平均評分(OR = 0.28; 99% CI: 0.13, 0.59)和手術前焦慮(OR = 1.12; 99% CI: 0.99, 1.28)可作為體驗這一低質量級別的有意義預測因素。我們的結果顯示ISAS可用來跟蹤監測下白內障護理的病人滿意度。白內障手術中和術後疼痛很常見，這也是患者對白內障護理滿意度低的一個主要原因。

(金 路 譯 薛張綱 校)

The Iowa Satisfaction with Anesthesia Scale (ISAS) is a reliable and valid tool to measure patient satisfaction with monitored anesthesia care. We used the ISAS to discover determinants of patient satisfaction with cataract care under topical local anesthesia and monitored sedation in a small community hospital. The ISAS (scored 1 to 6) was administered to 306 patients immediately after cataract surgery. All patients received topical local anesthesia and IV sedation administered by an anesthesiologist. Patient satisfaction was high: mean ISAS was 5.6 (sd 0.46; range: 3.3–6.0). The incidence of intraoperative and postoperative pain was 13% and 37%; other adverse events were infrequent (<5%). In multivariable logistic regression, significant predictors of satisfaction were postoperative pain (odds ratio [OR]: 4.84; 99% confidence interval [CI]: 2.21, 10.60), surgeon (OR: 0.21; 99% CI: 0.05, 0.91), and preoperative anxiety (OR: 1.17; 99% CI: 1.03, 1.34). ISAS mean scores (OR = 0.28; 99% CI: 0.13, 0.59) and preoperative anxiety (OR = 1.12; 99% CI: 0.99, 1.28) emerged as significant predictors of low rating of quality of experience. Our results indicate that the ISAS can be used to track patient satisfaction with monitored cataract care. Pain during and after cataract surgery is common and is a major reason for lower patient satisfaction with their cataract care.

非制動劑1，2-二氯己氟環丁烷（1,2-dichlorohexafluorocyclobutane（F6，2N））和異氟醚對突觸外γ-氨基丁酸受體的不同效應

The differential effects of the nonimmobilizer 1,2-dichlorohexafluorocyclobutane (F6, 2N) and isoflurane on extrasynaptic gamma-aminobutyric acid A receptors.

Perouansky M, Banks MI, Pearce RA.

Department of Anesthesiology, University of Wisconsin, Madison, WI 53792-3272, USA.

Anesth Analg. 2005 Jun;100 (6):1667-73.

非制動劑1，2-二氯己氟環丁烷（1,2-dichlorohexafluorocyclobutane（F6，也稱為2N））能夠分別在低於或高於預測濃度(MACpred)導致遺忘或驚厥。這些效應的細胞學以及分子學基礎還不清楚。我們先前報導過F6對軀體海馬錐體細胞突觸的γ-氨基丁酸(GABA)A受體沒有作用。然而，在海馬神經元的突觸下GABAA受體與位於突觸外的這些受體有不同的藥理學特性，這些不同的受體可能有不同的生理功能。因此我們研究了F6和異氟醚對通過暴露于短暫高濃度脈衝的γ-氨基丁酸的有核離體碎片，主要由從海馬神經元獲得的突觸外GABAA受體介導的電流的影響。我們發現大多數神經元的突觸外GABAA受體對110 microM濃度以下的F6不敏感，儘管從公認的中間神經元獲得的受體可以被43 microM濃度的F6有效抑制。與此相反，異氟醚能夠始終降低最大幅度以及減慢突觸外受體介導電流的弱化，與其對突觸受體作用相似。這些結果表明錐體神經元的突觸外GABAA受體對異氟醚有選擇性敏感，而對F6卻沒有。

（沈洪譯 薛張綱 校）

The nonimmobilizer 1,2-dichlorohexafluorocyclobutane (F6; also known as 2N) causes amnesia and seizures at concentrations less than and more than, respectively, than that predicted to cause immobility (MACpred). The molecular and cellular basis of these effects is not known. We reported previously that F6 has no effect on synaptic gamma aminobutyric acid (GABA)A receptors located on the somata of hippocampal pyramidal cells. However, in hippocampal neurons, GABAA receptors that are located subsynaptically have different pharmacologic properties from those at extrasynaptic sites, and these classes of receptors may serve different physiologic functions. Therefore, we investigated the effects of F6 and isoflurane on currents mediated predominantly by extrasynaptic GABAA receptors harvested from hippocampal neurons by exposing nucleated excised patches to brief, high-concentration pulses of GABA. We found that extrasynaptic GABAA receptors in the majority of neurons located in the pyramidal cell layer are insensitive to F6 at concentrations up to 110 microM, although receptors harvested from one putative interneuron were potently inhibited by 43 microM of F6. By contrast, isoflurane consistently reduced the peak amplitude and slowed deactivation of currents mediated by extrasynaptic receptors, similar to its effect on synaptic receptors. These results demonstrate the selective sensitivity of extrasynaptic GABAA receptors on pyramidal neurons to isoflurane but not F6.

NR3B亞組不改變重組N-甲基D-門冬氨酸受體的麻醉敏感性

The NR3B subunit does not alter the anesthetic sensitivities of recombinant N-methyl-D-aspartate receptors.

Yamakura T, Askalany AR, Petrenko AB, Kohno T, Baba H, Sakimura K.
Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan.

Anesth Analg. 2005 ,100 (6):1687-92.

N-甲基D-門冬氨酸受體或配有NR1和NR2的NR3B亞組構成一個受體或具有明確的通道特性。在最近的研究中，我們研究了表達在非洲蟾蜍卵母細胞上的NR1/NR2通道NR3B亞組在NMDA受體的麻醉敏感性共同表達的效應。儘管NR3B亞組顯著地減少NR1/NR2A-B通道的當前幅度，但通過NR3B亞組的複合表達，NR1/NR2A-B通道對Mg2+、胺碘酮、異氟醚、氧化氮及乙醇的敏感性不改變。這些結果提示NMDA受體的麻醉敏感性不依賴於NR3亞組的存在或缺乏。在NR3B亞組兩個氨基酸殘基的突變在同源的NR1和NR2的N和N + 1位點，它們構成阻斷Mg2+和胺碘酮的位點，但並不影響NR1/NR2B/NR3B通道對Mg2+、胺碘酮和異氟醚的敏感性。因而，NR3B亞組在N和N + 1位點的氨基酸殘基不太可能構成在NR1/NR2/NR3通道的阻斷位點。

（孫敏莉譯，薛張綱校）

The N-methyl-D-aspartate (NMDA) receptor NR3B subunit co-assembles with NR1 and NR2 subunits to form a receptor complex with distinct channel properties. In the present study, we investigated the effects of co-expression of the NR3B subunit on the anesthetic sensitivities of NMDA receptors for NR1/NR2 channels expressed in Xenopus oocytes. Although the NR3B subunit prominently reduced the current amplitude of NR1/NR2A-B channels, the sensitivities of NR1/NR2A-B channels to Mg2+, ketamine, isoflurane, nitrous oxide, and ethanol were not altered by coexpression of the NR3B subunit. These results suggest that the anesthetic sensitivities of NMDA receptors do not depend on the presence or absence of the NR3 subunit. Mutations of two amino acid residues in the NR3B subunit at positions homologous to the N and N + 1 sites in the NR1 and NR2 subunits, which constitute the blocking sites for Mg2+ and ketamine, did not affect the sensitivities of NR1/NR2B/NR3B channels to Mg2+, ketamine and isoflurane. Thus, the amino acid residues at the N and N + 1 sites in NR3 subunits are unlikely to be involved in the formation of channel blocking sites in NR1/NR2/NR3 channels.

頸外表面監測不能夠評估喉部神經肌肉阻滯作用（經驗交流）

An External Monitoring Site at the Neck Cannot Be Used to Measure Neuromuscular Blockade of the Larynx (Technical Communication)

Thomas M. Hemmerling, Guillaume Michaud, Stéphane Deschamps, and Guillaume Trager

Neuromuscular Research Group (NRG), Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal (CHUM) Hôtel-Dieu, Université de Montréal, Canada

Anesth Analg 2005(6) 100: 1718-1722.

肌音描計法是一種新型監測神經肌肉阻滯（NMB）的方法。在使用0.1mg/kg美維庫銨後，我們將環杓側肌（LCA）監測NMB與喉外監測NMB進行比較。我們收集了12位元患者的資料資料，包括以上兩個部位的肌音描計結果。麻醉誘導採用0.25–0.5 µg · kg–1 · min–1的瑞芬太尼、2–3 mg/kg異丙酚。將微型壓電傳聲器置於聲帶側方，在杓狀軟骨基底部插入肌肉層，以記錄LCA收縮產生的聲音信號。另外一個麥克風置於體外甲狀輭骨切跡下方的氣管外側。使用四個成串刺激（TOF）用最大強度連續刺激喉返神經12秒。NMB起始、詳細記錄起始期、峰效應及消失的資料並加以分析討論。無論是峰效應、控制25％、75％及90％顫搐反應及TOF比值恢復至0.5-0.8，體外測量的值都明顯延長。兩組測量的起效時間沒有顯著性差別。我們將帶有麥克風的肌音描計儀置於患者頸部，以評估在喉部進行體外NMB監測的可能性。與LCA監測相比，新法起效時間慢、有一個更為顯著的峰效應。在體外上述部位記錄到的聲音信號似乎與喉肌收縮無關，而與頸部帶肌的收縮有關。

（金琳 譯，薛張綱 校）

Using phonomyography, a new monitoring technique of neuromuscular blockade (NMB), we compared NMB after mivacurium 0.1 mg/kg at the lateral cricoarytenoid muscle (LCA) with a possible external monitoring site of the larynx. In 12 patients, data were obtained at both sites using phonomyography. Anesthesia was induced with remifentanil 0.25–0.5 µg · kg–1 · min–1 followed by propofol 2–3 mg/kg. A small piezo-electric microphone was positioned beside the vocal cords into the muscular process at the base of the arytenoid cartilage to record acoustic signals from the contraction of the LCA. A second microphone was positioned at an external site, lateral to the trachea, just below the thyroid notch. The recurrent laryngeal nerve was stimulated supramaximally using train-of-four (TOF) stimulation every 12 s. Onset, maximum effect, and offset of NMB were measured and compared. Peak effect, time to reach (T) 25%, 75%, and 90% of control twitch response, and TOF recovery to TOF ratios 0.5–0.8 were significantly longer at the external site. The onset time was not significantly different between the two sites. We used phonomyography with a microphone placed at the neck to evaluate the possibility to externally monitor NMB at the larynx. When compared with LCA, we found a more pronounced peak effect and longer offset of NMB. The acoustic signals recorded at this external site are unlikely to stem from laryngeal muscle contraction but are rather a result of contraction of the strap muscles of the neck.

慢性疼痛病人對阿片類鎮痛藥量的增加呈年齡依賴性

Age-dependent opioid escalation in chronic pain patients.

Buntin-Mushock C, Phillip L, Moriyama K, Palmer PP.

University of California, San Francisco, Department of Anesthesia and Perioperative Care, 513 Parnassus Ave., Box 0464, Room S-455, San Francisco, CA 94143, USA.

Anesth Analg. 2005 Jun;10 (6):1740-5.

在一些每日用鎮痛藥治療的病人中可觀察到對阿片類鎮痛藥劑量需求的快速增加，儘管這些病人的可鑒別的臨床特徵還未知。此現象可能由對藥物的耐受性導致。本文對206例患者進行回顧性研究，證明患者的年齡是否與阿片類鎮痛藥快速增加具有相關性。年輕患者和老年患者的初始劑量相似（< or =50 yr; 49 +/- 3 mg/d 口服嗎啡等效劑量 VS > or =60 yr; 42 +/- 3 mg/d）。年輕患者在15+/-1.3個月後達到最大劑量為452+/-63mg/d，老年患者則為14.4+/-1.5個月、211+/-23mg/d（P〈0.0001）。在最後的臨床觀察中，年輕患者平均劑量為365+/-61mg/d，老年患者為168+/-18mg/d（P < 0.0001）。從初始服藥到臨床出院，只有老年患者顯示了可觀察的疼痛評分是降低的（6.9 +/- 0.3 to 5.6 +/- 0.3; P < 0.01）。資料表明患者對阿片類鎮痛藥劑量需求增加因素中年齡是一個重要的變數。雖然也有除阿片類耐受之外的其他因素參與，但老年患者可能有更低的對阿片類鎮痛藥的耐受性。

（吳德華 譯 薛張綱 校）

Rapid opioid dose escalation, possibly caused by tolerance, has been observed in some patients on daily opioid therapy, although clinically identifiable characteristics of these patients are unknown. In this retrospective chart review of 206 patients, we examined whether the age of the patient was related to opioid escalation. Initial starting doses of long-acting opioids were similar in younger patients (< or =50 yr; 49 +/- 3 mg/d oral morphine-equivalent dose) versus older patients (> or =60 yr; 42 +/- 3 mg/d). Younger patients reached a maximum dose of 452 +/- 63 mg/d over 15.0 +/- 1.3 mo, whereas older patients achieved a maximum dose of 211 +/- 23 mg/d over 14.4 +/- 1.5 mo (P < 0.0001). At the last clinic visit, younger-patient dosing averaged 365 +/- 61 mg/d, with older patients averaging 168 +/- 18 mg/d (P < 0.0001). Only older patients demonstrated a reduction in visual analog scale scores from start of opioid therapy until discharge from the clinic (6.9 +/- 0.3 to 5.6 +/- 0.3; P < 0.01). These clinical data suggest that age is an important variable in opioid dose escalation. Although factors other than opioid tolerance can result in dose escalation, it is possible that older patients may have a reduced rate of tolerance development.

高頻通氣相和傳統通氣對急性肺損傷和急性呼吸窘迫綜合征治療的比較:系統性回顧和cochrane分析

High-frequency ventilation versus conventional ventilation for the treatment of acute lung injury and acute respiratory distress syndrome: a systematic review and cochrane analysis.

Wunsch H, Mapstone J, Takala J.
Department of Anesthesiology, Columbia Presbyterian Medical Center, 630 W. 168th St., New York, NY 10032, USA.

Anesth Analg. 2005 Jun;100(6).

這篇綜述,我們檢查了高頻通氣和傳統通氣對小兒和成人急性肺損傷和急性呼吸窘迫綜合征的治療結果.。我們以cochrane協作上的指導方針為根據進行了系統的文獻搜索。兩組試驗引用包含標準;一組招募小兒(n=58),另一組招募成人(n=148)。兩組都採用高頻振動通氣機和包含不同肺容量恢復策略的使用作為干預。干預組顯示了較小的30天後死亡率趨勢(小兒:相對危險[RR],0.83;95%信任時間間隔[CI],0.43-1.42;成人: RR,0.72;95%CI,0.50.-1.03),然而沒有研究顯示統計學上重要區別。同樣,干預組和控制組”呼吸機通氣天數”也沒有統計學的重要區別。兒科研究(RR, 0.36; 95% CI, 0.14-0.93),在復位術危險時補充氧有統計學意義。總體上沒有充分證據推斷高頻通氣可以減低具有急性肺損傷或急性呼吸窘迫綜合征患者的死亡率或長久的死亡率。 (這篇綜述作為Cochrane 綜述發表在The Cochrane Library 2004, Issue 3. Cochrane 綜述作為新證據.注釋.評論時常更新,而最新綜述可在Cochrane Library查閱.)。

(孫志榮 譯,薛張綱 校)

In this review, we examine outcomes from using high-frequency ventilation compared with conventional ventilation as therapy for acute lung injury and acute respiratory distress syndrome in children and adults. We conducted a systematic search of the literature based on the guidelines of the Cochrane Collaboration. Two trials met the inclusion criteria; one recruited children (n = 58), and the other recruited adults (n = 148). Both trials used a high-frequency oscillatory ventilator as the intervention and included variable use of lung-volume recruitment strategies. The intervention groups showed a trend toward less 30-day mortality (children: relative risk [RR], 0.83; 95% confidence interval [CI], 0.43-1.62; adults: RR, 0.72; 95% CI, 0.50-1.03), although neither study showed a statistically significant difference. Similarly, there was no statistically significant difference between the intervention and control groups for "total length of ventilator days." There was a statistically significant reduction in the risk of requiring supplemental oxygen among survivors at 30 days in the pediatric study (RR, 0.36; 95% CI, 0.14-0.93). Overall there is not enough evidence to conclude that high-frequency ventilation reduces mortality or long-term morbidity in patients with acute lung injury or acute respiratory distress syndrome. (This review is published as a Cochrane Review in The Cochrane Library 2004, Issue 3. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and The Cochrane Library should be consulted for the most recent version of the Review.).

單磷酰脂質A預處理後:危急的局部缺血組織的存活率

Preconditioning with Monophosphoryl Lipid A Improves Survival of Critically Ischemic Tissue.

Harder, Yves MD; Contaldo, Claudio MD; Klenk, Joachim MD; Banic, Andrej MD, PhD; Jakob, Stephan M. MD, PhD; Erni, Dominique MD

Department of Plastic Surgery and the Surgical Research Unit, Inselspital University Hospital, Berne, Switzerland

Anesth Analg. 2005;100(6):1786-1792

在這項試驗中,我們評估用單磷酰脂質A預處理後的危急局部缺血創傷組織邊緣的效果和全身及局部血流動力學改變以及使用揮發性麻醉藥物與麻醉性鎮痛藥維持的麻醉過程中的氧合效果.20頭大白豬在被切割臀肌前隨機地接受了單磷酰脂質A(35微克每千克經靜脈注射)或者Saline液體浸潤24小時.這些動物在術中用異氟烷(呼吸末濃度為1.25%)維持並監測全身及局部臀肌皮瓣的血流動力學與氧合效應至6小時後.結果為:預處理過的樣本心指數及氧供增加(兩者P<0.05),並且中心靜脈壓及外周血壓都有降低(兩者P<0.01).在預處理過的皮瓣中微循環血流(使用鐳射多普勒血流儀監測)及局部組織的氧張力(使用微探針極譜描計術)與對照組相比增長了2.5倍(兩者P<0.05);並且在術後14天裏發生皮瓣壞死減少了20%（P<0.05）。我們的結果表明：使用單次劑量單磷酰脂質A預處理能減少缺血相關的創傷癒合併發症，其機制可能與改善組織的灌注和氧合有關。此外，預處理在相對延長的異氟烷麻醉中有突出的對外周心血管的穩定作用。

(許文妍 譯 薛張綱 校)

In this study we sought to assess the effects of preconditioning with monophosphoryl lipid A on critically ischemic wound margins and on systemic and local hemodynamics and oxygenation during prolonged anesthesia with volatile anesthetics and narcotics. Twenty large white pigs were randomly assigned to receive either monophosphoryl lipid A 35 [mu]g/kg IV or saline 24 h before dissection of a buttock flap. The animals were anesthetized with isoflurane (end-tidal concentration approximately 1.25%) for surgery and subsequent monitoring of hemodynamics and oxygenation both systemically and in the flap tissue for 6 h. Preconditioning resulted in increased cardiac index and oxygen delivery (both P < 0.05) and in decreased central venous pressure and systemic vascular resistance (both P < 0.01). In the preconditioned flap tissue, microcirculatory blood flow (laser Doppler flowmetry) and partial tissue oxygen tension (polarographic microprobes) were up to 2.5-fold higher compared with control (both P < 0.05) and flap necrosis was reduced by 20% on postoperative day 14 (P < 0.05). Our results suggest that preconditioning with a single dose of monophosphoryl lipid A may attenuate ischemia-related wound healing complications, which may be related to an improvement in perfusion and oxygenation of this tissue. Furthermore, preconditioning exerted a systemic cardiovascular stabilization effect during prolonged isoflurane anesthesia.

昂丹司瓊全身性給藥能拮抗椎管內利多卡因的感覺阻滯作用

Systemic Ondansetron Antagonizes the Sensory Block Produced by Intrathecal Lidocaine

Argyro Fassoulaki, MD, PhD, DEAA*, A. Melemeni, MD, Marianna Zotou, MD, and Constantine Sarantopoulos, MD, MSc, PhD, DEAA

*Department of Anesthesiology, Aretaieio Hospital, Medical School, University of Athens; Department of Anesthesiology, St Savas Hospital, Athens, Greece; and Department of Anesthesia, Medical College of Wisconsin, Milwaukee

Address correspondence and reprint requests to A. Fassoulaki, 57-59 Raftopoulou St., 11744 Athens, Greece.

Anesth Analg 2005 100: 1817-1821.

這次前瞻性隨機對照雙盲研究中，我們研究了昂丹司瓊對於利多卡因蛛網膜下腔神經阻滯作用的影響。45例擇期行腰麻下經尿道手術的男性病人在術前晚上口服4毫克昂丹司瓊在腰麻前經靜脈給予4毫克昂丹司瓊（昂丹司瓊組）或給予安慰劑（安慰劑組）。椎管內給予2毫升5％利多卡因。 椎管內給藥20、25、30分鐘後測感覺阻滯平面， 30、60、90分鐘後測運動阻滯。由於技術原因2名對照組病人和5名昂丹司瓊組病人未有感覺阻滯。在昂丹司瓊組，30分鐘後感覺阻滯效果有顯著差別（p=0.048)。，蛛網膜下腔給予利多卡因15、20、25和30分鐘後感覺阻滯平面在對照組為T11、T12、T12和T12，在昂丹司瓊組為T12、T12、T12和L1，兩組在30分鐘後有差異（p=0.019)。在任何時間兩組運動阻滯沒有區別。在我們的研究條件下，得出昂丹司瓊能拮抗利多卡因的感覺阻滯作用的結論。

（蔡美華 譯 薛張綱 校）

In this prospective randomized, double-blind study, we investigated the effect of ondansetron on the lidocaine subarachnoid block. Fifty-four male patients scheduled for transurethral surgery under subarachnoid anesthesia received oral ondansetron 4 mg the evening before surgery and 4 mg IV 15 min before subarachnoid anesthesia (ondansetron group) or placebo (placebo group). Two milliliters of 5% hyperbaric lidocaine was administered intrathecally. Sensory block was assessed 20, 25, and 30 min and motor block 30, 60, and 90 min after lidocaine injection. In two patients in the control group and five in the ondansetron group, sensory block was not assessed for technical reasons. In the ondansetron group, sensory block values differed significantly over the 30-min period of assessments (P = 0.048). Fifteen, 20, 25, and 30 min after subarachnoid lidocaine, the level of sensory block was at T11, T12, T12, and T12 in the control group and T12, T12, T12, and L1 in the ondansetron group and differed between groups at 30 min (P = 0.019). Motor block did not differ between the two groups at any study time. We conclude that, under the conditions of our study, ondansetron antagonizes the sensory block produced by lidocaine.

比較在整形外科大手術中大劑量10%羥乙基澱粉264/0.45與5%白蛋白對凝血功能的影響：一項三盲隨機試驗

A triple-blinded randomized trial comparing the hemostatic effects of large-dose 10% hydroxyethyl starch 264/0.45 versus 5% albumin during major reconstructive surgery.

Arellano R, Gan BS, Salpeter MJ, Yeo E, McCluskey S, Pinto R, Irish J, Ross DC, Doyle DJ, Parkin J, Brown D, Rotstein L, Witterick I, Matthews W, Yoo J, Neligan PC, Gullane P, Lampe H.

Department of Anesthesia, Kingston General Hospital, 76 Stuart Street Kingston, Ontario, Canada K7L 2V7.

Anesth Analg. 2005 ;100(6):1846-53.

在加拿大，羥乙基澱粉264/0.45 (HES 264/0.45; 分子量 264 kDa, 取代級 0.45)已經在很大程度上取代了白蛋白成為圍手術期血管內擴容的膠體液。HES 264/0.45的最大推薦劑量為28 mL/kg;然而，並沒有臨床資料支援這一限制量。在本研究中，我們比較了在頭頸部整形外科大手術中HES 264/0.45與5%白蛋白高達45 mL/kg劑量、超過24小時時對凝血功能的影響。50個病人被隨機分為HES 264/0.45組和5%白蛋白組，時間從麻醉誘導到24小時後。白蛋白和HES 264/0.45在圍手術期和術後均能有效維持生理變數。在輸注30 mL/kg 和 45 mL/kg後，HES 264/0.45組病人的部分凝血酶原時間和國際標準化比（INR）較白蛋白組有顯著增高 (P < 0.05)。在輸注15 mL/kg 、30 mL/kg 和 45 mL/kg後，HES 264/0.45組的VIII因數和von Willebrand因數水平顯著低於白蛋白組 (P < 0.05)。HES 264/0.45組接受異體紅細胞輸注的病人明顯較多 (P < 0.02)。我們認為HES 264/0.45輸注大於30 mL/kg、超過24小時對凝血功能的損害在很大程度上高於白蛋白，並可能導致更多的異體血輸注。

（周曉敏 譯 薛張綱 校）

In Canada, hydroxyethyl starch 264/0.45 (HES 264/0.45; molar weight 264 kDa, molar substitution 0.45) has largely replaced albumin as the colloidal fluid of choice for perioperative intravascular volume expansion. The maximum recommended dose of HES 264/0.45 is 28 mL/kg; however, there are no clinical data supporting this limit. In this study we compared the hemostatic effects of HES 264/0.45 versus 5% albumin in doses up to 45 mL/kg over 24 h during major reconstructive head and neck surgery. Fifty patients were randomized to receive HES 264/0.45 or 5% human albumin from the induction of anesthesia until 24 h thereafter. Both albumin and HES 264/0.45 effectively maintained physiologic variables in the perioperative and postoperative periods. The partial thromboplastin time and international normalized ratio were significantly increased in the HES 264/0.45 group compared with the albumin group after infusion of 30 mL/kg and 45 mL/kg (P < 0.05). Factor VIII activity and von Willebrand factor level were significantly reduced in the HES 264/0.45 group compared with the albumin group after infusion of 15 mL/kg, 30 mL/kg, and 45 mL/kg (P < 0.05). Significantly more subjects in the HES 264/0.45 group received allogeneic red blood cell transfusions (P < 0.02). We conclude that HES 264/0.45 infusions >30 mL/kg over 24 h impair coagulation to a greater extent than albumin, possibly leading to more allogeneic transfusions.

體外迴圈下心臟手術期間嗜中性粒細胞介導基質金屬蛋白酶-9的分泌和啟動

Neutrophil-Mediated Secretion and Activation of Matrix Metalloproteinase-9 During Cardiac Surgery with Cardiopulmonary Bypass

Tso-Chou Lin, MD^*, Chi-Yuan Li, MD, MS^*, Chien-Sung Tsai, MD, Chih-Hung Ku, MS, ScD, Ching-Tang Wu, MD^*, Chih-Shung Wong, MD, PhD^*, and Shung-Tai Ho, MD, MS^*

*Department of Anesthesiology and Surgery, Tri-Service General Hospital; and School of Public Heath, National Defense Medical Center, National Defense University, Taipei, Taiwan, Republic of China

Anesth Analg 2005 100: 1554-1560.

體外迴圈（CPB）引起嗜中性粒細胞啟動，脫顆粒和系統性炎症反應。基質金屬蛋白酶-9（MMP-9）存在於嗜中性粒細胞中，在其啟動時釋放。CPB的病人中可以觀察到MMP-9的增高。作者設計了這個研究來確定CPB期間MMP-9是否來源於嗜中性粒細胞。研究包括了21名接受選擇性CABG手術的病人，進行或沒進行體外迴圈。採集血樣分析MMP-9和組織金屬蛋白酶抑制劑-1（TIMP-1）。分離嗜中性粒細胞並檢測MMP-9產物和m-RNA表達。CPB開始2-6小時後，血漿MMP-9水平和活性顯著升高，而不停跳心臟手術的病人MMP-9水平沒有升高。CPB開始後2小時，嗜中性粒細胞和m-RNA含量顯著升高。6小時內血漿TIMP-1的水平逐漸升高，體外迴圈開始後2-4小時MMP-9/ TIMP-1比值增高。研究顯示體外迴圈引起血漿MMP-9濃度和活性增高。相應的MMP-9表達和產物的增高提示MMP-9主要來源於嗜中性粒細胞並且會引起與體外迴圈有關的炎症反應。

（殷文淵 譯 陳傑 校）

Cardiopulmonary bypass (CPB) induces neutrophil activation, degranulation, and a systemic inflammatory response. Matrix metalloproteinase (MMP)-9 exists in neutrophils and is released on neutrophil activation. Increased levels of MMP-9 have been observed in patients undergoing CPB. We designed the present study to determine whether MMP-9 is derived from neutrophils during CPB. Twenty-one patients undergoing elective coronary artery bypass grafting with or without CPB were included in this study. Blood was collected and analyzed for MMP-9 and tissue inhibitor of metalloproteinase (TIMP)-1. Neutrophils were also isolated and examined for MMP-9 production and mRNA expression. Plasma levels and activity of MMP-9 increased significantly 2–6 h after beginning CPB, whereas the MMP-9 levels in patients with off-pump cardiac surgery did not increase. The neutrophil content of MMP-9 and mRNA increased significantly 2 h after beginning CPB. The plasma levels of TIMP-1 increased gradually for 6 h, whereas the MMP-9/TIMP-1 ratios were increased 2–4 h after beginning CPB. The present study demonstrated that CPB causes an increase in the concentration and activity of plasma MMP-9. The corresponding increase in neutrophil MMP-9 expression and production suggests that MMP-9 is derived primarily from neutrophils and may contribute to the inflammatory response associated with CPB.

血栓彈性描記法的最大振幅預測包括心肌梗死的術後血栓性併發症

Thromboelastography Maximum Amplitude Predicts Postoperative Thrombotic Complications Including Myocardial Infarction

Douglas J. McCrath, MD, Elisabetta Cerboni, Robert J. Frumento, MS, MPH, Andrew L. Hirsh, BS, and Elliott Bennett-Guerrero, MD

Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, New York

Anesth Analg 2005 100: 1576-1583.

術後血栓性併發症增加住院天數和費用。如果潛在的術後血栓併發症是由高凝狀態所導致，作者想確定使用血栓彈性描記法進行術後血液分析是否能預測術後血栓形成性併發症的發生，包括心肌梗死（MI）。預先登記了240名接受各種手術的病人。使用校正Goldman風險指數對每名病人進行心臟風險評估。手術後即刻進行血栓彈性描記法測定並確定最大振幅（MA），以此表示凝結力。以不知情的觀察者通過診斷性試驗來確定術後血栓性併發症。12名發生術後血栓性併發症的病人中的10名（4.2%）遭受了損害。MA增高的病人（95人中的8人，8.4%）術後血栓性併發症發生的幾率明顯高於MA≤68的病人（145人中的2人，1.4%）。此外，在MA增高組（95人中的6人，6.3%）中術後MI的百分比要顯著大於MA≤68組（145人中的0人，0 %）（P=0.0035）。在多元分析中，MA增高和Goldman風險評分都可以單獨預測術後MI。在不同組手術病人中，術後凝血彈性描記法確定的高凝狀態與包括MI在內的術後血栓性併發症相關。

（殷文淵 譯 陳傑 校）

Postoperative thrombotic complications increase hospital length of stay and health care costs. Given the potential for thrombotic complications to result from hypercoagulable states, we sought to determine whether postoperative blood analysis using thromboelastography could predict the occurrence of thrombotic complications, including myocardial infarction (MI). We prospectively enrolled 240 patients undergoing a wide variety of surgical procedures. A cardiac risk score was assigned to each patient using the established revised Goldman risk index. Thromboelastography was performed immediately after surgery and maximum amplitude (MA), representing clot strength, was determined. Postoperative thrombotic complications requiring confirmation by a diagnostic test were assessed by a blinded observer. Ten patients (4.2%) suffered a total of 12 postoperative thrombotic complications. The incidence of thrombotic complications with increased MA (8 of 95 = 8.4%) was significantly (P = 0.0157) more frequent than that of patients with MA 68 (2 of 145 = 1.4%). Furthermore, the percentage suffering postoperative MI in the increased MA group (6 of 95 = 6.3%) was significantly larger than that in the MA 68 group (0 of 145 = 0%) (P = 0.0035). In a multivariate analysis, increased MA (P = 0.013; odds ratio, 1.16; 95% confidence interval, 1.03–1.20) and Goldman risk score (P = 0.046; odds ratio, 2.39; 95% confidence interval, 1.02–5.61) both independently predicted postoperative MI. A postoperative hypercoagulable state as determined by thromboelastography is associated with postoperative thrombotic complications, including MI, in a diverse group of surgical patients.

兒科病人使用2 ProSeal^TM喉罩通氣與標準喉罩通氣的隨機交叉比較

A Randomized Crossover Comparison of the Size 2 Laryngeal Mask Airway ProSeal^TM Versus Laryngeal Mask Airway-Classic^TM in Pediatric Patients

Kai Goldmann, MD, DEAA, and Christian Jakob

Department of Anaesthesia and Intensive Care Therapy, Philipps University Marburg, Germany

Anesth Analg 2005 100: 1605-1610.

在成人麻醉中， ProSeal^TM喉罩通氣（P-LMA）較標準喉罩通氣(C-LMA) 的密封更為有效，且便於放置胃管。兒科病人尺寸的P-LMA最近新問世。作者選擇了30例麻醉而無肌松的兒科病人，年齡7.7 ± 2歲，體重27 (20–35) kg，隨機插入P-LMA或C-LMA。評價插入喉罩的難易度、喉罩插入開始時氣道的特性、光纖導管定位的位置、氣道漏氣壓力和最大潮氣量。插入P-LMA的病人再評價胃管放置的影響。兩種喉罩插入的難以程度相似。P-LMA組喉罩插入開始時氣道的特性優於另一組(P = 0.01)。頭正中位時氣道漏氣壓為（22.6和18.5 mbar，P = 0.003），最大屈曲時為（37 和26.3mbar，P < 0.001），最大伸展時為（15.2 和13 mbar; P = 0.045），最大潮氣量為(1088和949 mL；P = 0.002)，P-LMA組均優於C-LMA組。C-LMA組有氣體進入胃內，而P-LMA組未見此現象(P = 0.014)。所有病人都可以放置胃管。本研究顯示可靠放置胃管和氣道漏氣壓明顯升高，意味兒科病人可使用P-LMA行正壓通氣。

（肖潔 譯 陳傑 校）

The laryngeal mask airway (LMA)-ProSeal^TM (P-LMA) forms a more effective seal than the LMA-Classic^TM (C-LMA) and facilitates gastric tube (g-tube) placement in adults. The first pediatric sizes of P-LMA recently became available. In 30 anesthetized, nonparalyzed children, aged 7.7 ± 2 yr and weighing 27 (20–35) kg, we inserted the size P-LMA and C-LMA in random order. Ease of insertion, quality of initial airway, fiberoptic position, airway leak pressure, and maximum tidal volume were determined. G-tube placement was assessed for the P-LMA. Ease of insertion was similar for both devices. The quality of the initial airway was better for the P-LMA (P = 0.01). Airway leak pressure in neutral head position (22.6 versus 18.5 mbar; P = 0.003), maximum flexion (37 versus 26.3 mbar; P < 0.001), maximum extension (15.2 versus 13 mbar; P = 0.045), and maximum tidal volume (1088 versus 949 mL; P = 0.002) were significantly better for the P-LMA. Air entry into the stomach occurred with the C-LMA but not with the P-LMA (P = 0.014). G-tube placement was possible in all patients. The reliability of g-tube placement and the significantly increased airway leak pressure found in this investigation might have important implications for use of the size P-LMA for positive pressure ventilation in children.

預防性使用地塞米松以減少兒科斜視手術後噁心嘔吐的發生：劑量範圍和安全性評價研究

Prophylactic Dexamethasone for Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Dose Ranging and Safety Evaluation Study

Rashmi Madan, MD^*, Anuj Bhatia, MD^*, Sajith Chakithandy, MBBS^*, Rajeshwari Subramaniam, MD^*, Gurram Rammohan, MBBS^*, Shrinivas Deshpande, MD^*, Manorama Singh, MD^*, and H. L. Kaul, MD^*

*Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India; Department of Anaesthetics, Queen Elizabeth Hospital, Norfolk; and Department of Anesthetics, Addenbrookes Hospital, Cambridge, United Kingdom

Anesth Analg 2005 100: 1622-1626.

在這項雙盲、隨機、對照性研究中，作者評價了預防性靜脈內注射不同劑量的地塞米松治療兒科病人斜視術後噁心嘔吐(PONV)的有效性和安全性。168個病人，年齡（2–15）歲，全身麻醉誘導後接受靜脈內注射地塞米松0.25 mg/kg (D 0.25)，地塞米松(D 0.5) 0.5 mg/kg，地塞米松1.0 mg/kg (D 1)或生理鹽水(S)。術後隨訪24小時，分別在術後0–2h，2–6h和6–24h評價病人噁心嘔吐發生率。分別在術前和注射治療藥物後4h測量病人的血糖。術後一周評價病人傷口癒合和感染的情況。與地塞米松組相比，S組的大部分病人在術後的0–2h，2–6h和6–24h中發生嘔吐(P = 0.001, P = 0.003, 和P = 0.04)，而且需加用大劑量的止吐劑。與S組相比，地塞米松組中較少發生嚴重PONV(D0.25組6個，D0.5組3個，D1組6個，P = 0.001)。所有病人中，均未發現術後血糖升高，且傷口癒合滿意。結果表明，兒科斜視矯治手術中，使用地塞米松0.25 mg/kg較生理鹽水有更效地防治PONV，並與更大劑量的地塞米松有相等的作用。

（肖潔 譯 陳傑 校）

In this double-blind, randomized, placebo-controlled study, we evaluated the efficacy and safety of different doses of prophylactic IV dexamethasone for postoperative nausea and vomiting (PONV) in 168 children (aged 2–15 yr) scheduled for strabismus surgery. Patients received IV dexamethasone 0.25 mg/kg (D 0.25), 0.5 mg/kg (D 0.5), 1.0 mg/kg (D 1), or saline (S) immediately after induction of general anesthesia. Patients were discharged 24 h after surgery. Nausea and vomiting were assessed at 0–2, 2–6, and 6–24 h after surgery. Blood glucose was measured preoperatively and at 4 h after study drug administration. Wound healing and were assessed after 1 wk. More patients in group S had vomiting at 0–2, 2–6, and 6–24 h (P = 0.001, P = 0.003, and P = 0.04, respectively) and required larger doses of rescue antiemetics compared with the dexamethasone groups. Fewer patients in the dexamethasone groups (6, 3, and 6 in D 0.25, D 0.5, and D 1, respectively) had severe PONV compared with group S (P = 0.001). No significant increase in postoperative blood glucose levels was observed and wound healing was satisfactory in all four groups. The results suggest that dexamethasone 0.25 mg/kg is more effective than saline and equally effective compared with larger doses for preventing PONV for pediatric strabismus surgery.

異丙酚劑量依賴性地通過影響Bcl－2、BAX表達和NO產生減少腫瘤壞死因數（TNF－α）誘導的人臍靜脈內皮細胞凋亡

Propofol Dose-Dependently Reduces Tumor Necrosis Factor--Induced Human Umbilical Vein Endothelial Cell Apoptosis: Effects on Bcl-2 and Bax Expression and Nitric Oxide Generation

Tao Luo, MD^*, Zhengyuan Xia, MD, PhD^*, David M. Ansley, MD, FRCP, Jingping Ouyang, MD, David J. Granville, PhD, Yinping Li, PhD, Zhong-Yuan Xia, MD^*, Qing-Shan Zhou, MD, PhD^*, and Xian-Yi Liu, MD^*

*Department of Anesthesiology, Renmin Hospital, Wuhan University; Department of Pathophysiology, Faculty of Medicine, Wuhan University, Wuhan, People’s Republic of China; Centre for Anesthesia & Analgesia, Department of Pharmacology & Therapeutics, The University of British Columbia, Vancouver; and The James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Research, The University of British Columbia, Vancouver, British Columbia, Canada

Anesth Analg 2005 100: 1653-1659.

作者研究了異丙酚是否能抑制腫瘤壞死因數（TNF－α）誘導的人工培養的人臍靜脈內皮細胞（HUVECs）凋亡。分離的HUVECs置於20％小牛血清的改進的Eagle培養基中培養。HUVECs未處理組和HUVECs異丙酚處理組均在37°C下培養24.5h。行TNF處理的HUVECs 組一開始先在含有TNF或者不同濃度異丙酚中分別培養30min，然後放置於加有40ng/mlTNF的培養基中24h。採用末端去氧核苷酰酶酸轉移酶介導的切口末端標記法（TUNEL）來檢測凋亡，並用電鏡技術驗證。用免疫細胞化學分析法檢測抗凋亡的Bc l－2和前凋亡Bax蛋白表達。TNF刺激導致HUVECs中Bcl－2/Bax比率的下降，並且增加了凋亡指數（AI：凋亡細胞的百分比）。異丙酚在濃度≥12μM時，明顯減弱HUVECs中Bcl－2/Bax比率的下降，並且增加了AI（p<0.001），這種效果呈現劑量依賴性。同時伴隨著NO的產生增加，與Bcl－2/Bax比率和AI呈負相關（p=0.0009）。結果說明臨床相關劑量的異丙酚可減少腫瘤壞死因數（TNF－α）誘導的HUVECs凋亡。

（顧漪聞 譯 陳傑 校）

We investigated whether propofol can inhibit tumor necrosis factor (TNF)--induced apoptosis in cultured human umbilical vein endothelial cells (HUVECs). Isolated HUVECs were cultured in Dulbecco’s modified Eagle medium supplemented with 20% bovine calf serum. HUVECs in untreated and propofol control groups were cultured at 37°C for 24.5 h. HUVECs in the TNF treatment groups were initially cultured for 30 min in the presence of TNF or various concentrations of propofol, respectively, which were then cultured for 24 h with the addition of TNF at 40 ng/mL in the medium. Apoptosis was detected using terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) and confirmed by electron microscopy. The antiapoptotic Bcl-2 and proapoptotic Bax protein expressions were measured by immunocytochemical analysis. TNF stimulation resulted in a reduced Bcl-2/Bax ratio and increased apoptotic index (AI: percentage of apoptotic cells) in HUVECs. Propofol, at concentrations 12 µM, significantly (P < 0.001) and dose-dependently attenuated TNF-induced increase in AI and decrease in Bcl-2/Bax ratio. This was accompanied by increases in nitric oxide production. There is an inverse correlation between the ratio of Bcl-2/Bax expression and AI (P = 0.0009). These results suggest that propofol, at clinical relevant concentrations, can reduce TNF-induced HUVEC apoptosis.

局麻藥n－丁基－ p－氨基苯甲酸酯可完全阻滯鼠感覺神經元的N－型鈣離子傳導

The Block of Total and N-Type Calcium Conductance in Mouse Sensory Neurons by the Local Anesthetic n-Butyl-p-Aminobenzoate

Jeroen P. Beekwilder, MSc, Daniel L. B. Winkelman, MSc, Gertrudis Th. H. van Kempen, BSc, Rutgeris J. van den Berg, PhD, and Dirk L. Ypey, PhD

Department of Neurophysiology, Leiden University Medical Center, Leiden, The Netherlands

Anesth Analg 2005 100: 1674-1679.

為瞭解硬膜外給予局麻藥氨苯丁酯混懸液（BAB）所產生的選擇性麻醉的機制，作者研究了溶解的BAB對於感覺神經元的鈣離子通道的影響。取新生小鼠小直徑脊根神經節，通過電壓鉗制刺激術檢測其全細胞的鋇或鈣離子流。BAB抑制了這些細胞和電刺激相關的鋇離子流， BAB呈濃度依賴性（50％的抑制濃度為207±14μM，n＝40）。 BAB依賴劑量和藥理學上獨立全細胞鋇離子流的N－型成分的濃度相似。在有BAB時，N－型離子流的滅活和失活時間稍短，因此，作者認為，離子運動改變可能和離子流被抑制有關。當鈣離子流受到控制電勢的刺激，產生動作電位峰時， BAB同樣可以抑制全細胞鈣離子流和它的N－型成分。可以認為BAB抑制鈣離子流可能是硬膜外給予局麻藥混懸液所產生局部麻醉的機制。

（顧漪聞 譯 陳傑 校）

To contribute to the understanding of the mechanism underlying selective analgesia by epidural application of suspensions of the local anesthetic butamben (n-butyl-p-aminobenzoate; BAB), we investigated the effect of dissolved BAB on calcium channels in sensory neurons. Small-diameter dorsal root ganglion neurons from newborn mice were used to measure whole-cell barium or calcium currents through calcium channels upon voltage-clamp stimulation. BAB suppressed the voltage-step-evoked barium current of these cells in a concentration-dependent manner with a 50% inhibitory concentration of 207 ± 14 µM (n = 40). A similar concentration dependency was found for the pharmacologically isolated N-type component of the whole-cell barium current. The time constants of inactivation and deactivation of the N-type current became smaller in the presence of BAB, thus suggesting that kinetic changes are involved in the inhibition of this current. BAB caused a similar inhibition of the total calcium current and its N-type component when these currents were evoked by command potentials with the shape of an action potential. This inhibition of calcium currents by BAB should be considered in the search for the mechanism of selective analgesia by epidural suspensions of this local anesthetic.

硬膜外導管的電特性：神經刺激引導儀要求什麼?

The Electrical Properties of Epidural Catheters: What Are the Requirements for Nerve Stimulation Guidance?

Hisayoshi Tamai, MD, Shigehito Sawamura, MD, PhD, Hidenao Atarashi, BS, Kenji Takeda, MD, Kazuhiko Ohe, MD, PhD, and Kazuo Hanaoka, MD, PhD

Department of Anesthesiology, The University of Tokyo, Tokyo, Japan

Anesth Analg 2005 100: 1704-1707.

作者設計本研究，目的是觀測目前市場上常用的硬膜外導管的電阻抗，以尋找合適的產品用於引導神經刺激器的插入。選擇四種硬膜外導管，兩根是非金屬線加強導管（19號和20號，尼龍），另兩根是金屬線加強導管（19號無管芯和20號有管芯）。導管的電阻抗通過串聯電路中電壓與固定阻抗比例來計算。在生理鹽水中，非金屬線加強導管的阻抗超過700kΩ，金屬線加強導管無管芯和有管芯的分別為14.4±0.2 kΩ、10.1±0.42kΩ。當管芯通過了20號的尼龍導管時，阻抗減少到49.2±1.96 kΩ。當導管用10％的高滲鹽水處理過後，兩根非金屬線加強導管的阻抗和生理鹽水處理過的比較，減少了1/3。這些試驗的硬膜外導管，充滿生理鹽水後，其電阻抗都發生了改變。作者認為用於引導電刺激儀的硬膜外導管均應該有螺旋式的不銹鋼金屬線加強，或是有不銹鋼的管芯。

（顧漪聞 譯 陳傑 校）

We designed the present study to investigate the electrical resistance of commercially available epidural catheters and to search for products and procedures suitable for nerve stimulation-guided insertion. Four types of epidural catheters were evaluated: 2 nonwire-reinforced catheters (19-gauge and 20-gauge nylon) and 2 wire-reinforced catheters (19-gauge without stylet and 20-gauge with stylet). The resistance of a catheter was calculated from the voltage level proportional to the fixed resistance in series circuit. In case of physiologic saline, the resistance of nonreinforced catheters was more than 700 k, whereas the wire-reinforced catheter was 14.4 ± 0.20 k without stylet and 10.1 ± 0.42 k with stylet. When the stylet was passed through a 20-gauge nylon catheter, the resistance decreased to 49.2 ± 1.96 k. When catheters were primed with 10% hypertonic saline, the resistance of both nonreinforced catheters decreased by one third compared with physiologic saline. The electrical resistance of the saline-filled epidural catheters significantly differed among products tested. We conclude that epidural catheterization that is guided by electrical stimulation should be performed only with catheters equipped with spiral stainless steel wire reinforcement or with a stainless steel stylet.

通過改良壓力降低方式來檢測單向活瓣功能不全

Detecting Unidirectional Valve Incompetence by the Modified Pressure Decline Method

Wade A. Weigel, MD, and W. Bosseau Murray, MBChB, FRCA, MD

Department of Anesthesiology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania

Anesth Analg 2005 100: 1723-1727.

1993年FDA麻醉儀器調查委員會提供了一項指南，用於指導標準的麻醉儀器環路的檢查。但是，作者認為，這項指南沒能提供良好的檢測單向活瓣（UDV）的方法，因此，作者用改良壓力降低方式（MPDM)來檢測單向活瓣功能不全。這個方法通過壓力儲氣囊向UDV的順流來檢測活瓣的功能。用MPDM法檢測了18個麻醉呼吸回路中的36個單向活瓣。一台Draeger（Draeger醫療公司，Telford，PA）和一台Ohmeda（Datex－Ohmeda公司，Madison，WI）機器由於使用了功能不全活瓣盤而重新檢測。在18個麻醉呼吸回路中的36個單向活瓣中有一個UDV功能不全（3%）。將功能不全的UDV放置在每個型號的麻醉機時，用MPDM法可以檢測活瓣漏氣（Draeger0.6L/min 流量漏氣，Ohmeda為0.9L/min 流量漏氣）。MPDM用來檢測單向活瓣功能不全是一種快速和有效的方法。

（顧漪聞 譯 陳傑 校）

The 1993 Food and Drug Administration anesthesia apparatus checkout recommendation provides guidance for a standardized circle system checkout but, we believe, inadequately tests unidirectional valve (UDV) function. We developed the modified pressure decline method (MPDM) for checking UDVs. The test involves pressurizing reservoir bags downstream of the UDVs to check for competency. Thirty-six UDVs in 18 anesthesia circle systems were evaluated using the MPDM. One Draeger (Draeger Medical Inc., Telford, PA) and one Ohmeda (Datex-Ohmeda Inc., Madison, WI) machine were then retested using incompetent valve discs. One incompetent UDV (3%) was identified of the 36 valves tested in 18 anesthesia machines. The MPDM detected the valve leak (Draeger 0.6 L/min flow leak; Ohmeda 0.9 L/min flow leak) when the incompetent valve discs were intentionally introduced into each type of machine. MPDM provides a quick and effective way of identifying incompetent UDVs.

麻醉前訪視後病人的滿意度和所獲的資訊：面對面會談，宣傳資料和錄影三種方法的比較

Patient Satisfaction and Information Gain After the Preanesthetic Visit: A Comparison of Face-to-Face Interview, Brochure, and Video

Stephanie A. Snyder-Ramos, MD^*, Henrik Seintsch^*, Bernd W. Böttiger, MD, DEAA^*, Johann Motsch, MD^*, Eike Martin, MD, FANZCA^*, and Martin Bauer, MD, MPH^*

*Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany; and Department of Anesthesiology, Universities of Schleswig-Holstein, Campus Kiel, Kiel, Germany

Anesth Analg 2005 100: 1753-1758.

這項研究中作者比較了麻醉前訪視的三種方法。按順序研究197名接受全身麻醉的外科手術患者。病人隨機分成常規麻醉前會談，宣傳資料加會談或自製錄影加會談三組。麻醉前訪視後，每種方法病人的滿意度和所獲信息量通過調查表量化。病人滿意度的調查通過六點記分表評估，而所獲信息量通過多項選擇評估。錄影加會談組顯示得最高分（患者滿意度占可能最大點數總分的98％，所獲信息量占93％）。相反，宣傳資料加會談組病人滿意度和所獲信息量分別為93％和80％，而標準會談組為91％和72％。病人的滿意度和所獲信息量最大總分在會談組和錄影組間有顯著差異，但會談組和宣傳資料組間無顯著差異。因此，這些資料提示利用錄影作為麻醉前訪視的補充可提高患者的滿意度並獲得最大信息量。

（朱輝 譯 陳傑 校）

In this study we compared 3 methods of conducting the preanesthetic visit. We prospectively studied 197 consecutive surgical patients who were to undergo general anesthesia. The patients were randomized to a routine preanesthetic interview, a brochure plus an interview, or a self-made documentary video plus an interview. After the preanesthetic visit, the degree of patient satisfaction and information gain was quantified by a questionnaire for each method. The questions on patient satisfaction were assessed on a six-point scale, and those on information gain were assessed on a multiple-choice basis. The video plus interview group showed the highest point scores (98% of the possible maximum sum point score in patient satisfaction and 93% of the maximum sum score in information gain). In contrast, the patients of the brochure plus interview group revealed 93% for patient satisfaction and 80% for information gain, and in the standard interview group, the corresponding figures were 91% and 72%, respectively. The maximum sum scores in patient satisfaction and information gain were significantly different between the interview and the video groups, but not between the interview and the brochure groups. Therefore, these data suggest that the use of a documentary video to supplement a preoperative interview may enhance patient satisfaction and maximize information gain.

兩種不同羥乙基澱粉溶液（6％賀斯130/0.4和200/0.5）對血粘度的影響

The Influence of Two Different Hydroxyethyl Starch Solutions (6% HES 130/0.4 and 200/0.5) on Blood Viscosity

Thomas A. Neff, MD, Lukas Fischler, MD, Michael Mark, MD, Reto Stocker, MD, and Walter H. Reinhart, MD

Department of Internal Medicine, Kantonsspital, Chur, Switzerland, and Division of Surgical Intensive Care, University Hospital, Zurich, Switzerland

Anesth Analg 2005 100: 1773-1780.

本研究觀察兩種不同羥乙基澱粉溶液即新型中分子賀斯130/0.4（6％）和賀斯200/0.5（6%）對嚴重腦外傷患者離體和在體的血漿和全血液粘度的影響。離體試驗中，在血標本內不斷加入6％賀斯130/0.4或6%賀斯200/0.5溶液以增加賀斯濃度（0%-50%）。測定高（94.5s^-1）和低（0.1s^-1）切變率時血漿粘度和全血粘度（血球壓積45%）。兩種賀斯溶液都增加血漿粘度但賀斯130/0.4增加程度不及賀斯200/0.5。而賀斯濃度在37.5％或更大時賀斯130/0.4全血粘度顯著低於賀斯200/0.5。在體研究是通過31名嚴重腦外傷患者隨機給以賀斯130/0.4或賀斯200/0.5幾天治療，融化冰凍血漿並測定血漿壓積。輸注正常紅血球（O型，Rh陰性，壓積45％）重新溶解配成原來濃度以測得全血粘度。整個過程中血漿和全血粘度有增加趨勢但無統計學意義。儘管兩種賀斯在體外試驗中顯著增加血粘度，而在體研究中不明顯，但這可能反映出在重複、大劑量使用賀斯時真實的臨床狀況。因此，當大劑量使用時，賀斯130/0.4比傳統的賀斯200/0.5更具有血液流變學優點。

（朱輝 譯 陳傑 校）

We performed the current study to investigate the influence of 2 different hydroxyethyl starch (HES) solutions, the novel medium molecular weight HES 130/0.4 (6%) and HES 200/0.5 (6%), on plasma and whole blood viscosity in vitro and ex vivo in patients with severe head injury. For the in vitro experiments, blood was incubated with increasing concentrations (0%–50% vol/vol plasma) of either 6% HES 130/0.4 or 6% HES 200/0.5 solution. Plasma viscosity and whole blood viscosity (hematocrit [Hct] 45%) at high (94.5 s^–1) and low (0.1 s^–1) shear rates were determined. Both HES solutions increased plasma viscosity, but HES 130/0.4 to a lesser extent than HES 200/0.5. Whole blood viscosity was significantly less with HES 130/0.4 than with HES 200/0.5 at concentrations of 37.5% and larger. In the ex vivo study on 31 patients with severe cranio-cerebral trauma treated randomly with either HES 130/0.4 or HES 200/0.5 over several days, frozen plasma samples were thawed and plasma viscosity was determined. Blood was reconstituted with normal erythrocytes (0, Rh neg, Hct 45%) for whole blood viscosity measurements. In both groups plasma and blood viscosity tended to increase over time without statistical significance. Although the prominent effects found in vitro are not in keeping with the ex vivo data, they are likely to reflect the true clinical situation during repetitive, large-dose HES administration. We therefore conclude that HES 130/0.4 may have hemorheological advantages over conventional HES 200/0.5 when used in large quantities.

在兒科脊柱側彎手術中異氟醚和地氟醚逐步增加劑量腦雙頻指數維持在60時對皮層體感誘發電位的影響

The Effects of Isoflurane and Desflurane Titrated to a Bispectral Index of 60 on the Cortical Somatosensory Evoked Potential During Pediatric Scoliosis Surgery

James E. Fletcher, MB BS, MRCP, FRCA^*, Albert R. Hinn, MD^*, Christopher M. Heard, MB ChB, Linda S. Georges, MD^*, Eugene B. Freid, MD^*, Ann Keifer, MD^*, Sandra D. Brooks, R.EEG/EPT, CNIM^*, Ann G. Bailey, MD^*, and Robert D. Valley, MD^*

*Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and Department of Anesthesiology, Children’s Hospital Buffalo, Buffalo, New York

Anesth Analg 2005 100: 1797-1803.

在這項研究中，作者在兒科原發性脊柱側彎患者矯正手術中，比較異氟醚和地氟醚對通過頭皮電極記錄的脛後體感誘發電位的影響。研究中，鎮靜深度通過持續腦雙頻指數監測，維持在BIS60。患者吸入地氟醚和異氟醚時誘發的皮層振幅(N37-P45)，分別為0.53 ± 0.3 µV 和 1.3 ± 0.8 µV (P = 0.014)。此外，比較交叉吸入地氟醚或異氟醚改成其他麻醉藥時誘發電位的變化。結果也顯示異氟醚誘發的皮層振幅比地氟醚誘發的振幅要大。異氟醚和地氟醚對皮層下(N31-P34)或P37潛伏期振幅的作用無明顯區別。

（朱玫娟 譯 陳傑 校）

In this study, we compared the effect of isoflurane and desflurane on the posterior tibial somatosensory evoked potential recorded by scalp electrodes during correction of idiopathic scoliosis in pediatric patients. Depth of sedation was controlled by maintaining bispectral index (BIS) at 60 throughout the study. Comparison of patients breathing desflurane and isoflurane showed an evoked cortical amplitude (N37-P45) of 0.53 ± 0.3 µV versus 1.3 ± 0.8 µV (P = 0.014), respectively. In addition to this comparison, a crossover design was included whereby the desflurane or isoflurane received in the first part of the study was changed to the other anesthetic. Substituting one anesthetic for another confirmed our initial finding that the cortical evoked amplitude is greater with isoflurane than with desflurane. No differential effect was found between desflurane and isoflurane on the evoked subcortical (N31-P34) amplitude or the P37 latency.

家庭持續周圍神經阻滯:綜述

Continuous Peripheral Nerve Blocks at Home: A Review

Brian M. Ilfeld, MD, and F. Kayser Enneking, MD

From the Departments of Anesthesiology and Orthopaedics and Rehabilitation, University of Florida, Gainesville, Florida

Anesth Analg 2005 100: 1822-1833.

在單次局部神經阻滯後，術後鎮痛的時間通常限制在12－16小時或者更少。在初始注射局部阻滯藥物後，可以通過神經周圍置管來持續輸注局麻藥進行術後鎮痛。通過近來介紹的那些可信賴和攜帶的輸注泵，這項技術現在可以在門診中開展。在這篇綜述中，作者總結了與這項鎮痛新技術有關的文獻中的資料，特別是在患者家中進行持續神經周圍輸注相關的重要內容。內容包括持續輸注的優點和風險，適應症和患者選擇的原則，使用的導管、輸注泵、給藥配比、輸注選擇以及那些與家庭護理特別相關的內容。

（朱玫娟 譯 陳傑 校）

Postoperative analgesia is generally limited to 12–16 h or less after single-injection regional nerve blocks. Postoperative analgesia may be provided with a local anesthetic infusion via a perineural catheter after initial regional block resolution. This technique may now be used in the outpatient setting with the relatively recent introduction of reliable, portable infusion pumps. In this review article, we summarize the available published data related to this new analgesic technique and highlight important issues related specifically to perineural infusion provided in patients’ own homes. Topics include infusion benefits and risks, indications and patient selection criteria, catheter, infusion pump, dosing regimen, and infusate selection, and issues related specifically to home-care.

異氟醚與肌膜上K_ATP通道蛋白激酶C啟動劑的關係

The Interaction of Isoflurane and Protein Kinase C-Activators on Sarcolemmal K_ATP Channels

Lawrence A. Turner, MD^*, Kazuhiro Fujimoto, MD, PhD^*, Akihiro Suzuki, MD^*, Anna Stadnicka, PhD^*, Zeljko J. Bosnjak, PhD^* , and Wai-Meng Kwok, PhD^*

Departments of *Anesthesiology, Physiology, and Pharmacology & Toxicology, Medical College of Wisconsin, Milwaukee

Anesth Analg 2005;100: 1680-1686

蛋白激酶C（PKC）相關的信號傳導途徑可能與麻醉藥的記憶效應和缺血預適應有關，其可幫助心肌在隨後的缺血或ATP耗竭時促進ATP敏感鉀通道活化。應用膜片鉗技術研究分離豚鼠心肌，發現給予巴豆油酯刺激PKC後，心肌給予1mM異氟醚，與電極內含1mMATP相較，電極內含0.5mMATP者的肌膜ATP通道(I_KATP)電流更大(P <0.05)。其pA/pF分別為10 ± 5（n＝5 ） 和2 ± 1（n＝6）。PKC抑制劑bisindolylmaleinide能拮抗同等條件下第二次給予異氟醚引起的電流。電極內含有甘油二酯（PKC激動劑）能激發與其濃度相關的I_KATP。單獨給予0.5µM 甘油二酯激發的I_KATP電流pA/pF均值為5 ± 3（n＝9）。只對顯微鏡下肌細胞短暫給予異氟醚，隨後沖洗掉，電極內含有同樣的甘油二酯溶液能激發更大的(P <0.01) I_KATP, 均值為 40 ± 9 pA/pF (n＝10),其在麻醉藥處理後48 ± 2 min 出現。當細胞內ATP減少時，異氟醚能激發更大的I_KATP是依賴於PKC，以異氟醚預適應的肌細胞引起肌膜K_ATP持續改變，可加強甘油二酯誘導I_KATP的作用。

趙雪蓮 譯 李士通 校

Protein kinase C (PKC)-dependent signaling pathways may be involved in the "memory" effect of anesthetic and ischemic preconditioning, which facilitates activation of cardioprotective adenosine triphosphate (ATP)-sensitive potassium channels during later ischemic challenge and ATP depletion. Using patch-clamp techniques, we found that exposure of isolated guinea pig cardiomyocytes to 1 mM of isoflurane after phorbol ester stimulation of PKC facilitates the induction of larger (P 0.05) sarcolemmal K_ATP channel currents (I_KATP) during cell dialysis with 0.5, compared to 1.0, mM of ATP in the pipette (10 ± 5 versus 2 ± 1 pA/pF in five and six cells, respectively). A PKC inhibitor, bisindolylmaleimide, abolished the induction of I_KATP by a second brief isoflurane exposure under these conditions. A diacylglycerol PKC activator applied via the pipette elicited concentration-related activation of I_KATP. The diacylglycerol alone (0.5 µM) elicited I_KATP, averaging 5 ± 3 pA/pF in nine cells. Briefly treating myocytes on the microscope stage with isoflurane, followed by washout and patching with the same diacylglycerol solution, elicited larger (P 0.01) I_KATP, averaging 40 ± 9 pA/pF (10 cells), with an onset 48 ± 2 min after anesthetic pretreatment. Facilitation of I_KATP by isoflurane during the reduction of intracellular ATP is dependent on PKC, whereas "preconditioning" myocytes with isoflurane causes persistent changes in sarcolemmal K_ATP channel function, which enhance the induction of I_KATP by a diacylglycerol.

高位胸段硬膜外麻醉對冠心病病人左心室收縮及舒張功能的影響

The Effect of High Thoracic Epidural Anesthesia on Systolic and Diastolic Left Ventricular Function in Patients with Coronary Artery Disease

Christoph Schmidt, MD^*, Frank Hinder, MD, PhD^*, Hugo Van Aken, MD, PhD, FRCA, FANZCA^*, Gregor Theilmeier, MD^*, Christian Bruch, MD, PhD, Stefan P. Wirtz, MD^*, Hartmut Bürkle, MD, PhD^*, Tim Gühs, MD^*, Markus Rothenburger, MD, PhD, and Elmar Berendes, MD, PhD^*

Departments of *Anesthesiology and Surgical Intensive-Care Medicine, Cardiology, and Chest, Heart, and Vascular Surgery, University of Münster Hospital, Germany

Anesth Analg 2005;100:1561-1569

冠心病人通過交感神經系統的啟動引起血管收縮。心外膜及微血管上的腎上腺α₁及α₂樣的收縮作用是心肌缺血的潛在誘發因素。在高位胸段硬膜外麻醉（HTEA）抑制交感神經系統的活性時，已經觀察到心肌缺血減輕。然而，仍存在一種爭議的問題，即是否採用HTEA就能相應地改善左室（LV）功能。為了澄清這個問題，在HTEA之前和之後，使用一種新的綜合整個LV收縮/舒張功能的參數（心肌活動指數[MPI]）和更加明確地指示收縮功能（如分數區域變化）或舒張功能（如心室內流動傳播速度）的附加參數來連續量化左心功能。對37位計畫行冠脈手術病人置入高位胸段硬膜外導管，並對清醒病人施行HTEA。在HTEA開始前後記錄超聲心動圖及血流動力學。HTEA能使LV舒張功能明顯改善。（如，V_P從45.1±16.1上升至58.3±18.8cm/s；P<0.001），而收縮功能的指數無明顯改變。由於舒張特性的改變導致MPI從0.51±0.13改善至0.35±0.13(P<0.001)。.結論：心功能的改善是源於舒張特性的改變。

（裘毅敏 譯 李士通 校）

In patients with coronary artery disease, vasoconstriction is induced through activation of the sympathetic nervous system. Both ₁- and ₂-adrenergic epicardial and microvascular constriction are potent initiators of myocardial ischemia. Attenuation of ischemia has been observed when sympathetic nervous system activity is inhibited by high thoracic epidural anesthesia (HTEA). However, it is still a matter of controversy whether establishing HTEA may correspondingly translate into an improvement of left ventricular (LV) function. To clarify this issue, LV function was quantified serially before and after HTEA using a new combined systolic/diastolic variable of global LV function (myocardial performance index [MPI]) and additional variables that more specifically address systolic (e.g., fractional area change) or diastolic function (e.g., intraventricular flow propagation velocity [V_p]). High thoracic epidural catheters were inserted in 37 patients scheduled for coronary artery surgery, and HTEA was administered in the awake patients. Echocardiographic and hemodynamic measures were recorded before and after institution of HTEA. HTEA induced a significant improvement in diastolic LV function (e.g., V_p changed from 45.1 ± 16.1 to 53.8 ± 18.8 cm/s; P < 0.001), whereas indices of systolic function did not change. The change in the diastolic characteristics caused the MPI to improve from 0.51 ± 0.13 to 0.35 ± 0.13 (P < 0.001). We conclude that an improvement in cardiac function was due to improved diastolic characteristics.

揮發性麻醉藥的心臟保護作用：機制和臨床意義

Cardioprotection with Volatile Anesthetics: Mechanisms and Clinical Implications

Stefan G. De Hert, MD, PhD^*, Franco Turani, MD, Sanjiv Mathur, MD, and David F. Stowe, MD, PhD

*Department of Anesthesiology, University Hospital Antwerp, Edegem, Belgium; Department of Anesthesia and Intensive Care, European Hospital, University of Rome Tor Vergata, Rome, Italy; Department of Anesthesia and Critical Care, Sudbury Regional Hospital, Sudbury, Ontario, Canada; Departments of Anesthesiology and Physiology, The Medical College of Wisconsin, Department of Biomedical Engineering, Marquette University; Research Service, Veterans Affairs Medical Center, Milwaukee, Wisconsin

Anesth Analg 2005;100: 1584-1593

心臟手術和一些非心臟手術伴有圍術期心臟病事件的高風險。實驗室資料提示揮發性全麻藥的臨床濃度保護心肌以免缺血和再灌注損傷，正如顯示的梗塞面積較小且再灌注時收縮功能恢復較快。這些麻醉藥也可介導對其他器官（如腦和腎臟）的保護作用。最近許多報導已提示這些實驗室觀察到的保護作用在心臟手術中也有臨床意義。但是揮發性麻醉藥對結果（如心臟和非心臟手術的術後死亡率和恢復）的影響尚未明確。

（馬皓琳 譯 李士通 校）

Cardiac surgery and some noncardiac procedures are associated with a significant risk of perioperative cardiac morbid events. Experimental data indicate that clinical concentrations of volatile general anesthetics protect the myocardium from ischemia and reperfusion injury, as shown by decreased infarct size and a more rapid recovery of contractile function on reperfusion. These anesthetics may also mediate protective effects in other organs, such as the brain and kidney. Recently, a number of reports have indicated that these experimentally observed protective effects may also have clinical implications in cardiac surgery. However, the impact of the use of volatile anesthetics on outcome measures, such as postoperative mortality and recovery in cardiac and noncardiac surgery, is yet to be determined.

在豬動物模型使用電刺激來監測硬膜外穿刺進針位置

The Use of Electrical Stimulation to Monitor Epidural Needle Advancement in a Porcine Model

Ban C. H. Tsui, MD, MSc, FRCP(C)^*, Derek Emery, MD, FRCP(C), Richard R. E. Uwiera, DVM, PhD, and Brendan Finucane, MB, ChB, FRCP(C)^*

Departments of *Anesthesiology and Pain Medicine, Radiology and Diagnostic Imaging, and Health Sciences Laboratory Animal Services, University of Alberta, Edmonton, Canada

Anesth Analg 2005;100: 1611-1613

在硬膜外穿刺過程中使用電刺激引發肌肉顫搐，可指示硬膜外穿刺針的位置。我們在豬動物模型中給予5 mA電流刺激，研究其是否能持續監測硬膜外穿刺的進針位置。在本研究中使用了5只20公斤重的豬。在每只豬20個不同的節段穿刺帶有5 mA刺激電流的針。進針直到觀察到有肌肉顫搐但沒有阻力消失感，然後使用阻力消失法確定穿刺針的位置。試驗結束後，進行解剖，以確認脊髓是否受到損傷。5只豬共有100次穿刺。硬膜外間隙中閾電流為3.6 ± 0.6 mA。在59次穿刺中，在最初觀察到肌肉顫搐的深度沒有達到阻力消失感。但再進針1-2 mm就達到阻力消失感。在其他41次穿刺中，未進一步進針就觀察到了阻力消失感。解剖顯示，所有豬都沒有穿破硬膜和脊髓損傷。這些觀察資料顯示電刺激可用於提示硬膜外穿刺針已經或者即將進入硬膜外間隙。但是假陽性率高達59%，因此用這種方法來指導豬的硬膜外穿刺的準確路徑是不切實際和不可靠的。

（張瑩 譯 李士通 校）

Muscle twitches elicited with electrical stimulation (ES) during epidural insertion may indicate epidural needle location. We examined the potential application of ES at 5 mA as a continuous method of monitoring the response to epidural needle advancement in a porcine model. Five 20-kg pigs were used in this study. A needle with a stimulating current of 5 mA was inserted at 20 separate levels in each pig. The needle was advanced until a muscle twitch was observed without loss-of-resistance (LOR). The needle position was then assessed using LOR. At the end of the experiment, an autopsy was performed to assess the spinal cord for injury. A total of 100 needle insertions were performed in the 5 pigs. The threshold current in the epidural space was 3.6 ± 0.6 mA. In 59 of the needle insertions, LOR was not obtained at the depth at which a muscle twitch was initially observed. However, after advancing these 59 needles another 1–2 mm, LOR was obtained. In the other 41 insertions, LOR was observed without further advancement of the needle. Autopsies indicated there were no dural punctures or spinal cord damage in any of the pigs. These observations suggest that ES can be used to signal that the epidural needle is in or approaching the epidural space. However, the high false positive predictive value (59%) makes it impractical and unreliable to detect the precise entry of a needle into the epidural space in pigs.

愛荷華麻醉滿意量表是否可用于評價社區醫院白內障治療時局部麻醉和監護鎮靜下病人的滿意程度？

Can the Iowa Satisfaction with Anesthesia Scale Be Used to Measure Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation at a Community Hospital?

Donald Fung, MD, MSc^*, Marsha Cohen, MSc, MD, Susan Stewart, MSc, and Andy Davies, MD^*

*North Bay General Hospital, North Bay, and Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto; Centre for Research in Women’s Health, Sunnybrook & Women’s College Health Sciences Centre and the Department of Health Policy, Management & Evaluation, University of Toronto, Toronto; and North Shores District Health Council, North Bay, Ontario, Canada

Anesth Analg 2005;100: 1637-1643

病人滿意度分級提供了評價和監督衛生保健質量的一種手段。在一個社區醫院接受白內障治療的病人中，我們檢驗了用愛荷華麻醉滿意量表(ISAS)是否能評價對麻醉醫生進行局部麻醉和監護鎮靜的滿意度。對306例病人同時進行ISAS測量和其他衛生質量和病人滿意度分級。所有問卷都得到了完全的回答。ISAS表明相當的可靠(Cronbach’s α= 0.68; 檢驗-再檢驗 = 0.48–0.67)。ISAS具有出色的結構有效性；給出質量等級較低(4.98 vs 5.64)、滿意度視覺類比評分較低(5.12 vs 5.65)、希望改變對他們的治療(4.76 vs 5.67)、有改善服務的建議(5.08 vs 5.63)或希望更深的鎮靜程度(4.85vs 5.66)的病人的ISAS得分較低 (P < 0.0001)。我們的結果提示，ISAS問卷調查用於評價在局部麻醉和監護鎮靜下行白內障手術病人的滿意度，是一種可行、可靠且有效的工具。

（周志堅 譯 李士通 校）

Patient satisfaction ratings provide a means to evaluate and monitor quality of health care. We tested the ability of the Iowa Satisfaction with Anesthesia Scale (ISAS) to measure satisfaction with cataract care under topical local anesthesia and monitored sedation given by an anesthesiologist at a community hospital. Three hundred six patients were administered the ISAS along with alternate ratings of quality of care and patient satisfaction. There were no incomplete questionnaires. The ISAS demonstrated reasonable reliability (Cronbach’s = 0.68; test-retest = 0.48–0.67). The ISAS had excellent construct validity; ISAS scores were lower in patients who gave lower ratings of quality (4.98 versus 5.64), who had lower satisfaction visual analog scale scores (5.12 versus 5.65), who wanted changes in their care (4.76 versus 5.67), who had suggestions to improve care (5.08 versus 5.63), or who preferred more sedation (4.85 versus 5.66) (P < 0.0001). Our results indicate that the ISAS questionnaire is a feasible, reliable, and valid tool to measure patient satisfaction in patients undergoing cataract surgery under topical anesthesia and monitored sedation.

氯胺酮立體選擇性抑制培養海馬神經元的自發性鈣振盪

Ketamine Stereoselectively Inhibits Spontaneous Ca²-Oscillations in Cultured Hippocampal Neurons

Barbara Sinner, MD^*, Oliver Friedrich, MD, PhD, Wolfgang Zink, MD^*, Eike Martin, MD^*, Rainer H. A. Fink, PhD, and Bernhard M. Graf, MD, PhD^*

*Department of Anesthesiology, and Institute for Physiology and Pathophysiology, University of Heidelberg, Heidelberg, Germany

Anesth Analg 2005;100:1660-1666

自發性鈣振盪是胞漿內鈣週期性的增加和減少。在神經元中，它們被認為是具有整合的性能，因為振幅和頻率影響軸突的外延、神經元生長的錐形移行以及在發育中的皮層裏的遠端接線。氯胺酮的立體異構體之間對NMDA受體的親和力以及鎮痛和麻醉效力有差別。通過鈣離子敏感的染料fura－2AM，採用雙重激發鈣離子比例測量螢光技術，我們檢測了培養的海馬神經元細胞中的自發性鈣振盪。自發性鈣振盪的發展依賴於細胞外的鈣離子，而其振幅和頻率在不含鎂離子的溶液中會增加。鈣離子的振盪依賴於谷氨酸鹽，因為阻斷了NMDA、α-氨基-3-羥基-5-甲基-4-惡唑丙酸或紅藻氨酸受體會導致振盪完全中斷。氯胺酮的立體異構體劑量依賴和可逆地抑制自發性鈣振盪的幅度和頻率。這種效應是高度立體選擇性的，S()異構體差不多比R(–)鏡像體效力強4倍。這些結果和立體異構體的臨床麻醉和鎮痛效價相符，因此我們的實驗方法可以提供一個模型系統用來研究麻醉藥對鈣依賴的神經資訊整合的作用機制。

（黃施偉 譯 李士通 校）

Spontaneous Ca²-oscillations are a result of periodic increases and decreases of cytosolic Ca². In neurons, they are thought to possess integrative properties because amplitude and frequency influence axon outgrowth, neuronal growth cone migration, and long distant wiring within the developing cortex. Ketamine stereoisomers differ in their affinities for the N-methyl-d-aspartic acid receptor and analgesic and anesthetic effects. Using a dual-excitation Ca² ratiometric fluorescence technique with the Ca²-sensitive dye fura-2 AM, we detected spontaneous Ca²-oscillations in neurons of hippocampal cell cultures. Spontaneous Ca²-oscillations development is dependent on external Ca², and their amplitude and frequency increased in Mg²-free solution. Ca²-oscillations are glutamate dependent because blocking of the N-methyl-d-aspartic acid, -amino-3-hydroxy-5-methyl-4-isoxazolepropionic, or kainate receptor resulted in a complete disruption of the oscillations. The ketamine stereoisomers dose-dependently and reversibly suppressed the amplitude and frequency of the spontaneous Ca²-oscillations. This effect was highly stereoselective with the S() isomer being nearly four times more potent than the R(–) enantiomer. These results correlate well with the clinical anesthetic and analgesic potency of the stereoisomers and therefore our experimental approach might represent a model system to study mechanisms of anesthetic action on Ca²-dependent integration of neuronal information.

體循環阻力對麻醉犬阻抗心動描記法測量值的影響

The Effect of Peripheral Resistance on Impedance Cardiography Measurements in the Anesthetized Dog

Lester A. H. Critchley, MD, FFARCSI^*, Zhi Y. Peng, MB BS, MD^*, Benny S. Fok, BSc^*, and Anthony E. James, BVSc, MSc

*Department of Anaesthesia and Intensive Care and The Laboratory Animal Services Centre, The Chinese University of Hong Kong, Shatin, Hong Kong, China

Anesth Analg 2005;100: 1708-1712

對於血管擴張和膿毒血症的病人，測定心排量（CO）的阻抗法可能低估真實值。本研究旨在確定總體循環阻力（TPR）對阻抗CO（ CO_IC）測定值是否有影響。對八條進行麻醉及機械通氣的犬，置高精度流量探頭於升主動脈上直接測定CO（CO流量探頭（CO_FP））。於股動脈處測定平均動脈壓。同時測定 CO_IC。在1－2小時內通過輸注去氧腎上腺素和腎上腺素及吸入氟烷改變TPR（平均動脈壓×80/ CO_FP）。計算兩種CO測量值之間的偏差（CO_IC – CO_FP），並通過相關回歸分析與TPR比較。從8條犬TPR的變動中共收集了547對CO測量值。在實驗中CO_FP平均變動190％（範圍，89%–425%），TPR平均變動266%（範圍，94%–580%）。阻抗法測定的心排量值在TPR低時低於實際值，而當TPR高時則高於實際值。在CO偏差和TPR之間存在著對數關係。CO偏差和TPR之間的相關係數（r）變動範圍為0.46到0.89（P<0.0001）。每當TPR減半或翻倍時CO偏差變動0.62 ± 1.8 L/min或34％。此發現可解釋在涉及重症病人的正常研究中發現CO_IC和其他方法的CO測定值之間的吻合性差的原因。

（周雅春 譯 李士通 校）

In the vasodilated and septic patient, the impedance method of measuring cardiac output (CO) may underestimate the true value. In this study, we sought to determine whether impedance CO (CO_IC) measurements are influenced by total peripheral resistance (TPR). In eight anesthetized and ventilated dogs, a high-precision flowprobe was placed on the ascending aorta, and direct CO was measured (CO flowprobe (CO_FP)). Mean arterial blood pressure was measured from the femoral artery. Simultaneous CO_IC measurements were made. TPR (mean arterial blood pressure x 80/CO_FP) was varied over 1–2 h by using infusions of phenylephrine and adrenaline and inhaled halothane. The bias between methods of CO measurement (CO_IC – CO_FP) was calculated and compared with TPR by using correlation and regression analysis. A total of 547 pairs of CO measurements were collected from the 8 dogs as TPR was varied. CO_FP changed by a mean of 190% (range, 89%–425%), and TPR changed by a mean of 266% (range, 94%–580%) during the experiment. The impedance method underestimated CO when TPR was low and overestimated CO when TPR was high. There was a logarithmic relationship between the CO bias and TPR. Correlation coefficients (r) between the CO bias and TPR ranged from 0.46 to 0.89 (P < 0.0001). The bias changed by 0.62 ± 1.8 L/min, or by 34%, every time TPR halved or doubled. This finding explains the poor agreement between CO_IC and other methods of CO measurement found in validation studies involving critically ill patients.

現場麻醉機機械通氣時的氧氣消耗

Oxygen Consumption with Mechanical Ventilation in a Field Anesthesia Machine

Dale F. Szpisjak, MD^*,, Charles L. Lamb, MD, and Kenneth D. Klions, MD

*Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and the Anesthesia Department, Fleet Hospital, Bremerton, Washington

Anesth Analg 2005;100: 1713-1717

配有氣動式呼吸機的現場麻醉機（FAM）已逐漸用於可能沒有中心供氧系統的偏遠地區。這些呼吸機可能會快速耗盡氧氣瓶中的氧氣，尤其是在肺順應性下降的患者中。本研究的目的是確定現代FAM在肺順應性好(HC)和肺順應性差(LC)不同模式時的氧耗率。氧耗率用D型氧氣筒（初始壓力1700 psig）和Narkomed® M FAM測定，FAM用一空氣噴射器混入室內空氣作為驅動氣的一部分降低壓縮氣體的消耗。分別在HC和LC模式下測定三種不同（500，750，和1000 mL）潮氣量(Vt)的氧耗率，新鮮氣流量是1L/min。呼吸頻率維持在10次/分。氧氣的消耗直接隨Vt而變化，與順應性呈反比。氧氣的消耗從HC-500 mL Vt模式的4.8 ± 0.07 L/min增加到LC-1000 mL Vt模式的6.2 ± 0.05 L/min。D型氧氣筒持續的時間範圍在56.8 ± 0.4 到 73.6 ± 1.0分鐘。假設氧新鮮氣流量是1 L/min，用最快的消耗率計算筒中氧氣的持續時間會低估順應性好和Vt較小模式下氧氣的持續時間，但是增加了患者的安全界限。

（陳瑋 譯 李士通 審校）

Field anesthesia machines (FAM) with gas-powered ventilators have been developed for remote locations that may not have a central supply of oxygen. These ventilators may rapidly deplete oxygen cylinders, especially in patients with decreased pulmonary compliance. Our goal in this study was to determine oxygen consumption rates with a contemporary FAM in models of high (HC) and low (LC) pulmonary compliance. Oxygen consumption rates were tested using D cylinders (initial pressure 1700 psig) and the Narkomed® M FAM, which uses an air injector to decrease compressed gas consumption by entraining room air as part of the drive gas. Three different tidal volumes (Vt) were tested (500, 750, and 1000 mL) with HC and LC lung models, and the fresh gas flow rate was 1 L/min. Respiratory rate was constant at 10 breaths/min. Oxygen consumption varied directly with Vt and inversely with compliance, increasing from 4.8 ± 0.07 L/min with the HC-500 mL Vt model to 6.2 ± 0.05 L/min with the LC-1000 mL Vt model. D cylinder duration ranged from 56.8 ± 0.4 to 73.6 ± 1.0 minutes. Assuming oxygen fresh gas flow of 1 L/min, calculating tank duration with the fastest consumption rate underestimated the tank duration for more compliant and smaller Vt models but provided a greater margin of patient safety.

年齡對大鼠嗎啡耐藥性產生的影響

Age-Dependent Morphine Tolerance Development in the Rat

Yan Wang, MD, James Mitchell, MD, Kumi Moriyama, MD, Ki-jun Kim, MD, PhD, Manohar Sharma, PhD, Guo-xi Xie, MD, PhD, and Pamela Pierce Palmer, MD, PhD

Department of Anesthesia and Perioperative Care, University of California, San Francisco

Anesth Analg 2005;100: 1733-1739

在各個年齡組，用來治療慢性疼痛的阿片類藥物用量均有增加，而年齡對於阿片類藥物耐受性的影響，至今還沒有很全面的報導。在本研究中，我們觀察了大鼠對於嗎啡耐受性產生的年齡相關性差異。本研究選取出生3周、3個月、6個月和1年的大鼠作為研究物件。皮下注射嗎啡（8mg/kg），每日兩次。注射嗎啡前5min和注射後30min分別給予熱刺激，通過觀察大鼠擺尾反應時間的變化以評估嗎啡的鎮痛效應。與第一天相比，嗎啡引起的鎮痛效應降低75％定義為對嗎啡產生耐藥性。出生 3周、3 個月、6個月和1年的的大鼠 分別在第4天、第10天、第14天和第22天時對嗎啡產生耐藥性。 嗎啡及其代謝產物的血漿濃度表明，在各個年齡組嗎啡藥代動力學的差異與對嗎啡產生耐受性無關。本研究表明，對嗎啡的耐受性在年幼大鼠身上較年長大鼠發生得更迅速，而且不可能是藥物代謝和藥物清除存在差異的結果。年齡增長可能會影響參與嗎啡耐受性產生的分子機制，這為研究如何延遲對阿片類藥物產生耐受性提供了新的治療方向。

（邱鬱薇 譯 李士通 校）

In all age groups, the use of opioids to treat chronic pain conditions has increased, yet the impact of age on opioid tolerance development has not been comprehensively addressed. In this study, we investigated age-related differences in morphine tolerance development in rats. Rats aged 3 wk, 3 mo, 6 mo, and 1 yr were used in the study. Morphine (8 mg/kg) was injected subcutaneously twice each day and its analgesic effect assessed by the change in tail-flick latency using a thermal stimulus 5 min before and 30 min after dosing. Tolerance was defined as a 75% reduction in morphine-induced analgesia compared to Day 1. Rats aged 3 wk, 3 mo, 6 mo, and 1 yr developed tolerance on the 4th, 10th, 14th, and 22nd days of morphine treatment, respectively. Plasma levels of morphine and its metabolites showed that pharmacokinetic differences among the groups did not correlate with the differences in tolerance development. This study demonstrates that morphine tolerance occurs more rapidly in younger rats than older rats and is unlikely to be the result of differences in drug metabolism or clearance. Aging may impact molecular processes involved in tolerance development and provide insight into novel therapeutic targets to delay opioid tolerance development.

主要麻醉學期刊中隨機對照試驗的質量

The Quality of Randomized Controlled Trials in Major Anesthesiology Journals

Mary Lou V. H. Greenfield, MPH, MS, Andrew L. Rosenberg, MD, Michael O’Reilly, MS, MD, Amy M. Shanks, MS, Michelle J. Sliwinski, MS, and Michael D. Nauss, BS

Department of Anesthesiology, University of Michigan, Ann Arbor

Anesth Analg 2005;100: 1759-1764

人們越來越關注到隨機對照試驗的質量，以及它們是如何報導的。我們研究了主導的麻醉學雜誌，以確定是否有特定的領域針對已出版的臨床研究的設計及分析的改善。我們通過MEDLINE 檢索重新得到到2000年1月至2000年12月期間發表在主導麻醉學期刊(麻醉學（Anesthesiology）、麻醉與鎮痛（Anesthesia & Analgesia）、麻醉（Anaesthesia）和加拿大麻醉雜誌（Canadian Journal of Anaesthesia）)上的所有的隨機對照試驗。我們應用先前證明有效的評估工具，包括與研究質量有關的14個項目，為每篇文章的質量評分。總體平均質量得分是44% ± 16%。而選取適當對照的得分(77% ± 7%)及討論副作用的 (67% ± 6%)的總體平均得分相對較高。隨機盲法研究(5% ± 2%)、觀察者對結果的盲態處理(1% ± 1%),及post-beta評估的得分(16% ± 13%)則非常低。而所有研究中有32%缺少重要的處理前臨床預測方法。隨機對照試驗中報告及實施中需要重要改進，並且需要集中在隨機化的方法學、研究者的盲法和樣本大小的評估。對文獻重新評估會進一步促進採納提高隨機對照試驗質量的指南。

(黃麗娜 譯 李士通 校)

Increased attention has been directed at the quality of randomized controlled trials (RCTs) and how they are being reported. We examined leading anesthesiology journals to identify if there were specific areas for improvement in the design and analysis of published clinical studies. All RCTs that appeared between January 2000 and December 2000 in leading anesthesiology journals (Anesthesiology,Anesthesia & Analgesia,Anaesthesia, and Canadian Journal of Anaesthesia) were retrieved by a MEDLINE search. We used a previously validated assessment tool, including 14 items associated with study quality, to determine a quality score for each article. The overall mean weighted quality score was 44% ± 16%. Overall average scores were relatively high for appropriate controls (77% ± 7%) and discussions of side effects (67% ± 6%). Scores were very low for randomization blinding (5% ± 2%), blinding observers to results (1% ± 1%), and post-beta estimates (16% ± 13%). Important pretreatment clinical predictors were absent in 32% of all studies. Significant improvement in the reporting and conduct of RCTs is required and should focus on randomization methodology, the blinding of investigators, and sample size estimates. Repeat assessments of the literature may improve the adoption of guidelines for the improvement of the quality of randomized controlled trials.

在血栓彈性描記法中血小板計數對血塊退縮和組織纖溶酶原活化劑介導的纖維蛋白溶解的影響

The Effects of Platelet Count on Clot Retraction and Tissue Plasminogen Activator-Induced Fibrinolysis on Thrombelastography

Nobuyuki Katori, MD, Kenichi A. Tanaka, MD, Fania Szlam, MMS, and Jerrold H. Levy, MD

Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia

Anesth Analg 2005;100: 1781-1785

血塊退縮和纖維蛋白溶解在血栓彈性描記法(TEG®)中可能呈現描記圖幅度的減小。前者代表正常的或者過度活躍的血小板的功能，後者代表纖溶狀態。區分纖溶與血塊退縮是很重要的，因為兩者的治療是不同的。為了區別這兩種現象，我們用缺乏血小板的血漿(PPP)和富含血小板的血漿(PRP)進行TEG®，逐步增加血小板數量（範圍，50–1200 x 10⁹/L），加入或者不加入abciximab。每個樣本檢測最大幅度(MA)和MA後30分鐘和60分鐘時幅度下降的百分率。加入組織纖溶酶原活化劑(tPA)的血樣作為纖維蛋白溶解的陽性對照。同時檢測血凝塊形態學的改變和d-二聚體水平。隨著血小板計數的增高，MA後30分鐘和60分鐘時幅度下降的百分率顯著增大，但是在加入abciximab的樣本中無此結果。在PRP中血凝塊的形態學改變顯示了血塊退縮，但是在PPP或者用abciximab預處理的PRP中不顯示血塊退縮。d-二聚體水平僅僅在加入tPA的樣本中增加，但是在原本的PPP或者PRP樣本中不增加。結論，我們表明在30分鐘和60分鐘時幅度的減小可能是由於血小板介導的血塊退縮，且能夠被abciximab預處理所削弱，abciximab妨礙了血小板-纖維蛋白（原）聚集。

（張曦 譯 李士通 校）

Clot retraction and fibrinolysis may present as a decrease in amplitude on thrombelastography (TEG®). The former represents normal or hyperactive platelet function, and the latter represents a fibrinolytic state. It is important to distinguish clot retraction from fibrinolysis because the treatment of each condition is different. To distinguish between these phenomena, we performed TEG® with platelet-poor plasma (PPP) and platelet-rich plasma (PRP) with an increasing platelet count (range, 50–1200 x 10⁹/L) with or without abciximab. Maximum amplitude (MA) and the percentage decrease of amplitude at 30 and 60 min after MA were examined for each sample. Blood samples to which tissue plasminogen activator (tPA) was added served as positive controls for fibrinolysis. Morphological changes of clots and d-dimer levels were also examined. With higher platelet counts, the percentage decrease of amplitude after MA increased significantly at 30 and 60 min, but not in the abciximab samples. Morphological changes of clots have shown clot retraction in PRP, but not in PPP or PRP pretreated with abciximab. d-Dimer levels increased only in samples to which tPA was added, but not in native PPP or PRP samples. In conclusion, we have shown that the decrease in amplitude at 30 and 60 min can be due to platelet-mediated clot retraction and can be attenuated by sample pretreatment with abciximab, which interrupts platelet-fibrin(ogen) binding.

比較用利多卡因和其他局麻藥脊麻後的一過性神經症狀：對隨機對照試驗的一個系統性回顧

Transient Neurologic Symptoms After Spinal Anesthesia with Lidocaine Versus Other Local Anesthetics: A Systematic Review of Randomized, Controlled Trials

Dusanka Zaric, MD, PhD^*, Christian Christiansen, MD^*, Nathan L. Pace, MD, MStat, and Yodying Punjasawadwong, MD

*Department of Anesthesiology, Frederiksberg University Hospital, Frederiksberg, Denmark; Department of Anesthesiology, University of Utah, Salt Lake City, Utah; and Department of Anesthesiology, Chiang Mai University, Chiang Mai, Thailand

Anesth Analg 2005;100: 1811-1816

從1948年起利多卡因應用于脊麻，表面上看來沒有引起關注。然而，近10年中，大量研究提示利多卡因可能是引起脊麻後神經併發症的一個可能原因。對接受無意外脊麻的病人隨訪顯示一些病人有下肢疼痛--一過性神經症狀(TNS)。在這項研究中，我們試圖比較在用利多卡因和用其他局麻藥脊麻醉後TNS和神經併發症的發生率。通過電腦檢索Cochrane庫、MEDLINE、LILAC和EMBASE並檢查參考文獻清單中的試驗和綜述文章來尋找已發表的研究。檢索發現共14個試驗報導了在1347例病人中有117例發生了TNS。這些病人中沒有人顯示有神經併發症的體征。利多卡因用於脊麻後發生TNS的相對危險性為4.35（95%可信區間1.98-9.54）高於其他局麻藥（布比卡因、丙胺卡因、普魯卡因和甲呱卡因）。沒有證據顯示這些疼痛情況與神經病理學改變有關，所有病人的症狀在術後10天自行消失。

（朱慧 譯 李士通 校）

Lidocaine has been used for spinal anesthesia since 1948, seemingly without causing concern. However, during the last 10 years, a number of reports have appeared implicating lidocaine as a possible cause of neurologic complications after spinal anesthesia. Follow-up of patients who received uncomplicated spinal anesthesia revealed that some of them developed pain in the lower extremities—transient neurologic symptoms (TNS). In this study, we sought to compare the frequency of 1) TNS and 2) neurologic complications after spinal anesthesia with lidocaine with that after other local anesthetics. Published trials were identified by computerized searches of The Cochrane Library, MEDLINE, LILAC, and EMBASE and by checking the reference lists of trials and review articles. The search identified 14 trials reporting 1347 patients, 117 of whom developed TNS. None of these patients showed signs of neurologic complications. The relative risk for developing TNS after spinal anesthesia with lidocaine was higher than with other local anesthetics (bupivacaine, prilocaine, procaine, and mepivacaine), i.e., 4.35 (95% confidence interval, 1.98–9.54). There was no evidence that this painful condition was associated with any neurologic pathology; in all patients, the symptoms disappeared spontaneously by the 10th postoperative day.

氣管導管拔除時的殘餘肌松

Residual Paralysis at the Time of Tracheal Extubation

Glenn S. Murphy, MD^*, Joseph W. Szokol, MD^*, Jesse H. Marymont, MD^*, Mark Franklin, MD^*, Michael J. Avram, PhD, and Jeffery S. Vender, MD^*

*Department of Anesthesiology, Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Evanston, Illinois; and Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Anesth Analg 2005;100: 1840-1845

神經肌肉阻滯很小時呼吸肌和喉肌功能仍受損。氣管導管拔除時存在殘餘肌松可導致不良的呼吸事件。在本觀察中，我們評估了氣管導管拔除時殘餘神經肌肉阻滯的發生率和嚴重程度。選擇120例行婦科或普外科手術的患者。用羅庫溴銨維持神經肌肉阻滯（視覺四個成串計數為2），且所有患者在TOF計數為2-4時用新斯的明拮抗。在臨床醫生用標準臨床指標（抬頭5 s或舉手、根據指令睜眼、可接受的吸氣負力或肺活量呼吸值）和周圍神經刺激（無TOF或強直刺激後衰減跡象）認為神經肌肉已完全恢復後，氣管導管拔除前即刻、用肌加速度儀對TOF比定量。到達麻醉後恢復室時再測一次TOF比。氣管導管拔除前即刻的TOF比平均值為0.67 ± 0.2，120例患者中，70例（58%）的TOF比<0.7，105例（88%）的TOF比<0.9。在麻醉恢復室中TOF比<0.7（9例，8%）和<0.9（38例，32%）的患者顯著少於手術室（P <0.001）。我們的結果提示氣管導管拔除時很少存在完全的神經肌肉恢復。

（馬皓琳 譯 李士通 校）

Respiratory and pharyngeal muscle function are impaired during minimal neuromuscular blockade. Tracheal extubation in the presence of residual paresis may contribute to adverse respiratory events. In this investigation, we assessed the incidence and severity of residual neuromuscular block at the time of tracheal extubation. One-hundred-twenty patients presenting for gynecologic or general surgical procedures were enrolled. Neuromuscular blockade was maintained with rocuronium (visual train-of-four [TOF] count of 2) and all subjects were reversed with neostigmine at a TOF count of 2–4. TOF ratios were quantified using acceleromyography immediately before tracheal extubation, after clinicians had determined that complete neuromuscular recovery had occurred using standard clinical criteria (5-s head lift or hand grip, eye opening on command, acceptable negative inspiratory force or vital capacity breath values) and peripheral nerve stimulation (no evidence of fade with TOF or tetanic stimulation). TOF ratios were measured again on arrival to the postanesthesia care unit. Immediately before tracheal extubation, the mean TOF ratio was 0.67 ± 0.2; among the 120 patients, 70 (58%) had a TOF ratio <0.7 and 105 (88%) had a TOF ratio <0.9. Significantly fewer patients had TOF ratios <0.7 (9 subjects, 8%) and <0.9 (38 subjects, 32%) in the postanesthesia care unit compared with the operating room (P < 0.001). Our results suggest that complete recovery from neuromuscular blockade is rarely present at the time of tracheal extubation.