September
2007
CARDIOVASCULAR
ANESTHESIA:
无麻醉作用的惰性气体通过激活促存活信号激酶和抑制线粒跨膜通道通透性途径对心梗后心肌产生保护作用
陶颖莹 译 陈杰 校
Noble Gases Without Anesthetic Properties
Protect Myocardium Against Infarction by Activating Prosurvival Signaling
Kinases and Inhibiting Mitochondrial Permeability Transition In Vivo
Paul S. Pagel, John G. Krolikowski, Yon Hee Shim, Suneetha Venkatapuram, Judy R. Kersten, Dorothee Weihrauch, David C. Warltier, and Phillip F. Pratt, Jr
Anesth Analg 2007 105: 562-569.
减少围手术期血栓并发症：肝素导致的血小板减少症(HIT)的新进展
Reducing Thrombotic Complications in the
Perioperative Setting: An Update on Heparin-Induced Thrombocytopenia (Review
Article)
陈勇柱译 薛张纲校
Jerrold H. Levy, Kenichi A. Tanaka, and Marcie J.
Hursting
Anesth Analg 2007 105: 570-582.
彭中美 译 马皓琳 李士通 校
Perioperative Echocardiographic Examination
for Ventricular Assist Device Implantation (Review Article)
Siriluk Chumnanvej, Malissa J. Wood, Thomas E.
MacGillivray, and Marcos F. Vidal Melo
Anesth Analg 2007 105: 583-601.
周懿之 译 陈杰 校
The Incidental Finding of a Patent Foramen
Ovale During Cardiac Surgery: Should It Always Be Repaired? A Core Review (Review
Article)
Mikhail R. Sukernik and Elliott Bennett-Guerrero
Anesth Analg 2007 105: 602-610.
PEDIATRIC ANESTHESIOLOGY:
吴德华译 薛张纲校
The Effect of Varying Continuous Propofol
Infusions on Plasma Cyclic Guanosine 3',5'-Monophosphate Concentrations in
Anesthetized Children
Thomas Engelhardt, Man K. Chan, Alan J. McCheyne, Cengiz Karsli, Igor Luginbuehl, and Bruno Bissonnette
Anesth Analg 2007 105: 616-619.
胡湘
译 马皓琳 李士通 校
A Comparative Study of Endotracheal Tube
Positioning Methods in Children: Safety from Neck Movement
Seung-Yeon Yoo, Jin-Hee Kim, Sung-Hee Han, and Ah-Young Oh
Anesth Analg 2007 105: 620-625
ANESTHETIC PHARMACOLOGY:
潘方立 译 陈杰 校
Molecular Evidence of Late Preconditioning
After Sevoflurane Inhalation in Healthy Volunteers
Eliana Lucchinetti, José Aguirre, Jianhua Feng, Min Zhu, Marc Suter, Donat R. Spahn, Luc Härter, and Michael Zaugg
Anesth Analg 2007 105: 629-640.
对罗哌卡因作用于离体豚鼠心脏标本产生的毒性作用使用左西孟旦的强心功能
孙霞译 薛张纲校
The Effects of Levosimendan on Myocardial
Function in Ropivacaine Toxicity in Isolated Guinea Pig Heart Preparations
Sebastian N. Stehr, Torsten Christ, Berit Rasche, Stefan Rasche, Erich Wettwer, Andreas Deussen, Ursula Ravens, Thea Koch, and Matthias Hübler
Anesth Analg 2007 105: 641-647.
0.25MAC七氟醚优先影响高阶联合区：一项志愿者的功能性磁共振成像研究
朱慧
译 马皓琳 李士通 校
Sevoflurane 0.25 MAC Preferentially Affects
Higher Order Association Areas: A Functional Magnetic Resonance Imaging Study
in Volunteers
Ramachandran Ramani, Maolin Qiu, and Robert Todd Constable
Anesth Analg 2007 105: 648-655.
兰替洛尔—超短效β1受体拮抗剂不改变猪异氟醚的最小肺泡有效浓度
丁震敏 译 陈杰
Landiolol, an Ultra–Short-Acting ß1-Adrenoceptor Antagonist, Does Not Alter the Minimum Alveolar Anesthetic Concentration of Isoflurane in a Swine Model
Tadayoshi Kurita, Kotaro Takata, Masahiro Uraoka, Koji Morita, and Shigehito Sato
Anesth Analg 2007 105: 656-660.
王时来译 薛张纲校
Alterations in Spinal, but Not Cerebral,
Cerebrospinal Fluid Na+ Concentrations Affect the Isoflurane Minimum
Alveolar Concentration in Rats
Michael J. Laster, Yi Zhang, Edmond I. Eger, II, Dimitry Shnayderman, and James M. Sonner
Anesth Analg 2007 105: 661-665.
在猪模型上使用右美托咪定行深度镇静并不影响游离微血管皮瓣的活性（以微透析和组织氧张力表示）
黄施伟 译，马皓琳 李士通 校
Deep Sedation with Dexmedetomidine in a
Porcine Model Does Not Compromise the Viability of Free Microvascular Flap as
Depicted by Microdialysis and Tissue Oxygen Tension
Silvia Nunes, Leena Berg, L.-P Raittinen, Heikki Ahonen, Jussi Laranne, Leena Lindgren, Iikka Parviainen, Esko Ruokonen, and Jyrki Tenhunen
Anesth Analg 2007 105: 666-672.
於章杰 译 陈杰 校
Anesthetic Properties of the Ketone Bodies ß-Hydroxybutyric Acid and Acetone
Liya Yang, Jing Zhao, Pavle S. Milutinovic, Robert J.
Brosnan, Edmond I. Eger, II, and James M. Sonner
Anesth Analg 2007 105: 673-679.
TECHNOLOGY, COMPUTING, AND SIMULATION:
施 杨译 薛张纲校
Measurement of Anesthetics in Blood Using a Conventional Infrared Clinical Gas Analyzer
Philip J. Peyton, Michael Chong, Christopher Stuart-Andrews, Gavin J. B. Robinson, Robert Pierce, and Bruce R. Thompson
Anesth Analg 2007 105: 680-687.
黄丽娜 译 马皓琳 李士通 校
The Effect of Neuromuscular Block and Noxious
Stimulation on Hypnosis Monitoring During Sevoflurane Anesthesia
Andreas Ekman, Erik Stålberg, Eva Sundman, Lars I. Eriksson, Lars Brudin, and Rolf Sandin
Anesth Analg 2007 105: 688-695.
詹琼慧 译 陈杰 校
Exhaled Carbon Monoxide Levels Change in
Relation to Inspired Oxygen Fraction During General Anesthesia
Takehiko Adachi, Kiichi Hirota, Tomoko Hara, Yukiko Sasaki, and Yasufumi Hara
Anesth Analg 2007 105: 696-699.
陈佳莉译 薛张纲校
Control of Blood Loss During Sacral Surgery
by Aortic Balloon Occlusion (Technical Communication)
Lan Zhang, Quan Gong, Hong Xiao, Chongqi Tu, and Jin Liu
Anesth Analg 2007 105: 700-703.
CRITICAL CARE AND TRAUMA:
唐李隽 译 马皓琳 李士通 校
Antithrombin Levels, Morbidity, and Mortality
in a Surgical Intensive Care Unit
Yasser Sakr, Konrad Reinhart, Stefan Hagel, Michael Kientopf, and Frank Brunkhorst
Anesth Analg 2007 105: 715-723.
杨卫红 译 陈杰 校
Hydroxyethyl Starch: The Effect of Molecular
Weight and Degree of Substitution on Intravascular Retention In Vivo
Takashi Hitosugi, Toshiyuki Saito, Sono Suzuki, Ieko Kubota, Emi Shoda, Toru Shimizu, and Yoshiyuki Oi
Anesth Analg 2007 105: 724-728.
选择性肺复张对于严重低血容量患者的血流动力学是否安全？一项在肺萎陷猪的动物模型关于低血容量的试验性研究。
陈珺珺译 薛张纲校
Are Selective Lung Recruitment Maneuvers
Hemodynamically Safe in Severe Hypovolemia? An Experimental Study in
Hypovolemic Pigs with Lobar Collapse
Lars Kjærsgaard Hansen, Jacob Koefoed-Nielsen, Jonas Nielsen, and Anders Larsson
Anesth Analg 2007 105: 729-734.
周雅春 译 马皓琳 李士通 校
The Carina as a Useful Radiographic Landmark
for Positioning the Intraaortic Balloon Pump
Jin-Tae Kim, Jeong-Rim Lee, Jae-Kwang Kim, Seung Zhoo Yoon, Yunseok Jeon, Jae-Hyon Bahk, Ki-Bong Kim, Chong-Sung Kim, Young-Jin Lim, Hee-Soo Kim, and Seong-Deok Kim
Anesth Analg 2007 105: 735-738.
NEUROSURGICAL ANESTHESIOLOGY:
杜唯佳 译 陈杰 校
Physostigmine Reverses Cognitive Dysfunction
Caused by Moderate Hypoxia in Adult Mice
Alex Bekker, Michael Haile, Kevin Gingrich, Leslie Wenning, Alex Gorny, David Quartermain, and Thomas Blanck
Anesth Analg 2007 105: 739-743
秦 佳译 薛张刚校
Brain Metabolism During a Decrease in
Cerebral Perfusion Pressure Caused by an Elevated Intracranial Pressure in the
Porcine Neocortex
Norbert Zoremba, Joerg Schnoor, Michael Berens, Ralf Kuhlen, and Rolf Rossaint
Anesth Analg 2007 105: 744-750.
OBSTETRIC ANESTHESIOLOGY:
邱郁薇 译 马皓琳 李士通 校
Gastric Emptying of Water in Obese Pregnant
Women at Term
Cynthia A. Wong, Robert J. McCarthy, Paul C. Fitzgerald, Kiril Raikoff, and Michael J. Avram
Anesth Analg 2007 105: 751-755.
钱玲
译 陈杰 校）
Local Anesthetics and Mode of Delivery:
Bupivacaine Versus Ropivacaine Versus Levobupivacaine
Yaakov Beilin, Nicole R. Guinn, Howard H. Bernstein, Jeff Zahn, Sabera Hossain, and Carol A. Bodian
Anesth Analg 2007 105: 756-763.
东莨菪碱透皮给药预防蛛网膜下腔用吗啡导致的剖宫产术后恶心呕吐
罗 璇译 薛张纲校
Transdermal Scopolamine for Prevention of
Intrathecal Morphine-Induced Nausea and Vomiting After Cesarean Delivery
Miriam J. P. Harnett, Nollag O’Rourke, Mary Walsh, Jean Marie Carabuena, and Scott Segal
Anesth Analg 2007 105: 764-769.
GENERAL ARTICLES:
补充供氧可以提高猪正常和吻合的结肠组织氧压，但补充晶体液无影响
沈浩
译 马皓琳 李士通 校
Supplemental Oxygen, but Not Supplemental
Crystalloid Fluid, Increases Tissue Oxygen Tension in Healthy and Anastomotic
Colon in Pigs
Oliver Kimberger, Edith Fleischmann, Sebastian Brandt, André Kugener, Barbara Kabon, Luzius Hiltebrand, Vladimir Krejci, and Andrea Kurz
Anesth Analg 2007 105: 773-779.
成人肝移植期间在再灌注前、再灌注后早期、再灌注后晚期3个时期高钾血症的预测
张燕 译 陈杰 校
Predictors of Hyperkalemia
in the Prereperfusion, Early Postreperfusion, and Late Postreperfusion Periods
During Adult Liver Transplantation
Victor W. Xia, Rafik M. Ghobrial, Bin Du, Tabitha Chen, Ke-Qin Hu, Jonathan R. Hiatt, Ronald W. Busuttil, and Randolph H. Steadman
Anesth Analg 2007 105: 780-785.
ANALGESIA:
王光妍译 薛张纲校
The Effect of Analgesic Technique on
Postoperative Patient-Reported Outcomes Including Analgesia: A Systematic
Review
Spencer S. Liu and Christopher L. Wu
Anesth Analg 2007 105: 789-808.
裘毅敏译，马皓琳，李士通校
Epidural Blood Patch Therapy for Chronic
Whiplash-Associated Disorder
Shinichi Ishikawa, Masataka Yokoyama, Satoshi Mizobuchi, Hidenori Hashimoto, Eiji Moriyama, and Kiyoshi Morita
Anesth Analg 2007 105: 809-814.
矫形外科中原发性痛觉过敏的演变：全膝关节成形术前后定量感觉测试和临床评价
王鹏
译 陈杰 校
The Evolution of Primary Hyperalgesia in
Orthopedic Surgery: Quantitative Sensory Testing and Clinical Evaluation Before
and After Total Knee Arthroplasty
Valéria Martinez, Dominique Fletcher, Didier
Bouhassira, Daniel I. Sessler, and Marcel Chauvin
Anesth Analg 2007 105: 815-821.
周时蓓译 薛张纲校
Improving the Analgesic Efficacy of
Intrathecal Morphine with Parecoxib After Total Abdominal Hysterectomy (Brief
Report)
Supranee Niruthisard, Thewarug Werawataganon, Pavena Bunburaphong, Montson Ussawanophakiat, Chuthayuth Wongsakornchaikul, and Kusonsi Toleb
Anesth Analg 2007 105: 822-824.
用Resiniferatoxin 的坐骨神经阻滞：对大鼠无髓鞘神经纤维的 电子显微镜研究
张莹
译 马皓琳 李士通 校
Sciatic Nerve Block with Resiniferatoxin: An
Electron Microscopic Study of Unmyelinated Fibers in the Rat
Igor Kissin, Cristina F. Freitas, Howard L. Mulhern, and Umberto DeGirolami
Anesth Analg 2007 105: 825-831.
杜唯佳 译 陈杰 校
Reflex Sympathetic Activity After Intravenous
Administration of Midazolam in Anesthetized Cats
Ryoji Iida, Ken-ichi Iwasaki, Jitsu Kato, Shigeru
Saeki, and Setsuro Ogawa
Anesth Analg 2007 105: 832-837.
吴威译 薛张纲校
Pathophysiology of Peripheral Neuropathic Pain: Immune Cells and
Molecules (Review Article)
Michael
A. Thacker, Anna K. Clark, Fabien Marchand, and Stephen B. McMahon
Anesth Analg 2007 105: 838-847.
不管电刺激高于还是低于0.5mA超声引导下的肌间沟置针都能产生成功的麻醉
姜旭晖译 马皓琳 李士通校
Ultrasound-Guided Interscalene Needle
Placement Produces Successful Anesthesia Regardless of Motor Stimulation Above
or Below 0.5 mA
Sanjay K. Sinha, Jonathan H. Abrams, and Robert S. Weller
Anesth Analg 2007 105: 848-852.
陈伟
译 陈杰 校
Obturator Versus Femoral Nerve Block for Analgesia After Total Knee Arthroplasty
Ken Kardash, Don Hickey, Michael J. Tessler, Stacey Payne, David Zukor, and Ana Miriam Velly
Anesth Analg 2007 105: 853-858.
陈恺铮译 薛张纲校
Epidural, Intrathecal Pharmacokinetics, and
Intrathecal Bioavailability of Ropivacaine
François-Xavier Rose, Jean-Pierre Estebe, Maja Ratajczak, Eric Wodey, François Chevanne, Gilles Dollo, David Bec, Jean-Marc Malinovsky, Claude Ecoffey, and Pascal Le Corre Anesth
Analg 2007 105: 859-867.
持续正压通气呼吸可以增加颈胸段硬膜外注射利多卡因后的感觉阻滞头向扩散
黄佳佳译，马皓琳 李士通 校
Continuous Positive Airway Pressure Breathing Increases Cranial Spread of Sensory Blockade After Cervicothoracic Epidural Injection of Lidocaine
W. Anton Visser, Maarten J. P. G. van Eerd, Robert van Seventer, Mathieu J. M. Gielen, Janneke L. P. Giele, and Gert J. Scheffer
Anesth Analg 2007 105: 868-871.
朱玫娟 译 陈杰 校
Transscalene Brachial Plexus Block: A New
Posterolateral Approach for Brachial Plexus Block (Brief
Report)
Hoang C. Nguyen, Erwin Fath, Sebastian Wirtz, and Tareg Bey
Anesth Analg 2007 105: 872-875.
Perioperative Echocardiographic
Examination for Ventricular Assist Device Implantation
Siriluk Chumnanvej, MD*, Malissa
J. Wood, MD_files/image002.gif){kind=small}
,
Thomas E. MacGillivray, MD_files/image004.gif){kind=small}
,
and Marcos F. Vidal Melo, MD, PhD*
From the *Department of Anesthesia and
Critical Care; _files/image005.gif){kind=small}
Division
of Cardiology, Department of Medicine; and _files/image006.gif){kind=small}
Cardiac
Surgical Unit, Massachusetts General Hospital and Harvard Medical School,
Boston, Massachusetts.
Anesth Analg 2007;105:583-601
心室辅助设备（VADs）是用于有严重心衰病人的机械性循环支持的设备。围手术期经食道超声心动图是病的处理的主要组成，对于手术和麻醉决策极为重要。在本综述中我们介绍了对于接受VAD病人综合的超声心电图评估的原理和可得到的数据。除了标准检查，设备特异性术前、术中和术后考虑因素对于心超评估是必须的。这些包括：（1）VAD植入前心脏和大血管的检查以排除明显的主动脉反流、三尖瓣反流、二尖瓣狭窄、卵圆孔未闭或者可能引起左VAD植入后右向左分流的其他心脏异常，心内血栓、心室疤痕、肺动脉反流、肺动脉高压、肺栓塞和升主动脉粥样硬化疾病；并且评估右室功能；（2）VAD植入后检查设备及再评估心脏和大血管。设备检查的目的是用二维和彩色持续的脉冲多普乐模式确认设备完整性和心脏没有进气、插管的位置和开放及设备瓣膜的能力。植入后心脏检查的目的必须是排除主动脉反流或者无包被的右向左分流，并且评估右室功能、左室卸负荷和设备对全心功能的作用。各种VAD模型有不同的基础和操作原则，需要特别的心超评估以有利于植入设备的特性的发挥。
（彭中美 译 马皓琳 李士通 校）
Ventricular assist devices (VADs) are systems
for mechanical circulatory support of the patient with severe heart
failure. Perioperative transesophageal echocardiography is a major
component of patient management, and important for surgical and
anesthetic decision making. In this review we present the rationale
and available data for a comprehensive echocardiographic assessment
of patients receiving a VAD. In addition to the standard examination,
device-specific pre-, intra-, and postoperative considerations are
essential to the echocardiographic evaluation. These include: (a)
the pre-VAD insertion examination of the heart and large vessels to
exclude significant aortic regurgitation, tricuspid regurgitation,
mitral stenosis, patent foramen ovale, or other cardiac abnormality
that could lead to right-to-left shunt after left VAD placement,
intracardiac thrombi, ventricular scars, pulmonic regurgitation,
pulmonary hypertension, pulmonary embolism, and atherosclerotic
disease in the ascending aorta; and to assess right ventricular
function; and (b) the post-VAD insertion examination of the device
and reassessment of the heart and large vessels. The examination of
the device aims to confirm completeness of device and heart
deairing, cannulas alignment and patency, and competency of device
valves using two-dimensional, and color, continuous and pulsed wave
Doppler modalities. The goal for the heart examination after
implantation should be to exclude aortic regurgitation, or an
uncovered right-to-left shunt; and to assess right ventricular
function, left ventricular unloading, and the effect of device
settings on global heart function. The variety of VAD models with
different basic and operation principles requires specific
echocardiographic assessment targeted to the characteristics of the
implanted device.
一项儿童气管内插管位置确定方法的对照试验：颈部活动的安全性
A Comparative Study of Endotracheal Tube
Positioning Methods in Children: Safety from Neck Movement
Seung-Yeon Yoo, MD*, Jin-Hee
Kim, MD, PhD*_files/image007.gif){kind=small}
,
Sung-Hee Han, MD, PhD*_files/image008.gif){kind=small}
,
and Ah-Young Oh, MD, PhD_files/image009.gif){kind=small}
From the *Department of Anesthesiology,
Seoul National University Medical College, Seoul, Korea, _files/image010.gif){kind=small}
Department
of Anesthesiology, Seoul National University Bundang Hospital, Seongnam City,
Kyeonggi-do, Korea.
Anesth Analg 2007;105:620-625
背景：由于颈部活动引起的气管内导管的意外移位可以导致导管进入支气管和意外的拔管。气管内插管甚至可以在临床上或者X线定位下已确定适当位置后移位。
方法：107位2-8岁的儿童被随机分为3组。第1组，气管插管至主支气管然后退出直到听到双肺相等的呼吸音，然后拔出2公分。在第2组，气管插管的位置由在到达声门水平的气管导管上标记规定的记号来确定。第3组，由在胸骨上切迹触摸气管导管顶端来确定。在所有的分组中，由纤支镜来测量从气管导管顶端到隆突的距离。在颈部移动时的每一个位置评估气管导管在气管中的相对位置（隆突为0% ，声带为100%）。
结果：患者在中性位的气管导管的相对位置在1、2、3组分别为21.4% ± 6.7%、46.5% ± 13.0%和43.4% ± 11.1%。在第1组，颈部弯曲后气管导管的相对位置为9.5%
± 10.3%，且5位儿童发现导管进入支气管（14.3%）。在其他两组未发现拔管或者导管进入支气管。
结论：听诊来定位气管插管的位置较中段气管要深，可能加大颈部弯曲后气管导管进入支气管的风险。
（胡湘 译 马皓琳 李士通 校）
BACKGROUND: The
unexpected displacement of the endotracheal tube (ETT) as a result
of neck movements can cause endobronchial intubation and accidental
extubation. The ETT is subject to movement even after its proper
placement has been confirmed either clinically or radiographically.
METHODS: One-hundred-seven
children (2–8 yr) were divided randomly into three groups. In Group
I, the ETT was entered into the main bronchus and withdrawn until
equal sounds in both lung were heard, and then withdrawn 2 cm. In
Group II, the ETT position was determined by placing the prescribed
marks on the ETT at the level of the vocal cords, and in Group III,
by palpating the ETT tip at the suprasternal notch. In all groups,
the distance between the ETT tip and the carina was measured using a
fiberoptic bronchoscope. The relative ETT tip position along the
trachea (carina; 0%, vocal cords; 100%) was assessed in each
position during neck movement.
RESULTS: The
relative position of the ETT with the patient in the neutral
position in Groups I, II, and III was 21.4% ± 6.7%, 46.5% ± 13.0%,
and 43.4% ± 11.1%, respectively. In Group I, the relative ETT
position after flexion was 9.5% ± 10.3%, and endobronchial
intubation was observed in five children (14.3%). There was no
extubation or endobronchial intubation in the other two groups.
CONCLUSIONS: Positioning the ETT by auscultation places the ETT more
deeply than the midtrachea, which can increase the risk of
endobronchial intubation during neck flexion.
0.25MAC七氟醚优先影响高阶联合区：一项志愿者的功能性磁共振成像研究
Sevoflurane 0.25 MAC Preferentially
Affects Higher Order Association Areas: A Functional Magnetic Resonance Imaging
Study in Volunteers
Ramachandran Ramani, MD*, Maolin
Qiu, PhD_files/image011.gif){kind=small}
,
and Robert Todd Constable, PhD_files/image012.gif){kind=small}
From the *Department of Anesthesia; and _files/image013.gif){kind=small}
Magnetic
Resonance Research Center, Yale University School of Medicine, New Haven,
Connecticut.
Anesth Analg 2007;105:648-655
背景：功能性磁共振成像(Functional magnetic resonance imaging，fMRI)能客观地估量麻醉的主观效应。亚麻醉剂量的挥发性麻醉药能影响记忆相关的区域（联合区）。在这个研究中我们测定了0.25MAC七氟醚对健康志愿者局部神经元效应，并区分第一皮层区和联合区的效应。
方法：研究0.25MAC七氟醚对16例ASA I级的志愿者视觉、听觉和运动激活的影响。在使用fMRI（3特斯拉Siemens磁发电机）的情况下，用脉冲动脉自旋标记物技术测定局部脑血流(regional cerebral blood flow，rCBF) 。受试者吸入氧和0.25MAC七氟醚的混合气体，并进行标准的ASA监测。完成视觉、听觉和运动激活任务。测定非激活和激活时清醒状态下及吸入0.25MAC七氟醚时的rCBF。计算吸入0.25MAC七氟醚时基线状态下与视觉、听觉和运动激活有关的11个兴趣区中rCBF的变化（δCBF）。
结果：吸入0.25MAC七氟醚时在11个兴趣区中rCBF与基线的变化没有统计学意义。在激活时一些区域的CBF有显著升高。然而，只有在第一、第二视觉皮层(V1、V2)、丘脑、海马和辅助的运动区域，吸入0.25MAC七氟醚且激活时rCBF的减少是有统计学意义的(P < 0.05)。
结论：亚麻醉浓度的挥发性麻醉药能影响记忆相关区域（联合区）。在fMRI的帮助下，此研究表明0.25MAC七氟醚主要影响第一视觉皮层、相关联合皮层和某些其他的高阶联合皮层。
（朱慧 译 马皓琳 李士通 校）
BACKGROUND: Functional
magnetic resonance imaging (fMRI) can objectively measure the
subjective effects of anesthesia. Memory-related regions
(association areas) are affected by subanesthetic doses of volatile
anesthetics. In this study we measured the regional neuronal effects
of 0.25 MAC sevoflurane in healthy volunteers and differentiated the
effect between primary cortical regions and association areas.
METHODS: The
effect of 0.25 MAC sevoflurane on visual, auditory, and motor
activation was studied in 16 ASA I volunteers. With fMRI (3 Tesla
Siemens magnetom), regional cerebral blood flow (rCBF) was measured
by the pulsed arterial spin labeling technique. Subjects inhaled a
mixture of O2 and 0.25 MAC sevoflurane and standard ASA
monitoring was performed. Visual, auditory, and motor activation
tasks were used. rCBF was measured in the awake state and during inhalation
of 0.25 MAC sevoflurane, without and with activation. The change in
rCBF (_files/image015.gif){kind=small}
CBF)
with 0.25 MAC Sevoflurane during baseline state and with activation
was calculated in 11 regions of interest related to visual,
auditory, and motor activation tasks.
RESULTS: The
change from baseline rCBF with 0.25 MAC sevoflurane was not
statistically significant in the 11 regions of interest. With
activation there was a significant increase in CBF in several regions.
However, only in the primary and secondary visual cortices (V1, V2),
thalamus, hippocampus, and supplementary motor area was the decrease
in activation with 0.25 MAC sevoflurane statistically significant (P < 0.05).
CONCLUSION: Memory-related
regions (association areas) are affected by subanesthetic
concentrations of volatile anesthetics. Using fMRI, this study
showed that 0.25 MAC sevoflurane predominantly affects the primary
visual cortex, the related association cortex, and certain other
higher order association cortices.
在猪模型上使用右美托咪定行深度镇静并不影响游离微血管皮瓣的活性（以微透析和组织氧张力表示）
Deep Sedation with Dexmedetomidine in a
Porcine Model Does Not Compromise the Viability of Free Microvascular Flap as
Depicted by Microdialysis and Tissue Oxygen Tension
Silvia Nunes, MD, PhD*, Leena
Berg, MD, PhD_files/image016.gif){kind=small}
,
L.-P Raittinen_files/image017.gif){kind=small}
,
Heikki Ahonen, RN_files/image019.gif){kind=small}
,
Jussi Laranne, MD, PhD_files/image020.gif){kind=small}
,
Leena Lindgren, MD, PhD||, Iikka Parviainen, MD, PhD_files/image021.gif){kind=small}
,
Esko Ruokonen, MD, PhD_files/image022.gif){kind=small}
,
and Jyrki Tenhunen, MD, PhD*
From the Critical Care Medicine Research
Group, *Department of Intensive Care, Tampere University Hospital, Tampere,
Finland; _files/image023.gif){kind=small}
Department
of Surgery, Kuopio University Hospital, Kuopio, Finland; _files/image024.gif){kind=small}
Department
of Otorhinolaryngology, Tampere University Hospital, Tampere, Finland; _files/image025.gif){kind=small}
Department
of Intensive Care, Kuopio University Hospital, Kuopio, Finland; and
||Department of Anesthesiology, Tampere University Hospital, Tampere, Finland.
Anesth Analg 2007;105:666-672
背景：在面部和颈部整形大手术后往往有必要使用深度镇静来防止突然的自发移动对移植肌皮瓣造成机械性损伤。合适的定位可能有助于改善移植组织的氧合和灌注。我们假设右美托咪定，一种中枢性α2激动剂以及可能是理想的术后镇静药物，可能导致失神经支配皮瓣的血管收缩，从而增加组织坏死的风险。
方法：12头猪经麻醉后，两块对称的肌皮瓣被提升至每侧的上腹部。在其中一块皮瓣上将交感神经纤维从动脉上剥离（失神经支配皮瓣），而另一块则保持不动（神经支配皮瓣）。在模拟缺血和再灌注期后，动物被随机接受丙泊酚(n = 6)或右美托咪定(n = 6) 术后深度镇静。用微透析和组织氧分压来监测皮瓣组织的代谢。每30min对透析液中的葡萄糖、乳酸和丙酮酸浓度进行测定，共进行4h。
结果：右美托咪定组的平均动脉压更高(P = 0.036)。用乳酸－丙酮酸和乳酸－葡萄糖比值（中位数范围乳酸－丙酮酸为14.3–24.5，而乳酸－葡萄糖为
0.3–0.6）及组织氧分压测得的皮瓣组织的代谢在整个实验过程中保持稳定，且组间无差别。
结论：我们的资料显示：右美托咪定即使被用于深度镇静，也不会对失神经支配肌皮瓣的局部灌注或组织代谢产生有害的影响。
（黄施伟 译，马皓琳 李士通 校）
BACKGROUND: Deep
sedation is often necessary after major reconstructive plastic
surgery in the face and neck regions to prevent sudden spontaneous
movements capable of inflicting mechanical injury to the
transplanted musculocutaneous flap(s). An adequate positioning may
help to optimize oxygenation and perfusion of the transplanted tissues.
We hypothesized that dexmedetomidine, a central _files/image027.gif){kind=small}
2-agonist
and otherwise potentially ideal postoperative sedative drug, may
induce vasoconstriction in denervated flaps, and thus increase the
risk of tissue deterioration.
METHODS: Two
symmetrical myocutaneous flaps were raised on each side of the upper
abdomen in 12 anesthetized pigs. The sympathetic nerve fibers were
stripped from the arteries in one of the flaps (denervated flap),
while nerve fibers were kept untouched in the other (innervated
flap). After simulation of ischemia and reperfusion periods, the
animals were randomized to deep postoperative sedation with either
propofol (n = 6) or dexmedetomidine (n = 6). Flap tissue metabolism was monitored by
microdialysis and tissue-oxygen partial pressure. Glucose, lactate,
and pyruvate concentrations were analyzed from the dialysate every
30 min for 4 h.
RESULTS: Mean
arterial blood pressure was higher in the dexmedetomidine group (P = 0.036). Flap tissue metabolism remained stable throughout the
experiment as measured by lactate–pyruvate and lactate–glucose ratios
(median ranges 14.3–24.5 for lactate–pyruvate and 0.3–0.6 for
lactate–glucose) and by tissue-oxygen partial pressure, and no
differences were found between groups.
CONCLUSIONS: Our data suggest that dexmedetomidine, even if used for
deep sedation, does not have deleterious effects on local perfusion
or tissue metabolism in denervated musculocutaneous flaps.
The Effect of Neuromuscular Block and
Noxious Stimulation on Hypnosis Monitoring During Sevoflurane Anesthesia
Andreas Ekman, MD, DEAA*, Erik
Stålberg, MD, PhD_files/image028.gif){kind=small}
,
Eva Sundman, MD, PhD*, Lars I. Eriksson, MD, PhD*, Lars
Brudin, MD, PhD_files/image029.gif){kind=small}
,
and Rolf Sandin, MD, PhD*
From the *Department of Physiology and
Pharmacology, Section for Anesthesiology and Intensive Care Medicine,
Karolinska Institute, Stockholm; _files/image030.gif){kind=small}
Department
of Clinical Neurophysiology, Uppsala University Hospital, Uppsala; and _files/image031.gif){kind=small}
Department
of Medicine and Care, Linköping University, Linköping, Sweden.
Anesth Analg 2007;105:688-695
背景：关于神经肌肉阻滞（NMB）对脑电双频指数（BIS）的影响，有相反的结果。我们研究了两个NMB阻滞深度对BIS，腋生听觉诱发电位指数（AAI）以及肌电图（EMG，用针电极从额部和颞部紧靠近BIS传感器的肌肉处获得）的影响。
方法：20名患者均应用七氟醚进行麻醉，吸入30min达到呼气末浓度在1.2%（基线水平）。输注罗库溴铵分别达到4个成串刺激中第1个肌颤搐高度降低50%（部分阻滞）和95%（深度阻滞），次序是随机选择的。伤害性的强直性电刺激应用于以下4种情况下：1）在基线水平（对照），2和3）在每个程度的NMB时，4）在新斯的明拮抗后。在每一次伤害性刺激前后2min时，分别采集BIS、AAI和EMG。
结果：BIS和AAI的基础值的中位数分别为 44 (39–50)和15 (14–16)。在伤害性刺激前，NMB的两个阻滞深度均不影响BIS、AAI和EMG。相反，与部分NMB相比较，深度NMB会改变BIS和AAI对伤害性刺激的反应 (BIS P
= 0.01, AAI P < 0.01)。而新斯的明拮抗后(BIS P < 0.01, AAI P = 0.01) ，与基线相比(BIS P = 0.08, AAI P = 0.02)。未发现EMG显著性增高。
结论：在七氟醚麻醉下，NMB程度影响BIS和AAI对伤害性的强直性电刺激的反应，而在没有伤害性刺激的情况下，NMB并不影响BIS和AAI。
（黄丽娜 译 马皓琳 李士通 校）
BACKGROUND: There
are conflicting results on the influence of neuromuscular block
(NMB) on the bispectral index (BIS). We investigated the influence
of two degrees of NMB on BIS, Alaris auditory-evoked potential index
(AAI), and the electromyogram (EMG) obtained with needle electrodes
from the frontal and temporal muscles, immediately adjacent to the
BIS-sensor.
METHODS: Twenty
patients were anesthetized with sevoflurane, titrated for 30 min to
an end-tidal concentration of 1.2% (baseline). Rocuronium was
infused to 50% (partial) and 95% (profound) depression of the first
twitch in a train-of-four response, the order being randomly chosen.
Noxious tetanic electrical stimulation was applied at four
occasions: 1) at baseline (control measurement), 2 and 3) at each
degree of NMB, and 4) after neostigmine reversal. BIS, AAI, and EMG
were obtained 2 min before and 2 min after each noxious stimulation.
RESULTS: Median
BIS and AAI at baseline were 44 (39–50) and 15 (14–16),
respectively. The two degrees of NMB did not affect BIS, AAI, and
EMG before noxious stimulation. In contrast, profound NMB altered
the BIS and AAI responses to noxious stimulation when compared with
partial NMB, (BIS P = 0.01, AAI P < 0.01), after neostigmine reversal (BIS P < 0.01, AAI P = 0.01)
and compared with baseline (BIS P = 0.08, AAI
P = 0.02). No significant increase in EMG was
found.
CONCLUSION: BIS
and AAI responses to noxious tetanic electrical stimulation are
affected by the degree of NMB during sevoflurane anesthesia whereas
NMB does not affect BIS or AAI in the absence of noxious
stimulation.
Antithrombin Levels, Morbidity, and
Mortality in a Surgical Intensive Care Unit
Yasser Sakr, MB
BCh*, Konrad Reinhart, MD*, Stefan Hagel, MD*,
Michael Kientopf, MD_files/image032.gif){kind=small}
, and Frank Brunkhorst, MD*
From the *Department of Anesthesiology and
Intensive Care, and _files/image033.gif){kind=small}
Institute
of Clinical Chemistry and Laboratory Medicine, Friedrich-Schiller-University
Hospital, Jena, Germany.
Anesth Analg 2007;105:715-723
背景：抗纤维蛋白酶(AT)水平已被建议作为重症监护室(ICU)中感染性休克患者预后的预测指标。我们研究了外科ICU中AT水平的时程，并验证了AT水平可能与部分外科ICU患者的发病率、死亡率增加有关的假设。
方法：连续选取327名预计入ICU治疗超过48小时的患者，每日测定AT水平。结果：入ICU时，84.1% (n = 275)患者AT水平低于正常下限；入ICU48小时内明显升高且到第7日内恢复正常的患者从未罹患脓毒血症(n = 208)。此种AT水平升高在脓毒症患者中延迟出现。重症脓毒血症患者(n = 55)的AT水平始终低于其他患者。较ICU其他患者，低水平AT患者对血制品的需求增大、器官功能障碍的最大程度更严重。不管入ICU时的AT水平如何，患者在ICU停留时间相似。多变量分析显示入ICU的AT水平与死亡率的增加无相关性。
结论：不论是否发生脓毒血症，入ICU时AT水平很低。虽然AT水平与器官功能障碍水平及脓毒血症的严重程度有关，但不是外科ICU患者预后较差的独立相关因素。
（唐李隽 译 马皓琳 李士通 校）
BACKGROUND: Antithrombin
(AT) levels have been suggested as being predictive of outcome in
intensive care unit (ICU) patients with septic shock. We
investigated the time course of AT levels in a surgical ICU and
tested the hypothesis that AT levels may be associated with
morbidity and increased mortality rates in a cohort of surgical ICU
patients.
METHODS: Three-hundred-twenty-seven
consecutive patients admitted to the ICU with an estimated length of
stay more than 48 h were included. AT levels were measured daily.
RESULTS: On
admission to the ICU, AT levels were below the lower limit of normal
in 84.1% (n = 275) of patients and increased
significantly by 48 h after admission to reach normal values by
the 7th ICU day in patients who never had sepsis (n = 208). This increase in AT levels was delayed in patients
with sepsis. Patients with severe sepsis (n = 55) had consistently lower AT levels compared with
other patients. Patients with lower AT levels were more likely to
need blood products and had a greater maximum degree of organ
dysfunction in the ICU than did other patients. The ICU length of
stay was similar, regardless of the AT level on admission. Admission
AT levels were not associated with increased ICU mortality in a
multivariable analysis.
CONCLUSIONS: AT levels are low on admission to the ICU, regardless of
the presence of sepsis. Although associated with the degree of organ
dysfunction and the severity of sepsis, AT levels were not
independently associated with worse outcome in this group of
surgical ICU patients.
The Carina as a Useful Radiographic
Landmark for Positioning the Intraaortic Balloon Pump
Jin-Tae Kim, MD, PhD*, Jeong-Rim
Lee, MD*, Jae-Kwang Kim, MD*, Seung Zhoo Yoon, MD, PhD*,
Yunseok Jeon, MD, PhD*, Jae-Hyon Bahk, MD, PhD*, Ki-Bong
Kim, MD, PhD_files/image034.gif){kind=small}
,
Chong-Sung Kim, MD, PhD*, Young-Jin Lim, MD, PhD*,
Hee-Soo Kim, MD, PhD*, and Seong-Deok Kim, MD, PhD*
From the Department of *Anesthesiology, _files/image035.gif){kind=small}
Thoracic
and Cardiovascular Surgery, College of Medicine, Seoul National University,
Seoul, Korea.
Anesth Analg 2007;105:735-738
研究背景：一般认为主动脉结是用于主动脉内球囊搏动（IABP）尖端恰当定位的最有效影像学标志。但是这并未经过正式研究验证。在本研究中我们评估了主动脉结是否为IABP定位的可靠影像学标志，且将其与另一潜在影像学标志隆凸作比较。
研究方法：我们测量了100名患者三维计算机断层血管造影术中自远心端主动脉弓顶点（主动脉结）至左锁骨下动脉（LSCA）之间的距离。在另150名患者用三维计算机断层摄片测量LSCA起点水平至隆凸水平的距离。
研究结果：以主动脉结作为影像学标志研究的人群中有16％的患者LSCA 至主动脉结的距离<0 cm或等于0 cm。LSCA至隆凸距离的中位数为42mm（范围36－63mm）。在以隆凸作为影像学标志研究的人群中，95.3%的患者LSCA起点在隆凸之上35－55mm。
结论：当IABP放置于主动脉结处时，对于16％的患者而言IABP距离LSCA太近，而当IABP放置于隆凸上2cm处时，对于95.3%的患者而言，IABP尖端位置放置恰当（距LSCA起点处1.5－3.5cm）。相对于主动脉结而言，隆凸是定位IABP更可靠的影像学标志。
（周雅春 译 马皓琳 李士通 校）
BACKGROUND: The
aortic knob is thought to be the most useful radiographic landmark
for the proper positioning of the intraaortic balloon pump (IABP)
tip. However, this has not been studied formally. In this study we
assessed whether the aortic knob is a reliable landmark for
positioning the IABP and compared it with another potential
landmark, the carina.
METHODS: We
measured the distance from the top of the distal aortic arch (aortic
knob) to the left subclavian artery (LSCA) on three-dimensional
computed tomography angiography in 100 patients. The distance from
the level of the LSCA origin to the level of the carina was also
measured using three-dimensional computed tomography in 150
additional patients.
RESULTS: In
16% of the aortic knob study population, the LSCA to aortic knob
distance was <0 cm or 0 cm. The median distance from the LSCA to
the carina was 42 mm (range: 30–63 mm). In the carina study
population, the origin of the LSCA was 35–55 mm above the carina in
95.3% of patients.
CONCLUSION: In
16% of patients, the IABP was too close to the LSCA origin when it
was placed at the aortic knob, whereas positioning the IABP at 2 cm
above the carina provided an adequate position for the IABP tip
(1.5–3.5 cm distal to the origin of the LSCA) in 95.3% of patients.
The carina may be a more reliable landmark for positioning the IABP
than the aortic knob.
Gastric Emptying of Water in Obese
Pregnant Women at Term
Cynthia A. Wong, MD, Robert J. McCarthy,
PharmD, Paul C. Fitzgerald, RN, MS, Kiril Raikoff, MS, and Michael J. Avram,
PhD
From the Department of Anesthesiology and
Mary Beth Donnelley Clinical Pharmacology Core Facility, Northwestern
University, Feinberg School of Medicine, Chicago, Illinois.
Anesth Analg 2007;105:751-755
背景：麻醉诱导前2小时健康妊娠病人和非妊娠病人饮用适当清水对胃容量并无不良影响。本研究拟比较肥胖足月非产程妇女（妊娠前体重指数>35 kg/m2）饮用50mL和300mL水后胃排空的情况。
方法：选取10例肥胖、足月妊娠志愿者，在交叉研究设计中使用连续胃超声检查和对乙酰氨基酚的吸收率评价胃的排空情况。一夜禁食后，志愿者口服1.5克对乙酰氨基酚和50mL或300mL清水（随机设计），之间间隔至少二天。使用胃超声显像技术连续评估胃窦横断面面积，计算胃排空的半衰期(T[1/2])。比较饮用50mL和300mL后，对乙酰氨基酚血浆浓度－时间曲线下面积(AUC)、峰浓度(Cmax)到达峰浓度的时间(tmax)。
结果：妊娠前平均体重指数为41 ± 9 kg/m2。饮用300mL清水与饮用50mL清水比较，胃排空T[1/2]无显著性差异(23 ± 11 min vs 32 ± 15 min)。在60、90或120分钟时的对乙酰氨基酚AUC、Cmax和tmax 均无明显差异。
结论：肥胖非产程足月孕妇饮用300mL清水后胃排空的时间较50mL清水并无延长。摄入300mL水后60min时的胃窦容量与禁食一夜后的基础值相似。
（邱郁薇 译 马皓琳 李士通 校）
BACKGROUND: Healthy
nonpregnant and pregnant patients may ingest clear liquids until 2 h
before induction of anesthesia without adversely affecting gastric
volume. In this study, we compared gastric emptying in obese, term,
nonlaboring pregnant women (prepregnancy body mass index >35 kg/m2)
after the ingestion of 50 and 300 mL of water.
METHODS: Gastric
emptying was assessed in 10 obese, term pregnant volunteers using
both serial gastric ultrasound examinations and acetaminophen
absorption in a crossover study design. After an overnight fast,
volunteers ingested 1.5 g acetaminophen and 50 or 300 mL water
(randomly assigned) on two occasions separated by at least 2 days.
Serial gastric antrum cross-sectional areas were determined using
gastric ultrasound imaging and the half-time to gastric emptying (T[1/2]) was calculated. Areas under the plasma
acetaminophen concentration versus time curve (AUC), peak
concentrations (Cmax), and time to
peak concentration (tmax) for
50 mL and 300 mL ingestions were compared.
RESULTS: Mean
prepregnancy body mass index was 41 ± 9 kg/m2. Gastric
emptying T[1/2] was not different
after ingestion of 300 mL water compared with 50 mL (23 ± 11 min vs
32 ± 15 min). There were no differences between acetaminophen AUCs
at 60, 90, or 120 min, Cmax or tmax after ingestion of 300 mL compared with 50
mL of water.
CONCLUSIONS: Gastric emptying in obese, nonlaboring term pregnant women
is not delayed after ingestion of 300 mL compared with 50 mL of
water. Gastric antral volume after ingestion of 300 mL of water is
similar to the baseline fasting level at 60 min.
补充供氧可以提高猪正常和吻合的结肠组织氧压，但补充晶体液无影响
Supplemental Oxygen, but Not
Supplemental Crystalloid Fluid, Increases Tissue Oxygen Tension in Healthy and
Anastomotic Colon in Pigs
Oliver Kimberger, MD*, Edith
Fleischmann, MD_files/image036.gif){kind=small}
,
Sebastian Brandt, MD*, André Kugener, MD_files/image037.gif){kind=small}
,
Barbara Kabon, MD_files/image038.gif){kind=small}
,
Luzius Hiltebrand, MD*, Vladimir Krejci, MD*, and Andrea
Kurz, MD*_files/image039.gif){kind=small}
From the *Department of Anesthesiology,
University of Bern, Switzerland; _files/image040.gif){kind=small}
Department
of Anesthesia and General Intensive Care, Division of Cardiothoracic and
Vascular Anesthesia and Intensive Care, and _files/image041.gif){kind=small}
Department
of Anesthesia and General Intensive Care, Medical University Vienna, Austria;
and _files/image042.gif){kind=small}
Outcomes
Research Institute, University of Louisville, Louisville, Kentucky.
Anesth Analg 2007;105:773-779
背景资料：低组织氧压是导致结肠手术后伤口裂开和吻合口漏的重要原因。我们作结肠吻合手术的猪模型中检验了补充供氧和补充液体可否提高健康的和损伤的吻合口附近以及吻合口的结肠组织氧分压。
方法：16头瑞士长白猪用异氟醚0.8-1.0%麻醉并机械通气。动物随机分组，在结肠吻合手术中及其后测定的4个小时里，低容量治疗（低组，乳酸林格氏液3ml/kg/h连续输注）或高容量治疗（高组，乳酸林格氏液10ml/kg/h单次输注，后以18ml/kg/h维持）。在手术后两个半小时以30%浓度的氧气进行机械通气，每隔30min记录一次组织氧压。术后3小时以100%的氧浓度进行机械通气60min。在最后的30min中记录组织氧压。分别在健康结肠壁、吻合口附近2cm以及吻合口用极谱描记克拉克型电极测定组织氧分压。
结果：在每个组中，以100%浓度的氧气进行机械通气时的组织氧分压都是用30%浓度氧气进行机械通气时的近2倍，并且用统计学意义。高容量还是低容量晶体液输注对于结肠组织氧压没有影响。
结论：补充供氧可以提高健康的、吻合口附近和吻合口的结肠组织氧压，但补充晶体液无影响。
（沈浩 译 马皓琳 李士通 校）
BACKGROUND: Low
tissue oxygen tension is an important factor leading to the
development of wound dehiscence and anastomotic leakage after colon
surgery. We tested whether supplemental fluid and supplemental
oxygen can increase tissue oxygen tension in healthy and injured,
perianastomotic, and anastomotic colon in an acutely instrumented
pig model of anastomosis surgery.
METHODS: Sixteen
Swiss Landrace pigs were anesthetized (isoflurane 0.8%–1%) and their
lungs ventilated. The animals were randomly assigned to low fluid
treatment ("low" group, 3 mL · kg–1 · h–1
lactated Ringer’s solution) or high fluid treatment
("high" group, 10 mL/kg bolus, 18 mL · kg–1 · h–1
lactated Ringer’s solution) during colon anastomosis surgery and a
subsequent measurement period (4 h). Two-and-half hours after
surgery, tissue oxygen tension was recorded for 30 min during
ventilation with 30% oxygen. Three hours after surgery, the animals’
lungs were ventilated with 100% oxygen for 60 min. Tissue oxygen tension
was recorded in the last 30 min. Tissue oxygen tension was measured
with polarographic Clark-type electrodes, positioned in healthy
colonic wall, close (2 cm) to the anastomosis, and in the
anastomosis.
RESULTS: In
every group, tissue oxygen tension during ventilation with 100%
oxygen was approximately twice as high as during ventilation with
30% oxygen, a statistically significant result. High or low volume
crystalloid fluid treatment had no effect on colon tissue oxygen
tension.
CONCLUSIONS: Supplemental oxygen, but not supplemental crystalloid fluid,
increased tissue oxygen tension in healthy, perianastomotic, and
anastomotic colon tissue.
Epidural Blood Patch Therapy for Chronic
Whiplash-Associated Disorder
Shinichi Ishikawa, MD*_files/image043.gif){kind=small}
,
Masataka Yokoyama, MD_files/image044.gif){kind=small}
,
Satoshi Mizobuchi, MD_files/image045.gif){kind=small}
,
Hidenori Hashimoto, MD*, Eiji Moriyama, MD_files/image046.gif){kind=small}
,
and Kiyoshi Morita, MD_files/image047.gif){kind=small}
From the *Department of Anesthesiology,
Fukuyama Kohnan Hospital, Kohnan-cho, Fukuyama City, Hiroshima, Japan; _files/image048.gif){kind=small}
Department
of Anesthesiology and Resuscitology, Okayama University Medical School,
Shikata-cho, Okayama City, Okayama, Japan; _files/image049.gif){kind=small}
Department
of Neurosurgery, National Hospital Organization Fukuyama Medical Center,
Okinogami-cho, Fukuyama City, Hiroshima, Japan.
Anesth Analg 2007;105:809-814
背景资料：慢性颈部扭伤相关性疾患(WAD)患者，尽管没有客观存在的神经功能缺损，仍主诉有诸如头痛、眩晕及恶心的症状。脑脊液渗漏(CSF)的患者也常会经历这些症状。最近有报道：放射性同位素(RI) 脑池造影术有助于诊断因CSF渗漏引起的颅内低压。我们使用 RI脑池造影术研究了慢性WAD与CSF渗漏之间的关系，并评估了使用硬膜外腔注射自体静脉血（EBP）对治疗慢性WAD是否有效。
方法：我们研究了66位症状超过3个月的慢性WAD患者。所有的患者均经RI脑池造影来测定CSF渗漏的存在。对于确诊有CSF渗漏的患者，使用EBP治疗。在EBP治疗前、治疗后1周及6个月的时候评估症状。同时评估其工作状态并随访RI脑池造影。
结果：在66位患者中，37位显示了存在CSF渗漏，其中36位患者接受了2.2 ± 0.7次EBP治疗。症状平均持续33个月。与治疗前相比，EBP治疗后1周，存在症状的患者的百分比明显下降；头痛：100%比17%，记忆缺失：94%比28%，眩晕：83%比47%，视觉损伤：81%比25%，恶心：78%比42% (P < 0.01)。在6个月后的随访检查中也观察到这些疗效(P < 0.01)。随访发现其工作状态也有明显改善。
结论：我们得出结论：对于某些慢性WAD患者，需考虑CSF渗漏的因素，而EBP治疗对于慢性WAD是有效的。
（裘毅敏译，马皓琳，李士通校）
BACKGROUND: Despite
the absence of objective neurological deficits, patients with
chronic whiplash-associated disorder (WAD) complain of symptoms such
as headache, dizziness, and nausea. These symptoms are also often
experienced by patients with cerebrospinal fluid (CSF) leak. It was
recently reported that radioisotope (RI) cisternography is useful in
the diagnosis of intracranial hypotension due to CSF leak. We
investigated the relation between chronic WAD and CSF leak by RI
cisternography and evaluated whether epidural blood patch (EBP)
administration is effective in the treatment of chronic WAD.
METHODS: We
studied 66 patients with chronic WAD with symptoms lasting longer than
3 mo. All patients underwent RI cisternography to determine the
presence of CSF leak. In patients in whom CSF leak was identified,
EBP was administered. Symptoms were assessed before, 1 wk after, and
6 mo after EBP. Work status was also assessed and follow-up RI
cisternography was performed.
RESULTS: Of
the 66 patients, 37 showed CSF leak, and 36 of these patients
received EBP 2.2 ± 0.7 times. The mean duration of symptoms was 33
mo. One week after EBP, the percentage of patients with symptoms was
decreased significantly compared with that before EBP; headache:
100% vs 17%, respectively, memory loss: 94% vs 28%, dizziness: 83%
vs 47%, visual impairment: 81% vs 25%, nausea: 78% vs 42% (P < 0.01). These effects were also observed at the 6
month follow-up examination (P < 0.01).
Work status was also significantly improved at follow-up.
CONCLUSIONS: We conclude that CSF leak should be considered in some
cases of chronic WAD and that EBP is an effective therapy for
chronic WAD.
用Resiniferatoxin 的坐骨神经阻滞：对大鼠无髓鞘神经纤维的 电子显微镜研究
Sciatic Nerve Block with
Resiniferatoxin: An Electron Microscopic Study of Unmyelinated Fibers in the
RatIgor Kissin, MD, PhD*, Cristina F.
Freitas, BA*, Howard L. Mulhern, BS_files/image050.gif){kind=small}
,
and Umberto DeGirolami, MD_files/image051.gif){kind=small}
From the *Department of Anesthesiology,
Perioperative and Pain Medicine, Brigham and Women’s Hospital, and _files/image052.gif){kind=small}
Department
of Pathology, Children’s Hospital, Harvard Medical School, Boston,
Massachusetts.
Anesth Analg 2007;105:825-831
背景：神经周围给予天然存在的vanilloids (辣椒素, resiniferatoxin [RTX]) 可以产生选择性伤害性疼痛的阻滞作用。在神经周围给予高浓度vanilloids的研究发现，它们可导致无髓鞘神经纤维退行性变。但是，使用电子显微镜研究vanilloid的局部毒性，结果则与此相反。在本研究中，我们拟确定RTX诱发的可逆性坐骨神经阻滞是否可以导致无髓鞘神经纤维退行性变。
方法：在大鼠实验中，经皮在坐骨神经给予RTX。用测定大鼠对伤害性热刺激的反应来监测RTX的作用。阻滞起效后48小时，取出坐骨神经。在三组动物中，RTX 0.0001% 组(0.1 µg)、RTX 0.001%组 (1 µg)和对照组(RTX 溶剂, 0.1 mL)，对无髓鞘神经纤维进行定量电子显微镜分析。
结果：RTX诱发的可逆性神经阻滞开始后48小时，坐骨神经的横切面基本是正常的。一个很罕见的发现是无髓鞘神经轴突上有不规则的紧密膜状沉积物。在两种不同浓度RTX时的这种情况发生率均近1‰。
结果：研究结果说明RTX可以提供选择性长时效坐骨神经阻滞（最长2周），对无髓鞘神经纤维没有明显损害。
（张莹 译 马皓琳 李士通 校）
BACKGROUND: Perineural
administration of the naturally occurring vanilloids (capsaicin,
resiniferatoxin [RTX]) produces selective nociceptive blockade.
Studies using perineural vanilloids in high concentrations suggest
that they can cause a degeneration of unmyelinated fibers. However,
electron microscopic studies of local vanilloid toxicity produced
conflicting outcomes. In the present study, we sought to determine
whether RTX-induced reversible sciatic nerve block results in the
degenerative changes of unmyelinated fibers.
METHODS: In
rat experiments, RTX was administered percutaneously at the sciatic
nerve. The effect of RTX was monitored by measuring the rat’s
response to noxious heat. The sciatic nerves were removed 48 h after
the blockade initiation. Quantitative electron microscopic
evaluation of the unmyelinated fibers was performed in three groups
of animals: RTX 0.0001% (0.1 µg), RTX 0.001% (1 µg), and control
(RTX vehicle, 0.1 mL).
RESULTS: Cross-sections
of the sciatic nerve 48 h after the initiation of RTX-induced
reversible nerve blockade appeared essentially normal. One rarely
observed finding was the irregularly compacted membranous deposits
in the unmyelinated axons. The frequency of this finding was
approximately one per thousand fibers with both concentrations of
RTX.
CONCLUSIONS: The results of the study suggest that a selective and
long-lasting sciatic nerve block (up to 2 wk) can be provided by RTX
without any significant damage to the unmyelinated nerve fibers.
不管电刺激高于还是低于0.5mA超声引导下的肌间沟置针都能产生成功的麻醉
Ultrasound-Guided Interscalene Needle
Placement Produces Successful Anesthesia Regardless of Motor Stimulation Above
or Below 0.5 mA
Sanjay K. Sinha, MBBS*, Jonathan
H. Abrams, MD*, and Robert S. Weller, MD_files/image053.gif){kind=small}
From the *Department of Anesthesiology,
Saint Francis Hospital and Medical Center, Hartford, Connecticut; and _files/image054.gif){kind=small}
Department
of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem,
North Carolina.
Anesth Analg 2007;105:848-852
背景：我们定量检测了超声引导下置针用于肌间沟阻滞（ISB）后不同电流强度引起的反应。然后我们比较了高于或低于0.5mA的电刺激反应下不同的阻滞特征。
方法：这次前瞻性观测性的研究包括了61位择期在ISB和全麻下行非住院肩关节手术的病人。术前一根绝缘的探针通过超声引导放置在了肌间沟。在测定了能够引起运动反应的最低电流量后，注射加入肾上腺素的30ml 0.5%的布比卡因。全麻诱导前测定在上躯干分布的运动和感觉阻滞范围15min。术后记录上躯干阻滞成功率、麻醉后复苏室中的疼痛评分、阻滞持续时间和术后整夜的止痛药片消耗量。病人事先被分成A组（电流强度_files/image056.gif){kind=small}
0.5
mA）和B组（电流强度>0.5 mA），比较两组之间的结果。
结果：观测的电流变化在0.14–1.7 mA，其中42%的病人电流_files/image057.gif){kind=small}
0.5
mA（A组）。所有的病人上躯干运动感觉阻滞都很完全，在麻醉后复苏室中不需要麻醉药物。两组的麻醉持续时间（17.8 ± 4.9 h，平均值±标准差）和在家中止痛药需求量相当。两组感觉阻滞起效时间相当，但B组在15min时的不完全运动阻滞发生率更高（B组37%比A组12%，P=0.03）。
结论：用神经刺激的超声引导下ISB过程中，在电流大于或小于0.5mA观察到的运动反应不影响上躯干阻滞的成功率和持续时间。
（姜旭晖译 马皓琳 李士通校）
BACKGROUND: We
quantified the motor response after ultrasound (U-S)-guided needle
placement for interscalene block (ISB). We then compared block
characteristics based on motor response above or below 0.5 mA.
METHODS: Sixty-one
patients scheduled for ambulatory shoulder surgery under ISB and
general anesthesia were included in this prospective, observational
study. Preoperatively, an insulated needle was positioned by U-S in
the interscalene groove. The lowest current producing motor response
was determined, and 30 mL 0.5% bupivacaine with epinephrine was
injected. Motor and sensory block were tested in the upper trunk
distribution for 15 min until general anesthesia was induced.
Postoperatively, the success of upper trunk block, pain score in the
postanesthesia care unit and block duration, and analgesic tablet
consumption overnight were recorded. Patients were divided a
priori into Group A (current _files/image058.gif){kind=small}
0.5
mA) and Group B (current >0.5 mA), and results were compared
between groups.
RESULTS: The
observed current range was 0.14–1.7 mA, with current _files/image059.gif){kind=small}
0.5
mA in 42% of patients (Group A). All patients had complete
sensorimotor upper trunk block and none required narcotics in the
postanesthesia care unit. Block duration (both groups: 17.8 ± 4.9 h,
mean ± sd) and home analgesic use were equivalent. Sensory block
onset was equivalent between groups, but incomplete motor block at
15 min was more likely in Group B: 37% vs 12% in Group A (P = 0.03).
CONCLUSION: During
U-S-guided ISB using nerve stimulation, the observed motor response
below or above 0.5 mA had no impact on success or duration of upper
trunk block.
持续正压通气呼吸可以增加颈胸段硬膜外注射利多卡因后的感觉阻滞头向扩散
Continuous Positive Airway Pressure
Breathing Increases Cranial Spread of Sensory Blockade After Cervicothoracic
Epidural Injection of Lidocaine
W. Anton Visser,
MD*, Maarten J. P. G. van Eerd, MD*, Robert van Seventer,
MD*, Mathieu J. M. Gielen, MD, PhD_files/image060.gif){kind=small}
, Janneke L. P. Giele, MSc_files/image061.gif){kind=small}
, and Gert J. Scheffer, MD, PhD_files/image062.gif){kind=small}
From the *Department of Anesthesiology,
Intensive Care and Pain Management, Amphia Hospital, Breda, The Netherlands;
and _files/image063.gif){kind=small}
Department
of Anesthesiology, University Medical Center Nijmegen, Nijmegen, The
Netherlands.
Anesth Analg 2007;105:868-871
背景：持续正压通气（CPAP）可以增加低胸段硬膜外注射利多卡因后的感觉阻滞尾向扩散。我们假设，CPAP会增加颈胸段硬膜外注射后阻滞头向扩散。
方法：二十例硬膜外导管位于C6-7或C7-T1间隙的病人，在环境压力下呼吸（对照组）或用7.5cm水柱CPAP呼吸时给予一个硬膜外剂量的利多卡因。注射后，我们评估了感觉阻滞平面的扩散。并记录注射前后肺量参数。
结果：数据以中位数（25%-75%范围）值表示。感觉神经阻滞的平面对照组在C7 (C4–7)到 T4 (T4–6)，CPAP组在C2 (C2–4)到T4 (T2–5) (P = 0.003)。总的阻滞节段数在对照组和CPAP组分别为7.5 (6.8–9.8)和10 (8–12) (P = 0.13)。从阻滞点头向阻滞节段数在对照组和CPAP组分别为1(0.8–3.5)和5 (3.5–7)(P = 0.006))。达到最高脑神经阻滞（上到C2）的病人数在对照组和CPAP组分别为一位和七位(P = 0.02)。两组病人的肺量值均有较小的但显著的下降，组间无差异。
结论：和环境压力下呼吸相比，在颈胸段硬膜外利多卡因麻醉时提供CPAP可以增加感觉阻滞的头向扩散。
（黄佳佳译，马皓琳 李士通 校）
BACKGROUND: Continuous
positive airway pressure (CPAP) increases the caudad spread of
sensory blockade after low-thoracic epidural injection of lidocaine.
We hypothesized that CPAP would increase cephalad spread of blockade
after cervicothoracic epidural injection.
METHODS: Twenty
patients with an epidural catheter at the C6–7 or C7–T1 interspace
received an epidural dose of lidocaine while breathing at ambient
pressure (control group), or while breathing with 7.5 cm H2O
CPAP. After injection, we evaluated the spread of sensory blockade.
Spirometry variables before and after epidural injection were also
measured.
RESULTS: Data
are presented as median (interquartile range) values. Sensory block
ranged from C7 (C4–7) to T4 (T4–6) in the control group and from C2
(C2–4) to T4 (T2–5) in the CPAP group (P = 0.003 for the cranial border). The total number of
segments blocked was 7.5 (6.8–9.8) in the control group and 10
(8–12) in the CPAP group (P = 0.13). The number
of segments blocked cranial to the injection site was one (0.8–3.5)
in the control group and five (3.5–7) in the CPAP group (P = 0.006). The number of patients with a maximal cranial
block (up to C2) was one in the control group and seven in the CPAP
group (P = 0.02). In both groups, there was
a small but significant decrease from baseline in spirometry values,
with no differences between groups.
CONCLUSION: Applying
CPAP during cervicothoracic epidural injection of lidocaine resulted
in a more cranial extension of sensory blockade when compared with
breathing at ambient pressure.
减少围手术期血栓并发症：肝素导致的血小板减少症(HIT)的新进展
Reducing thrombotic complications in the
perioperative setting: an update on heparin-induced thrombocytopenia.
Levy JH, Tanaka KA, Hursting MJ.
Emory University School of Medicine,
Atlanta, Georgia 30322, USA.
Anesth Analg 2007 105: 570-582.
肝素被广泛的用于围手术的处理。肝素免疫导致的HIT是一严重的抗体介导的并发症，它在肝素治疗5天以上病人中的发生率大约在0.5%-5%。在明显的栓前障碍下，在发生的病人中HIT有发生血栓及加重后果的严重危险：大约38%-76%发生血栓，发生血栓的大约需要截肢，而大约20%-30%死于1个月内。HIT抗体存在短暂，一般3个月内消失。在抗体延时的病人中，肝素的再暴露可能是致命的。在围手术的处理中，加强对HIT的及时辨别、诊断和治疗是重要的。如果在肝素使用5-14天后血小板数量下降50%和或血栓发生，HIT当被考虑，在排除其他诊断的情况下。严重怀疑HIT的，即使在实验室确诊HIT之前，肝素即可停用，并应用肠外抗凝治疗。实验室检验结果可以帮助决定继续非肝素化治疗还是转回使用肝素。在多数情况下，近期或当前有HIT的病人避免使用肝素是可行的。除了心血管手术。如果在HIT抗体未消失时手术不能延时，术中抗凝是可取的。
（陈勇柱译 薛张纲校）
Heparins are widely used in the
perioperative setting. Immune heparin-induced thrombocytopenia (HIT) is a
serious, antibody-mediated complication of heparin therapy that occurs in
approximately 0.5%-5% of patients treated with heparin for at least 5 days. An
extremely prothrombotic disorder, HIT confers significant risks of thrombosis
and devastating consequences on affected patients: approximately 38%-76%
develop thrombosis, approximately 10% with thrombosis require limb amputation,
and approximately 20%-30% die within a month. HIT antibodies are transient and
typically disappear within 3 mo. In patients with lingering antibodies,
however, re-exposure to heparin can be catastrophic. In the perioperative
setting, heightened awareness is important for the prompt recognition,
diagnosis, and treatment of HIT. HIT should be considered if the platelet count
decreases 50% and/or thrombosis occurs 5-14 days after starting heparin, with
other diagnoses excluded. On strong clinical suspicion of HIT, heparin should
be discontinued and a parenteral alternative anticoagulant initiated, even before
laboratory confirmation of HIT is obtained. Subsequent laboratory test results
may help with the decision to continue with nonheparin therapy or switch back
to heparin. Heparin avoidance in patients with current or previous HIT is
feasible in most clinical situations, except perhaps in cardiovascular surgery.
If the surgery cannot be delayed until HIT antibodies have disappeared,
intraoperative alternative anticoagulation is recommended.
异丙酚输注浓度变化对麻醉小儿血浆cGMP浓度的影响
The effect of varying continuous
propofol infusions on plasma cyclic guanosine 3',5'-monophosphate
concentrations in anesthetized children.
Engelhardt T, Chan MK, McCheyne AJ, Karsli C, Luginbuehl I, Bissonnette B.
Department of Anaesthesia and Laboratory
Medicine, The Hospital for Sick Children, University of Toronto, Toronto,
Ontario, Canada.
Anesth Analg 2007 105: 616-619.
谷氨酸盐-NO-cGMP通路是全身麻醉药物的有效作用靶点。在健康成年志愿者镇静期间血浆异丙酚浓度升高后伴随血浆cGMP的降低。我们推测在麻醉的小儿中血浆异丙酚浓度升高能够导致血浆cGMP浓度降低。方法：18例既往健康、年龄46.8+/—19.6月、需要全身麻醉、下腹部手术患儿。吸入诱导后行气管插管、间歇正压通气、骶部硬膜外麻醉。麻醉维持采用连续异丙酚输注，按照先前的方案以达到预计血浆异丙酚浓度：分别在30min、50imn、70min达到6、3和1.5mg/ml。收集血浆标本，采用高效液相色谱法和免疫分析法测量异丙酚和cGMP浓度。结果：在每个预计血浆浓度点血浆cGMP浓度明显改变分别为19.2（11.8-23.5），21.3（14.6-30.8），24.9（15.7-37.8）nmol/L，相关系数为-0.62。结论：健康小儿中血浆异丙酚浓度增加可导致血浆cGMP浓度降低，血浆cGMP浓度可作为异丙酚麻醉深度的生化指标。
（吴德华译 薛张纲校）
BACKGROUND: The glutamate-nitric
oxide-cyclic guanosine 3',5'-monophosphate (cGMP) pathway is potentially an
effective target for general anesthetics. Plasma cGMP concentrations are
reduced after an increase in predicted plasma propofol concentrations during
sedation in healthy adult volunteers. We hypothesized that an increase in measured
plasma propofol concentration leads to a reduction in plasma cGMP in
anesthetized children. METHODS: Eighteen healthy children aged 46.8 (+/-19.6)
mo, requiring general anesthesia for lower body surgical procedures were
enrolled. After inhaled induction, tracheal intubation and initiation of
intermittent positive pressure ventilation, caudal epidural analgesia was
performed. Anesthesia was maintained using a continuous propofol infusion
adapted from a previously published regimen to achieve predicted propofol
plasma concentration of 6, 3, and 1.5 microg/mL after 30, 50, and 70 min,
respectively. Samples for propofol and cGMP plasma concentrations were
collected and analyzed using high-performance liquid chromatography and an
enzyme immunoassay system. RESULTS: The plasma cGMP concentrations varied
significantly (median [range]) 19.2 [11.8-23.5], 21.3 [14.6-30.8], and 24.9
[15.7-37.8] nmol/L among each predicted plasma propofol concentration, . The
correlation coefficient (r) was -0.62. CONCLUSIONS: This study demonstrates
that an increase in plasma propofol concentration leads to a decrease in plasma
cGMP in healthy children, and could serve as a biochemical marker for depth of
propofol anesthesia in children.
对罗哌卡因作用于离体豚鼠心脏标本产生的毒性作用使用左西孟旦的强心功能
The Effects of Levosimendan on Myocardial
Function in Ropivacaine Toxicity in Isolated Guinea Pig Heart Preparations
Sebastian N. Stehr, MD*,
Torsten Christ, MD, Berit Rasche, MD*, Stefan Rasche, MD*, Erich Wettwer, PhD, Andreas
Deussen, MD, Ursula Ravens, MD, Thea Koch, MD*, and Matthias Hübler, MD*
From the Departments of *Anesthesiology and
Intensive Care Medicine, Pharmacology and Toxicology, and Institute of
Physiology, Medical Faculty Carl Gustav Carus, Dresden, Germany.
Anesth Analg 2007 105: 641-647.
背景：左西孟旦是一种作用于心衰的新型强心药，但其对于局麻药导致的心肌抑制作用尚未知。因此，我们研究了左西孟旦对于罗哌卡因在离体豚鼠心脏标本产生的负性强心效应的作用。方法：使用传统方法测量了豚鼠乳头肌的动作电位和收缩力。心率、收缩压、+dP/dtmax、冠脉血流及PR、QRS间期被测量于离体恒压灌流、非再循环豚鼠心脏标本。单独或累积的左西孟旦及罗哌卡因浓度增加被单独或联合应用。结果：在离体乳头肌，罗哌卡因导致浓度依赖的收缩力改变。使用10µM左西孟旦可以几乎完全反转使用10µM罗哌卡因产生的负性强心作用。左西孟旦产生的强心作用的敏感性不会被10µM的罗哌卡因所改变。动作电位只有在最高浓度的时候被影响。在豚鼠心脏，左西孟旦显著的反转了罗哌卡因产生的心率、收缩压、冠脉血流及+dP/dtmax减少，使回复至基线值。结论：对于罗哌卡因产生的心肌抑制，左西孟旦是一种有效的强心药，且其心肌敏感性、效能并不被局麻药所影响。我们的结果提示左西孟旦的钙增敏反应可有效的作用于局麻药产生的心肌抑制。
(孙霞译 薛张纲校）
BACKGROUND: Levosimendan is a novel drug used
for inotropic support in heart failure, but its efficacy in local
anesthetic-induced myocardial depression is not known. Therefore, we
investigated the effects of levosimendan on the negative inotropic response to
ropivacaine in isolated heart preparations of guinea pigs. METHODS: Action
potentials and force of contraction were studied with conventional techniques
in guinea-pig papillary muscles. Heart rate, systolic pressure, the first derivative
of left ventricular pressure (+dP/dtmax), coronary flow, and PR and QRS
intervals were measured in isolated constant-pressure perfused,
nonrecirculating Langendorff heart preparations. Single or cumulatively
increasing concentrations of levosimendan and ropivacaine were used either
alone or in combination. RESULTS: In isolated papillary muscle, ropivacaine
reduced force of contraction in a concentration-dependent manner. Exposure to
10 µM levosimendan in the presence of 10 µM ropivacaine almost completely
reversed the negative inotropic response. Sensitivity to the positive inotropic
effect of levosimendan was not altered by 10 µM ropivacaine (–logEC50 [M] =
7.03 without versus 6.9 with ropivacaine, respectively). Action potential
parameters were influenced only at the highest concentration. In the
Langendorff heart, levosimendan significantly reversed the ropivacaine-induced
reduction in heart rate, systolic pressure, coronary flow, and +dP/dtmax to
baseline values. CONCLUSION: Levosimendan is an effective inotropic drug in
ropivacaine-induced myocardial depression and levosimendan myocardial
sensitivity, and efficacy was not affected by the local anesthetic. Our results
suggest that the calcium-sensitizing action of levosimendan is effective in local
anesthetic-induced cardiac depression.
Alterations in Spinal, but Not
Cerebral, Cerebrospinal Fluid Na+ Concentrations Affect the Isoflurane Minimum
Alveolar Concentration in Rats
Michael J. Laster, DVM*, Yi Zhang, MD_files/image064.gif){kind=small}
,
Edmond I. Eger, II, MD*, Dimitry Shnayderman, BS*, and James M. Sonner, MD*
Anesth Analg 2007 105: 661-665.
背景：过去的研究表明氟烷的MAC值（50％的受试者对伤害性刺激无反映的吸入麻醉药最低肺泡浓度）与中枢神经系统的钠离子浓度直接相关。然而，这些研究改变了钠离子的总浓度，但对脊髓和大脑的影响并没有很好的区分。这里存在明显的区别，因为脊索是吸入麻醉药产生制动作用的初级介导场所。相应的，在这个研究中，我们检测了不同鞘内钠离子浓度对比脑室内钠离子浓度对MAC的影响。方法：我们通过大鼠身上的留置管或留置针在腰椎的蛛网膜下腔和脑室内注射无钠溶液或重钠溶液，并分别在注射前、注射中和注射后测量异氟醚的MAC值。结果：异氟醚的MAC值与鞘内注射的钠离子浓度有关，而与脑室内注射的钠离子浓度无关。结论：这一结果与通过钠离子通道对MAC的介导或调节一致。这些包括电压门控通道、配体门控通道和其他钠离子敏感靶位。（例如：离子泵、转运体、交换体）
（王时来译 薛张纲校）
BACKGROUND: Previous studies demonstrated
that MAC (the minimum alveolar concentration of an inhaled anesthetic that
produces immobility in 50% of subjects exposed to noxious stimulation) for
halothane directly correlates with the central nervous system concentration of
Na+. However, those studies globally altered Na+ concentrations, and thus did
not distinguish effects on the spinal cord from cerebral effects. This is an
important distinction because the cord appears to be the primary site for
mediation of the immobility produced by inhaled anesthetics. Accordingly, in
the present study, we examined the effect of altering intrathecal versus
intracerebroventricular concentrations of Na+ on MAC. METHODS: In rats prepared
with chronic indwelling catheters or stylets, we infused solutions deficient in
Na+ and with an excess of Na+ into the lumbar subarachnoid and
intracerebroventricular spaces and measured MAC for isoflurane before, during,
and after infusion. RESULTS: MAC of isoflurane correlated directly with
concentrations of Na+ infused intrathecally but did not correlate with
concentrations infused intracerebroventricularly. CONCLUSION: The results are
consistent with a mediation or modulation of MAC by Na+ channels. These might
include voltage-gated or ligand-gated channels or other Na-sensitive targets
(e.g., pumps, transporters, exchangers).
Measurement of Anesthetics in Blood
Using a Conventional Infrared Clinical Gas Analyzer
Philip J. Peyton, Michael Chong, Christopher
Stuart-Andrews, Gavin J. B. Robinson, Robert Pierce, and Bruce R. Thompson
Anesth Analg 2007 105: 680-687.
背景：通常我们用气相色谱分析的顶空平衡方法来测定血液中的吸入麻醉气体分压，但是由于技术、设备和后勤要求等原因在临床工作中我们不常应用这种方法。为了使这种测量更可行，我们尝试使用一种传统的红外线气体分析仪：Datex-Ohmeda Capnomac。方法：在描述了这个仪器测量吸入麻醉气体的浓度相对于一氧化二氮、二氧化碳和水蒸气的线性关系后，血液被含有已知浓度七氟醚（0.5%和5%）的氧气和笑气氧气混合充满，或者被同时含有异氟醚和地氟醚的氧气充满。结果：测得氧气中七氟醚的浓度相对于张力仪测得的参考分压值的偏差是-4.5（(4.8%)，这在40%氧气混合60%笑气中的变化不大。异氟醚和地氟醚相对于实际浓度的偏差分别为-3.9 (3.3%) 和 -4.6 (3.8%)。结论：用临床红外线气体分析仪的双顶空平衡技术测量血液中吸入麻醉气体分压的精确度可以和之前我们研究所用的气相色谱分析仪相媲美。
(施 杨译 薛张纲校)
BACKGROUND:
Measurement of the partial pressure of volatile anesthetics in blood is usually
done using a "headspace equilibration" method with gas
chromatography. However, it is not often performed in clinical studies because
of the technical, equipment, and logistic requirements. To improve the
accessibility of this measurement, we tested the use of a common infrared
clinical gas analyzer, the Datex-Ohmeda Capnomac, for this purpose. METHODS:
After characterization of the linearity of the device in measuring the volatile
anesthetic concentration in the presence of nitrous oxide, carbon dioxide, and
water vapor, blood was tonometered with known concentrations of sevoflurane
(actual value between 0.5% and 5.0%) in oxygen and oxygen/nitrous oxide
mixtures, as well as mixtures of isoflurane and desflurane in oxygen. RESULTS:
Mean bias (standard deviation) overall for sevoflurane in oxygen relative to
the tonometered reference partial pressure was -4.5 (4.8%) of the actual
concentration. This was not altered significantly by measurement in 40%
oxygen/60% nitrous oxide. For isoflurane and desflurane it was -3.9 (3.3%) and
-4.6 (3.8%), respectively, of the actual concentration. CONCLUSIONS: The
accuracy and precision of measurement of volatile anesthetic gas partial
pressures in blood by a double headspace equilibration technique, using a
clinical infrared gas analyzer, were comparable to that achieved by previous
studies using gas chromatography.
Control of Blood Loss During Sacral
Surgery by Aortic Balloon Occlusion
Lan Zhang,*Quan Gong, Hong Xiao,Chongqi
Tu,and Jin Liu,
Address correspondence to Quan Gong, MM,
Department of Orthopedics, West China Hospital, Sichuan University, No. 37,
Guo-xue-xiang, Chengdu, Sichuan 610041, People's Republic of China.
Anesth Analg 2007 105: 700-703.
骶骨根治性手术会导致术中致命性的出血量。控制这种出血的安全有效的方法仍未发现。我们在这里报导一种可充气的胶质球囊的使用，它可以间断地阻塞远端腹主动脉，控制骶骨肿瘤切除术中失血量。球囊导管经过股动脉引导进入腹主动脉。通过测量双足趾的血氧饱和度和超声定位来指导并确定球囊在腹主动脉的肾动脉以下段。球囊每充气60分钟要放气10分钟。在5个进行骶骨肿瘤切除的病人中，使用球囊阻塞的病人估计出血量<300ml，手术时间<2小时。术后肾功能无明显变化，盆腔器官和下肢功能完好。经皮动脉球囊阻塞可以提供安全有效的骶骨肿瘤切除术术中的失血量。
（陈佳莉译 薛张纲校）
Radical sacral surgery can be associated
with life-threatening blood loss. Effective and safe methods for controlling
this blood loss remain elusive. We here report the use of an inflatable sizing
balloon to intermittently occlude the distal abdominal aorta and control blood
loss during sacral tumor resections. The balloon catheter was introduced into
the abdominal aorta via the femoral artery. Pulse oxygen saturation signals
from bilateral toes and ultrasonography were used to guide and confirm the
location of the balloon in the abdominal aorta and distal to the
renal arteries. The balloon was deflated for 10 min after each 60
min occlusion period. In five patients undergoing sacral tumor
resection, the estimated blood loss when using balloon occlusion was
<300 mL, and surgical duration was <2 h. No significant change
in kidney, pelvic organ, and lower extremity function was found
after the surgeries. Percutaneous aortic balloon occlusion can
provide safe and effective control of blood loss during
sacrococcygeal tumor resection.
选择性肺复张对于严重低血容量患者的血流动力学是否安全？一项在肺萎陷猪的动物模型关于低血容量的试验性研究。
Are Selective Lung Recruitment Maneuvers
Hemodynamically Safe in Severe Hypovolemia? An Experimental Study in
Hypovolemic Pigs with Lobar Collapse
Lars Kjærsgaard Hansen, MD*,
Jacob Koefoed-Nielsen, MD*_files/image065.gif){kind=small}
,
Jonas Nielsen, MD, PhD_files/image066.gif){kind=small}
,
and Anders Larsson, MD, PhD*_files/image067.gif){kind=small}
From the *Department of Anesthesia and
Intensive Care, Center for Cardiovascular Research, Aalborg Hospital, Århus
University Hospitals, Aalborg; _files/image068.gif){kind=small}
Clinical
Institute, Århus University, Århus; and _files/image069.gif){kind=small}
Department
of Anaesthesia and Intensive Care, Copenhagen University Hospital Gentofte,
Hellerup, Denmark.
Anesth Analg 2007 105: 729-734.
背景：我们先前已经显示，在正常血容量的实验猪，选择性肺复张(S-LRM)，即在带囊气管导管的顶端插入萎陷肺侧的支气管中，并经此吹入空氧混合气，可以有效改善氧合和肺容量，并且鲜有血流动力血方面的副作用。在这项研究中，我们研究了循环尚可维持的低血容量条件下，S-LRM对于呼吸和循环的影响。方法：8只麻醉了的实验猪给予通气（Fio2 1.0），将带囊的气管导管插入右下肺叶支气管中，肺叶选择性灌洗以产生更好的肺叶萎陷。分别在正常血容量、静脉放血20％、40％血容量时，给予实验猪S-LRM。测定在S-LRM之前、当时、之后的血气、呼吸系统顺应性、血管压力、心排量。结果：PaO2、静脉混合血、呼吸系统顺应性在S-LRM的三个容量水平均有显著改善。在正常血容量和减少20％血容量时，S-LRM组的血流动力学没有改变。在减少40％血容量时，S-LRM组心排量没有改变，平均动脉压轻度降低：S-LRM之前3分钟时48 (37–52) mm Hg (平均, 25和75百分位数), S-LRM 刚结束时40 (35–44) mm
Hg (P = 0.0207), S-LRM之后3分钟时47 (39–54) mm Hg 。结论：S-LRM可以有效改善氧合作用和呼吸系统顺应性，对于循环只有很小的副作用，甚至在肺萎陷的动物模型出现严重低血容量时也是如此。
（陈珺珺译 薛张纲校）
BACKGROUND: We have previously shown, in
normovolemic pigs, that a selective lung recruitment maneuver
(S-LRM), i.e., insufflation of air-oxygen via a balloon catheter
with its tip located in the bronchus of a collapsed lung lobe,
effectively improves oxygenation and lung volume without affecting
hemodynamics negatively. In this study, we examined the respiratory
and circulatory effects of S-LRM during hypovolemia with compromised
circulation. METHODS: In eight ventilated (fraction of inspired
oxygen, Fio2 1.0) and anesthetized pigs a balloon
catheter was inserted in the bronchus of the right lower lung lobe.
The lobe was selectively lavaged to create a dense lobar collapse.
The pigs were then subjected to S-LRM (40 cm H2O airway
pressure for 30 s) at normovolemia, after venesection of 20% and 40%
of the blood volume, respectively. Blood gases, compliance of the
respiratory system (Crs), vascular pressures, and cardiac output
were registered before, during, and after the S-LRM. RESULTS:
Pao2, venous admixture, and Crs improved significantly with
S-LRM at all three volume levels. No change in hemodynamics with
S-LRM occurred in normovolemia and 20% hypovolemia. For 40%
hypovolemia, cardiac output was unchanged by S-LRM, whereas minor
decreases in mean arterial blood pressure were seen: 48 (37–52) mm
Hg (median, 25th and 75th percentiles) 3 min before S-LRM, 40
(35–44) mm Hg at the end of S-LRM (P = 0.0207), and 47 (39–54) mm Hg
3 min after S-LRM.
CONCLUSION: A S-LRM effectively improved
oxygenation and Crs and had only minor circulatory side effects,
even in severe hypovolemia in this animal model of lobar collapse.
Brain Metabolism During a Decrease in
Cerebral Perfusion Pressure Caused by an Elevated Intracranial Pressure in the
Porcine Neocortex
Norbert Zoremba, MD*, Joerg
Schnoor, MD*, Michael Berens, MD*, Ralf Kuhlen, MD, PhD_files/image070.gif){kind=small}
,
and Rolf Rossaint, MD, PhD*
From the Departments of *Anesthesiology and
_files/image071.gif){kind=small}
Intensive
Care Medicine, University Hospital RWTH Aachen, Aachen, Germany.
Anesth Analg 2007 105: 744-750
背景：颅内压的增高伴随着脑血流的减少，并会影响氧供和输出。在这个研究里，我们监测猪的大脑皮层在颅内压增高时的能量依赖性代谢，并找出在什么水平会产生伤害。方法：将32-40kg的驯养公猪麻醉，机械通气，并将其随机的分为实验组（六只）和对照组（五只）。将一个微量测析探针放入大脑皮质测量细胞外液中乳酸、丙酮酸、谷氨酸、丙三纯的浓度。每小时向脑室系统打入一定量的人工脑脊液以升高10mmhg的颅内压，直到达到最高值50mmhg。结果：当颅内压大于等于30mmhg、脑灌注压力低于50mmhg时，可以检测到乳酸、丙三醇的显著上升。当颅内压大于等于40mmhg、脑灌注压低于40mmhg时，乳酸丙酮酸比值及谷氨酸值显著上升，而糖的水平明显下降。结论：数据可以证明，ICP、CPP可能产生危害的临界值分别为30mmhg和40mmhg。
（秦 佳译 薛张刚校）
BACKGROUND: Cranial hypertension coincides
with a reduction in cerebral blood flow as well as in oxygen
delivery and influences outcome. In this study, we monitored changes
in energy-related metabolites in the porcine cortex during an
increase of intracranial pressure (ICP) and to determine the level
at which damage occurs.
METHODS: Male domestic pigs (32–40 kg) were
anesthetized, mechanically ventilated, and randomly assigned to
either the experimental (n = 6) or control groups (n = 5). A
microdialysis probe (CMA 70) was inserted into the cortex to measure
extracellular dialysate concentrations of lactate, pyruvate,
glucose, glutamate, and glycerol. Every hour an increase of 10 mm Hg
in ICP was preformed in the experimental group by infusion of
artificial cerebrospinal fluid into the ventricular system of the
brain until a maximum ICP of 50 mm Hg was reached. RESULTS:
We demonstrated a significant increase of lactate and glycerol
compared with control at ICP values _files/image073.gif){kind=small}
30
mm Hg and cerebral perfusion pressure (CPP) below 50 mm Hg. The
increase of ICP to _files/image074.gif){kind=small}
40
mm Hg in conjunction with a reduction in CPP below 40 mm Hg led to a
significant increase in the lactate/pyruvate-ratio and glutamate, as
well as a decrease of glucose in relation to control. CONCLUSIONS:
Our data strongly suggest that, during a defined ICP increase, lower
CPP values may be tolerable until severe damage occurs. Borderline
ICP and CPP values of 30 and 40 mm Hg, respectively, could be
advised.
东莨菪碱透皮给药预防蛛网膜下腔用吗啡导致的剖宫产术后恶心呕吐
Transdermal scopolamine for prevention
of intrathecal morphine-induced nausea and vomiting after cesarean delivery.
Harnett MJ, O'Rourke N, Walsh M, Carabuena
JM, Segal S.
Department of Anesthesiology, Perioperative
and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School,
Boston, Massachusetts 02115, USA.
Anesth Analg. 2007 105(3):764-9
背景：蛛网膜下腔用吗啡是剖宫产术后极佳的镇痛方式，但导致明显的恶心呕吐。方法：比较术后最初24小时透皮给东莨菪碱、静注昂丹思琼和安慰剂的镇吐效能。240名接受脊麻的剖宫产妇随机分配，研究设计为双盲，在断脐时给东莨菪碱1.5mg、昂丹思琼4mg或安慰剂。结果：研究显示安慰剂组呕吐发生率59.3%，东莨菪碱组降低至40%，昂丹思琼组降低至41.8%。与安慰剂相比，东莨菪碱组在6-24小时呕吐率下降最明显。结论：东莨菪碱对接受蛛网膜下腔吗啡镇痛的剖宫产妇是有效的预防用药。然而它的使用与口干、视力模糊等副作用较高的发生率有关。
（罗 璇译 薛张纲校）
BACKGROUND: Intrathecal morphine for
cesarean delivery provides excellent postoperative analgesia but is associated
with significant nausea and vomiting. METHODS: We compared the antiemetic
efficacy of transdermal scopolamine, IV ondansetron, and placebo during the
first 24 h postoperatively. Two-hundred forty women undergoing cesarean
delivery under spinal anesthesia were randomly allocated, in a double-blind
study design, to receive transdermal scopolamine 1.5 mg, ondansetron 4 mg, or
placebo at the time of cord clamping. RESULTS: Our study showed that the
overall rates for all emesis were 59.3% in the placebo group and were reduced
to 40% in the scopolamine group and 41.8% in the ondansetron group. The
greatest reduction in emesis in the scopolamine group when compared with
placebo was in the 6-24 h time period. CONCLUSION: Scopolamine is an effective
medication for prophylactic use in parturients receiving intrathecal morphine
while undergoing cesarean delivery. Its use, however, was associated with a
higher incidence of side effects such as dry mouth and blurry vision.
The Effect of Analgesic Technique on
Postoperative Patient-Reported Outcomes Including Analgesia: A Systematic
Review
Spencer S. Liu, MD*, and
Christopher L. Wu, MD_files/image075.gif){kind=small}
From the *Department of Anesthesiology, The
Hospital of Special Surgery, and the Cornell Weill Medical Center, New York,
New York; and _files/image076.gif){kind=small}
Department
of Anesthesiology and Critical Care Medicine, The Johns Hopkins University,
Baltimore, Maryland.
Address correspondence to Christopher Wu,
MD, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins
Hospital, Carnegie 280, 600 North Wolfe St., Baltimore, MD 21287.
Anesth Analg 2007 105: 859-867.
背景：术后患者回馈的镇痛效果，包括生活质量、恢复质量、患者满意度，到目前为止还没有系统性的评测过。这些结果是根据患者的个人看法测评，并且被认为有效的最终临床研究结果。我们进行了一项系统性的回顾调查来检测患者术后回馈的镇痛效果。方法：医学检索系统国立图书馆和Cochrane图书馆数据库对近十年的资料进行检索（1996年6月至2006年1月）。医学文献检索系统同时搜索了一些结果，包括满意度、生活质量、恢复质量。
结果：局部镇痛技术与全身使用阿片类药物相比，在统计学上镇痛效果更好。部分由于重要的方法问题，数据不足以评估镇痛的类型、镇痛的程度以及副作用是否会影响生活质量、满意度以及住院天数。结论：虽然有数据显示改进术后镇痛可以提高患者的回馈结果，但是住院患者中心的结果关于生活质量以及恢复质量有所改善的证据仍然不足。适当的减低疼痛评分实际上并不等同于临床上有意义的疼痛改善。需要进一步的研究来验证病人回馈方法的有效性，评估整个围手术期患者回馈的镇痛效果。
（王光妍译 薛张纲校）
BACKGROUND: The effect of postoperative
analgesia on patient-reported outcomes, such as quality of life,
quality of recovery, and patient satisfaction, has not been
systematically examined. These outcomes are assessed from the
patient's perspective and are recognized as valid and important
end-points in clinical medicine and research. We performed a
systematic review to examine the effect of postoperative analgesia
on patient-reported outcomes.METHODS: The National Library of Medicine's
Medline and the Cochrane Library databases were searched for the
past decade (Jan, 1996 to Jun 1, 2006). Additional Medline searches
for specific outcomes (i.e., satisfaction, quality of life, and
quality of recovery) were also conducted。
RESULTS: Regional analgesic techniques
provide statistically superior analgesia compared with systemic
opioids. There are insufficient data to determine if the type of
analgesic technique, degree of analgesia, and presence of side
effects may influence quality of life, quality of recovery,
satisfaction, and length of stay, due in part to some significant
methodologic issues.CONCLUSIONS: Although there are data suggesting that
improved postoperative analgesia leads to better patient outcomes,
there is insufficient evidence to support subsequent improvements
inpatient-centered outcomes such as quality of life and quality of
recovery. Modest reductions in pain scores do not necessarily equate
to clinically meaningful improved pain relief for the patient. Further
studies are needed to develop validated patient-reported instruments
and to assess the effect of analgesic techniques on patient-reported
outcomes in the perioperative period.
Improving the Analgesic Efficacy of
Intrathecal Morphine with Parecoxib After Total Abdominal Hysterectomy (Brief
Report)
Supranee Niruthisard, Thewarug
Werawataganon, Pavena Bunburaphong, Montson Ussawanophakiat, Chuthayuth
Wongsakornchaikul, and Kusonsi Toleb
Department of Anesthesiology, Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand.
Anesth Analg 2007 105: 822-824.
背景：帕瑞考西的使用连同鞘内注射吗啡和布比卡因可能可以增加镇痛效果，减少吗啡的阿片类物质相关的副反应。方法：在这项前瞻性，双盲，随机，安慰剂对照实验中，经腹全子宫切除的患者在鞘内注射布比卡因和0.2mg吗啡之前先静脉注射生理盐水或者40mg帕瑞考西。12小时后，重复给药一次。观察患者48小时。结果：鞘内注射布比卡因和吗啡之外额外使用帕瑞考西可以显著减少术后24小时累计的吗啡消耗量，降低视觉痛觉评分，以及提升的患者满意程度，并且不伴有明显增加的副作用。结论：围术期给与帕瑞考西可以增强鞘内注射吗啡和布比卡因的术后镇痛效果和改善患者舒适度。
（周时蓓译 薛张纲校）
BACKGROUND: The addition of parecoxib to intrathecal morphine and
bupivacaine may improve analgesia and reduce morphine's opioid-related side
effects. METHODS: In this prospective, double-blind, randomized,
placebo-controlled trial, total abdominal hysterectomy patients received either
IV normal saline or parecoxib 40 mg before receiving intrathecal bupivacaine
and morphine 0.2 mg. Twelve hours later, this administration was repeated.
Patients were observed for 48 h. RESULTS: The addition of parecoxib to
intrathecal morphine and bupivacaine significantly reduced cumulative morphine
consumption, Visual Analog Pain scores, and increased patient satisfaction for
24 h postoperatively without an obvious decrease of adverse side effects.
CONCLUSION: Perioperative parecoxib enhanced the postoperative analgesia of
intrathecal morphine and bupivacaine and improved patient satisfaction.
Pathophysiology of Peripheral Neuropathic Pain: Immune Cells and
Molecules
Michael A. Thacker, Anna
K. Clark, Fabien Marchand, Stephen B. McMahon.
Address correspondence and reprint requests to S.B. McMahon, Kings
College London, Neurorestoration group, Wolfson Centre for Age Related Diseases, Wolfson Wing, Hodgkin Building, Guys Campus,
London, SE1 1UL, UK. Anesth Analg 2007; 105 : 838–47
背景：对于末梢神经系统的损伤通常导致慢性的神经性疼痛，表现为自发性疼痛和（或）对于疼痛或无害刺激的过度反应。这种疼痛的状态使病人感到极其虚弱并且很难得到治疗。尽管炎症性疼痛与神经性疼痛通常被认为是两个分离的事件，有证据却显示出了与这种严格的二分法不同的结果。炎症是一种极具特征性的现象，涉及到一系列不同的免疫细胞类型，如：肥大细胞、中性粒细胞、巨噬细胞及T淋巴细胞。另外，这些细胞也释放许多导致疼痛的复合物。最近有证据显示免疫细胞在末梢的神经性疼痛中起到一定的作用。在这篇综述里，我们鉴别各种不同的导致末梢神经性疼痛的免疫细胞以及在这种特殊状况下起到关键作用的各种释放因子。
（吴威译 薛张纲校）
BACKGROUD: Damage to the peripheral nervous system often leads to
chronic neuropathic pain characterized by spontaneous pain and an exaggerated
response to painful and/or innocuous stimuli. This pain condition is extremely
debilitating and usually difficult to treat. Although inflammatory and
neuropathic pain syndromes are often considered distinct entities, emerging
evidence belies this strict dichotomy. Inflammation is a well-characterized
phenomenon, which involves a cascade of different immune cell types, such as
mast cells, neutrophils, macrophages, and T lymphocytes. In addition, these
cells release numerous compounds that contribute to pain. Recent evidence suggests
that immune cells play a role in neuropathic pain in the periphery. In this review
we identify the different immune cell types that contribute to neuropathic pain
in the periphery and release factors that are crucial in this particular
condition.
硬膜外,鞘内注射罗哌卡因的药代动力学和生物利用度
Epidural,
intrathecal pharmacokinetics, and intrathecal bioavailability of ropivacaine.
François-Xavier Rose, Jean-Pierre Estebe,
Maja Ratajczak, Eric Wodey, François Chevanne, Gilles Dollo, David Bec,
Jean-Marc Malinovsky, Claude Ecoffey, and Pascal Le Corre
Anesth Analg. 2007 Sep;105(3):859-67
背景:罗哌卡因通过不同神经轴索阻滞用于硬膜外术后镇痛.由于这些技术的广泛使用和局麻药在髓内分布数据的相对贫乏,我们通过一个动物模型来评估罗哌卡因的髓内分布,从而更多的研究罗哌卡因鞘内生物利用度的影响因素.方法:羊静脉注射50mg罗哌卡因,一周后鞘内注射20mg罗哌卡因3h后硬膜外注射罗哌卡因100mg,通过同步微量渗析技术测量硬膜外和鞘内注射后硬膜外和鞘内的药物浓度 。结果:吸收-时间曲线提示在鞘内和硬膜外注射后全身吸收有很大的变异性,但鞘内注射的吸收速度明显快于硬膜外.在蛛网膜下腔,消除率比分布率要高出近三倍.而在硬膜外腔隙,清除和分布对于罗哌卡因的分布作用有所不同,提示分布过程的影响较大.硬膜外注射后鞘内的生物利用度为11.1% +/- 7.6%. 结论:通过动物模型,我们发现药物在鞘内和硬膜外的分布是不同的,硬膜外注射罗哌卡因的鞘内生物利用度是低的且存在较大的差异性.
（陈恺铮译 薛张纲校）
BACKGROUND: Ropivacaine is used by the epidural route for postoperative pain
management with various neuraxial techniques. Given the widespread use of these
techniques and the relative paucity of data on spinal disposition of local
anesthetics, we evaluated through an experimental animal model, the spinal
disposition of ropivacaine, allowing further studies of factors influencing
their intrathecal bioavailability.
METHODS: Sheep received an IV bolus dose of ropivacaine (50 mg), and 1 wk
after, an intrathecal dose of ropivacaine (20 mg) followed 3 h later by
epidural ropivacaine (100 mg). A simultaneous microdialysis technique was used
to measure epidural and intrathecal drug concentrations after both epidural and
intrathecal administrations.RESULTS: Absorption-time
plots showed a large variability in the systemic absorption after both
intrathecal and epidural administration, with an apparent faster systemic
absorption after intrathecal administration. In the intrathecal space, the
elimination clearance was around three-times higher than the distribution
clearance. In the epidural space, the relative contribution of elimination and
distribution to ropivacaine disposition was different, indicating a more
pronounced influence of the distribution process. The intrathecal
bioavailability after epidural administration was 11.1% +/- 7.6%. CONCLUSIONS:
Using an animal model, we showed that drug dispositions in the intrathecal and
epidural compartments are different, and that the intrathecal bioavailability
of ropivacaine after epidural administration is low, and highly variable.
无麻醉作用的惰性气体通过激活促存活信号激酶和抑制线粒跨膜通道通透性途径对心梗后心肌产生保护作用
Noble Gases Without Anesthetic Properties Protect
Myocardium Against Infarction by Activating Prosurvival Signaling Kinases and
Inhibiting Mitochondrial Permeability Transition In Vivo
Paul S. Pagel, MD, PhD*_files/image077.gif){kind=small}
,
John G. Krolikowski, BS*, Yon Hee Shim, MD*, Suneetha
Venkatapuram, MD_files/image078.gif){kind=small}
,
Judy R. Kersten, MD*_files/image079.gif){kind=small}
,
Dorothee Weihrauch, DVM, PhD*, David C. Warltier, MD, PhD*_files/image080.gif){kind=small}
_files/image081.gif){kind=small}
_files/image082.gif){kind=small}
,
and Phillip F. Pratt, Jr, PhD*_files/image083.gif){kind=small}
From the *Department of Anesthesiology, The
Medical College of Wisconsin and the Clement J. Zablocki Veterans Affairs
Medical Center, Milwaukee, Wisconsin; _files/image084.gif){kind=small}
Department
of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin; and
Departments of _files/image085.gif){kind=small}
Medicine
(Division of Cardiovascular Diseases) and _files/image086.gif){kind=small}
Pharmacology
and Toxicology, The Medical College of Wisconsin and the Clement J. Zablocki
Veterans Affairs Medical Center, Milwaukee, Wisconsin.
Anesth Analg 2007 105: 562-569.
背景：麻醉惰性气体--氙气具有心脏保护作用。作者假设其他没有麻醉作用的惰性气体[氦He、氖Ne、氩Ar]同样具有心脏保护作用，并进一步假设所产生的心脏保护作用是通过激活促存活信号激酶[包括三磷酸肌醇激酶、细胞外信号调节激酶和70-kDa核糖体蛋白s6激酶]以及抑制体内线粒体膜通道通透性[mPTP]的开放所介导。
方法：对98只家兔进行血流动力学监测，阻塞左前降支冠状动脉30min后给予3小时的0.9%生理盐水再灌注（对照组）；在左前降支阻塞前给予3轮70%He、Ne或Ar －30%氧气5分钟并间断给与70%氮气－30%氧气5分钟，或长时间的左前降支阻塞及再灌注前给于三轮短暂的（5分钟）缺血刺激并间断给予5分钟再灌注（缺血预适应组）。另外无论是否给予He预处理，选择性给予每组家兔三磷酸肌醇激酶抑制剂（渥曼青霉素0.6mg/kg）,细胞外信号调节激酶抑制剂 (PD098059 2mg/kg), 70-kDa核糖体蛋白s6激酶抑制剂（雷帕霉素0.25mg/kg）, 或线粒体膜通道开放剂(苍术苷5mg/kg)。
结果：使用氦、氖、氩和缺血预适应组显著降低了梗阻面积（用氯化三苯基四氮唑(TTC)确定心肌梗死范围），左室面积（平均值±标准差）分别为23%±4%，20%±3%，22%±2%，17%±3%；而对照组为45%±5%。渥曼青霉素（wortmannin，PI3－K家族激酶特异抑制剂）、PD098059、雷帕霉素(Rapamycin)和 苍术苷(atractyloside，MPT 孔道开放剂)均不影响梗死面积，但这些药能抑制He所产生的心肌保护作用。
结论：没有麻醉作用的惰性气体可以通过激活促存活信号激酶，以及抑制家兔体内线粒体膜通透性通道的开放等作用产生心肌保护的作用。
(陶颖莹 译 陈杰 校)
BACKGROUND: The anesthetic noble gas,
xenon, produces cardioprotection. We hypothesized that other noble
gases without anesthetic properties [helium (He), neon (Ne), argon
(Ar)] also produce cardioprotection, and further hypothesized that
this beneficial effect is mediated by activation of prosurvival
signaling kinases [including phosphatidylinositol-3-kinase, extracellular
signal-regulated kinase, and 70-kDa ribosomal protein s6 kinase] and
inhibition of mitochondrial permeability transition pore (mPTP)
opening in vivo.
METHODS: Rabbits (n = 98) instrumented for hemodynamic measurement and
subjected to a 30-min left anterior descending coronary artery (LAD)
occlusion and 3 h reperfusion received 0.9% saline (control), three
cycles of 70% He-, Ne-, or Ar-30% O2 administered for 5
min interspersed with 5 min of 70% N2–30% O2 before LAD
occlusion, or three cycles of brief (5 min) ischemia interspersed with
5 min reperfusion before prolonged LAD occlusion and reperfusion (ischemic
preconditioning). Additional groups of rabbits received selective
inhibitors of phosphatidylinositol-3-kinase (wortmannin; 0.6 mg/kg),
extracellular signal-regulated kinase (PD 098059; 2 mg/kg), or
70-kDa ribosomal protein s6 kinase (rapamycin; 0.25 mg/kg) or mPTP
opener atractyloside (5 mg/kg) in the absence or presence of He
pretreatment.
RESULTS: He, Ne, Ar, and ischemic
preconditioning significantly (P <
0.05) reduced myocardial infarct size [23% ± 4%, 20% ± 3%, 22% ± 2%,
17% ± 3% of the left ventricular area at risk (mean ± sd);
triphenyltetrazolium chloride staining] versus control (45% ± 5%).
Wortmannin, PD 098059, rapamycin, and atractyloside alone did not
affect infarct size, but these drugs abolished He-induced
cardioprotection.
CONCLUSIONS: The results indicate that
noble gases without anesthetic properties produce cardioprotection
by activating prosurvival signaling kinases and inhibiting mPTP
opening in rabbits.
The Incidental Finding of a Patent
Foramen Ovale During Cardiac Surgery: Should It Always Be Repaired? A Core
Review
Mikhail R. Sukernik, MD, PhD*,
and Elliott Bennett-Guerrero, MD_files/image087.gif){kind=small}
From the *Department of Anesthesiology,
Pennsylvania State University College of Medicine, Hershey, Pennsylvania; and _files/image088.gif){kind=small}
Duke
Clinical Research Institute, Durham, North Carolina.
Anesth Analg 2007 105: 602-610. [
随着术中经食道超声心动图应用增加，心脏手术中常发现卵圆孔未闭。由于术中诊断卵圆孔未闭对术后结局的影响尚未知晓，使心脏外科医生陷入两难的境地。改变手术方案修补卵圆孔未闭使患者面临风险增加。而另一方面，不修补卵圆孔使患者面临未知的即刻与长期不良结果。目前决定是否修补卵圆孔取决于临床医生个人偏好、术中术后低氧血症的可能性、以及任何与最初手术方案的偏差。多数临床医生同意如果手术有导致低氧血症的高危风险（例如安置左心室辅助装置，心脏移植），则必须修补术中诊断出的卵圆孔未闭；心脏手术期间不进行心房切开和上下腔静脉插管的操作可使卵圆孔未闭相关的围术期和远期并发症增加，因而建议应该关闭卵圆孔。经皮卵圆孔未闭修补技术为卵圆孔未闭未修补而术后低氧血症或其它并发症可能导致无法修补卵圆孔的案例提供有价值的替代方案。
（周懿之 译 陈杰 校）
With the increased use of intraoperative
transesophageal echocardiography, patent foramen ovale (PFO) has
become a common finding during heart surgery. This finding presents
a difficult dilemma for cardiac surgeons, since the impact of
intraoperatively diagnosed PFOs on postoperative outcome is unknown.
Changes in the surgical plan required for closure of a PFO subject
the patient to the possibility of additional risk. On the other
hand, a decision to not close a PFO exposes the patient to unclear
immediate and long-term consequences. Deciding whether or not to
close a PFO currently depends on the clinicians’ personal
preferences, the probability of intraoperative and postoperative
hypoxemia, and any anticipated deviation from the initial surgical
plan. Most clinicians agree that an intraoperatively diagnosed PFO
must be closed when surgery leads to a high risk of hypoxemia (e.g.,
left ventricular assist devices placement, heart transplantation); should
be closed in most cases when minimal deviation from the initial
surgical plan is needed for PFO closure (e.g., mitral valve or
tricuspid valve surgeries); and probably, should be closed during
heart surgeries performed without atriotomy and bicaval cannulation
when the risk of perioperative or remote PFO-related complications
is increased. The recent development of percutaneous methods of PFO
closure provides a valuable backup for those cases when PFO is not
closed and postoperative hypoxemia or other complications may be
attributable to the uncorrected PFO.
Molecular Evidence of Late
Preconditioning After Sevoflurane Inhalation in Healthy Volunteers
Eliana Lucchinetti, PhD*, José
Aguirre, MD*, Jianhua Feng, MD, PhD*, Min Zhu, PhD*,
Marc Suter, MD*, Donat R. Spahn, MD*, Luc Härter, PhD_files/image089.gif){kind=small}
,
and Michael Zaugg, MD*
From the *Institute of Anesthesiology; and _files/image090.gif){kind=small}
Department
of Trauma Surgery, University Hospital Zurich, Switzerland.
Anesth Analg 2007 105: 629-640.
背景：挥发性麻醉药的预处理晚期作用涉及到对转录改变的应答。作者假设吸入七氟醚将改变人血液细胞的转录，并调整白细胞黏附分子的表达，这与晚期预处理时的发现一致。
方法：五名健康男性受试者持续吸入浓度0.5%-1.0%的七氟醚60min。分别在吸入前，吸入后15min和60min及此后的6h、24h、48h采集静脉血样本，并立即用流式细胞仪进行细胞计数，提取mRNA并与Affymetrix U133 Plus 2.0 微点阵杂交。数据应用微点阵显著性分析、基因位点浓缩分析和实时逆转录聚合酶连反应分析。L-选择蛋白（CD62L）,B2-整合蛋白（CD11b）的表达通过流式细胞仪计算粒细胞和单核细胞数来确定。
结果：吸入七氟醚能迅速地、显著地改变白细胞的基因表达。包括对氧磷酸酶、12-脂肪氧化酶、热休克蛋白40、趋化因子配体5、磷酸二酯酶5A的关键转录物在七氟醚作用下的调整可能涉及到晚期预处理或器官保护。七氟醚进一步降低涉及过氧化物酶体增值子受体共激动剂-1a（PGC-1a）信号和脂肪酸氧化的转录。降低粒细胞L-选择蛋白的表达伴随着增加抑制炎症反应激活能力，在吸入七氟醚24-48小时后表现出来。
结论：七氟醚在亚麻醉浓度能改变血细胞转录，减少促炎因子L-选择蛋白的表达，符合人的“第二窗口保护作用”。
（潘方立 译 陈杰 校）
BACKGROUND: Late preconditioning by
volatile anesthetics evolves in response to transcriptional changes.
We hypothesized that sevoflurane inhalation would modify the
transcriptome in human blood and modulate the expression of adhesion
molecules in white blood cells consistent with the occurrence of a
late preconditioning phase.
METHODS: Five healthy male subjects inhaled
sevoflurane at an end-tidal concentration of 0.5%–1.0% for 60 min.
Venous blood samples were collected at baseline, after 15 and 60 min
of inhalation, and 6, 24, 48, and 72 h thereafter and immediately processed
for flow cytometry and mRNA extraction and hybridization to
Affymetrix U133 Plus 2.0 microarrays. Data were analyzed using
Significance Analysis of Microarray and Gene Set Enrichment Analysis
and confirmed by real-time reverse transcription polymerase chain
reaction. L-selectin (CD62L) and ß2-integrin (CD11b)
expression was determined on granulocytes and monocytes using flow
cytometry.
RESULTS: Sevoflurane inhalation rapidly and
markedly altered gene expression in white blood cells. Key
transcripts potentially involved in late preconditioning or organ
protection including paraoxonase, 12-lipoxygenase, heat shock
protein 40, chemokine ligand 5, and phosphodiesterase 5A were
regulated in response to sevoflurane. Sevoflurane further decreased
transcripts involved in peroxisome proliferator-activated receptor _files/image092.gif){kind=small}
coactivator-1_files/image093.gif){kind=small}
(PGC-1_files/image094.gif){kind=small}
)
signaling and fatty acid oxidation. Reduced L-selectin (CD62L)
expression on granulocytes accompanied with increased resistance to
inflammatory activation was present at 24 to 48 h after sevoflurane
exposure.
CONCLUSIONS: Sevoflurane at subanesthetic
concentrations modifies blood transcriptome and decreases the
expression of the proinflammatory L-selectin (CD62L), consistent
with a "second window of protection" in humans.
兰替洛尔—超短效β1受体拮抗剂不改变猪异氟醚的最小肺泡有效浓度
Landiolol, an Ultra–Short-Acting ß1-Adrenoceptor Antagonist, Does
Not Alter the Minimum Alveolar Anesthetic Concentration of Isoflurane in a
Swine Model
Tadayoshi Kurita, MD, Kotaro Takata, MD,
Masahiro Uraoka, MD, Koji Morita, PhD, and Shigehito Sato, MD
From the Department of Anesthesiology and
Intensive Care, Hamamatsu University School of Medicine, Handayama, Hamamatsu,
Japan.
Anesth Analg 2007 105: 656-660.
.
背景：作者先前曾报道过超短效β1受体拮抗剂—兰替洛尔不改变异氟醚的脑电效应。本文作者研究兰替洛尔对能够防止50%受试者对有害刺激产生体动反应的异氟醚的MAC的影响。
技术：十只猪（29.0±3.4kg）施行异氟醚吸入麻醉。通过使用悬蹄夹技术记录夹紧时的体动确定MAC。测定MAC后，开始输注兰替洛尔（第1分钟0.125mg·kg-1·min-1，然后0.04 mg·kg-1·min-1）。经过20分钟的稳定期，再次评估MAC（兰替洛尔0.04 mg·kg-1·min-1）。然后兰替洛尔的输注速度从0.04 mg·kg-1·min-1提高到0.2mg·kg-1·min-1，经过20分钟的稳定期，再次评估MAC（0.2 mg·kg-1·min-1）。最后，停止输注兰替洛尔，经过20分钟稳定期第四次评估MAC（基线2）。
结果：兰替洛尔明显减弱悬蹄夹刺激时的心率和平均动脉压升高效应，但并不改变异氟醚的MAC。
结论：兰替洛尔不改变异氟醚的抗伤害效应。这个结果结合作者先前的工作，提示了兰替洛尔不影响吸入麻醉药的麻醉效能。
（丁震敏 译 陈杰）
BACKGROUND: We previously reported that
landiolol, an ultra–short-acting ß1-adrenoceptor antagonist, does
not alter the electroencephalographic effect of isoflurane. Here, we
investigated the influence of landiolol on the minimum alveolar
anesthetic concentration (MAC) of isoflurane required to prevent
movement in response to a noxious stimulus in 50% of subjects.
METHODS: Ten swine (29.0 ± 3.4 kg) were
anesthetized by inhalation of isoflurane. MAC was determined using
the dewclaw clamp technique, in which movement in response to
clamping is recorded. After determination of MAC in the baseline
period, an infusion of landiolol (0.125 mg · kg–1 · min–1
for 1 min, then 0.04 mg · kg–1 · min–1) was
started. After a 20-min stabilization period, MAC was again assessed
(0.04 mg · kg–1 · min–1 landiolol). The
infusion of landiolol was then increased from 0.04 to 0.2 mg · kg–1
· min–1, and after a 20-min stabilization period, MAC was
again assessed (0.2 mg · kg–1 · min–1
landiolol). Finally, the infusion of landiolol was stopped, and
after a 20-min stabilization period, MAC was assessed for a fourth
time (Baseline 2).
RESULTS: Landiolol clearly attenuated the
increases in heart rate and mean arterial blood pressure that
occurred in response to the dewclaw clamp, but did not alter the MAC
of isoflurane.
CONCLUSIONS: Landiolol does not alter the
antinociceptive effect of isoflurane. This result, combined with
that from our previous work, also suggests that landiolol does not
influence the anesthetic potency of inhaled anesthetics.
Anesthetic Properties of the Ketone Bodies ß-Hydroxybutyric
Acid and Acetone
Liya Yang, PhD*, Jing Zhao, MD*,
Pavle S. Milutinovic, MS, Robert J. Brosnan, DVM, PhD_files/image096.gif){kind=small}
,
Edmond I. Eger, II, MD*, and James M. Sonner, MD*
From the *Department of Anesthesia and
Perioperative Care, University of California, San Francisco, California; _files/image097.gif){kind=small}
Peking
Union Medical College, Beijing, China; _files/image098.gif){kind=small}
University
of Pittsburg School of Medicine, Pittsburg, Pennsylvania; and _files/image099.gif){kind=small}
Department
of Surgical and Radiological Sciences, School of Veterinary Medicine,
University of California, Davis, California.
.Anesth Analg 2007 105: 673-679.
背景：作者验证如下假说――酮症酸中毒发生过程中的两个蓄积代谢产物（β羟基丁酸和丙酮）具有类似麻醉药物的作用方式改变离子通道，且在动物身上产生麻醉效果。
方法：在非洲蟾蜍卵母细胞上分别有α1β2γ2sA型γ-氨基丁酸（GABAA）、α1甘氨酸、NR1/NR2A N-甲基-D-天（门）冬氨酸和双孔域TRESK通道的表达。作者使用双电极电压钳技术进行研究，测量β羟基丁酸和丙酮对通道功能的效应。并在非洲蟾蜍的蝌蚪上测量两者的麻醉效应。
结果：在引起人体酮症酸中毒的浓度范围内，β羟基丁酸和丙酮都增强了甘氨酸受体功能。β羟基丁酸也在此浓度范围内增强了GABAA 受体功能。两者在蝌蚪上都产生了麻醉效应,其EC50值分别为：β羟基丁酸151±11mM（均数±标准差）和丙酮264±2mM（均数±标准差）。丙酮在浓度大等于50mM时有增强GABAA受体作用，在浓度大等于100mM时可见其抑制TRESK通道功能的现象，在浓度大等于200mM时则可抑制NMDA受体功能。
结论：β羟基丁酸和丙酮都有麻醉效应。两种酮体在产生临床表现的酮症酸中毒浓度范围内都增强了对甘氨酸受体的抑制作用。另外，β羟基丁酸也在此浓度范围内增强了GABAA 受体功能。在亚麻醉效应浓度下，两者可能产生伴随酮症而表现的昏睡和意识减退。
（於章杰 译 陈杰 校）
BACKGROUND: We tested the hypothesis that
two metabolites that are elevated in ketosis (ß-hydroxybutyric acid,
and acetone) modulate ion channels in a manner similar to
anesthetics and produce anesthesia in animals.
METHODS: _files/image100.gif){kind=small}
1ß2_files/image101.gif){kind=small}
2s_files/image102.gif){kind=small}
-aminobutyric
acid type A (GABAA), _files/image103.gif){kind=small}
1
glycine, NR1/NR2A N-methyl-d-aspartate, and two
pore domain TRESK channels were expressed in Xenopus laevis oocytes and studied using two-electrode voltage
clamping. The effect of ß hydroxybutyric acid and acetone on channel
function was measured. The anesthetic effects of these drugs were
measured in X. laevis tadpoles.
RESULTS: Both ß hydroxybutyric acid and
acetone enhanced glycine receptor function in the concentration
range that is obtained in ketoacidosis in humans. Beta
hydroxybutyric acid also enhanced GABAA receptor function
at these concentrations. Both acetone and ß-hydroxybutyric acid
anesthetized tadpoles, with an EC50 for acetone of 264 ±
2 mM (mean ± se) and for ß-hydroxybutyric acid of 151 ±
11 mM at pH 7.0. Acetone enhanced GABAA receptors at concentrations
of 50 mM and above. Inhibition of TRESK channel function was seen
with 100 mM acetone or larger concentration. N-methyl-D-aspartate
receptor function was inhibited at concentrations of acetone of 200
mM and larger.
CONCLUSIONS: Beta hydroxybutyric acid and
acetone are anesthetics. Both ketone bodies enhance inhibitory
glycine receptors at concentrations observed clinically in
ketoacidosis. In addition, ß-hydroxybutyric acid enhances GABAA
receptor function at these concentrations. Subanesthetic
concentrations of these drugs may contribute to the lethargy and impairment
of consciousness seen in ketoacidosis.
Exhaled Carbon Monoxide Levels Change in
Relation to Inspired Oxygen Fraction During General Anesthesia
Takehiko Adachi, MD, PhD*,
Kiichi Hirota, MD, PhD*_files/image104.gif){kind=small}
,
Tomoko Hara, MD*, Yukiko Sasaki, MD, PhD*, and Yasufumi
Hara, MD*
From the *Department of Anesthesiology,
Kitano Hospital, The Tazuke Kofukai Medical Research Institute; and _files/image105.gif){kind=small}
Department
of Anesthesia, Kyoto University Hospital, Osaka, Japan.
.Anesth Analg 2007 105: 696-699.
背景：血红素加氧酶降解亚铁血红素时会产生一氧化碳。许多应激因素会上调这种酶的活性并提高呼出气一氧化碳的水平。最近，有报道显示在麻醉和手术后的患者及危重症患者中呼出一氧化碳的水平是提高的，为了监测机械通气期间的一氧化碳水平，阐明影响呼出气一氧化碳水平的相关因素是十分重要的。人工通气时吸入氧浓度是经常变化的。为了研究吸入氧浓度的变化对呼出一氧化碳水平的影响，作者监测了全身麻醉过程中呼出气一氧化碳的水平。
方法：30名择期手术的患者入选本研究，麻醉维持使用七氟醚和芬太尼，所有患者都进行气管插管并行非复吸通气。在呼吸回路的分岔口使用一氧化碳监测仪来监测呼出气一氧化碳的水平，从而研究吸入氧浓度对呼出一氧化碳水平的影响，长时间吸入75％和35％氧时对呼出一氧化碳水平和动脉碳氧血红蛋白浓度的影响。
结果：呼出气一氧化碳的水平随着氧浓度的改变而迅速改变。长时间吸入75％氧气时在最初会增加呼出气一氧化碳的水平，但继之逐渐下降并伴有动脉碳氧血红蛋白的减少。而长时间吸入35％氧气时不会产生这些改变。
结论：在机械通气期间监测呼出气一氧化碳的水平时，考虑吸入氧浓度产生的影响是十分重要的。
（詹琼慧 译 陈杰 校）
BACKGROUND: Heme oxygenase produces carbon
monoxide (CO) during the breakdown of heme molecules. A variety of
stressors upregulate this enzymatic activity and can increase
exhaled CO levels. Recently, exhaled CO levels have been reported to
increase in critically ill patients and after anesthesia and
surgery. To use this measurement during mechanical ventilation, it
is important to clarify the effects of factors which interfere with
exhaled CO levels. The fraction of inspired oxygen (Fio2)
is often changed during artificial ventilation. To investigate the
effect of changes of Fio2 on exhaled CO, we measured
exhaled CO levels during general anesthesia.
METHODS: Thirty patients who underwent
elective operations were enrolled in this study. Anesthesia was
maintained with sevoflurane and fentanyl. All patients were
tracheally intubated and ventilated with a non-rebreathing
ventilator. Exhaled CO levels were measured in gas sampled from the
expired limb of the respiration circuit using a CO monitor. The
effects of sequential changes of Fio2 on exhaled CO
levels, and the effects of long-term inhalation of Fio2
0.75 and Fio2 0.35 on exhaled CO levels and arterial
carboxyhemoglobin concentrations were investigated.
RESULTS: Exhaled CO levels changed rapidly
in response to changes of Fio2. Long-term inhalation of
Fio2 0.75 initially increased and then gradually
decreased exhaled CO to basal levels, concomitant with a decrease of
arterial carboxyhemoglobin. Long-term inhalation of Fio2
0.35 did not elicit any significant change in the observed variables.
CONCLUSION: When monitoring exhaled CO levels
during mechanical ventilation, it is important to consider the
effects of Fio2.
羟乙基淀粉:分子量和取代级对血管内贮留的影响
Hydroxyethyl Starch: The Effect of
Molecular Weight and Degree of Substitution on Intravascular Retention In
Vivo
Takashi Hitosugi, DDS*, Toshiyuki
Saito, MD, PhD*_files/image106.gif){kind=small}
,
Sono Suzuki, DDS*, Ieko Kubota, DDS*, Emi Shoda, DDS*,
Toru Shimizu, MD, PhD_files/image107.gif){kind=small}
,
and Yoshiyuki Oi, MD, PhD*
From the *Department of Anesthesiology,
Nihon University Graduate School of Dentistry; _files/image108.gif){kind=small}
Department
of Anatomy, Tokyo Medical University, Tokyo, Japan; and _files/image109.gif){kind=small}
Department
of Bioengineering, University of California, San Diego, La Jolla, California.
.Anesth Analg 2007 105: 724-728.
背景:羟乙基淀粉(HES) 的特性由其平均分子量(MW),浓度和取代级(DS)等决定。这一特性不断地变化。
方法:将HES与异硫氰酸荧光素结合形成FITC-HES之后,在一个轻度失血的模型中(失血量占血容量的10%)应用活体显微镜检查小鼠的提睾肌A2和V2血管,以此来评估三种6%HES浓度。在抽血建立轻度失血模型后,分别输入三种FITC-HES:HES-A(MW150-200kDa,DS0.6-0.68),HES-B(MW175-225kDa,DS0.45-0.55),或HES-C(MW550-850kDa,DS0.7-0.8),然后利用活体显微镜检查测定FITC-HES的贮留率。
结果: V2血管输注后120Min时FITC-HES的贮留率分别为:HES-A：27%±6.6%;HES-B:65%±9.1%;HES-C:89%±8.7% ; A2血管HES-A27%±6.6%;HES-B73%±10.2%;HES-C89%±8.7%。HES-B和HES-C比HES-A在血管内贮留的时间长（HES-B和HES-A相比，V2组P=0.028； A2组P＝0.038。HES-C和HES-A相比， V2组P=0.022；A2组P＝0.037）。HES-B和HES-C的血管消除率无明显差异。
结论： HES-B和HES-C在血管中贮留的时间相似。低DS和中度DS的中等分子量HES－B和大分子量的HES在血管中贮留的时间相同。因此，应研究不同种类HES变化特征以此优化HES输注。
（杨卫红 译 陈杰 校）
BACKGROUND: Hydroxyethyl starch (HES)
solution is characterized by its mean molecular weight (MW), concentration,
and degree of substitution (DS). This character varies worldwide.
METHODS: After binding
fluorescein-isothiocyanate (FITC-HES), we evaluated the retention
rate of three types of 6% HES in the A2 and V2 blood vessels of rat
cremaster muscles using intravital microscopy in a mild hemorrhage
model (10% of total blood volume). After blood withdrawal, we
infused three types of FITC-HES: HES-A (MW 150–200 kDa, DS
0.6–0.68), HES-B (MW 175–225 kDa, DS 0.45–0.55), or HES-C (MW
550–850 kDa, DS 0.7–0.8) before determining the FITC-HES retention
rate in the intravital microscope.
RESULTS: For V2, the FITC-HES retention
rates 120 min after the start of the infusion were 27% ± 7.2% of
baseline values (HES-A), 65% ± 9.1% (HES-B), and 86% ± 9.6%
(HES-C); for A2 they were 27% ± 6.6%, 73% ± 10.2%, and 89% ± 8.7%,
respectively. HES-B and HES-C were retained in the vessels longer
than HES-A (P = 0.028 for V2, P = 0.038 for A2 between HES-B and HES-A; P = 0.022 for V2, P = 0.037
for A2 between HES-C and HES-A). There was no difference in the rate
of disappearance from the vessels between HES-B and HES-C.
CONCLUSIONS: HES-B and HES-C are equally
retained in the blood vessels. Middle-sized HES-B with low DS and
middle substitution pattern stayed in the blood vessels as long as
the large-sized HES. HES solutions of varying characters should be
examined to optimize HES infusion.
Physostigmine Reverses Cognitive
Dysfunction Caused by Moderate Hypoxia in Adult Mice
Alex Bekker, MD, PhD, Michael Haile, MD,
Kevin Gingrich, MD, Leslie Wenning, BA, Alex Gorny, MD, David Quartermain, PhD,
and Thomas Blanck, MD, PhD
From the Department of Anesthesiology, New
York University Medical Center, New York, New York.
Anesth Analg 2007 105: 739-743. Abstract
背景：啮齿类动物由于中度缺氧产生的相关认知功能改变可能与中枢胆碱能神经传导功能的减退有关。本文作者通过实验来研究毒扁豆碱——一种乙酰胆碱酯酶抑制剂，是否能够改善低氧性缺氧后的活动记忆。
方法：把90只体重在30－35g,6-8周的Swiss Webster小鼠随机分在三个低氧组，吸入氧浓度FiO2＝0.10（组1：未经任何处理；组2：试验最初腹腔内注射毒扁豆碱0.1mg/kg；组3：缺氧后腹腔内注射毒扁豆碱0.1mg/kg），或随机分在两个室内空气组,一组在缺氧发作后未予任何处理，另一组给予毒扁豆碱。一次实物认知测试用来评估短期的记忆功能。测试中观察小鼠探究新伙伴的倾向，试验中，另一只相似的小鼠也同样参与其中。在15分钟的尝试试验中，两只相同的小鼠被分别安置在箱子的两处特定区域。尝试试验进行1小时后，其中一只小鼠被一只外形完全不同的小鼠所替代。两只试验小鼠在整个试验过程中表现由摄像机及相关电脑程序全程监视。数据结果进行方差分析，如需要的话，还可以继续用Newman－Keuls测试进行事后比较。P值<0.05有显著性差异。
结果：试验第一天，在FiO2＝0.10的缺氧状态下，未处理小鼠比起呼吸室内空气的未处理小鼠，所花费的认识新伙伴的时间要短的多。而同样在缺氧的环境中，事后给予毒扁豆碱的试验小鼠，缺氧对其的影响与对照组相比没有明显差别。
结论：通过活动记忆评估发现，中度缺氧会损害到啮齿动物的行为表现。但是影响是短期的，因为在给予治疗后，小鼠认知功能在7天后可以回复到正常水平。缺氧发作后给予毒扁豆碱可以预防认知功能的下降。中枢神经系统乙酰胆碱水平的升高可能与缺氧小鼠给药后行为改善有关。
（杜唯佳 译 陈杰 校）
BACKGROUND: Cognitive changes associated
with moderate hypoxia in rodents may result from the diminished
functioning of central cholinergic neurotransmission. We designed
this study to examine whether treatment with physostigmine (PHY), an
acetylcholinesterase inhibitor, could improve the impairment of working
memory after hypoxic hypoxia.
METHODS: We randomized 90 Swiss Webster,
30–35 g mice (6–8 wks) to three hypoxia groups at fraction of
inspired oxygen, FiO2 = 0.10 (1. no treatment; 2. PHY 0.1
mg/kg intraperitoneally administered immediately before; or 3. after
hypoxia), or to two room air groups (given either no treatment or
PHY after an insult). An object recognition test was used to assess
short-term memory function. The object recognition test exploits the
tendency of mice to prefer exploring novel objects in an environment
when a familiar object is also present. During the 15 min training trial,
two identical objects were placed in two defined sites of the box.
During the test trial performed 1 h later, one of the objects was
replaced by a new object with a different shape. The time spent
exploring the two objects was automatically recorded by a video
camera and associated software. The performance was analyzed with
ANOVA, followed by post hoc comparisons using
the Newman– Keuls test when appropriate. P
values <0.05 were considered significant.
RESULTS: Untreated mice subjected to
hypoxia at Fio2 = 0.1 spent significantly less time
exploring a novel object on testing day 1 than did untreated mice
breathing room air. Performance of the mice subjected to hypoxia,
who received physostigmine after, but not before, the insult did not
differ from the control group.
CONCLUSION: Moderate hypoxia impairs
rodents' performance in a working memory task. It appears that
changes are transient, because the cognitive functioning of the mice
returned to the baseline level 7 days after treatment. Postinsult
administration of PHY prevented deterioration of cognitive function.
An increased level of acetylcholine in the central nervous system
may be responsible for the improved performance of the
hypoxia-treated mice.
局麻药和分娩方式:布比卡因、罗哌卡因及左旋布比卡因的比较
Local Anesthetics and Mode of Delivery:
Bupivacaine Versus Ropivacaine Versus Levobupivacaine
Yaakov Beilin, MD*_files/image110.gif){kind=small}
,
Nicole R. Guinn, BS*, Howard H. Bernstein, MD*_files/image111.gif){kind=small}
,
Jeff Zahn, MD*, Sabera Hossain, MS_files/image112.gif){kind=small}
,
and Carol A. Bodian, DrPH_files/image113.gif){kind=small}
From the Departments of *Anesthesiology,
and _files/image114.gif){kind=small}
Obstetrics,
Gynecology and Reproductive Sciences, and the _files/image115.gif){kind=small}
Division
of Biostatistics, Mount Sinai School of Medicine of New York University, New
York, New York.
.Anesth Analg 2007 105: 756-763.
背景:硬膜外局麻药对产妇分娩方式的影响研究并不多。在这项研究中,作者研究布比卡因、罗哌卡因及左旋布比卡因进行硬膜外分娩镇痛中,分娩方式是否不同。
方法:要求无痛分娩的初产妇在宫口扩张<5cm时随机接受布比卡因或罗哌卡因或左旋布比卡因进行硬膜外镇痛。镇痛方法：单次注射15ml 0.0625%的指定局麻药复合芬太尼2ug/ml，随后以10ml/h的速度输注同种局麻药维持镇痛。主要观察是手术分娩率(包括器械辅助的阴道分娩和剖宫产分娩)。
结果:98名接受了布比卡因,90名接受了罗哌卡因,34名接受了左旋布比卡因(在其从美国市场淘汰之前)。结果所有组中手术分娩率方面没有显著的不同(布比卡因是46%,罗哌卡因是39%,左旋布比卡因是32%,p=0.35)。与罗哌卡因及布比卡因两组相比,左旋布比卡因的运动阻滞更少（p<0.05）。三组中第一及第二产程的持续时间,产程中接受的每小时局麻药的总量,及对新生儿的影响没有显著的区别.
结论:布比卡因,罗哌卡因及左旋布比卡因都适用于硬膜外分娩镇痛,同时对分娩方式、产程的持续时间及对新生儿没有显著的影响。
（潘钱玲 译 陈杰 校）
BACKGROUND: The influence of the labor
epidural local anesthetic (LA) on mode of delivery has not been
adequately studied. In this study, we sought to determine if there
is a difference in mode of delivery among parturients who receive
epidural bupivacaine, ropivacaine, or levobupivacaine.
METHODS: Nulliparous women at term
requesting labor analgesia with a cervical dilation <5 cm were
randomized to receive epidural bupivacaine, ropivacaine, or levobupivacaine.
Analgesia was initiated with a bolus of 15 mL of 0.0625% of the
assigned LA with fentanyl 2 µg/mL. Analgesia was maintained with
an infusion of the same solution at 10 mL/h. The primary endpoint was
the operative delivery rate (instrumental assisted vaginal delivery
plus cesarean delivery).
RESULTS: Ninety-eight women received
bupivacaine, 90 ropivacaine, and 34 levobupivacaine (before it was
removed from the US market). There was no significant difference in
the operative delivery rate (bupivacaine = 46%, ropivacaine = 39%,
and levobupivacaine = 32%, P = 0.35)
among groups. There was less motor block in the levobupivacaine
group when compared with the ropivacaine and bupivacaine groups, P < 0.05. There was no significant difference in the
duration of the first or second stage of labor, the total dose of LA
received per hour of labor, or neonatal outcome among groups.
CONCLUSIONS: Bupivacaine, ropivacaine, and
levobupivacaine all confer adequate labor epidural analgesia, with
no significant influence on mode of delivery, duration of labor, or
neonatal outcome.
成人肝移植期间在再灌注前、再灌注后早期、再灌注后晚期3个时期高钾血症的预测
Predictors of Hyperkalemia in the
Prereperfusion, Early Postreperfusion, and Late Postreperfusion Periods During
Adult Liver Transplantation
Victor W. Xia, MD*, Rafik M.
Ghobrial, MD_files/image116.gif){kind=small}
,
Bin Du, MD*_files/image117.gif){kind=small}
,
Tabitha Chen, BS*, Ke-Qin Hu, MD_files/image118.gif){kind=small}
,
Jonathan R. Hiatt, MD_files/image119.gif){kind=small}
,
Ronald W. Busuttil, MD, PhD_files/image120.gif){kind=small}
,
and Randolph H. Steadman, MD*
From the Departments of *Anesthesiology and
_files/image121.gif){kind=small}
Surgery,
David Geffen School of Medicine, University of California, Los Angeles, Los
Angeles, California; _files/image122.gif){kind=small}
Division
of Gastroenterology, University of California, Irvine Medical Center, Orange,
California; and _files/image123.gif){kind=small}
Department
of Anesthesiology, 2nd Affiliated Hospital, Kunming Medical College, Kunming,
China.
.Anesth Analg 2007 105: 780-785.
背景：高钾血症对接受原位肝移植的病人构成严重的危害，且不易预测。
方法：作者回顾性研究了1124例接受原位肝移植的成年病人。高钾血症定义为血清[K＋] _files/image124.gif){kind=small}
5.5/L。在单变量分析中，共有47个受体，供体，手术不同期及实验室指标用来做多变量初始分析。在原位肝移植3个时期（再灌注前，再灌注后早期，再灌注后晚期）高钾血症的独立预测是由多元对数回归分析来决定的。
结果：1124个病人中，在再灌注前，再灌注后早期，再灌注后晚期中分别有10.2%、19.1%和7.9%的病人发生高钾血症。高基础血K＋和输血为独立预测再灌注前高钾血症。高基础血K＋（或再灌注前高基础血K＋）和心脏病死亡供体为独立预测再灌注后早期高钾血症。高基础血K＋，热缺血时间，供体较长的住院时间，术中尿量减少，静脉转流等为再灌注后晚期高钾血症独立预测因子。
结论：数个实验室指标，手术不同时期和不同类别供体可作为不同时期高钾血症的独立预测因子。上述结果有助于为成人原位肝移植中有高钾血症危险的病人更有针对性的超前治疗。
（张燕 译 陈杰 校）
BACKGROUND: Hyperkalemia poses serious
hazards to patients undergoing orthotopic liver transplantation
(OLT), and its predictors have not been thoroughly examined.
METHODS: We retrospectively studied 1124
consecutive adult patients who underwent OLT. Hyperkalemia was
defined as serum K+ _files/image125.gif){kind=small}
5.5
mmol/L. A total of 47 recipient, donor, intraoperative, and
laboratory variables were initially analyzed in univariate analyses.
Independent predictors of hyperkalemia in three periods of OLT
(prereperfusion, early postreperfusion, and late postreperfusion) were
determined in multivariate logistic regression analyses.
RESULTS: Of 1124 patients, 10.2%, 19.1%,
and 7.9% had hyperkalemia in the prereperfusion, early
postreperfusion, and late postreperfusion periods, respectively.
Higher baseline K+ and red blood cell transfusion were
independent predictors of prereperfusion hyperkalemia. Higher baseline
K+ (or prereperfusion K+) and donation after cardiac
death donor were independent predictors of early postreperfusion hyperkalemia.
Higher baseline K+, longer warm ischemia time, longer
donor hospital stay, lower intraoperative urine output, and the use
of venovenous bypass were independent predictors of late
postreperfusion hyperkalemia.
CONCLUSIONS: Several laboratory,
intraoperative, and donor variables were identified as independent
predictors of hyperkalemia in the different periods. Such information
may be used for more targeted preemptive interventions in patients
who are at risk of developing hyperkalemia during adult OLT.
矫形外科中原发性痛觉过敏的演变：全膝关节成形术前后定量感觉测试和临床评价
The Evolution of Primary Hyperalgesia in
Orthopedic Surgery: Quantitative Sensory Testing and Clinical Evaluation Before
and After Total Knee Arthroplasty
Valéria Martinez,
MD*_files/image126.gif){kind=small}
, Dominique Fletcher, MD, PhD*_files/image127.gif){kind=small}
, Didier Bouhassira, MD, PhD_files/image128.gif){kind=small}
, Daniel I. Sessler, MD_files/image129.gif){kind=small}
, and Marcel Chauvin, MD*_files/image130.gif){kind=small}
From the
*Department of Anesthesia, Assistance Publique Hôpitaux de Paris, Hôpital
Raymond Poincaré, Garches; _files/image131.gif){kind=small}
INSERM, U-792, Hôpital Ambroise Paré,
Centre d’Evaluation et de Traitement de la Douleur, Université Versailles
Saint-Quentin, Versailles, France; and _files/image132.gif){kind=small}
Department of Outcomes Research, The
Cleveland Clinic, University of Louisville, Louisville, Kentucky.
.Anesth Analg 2007 105: 815-821.
背景：定量感觉测试(QST)能发现微小的感觉缺失和疼痛，并额外提供了术后疼痛的病理生理学信息。
方法： 20位择期行膝关节成形术的病人，在术前、术后第1天和第4天以及术后第1月和第4个月进行定量感觉测试和临床评估。临床评估包括术前疼痛，膝关节手术操作引发的炎症以及术后在静止休息时的疼痛和运动引起的疼痛（直观类比标度评分），还包括吗啡的累计使用量，双侧膝关节周径和皮肤温度。定量感觉测试包括温度和机械压力阈值和阈上刺激的灵敏度。并评估皮肤无害性的擦试而引起的异常性疼痛。同时在手术侧和非手术侧膝关节进行疼痛评估，并以手为参照对象。
结果：所有病人在手术前患侧的膝关节都有长时间的剧烈疼痛和炎症。手术前的QST为进行手术的膝关节的炎症区域存在热痛觉过敏提供了证据，但是在与非炎症区域的交界处不存在皮肤无害性接触而引起的异常性疼痛。病人存在强烈的术后疼痛，大多数由于运动导致。原发性热痛觉过敏表现在手术后的第一天和第四天，伴随炎症区域无害性的接触引起的异常性疼痛。手术后吗啡的用量与术前的热痛觉过敏相关联。QST在第4个月恢复到基线，此时只有四位病人还存在运动导致的膝关节中度疼痛。
结论：热痛觉过敏在所有QST症状中与全膝关节成型术围术期疼痛的密切相关，且可预测术后吗啡的用量。
（王鹏 译 陈杰 校）
BACKGROUND: Quantitative sensory testing (QST) allows precise
characterization of sensory deficits and painful symptoms and may
offer additional information on the pathophysiology of postoperative pain.
METHODS: We evaluated 20 patients scheduled
for total knee arthroplasty clinically and with QST before surgery,
at 1 and 4 days after surgery, and at 1 and 4 mo after surgery. The
clinical evaluation included preoperative pain and inflammation of
the operative knee, postoperative assessment of pain at rest and
during movement ( Visual
Analog Scale score), cumulative morphine consumption, and
circumference and temperature of both knees. QST included thermal
and mechanical (pressure) pain threshold measurements and assessment
of responses to suprathreshold stimuli. Brush-evoked allodynia was
also evaluated. Measurements were taken on the operative knee,
contralateral knee, and on the hand as a control site.
RESULTS: All patients had prolonged and
severe pain before surgery and inflammation of the operative knee.
Preoperative QST provided evidence of heat hyperalgesia in the
inflammatory area on the operative knee, but absence of punctate or
brush-evoked allodynia in the adjacent noninflamed area. Patients
had intense postoperative pain, mostly induced by movement. Primary
heat hyperalgesia was present on the operative knee on the first
and fourth day after surgery, and was associated with punctate mechanical
allodynia in the inflammatory area, but not in the adjacent
noninflamed area. Postoperative morphine consumption was correlated
with preoperative heat hyperalgesia (r = 0.63;
P = 0.01). QST returned to baseline at the
4-mo evaluation. Only four patients had moderate knee pain induced
by movement at that time.
CONCLUSION: Heat hyperalgesia was the
predominant QST symptom associated with perioperative pain after
total knee arthroplasty, and was predictive of postoperative
morphine consumption.
Reflex Sympathetic Activity After
Intravenous Administration of Midazolam in Anesthetized Cats
Ryoji Iida, MD, PhD*, Ken-ichi
Iwasaki, MD, PhD_files/image133.gif){kind=small}
,
Jitsu Kato, MD, PhD*, Shigeru Saeki, MD, PhD*, and
Setsuro Ogawa, MD, PhD*
From the Departments of *Anesthesiology and
_files/image134.gif){kind=small}
Hygiene
and Space Medicine, Nihon University School of Medicine, Tokyo, Japan.
Anesth Analg 2007 105: 832-837.
背景：虽有报道，在蛛网膜下腔应用咪唑安定所产生的抗伤害性反射机制是由脊髓的A型r-氨基丁酸（即苯二氮卓类受体复合物）所介导的，但是咪唑安定全身系统性的抗伤害反射机制仍然未知。本次试验，分别对完整大脑和去大脑（中脑水平离断）状态的猫静脉注射咪唑安定后，观察对躯体交感神经A，C反射的影响。
方法： 28只成年猫，用电刺激腓浅神经的传出神经纤维A（有髓鞘）和传出神经纤维C（脱髓鞘）来诱发心内交感神经的躯体交感A，C反射。控制下的体－交感反射产生后，我们把猫随机分成四组，分别静脉注射如下剂量的咪唑安定：大脑完整的猫注射剂量分别为0.03mg/kg、 0.1mg/kg、0.5mg/kg;去大脑的猫注射剂量为0.1mg/kg.
结果：在完整大脑的猫中，躯体交感C反射在注射咪唑安定0.03mg/kg时明显增强， 0.1-0.5 mg/kg时明显减弱。在去大脑猫中，躯体交感C反射在剂量为0.1mg/kg时也是削弱的。
结论：静脉使用咪唑安定对于躯体交感反射的效应与剂量相关。因此，咪唑安定有剂量依赖性的抗伤害反射效应。同时，咪唑安定产生的躯体交感C反射抑制效应，主要作用于中脑平面以下。
（杜唯佳 译 陈杰 校）
BACKGROUND: Although intrathecal midazolam
has been reported to produce antinociceptive effects mediated by _files/image135.gif){kind=small}
-aminobutyric
acid type A-benzodiazepine receptor complexes in the spinal cord,
the effects of systemic midazolam on nociception remain unclear. We
performed this study to examine the effects of IV-administered midazolam
on somatosympathetic A_files/image136.gif){kind=small}
and C reflex discharges in brain-intact cats and decerebrate cats
(with transection at midbrain level).
METHODS: Somatosympathetic A_files/image137.gif){kind=small}
and
C reflexes were elicited in the inferior cardiac sympathetic nerve
by electrical stimulation of myelinated (A_files/image138.gif){kind=small}
)
and unmyelinated (C) afferent fibers of the superficial peroneal
nerve in 28 mature cats. After control somatosympathetic reflex
responses were obtained, midazolam was administered IV to four
groups of randomly allocated cats as follows: brain-intact cats at a
dose of 0.03 mg/kg, brain-intact cats at a dose of 0.1 mg/kg,
brain-intact cats at a dose of 0.5 mg/kg, and decerebrate cats at a
dose of 0.1 mg/kg.
RESULTS: C reflex discharges were
significantly augmented at the dose of 0.03 mg/kg and significantly
depressed at the dose of 0.1 and 0.5 mg/kg in brain-intact cats. C
reflex discharges were also significantly depressed at the dose of
0.1 mg/kg in decerebrate cats.
CONCLUSIONS: We have demonstrated that IV
midazolam produces dose-related effects on somatosympathetic reflex
discharges. The clinical implication of these findings is that the
effect of midazolam on nociception depends on its dosage. It also
appears that the infra-midbrain region plays a major role in
mediating the depressive effects of midazolam on somatosympathetic C
reflex discharges.
Obturator Versus Femoral Nerve Block for
Analgesia After Total Knee Arthroplasty
Ken Kardash, MD*, Don Hickey, MD*,
Michael J. Tessler, MD*, Stacey Payne, BScN_files/image139.gif){kind=small}
,
David Zukor, MD_files/image140.gif){kind=small}
,
and Ana Miriam Velly, DDS, PhD_files/image141.gif){kind=small}
From the Departments of *Anesthesia, _files/image142.gif){kind=small}
Nursing,
and _files/image143.gif){kind=small}
Orthopedic
Surgery, Jewish General Hospital, McGill University, Montreal, Canada; and _files/image144.gif){kind=small}
Department
of Diagnostic and Behavioral Sciences, University of Minnesota, Minneapolis,
Minnesota.
Anesth Analg 2007 105: 853-858.
背景：股神经和闭孔神经阻滞在缓解膝关节成形术后疼痛方面都已被认为是有用的。本文作者比较两者的效能。
方法：60名在脊麻下择期行单侧膝关节成形术的患者，在手术结束后接受随机双盲的股神经阻滞或闭孔神经阻滞或未作神经阻滞的临床研究。神经阻滞用神经刺激仪定位，用药为含有肾上腺素5ug/ml的0.5％布比卡因20ml。病人自控镇痛包括芬太尼、口服塞来考昔100mg （2次/天）和每6小时口服扑热息痛650mg,从到达恢复室就开始实行。记录48小时休息和活动时疼痛情况、镇痛剂使用量和镇痛效果，以及膝关节屈曲的极限和住院天数作为疗效成果。
结果：在任何结果变量中，闭孔神经阻滞组与病人自控镇痛组没有显示显著差异。扣除基础疼痛评分，股神经阻滞组与病人自控镇痛组相比在休息时所受疼痛较轻，在恢复室活动也经受较少疼痛。没有一种阻滞作用对阿片类药物的使用、功能恢复和单侧疗效有显著影响。仅有一例股神经阻滞患者出现闭孔神经阻滞。
结论：股神经阻滞很少阻滞闭孔神经。在脊麻下行膝关节成形术后单次注射行股神经阻滞可改善术后多模式镇痛效果，但这一作用只在手术日。单独闭孔神经阻滞没有益处。
（陈伟 译 陈杰 校）
BACKGROUND: Both femoral and obturator
nerve blocks have been suggested to be useful in relieving pain
after total knee arthroplasty (TKA). We sought to compare their
efficacy.
METHODS: Sixty patients undergoing elective
unilateral TKA under spinal anesthesia received in a randomized,
double-blind manner a femoral, obturator, or sham nerve block at the
end of surgery. Blocks were performed using nerve stimulation and
20 mL bupivacaine 0.5% containing epinephrine 5 µg/mL. Patient-controlled
IV analgesia with fentanyl, celecoxib 100 mg PO bid, and
acetaminophen 650 mg PO every 6 h were started on arrival in the
recovery room. Pain (0–10 numeric rating scale, NRS) at rest and
with movement, analgesic use, and side effects were recorded for 48
h. Maximum knee flexion and total days in hospital were recorded as
functional outcomes.
RESULTS: There were no significant
differences in the obturator block group and the control group in
any outcome variable. With baseline pain scores subtracted, femoral
block resulted in less pain at rest compared with control (NRS
difference from baseline 2.1 ± 0.4 sem vs 3.4 ± 0.4, respectively; P = 0.02) and less pain with movement (NRS difference 2.6
± 0.6, 4.3 ± 0.6, P = 0.05) at
recovery room discharge. Neither block had a significant effect on
opioid use, functional outcome, or side effects. Only one (5%)
patient with femoral block developed obturator motor block.
CONCLUSION: Femoral nerve blocks rarely
block the obturator nerve. Single-injection femoral nerve block
improved multimodal analgesia after spinal anesthesia for TKA, but
this effect did not persist beyond the day of surgery. Obturator
nerve block alone was of no benefit.
Transscalene Brachial Plexus Block: A
New Posterolateral Approach for Brachial Plexus Block
Hoang C. Nguyen, MD*, Erwin
Fath, MD*, Sebastian Wirtz, MD*, and Tareg Bey, MD_files/image145.gif){kind=small}
From the *Department of Anesthesiology and
Intensive Care Medicine, Asklepios Klinik Barmbek, Hamburg, Germany; and _files/image146.gif){kind=small}
Department
of Emergency Medicine, University of California Irvine Medical Center, Orange,
California.
.Anesth Analg 2007 105: 872-875.
有报道上段臂丛阻滞发生严重并发症。本文作者介绍一种从解剖学角度上较为有优势的后外侧臂丛阻滞法。随机选择27位择期行上臂或肩部开放性手术的病人接受该新方法。神经阻滞成功率为85.2%。其中有2名病人要求术中额外静脉予以舒芬太尼止痛，另外有2名病人局部阻滞不理想。使用该新途径阻滞出现的副作用包括可逆性喉返神经阻滞（2名）可逆性Horner综合症（1名）。仍需进一步研究来比较经斜角肌臂丛阻滞与其它径路臂丛阻滞的优劣。
（朱玫娟 译 陈杰 校）
Depending on the approach to the upper
brachial plexus, severe complications have been reported. We
describe a novel posterolateral approach for brachial plexus block
which, from an anatomical and theoretical point of view, seems to
offer advantages. Twenty-seven patients were scheduled to undergo elective
major surgery of the upper arm or shoulder using this new
transscalene brachial plexus block. The success rate was 85.2% for
surgery. Two patients required additional analgesia with IV
sufentanil. In two others, regional anesthesia was inadequate. The
side effects of this technique included reversible recurrent
laryngeal nerve blockade in two patients and a reversible Horner
syndrome in one patient. Further studies are needed to compare the
transscalene brachial plexus block with other approaches to the
brachial plexus.