December 2007
CARDIOVASCULAR ANESTHESIOLOGY:
活性氧介导七氟醚和地氟醚诱导预处理在人离体右心房心肌保护作用
陈恺铮译 薛张刚校
Reactive Oxygen Species Mediate Sevoflurane-
and Desflurane-Induced Preconditioning in Isolated Human Right Atria In
Vitro
Jean-Luc Hanouz, Lan Zhu, Sandrine Lemoine, Charline Durand, Olivier Lepage, Massimo Massetti, André Khayat, Benoît Plaud, and Jean-Louis Gérard
Anesth Analg 2007 105: 1534-1539.
磺达肝素在下肢较大整形手术（留置或未留置轴索或深部周围神经导管）术后长期应用预防血栓形成的安全性及有效性研究：EXPERT研究
邱郁薇 译 马皓琳 李士通 校
The Safety and Efficacy of Extended
Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the
Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The
EXPERT Study
François J. Singelyn, Cees C.P.M. Verheyen, Franco Piovella, Hugo K. Van Aken, Nadia Rosencher for the EXPERT Study Investigators
Anesth Analg 2007 105: 1540-1547.
杜唯佳 译 陈杰 校
The Role of Heart Rate Variability in Risk Stratification for Adverse Postoperative Cardiac Events (Review Article)
Timo Laitio, Jouko Jalonen, Tom Kuusela, and Harry
Scheinin
Anesth Analg 2007 105: 1548-1560.
PEDIATRIC ANESTHESIOLOGY:
氯胺酮不增加肺动脉高压儿童在自主呼吸行七氟醚麻醉时的肺血管阻力
陈佳丽译，薛张纲校
Ketamine Does Not Increase Pulmonary Vascular Resistance in Children
with Pulmonary Hypertension Undergoing Sevoflurane Anesthesia and Spontaneous
Ventilation
Glyn D. Williams, Bridget M. Philip, Larry F. Chu, M. Gail Boltz, Komal Kamra, Heidi Terwey, Gregory B. Hammer, Stanton B. Perry, Jeffrey A. Feinstein, and Chandra Ramamoorthy
Anesth Analg 2007 105: 1578-1584.
彭中美 译 马皓琳 李士通 校
Programming Pressure Support Ventilation in
Pediatric Patients in Ambulatory Surgery with a Laryngeal Mask Airway
Javier Garcia-Fernandez, Gerardo Tusman, Fernando Suarez-Sipmann, Julio Llorens, Marina Soro, and Javier F. Belda
Anesth Analg 2007 105: 1585-1591.
於章杰 译 陈杰 校
A Prospective Evaluation of the POVOC Score
for the Prediction of Postoperative Vomiting in Childre
Peter Kranke, Leopold H. Eberhart, Hakki Toker, Norbert Roewer, Hinnerk Wulf, and Peter Kiefer
Anesth Analg 2007 105: 1592-1597.
新式含氧饱和度探头中心静脉导管用于小儿心脏手术的试验和临床性评价
陈勇柱译 薛张刚校
An Experimental and Clinical Evaluation of a
Novel Central Venous Catheter with Integrated Oximetry for Pediatric Patients
Undergoing Cardiac Surgery
Oliver J. Liakopoulos, Jonathan K. Ho, Aaron Yezbick, Elizabeth Sanchez, Clayton Naddell, Gerald D. Buckberg, Ryan Crowley, and Aman Mahajan
Anesth Analg 2007 105: 1598-1604.
裘毅敏译，马皓琳 李士通校
The Relationship Between Current Intensity
for Nerve Stimulation and Success of Peripheral Nerve Blocks Performed in
Pediatric Patients Under General Anesthesia
Harshad Gurnaney, Arjunan Ganesh, and Giovanni Cucchiaro
Anesth Analg 2007 105: 1605-1609.
陈伟 译 陈杰 校
Reference Values for Kaolin-Activated
Thromboelastography in Healthy Children
Kah-Lok Chan, Robyn G. Summerhayes, Vera Ignjatovic,
Stephen B. Horton, and Paul T. Monagle
Anesth Analg 2007 105: 1610-1613.
AMBULATORY ANESTHESIOLOGY:
罗 璇译 薛张纲校
Society for Ambulatory Anesthesia Guidelines
for the Management of Postoperative Nausea and Vomiting (Special
Article)
Tong J. Gan, Tricia A. Meyer, Christian C. Apfel, Frances Chung, Peter J. Davis, Ashraf S. Habib, Vallire D. Hooper, Anthony L. Kovac, Peter Kranke, Paul Myles, Beverly K. Philip, Gregory Samsa, Daniel I. Sessler, James Temo, Martin R. Tramèr, Craig Vander Kolk, and Mehernoor Watcha
Anesth Analg 2007 105: 1615-1628.
ANESTHETIC PHARMACOLOGY:
评估基于贝叶斯的闭环系统用于丙泊酚输注的理想模型权重，应用双频指数作为对照变量：一个模拟研究
张曦
译，马皓琳 李士通 校
Estimation of Optimal Modeling Weights for a
Bayesian-Based Closed-Loop System for Propofol Administration Using the
Bispectral Index as a Controlled Variable: A Simulation Study
Tom De Smet, Michel M. R. F. Struys, Scott Greenwald, Eric P. Mortier, and Steven L. Shafer
Anesth Analg 2007 105: 1629-1638.
张燕 译 陈杰 校
The Influence of Hemorrhagic Shock on the Minimum Alveolar Anesthetic Concentration of Isoflurane in a Swine Model
Tadayoshi Kurita, Kotaro Takata, Masahiro Uraoka, Koji Morita, Yoshimitsu Sanjo, Takasumi Katoh, and Shigehito Sato
Anesth Analg 2007 105: 1639-1643.
依托咪酯的麻醉效应：种族特异性的与_files/image002.gif){kind=small}
2-肾上腺素能受体的相互作用
陈珺珺译 薛张纲校
The Anesthetic Effects of Etomidate:
Species-Specific Interaction with 
2-Adrenoceptors
Andrea Paris, Lutz Hein, Marc Brede, Philipp-Alexander Brand, Jens Scholz, and Peter H. Tonner
Anesth Analg 2007 105: 1644-1649.
术后疼痛模型中的继发性痛觉过敏取决于脊髓钙－钙调蛋白依赖的蛋白激酶IIα的激活
周雅春 译 马皓琳 李士通 校
Secondary Hyperalgesia
in the Postoperative Pain Model Is Dependent on Spinal
Calcium/Calmodulin-Dependent Protein Kinase II
Activation
Toni L. Jones, Adam C. Lustig, and Linda S. Sorkin
Anesth Analg 2007 105: 1650-1656.
p38丝裂原激活蛋白激酶（p38MAP激酶）抑制剂可以保护离体试验中利多卡因诱导的神经轴突损伤，而半胱氨酸蛋白酶活性抑制剂无此作用
陶颖莹 译 陈杰 校
In Vitro,
Lidocaine-Induced Axonal Injury Is Prevented by Peripheral Inhibition of the
p38 Mitogen-Activated Protein Kinase, but Not by Inhibiting Caspase Activity
Philipp Lirk, Ingrid Haller, Hans Peter Colvin, Silke Frauscher, Lukas Kirchmair, Peter Gerner, and Lars Klimaschewski
Anesth Analg 2007 105: 1657-1664.
骶骨背侧角神经元的痛觉域值的时间空间决定因素与异氟醚诱导的制动性的关系
秦 佳译，薛张刚校
Temporal and Spatial Determinants of Sacral
Dorsal Horn Neuronal Windup in Relation to Isoflurane-Induced Immobility
Robert C. Dutton, Jason M. Cuellar, Edmond I. Eger, II, Joseph F. Antognini, and Earl Carstens
Anesth Analg 2007 105: 1665-1674.
唐李隽 译 马皓琳 李士通 校
Concentrations of Isoflurane Exceeding Those
Used Clinically Slightly Increase the Affinity of Methane, but Not Toluene, for
Water
Charles W. Buffington, Michael J. Laster, Katarzyna Jankowska, and Edmond I. Eger, II
Anesth Analg 2007 105: 1675-1680.
TECHNOLOGY, COMPUTING, AND SIMULATION:
在志愿者身上新的循环水装置比强风装置加热更快#New_Circulating_Water_Devices_Warm
潘钱玲 译 陈杰 校
New Circulating-Water Devices Warm More
Quickly than Forced-Air in Volunteers
Anupama Wadhwa, Ryu Komatsu, Mukadder Orhan-Sungur, Pamela Barnes, JangHyeok In, Daniel I. Sessler, and Rainer Lenhardt
Anesth Analg 2007 105: 1681-1687.
施杨译,薛张纲校
The Usefulness of an Earphone-Type Infrared Tympanic Thermometer for Intraoperative Core Temperature Monitoring
Tomohiro Kiya, Michiaki Yamakage, Tomo Hayase, Jun-Ichi Satoh, and Akiyoshi Namiki
Anesth Analg 2007 105: 1688-1692.
CRITICAL CARE AND TRAUMA:
细胞外PH值对血管加压素所引起的血管平滑肌细胞上ATP敏感性K通道阻滞作用的影响
潘方立 译 陈杰 校
The Effects of Extracellular pH on
Vasopressin Inhibition of ATP-Sensitive K+ Channels in Vascular
Smooth Muscle Cells
Takashi Kawano, Katsuya Tanaka, Hossein Nazari, Shuzo Oshita, Akira Takahashi, and Yutaka Nakaya
Anesth Analg 2007 105: 1714-1719.
NEUROSURGICAL ANESTHESIA:
孙霞译 薛张纲校
The Effects of Centrally Administered
Dexmedetomidine on Cardiovascular and Sympathetic Function in Conscious Rats
Tetsuro Shirasaka, De-Lai Qiu, Hiroshi Kannan, and Mayumi Takasaki
Anesth Analg 2007 105: 1722-1728.
沈浩 译 马皓琳 李士通 校
Mechanisms of Morphine Enhancement of Spontaneous Seizure Activity
Ehsan Saboory, Miron Derchansky, Mohammed Ismaili, Shokrollah S. Jahromi, Richard Brull, Peter L. Carlen, and Hossam El Beheiry
Anesth Analg 2007 105: 1729-1735.
OBSTETRIC ANESTHESIOLOGY:
王腾
译 陈杰 校
The Accuracy of Blood Loss Estimation After
Simulated Vaginal Delivery (Brief Report)
Paloma Toledo, Robert J. McCarthy, Bradley J. Hewlett, Paul C. Fitzgerald, and Cynthia A. Wong
Anesth Analg 2007 105: 1736-1740.
GENERAL ARTICLES:
王光妍译 薛张纲校
A Bibliometric Analysis of Global Clinical
Research by Anesthesia Departments
Madhav Swaminathan, Barbara G. Phillips-Bute, and Katherine P. Grichnik
Anesth Analg 2007 105: 1741-1746.
ANALGESIA:
姜旭晖 译 马皓琳 李士通 校
The Ability of Diagnostic Spinal Injections
to Predict Surgical Outcomes (Medical Intelligence)
Steven P. Cohen and Robert W. Hurley
Anesth Analg 2007 105: 1756-1775.
阿片类药物和沉浸式虚拟现实分散注意力的镇痛作用：来自主观性和功能性脑显像评估的证据
黄佳佳 译 马皓琳 李士通 校
The Analgesic Effects of Opioids and
Immersive Virtual Reality Distraction: Evidence from Subjective and Functional
Brain Imaging Assessments (Medical Intelligence)
Hunter G. Hoffman, Todd L. Richards, Trevor Van Oostrom, Barbara A. Coda, Mark P. Jensen, David K. Blough, and Sam R. Sharar
Anesth Analg 2007 105: 1776-1783.
王鹏
译 陈杰 校
The Use of Brain Positron Emission Tomography
to Identify Sites of Postoperative Pain Processing With and Without Epidural
Analgesia (Brief Report)
Asokumar Buvanendran, Amjad Ali, Travis R. Stoub, Richard A. Berger, and Jeffrey S. Kroin
Anesth Analg 2007 105: 1784-1786.
王时来译 薛张纲校
The Influence of Race and Socioeconomic
Factors on Patient Acceptance of Perioperative Epidural Analgesia (Brief
Report)
Edward Andrew Ochroch, Andrea B. Troxel, Jonathan K. Frogel, and John T. Farrar
Anesth Analg 2007 105: 1787-1792.
与环氧化酶-2选择性抑制剂和非选择性抗炎药物有关的心血管血栓栓塞的副作用
朱 慧译 马皓琳 李士通校
Cardiovascular Thromboembolic Adverse Effects
Associated with Cyclooxygenase-2 Selective Inhibitors and Nonselective
Antiinflammatory Drugs (Brief Report)
Girish P. Joshi, Ralph Gertler, and Ruth Fricker
Anesth Analg 2007 105: 1793-1804.
周懿之 译 陈杰 校
Pregabalin: Its Pharmacology and Use in Pain
Management (Review Article)
Noor M. Gajraj
Anesth Analg 2007 105: 1805-1815.
张俪译 薛张纲校
Needlestick Distal Nerve Injury in Rats
Models Symptoms of Complex Regional Pain Syndrome
Sandra M. Siegel, Jeung W. Lee, and Anne Louise Oaklander
Anesth Analg 2007 105: 1820-1829.
抑制环腺苷酸通路可以缓解神经性疼痛且减轻大鼠坐骨神经部分结扎后脊髓相应部位环腺苷酸磷酸化
张莹译 马皓琳 李士通校
Inhibition of the Cyclic Adenosine
Monophosphate Pathway Attenuates Neuropathic Pain and Reduces Phosphorylation
of Cyclic Adenosine Monophosphate Response Element-Binding in the Spinal Cord
After Partial Sciatic Nerve Ligation in Rats
Jiin-Tarng Liou, Fu-Chao Liu, Shi-Tai Hsin, Ching-Yue Yang, and Ping-Wing Lui
Anesth Analg 2007 105: 1830-1837.
p38 细胞分裂素活化蛋白激酶对大鼠慢性缩窄性损伤导致脊髓炎性细胞因子肿瘤坏死因子α合成的影响。
张艳 译 陈杰 校
The Influence of p38 Mitogen-Activated
Protein Kinase Inhibitor on Synthesis of Inflammatory Cytokine Tumor Necrosis
Factor Alpha in Spinal Cord of Rats with Chronic Constriction Injury
Li Xu, Yuguang Huang, Xuerong Yu, Jianying Yue, Nan Yang, and Pingping Zuo
Anesth Analg 2007 105: 1838-1844.
周时蓓译，薛张纲校
Thoracic Paravertebral Block for
Breast Cancer Surgery: A Randomized Double-Blind Study (Case Report)
Jytte F. Moller, Lone Nikolajsen, Svein Aage Rodt, Hanne Ronning, and Palle S. Carlsson
Anesth Analg 2007 105: 1848-1851.
关于股骨创伤后临床症状出现前股神经阻滞缓解疼痛的一项随机对照试验
黄丽娜 译 马皓琳 李士通 校
A Randomized Controlled Trial of Femoral
Nerve Blockade Administered Preclinically for Pain Relief in Femoral Trauma (Brief
Report)
Arno Schiferer, Carmen Gore, Laszlo Gorove, Thomas Lang, Barbara Steinlechner, Michael Zimpfer, and Alexander Kober
Anesth Analg 2007 105: 1852-1854.
胡湘
译 马皓琳 李士通 校
The Paramedian Technique: A Superior Initial
Approach to Continuous Spinal Anesthesia in the Elderly (Brief
Report)
Anna Rabinowitz, Benoît Bourdet, Vincent Minville, Clément Chassery, Antoine Pianezza, Aline Colombani, Bernard Eychenne, Kamran Samii, and Olivier Fourcade
Anesth Analg 2007 105: 1855-1857.
朱玫娟 译 陈杰 校
Piezoelectric Vibrating Needle and Catheter for Enhancing Ultrasound-Guided Peripheral Nerve Blocks (Technical Communication)
Stephen M. Klein, Matthew P. Fronheiser, John Reach, Karen C. Nielsen, and Stephen W. Smith
Anesth Analg 2007 105: 1858-1860.
The Role of Heart Rate Variability in
Risk Stratification for Adverse Postoperative Cardiac Events
Timo Laitio, MD*, Jouko
Jalonen, MD*, Tom Kuusela, PhD_files/image004.gif){kind=small}
,
and Harry Scheinin, MD_files/image006.gif){kind=small}
From the *Department of Anesthesiology and Intensive Care, Turku
University Hospital; _files/image007.gif){kind=small}
Department
of Physics; and _files/image008.gif){kind=small}
Turku
PET Centre and Department of Pharmacology and Clinical Pharmacology, University
of Turku, Turku, Finland.
Anesth Analg 2007 105: 1548-1560.
越来越多的证据表明自主神经功能的损害和心脏猝死之间有密切的关系。心率变异性（HRV）的测定广泛用于评估自主神经功能的变化。对于心脏病患者的许多研究均显示心率变异性的下降和压力反射功能异常较以前公认的临床指标（比如左室射血分数）在心脏猝死的预测中更有意义。三分之一的术后并发症和半数以上的死亡是由于心脏并发症引起的。许多危险性指标对患者围术期短期内的危险分层很有帮助，但对长期预后的危险分层作用不大。目前还没有关于术后危险评估的类似临床方法。最近有少数研究显示术前心率变异性降低是术后远期死亡的独立预测因素。今后，宜开展更多针对手术病人的研究，来确立术前压力反射功能异常或者和心率变异性异常一起对术后短期或者远期的预后的价值。
（杜唯佳 译 陈杰 校）
There is growing evidence of a strong association between the compromised
autonomic nervous system and sudden cardiac death. Heart rate
variability (HRV) measures are widely used to measure alterations in
the autonomic nervous system. Several studies with cardiac patients
show that decreased HRV as well as baroreceptor dysfunction are more
powerful predictors for sudden cardiac death than established
clinical predictors such as left ventricular ejection fraction.
One-third of all postoperative complications and more than half of
the deaths are due to cardiac complications. Several risk indices
are useful for immediate perioperative short-term, but not for
long-term outcome risk stratification of an individual patient.
Currently, there are no clinically assimilated methods for long-term
postoperative risk assessment. Recently, few studies have shown that
preoperatively decreased HRV can independently predict postoperative
long-term mortality. Further studies with surgical patients are
needed to establish a possible predictive value of preoperative
baroreceptor dysfunction, alone and combined with HRV, for short-
and long-term postoperative outcome.
一项关于POVOC评分预测儿童术后呕吐的前瞻性评估
A Prospective Evaluation of the POVOC
Score for the Prediction of Postoperative Vomiting in Children
Peter Kranke, MD, PhD, MBA*,
Leopold H. Eberhart, MD, PhD_files/image009.gif){kind=small}
,
Hakki Toker, MD_files/image010.gif){kind=small}
,
Norbert Roewer, MD, PhD*, Hinnerk Wulf, MD, PhD_files/image011.gif){kind=small}
,
and Peter Kiefer, MD, PhD_files/image012.gif){kind=small}
From the *Department of Anaesthesiology, University Hospitals of
Würzburg, Würzburg, Germany; _files/image013.gif){kind=small}
Department
of Anaesthesiology and Critical Care, University Hospitals of Marburg and
Giessen GmbH, Campus Marburg, Germany; and _files/image014.gif){kind=small}
Department
of Anaesthesiology, Evangelischen Krankenhauses Oberhausen, Germany.
Anesth Analg 2007 105: 1592-1597.Abstract
背景：POVOC是最近发表的一项预测儿童术后呕吐（PV）的评分标准，但还未客观验证。
方法：作者以使用标准麻醉技术但不预先使用止吐药的方式，研究673位施行各种外科手术（但排除斜视手术，因其为POVOC评分的危险因素之一）的0至16岁病人。在术后阶段关于是否发生术后呕吐，对患者行筛选。再将这些发生率与POVOC评分所得出的预计危险度相比较。评估POVOC评分时，充分考虑到其易于使用、描述和校正的特点。
结果：95%病人收集到预测术后呕吐危险度的完整数据。结果显示当风险因素为0，1，2和3时的PV发生率分别为3.4%，11.6%，8.2%和42.3%。并得出一条斜率为0.78、截距为2.37的回归线。其特征曲线下面积为0.72（95%可信区间为0.68-0.76）。
结论：即使有些危险因素未能提供， POVOC评分能比较准确地评估儿科病人，且其结果并不逊于成人。
（於章杰 译 陈杰 校）
BACKGROUND: A score to predict
postoperative vomiting (PV) in children (POVOC score) has recently
been published but has not yet undergone an external validation.
METHODS: We studied 673 patients (age
0–16 yr) undergoing a variety of surgical procedures (but excluding
strabismus surgery, one of the risk factors according to the POVOC
score) using standardized anesthesia techniques without
administering antiemetics. The patients were prospectively screened
for PV in the postoperative period and these incidences were
compared with the predicted risk for PV according to the POVOC
score. The POVOC score was evaluated with respect to its ease of
use, discrimination, and calibration.
RESULTS: Complete data to predict the
risk for PV could be obtained in 95% of patients. The actual
observed incidences of PV were 3.4, 11.6, 28.2, and 42.3% for the
presence of 0, 1, 2, or 3 risk factors, resulting in a regression
line with a slope of 0.78 and an offset of 2.37. The area under the
receiver operating characteristic curve was 0.72 (95% CI:
0.68–0.76).
CONCLUSIONS: Using the POVOC score,
PV in pediatric patients can be predicted with sufficient accuracy
comparable to the results in adult patients, even if one of the risk
factors is not applicable.
Reference Values for Kaolin-Activated
Thromboelastography in Healthy Children
Kah-Lok Chan*_files/image015.gif){kind=small}
,
Robyn G. Summerhayes, BSc (Hons)*_files/image016.gif){kind=small}
_files/image017.gif){kind=small}
,
Vera Ignjatovic, PhD*_files/image018.gif){kind=small}
_files/image019.gif){kind=small}
,
Stephen B. Horton, PhD, FACBS_files/image021.gif){kind=small}
||,
and Paul T. Monagle, MD, FRACP, FRCPA, FCCP*_files/image022.gif){kind=small}
From the *Department of Clinical Hematology, Royal Children’s
Hospital; _files/image023.gif){kind=small}
Department
of Pathology, The University of Melbourne; _files/image024.gif){kind=small}
Murdoch
Children’s Research Institute; _files/image025.gif){kind=small}
Cardiac
Surgical Unit, Royal Children’s Hospital; and ||Department of Pediatrics, The
University of Melbourne, Melbourne, Australia.
Anesth Analg 2007 105: 1610-1613.
背景：儿童的凝血系统随年龄的变化而改变，也不同于成人的凝血系统。因此，需确定特定年龄的凝血变量参考值。凝血弹性描记法（ TEG）是凝血试验一部分，可以提供良好的评估和处理大剂量不间断使用肝素的体外转流术的心脏手术后的凝血紊乱。本研究作者拟确定健康儿童白陶土激活的凝血弹性描记法的参考值，以便为儿童凝血弹性描记法的结果有个准确的诠释。
方法：研究100名择期手术的健康儿童和25个健康成人志愿者的白陶土激活凝血弹性描记法试验结果。记录以下凝血弹性描记法变量：反应时间，凝固时间，角度，最大变幅，达到最大变幅后30分钟的溶解百分率和凝固指数。不同年龄组之间的差异通过方差分析来评定。
结果：研究提供了一个月小儿至16岁儿童之间各特定年龄的参考值。在成人和儿童之间所有测定值无显著差异。
结论：凝血弹性描记法的结果需考虑到年龄的特定性，以及分析仪和激活剂的特殊性，以便根据测定结果提供了恰当的诠释。本研究提供的参考值对于需要监测实际凝血状态的急症者是有意义的。
（陈伟 译 陈杰 校）
BACKGROUND: The hemostatic system of
children changes with age and differs significantly from the
hemostatic system of adults. Age-specific reference values are
therefore required for most hemostatic variables.
Thromboelastography (TEG®) is a point-of-care coagulation test that
may provide superior evaluation and management of coagulopathies
after cardiac surgery, when large-dose unfractionated heparin is
administered for cardiopulmonary bypass. In this study, we
established reference values for kaolin-activated TEG in healthy
children, to facilitate accurate interpretation of pediatric TEG
results.
METHODS: Kaolin-activated TEG was
performed on 100 healthy children undergoing elective day surgery
and 25 healthy adult volunteers. The following TEG variables were
recorded: reaction time, coagulation time, _files/image027.gif){kind=small}
angle,
maximum amplitude, percentage lysis 30 min after maximum amplitude
was reached, and the coagulation index. Differences between
age-groups were evaluated using analysis of variance.
RESULTS: Age-specific reference
values for kaolin-activated TEG in healthy children between 1 mo and
16 yr of age are presented. No significant differences between
children and adults were observed.
CONCLUSIONS: TEG results, from a
particular clinical setting, must be compared to age-specific, as
well as analyzer- and activator-specific, reference values to allow
for correct interpretation of the results. Reference values provided
here will be of use in acute clinical situations where a practical
monitor of hemostasis is required.
The Influence of Hemorrhagic Shock on
the Minimum Alveolar Anesthetic Concentration of Isoflurane in a Swine Model
Tadayoshi Kurita, MD, Kotaro Takata, MD,
Masahiro Uraoka, MD, Koji Morita, PhD, Yoshimitsu Sanjo, PhD, Takasumi Katoh,
MD, and Shigehito Sato, MD
From the Department of Anesthesiology and Intensive Care, Hamamatsu
University School of Medicine, Hamamatsu, Japan.
Anesth Analg 2007 105: 1639-1643.
背景: 虽然失血性休克降低吸入麻醉的最小肺泡浓度，但是很少影响脑电图。失血性休克也可诱发内啡呔的释放，它是一种天然合成的阿片类物质。作者研究这种阿片类物质的释放是否可解释MAC的降低。
方法: 选取11头猪，使用露爪钳夹技术测定各阶段异氟醚的MAC，分别为出血前；出血预计血容量30%后(出血21ml/kg，时间大于30分钟)；液体复苏后（使用相当于血液丢失量的羟乙基淀粉）；及给予0.1mg/kg的u受体拮抗剂纳洛酮后。
结果：失血性休克使异氟醚的MAC从2.05%±0.28%降到1.50%±0.51%(P=0.0007)。液体复苏不能逆转下降的MAC（1.59%±0.53%）,但是给予纳洛酮后MAC恢复到基础水平（1.96%±0.26%）。MAC值的降低取决于休克的严重度，但是伴随着液体复苏和给予纳洛酮引起的血流动力学改变和代谢变化并不能解释MAC的变化 。
结论：与以往的报道一致，失血性休克降低MAC。给予纳洛酮后能逆转MAC的影响。失血性休克期间激活内源性阿片系统从而来降低MAC。这种激活不能改变脑电图。上述结果与以往发现的失血性休克很少改变脑电图结论相一致。
（张燕 译 陈杰 校）
BACKGROUND: Although hemorrhagic
shock decreases the minimum alveolar concentration (MAC) of inhaled
anesthetics, it minimally alters the electroencephalographic (EEG)
effect. Hemorrhagic shock also induces the release of endorphins,
which are naturally occurring opioids. We tested whether the release
of such opioids might explain the decrease in MAC.
METHODS: Using the dew claw-clamp
technique in 11 swine, we determined the isoflurane MAC before
hemorrhage, after removal of 30% of the estimated blood volume (21
mL/kg of blood over 30 min), after fluid resuscitation using a
volume of hydroxyethylstarch equivalent to the blood withdrawn, and
after IV administration of 0.1 mg/kg of the µ-opioid antagonist
naloxone.
RESULTS: Hemorrhagic shock decreased
the isoflurane MAC from 2.05% ± 0.28% to 1.50% ± 0.51% (P = 0.0007). Fluid resuscitation did not reverse MAC
(1.59% ± 0.53%), but additional administration of naloxone restored
it to control levels (1.96% ± 0.26%). The MAC values decreased
depending on the severity of the shock, but the alterations in
hemodynamic variables and metabolic changes accompanying fluid
resuscitation or naloxone administration did not explain the changes
in MAC.
CONCLUSIONS: Consistent with previous
reports, we found that hemorrhagic shock decreases MAC. In addition,
we found that naloxone administration reversed the effect on MAC,
and we propose that activation of the endogenous opioid system
accounts for the decrease in MAC during hemorrhagic shock. Such an
activation would not be expected to materially alter the EEG, an
expectation consistent with our previous finding that hemorrhagic
shock minimally alters the EEG.
p38丝裂原激活蛋白激酶（p38MAP激酶）抑制剂可以保护离体试验中利多卡因诱导的神经轴突损伤，而半胱氨酸蛋白酶活性抑制剂无此作用
In Vitro, Lidocaine-Induced Axonal Injury Is Prevented by Peripheral
Inhibition of the p38 Mitogen-Activated Protein Kinase, but Not by Inhibiting
Caspase Activity
Philipp Lirk, MD, MSc*,
Ingrid Haller, MD*, Hans Peter Colvin*, Silke Frauscher,
MD_files/image028.gif){kind=small}
,
Lukas Kirchmair, MD*, Peter Gerner, MD_files/image029.gif){kind=small}
,
and Lars Klimaschewski, MD_files/image030.gif){kind=small}
From the *Department of Anesthesiology and Critical Care Medicine,
and _files/image031.gif){kind=small}
Division
of Neuroanatomy, Innsbruck Medical University, Austria; and _files/image032.gif){kind=small}
Department
of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's
Hospital, Harvard Medical School, Boston, Massachusetts.
Anesth Analg 2007 105: 1657-1664.
背景：所有的局麻药都在一定程度上存在神经毒性，目前已在分离培养的神经细胞（包括轴突和神经元胞体）进行了局麻药的毒性研究。然而由于临床操作中外周神经阻滞主要是局麻药作用于轴突的过程，故此类方法或许未能准确地反映体内外周神经处于阻滞时的状态。
方法：作者研究了在房室分割感觉神经元培养模型（包括神经元胞体组成的中央室和轴突组成的外周室）中利多卡因的神经毒性表现。在试验中观察神经元胞体或轴突在使用利多卡因配合或不配合神经保护剂，并评估神经元的存活性及轴突在培养皿上的生长。
结果：在外周室模型中使用利多卡因可以导致轴突数量降低59%±9%，而不影响神经元胞体的存活。对轴突培养中加入利多卡因，再对轴突加入p38丝裂原激活蛋白激酶抑制剂--SB203580，观察到轴突细胞的损伤情况减轻（轴突生长晕的最大距离只降低至93%±9%），而对神经元胞体加入SB203580时轴突生长的最大距离降低至48%±6%。而 改用半胱氨酸蛋白酶活性抑制剂z-vad-fmk时并未显示相应的保护作用 。
结论：无论是p38MAP激酶的抑制剂或半胱氨酸蛋白酶活性抑制剂，均能增加分离培养的神经元在局麻药作用时的生存活性。p38MAP激酶抑制剂可以预防利多卡因造成的神经细胞的轴突变性，而半胱氨酸蛋白酶活性抑制剂却无此作用。作者认为在分离培养的神经元上局麻药所造成的神经毒性的过程，可能与临床中单纯轴突上使用局麻药产生的现象不同。
（陶颖莹 译 陈杰 校）
BACKGROUND: All local anesthetics
(LAs) are, to some extent, neurotoxic. Toxicity studies have been
performed in dissociated neuron cultures, immersing both axon and
soma in LA. This approach, however, does not accurately reflect the in
vivo situation for peripheral nerve
blockade, where LA is applied to the axon alone.
METHODS: We investigated lidocaine
neurotoxicity in compartmental sensory neuron cultures, which are
composed of one central compartment containing neuronal cell bodies
and a peripheral compartment containing their axons, allowing for
selective incubation. We applied lidocaine ± neuroprotective drugs
to neuronal somata or axons, and assessed neuron survival and axonal
outgrowth.
RESULTS: Lidocaine applied to the
peripheral compartment led to a decreased number of axons (to 59% ±
9%), without affecting survival of cell bodies. During axonal
incubation with lidocaine, the p38 mitogen-activated protein kinase
inhibitor SB203580 (10 µM) attenuated axonal injury when applied
to the axon (insignificant reduction of maximal axonal distance to
93% ± 9%), but not when applied to the cell body (deterioration of
maximal axonal length to 48% ± 6%). Axonal co-incubation of
lidocaine with the caspase inhibitor z-vad-fmk (20 µM) was not
protective.
CONCLUSIONS: Whereas inhibition of
either p38 mitogen-activated protein kinase or caspase activity
promote neuronal survival after LA treatment of dissociated neuronal
cultures, axonal degeneration induced by lidocain (40 mM) is
prevented by p38 MAP kinase but not by caspase inhibition. We
conclude that processes leading to LA-induced neurotoxicity in
dissociated neuronal culture may be different from those observed
after purely axonal application.
New Circulating-Water Devices Warm
More Quickly than Forced-Air in Volunteers
Anupama Wadhwa, MD*, Ryu
Komatsu, MD_files/image033.gif){kind=small}
,
Mukadder Orhan-Sungur, MD_files/image034.gif){kind=small}
,
Pamela Barnes, MD_files/image035.gif){kind=small}
,
JangHyeok In, MD_files/image036.gif){kind=small}
,
Daniel I. Sessler, MD_files/image037.gif){kind=small}
,
and Rainer Lenhardt, MD*||
From the *Outcomes Research Institute, University of Louisville,
Louisville, Kentucky; _files/image038.gif){kind=small}
Department
of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville,
Kentucky; _files/image039.gif){kind=small}
Department
of Anesthesiology, University of Chicago, Chicago, Illinois; _files/image040.gif){kind=small}
Department
of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio; and
||Neurosciences Intensive Care Unit, University of Louisville, Louisville,
Kentucky.
Anesth Analg 2007 105: 1681-1687.
背景：新的循环水系统比强风能提供更多的热量，主要是由于水的热容量比干热空气大，其次是由于它能像使身体前面热起来一样使身体后面也热起来。目前已有几种加热系统，但其中三个主要的系统已经进行过直接的比较了。因此作者在志愿者身上进行与上腹部或胸腔手术相似操作时进行两种循环水系统和一种强风系统的比较。
方法:7个健康的志愿者分别参加3天的研究。受试者每天在麻醉后开始降低体温，使其中心体温降低到34℃左右，并持续45－60分钟。然后用三种加热系统中的一种对其进行复温直到远端食管中心温度接近36℃或者麻醉持续8小时。这三种加热系统分别是：1）能量转换垫（两个分开的躯干垫及两个整体垫；型号为Kimberly Clark,Roswell,GA）；2）循环水系统（型号为以色列产的用于心脏手术的Allon MTRE 3365）；3）下肢的强风加热系统（型号为Bair Hugger#525,＃750blower，Eden Prairie,MN）.数据取平均数±标准差；P＜0.05表示有统计学意义。
结果：用Kimberly Clark系统加热后中心体温从34℃升至36℃速率为1.2℃±0.2℃/h，用Allon
系统为0.9℃±0.2℃/h，用Bair Hugger为0.6℃±0.1℃/h（P＝0.002）。
结论：Kimberly Clark系统的加热速率比Allon系统快25％，比Bair
Hugger系统快两倍。两种循环水系统使低体温的志愿者复温所需的时间显著短于强风系统。
（潘钱玲 译 陈杰 校）
BACKGROUND: Newer circulating-water
systems supply more heat than forced-air, mainly because the heat
capacity of water is much greater than for that of dry warm air and,
in part, because they provide posterior as well as anterior heating.
Several heating systems are available, but three major ones have yet
to be compared directly. We therefore compared two circulating-water
systems with a forced-air system during simulation of upper abdominal
or chest surgery in volunteers.
METHODS: Seven healthy volunteers
participated on three separate study days. Each day, they were
anesthetized and cooled to a core temperature near 34°C, which was
maintained for 45–60 min. They were then rewarmed with one of three
warming systems until distal esophageal core temperature reached
36°C or anesthesia had lasted 8 h. The warming systems were 1)
energy transfer pads (two split torso pads and two universal pads;
Kimberly Clark, Roswell, GA); 2) circulating-water garment (Allon MTRE
3365 for cardiac surgery, Akiva, Israel); and 3) lower body
forced-air warming (Bair Hugger #525, #750 blower, Eden Prairie,
MN). Data are presented as mean ± sd; P <
0.05 was statistically significant.
RESULTS: The rate of increase of core
temperature from 34°C to 36°C was 1.2°C ± 0.2°C/h with the Kimberly
Clark system, 0.9°C ± 0.2°C/h with the Allon system, and 0.6°C
± 0.1°C/h with the Bair Hugger (P =
0.002).
CONCLUSIONS: The warming rate with the
Kimberly Clark system was 25% faster than with the Allon system and
twice as fast as with the Bair Hugger. Both circulating-water
systems thus warmed hypothermic volunteers in significantly less
time than the forced-air system.
细胞外PH值对血管加压素所引起的血管平滑肌细胞上ATP敏感性K通道阻滞作用的影响
The Effects of Extracellular pH on
Vasopressin Inhibition of ATP-Sensitive K+ Channels in Vascular
Smooth Muscle Cells
Takashi Kawano, MD*, Katsuya
Tanaka, MD*, Hossein Nazari, PhD_files/image041.gif){kind=small}
,
Shuzo Oshita, MD*, Akira Takahashi, MD_files/image042.gif){kind=small}
,
and Yutaka Nakaya, MD_files/image043.gif){kind=small}
From the Departments of *Anesthesiology and _files/image044.gif){kind=small}
Nutrition
and Metabolism, Institute of Health Biosciences, The University of Tokushima
Graduate School, Tokushima, Japan.
Anesth Analg 2007 105: 1714-1719.
背景：精氨酸血管加压素（AVP）可以阻滞ATP敏感的K通道（KATP）并有助于恢复由于血管舒张引起的休克病人的血管张力。在目前的研究中，笔者观察了酸化细胞外环境是否改变AVP对血管平滑肌KATP的阻滞作用。
方法：笔者应用细胞膜片钳技术研究细胞外PH值（PH0）对大鼠主动脉平滑肌细胞上AVP-KATP通道的作用。
结果：浸浴在AVP溶液中能显著阻滞细胞外环境酸化（PH0=7.0）引起的KATP通道的活动，具有浓度依赖性，IC50为16.8pM。且在中度（PH0=7.0）和重度(PH0=6.5)细胞外酸性环境时，浸浴在AVP中能阻滞吡那地尔引起的KATP通道活动，IC50分别为266.7和21.4pM，但是在中性（PH0=7.4）和碱性(PH0=9.0)环境下不能阻滞。细胞外环境酸化增强AVP对 KATP通道的阻滞作用可以在预先使用OPC21268，一种 V1受体阻滞剂后而被消除，但不能被V2受体阻滞剂OPC31260消除。在预先使用了蛋白激酶C阻滞剂卡弗他丁C后AVP引起的阻滞作用被抑制。
结论：作者的实验结果显示AVP可以阻滞在酸化的细胞外环境中血管平滑肌细胞上KATP通道的活性，并且其阻滞效果受细胞外环境酸化程度的影响，通过V1受体蛋白激酶C细胞信号途径。这种在酸性环境下有效的对血管平滑肌细胞上KATP通道的阻滞作用使其成为治疗血管源性休克的合适的方法。
（潘方立 译 陈杰 校）
BACKGROUND: Arginine vasopressin
(AVP) inhibits ATP-sensitive potassium (KATP) channels
and may help to restore vascular tone in patients with vasodilatory
shock. In the present study, we investigated whether extracellular
acidification modifies the inhibition of vascular KATP
channels by AVP.
METHODS: We used a cell-attached patch-clamp
configuration to investigate the effects of extracellular pH (pHo)
on AVP-KATP channel interaction in rat aortic smooth
muscle cells.
RESULTS: Bath application of AVP
significantly inhibited extracellular acidification (pHo
= 6.5)-induced KATP channel activity in a concentration-dependent
manner, with an half-maximal inhibitory concentration (IC50)
value of 16.8 pM. Furthermore, bath application of AVP significantly
inhibited pinacidil-induced KATP channel activity at mild
(pHo = 7.0) and severe (pHo = 6.5) extracellular acidification,
with IC50 values of 266.7 and 21.4 pM, respectively, but
failed to significantly inhibit at normal pH (pHo = 7.4) or
under alkalosis (pHo = 9.0). Augmentation of AVP inhibition of
vascular KATP channels during extracellular acidification was
eliminated by pretreatment with OPC-21268, a specific blocker of the
V1 receptor, but not by a V2 blocker, OPC-31260.
AVP-induced inhibition was also suppressed by pretreatment with a
protein kinase C inhibitor, calphostin C.
CONCLUSIONS: Our results suggest that
AVP inhibits extracellular acidification-induced vascular KATP
channel activity, and that the inhibitory effects of AVP on vascular
KATP channels are enhanced by extracellular acidification
via the V1 receptor-protein kinase C cell-signaling
pathway. The potent inhibition of vascular KATP channels
by AVP under acidic conditions may make it suitable for management
of vasodilatory shock.
The Accuracy of Blood Loss Estimation
After Simulated Vaginal Delivery
Paloma Toledo, MD, Robert J. McCarthy,
PharmD, Bradley J. Hewlett, BS, Paul C. Fitzgerald, RN, MS, and Cynthia A.
Wong, MD
From the Department of Anesthesiology, Northwestern University
Feinberg School of Medicine, Chicago, Illinois.
Anesth Analg 2007 105: 1736-1740.
背景：用肉眼观察估计血液损失量往往比实际失血量低。在这个研究中，作者设法确定用标有刻度的被垫测量模拟阴道分娩中失血量的估测效果。
方法：受试者被随机分组，用标有刻度和未标刻度的被垫测量阴道分娩过程中的失血量，而失血量又被分为300，500，1000，和2000ml四组，然后相互比较。
结果：用视觉直估未标有刻度被垫上的失血量数值低于实际失血量，估测的差距随失血量增大而增大（从300ml到2000ml，错误率由16%增大到41%），而用标有刻度的被垫估测错误率均小于15%。
结论：标有刻度阴道分娩被垫可以改善失血量估测的准确度。
（王腾 译 陈杰 校）
BACKGROUND: Visual blood loss
estimation often underestimates blood loss. In this study we sought
to determine the effect of calibrated drape markings on blood loss
estimation in a simulated vaginal delivery.
METHODS: Subjects were randomized to
estimate simulated blood loss (300, 500, 1000, and 2000 mL) in
calibrated or noncalibrated vaginal delivery drapes and then
crossover.
RESULTS: Visual blood loss estimation
with noncalibrated drapes underestimated blood loss, with worsening accuracy
at larger volumes (16% error at 300 mL to 41% at 2000 mL). The
calibrated drape error was <15% at all volumes.
CONCLUSIONS: Calibrated vaginal
delivery drapes improve blood loss estimation.
脑部PET对术后疼痛是否使用硬膜外镇痛的鉴别
The Use of Brain Positron Emission
Tomography to Identify Sites of Postoperative Pain Processing With and Without
Epidural Analgesia
Asokumar Buvanendran, MD*,
Amjad Ali, MD_files/image045.gif){kind=small}
,
Travis R. Stoub, PhD_files/image046.gif){kind=small}
,
Richard A. Berger, MD_files/image047.gif){kind=small}
,
and Jeffrey S. Kroin, PhD*
From the Departments of *Anesthesiology, _files/image048.gif){kind=small}
Radiology,
_files/image049.gif){kind=small}
Neurology,
and _files/image050.gif){kind=small}
Orthopedic
Surgery, Rush University Medical Center, Chicago, Illinois.
Anesth Analg 2007 105: 1784-1786.
为了减轻术后疼痛而使用不同镇痛方法时脑部的变化尚未阐明。作者在一名69岁的妇女行全膝置换术术后两天内，分别在她处于中等程度的术后疼痛和在硬膜外镇痛下完全缓解疼痛的情况下，利用PET(正电子发射型计算机断层显像)进行了头部扫描。利用术后第一天（没有进行硬膜外镇痛而处于中等疼痛）PET扫描得到的数据减去术后第二天（硬膜外完全镇痛）PET扫描的数据确定疼痛引起的活动的大脑区域。术后疼痛伴随着对侧初级自身感觉大脑皮层活动性的增强。术后活动性增强的大脑区域还有对侧的颅顶部的大脑皮层，两侧的丘脑后结节和下丘脑的背内侧核，对侧的壳核，对侧的上部颞侧脑回，同侧的梭状回，同侧的后叶和对侧的小脑前叶。这些研究证明了可利用PET评估术后急性疼痛的中枢变化。
（王鹏 译 陈杰 校）
It is not known how different analgesic regimes affect the brain
when reducing postoperative pain. We performed positron emission tomography
(PET) scans on a 69-yr-old woman in the presence of moderate postoperative
pain and then with epidural analgesia producing complete analgesia,
during the first 2 days after total knee arthroplasty. Day 2
postsurgery PET scan data (no pain with epidural analgesia) were
subtracted from Day 1 postsurgery PET scan data (time of moderate
pain without epidural analgesia) to determine the brain regions
activated. Postsurgical pain was associated with increased activity
in the contralateral primary somatosensory cortex. Other brain
regions showing increased postsurgical activity were the
contralateral parietal cortex, bilateral pulvinar and ipsilateral
medial dorsal nucleus of the thalamus, contralateral putamen,
contralateral superior temporal gyrus, ipsilateral fusiform gyrus,
ipsilateral posterior lobe, and contralateral anterior cerebellar
lobe. This study demonstrates the feasibility of evaluating the
central processing of acute postoperative pain using PET.
Pregabalin: Its Pharmacology and Use in
Pain Management
Noor M. Gajraj, MD, FRCA, DABPM
From the Texas Anodyne Research Institute and Sherman Pain Care,
Texas.
Anesth Analg 2007 105: 1805-1815.
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-氨基丁酸的衍生物。它是_files/image053.gif){kind=small}
2-_files/image055.gif){kind=small}
(_files/image056.gif){kind=small}
2-_files/image057.gif){kind=small}
)配合物，具有镇痛、抗惊厥、抗焦虑和睡眠调节作用。普巴加林与钙离子通道的_files/image058.gif){kind=small}
2-_files/image059.gif){kind=small}
亚基牢固结合，可导致数种神经递质的释放减少，包括谷氨酸、去甲肾上腺素、5-羟色胺、多巴胺和P-物质。本综述讨论普加巴林的药理特性，以及在疼痛治疗中疗效。本综述将重点讨论在2005年作者前一综述后普加巴林药理学的进展。
（周懿之 译 陈杰 校）
Pregabalin is a new synthetic molecule and a structural derivative
of the inhibitory neurotransmitter _files/image060.gif){kind=small}
-aminobutyric
acid. It is an _files/image061.gif){kind=small}
2-_files/image062.gif){kind=small}
(_files/image063.gif){kind=small}
2-_files/image064.gif){kind=small}
)
ligand that has analgesic, anticonvulsant, anxiolytic, and
sleep-modulating activities. Pregabalin binds potently to the _files/image065.gif){kind=small}
2-_files/image066.gif){kind=small}
subunit of calcium channels, resulting in a reduction in the release
of several neurotransmitters, including glutamate, noradrenaline,
serotonin, dopamine, and substance P. In this review, I will discuss
the pharmacology of pregabalin and available efficacy studies in
pain management. This review will focus on the advances in
pregabalin pharmacology since my previous review in 2005.
p38 细胞分裂素活化蛋白激酶对大鼠慢性缩窄性损伤导致脊髓炎性细胞因子肿瘤坏死因子α合成的影响。
11.The Influence of p38
Mitogen-Activated Protein Kinase Inhibitor on Synthesis of Inflammatory
Cytokine Tumor Necrosis Factor Alpha in Spinal Cord of Rats with Chronic
Constriction Injury
Li Xu, MD*, Yuguang Huang, MD*,
Xuerong Yu, MD*, Jianying Yue, MD_files/image067.gif){kind=small}
,
Nan Yang, PhD_files/image068.gif){kind=small}
,
and Pingping Zuo, PhD_files/image069.gif){kind=small}
Anesth Analg 2007 105: 1838-1844.
背景：肿瘤坏死因子α（TNF-α）可触发p38细胞分裂素活化蛋白激酶（MAPK）的激活。磷酸化p38（p－p38）可诱导TNF-α的上调。在此次试验中，作者验证如下假设：对坐骨神经造成慢性缩窄性损伤（CCI）刺激脊髓释放TNF-α以及产生异常性疼痛是通过p38 MAPK途径。
方法：将Sprague–Dawley大鼠分成5组：1）对照组，2）假手术组，3)未治疗的CCI组,4)生理盐水治疗组，5)p38
MAPK抑制剂SB203580治疗组。治疗组，在CCI前一天、后一天和后七天向鞘内给予生理盐水或SB203580（2μg，一天两次）。在手术后不同时间处死大鼠并通过]Western blot分析（蛋白印迹分析）或免疫组化来验证脊髓中p38 MAPK的活化和TNF－α水平。在手术后3、7、14天通过von Frey hairs法测定机械性异常痛。
结果：与时间相匹配，p－p38 M APK 在CCI手术后3、7、14天显著增高（P<0.05），末梢神经损伤诱导机械性异常痛和脊髓中TNF-α的浓度增加（P<0.05）。用SB203580前处理或早处理能抑制p38
MAPK的活化，减少TNF-α合成物，以及减弱机械性异常性疼痛。
结论：P38 MAPK 活化是TNF-α合成物达到高峰以及在末梢神经损伤后的机械性异常痛的信号级联放大中的一步。
（张艳 译 陈杰 校）
BACKGROUND: Tumor necrosis factor _files/image070.gif){kind=small}
(TNF-_files/image071.gif){kind=small}
)
could trigger p38 mitogen-activated protein kinase (MAPK)
activation. Conversely phosphorylated p38 (p-p38) could induce the
upregulation of TNF-_files/image072.gif){kind=small}
.
In this study, we examined the hypothesis that chronic constrictive
injury (CCI) of the sciatic nerve could promote spinal cord release
of TNF-_files/image073.gif){kind=small}
and produce allodynia via the p38 MAPK pathway.
METHODS: Sprague–Dawley rats were
divided into five groups: 1) naïve control rats, 2) sham surgery
rats, 3) CCI surgery rats without treatment, 4) CCI surgery rats
with saline (0.9%) treatment, and 5) CCI surgery rats with the p38
MAPK inhibitor SB203580 treatment. In treatment groups, saline or
SB203580 (2 µg, twice a day) was given intrathecally starting 1
day before or 1 day or 7 days after CCI. All rats were killed at
different times after surgery to examine p38 MAPK activity and TNF-_files/image074.gif){kind=small}
levels in the spinal cord by Western blot analysis or
immunohistochemistry. Mechanical allodynia was tested by a series of
von Frey hairs 3, 7, and 14 days after surgery.
RESULTS: p-p38 MAPK was significantly
increased at 3, 7, and 14 days after CCI surgery compared with
time-matched shams (P < 0.05).
Peripheral nerve injury induced mechanical allodynia and enhanced
spinal concentrations of TNF-_files/image075.gif){kind=small}
(P < 0.05). Pretreatment or early
treatment with SB203580 inhibited p38 MAPK activity, resulting in
reduction of TNF-_files/image076.gif){kind=small}
synthesis and attenuation of mechanical allodynia (P < 0.05).
CONCLUSION: p38 MAPK activation is
one aspect of the signaling cascade that culminates in TNF-_files/image077.gif){kind=small}
synthesis and contributes to mechanical allodynia after peripheral
nerve injury.
Piezoelectric Vibrating Needle and
Catheter for Enhancing Ultrasound-Guided Peripheral Nerve Blocks
Stephen M. Klein, MD*,
Matthew P. Fronheiser, BS_files/image078.gif){kind=small}
,
John Reach, MD_files/image079.gif){kind=small}
,
Karen C. Nielsen, MD*, and Stephen W. Smith, PhD_files/image080.gif){kind=small}
Anesth Analg 2007; 105:1858-1860
超声显影已被用于单次周围神经阻滞和连续置管。目前此技术的一个局限性在于不能确定针尖或导管顶端的位置。作者设计了一种新的针和导管，使其远端可以被彩色血流Doppler超声显影。定制一根18G100mm长的绝缘Tuohy针，一根20G50mm聚酰胺导管（顶端开口）和一根Teflon包裹的钢导芯（B. Braun, Bethlehem, PA），在其适当位置粘附两个压电式传动装置。当结合一个功能发生器（FG502,Tektronix,
Richardson, TX）和一个100W的声波放大器（R3000,KLH, Sun Valley，CA）时，这个装置可以产生1-8KHz的震动。模拟进行一次侧路腘窝神经阻滞，针和导管刺入用防腐剂保存尸体的大腿。激活时，在短轴上使用二维彩色Doppler超声模式和12MHz L38探头（MicroMaxx, Sonosite, Bothell, WA）进行超声扫描，可以看到针和导管的顶端均被彩色显影。震动技术可能是进行超声引导区域麻醉的一项有效辅助方法。需要更多的研究来评估其的有效性和在活体组织的安全性。
（朱玫娟 译 陈杰 校）
Ultrasound imaging has been used for performing single-injection
peripheral nerve blocks and continuous catheters. One limitation with
current technology is the inability to confirm the location of the
needle or catheter tip. We describe a new needle and catheter design
that permits distal tip visualization using color flow Doppler. An
18-gauge 100-mm insulated Tuohy needle and a 20-gauge 50-mm
polyamide catheter (open tip) with a Teflon-coated steel stylet (B.
Braun, Bethlehem, PA) were customized by adhering in place two
piezoelectric actuators. These created 1–8 kHz vibrations when
coupled to a function generator (FG502, Tektronix, Richardson, TX)
and a 100 W audio amplifier (R3000, KLH, Sun Valley, CA). Mimicking
a lateral popliteal fossa block, the needle and catheter were inserted
into the leg of an unembalmed cadaver. When activated, the tip of
each was highlighted in color when scanned in the short axis using
the color Doppler mode of a two-dimensional ultrasound and a 12 MHz
L38 probe (MicroMaxx, Sonosite, Bothell, WA). Vibration technology
may be a useful adjunct while performing ultrasound-guided regional
anesthesia. Further study evaluating its usefulness and safety in
live tissue is warranted.
氯胺酮不增加肺动脉高压儿童在自主呼吸行七氟醚麻醉时的肺血管阻力
Ketamine Does Not Increase Pulmonary Vascular Resistance in
Children with Pulmonary Hypertension Undergoing Sevoflurane Anesthesia and Spontaneous
Ventilation
Glyn D. Williams, Bridget M. Philip, Larry F. Chu, MD, M. Gail
Boltz, Komal Kamra, Heidi Terwey, Gregory
B. Hammer, Stanton B. Perry, Jeffrey A. Feinstein, Chandra
Ramamoorthy
From the *Department of Anesthesia, Stanford School of Medicine, and
_files/image081.gif){kind=small}
Department
of Pediatrics, Division of Pediatric Cardiology, Stanford School of Medicine,
Stanford University, Stanford, California.
Anesth Analg 2007;105:1578 –84
背景：在肺血管阻力增高的儿童中使用氯胺酮是存在争议的。在此次前瞻性、空开标签的研究中，我们评估了肺动脉高压儿童（平均肺动脉压力＞25mmHg）的血流动力学对于氯胺酮的反应。
方法：参予研究的是年龄在3个月至18岁，预约了在全麻下行心导管检查的肺动脉高压患儿。病人通过面罩自主呼吸含1.0MAC七氟醚的空气进行麻醉。在心导管测量完基础值后，七氟醚下调至0.5MAC，并注入氯胺酮(2 mg/kg IV over 5 min),随之以维持剂量(10ug/kg/min)。在氯胺酮负荷剂量输注完成后的5、10、15分钟分别重复心导管测量，并将不同时间的数据进行比较（ANOVA，P＜0.05）。
结果：研究包含了15例病人（年龄在108－147个月），其中包括：原发性肺动脉高压（5例），先天性心脏病（9例），膈疝（1例）。肺血管阻力指数在基础值的中位数是11.3Wood单位。33％的病人有高于系统平均值的肺动脉压力。心率（99，94此/分，P＝0.016）及PaO2（95，104mmHg，P＝0.07）在氯胺酮给药后发生改变（基础值，氯胺酮给药后15分钟值，P值）。在平均全身动脉压、平均肺动脉压、全身或肺血管阻力指数、心排指数、动脉pH和PaO2间无明显差异。
结论：在七氟醚的共同作用下，氯胺酮并不增加自主呼吸的肺动脉高压儿童的肺血管阻力。
（陈佳丽译，薛张纲校）
BACKGROUND: The use of ketamine in children with increased pulmonary
vascular
resistance is controversial. In this prospective, open label study,
we evaluated thehemodynamic responses to ketamine in children with pulmonary
hypertension(mean pulmonary artery pressure _25 mm Hg).
METHODS: Children aged 3 mo to 18 yr with pulmonary hypertension,
who were
scheduled for cardiac catheterization with general anesthesia, were
studied.
Patients were anesthetized with sevoflurane (1 minimum alveolar
anesthetic
concentration [MAC]) in air while breathing spontaneously via a
facemask. Afterbaseline catheterization measurements, sevoflurane was reduced
(0.5 MAC) andketamine (2 mg/kg IV over 5 min) was administered, followed by a
ketamineinfusion (10 _g _ kg_1 _ min_1). Catheterization measurements were
repeated at 5,10, and 15 min after completion of ketamine load. Data at various
time points werecompared (ANOVA, P _ 0.05).RESULTS:
Fifteen patients (age 147, 108 mo; median, interquartile range) were
studied.Diagnoses included idiopathic pulmonary arterial hypertension (5),
congenital heartdisease (9), and diaphragmatic hernia (1). At baseline, median
(interquartile range)baseline pulmonary vascular resistance index was 11.3
(8.2) Wood units; 33% ofpatients had suprasystemic mean pulmonary artery
pressures. Heart rate (99, 94 bpm;P _ 0.016) and
Pao2 (95, 104 mm Hg; P _ 007) changed after
ketamine administration(baseline, 15 min after ketamine; P value). There were no significant differences in mean systemic
arterial blood pressure, mean pulmonary artery pressure, systemic orpulmonary
vascular resistance index, cardiac index, arterial pH, or Paco2.CONCLUSIONS: In
the presence of sevoflurane, ketamine did not increase pulmonaryvascular
resistance in spontaneously breathing children with severe pulmonary hypertension.
活性氧介导七氟醚和地氟醚诱导预处理在人离体右心房心肌保护作用
Reactive Oxygen
Species Mediate Sevoflurane- and Desflurane-Induced Preconditioning in Isolated
Human Right Atria In Vitro
Jean-Luc
Hanouz, MD, PhD*, Lan Zhu, MD_files/image082.gif){kind=small}
, Sandrine Lemoine, BSc_files/image083.gif){kind=small}
, Charline Durand, BSc_files/image084.gif){kind=small}
, Olivier Lepage, MD_files/image085.gif){kind=small}
, Massimo Massetti, MD, PhD_files/image086.gif){kind=small}
, André Khayat, MD_files/image087.gif){kind=small}
, Benoît Plaud, MD, PhD*, and Jean-Louis
Gérard, MD, PhD*
From the *Department of Anesthesiology; _files/image088.gif){kind=small}
Laboratory
of Experimental Anesthesiology and Cellular Physiology; and _files/image089.gif){kind=small}
Department
of Cardiac and Thoracic Surgery, CHU Caen, France.
Anesth Analg 2007; 105:1534-1539
背景：活性氧介导七氟醚和地氟醚诱导预处理在人离体右心房心肌保护作用。方法：我们记录右心房小梁在充氧短杆菌素溶液中的等长收缩（34°C，刺激频率1HZ）。在所有组中，都是一个30分钟的缺氧期和60分钟再充氧。在缺氧再充氧前10分钟，肌肉暴露在2％七氟醚或6％地氟醚中5分钟。在单独组中，2％七氟醚＋氮-甘氨酸或6％地氟醚＋氮-甘氨酸中都加入0.1mM氮-甘氨酸MPG（一种活性氧清除剂）。0.1mM氮-甘氨酸单独作用的效果也被测试，比较组与组间60分钟再氧合后复苏的力量。（平均数± 标准差）结果：2％七氟醚（85% ± 4%）或6％地氟醚（86% ± 7%）预处理与对照组相(56% ± 12%）比增加心肌细胞收缩力（P<0.001），这种作用在加入MPG后消失（七氟醚56% ± 12%，地氟醚48% ± 13%）。MPG单独使用组与对照组没有差别（57% ± 7%比53% ± 11%）总结：在离体试验中，七氟醚合地氟醚预处理人心肌细胞，使心肌细胞对缺氧的产生耐受是通过活性氧机制。
（陈恺铮译 薛张刚校）
BACKGROUND: We
examined the role of reactive oxygen species (ROS) in sevoflurane- and
desflurane-induced preconditioning on isolated human right atrial myocardium.METHODS:
We recorded isometric contraction of human right
atrial trabeculae suspended in an oxygenated Tyrode’s solution (34°C,
stimulation frequency 1 Hz). In all groups, a 30-min hypoxic period was
followed by 60 min of reoxygenation. Ten minutes before hypoxia reoxygenation,
muscles were exposed to 5 min of sevoflurane 2% or desflurane 6%. In separate
groups, the sevoflurane 2% (Sevo + N-(2-mercaptopropionyl)-glycine
[MPG]) or desflurane 6% (Des + MPG) was administered in the presence of 0.1 mM
MPG, a ROS scavenger. The effect of 0.1 mM MPG alone was tested. Recovery of
force after a 60-min reoxygenation period was compared between groups (mean ±
sd). RESULTS: Preconditioning with sevoflurane
2% (85% ± 4% of baseline) or desflurane 6% (86% ± 7% of baseline) enhanced the
recovery of the force of myocardial contraction after 60 min reoxygenation
compared with the control group (53% ± 11% of baseline, P < 0.001). This effect was abolished in the presence of MPG (56%
± 12% of baseline for Sevo + MPG, 48% ± 13% of baseline for Des + MPG). The
effect of MPG alone on the recovery of force was not different from the control
group (57% ± 7% of baseline versus 53% ± 11%; P
= NS).CONCLUSIONS: In vitro, sevoflurane and desflurane preconditioned human myocardium against
hypoxia through a ROS-dependent mechanism.
The
Usefulness of an Earphone-Type Infrared Tympanic Thermometer for Intraoperative
Core Temperature Monitoring
Tomohiro Kiya, Michiaki Yamakage, Tomo
Hayase, Jun-Ichi Satoh, and Akiyoshi
Namiki
From the Department of Anesthesiology,
Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan.
Anesth Analg.
2007 Dec;105(6):1688-92,
背景：在这个研究中，我们想要确认新型的耳机式红外线鼓膜测温仪（IRT）在术中监测核心体温的有效性。方法：两组病人在不同的手术条件下进行研究。第一组包括18名在全麻下择期手术的成年病人（ASA评级I－II），麻醉诱导前，耳机式IRT被放置在左耳道或右耳道，麻醉中监测鼓膜温度和直肠以及食道温度。第二组包括择期行体外循环下的心外科手术病人18名（ASA评级II－III）。和第一组一样，在降温和复温过程中用IRT监测鼓膜温度，同时行直肠和食道温度监测。结果：实验组一：用IRT测得的平均体温（±2个标准差）比食道温度高了0.08℃（±0.34℃），比直肠温度高了0.11℃（±0.55℃）。实验组二：在体外循环的降温和复温过程中用IRT测得的平均体温（±2个标准差）比食道温度高了0.72℃（±2.2℃）。结论：在术中用耳机式IRT在临床中用于连续检测核心体温是可靠的。
(施杨译,薛张纲校)
BACKGROUND:
In this study we sought to determine the usefulness of a novel earphone-type
infrared tympanic thermometer (IRT) for core temperature monitoring during
surgery. METHODS: Two groups of patients were studied under different surgical
conditions. The first group consisted of 18 adult patients (ASA I or II) who
had been scheduled for elective surgery under general anesthesia. Before
induction of general anesthesia, an earphone-type IRT was inserted into either
the left or right ear canal. Tympanic temperature was monitored and recorded
along with both rectal and esophageal temperatures during anesthesia. The
second group consisted of eight adult patients (ASA II or III) who had been
scheduled for cardiac surgery with cardiopulmonary bypass. Similar to the first
group, tympanic temperature was measured by the earphone-type IRT and recorded
along with the rectal and esophageal temperatures during cooling and rewarming
phases of cardiopulmonary bypass. RESULTS: Study 1-The average temperature
(+/-2 sd) measured with the IRT was +0.08 degrees C (+/-0.34 degrees C) above
the esophageal temperature, and that with the rectal temperature was +0.11
degrees C (+/-0.55 degrees C) above the esophageal temperature. Study 2-The
average temperature (+/-2 sd) measured with the IRT was +0.72 degrees C (+/-2.2
degrees C) above the esophageal temperature during cooling and warming phases
during cardiac surgery with cardiopulmonary bypass. CONCLUSIONS: The
earphone-type IRT might be used in a clinical setting for reliable and
continuous core temperature monitoring during an operation.
The Influence of Race and
Socioeconomic Factors on Patient Acceptance of Perioperative Epidural Analgesia
Edward Andrew Ochroch, MD, MSCE*, Andrea B.
Troxel, ScD_files/image090.gif){kind=small}
,
Jonathan K. Frogel, MD_files/image091.gif){kind=small}
,
and John T. Farrar, MD, PhD_files/image092.gif){kind=small}
From the *Department of Anesthesiology and
Critical Care, University of Pennsylvania Health System; _files/image093.gif){kind=small}
Center
for Clinical Epidemiology and Biostatistics, University of Pennsylvania; _files/image094.gif){kind=small}
Henry
Ford Hospital, Detroit, Michigan; and _files/image095.gif){kind=small}
Center
for Clinical Epidemiology and Biostatistics, University of Pennsylvania,
Pennsylvania.
Anesth Analg 2007 105:1787-1792.
背景：尽管证据显示对患者有利，但是少数民族和社会经济状况较低的患者可能较非少数民族和社会经济状况较高的患者更为抵触硬膜外镇痛。
方法：一个专家小组基于2000年美国人口普查进行了电话调查记录。在超过四个时间节点上对宾西法尼亚大学附属医院的所有手术病人至少联系两次。
结果：致电3739名患者，与其中1265名患者取得了联系并有1193人接受了调查，72人拒绝参与。762人（64％）表示如果麻醉师推荐的话会接受的硬膜外操作，425人（36％）表示拒绝。如果麻醉师和外科医生都推荐硬膜外的话接受者会增加到932人（78.5％）。拒绝围术期硬膜外镇痛的单变量预测因素是美籍非裔。接受的单变量预测因素是有全职或兼职工作者，总家庭收入>$50,001/每年，大学毕业学历，曾接受硬膜外治疗和了解硬膜外知识。当把种族、总家庭收入、职业和教育背景混合于同一多变量对数回归模型时，美籍非裔是一个预计拒绝的因素，（优势比为0.58，P < 0.006，可信区间为0.41–0.81）并且是唯一的拒绝或接受硬膜外镇痛的预计因素。
结论：围术期是否接受硬膜外镇痛主要受种族和社会经济状况的影响。当麻醉师尽力改善患者预后和舒适度的时候必需考虑到这一潜在的障碍。
（王时来译 薛张纲校）
BACKGROUND: Ethnic minorities and patients
of lower socioeconomic status may be more averse to the acceptance of epidural
analgesia than nonminority counterparts and those of higher socioeconomic
status, despite evidence for substantial benefit to the patient. METHODS: A
scripted telephone survey was developed from the 2000 United States Census by a
panel of experts. Contact was attempted at least twice for all patients listed
for surgery at the Hospital of the University of Pennsylvania over a 4-mo
period. RESULTS: Three thousand seven hundred thirty-nine patients were called
and 1265 subjects were successfully contacted and 1193 consented, whereas 72
refused to participate. Seven hundred sixty-two subjects (64%) would accept an
epidural if recommended by an anesthesiologist and 425 (36%) would refuse. If
the epidural was recommended by both the anesthesiologist and surgeon
acceptance increased to 932 (78.5%). The univariate predictor of refusal of
perioperative epidural analgesia was African American race. Univariate
predictors of acceptance include full- or part-time employment, total household
income >$50,001/yr, college graduate, prior epidural treatment, and
knowledge of what an epidural is. When the potential confounders of race, total
household income, employment, and education were included in a multivariate
logistic regression model, African American race predicted refusal (odds ratio
[OR], 0.58; P < 0.006; confidence interval [CI], 0.41–0.81) and was the only
factor that predicted refusal or acceptance of epidural analgesia. CONCLUSIONS:
Acceptance of perioperative epidural analgesia is strongly affected by race and
socioeconomic status. Anesthesiologists need to recognize this potential
barrier when trying to maximize patient comfort and outcome.
新式含氧饱和度探头中心静脉导管用于小儿心脏手术的试验和临床性评价
An experimental and clinical evaluation
of a novel central venous catheter with integrated oximetry for pediatric
patients undergoing cardiac surgery.
Liakopoulos OJ, Ho JK, Yezbick A, Sanchez
E, Naddell C, Buckberg GD, Crowley R, Mahajan A.
Department of Cardiothoracic Surgery, David
Geffen School of Medicine, University of California, Los Angeles, California
90095, USA.
Anesth Analg 2007 105: 1598-1604.
背景：中心静脉氧饱和度(ScvO2)精确反映心脏循环功能，但在小儿患者并不总是可行的。通过试验和临床性方法，我们运用一种新式含纤维光学氧饱和度探头的中心静脉导管监测围手术期必需的ScvO2及检测在小儿心脏手术中的可行性。
方法：在5只已麻醉的猪上，血流动力学（心脏指数[CI],心率，平均动脉压[MAP]，平均肺动脉压[MPAP]，中心静脉压[CVP]），纤维光学ScvO2 (ScvO2-cath)和血气氧饱和度(ScvO2-blood)将在稳定基础状态、前负荷减少（腔静脉阻断）和多巴胺输注(5 mcg x kg(-1) x min(-1))状态下监测。在15名小儿心脏手术患者（中位年龄8.4月，体重8.0 kg）中 ，含氧饱和度探头中心静脉导管经皮放置，ScvO2-cath和血流动力学在术中及术后24 h的时间点将被检测。氧饱和度和血流动力学数据将被检验相关性(Pr)和Bland-Altman分析。结果：无导管相关的并发症。ScvO2-cath和ScvO2-blood的检测结果具有显著(P < 0.001)相关性：试验组(Pr = 0.96)，临床组(Pr = 0.94)。在两方案中的所有时间点的相似偏倚和精确度被检验（试验组偏倚: +0.03% +/- 4.11%;临床组偏倚: -0.03% +/- 4.41%)。ScvO2-cath与CI (Pr = 0.87), MAP (Pr = 0.59), MPAP (Pr = 0.44)和 CVP (Pr = 0.38)的相关性(P <
0.001)好与MAP (Pr = 0.61), MPAP (Pr = 0.38), CVP (Pr = 0.35)或 heart rate (Pr
= 0.25)。结论：在小儿心脏手术中新式含氧饱和度探头中心静脉导管提供了精确持续的ScvO2检测管理。ScvO2纤维光学氧饱和度与CI的变化的相关性比常规血流动力学变化更好。
（陈勇柱译 薛张刚校）
BACKGROUND: Central venous oxygen
saturation (ScvO2) accurately reflects cardiocirculatory function, but is not
always feasible in pediatric patients. Using an experimental and clinical
approach, we determined the accuracy of a novel pediatric central venous
catheter with integrated fiberoptic oximetry, correlated ScvO2 to
periprocedural vital variables, and tested its feasibility in pediatric cardiac
surgery patients. METHODS: In five anesthetized pigs, hemodynamics (cardiac
index [CI], heart rate; mean arterial blood [MAP]; mean pulmonary artery
[MPAP], central venous pressure [CVP]), fiberoptic ScvO2 (ScvO2-cath), and
blood gas oximetry (ScvO2-blood) were measured during stable baseline
conditions, preload reduction (caval occlusion), and dopamine infusion (5 mcg x
kg(-1) x min(-1)). In 16 pediatric patients undergoing cardiac surgery (median
age 8.4 mo; weight 8.0 kg), central venous oximetry catheters were placed
percutaneously, and ScvO2-cath and hemodynamics recorded at several time-points
during and until 24 h after surgery. Oximetry and hemodynamic data were
compared by correlation (Pr) and the Bland-Altman analysis. RESULTS: There were
no catheter-related complications. ScvO2-cath and ScvO2-blood measurements
correlated significantly (P < 0.001) in both the experimental (Pr = 0.96)
and clinical protocol (Pr = 0.94). A similar bias and precision over all
time-points was detected in both protocols (Exp-bias: +0.03% +/- 4.11%;
Clinical-bias: -0.03% +/- 4.41%). ScvO2-cath correlated (P < 0.001) with CI
(Pr = 0.87), MAP (Pr = 0.59), MPAP (Pr = 0.44), and CVP (Pr = 0.38) and
estimated CI better than MAP (Pr = 0.61), MPAP (Pr = 0.38), CVP (Pr = 0.35), or
heart rate (Pr = 0.25). CONCLUSION: Integrated central venous oximetry
catheters provide accurate continuous ScvO2 monitoring in pediatric patients
undergoing cardiac surgery. ScvO2 fiberoptic oximetry correlates better with
changes in CI as compared to routine hemodynamic variables.
骶骨背侧角神经元的痛觉域值的时间空间决定因素与异氟醚诱导的制动性的关系
Temporal and Spatial Determinants of
Sacral Dorsal Horn Neuronal Windup in Relation to Isoflurane-Induced Immobility
Robert C. Dutton, MD*, Jason M. Cuellar,
PhD, Edmond I. Eger, II, MD*, Joseph F. Antognini, MD, and Earl Carstens, PhD
From the *Department of Anesthesia and
Perioperative Care, University of California, San Francisco; _files/image096.gif){kind=small}
Department
of Anesthesia, Stanford University School of Medicine; _files/image097.gif){kind=small}
Department
of Anesthesiology and Pain Medicine; and _files/image098.gif){kind=small}
Section
of Neurobiology, Physiology and Behavior, University of California, Davis,
California.
Anesth Analg 2007 105: 1665-1674.
背景：痛觉域值是骶骨背侧神经元对C-纤维重复性刺激的累加性疼痛反应。我们调查域值的强度和频率依赖性，及异氟醚的NMDA受体阻滞作用，来决定异氟醚对其他麻醉药物在痛觉抑制上有无协同作用。方法：我们对20组老鼠的骶骨背侧神经元给于不同频率（0.3-10hz）不同强度（0.8-5刺激阈）的电刺激，此时肺泡气的异氟醚浓度为0.7-1.3。累计反应（曲线下面积），起始反应，和绝对阈值（曲线下面积减去二十次的起始反应），并计算阈值的斜率。结论：增加刺激强度和频率可以逐渐增加曲线下面积，制动性也与肺泡气的浓度需要量有关。增加异氟醚的肺泡气浓度可以显著抑制低强度和低频率刺激的痛觉域值，但对高强度高频率的刺激并无明显作用。NMDA受体阻滞剂MK801可明显降低痛觉域值1Hz.结论：骶骨背角神经元的疼痛阈值在低刺激强度和频率下增加了异氟醚的需要量，可能与NMDA受体依赖性机制有关。 在高刺激频率和强度下，异氟醚则需要联用大量其他麻醉药来达到制动性。
（秦 佳译，薛张刚校）
BACKGROUND: Windup
is a progressive increase in response of dorsal horn neurons to repetitive
C-fiber stimulation that may underlie temporal
summation of pain. We investigated the frequency- and intensity-dependency of windup, and the effects of isoflurane and N-methyl-d-aspartate
(NMDA) receptor blockade, to determine if they parallel the influence of temporal and spatial summation of noxious stimuli on anesthetic
requirements. METHODS: We recorded responses of
rat sacral dorsal horn neurons to 20-s trains of electrical tail stimulation at
different frequencies (0.3–10 Hz) and
intensities (0.8–5 x stimulus threshold) during delivery of 0.7 to 1.3 minimum
alveolar anesthetic concentration isoflurane. Summed responses (area under the
curve [AUC] windup), initial response, absolute windup (AUC minus 20 times the
initial response), and
slope of windup were quantified. RESULTS: Increases
in stimulus intensity and
frequency progressively increased AUC windup (P
< 0.01 for both) and
correlated with isoflurane concentrations required for immobility (R2 = 0.98 and
0.97, respectively). Increasing the isoflurane concentration significantly
suppressed each measure of windup elicited by low-intensity and low-frequency, but not high-intensity
and high-frequency
stimulus trains. The initial response magnitude significantly correlated with
slope of windup across stimulus intensities and isoflurane concentrations. The NMDA receptor
antagonist MK801 significantly reduced windup (to 53%; P < 0.05) at 1 Hz. CONCLUSION: Windup of dorsal horn neurons at
low stimulus intensities and
frequencies increases isoflurane requirements for immobility via a NMDA
receptor-dependent mechanism. At high stimulus intensities and frequencies, windup was resistant
to isoflurane consistent with larger anesthetic requirements for immobility.
依托咪酯的麻醉效应：种族特异性的与_files/image099.gif){kind=small}
2-肾上腺素能受体的相互作用
The Anesthetic Effects of Etomidate: Species-Specific
Interaction with _files/image100.gif){kind=small}
2-Adrenoceptors
Andrea Paris, MD*, Lutz Hein, MD_files/image101.gif){kind=small}
,
Marc Brede, MD_files/image102.gif){kind=small}
,
Philipp-Alexander Brand, MD*, Jens Scholz, MD*, and Peter H. Tonner, MD*
From the *Department of Anaesthesiology and
Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel,
Kiel; _files/image103.gif){kind=small}
Institute
of Experimental and Clinical Pharmacology and Toxicology, University of
Freiburg, Freiburg im Breisgau; and _files/image104.gif){kind=small}
Department
of Anaesthesia and Critical Care, University of Wuerzburg Hospitals, Wuerzburg,
Germany.
Anesth Analg 2007 105: 1644-1649.
背景：在静脉麻醉药中，依托咪酯在结构和临床上和_files/image105.gif){kind=small}
2肾上腺素能受体激动剂如右旋美托咪啶相似。我们研究依托咪酯的镇静效应是否由_files/image106.gif){kind=small}
2肾上腺素能受体介导。方法：在非洲爪蛙蝌蚪，使用和不使用_files/image107.gif){kind=small}
2肾上腺素能受体拮抗剂阿替咪唑，判定依托咪酯的麻醉效能（1–20 µM）。正向反射消失确定了感觉缺失。通过非线性对数回归曲线，获得数据，计算半数最大有效浓度和曲线的斜率。此外，在野生型(WT)小鼠上和携带_files/image108.gif){kind=small}
2A肾上腺素能受体缺失基因(_files/image109.gif){kind=small}
2A-KO)的小鼠，依托咪酯的镇静、催眠作用(8
mg/kg IP)通过旋转试验研究。统计了平均数±标准差。结果：麻醉的蝌蚪的数量随着依托咪酯浓度增加而增加。阿替美唑明显增加了依托咪酯半数最大有效浓度，从（4.5±0.2 µM；斜率:2.6±0.3) 变为8.4±0.4 µM (斜率:2.3 ±0.3)。依托咪酯在所有的小鼠中都表现出时间依赖的镇静效应，通过旋转试验评估。在WT小鼠中，依托咪酯的镇静效应没有因为阿替美唑(2 mg/kg)的使用降低。同样的是，与WT小鼠相比，(_files/image110.gif){kind=small}
2A-KO)的小鼠身上依托咪酯的镇静作用也没有降低。结论：依托咪酯的镇静效应表现为种族特异性的与a2肾上腺素能受体相互作用。尽管在非洲爪蛙蝌蚪身上，依托咪酯的镇静效应因为阿替美唑降低，但在小鼠中表现为依托咪酯的镇静效应非_files/image111.gif){kind=small}
2肾上腺素能受体介导的
（陈珺珺译 薛张纲校）
BACKGROUND: The IV
anesthetic, etomidate, has structural and clinical similarities to specific _files/image113.gif){kind=small}
2-adrenoceptor
agonists such as dexmedetomidine. We investigated whether the sedative effects
of etomidate may be mediated by _files/image114.gif){kind=small}
2-adrenoceptors.
METHODS: The anesthetic potency of etomidate
(1–20 µM) was determined in Xenopus laevis
tadpoles in the absence and presence of the specific _files/image115.gif){kind=small}
2-adrenoceptor
antagonist atipamezole (10 µM). Anesthesia was defined as loss of righting
reflex. Nonlinear logistic regression curves were fitted to the data and
half-maximal effective concentrations and the slopes of the curves were
calculated. Additionally, sedative/ hypnotic effects of etomidate (8 mg/kg IP)
were studied by rotarod test in wild-type (WT) mice and mice carrying targeted
deletions of the _files/image116.gif){kind=small}
2A-adrenoceptor
gene (_files/image117.gif){kind=small}
2A-KO).
Data are presented as mean ± sem. RESULTS: The
fraction of anesthetized tadpoles increased with increasing concentrations of
etomidate. Atipamezole significantly increased the half-maximal effective
concentration of etomidate (4.5 ± 0.2 µM; slope: 2.6 ± 0.3) to 8.4 ± 0.4 µM
(slope: 2.3 ± 0.3). Etomidate resulted in time-dependent sedative effects in
all mice, as assessed by rotarod performance. In WT mice, the sedative effects
of etomidate were not decreased by atipamezole (2 mg/kg). Consistently,
etomidate-induced sedation was not reduced in _files/image118.gif){kind=small}
2A-KO
animals compared with WT mice. CONCLUSIONS: The
sedative effects of etomidate exhibit a species-specific interaction with _files/image119.gif){kind=small}
2-adrenoceptors.
Although the decrease in potency of etomidate by atipamezole may be caused by
an interaction with _files/image120.gif){kind=small}
2-adrenoceptors
in X. laevis tadpoles, results in mice indicate
that the hypnotic effect of etomidate does not require _files/image121.gif){kind=small}
2-adrenoceptors.
Society for Ambulatory Anesthesia
guidelines for the management of postoperative nausea and vomiting.
Gan TJ, Meyer TA, Apfel CC, Chung F, Davis
PJ, Habib AS, Hooper VD, Kovac AL, Kranke P, Myles P, Philip BK, Samsa G,
Sessler DI, Temo J, Tramèr MR, Vander Kolk C, Watcha M; Society for Ambulatory
Anesthesia.
Department of Anesthesiology, Duke
University Medical Center, Durham, North Carolina 27710, USA.
Anesth Analg. 2007 105(6):1615-28, table of
contents.
该指南是在门诊麻醉协会发起下，由一个跨学科的国际性小组编纂而成，小组的成员都关注术后恶心呕吐（PONV）且为这方面的专家。这个小组批判性地评价了当前有关PONV的医学文献，为处理PONV高危的成人和儿童提供了一套有证据支持的方案。概况说来，该指南鉴别出成人和儿童发生PONV的高危因素；推荐了减少PONV基线发生率的措施；评定出预防PONV最有效的单一和联合治疗方法；推荐了PONV发生时的处理程序；提供了管理PONV高危个体的运算法则。
（罗 璇译 薛张纲校）
The present guidelines were compiled by a
multidisciplinary international panel of individuals with interest and
expertise in postoperative nausea and vomiting (PONV) under the auspices of The
Society of Ambulatory Anesthesia. The panel critically evaluated the current
medical literature on PONV to provide an evidence-based reference tool for the
management of adults and children who are undergoing surgery and are at
increased risk for PONV. In brief, these guidelines identify risk factors for
PONV in adults and children; recommend approaches for reducing baseline risks
for PONV; identify the most effective antiemetic monotherapy and combination
therapy regimens for PONV prophylaxis; recommend approaches for treatment of
PONV when it occurs; and provide an algorithm for the management of individuals
at increased risk for PONV.
Needlestick distal nerve injury in rats
models symptoms of complex regional pain syndrome.
Sandra M. Siegel,
Jeung W. Lee, and Anne L. Oaklander
Department of Neurology, Massachusetts
General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
Anesth Analg 2007 105: 1820-1829.
背景：局部疼痛症候群由慢性肢体疼痛和有时候看起来似乎微不足道的由外伤引起的家族性自主神经异常组成。一些病理学方面的研究已经证实了局部疼痛症候群患者中发现有较小的末梢神经损伤，但在回顾性研究当中却不能建立因果关系。因此，我们预想末梢神经损伤是否可以引起局部疼痛症候群类似于动物畸形。我们利用针刺，是人类局部疼痛症候群的一个原因，来评价损害的效果。方法：分别用30号，22号，和18号的针刺穿雄性的SD小鼠的左侧胫神经。非手术和佯装手术的老鼠作为对照。测量后爪的功能，浮肿和姿态。结果：手术后的七天，测量同侧后爪收缩的最大极限，S-W单纤维丝减少>=51％的在佯装手术治疗的组中为0％，在18号穿刺针组中为67%，在22号针刺组中为88％，30号针刺组中为89％。57％的所有针刺老鼠都有对侧后爪“镜像”表现。这种保护机制的普遍性和严重性显示了其对伤害的独立性。对脚底寒冷和针刺刺激引起的疼痛反应并不普遍而且只有同侧的疼痛反应，因为后爪出现了神经性水肿。同侧后爪姿态出现强直在18号针刺组中为42％
(张俪译 薛张纲校)
BACKGROUND: Complex
Regional Pain Syndrome (CRPS)-I consists of chronic limb pain and dysautonomia
triggered by traumas that sometime seem too trivial to be causative. Several
pathological studies have identified minor distal nerve injuries (DNIs) in
CRPS-I patients, but retrospective studies cannot establish causality.
Therefore, we, prospectively investigated whether DNIs are sufficient to cause
CRPS-like abnormalities in animals. We used needlestick, a cause of human CRPS,
to evaluate lesion-size effects. METHODS: Left tibial nerves of male
Sprague–Dawley rats were transfixed once by 30G, 22G, or 18G needles.
Unoperated and sham-operated rats provided controls. Hindpaw sensory function,
edema, and posture were measured. RESULTS: At Day-7 postoperatively, thresholds
for ipsilateral-hindpaw withdrawal from Semmes–Weinstein monofilaments were
reduced by _files/image123.gif){kind=small}
51%
in 0% of sham-operated controls; 67% of rats that received 18G-DNI, 88% that
received 22G-DNI, and 89% that received 30G-DNI. Fifty-seven percent of all DNI
rats had contralateral hindpaw "mirror" changes. The prevalence and
severity of allodynia appeared independent of lesion size. Hyperalgesic responses
to cold and pinprick applied to the plantar hindpaw were less common and were
ipsilesional only, as was neurogenic hindpaw edema. Ipsilesional-only, tonic,
dystonic-like hindpaw postures were evident in 42% of 18G-DNI, 6% of 22G-DNI,
and no 30G-DNI or sham-operated control rats. The prevalence of postural
abnormalities correlated with needle diameter (P
= 0.001). Counting protein gene product 9.5-immunolabeled axons in skin
biopsies from rats’ ipsilesional hindpaws demonstrated mean reductions of 0%
after 30G-needlestick, 15% after 22G-needlestick, and 26% after
18G-needlestick, which closely reproduces the 29% mean epidermal neurite losses
of CRPS-I patients. CONCLUSIONS: Needlestick DNI
models several clinical and pathological features of human CRPS and provides
direct prospective evidence that even minor DNI can cause CRPS-like
abnormalities in rats.
A Bibliometric Analysis of Global
Clinical Research by Anesthesia Departments
Madhav Swaminathan, MD, FASE, FAHA, Barbara
G. Phillips-Bute, PhD, and Katherine P. Grichnik, MD, FASE
From the Division of Cardiothoracic Anesthesiology
and Critical Care Medicine, Department of Anesthesiology, Duke University Medical
Center, Durham, North Carolina.
Anesth. Analg.
2007 105: 1741-1746.
背景：为数不多的研究调查过麻醉基础的研究员从事研究的多样性。我们用Medline和Ovid数据库检测了属于麻醉科的全球临床研究。我们同时也研究了经济发展对学术发展的影响。方法：我们使用Medline检索了2000到2005的英文出版物。仅检测临床研究，其中学术联盟包括与麻醉相关的词汇（比如麻醉学，麻醉等）。同时从公开可及的资料中获取人口数量和粗略国家收入数据。杂志的影响因素从杂志引用报告中获取。结果：总共检索出了6736篇文章包括64个国家的551种杂志。全部文章中的85%被发表在了46种杂志上。随即对照实验构成了4685（70%）的出版物。土耳其的随机对照实验占的百分比是最高的为88%。美国占有最大的比例（总量的20%）以及平均出版刊物的影响因素（3.0）。结论：属于研究者的临床研究是多样的，其超越了传统领域的麻醉和重症监护。美国创造了最多的临床研究，但是按照每个人口算却是欧洲国家更高。
(王光妍译 薛张纲校)
BACKGROUND: Few
studies have investigated the diversity in research conducted by anesthesia-based
researchers. We examined global clinical research attributed to anesthesia departments
using Medline® and Ovid® databases. We also investigated the impact of economic
development on national academic productivity.METHODS: We conducted a Medline
search for English-language publications from 2000 to 2005. The search included
only clinical research in which institutional affiliation included words relating
to anesthesia (e.g., anesthesiology, anesthesia, etc.). Population and gross national
income data were obtained from publicly available databases. Impact factors for
journals were obtained from Journal Citation Reports (Thomson Scientific).RESULTS:
There were 6736 publications from 64 countries in 551 journals. About 85% of all
publications were represented by 46 journals. Randomized controlled trials
constituted 4685 (70%) of publications. Turkey had the highest percentage of randomized
controlled trials (88%). The United States led the field in quantity (20% of
total) and mean impact factor (3.0) of publications. Finland had the highest
productivity when adjusted for population (36 publications per million population).
Publications from the United States declined
from 23% in 2000 to 17% in 2005.CONCLUSIONS: Clinical research attributable to
investigators in our specialty is diverse, and extends beyond the traditional
field of anesthesia and intensive care. The United States produces the most clinical
research, but per capita output is higher in European nations.
Thoracic paravertebral block for breast
cancer surgery: a randomized double-blind study.
Jytte F. Moller, Lone Nikolajsen, Svein
Aage Rodt, Hanne Ronning, and Palle S. Carlsson
Department of Anesthesiology, Aarhus
University Hospital, Denmark
Anesth Analg 2007 105:1848-51
背景：在这项随机、双盲试验中，我们测验在使用异丙酚和喉罩进行全身麻醉前完成多极胸段脊柱周围阻断是否能增强书后阵痛作用。方法：88名患者随机在脊柱旁注射0.5%罗哌卡因（30ml）或者等量的等张生理盐水。9名患者被排除出去，剩下79名患者进行评估。（罗哌卡因，n = 38；安慰剂，n = 41)。不同的效果体现在病人在苏醒室内使用患者自控阵痛需求的芬太尼的总量，以及术后当天至术后第二天固定的间隔时间内用数值来评价疼痛指数。结果：罗哌卡因组较之安慰剂组，患者在苏醒室内消耗的芬太尼总量的中位数小。（0微克[范围：0-250微克]vs100微克[范围：0-800微克]，P = 0.001)。同样的，在苏醒室内，罗哌卡因组较之安慰剂组较少的病人疼痛指数〉=3（13 vs 31，P < 0.0001)。在离开苏醒时候，无论是疼痛平分还是阵痛药的消耗量都没有统计学上的差异。结论：多级脊柱周围阻断能为乳腺手术提供良好的阵痛效果，但是持续的时间要比之前的报告短暂。
（周时蓓译，薛张纲校）
BACKGROUND:
We examined in this randomized, double-blind study whether a multilevel
paravertebral block performed before general anesthesia with propofol and a
laryngeal mask enhances postoperative analgesia after breast cancer surgery.
METHODS: Eighty-eight patients were randomized to receive paravertebral
injections with either ropivacaine 0.5% (30 mL) or an equivalent amount of
isotonic saline. Nine patients were excluded after randomization, thus 79
patients remained for evaluation (ropivacaine, n = 38; placebo, n = 41).
Variables of efficacy were the amount of fentanyl delivered by the
patient-controlled analgesia device in the postanesthesia care unit (PACU),
postoperative pain measured on a numeric rating scale at regular intervals from
the day of surgery and until the second postoperative day. RESULTS: The median
consumption of fentanyl in the PACU was less in the ropivacaine group compared
with the placebo group (0 microg [range: 0-250 microg] versus 100 microg [range:
0-800 microg], P = 0.001). Also, fewer patients in the ropivacaine group
reported pain > or =3 on the numbers rating scale in the PACU (13 vs 31, P
< 0.0001). No statistical difference in pain scores or consumption of
analgesics could be demonstrated after discharge from the PACU. CONCLUSIONS: A
multilevel paravertebral block provides good analgesia for breast surgery, but
the duration of analgesia is briefer than described in previous studies.
The Effects
of Centrally Administered Dexmedetomidine on Cardiovascular and Sympathetic
Function in Conscious Rats
Tetsuro
Shirasaka, MD, PhD*, De-Lai Qiu, MD,
PhD_files/image125.gif){kind=small}
, Hiroshi Kannan, MD, PhD_files/image126.gif){kind=small}
,and Mayumi Takasaki, MD, PhD*
From the Departments of *Anesthesiology
and Intensive Care and _files/image127.gif){kind=small}
Integrative
Physiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.
Anesth Analg 2007; 105:1722-1728
背景:_files/image129.gif){kind=small}
2受体在大脑中有表达,包括与自主神经系统控制有所牵涉的下丘脑.全身性给予DEX对心血管的作用是已经明确的,然而脑室内给予DEX对清醒动物心血管功能的影响仍然所知甚少.在这项研究中,我们研究脑室内给予DEX对清醒的,不受限制的大鼠心血管反应及交感神经活性的影响及其机制.方法:分别脑内给予58例清醒大鼠0.5, 1及2 µg/kg的DEX ,测量MAP,HR及血浆儿茶酚胺浓度.大鼠被同时给予阿托品(n = 8), 心得安(n = 8), 或六甲双铵(n = 8), 以评估DEX引起的迷走或交感传出神经活性的影响.一些大鼠行颈动脉窦及减压神经去神经以排除压力感受器反射的影响.结果:脑室内给予DEX有剂量依赖性MAP,HR及血浆去甲肾上腺素浓度降低.大剂量DEX降低血浆肾上腺素浓度.DEX对MAP影响的幅度被六甲双铵及心得安所减少.对HR影响的幅度被阿托品及心得安所减少.用六甲双铵预处理的大鼠比未作处理的大鼠对于DEX引起的MAP及HR减小的幅度要小.行颈动脉窦及减压神经去神经预处理的大鼠比未行预处理的大鼠对于DEX引起的MAP及HR减小的幅度要大.结论:结果表明脑室内给予DEX通过交感抑制降低MAP,通过交感抑制和迷走刺激降低HR.
(孙霞译 薛张纲校)
BACKGROUND: The _files/image131.gif){kind=small}
2-receptor is expressed in the brain,
includingthe hypothalamus, where it is implicated in autonomic nervoussystem
control. The effects of systemic administration of
dexmedetomidine(DEX) on cardiovascular responses are well known; however,
littleis known about the effects of central administration of DEXon
cardiovascular responses in conscious animals. In this study,we explored the
effects and the mechanism of intracerebroventricularly(icv) administered DEX on
cardiovascular responses and sympatheticnerve activity in conscious,
unrestrained rats. METHODS: We administered DEX (0.5, 1, and 2 µg/kg) icvand
measured the mean arterial blood pressure (MAP), heart rate(HR), and plasma
catecholamine in conscious rats (n = 58).
Ratswere also administered atropine (n = 8),
propranolol (n = 8),or hexamethonium (n = 8) to assess the influence of vagal orsympathetic efferent
activity in the DEX-induced responses.Some of the rats underwent carotid sinus
and aortic nerve denervationto exclude the effect of the baroreceptor reflex.
RESULTS: Intracerebroventricular administration of DEX
dose-dependentlydecreased MAP, HR, and plasma norepinephrine. Large dose ofDEX
decreased plasma epinephrine. The amplitude of MAP reductioninduced by DEX was
reduced by hexamethonium or propranolol.The amplitude of HR reduction was
reduced by atropine or propranolol.The amplitude of MAP and HR reduction
induced by DEX were smallerin hexamethonium-pretreatment rats than in intact
ones. Theamplitude of MAP and HR reduction induced by DEX were largerin sinus
and aortic nerve denervation rats than in intact ones. CONCLUSIONS: These
results indicate that icv administrationof DEX decreases MAP by sympathetic
inhibition and decreasesHR by sympathetic inhibition and vagal stimulation.
磺达肝素在下肢较大整形手术（留置或未留置轴索或深部周围神经导管）术后长期应用预防血栓形成的安全性及有效性研究：EXPERT研究
The Safety and Efficacy of Extended
Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the
Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The
EXPERT Study
François J. Singelyn, MD, PhD*, Cees C.P.M.
Verheyen, MD_files/image132.gif){kind=small}
,
Franco Piovella, MD_files/image133.gif){kind=small}
,
Hugo K. Van Aken, MD_files/image134.gif){kind=small}
,
Nadia Rosencher, MD|| for the EXPERT Study Investigators
From the *Department of Anesthesiology,
Clinical Center, Soyaux, France; _files/image135.gif){kind=small}
Department
of Orthopaedic Surgery and Traumatology, Isala Clinics, Zwolle, The
Netherlands; _files/image136.gif){kind=small}
Thromboembolic
Disease Unit, IRCCS Policlinico San Matteo, Pavia, Italy; _files/image137.gif){kind=small}
Department
of Anaesthesiology and Intensive Care, University Hospital Münster, Germany;
and ||Paris 5 University Anesthesiology, Cochin Hospital AP-HP, Paris, France.
Anesth Analg 2007; 105:1540-1547
背景：没有人对下肢大关节成形术患者长期使用磺达肝素治疗的利弊比值进行过评估。磺达肝素与持续轴索或深部周围神经阻滞同时应用的试验资料也几乎没有。我们在较大整形手术患者中进行了一项前瞻性干预试验，主要设计停药48小时以允许拔出轴索或深部周围神经导管时评估磺达肝素的功效。同时评估磺达肝素长时间应用治疗用于预防静脉血栓栓塞的安全性及有效性。方法：患者术后3-5周每日一次皮下注射2.5 mg磺达肝素。在留置轴索或深部周围神经导管的患者，磺达肝素最后一次注射后36h拔出导管。导管拔出后12h重新给予下一次剂量的磺达肝素。主要试验终点为术后4-6周出现有症状的静脉血栓栓塞以及大出血。结果：5704例患者参与了这项研究。置入轴索或深部周围神经留置导管的患者分别为1553 例（27%）和78 例（1.4%）。静脉血栓栓塞发生率为1.0%(54/5387)。留置导管者与未留置导管者静脉血栓栓塞发生率无显著性差异（1.1%比0.8%）（优势比95%可信区间的上限为1.49，低于预先设置的非劣效边界值1.75）。大出血的发生率为0.8%(42/5382)。没有1例患者发生轴索或神经周围血肿。结论：每日一次皮下注射2.5 mg 磺达肝素3-5周可以安全有效预防较大整形手术后的静脉血栓栓塞。暂时的停用磺达肝素48h以利于安全拔出轴索或深部周围神经导管不会降低预防血栓的效果。
（邱郁薇 译 马皓琳 李士通 校）
BACKGROUND: The benefit-risk ratio of
extended fondaparinux therapy has not been assessed in patients undergoing
major lower limb joint arthroplasty. Few data on the concomitant use of
fondaparinux and continuous neuraxial or deep peripheral nerve blockade are
available. We performed a prospective intervention study in patients undergoing
major orthopedic surgery primarily designed to assess the efficacy of
fondaparinux when drug administration was withheld for 48 h to permit removal
of a neuraxial or deep peripheral nerve catheter. The safety and efficacy of
extended fondaparinux therapy for the prevention of venous thromboembolism were
also evaluated. METHODS: Patients received a
daily subcutaneous injection of 2.5 mg fondaparinux for 3 to 5 wk
postoperatively. In patients with a neuraxial or deep peripheral nerve
catheter, the catheter was removed 36 h after the last fondaparinux dose. The
next fondaparinux dose was administered 12 h after catheter removal. The
primary end points were symptomatic venous thromboembolism and major bleeding
up to 4–6 wk after surgery. RESULTS: We
recruited 5704 patients. A neuraxial or deep peripheral nerve catheter was
inserted in 1553 (27%) patients and 78 (1.4%) patients, respectively. The rate
of venous thromboembolism was 1.0% (54 of 5387). There was no difference
between patients without (1.1%) or with (0.8%) a catheter (the upper limit of
the 95% confidence interval of the odds ratio, 1.49, being below the predetermined
noninferiority margin of 1.75). The incidence of major bleeding was 0.8% (42 of
5382). No neuraxial or perineural hematoma was reported. CONCLUSIONS: Once-daily subcutaneous injection of 2.5 mg fondaparinux given for 3
to 5 wk was effective and safe for prevention of venous thromboembolism after
major orthopedic surgery. Temporary discontinuation of fondaparinux for 48 h
permitted safe removal of a neuraxial or deep peripheral nerve catheter without
decreasing thromboprophylatic efficacy.
Programming Pressure Support Ventilation
in Pediatric Patients in Ambulatory Surgery with a Laryngeal Mask Airway
Javier Garcia-Fernandez, MD, PhD*, Gerardo
Tusman, MD_files/image138.gif){kind=small}
,
Fernando Suarez-Sipmann, MD_files/image139.gif){kind=small}
,
Julio Llorens, MD, PhD_files/image140.gif){kind=small}
,
Marina Soro, MD, PhD_files/image141.gif){kind=small}
,
and Javier F. Belda, MD, PhD_files/image142.gif){kind=small}
From the *Pediatric Anesthesiology and
Postsurgical Critical Care Department, La Paz Universitary Hospital, Madrid,
Spain; _files/image143.gif){kind=small}
Anesthesiology
Department, La Comunidad Hospital, Mar de Plata, Argentina; _files/image144.gif){kind=small}
Intensive
Care Department, Fundación Jiménez Díaz-Capio, Madrid, Spain; _files/image145.gif){kind=small}
Anesthesiology
Department, Clinical Universitary Hospital, University of Valencia, Valencia,
Spain.
Anesth Analg 2007; 105:1585-1591
背景：用压力支持通气技术（PSV）的麻醉工作站是可取的，但很少的文献报道如何在小儿全麻中用喉罩导气管（LMA）编程流量触发的PSV。方法：我们研究了60例ASA I和II级、2个月-14岁、安排在用LMA行全麻和局域麻醉联合下行门诊手术的病人。病人根据他们的体重分组：A组_files/image147.gif){kind=small}
10
kg，B组11–20 kg，和C组>20 kg。所有的都用下列设置行PSV通气：呼气末正压4 cm H2O，没有诱发自主触发的最小流量触发，和最小水平的压力支持使潮气量达到10 mL/kg 。
结果：我们研究中最常用的流量触发为0.4 L/min，范围0.2 - 0.6 L/min。我们发现在流量触发设置与病人年龄、体重、顺应性、气道阻力和呼吸频率之间没有相关性。在压力支持水平(A组 = 15 cm H2O, B组 = 10 cm H2O 和 C组 = 9 cm H2O)与年龄(P < 0.001)、体重(P < 0.001)、动态顺应性(P < 0.001)和气道阻力(P < 0.001)之间有很好的相关性。结论：在门诊小儿麻醉中，用ProsealTM LMA行压力支持通气可简单地用研究的常用临床非创伤性变量编程。然而，需要更多研究来评估可能需要用于其他临床情况（呼吸病理学、气管内导管或者其他手术类型）或者其他麻醉工作站的压力支持通气的水平。
（彭中美 译 马皓琳 李士通 校）
BACKGROUND: Anesthesia workstations with
pressure support ventilation (PSV) are available, but there are few studies
published on how to program flow-triggered PSV using a laryngeal mask airway
(LMA) under general anesthesia in pediatric patients. METHODS: We studied 60 ASA I and II patients, from 2 mo to 14 yr, scheduled
for ambulatory surgery under combined general and regional anesthesia with a
LMA. Patients were classified according to their body weight as follows: Group
A _files/image148.gif){kind=small}
10
kg, Group B 11–20 kg, and Group C >20 kg. All were ventilated in PSV using
the following settings: positive end-expiratory pressure of 4 cm H2O, the
minimum flow-trigger without provoking auto-triggering, and the minimum level
of pressure support to obtain 10 mL/kg of tidal volume. RESULTS: The
flow-trigger most frequently used in our study was 0.4 L/min, ranging from 0.2
to 0.6 L/min. We found no correlation between the flow-trigger setting and the
patient’s age, weight, compliance, resistance, or respiratory rate. There was a
good correlation between the level of pressure support (Group A = 15 cm H2O,
Group B = 10 cm H2O and Group C = 9 cm H2O) and age (P < 0.001), weight (P < 0.001),
dynamic compliance (P < 0.001), and airway
resistances (P < 0.001). CONCLUSIONS: PSV with a ProsealTM LMA in outpatient pediatric anesthesia can be
programmed simply using the common clinical noninvasive variables studied.
However, more studies are needed to estimate the level of pressure support that
may be required in other clinical situations (respiratory pathology,
endotracheal tubes, or other types of surgeries) or with other anesthesia
workstations.
The Relationship Between Current
Intensity for Nerve Stimulation and Success of Peripheral Nerve Blocks
Performed in Pediatric Patients Under General Anesthesia
Harshad Gurnaney, MBBS, Arjunan Ganesh,
MBBS, and Giovanni Cucchiaro, MD
From the Department of Anesthesia and
Critical Care Medicine, The Children’s Hospital of Philadelphia and University
of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
Anesth Analg 2007; 105:1605-1609
背景：我们评估了全麻患儿用来获得运动反应的最低电流安培数与周围神经阻滞(PNB)的成功率及神经学并发症发生率之间的关系。方法：我们回顾了2002年10月至2006年7月费城儿童医院的局域麻醉数据库，并且包括了所有全麻下在周围神经刺激仪辅助下施行单次注射法PNB的患儿数据。分析的数据包括：年龄、性别、阻滞类型、刺激阈、感觉与运动阻滞的存在及神经并发症。结果：在研究期间有660位患儿接受了PNB。患儿的平均年龄13.8岁（范围=2-18岁）。所有的阻滞均在0.2 至1 mA（中位数=0.5 mA,四分位距: 0.45–0.55 mA)的电流下实施。总的成功率为96%。使用刺激阈_files/image149.gif){kind=small}
0.5
及>0.5
mA实施的阻滞成功率无差别 (96.3% 相对 95.9%; P = 0.793)。成功率与性别、实施的阻滞类型或使用的电流强度之间无相关性。有两位接受坐骨神经阻滞的患儿，其大拇趾及足背的神经阻滞延长，持续72小时。我们的患儿未发现有长期的后遗症。结论：本研究中，使用低刺激阈值(_files/image150.gif){kind=small}
0.5
mA)及高刺激阈值(>0.5 mA)刺激所得到的PNB成功率是相似的。因此，可能没有必要使用针头操作来得到一个低刺激阈值(_files/image151.gif){kind=small}
0.5
mA)，因为这样可能会增加神经内注射的危险性。
（裘毅敏译，马皓琳 李士通校）
BACKGROUND: We evaluated the relationship
between the lowest current amperage used to obtain a motor response, the
success rate and the incidence of neurological complications with peripheral
nerve blocks (PNB) in pediatric patients under general anesthesia. METHODS: We
reviewed the regional anesthesia database at The Children’s Hospital of
Philadelphia and included all pediatric patients who received a
single-injection PNB under general anesthesia with the aid of a peripheral
nerve stimulator between October 2002 and July 2006. Data analyzed included
age, sex, type of block, stimulation threshold, presence of sensory and motor
blockade, and neurological complications. RESULTS: Six-hundred sixty patients
received a PNB during the study period. The average age of the patients was
13.8 yr (range = 2–18 yr). All the blocks were performed using a current
ranging between 0.2 and 1 (median = 0.5 mA, interquartile range: 0.45–0.55 mA).
The overall success rate was 96%. There was no difference in success rate
between blocks performed using a stimulation threshold of _files/image152.gif){kind=small}
0.5
or >0.5 mA (96.3% vs 95.9%; P = 0.793). There
was no correlation between the success rate and sex, type of block performed or
intensity of current used. Two patients reported prolonged nerve blockade of
the great toe and dorsum of the foot after a sciatic nerve block, which lasted
for 72 h. No long-term sequelae were noted in our patients. CONCLUSION: In this study, a similar PNB success rate was observed with both a
low (_files/image153.gif){kind=small}
0.5
mA) and a high stimulation threshold (>0.5 mA). Therefore, it may not be
necessary to perform needle manipulations to achieve a low stimulation
threshold (_files/image154.gif){kind=small}
0.5
mA), as this may increase the risk of intraneural injection.
评估基于贝叶斯的闭环系统用于丙泊酚输注的理想模型权重，应用双频指数作为对照变量：一个模拟研究
Estimation of Optimal Modeling Weights
for a Bayesian-Based Closed-Loop System for Propofol Administration Using the
Bispectral Index as a Controlled Variable: A Simulation Study
Tom De Smet, MSc*, Michel M. R. F. Struys,
MD, PhD_files/image155.gif){kind=small}
_files/image156.gif){kind=small}
,
Scott Greenwald, PhD_files/image157.gif){kind=small}
,
Eric P. Mortier, MD, DSc_files/image158.gif){kind=small}
,
and Steven L. Shafer, PhD||¶
From *Demed Engineering, Temse, Belgium; _files/image159.gif){kind=small}
Department
of Anesthesia, Ghent University Hospital, Gent, Belgium; _files/image160.gif){kind=small}
Heymans
Institute of Pharmacology, Ghent University, Gent, Belgium; _files/image161.gif){kind=small}
Aspect
Medical Systems, Inc., Newton, Massachusetts; ||Stanford University School of
Medicine, Stanford, California; and ¶University of California at San Francisco,
San Francisco, California.
Anesth Analg 2007; 105:1629-1638
背景：将贝叶斯方法应用于基于模型的闭环系统，要求整合标准反应模型和病人特有的反应模型。这个过程利用特殊的模型权重，被称作贝叶斯变量，此变量决定此特有的模型怎样偏离标准模型。在这个研究中，我们应用模拟来选择产生理想控制器的贝叶斯变量，用于丙泊酚输注的贝叶斯闭环系统的，应用双频指数（BIS）作为对照变量。方法：测定模型过程的有关贝叶斯变量是经过鉴定的。每组这样的贝叶斯变量表示一个潜在的控制器。终成理想控制的组，由模拟人群计算后来评估。我们选择了625个候选组。与我们之前的闭环研究相似，我们应用模拟草案来评估控制器的表现。我们的人群包括了用来自于以前工作的人群特性产生的416个虚拟病人。应用与外科案例相似的BIS偏离轨道。结果：我们能应用贝叶斯优化来发展、描绘和优化用于病人个体化模型基础的闭环控制器的参数设定。在BIS目标为30、50和70时，选择优化组产生的控制器表现的绝对预测误差中位数分别为12.9 ± 2.87、7.59 ± 0.74和5.76 ± 1.03。
结论：我们相信这个系统能被安全地引入麻醉医师直接观察下的用于麻醉诱导和维持的临床试验中。
（张曦 译，马皓琳 李士通 校）
BACKGROUND: Implementing Bayesian methods
in a model-based closed-loop system requires the integration of a standard
response model with a patient-specific response model. This process makes use
of specific modeling weights, called Bayesian variances, which determine how
the specific model can deviate from the standard model. In this study we
applied simulations to select the Bayesian variances yielding the optimal
controller for a Bayesian-based closed-loop system for propofol administration
using the Bispectral Index (BIS) as a controlled variable. METHODS: The relevant Bayesian variances determining the modeling process
were identified. Each set of such Bayesian variances represents a potential
controller. The set, which will result in optimal control, was estimated using
calculations on a simulated population. We selected 625 candidate sets. Similar
to our previous closed-loop performance study, we applied a simulation protocol
to evaluate controller performance. Our population consisted of 416 virtual
patients, generated using population characteristics from previous work. A BIS
offset trajectory similar to a surgical case was used. RESULTS: We were able to develop, describe, and optimize the parameter
setting for a patient-individualized model-based closed-loop controller using
Bayesian optimization. Selection of the optimal set yields a controller
performing with the following median absolute prediction errors at BIS targets
30, 50, and 70: 12.9 ± 2.87, 7.59 ± 0.74, and 5.76 ± 1.03 respectively. CONCLUSIONS:
We believe this system can be introduced safely
into clinical testing for both induction and maintenance of anesthesia under
direct observation of an anesthesiologist.
术后疼痛模型中的继发性痛觉过敏取决于脊髓钙－钙调蛋白依赖的蛋白激酶IIα的激活
Secondary Hyperalgesia in the
Postoperative Pain Model Is Dependent on Spinal Calcium/Calmodulin-Dependent
Protein Kinase II_files/image162.gif){kind=small}
Activation
Toni L. Jones, PhD, Adam C. Lustig, BS, and
Linda S. Sorkin, PhD
From the Department of Anesthesiology,
University of California San Diego, La Jolla, California.
Anesth Analg 2007; 105:1650-1656
背景：鞘内给予非N-甲基-d-天冬氨酸（NMDA）受体拮抗剂可阻断足底切皮后原发性（1°）和继发性（2°）机械痛觉过敏和自发痛，而鞘内给予NMDA受体拮抗剂并无此作用。热刺激后痛觉过敏也由非NMDA受体而不是NMDA受体介导。尽管以前对热刺激模型的疼痛行为学研究表明蛋白激酶明确参与其下游脊髓非NMDA受体激活，但是蛋白激酶信号传导机制尚未在术后疼痛模型中得到验证。在本实验中我们研究了脊髓钙－钙调蛋白依赖的蛋白激酶IIα（CaMKIIα）是否介导了足底切皮后1°和/或2°痛觉过敏及自发痛行为。方法：在插入鞘内导管的大鼠后爪行一1cm切口，在随后的2天内测试大鼠对邻近切口或距切口1cm处机械刺激的反应。一些大鼠接受鞘内预处理CaMKIIα抑制剂（14、34或104 nmol KN-93）或赋形剂（无菌生理盐水中的5％二甲基亚砜）。其余组单独接受鞘内注射34nmol或104nmol KN-93并接受后爪承重测试。切皮或假处理后1h取出腰段脊髓用Western免疫印迹法测定CaMKIIα和α-氨基-3-羟基-5-甲基异噁唑-4-丙酸GLUR1-831磷酸化程度。结果：切皮增加脊髓CaMKIIα和 GLUR1-831磷酸化程度。尽管预处理鞘内注射KN-93的所有剂量均可减轻2° 痛觉过敏的发展，但是仅鞘内注射34nmol KN-93对于1° 痛觉过敏有效。鞘内注射KN-93不影响非激发性疼痛。结论：脊髓CaMKIIα激活和α-氨基-3-羟基-5-甲基异噁唑-4-丙酸受体（AMPA）功能增强参与了切皮激发痛觉过敏模型中脊髓致敏机制。
（周雅春 译 马皓琳 李士通 校）
BACKGROUND: Spinally
administered non-N-methyl-d-aspartate (NMDA),
but not NMDA, receptor antagonists block primary (1°) and secondary (2°)
mechanical hyperalgesia and spontaneous pain after plantar incision.
Hyperalgesia after thermal stimulation is also mediated by non-NMDA, but not
NMDA, receptors. Although previous pain behavior studies in the thermal
stimulus model demonstrated distinct protein kinase involvement downstream from
spinal non-NMDA receptor activation, protein kinase signaling mechanisms have
not been examined in the postoperative pain model. In the present study, we
investigated whether spinal calcium/calmodulin-dependent protein kinase II_files/image163.gif){kind=small}
(CaMKII_files/image164.gif){kind=small}
)
mediates 1° and/or 2° hyperalgesia and spontaneous pain behavior after plantar
incision. METHODS: Catheterized rats received a 1 cm incision in the hindpaw
and were tested over 2 days for responses to mechanical stimulation adjacent to
or 1 cm away from the incision site. Some rats received intrathecal (IT)
pretreatment with a CaMKII_files/image165.gif){kind=small}
inhibitor (14, 34, or 104 nmol KN-93) or vehicle (5% dimethyl sulfoxide in
sterile saline). Separate groups received IT 34 nmol or 104 nmol KN-93 and were
tested for hindpaw weight bearing. Lumbar spinal cords were extracted 1 h after
incision or sham treatment to measure phosphorylated CaMKII_files/image166.gif){kind=small}
and _files/image167.gif){kind=small}
-amino-3-hydroxy-5-methylisoxazole-4-proprionic
acid GLUR1-831 in Western immunoblots. RESULTS: Incision
increased spinal CaMKII_files/image168.gif){kind=small}
and GLUR1-831 phosphorylation. Although pretreatment with all doses of IT KN-93
reduced the development of 2° hyperalgesia, only 34 nmol KN-93 appeared to have
an effect on 1° hyperalgesia. IT KN-93 did not affect nonevoked pain. CONCLUSION:
Spinal sensitization underlying incision-evoked
hyperalgesia involves spinal CaMKII_files/image169.gif){kind=small}
activation and enhanced spinal _files/image170.gif){kind=small}
-amino-3-hydroxy-5-methylisoxazole-4-proprionic
acid receptor (AMPA) function.
Concentrations of Isoflurane Exceeding
Those Used Clinically Slightly Increase the Affinity of Methane, but Not
Toluene, for Water
Charles W. Buffington, MD*, Michael J.
Laster, DVM_files/image171.gif){kind=small}
,
Katarzyna Jankowska, DVM_files/image172.gif){kind=small}
,
and Edmond I. Eger, II, MD_files/image173.gif){kind=small}
From the *Department of Anesthesiology,
University of Pittsburgh, Pittsburgh, Pennsylvania; and _files/image174.gif){kind=small}
Department
of Anesthesia and Perioperative Care, University of California San Francisco,
San Francisco, California.
Anesth Analg 2007; 105:1675-1680
背景：吸入麻醉剂可影响在脂膜和周围水相交界处的蛋白质。其基础的溶液化学性质不明。由于非极性蛋白成份的疏水性对构相有重要影响，我们验证了以下假设：异氟烷影响两种非极性化合物甲烷和甲苯在盐水中的可溶性。方法：我们在37°C无异氟烷和约存在1%、5%和15%异氟烷时，用连续稀释技术测定甲烷和甲苯的盐水/气分配系数(PCs)。我们还测量了用以前研究中用的麻醉药环丙烷或氯乙烷使苯饱和对苯蒸汽压的影响，以证实它们和苯的平衡使苯在水中溶解度降低。结果：临床相关的异氟烷浓度(1%和5%)对甲烷和甲苯的盐水/气PC没有影响，但15%–20%异氟烷增加甲烷的PC (P < 0.05)而对甲苯没有作用。用环丙烷或氯乙烷使苯饱和降低苯蒸汽压力，其降低程度与苯中溶解的麻醉药量成比例。
结论：异氟烷在远远大于临床相关浓度时有轻微的疏水作用，而这种作用无法解释麻醉剂如何作用。那个发现环丙烷和氯乙烷降低苯在水中溶解度的既往研究，可能在这些麻醉剂干扰了苯和水的相互作用的结论方面有误。应该改为这些麻醉剂只是降低了苯的蒸汽压力，这样做是遵循了拉乌尔定律。
（唐李隽 译 马皓琳 李士通 校）
BACKGROUND: Inhaled anesthetics may affect
proteins at the interface between membrane lipids and the surrounding aqueous
phase. The underlying solution chemistry is not known. Because the
hydrophobicity of nonpolar protein components importantly influences their
conformation, we tested the hypothesis that isoflurane affects the solubility
of two nonpolar compounds, methane and toluene, in saline.
METHODS: Using
a serial dilution technique, we determined the saline:gas partition
coefficients (PCs) of methane and toluene at 37°C in the absence of isoflurane
and in the presence of approximately 1%, 5%, and 15% isoflurane. We also
measured the effect on the vapor pressure of benzene produced by saturating
benzene with either cyclopropane or chloroethane, anesthetics used in a
previous study to demonstrate that their equilibration with benzene decreased
the solubility of benzene in water. RESULTS: Clinically relevant concentrations
of isoflurane (1% and 5%) did not affect the saline:gas PC of methane and
toluene, but 15%–20% isoflurane increased the PC of methane (P < 0.05) but not toluene. Saturating benzene with cyclopropane or
chloroethane, decreased the vapor pressure of benzene in proportion to the
amount of anesthetic dissolved in the benzene. CONCLUSION: Isoflurane has a
weak antihydrophobic effect at concentrations far above the clinically relevant
range, and this effect is unlikely to explain how anesthetics act. A previous
study, which found that cyclopropane and chloroethane decreased the solubility
of benzene in water, probably erred in its conclusion that these anesthetics
interfered with the interaction of benzene and water. Instead, the anesthetics
simply decreased the vapor pressure of benzene, doing so in accordance with
Raoult's Law.
Mechanisms of Morphine Enhancement of
Spontaneous Seizure Activity
Ehsan Saboory, PhD*, Miron Derchansky, PhD*_files/image175.gif){kind=small}
,
Mohammed Ismaili, PhD*, Shokrollah S. Jahromi, PhD*, Richard Brull, MD, FRCPC_files/image176.gif){kind=small}
,
Peter L. Carlen, MD, FRCPC*_files/image177.gif){kind=small}
_files/image178.gif){kind=small}
,
and Hossam El Beheiry, MBBCh, PhD, FRCPC*_files/image179.gif){kind=small}
From the *Toronto Western Research
Institute, Departments of _files/image180.gif){kind=small}
Physiology,
_files/image181.gif){kind=small}
Anesthesia
and Pain Management, and _files/image182.gif){kind=small}
Medicine
(Neurology), University of Toronto, University Health Network, Toronto,
Ontario, Canada.
Anesth Analg 2007; 105:1729-1735
背景：大剂量阿片类药物治疗可以使癫痫突然发生；然而这种危险副作用产生的机制尚不清楚。我们的研究目的在于揭示大剂量吗啡的神经兴奋活性是否通过选择性刺激阿片受体来介导。方法：完整分离小鼠海马组织并孵育在低镁人工脑脊液中，诱发CA1神经元产生自发性癫痫样事件。结果：运用吗啡对记录的自发性癫痫样事件有双相作用。低浓度吗啡（10µM）降低癫痫的电活动。而大剂量吗啡（30µM和100µM）会增强癫痫放电并且呈现明显的剂量依赖性。非选择性阿片类受体拮抗药纳络酮阻断吗啡的致惊厥作用。选择性µ受体和_files/image184.gif){kind=small}
受体激动剂和拮抗剂可以分别增加或抑制自发性癫痫活性。相反，_files/image185.gif){kind=small}
受体配体药物没有作用。
结论：吗啡产生的致癫痫作用是通过选择性激活µ和_files/image186.gif){kind=small}
阿片受体介导，而与_files/image187.gif){kind=small}
阿片受体系统的激活无关。吗啡神经兴奋性的剂量依赖性机制强调了临床谨慎调节和个体化吗啡剂量。
（沈浩 译 马皓琳 李士通 校）
BACKGROUND: High-dose opioid therapy can
precipitate seizures; however, the mechanism of such a dangerous adverse effect
remains poorly understood. The aim of our study was to determine whether the
neuroexcitatory activity of high-dose morphine is mediated by selective
stimulation of opioid receptors. METHODS: Mice
hippocampi were resected intact and bathed in low magnesium artificial
cerebrospinal fluid to induce spontaneous seizure-like events recorded from CA1
neurons. RESULTS: Application of morphine had a biphasic effect on the recorded
spontaneous seizure-like events. In a low concentration (10 µM), morphine
depressed electrographic seizure activity. Higher morphine concentrations (30
and 100 µM) enhanced seizure activity in an apparent dose-dependent manner.
Naloxone, a nonselective opiate antagonist blocked the proconvulsant action of
morphine. Selective µ and _files/image188.gif){kind=small}
opiate
receptor agonists and antagonists enhanced and suppressed the spontaneous
seizure activity, respectively. On the contrary, _files/image189.gif){kind=small}
opioid
receptor ligands did not have an effect. CONCLUSIONS: The proseizure effect of
morphine is mediated through selective stimulation of µ and _files/image190.gif){kind=small}
opiate
receptors but not the activation of the _files/image191.gif){kind=small}
receptor
system. The observed dose-dependent mechanism of morphine neuroexcitation
underscores careful adjustment and individualized opioid dosing in the clinical
setting.
The Ability of Diagnostic Spinal
Injections to Predict Surgical Outcomes
Steven P. Cohen, MD*_files/image192.gif){kind=small}
,
and Robert W. Hurley, MD, PhD*
From the *Pain Management Division,
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School
of Medicine, Baltimore, Maryland; and _files/image193.gif){kind=small}
Department
of Surgery, Walter Reed Army Medical Center, Washington, DC.
Anesth Analg 2007; 105:1756-1775
背景：自从80多年前第一次描述诊断性鞘内注射以来，关于其用来预测手术结果的应用一直是广受争议的对象。因为在这个论题上既没有标准化的指导方针也没有实质性的综述，其应用结果仍不一致。方法：在这次综述中包括的诊断过程为腰段和颈段椎间盘造影、腰段椎间关节阻滞、腰段和颈段选择性神经根阻滞和骶髂关节内注射。我们通过MEDLINE和OVID搜索引擎、书籍、书籍章节、参考文献和会议录来获取资料。结果：由于所有阻滞方法均缺乏随机、对照性研究，得出的结论具有一定的局限性。通过现有的资料，能揭示腰段椎间盘造影改善融合手术结果的证据很有限，且没有证据证实其可以影响椎间盘置换的效果。虽然范围很有限，但是目前的文献支持颈段椎间盘造影可以预测手术结果。有强有力的证据提示腰段选择性神经根阻滞可以改善对有症状的神经根的识别，中等程度的证据提示腰段和颈段神经根阻滞都可以改善手术结果。支持椎间关节病手术的资料很少，而且应用筛选性阻滞也不可能预测结果。支持用于退行性、非创伤性损伤的骶髂关节融合的资料同样也很少。因为用来诊断疼痛性骶髂关节的最可靠方法是小剂量诊断性注射，一个可能合理的结论是筛选性阻滞改善手术结果。但是这一结论没有间接的证据支持。结论：随机性研究的缺乏、方法学上的缺陷以及在注射变量、手术方法和结果测定方面的差异限制了对诊断性阻滞影响手术结果的评价能力。需要进行更多的研究来优化注射技术，并确定即便要，哪一种诊断性筛选阻滞方法可以改善手术结果。
（姜旭晖 译 马皓琳 李士通 校）
BACKGROUND: Since their first description
more than 80 yr ago, the use of diagnostic spinal injections to predict
surgical outcomes has been the subject of intense controversy. Because there
are no standardized guidelines or substantive reviews on this topic, their use
has remained inconsistent. METHODS: Diagnostic procedures included in this
review were lumbar and cervical discography, lumbar facet blocks, lumbar and
cervical selective nerve root blocks, and sacroiliac (SI) joint injections. We
garnered materials via MEDLINE and OVID search engines, books and book
chapters, bibliographic references, and conference proceedings. RESULTS: The lack of randomized, comparative studies for all blocks limited
the conclusions that could be drawn. For the data that do exist, there is
limited evidence that lumbar discography improves fusion outcomes, and no
evidence that it influences disk replacement results. Although limited in
scope, the current literature supports the notion that cervical discography
improves surgical outcomes. There is strong evidence that lumbar selective
nerve root blocks improve the identification of a symptomatic nerve root(s),
and moderate evidence that both lumbar and cervical nerve root blocks improve
surgical outcomes. The data supporting surgery for facet arthropathy are weak,
and the use of screening blocks does not appear to improve outcomes. The data
supporting SI joint fusion for degenerative, nontraumatic injuries are
similarly weak. Because the most reliable method to diagnose a painful SI joint
is with low volume, diagnostic injections, one might reasonably conclude that
screening blocks improve surgical outcomes. However, this conclusion is not
supported by indirect evidence. CONCLUSIONS: The
ability to evaluate the effect of diagnostic blocks on surgical outcomes is
limited by a lack of randomized studies, methodological flaws, and wide-ranging
discrepancies with regard to injection variables, surgical technique, and
outcome measures. More research is needed to optimize injection techniques and
determine which, if any, diagnostic screening blocks can improve surgical
outcomes.
阿片类药物和沉浸式虚拟现实分散注意力的镇痛作用：来自主观性和功能性脑显像评估的证据
The Analgesic Effects of Opioids and
Immersive Virtual Reality Distraction: Evidence from Subjective and Functional
Brain Imaging Assessments
Hunter G. Hoffman, PhD*_files/image194.gif){kind=small}
,
Todd L. Richards, PhD_files/image195.gif){kind=small}
,
Trevor Van Oostrom, MD_files/image196.gif){kind=small}
,
Barbara A. Coda, MD_files/image197.gif){kind=small}
,
Mark P. Jensen, PhD||, David K. Blough, PhD¶, and Sam R. Sharar, MD_files/image198.gif){kind=small}
From the Department of *Mechanical
Engineering, _files/image199.gif){kind=small}
Radiology,
and _files/image200.gif){kind=small}
Anesthesiology,
University of Washington, Seattle, Washington; _files/image201.gif){kind=small}
McKenzie
Anesthesia Group, Springfield, Oregon; and Department of ||Rehabilitation
Medicine and ¶Pharmacy, University of Washington, Seattle, Washington.
Anesth Analg 2007; 105:1776-1783
背景：沉浸式虚拟现实（VR）是一种通过分散注意力达到镇痛作用的新方法，然而，它和阿片类药物联合应用对疼痛相关大脑活动的影响尚不得而知。我们利用主观疼痛分级和功能性磁共振显像来衡量接受阿片类药物和/或VR分散注意力治疗的受试者的疼痛和疼痛相关脑活动。方法：九位健康受试者接受温度痛觉刺激并在一受试者内部设计中接受四种干预条件：(a) 对照（无镇痛），(b)给予阿片类药物（氢吗啡酮血浆靶浓度4 ng/mL ）(c) 沉浸式VR分散注意力，和(d)联合阿片类药物+VR。 观察结果包括主观疼痛分级（标记图形量表0-10分）和五个特定疼痛相关部位脑活动的血氧水平依赖性评价。结果：阿片类药物单独使用可显著降低受试者的疼痛不适感分级(P < 0.05)，并显著减少脑岛（P < 0.05）和丘脑（P < 0.05）的疼痛相关脑活动。VR 单独使用可以显著减少顶级疼痛(P < 0.01)和疼痛不适感(P < 0.01)，并显著减少脑岛(P < 0.05)、丘脑(P < 0.05)和SS2(P < 0.05)的疼痛相关脑活动。阿片类药物和VR 联合应用比单独应用阿片类药物在所有主观疼痛测量值上都更为有效地减少疼痛报告(P < 0.01)。疼痛相关的脑血氧水平依赖性脑活动模式和主观疼痛报告是相一致的。结论：这些主观的疼痛报告和客观的功能性磁共振显像结果提示单独阿片类药物和单独VR的镇痛效能具有会聚作用的证据。另外，疼痛相关脑活动也支持，当VR作为阿片类药物的辅助镇痛方法时，具有显著的主观镇痛作用。这些结果为临床上多模式镇痛机制（如联合药物和非药物）的应用提供了初步数据。
（黄佳佳 译 马皓琳 李士通 校）
BACKGROUND: Immersive virtual reality (VR)
is a novel form of distraction analgesia, yet its effects on pain-related brain
activity when used adjunctively with opioid analgesics are unknown. We used subjective
pain ratings and functional magnetic resonance imaging to measure pain and
pain-related brain activity in subjects receiving opioid and/or VR distraction.
METHODS: Healthy subjects (n = 9) received thermal pain stimulation and were exposed to four
intervention conditions in a within-subjects design: (a) control (no
analgesia), (b) opioid administration [hydromorphone (4 ng/mL target plasma
level)], (c) immersive VR distraction, and (d) combined opioid + VR. Outcomes
included subjective pain reports (0–10 labeled graphic rating scales) and blood
oxygen level-dependent assessments of brain activity in five specific,
pain-related regions of interest. RESULTS: Opioid alone significantly reduced
subjective pain unpleasantness ratings (P <
0.05) and significantly reduced pain-related brain activity in the insula (P < 0.05) and thalmus (P <
0.05). VR alone significantly reduced both worst pain (P < 0.01) and pain unpleasantness (P < 0.01) and significantly reduced pain-related brain activity in
the insula (P < 0.05), thalmus (P < 0.05), and SS2 (P < 0.05).
Combined opioid + VR reduced pain reports more effectively than did opioid
alone on all subjective pain measures (P <
0.01). Patterns of pain-related blood oxygen level-dependent activity were
consistent with subjective analgesic reports. CONCLUSIONS: These subjective
pain reports and objective functional magnetic resonance imaging results
demonstrate converging evidence for the analgesic efficacy of opioid
administration alone and VR distraction alone. Furthermore, patterns of
pain-related brain activity support the significant subjective analgesic
effects of VR distraction when used as an adjunct to opioid analgesia. These
results provide preliminary data to support the clinical use of multimodal
(e.g., combined pharmacologic and nonpharmacologic) analgesic techniques.
与环氧化酶-2选择性抑制剂和非选择性抗炎药物有关的心血管血栓栓塞的副作用
Cardiovascular Thromboembolic Adverse
Effects Associated with Cyclooxygenase-2 Selective Inhibitors and Nonselective
Antiinflammatory Drugs
Girish P. Joshi, MBBS, MD, FFARCSI*, Ralph
Gertler, MD_files/image202.gif){kind=small}
,
and Ruth Fricker, MD_files/image203.gif){kind=small}
From the *Department of Anesthesiology and
Pain Management, University of Texas Southwestern Medical Center, Dallas,
Texas; _files/image204.gif){kind=small}
Institute
of Anesthesiology and Intensive Care, German Heart Centre of the State of
Bavaria and the Technical University Munich; and _files/image205.gif){kind=small}
Pfizer
GmbH, Karlsruhe, Germany.
Anesth Analg 2007; 105:1793-1804
背景：非甾类抗炎药（nonsteroidal antiinflammatory drugs，NSAIDs，包括非选择性〔NS〕-NSAIDs和环氧化酶-2〔cyclooxygenase-2，COX-2〕选择性抑制剂）尽管有众多优点，但其引起心血管(cardiovascular，CV)血栓栓塞副作用的增多限制了它们的应用。方法：在这个描述性综述中，我们精密地调查了评估长期和短期应用COX-2选择性抑制剂和NS-NSAIDs引起的心血管副作用的随机、有效和安慰剂对照的研究、观察性试验和mata分析。同时提出这些心血管副作用的潜在机制。结果：尽管评估心血管风险的研究有局限性，但COX-2选择性抑制剂和NS-NSAIDs的心血管风险仍都增加，尤其在高危患者中。因此，美国食品药物管理局已给予一个相似的“装箱”警告来突出与这些药物应用相关的心血管事件增加的潜在性。然而，COX-2选择性抑制剂之间的心血管风险不同（例如罗非昔布比塞来昔布的心血管风险高），同样NS-NSAIDs药物之间的心血管风险也不同（如双氯芬酸比萘普生的心血管风险高）。结论：在长期、前瞻性、随机、充足的对相关患者人群的临床研究完成以前，与NSAIDs应用有关，尤其对高危患者的心血管风险将可能仍是有争论的。然而，在没有心血管风险的患者中短期应用（如围术期）的益处可能大于其潜在的心血管副作用。最后，应谨慎地进行风险/利益评估，且COX-2选择性抑制剂和NS-NSAIDs在有心血管风险因素的患者中应用都应慎重。
（朱 慧译 马皓琳 李士通校）
BACKGROUND: Concerns of increased
cardiovascular (CV) thromboembolic adverse effects from nonsteroidal
antiinflammatory drugs (NSAIDs, both nonselective [NS]-NSAIDs and
cyclooxygenase [COX]-2 selective inhibitors) have prevented their use despite
numerous benefits. METHODS: In this descriptive review, we critically examine
the randomized, active- and placebo-controlled studies, observational trials,
and meta-analyses evaluating the CV adverse effects associated with long-term
and short-term use of COX-2 selective inhibitors and NS-NSAIDs. The potential
mechanisms for these CV effects are also presented. RESULTS: Although the studies evaluating the CV risks have limitations, there
appears to be an increased CV risk with both COX-2 selective inhibitors and
NS-NSAIDs, particularly in high-risk patients. Therefore, the United States
Food and Drug Administration has given a similar "boxed" warning
highlighting the potential for increased risk of CV events associated with
their use. Nevertheless, there are differences in the CV risks between COX-2
selective inhibitors (e.g., higher CV risk with rofecoxib than celecoxib) as
well as differences in the CV risks between individual NS-NSAIDs (e.g., higher
CV risks with diclofenac than naproxen). CONCLUSIONS: Until long-term, prospective, randomized, adequately powered,
clinical studies in relevant patient populations have been completed, the CV
risks associated with the use of NSAIDs, especially in high-risk patients, will
likely continue to be controversial. Nevertheless, the benefits of their
short-term (e.g., perioperative) use in patients without CV risks probably
outweigh their potential CV adverse effects. Finally, careful risk/benefit
assessment should be undertaken and both COX-2 selective inhibitors and
NS-NSAIDs should be used with caution in patients with CV risk factors.
抑制环腺苷酸通路可以缓解神经性疼痛且减轻大鼠坐骨神经部分结扎后脊髓相应部位环腺苷酸磷酸化
Inhibition of the Cyclic Adenosine
Monophosphate Pathway Attenuates Neuropathic Pain and Reduces Phosphorylation
of Cyclic Adenosine Monophosphate Response Element-Binding in the Spinal Cord
After Partial Sciatic Nerve Ligation in Rats
Jiin-Tarng Liou, MD*_files/image206.gif){kind=small}
,
Fu-Chao Liu, MD*_files/image207.gif){kind=small}
,
Shi-Tai Hsin, MD*, Ching-Yue Yang, MD*, and Ping-Wing Lui, MD, PhD_files/image208.gif){kind=small}
From the *Department of Anesthesiology,
Chang Gung Memorial Hospital; _files/image209.gif){kind=small}
Graduate
Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan; and _files/image210.gif){kind=small}
Suao
and Yuanshan Veterans Hospital, Yilan, National Yang-Ming University, Taipei,
Taiwan.
Anesth Analg 2007; 105:1830-1837
背景：近来的研究表明，环腺苷酸（cAMP）转导在感受伤害性处理中有一定作用。脊髓中cAMP的激活通过蛋白激酶A和cAMP反应结合蛋白 (CREB)的激活从而诱导基因转录。鞘内注射蛋白激酶A抑制剂可以逆转机械性感觉过敏，而注射CREB反义引物可以减弱大鼠坐骨神经部分结扎引发的触觉异常性疼痛。在这个研究中，我们的目的是在慢性神经性疼痛模型中观察脊髓cAMP转导对伤害性感受处理的作用。方法: 雄性SD大鼠鞘内置管1周后，行坐骨神经部分结扎。结扎后2小时、3、7和14天，评价大鼠后爪对机械和热刺激的伤害感受。观察鞘内注射腺苷酸环化酶抑制剂 SQ22536 0.7 µmol对伤害感受的影响。并且测定脊髓背角CREB表达和免疫反应以及CREB磷酸化蛋白 (CREB-IR 和 pCREB-IR)含量的变化。. 结果: 坐骨神经部分结扎后两周，大鼠脊髓背角 CREB-IR 和 pCREB-IR蛋白的表达增高。在最早3天里，pCREB-IR的增高部分可被 cAMP通路阻滞所逆转。 机械和热刺激的退缩反应阈值平行增高。结论: 这些结果显示大鼠坐骨神经部分结扎引起的触觉异常疼痛和热感觉过敏，pCREB的增高可能有一定作用。如果对于有慢性神经性疼痛的病人可以达到早期干预，调制 cAMP 通路就可能有临床相关性。
（张莹译 马皓琳 李士通校）
BACKGROUND: Recent reports have identified
a role for cyclic adenosine monophosphate (cAMP) transduction in nociceptive
processing. Spinal activation of the cAMP induced gene transcription through the
activation of protein kinase A and cAMP response element-binding protein
(CREB). Intrathecal injection of protein kinase A inhibitor reversed the
mechanical hyperalgesia, whereas injection of CREB antisense attenuated tactile
allodynia caused by partial sciatic nerve ligation (PSNL) in rats. In the
present study, we aimed to assess the effects of spinal cAMP transduction on
the nociceptive processing in a chronic neuropathic pain model.
METHODS: PSNL was performed in male
Sprague-Dawley rats 1 wk after intrathecal catheterization. Nociception to
mechanical and thermal stimuli was assessed at the hindpaw 2 h, 3, 7, and 14
days after PSNL. The effects of adenylate cyclase inhibitor, SQ22536 (0.7 µmol,
intrathecal) on these nociceptions were evaluated. Changes in the expression
and immunoreactivity of CREB and its phosphorylated proteins (CREB-IR and
pCREB-IR) in the dorsal horn of the spinal cord were also measured. RESULTS:
The expression of CREB-IR and pCREB-IR proteins was
shown to increase for 2 wk after PSNL. The increase in pCREB was partially
reversed by the blockade of the cAMP pathway in the early 3 days, with a
parallel increase in mechanical and thermal withdrawal thresholds. CONCLUSION:
These results revealed the possible contribution of
an increase in pCREB to the PSNL-induced tactile allodynia and thermal
hyperalgesia. Modulation of the cAMP pathway may be clinically relevant if
early intervention can be achieved in patients with chronic neuropathic pain.
关于股骨创伤后临床症状出现前股神经阻滞缓解疼痛的一项随机对照试验
A Randomized Controlled Trial of Femoral
Nerve Blockade Administered Preclinically for Pain Relief in Femoral Trauma
Arno Schiferer,
MD, DEAA*, Carmen Gore, MD_files/image211.gif){kind=small}
, Laszlo Gorove, MD_files/image212.gif){kind=small}
, Thomas Lang, MD*, Barbara Steinlechner,
MD*, Michael Zimpfer, MD, MBA_files/image213.gif){kind=small}
, and Alexander Kober, MD||
From the *Department of Anesthesiology and
General Intensive Care, Medical University of Vienna, Austria; _files/image214.gif){kind=small}
Department
of Anesthesiology, University Hospital of Bucharest, Rumania; _files/image215.gif){kind=small}
Hungarian
National Emergency and Ambulance Service, Budapest, Hungary; _files/image216.gif){kind=small}
Department
of Anesthesiology and General Intensive Care, Medical University of Vienna,
Austria; and ||Vienna Red Cross, Van Swieten and the Research Institute of the
Vienna Red Cross, Vienna, Austria.
Anesth Analg 2007; 105:1852-1854
背景：股骨创伤后在意外发生地点以及搬运过程中的镇痛通常会被延误或者镇痛不充分。在该项前瞻性的随机对照试验中，我们评价了临床症状出现前应用股神经阻滞缓解疼痛与焦虑，并与用安乃近静脉镇痛进行比较。方法：有疼痛的股骨创伤（例如骨折或严重的挫伤）的病人，随机分入两组，一组为在意外发生地点行股神经阻滞(n = 31)，一组为静脉给予安乃近镇痛(n = 31)。应用视觉模拟评分（VAS）评价疼痛程度与焦虑程度。分别采集基线水平、搬运过程中以及到达医院时的变量值。结果：应用股神经阻滞的病人，疼痛分值下降一半，VAS评分由意外发生地的 86 ± 6 mm下降到搬运过程中的41 ± 15 mm。同时焦虑程度也下降一半，VAS评分由84 ± 11 mm 下降到 39 ± 14 mm。心率下降20 ± 5 bpm。在安乃近组，疼痛、焦虑以及心率没有下降(P < 0.001)。股神经阻滞组的治疗时间长7.4 ± 3.5 min。结论：临床症状出现前进行股神经阻滞可以有效地缓解股骨创伤后的疼痛、焦虑，降低心率。区域阻滞可以成为训练有素的医生进行医院外镇痛的一项选择。
（黄丽娜 译 马皓琳 李士通 校）
BACKGROUND: Analgesia at the location of
the accident and on transport for femoral trauma is often delayed or
insufficient. In this prospective, randomized, controlled study, we evaluated
the preclinical use of femoral nerve blockade for reducing pain and anxiety
compared with IV analgesia using metamizol. METHODS: Patients with painful
femoral trauma, such as fracture or severe contusion, were randomized to
receive at the site of the accident a femoral nerve blockade (n = 31) or IV analgesia with metamizol (n = 31). A visual analog scale (VAS) was used to assess pain and
anxiety. Variables were assessed at baseline, during transport and upon arrival
at the hospital. RESULTS: In patients receiving
the femoral nerve blockade, pain values decreased by half from VAS 86 ± 6 mm at
the site of the accident to VAS 41 ± 15 mm during transport. Anxiety decreased
by half from VAS 84 ± 11 mm to VAS 39 ± 14 mm. Heart rate decreased by 20 ± 5
bpm. In the metamizol group, pain, anxiety, and heart rate did not decrease (P < 0.001). Time of treatment was 7.4 ± 3.5 min longer in the
femoral nerve blockade group. CONCLUSION: Preclinically
administered femoral nerve blockade effectively decreases pain, anxiety, and
heart rate after femoral trauma. Regional blockade is an option for
out-of-hospital analgesia administered by a trained physician.
The Paramedian Technique: A Superior
Initial Approach to Continuous Spinal Anesthesia in the Elderly
Anna Rabinowitz, MS*_files/image217.gif){kind=small}
,
Benoît Bourdet, MD*, Vincent Minville, MD*, Clément Chassery, MD*, Antoine
Pianezza, MD*, Aline Colombani, MD*, Bernard Eychenne, MD*, Kamran Samii, MD*,
and Olivier Fourcade, MD, PhD*
From the *Department of Anesthesiology and
Intensive Care, University Hospital of Toulouse, University Paul Sabatier,
Toulouse, France; and _files/image218.gif){kind=small}
School
of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Anesth Analg 2007; 105:1855-1857
背景：老年患者的脊麻经常会涉及到显著的技术困难。因此，我们对经典的正中法进路和旁正中法行连续脊麻（CSA）进行了比较。 方法：我们前瞻性地研究了40位年龄〉75岁的髋骨折行开放性手术复位的病人。他们随机被分为2组：M组：正中法，PM组：旁正中法。病人侧卧位，于L4-5进针行连续脊麻。由穿刺针中流出脑脊液表示腰穿成功。万一初次失败，由同一位操作者来重复同种进针法。如果两次尝试都不成功，则由同一位操作者来行另一解剖学进路进针。如果都失败了，那么由麻醉医师同事进行最后一次尝试。万一失败或阻滞不全，则病人接受全麻。 结果：PM组的初次尝试成功率为85%（17）而M组为45%（9）（P=0.02）。所有的导管都成功置入。没有病人需要全麻。在M组有6位病人针穿破血管而PM组为0（P=0.03），但是都没有临床后遗症。没有其它的显著临床并发症发生。 结论：总而言之，在老年病人行连续脊麻的首次尝试后，旁正中进针法较正中法成功率高。
（胡湘 译 马皓琳 李士通 校）
BACKGROUND: Spinal
anesthesia in elderly patients is frequently associated with significant
technical difficulties. Thus, we compared the classical midline approach to the
paramedian approach to perform continuous spinal anesthesia (CSA). METHODS: We
prospectively studied 40 patients aged >75 yr who underwent open surgical
repair of a hip fracture. These patients were randomly allocated to one of two
groups: Group M: midline approach, and Group PM: paramedian approach. Patients
were positioned in the lateral decubitus to receive CSA at L4-5 level. CSA was
considered successful if cerebrospinal fluid was obtained through the needle.
In case of initial failure in either approach, the same approach was repeated
by the same operator. If two attempts were unsuccessful, the other anatomical
approach was used by the same operator. If both approaches failed, a staff
anesthesiologist performed a final attempt. In case of failure or insufficient
block, the patient received general anesthesia. RESULTS: The success rate after the first attempt was 85% (17) for Group PM
and 45% (9) for Group M (P = 0.02). All
catheters were successfully introduced. No patient required general anesthesia.
Vascular puncture after needle puncture was observed in six patients in Group M
versus 0 in Group PM (P = 0.03), but none were
of clinical consequence. No other clinically significant complications were
observed.
CONCLUSION: In summary, after the initial
attempt, the paramedian approach is associated with an increased success rate,
compared with the midline approach, during the performance of CSA in elderly
patients.