Table of Contents

May 2008

CARDIOVASCULAR ANESTHESIOLOGY:

乳化異氟醚對兔子缺血再灌注損傷後的心臟保護

胡豔譯 薛張剛校

Emulsified Isoflurane Produces Cardiac Protection After Ischemia-Reperfusion Injury in Rabbits

Yan Rao, Yan-lin Wang, Wen-sheng Zhang, and Jin Liu

Anesth Analg 2008 106: 1353-1359.

濃縮纖維蛋白原、ⅩⅢ因數和新鮮冷凍血漿對離體血液稀釋（60%）導致血凝形成障礙的影響

胡瀟 譯 陳傑 校

The In Vitro Effects of Fibrinogen Concentrate, Factor XIII and Fresh Frozen Plasma on Impaired Clot Formation After 60% Dilution

Thorsten Haas, Dietmar Fries, Corinna Velik-Salchner, Christian Reif, Anton Klingler, and Petra Innerhofer

Anesth Analg 2008 106: 1360-1365.

凝血功能監測：新技術以及粘彈性重點照護檢驗凝血設備的臨床應用

邱郁薇 譯 馬皓琳 李士通 校

Coagulation Monitoring: Current Techniques and Clinical Use of Viscoelastic Point-of-Care Coagulation Devices (Review Article)

Michael T. Ganter and Christoph K. Hofer

Anesth Analg 2008 106: 1366-1375

PEDIATRIC ANESTHESIOLOGY:

新式麻醉通氣機能否在容積控制通氣時準確輸送小潮氣量?

黃凝譯 薛張綱校

Do New Anesthesia Ventilators Deliver Small Tidal Volumes Accurately During Volume-Controlled Ventilation?

Patricia R. Bachiller, Joseph M. McDonough, and Jeffrey M. Feldman

Anesth Analg 2008 106: 1392-1400.

AMBULATORY ANESTHESIOLOGY:

氟呱啶醇聯合地塞米松對腹腔鏡輔助下陰式子宮切除術後噁心嘔吐的預防作用

潘方立 譯 陳傑 校

The Prophylactic Effect of Haloperidol Plus Dexamethasone on Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopically Assisted Vaginal Hysterectomy

Chin-Chen Chu, Ja-Ping Shieh, Jann-Inn Tzeng, Jen-Yin Chen, Yi Lee, Shung-Tai Ho, and Jhi-Joung Wang

Anesth Analg 2008 106: 1402-1406.

氟呱啶醇與樞複寧用於術後噁心嘔吐（短訊）

蔣宗明譯 薛張綱校

Haloperidol Versus Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting (Brief Report)

Carl E. Rosow, Kenneth L. Haspel, Sarah E. Smith, Loreta Grecu, and Edward A. Bittner

Anesth Analg 2008 106: 1407-1409.

氟呱啶醇伍用昂丹司瓊與單用昂丹司瓊對術後噁心嘔吐預防作用的比較

陶穎瑩 譯 陳傑 校

Haloperidol Plus Ondansetron Versus Ondansetron Alone for Prophylaxis of Postoperative Nausea and Vomiting (Brief Report)
Loreta Grecu, Edward A. Bittner, Jay Kher, Sarah E. Smith, and Carl E. Rosow

Anesth Analg 2008 106: 1410-1413.

門診手術病人監測麻醉後與快通道不可行相關的危險因素

吳進 譯 馬皓琳 李士通 校

Risk Factors Associated with Fast-Track Ineligibility After Monitored Anesthesia Care in Ambulatory Surgery Patients

Rebecca S. Twersky, Svetlana Sapozhnikova, and Ben Toure

Anesth Analg 2008 106: 1421-1426.

ANESTHETIC PHARMACOLOGY:

全麻對局麻藥的中樞神經系統和心血管系統毒性的影響

唐亮 譯 馬皓琳 李士通 校

The Effects of General Anesthesia on the Central Nervous and Cardiovascular System Toxicity of Local Anesthetics

Susan E. Copeland, Leigh A. Ladd, Xiao-Qing Gu, and Laurence E. Mather

Anesth Analg 2008 106: 1429-1439.

局麻藥的中毒劑量在全麻中對其全身及局部藥代動力學的影響

劉沁譯 薛張綱校

The Effects of General Anesthesia on Whole Body and Regional Pharmacokinetics of Local Anesthetics at Toxic Doses

Susan E. Copeland, Leigh A. Ladd, Xiao-Qing Gu, and Laurence E. Mather

Anesth Analg 2008 106: 1440-1449.

普萘洛爾增加清醒大鼠利多卡因誘導的驚厥閾值:對大腦的直接影響

杜唯佳 譯 陳傑 校

Propranolol Increases the Threshold for Lidocaine-Induced Convulsions in Awake Rats: A Direct Effect on the Brain

Taketo Nakamura, Yutaka Oda, Ryota Takahashi, Katsuaki Tanaka, Ichiro Hase, and Akira Asada

Anesth Analg 2008 106: 1450-1455.

體外抑制有絲分裂原活化蛋白激酶通路對布比卡因和羅呱卡因誘發的神經毒性有保護作用

顏濤 譯， 馬皓琳 李士通 校

In Vitro, Inhibition of Mitogen-Activated Protein Kinase Pathways Protects Against Bupivacaine- and Ropivacaine-Induced Neurotoxicity

Philipp Lirk, Ingrid Haller, Hans Peter Colvin, Leopold Lang, Bettina Tomaselli, Lars Klimaschewski, and Peter Gerner

Anesth Analg 2008 106: 1456-1464.

通過Lymnaea神經元觀察利多卡因通過Na+-H+交換增加細胞內鈉濃度的研究

劉婷潔譯 薛張鋼校

Lidocaine Increases Intracellular Sodium Concentration Through a Na⁺-H⁺ Exchanger in an Identified Lymnaea Neuron

Shin Onizuka, Toshiharu Kasaba, Ryuji Tamura, and Mayumi Takasaki

Anesth Analg 2008 106: 1465-1472.

地氟醚預處理通過靶向作用於TNF-α近端信號而抑制NF-κB的活化

潘錢玲譯 陳傑 校

Desflurane Preconditioning Inhibits Endothelial Nuclear Factor--B Activation by Targeting the Proximal End of Tumor Necrosis Factor- Signaling

Yuan Li, Xiaonan Zhang, Biao Zhu, and Zhanggang Xue

Anesth Analg 2008 106: 1473-1479.

TECHNOLOGY, COMPUTING, AND SIMULATION:

肝移植病人的心輸出量監測：肺動脈導管和未校準動脈壓波形分析比較

彭中美 譯 馬皓琳 李士通 校

Cardiac Output Measurement in Patients Undergoing Liver Transplantation: Pulmonary Artery Catheter Versus Uncalibrated Arterial Pressure Waveform Analysis

Biais Matthieu, Nouette-Gaulain Karine, Cottenceau Vincent, Vallet Alain, Cochard Jean François, Revel Philippe, and Sztark François

Anesth Analg 2008 106: 1480-1486.

不同吸入氧分數的單增量變化對使用氧氣洗出技術測定機械通氣病人的功能潮氣量的影響

秦敏菊譯 薛張綱校

The Impact of Different Step Changes of Inspiratory Fraction of Oxygen on Functional Residual Capacity Measurements Using the Oxygen Washout Technique in Ventilated Patients (Technical Communication)

Hermann Heinze, Beate Sedemund-Adib, Matthias Heringlake, Ulrich W. Gosch, Hartmut Gehring, and Wolfgang Eichler

Anesth Analg 2008 106: 1491-1494.

PATIENT SAFETY:

直接喉鏡法中顯示不佳和上唇咬診評分增高是GlideScope®視頻喉鏡困難氣管插管的預測因數

張燕 譯 陳傑 校

Poor Visualization During Direct Laryngoscopy and High Upper Lip Bite Test Score Are Predictors of Difficult Intubation with the GlideScope® Videolaryngoscope

Marie-Hélène Tremblay, Stephan Williams, Arnaud Robitaille, and Pierre Drolet

Anesth Analg 2008 106: 1495-1500.

靜脈注射布比卡因造成心跳驟停的豬模型中複合使用腎上腺素和加壓素與脂肪乳劑比較

沈浩 譯 馬皓琳 李士通 校

A Comparison of the Combination of Epinephrine and Vasopressin with Lipid Emulsion in a Porcine Model of Asphyxial Cardiac Arrest After Intravenous Injection of Bupivacaine

Viktoria D. Mayr, Lukas Mitterschiffthaler, Andreas Neurauter, Christian Gritsch, Volker Wenzel, Tilko Müller, Günter Luckner, Karl H. Lindner, and Hans-Ulrich Strohmenger

Anesth Analg 2008 106: 1566-1571.

OBSTETRIC ANESTHESIOLOGY:

關於產痛評估的動態模型的建立與驗證

施穎譯 薛張綱校

The Development and Validation of a Dynamic Model to Account for the Progress of Labor in the Assessment of Pain

Jessamyn Conell-Price, Jennifer B. Evans, Daewha Hong, Steven Shafer, and Pamela Flood

Anesth Analg 2008 106: 1509-1515.

NEUROSURGICAL ANESTHESIOLOGY:

咪達唑侖對大鼠腦局部糖代謝具有時間依賴性的影響

陳偉 譯 陳傑 校

The Time-Dependent Effects of Midazolam on Regional Cerebral Glucose Metabolism in Rats

Ulderico Freo, Mauro Dam, and Carlo Ori

Anesth Analg 2008 106: 1516-1523.

GENERAL ARTICLES:

麻醉學活躍的研究領域：麻醉學文獻的同引分析

朱 慧譯 馬皓琳 李士通校

Active Research Fields in Anesthesia: A Document Co-Citation Analysis of the Anesthetic Literature

Milan P. Jankovic, Mark Kaufmann, and Christoph H. Kindler

Anesth Analg 2008 106: 1524-1533.

ANALGESIA:

麻醉後監護室中嚴重疼痛的有關因素

孫鵬飛譯 薛張綱校

Predictive Factors of Severe Postoperative Pain in the Postanesthesia Care Unit

Frédéric Aubrun, Nathalie Valade, Pierre Coriat, and Bruno Riou

Anesth Analg 2008 106: 1535-1541.

用超聲判斷頸部硬膜外阻滯穿刺針的深度

王騰 譯 陳傑 校

Sonographic Estimation of Needle Depth for Cervical Epidural Blocks

Soo Hwan Kim, Kang Hun Lee, Kyung Bong Yoon, Woo Young Park, and Duck-Mi Yoon

Anesth Analg 2008 106: 1542-1547.

關節內注射硫酸鎂和/或布比卡因用於膝關節鏡手術後的鎮痛

黃麗娜 譯 馬皓琳 李士通 校

Intraarticular Injection of Magnesium Sulphate and/or Bupivacaine for Postoperative Analgesia After Arthroscopic Knee Surgery

Noha M. Elsharnouby, Hala E. Eid, Nahla F. Abou Elezz, and Ashraf N. Moharram

Anesth Analg 2008 106: 1548-1552.

REGIONAL ANESTHESIA:

一項關於超聲及神經刺激聯合定位膕窩－坐骨神經阻滯的前瞻性隨機對照研究

夏俊明譯 薛張綱校

Combined Ultrasound and Neurostimulation Guidance for Popliteal Sciatic Nerve Block: A Prospective, Randomized Comparison with Neurostimulation Alone

Eric Dufour, Patrick Quennesson, Anne Laure Van Robais, Françoise Ledon, Pierre-Antoine Laloë, Ngai Liu, and Marc Fischler

Anesth Analg 2008 106: 1553-1558.

BRIEF REPORTS:

全膝關節成形術後周圍神經應用左旋布比卡因和羅呱卡因的鎮痛效果：一個前瞻性的、隨機雙盲研究

王鵬 譯 陳傑 校）

Postoperative Analgesic Efficacy of Peripheral Levobupivacaine and Ropivacaine: A Prospective, Randomized Double-Blind Trial in Patients After Total Knee Arthroplasty (Brief Report)

Florian Heid, Nicole Müller, Tim Piepho, Maren Bäres, Markus Giesa, Philipp Drees, Andreas Rümelin, and Christian Werner

Anesth Analg 2008 106: 1559-1561.

比較全身複合硬膜外麻醉（0.375％羅呱卡因）和單純全麻用於上腹部手術

黃佳佳譯，馬皓琳，李士通校

Combined General/Epidural Anesthesia (Ropivacaine 0.375%) Versus General Anesthesia for Upper Abdominal Surgery (Brief Report)

Yuhong Li, Shengmei Zhu, and Meijuan Yan

Anesth Analg 2008 106: 1562-1565.

凝血功能監測：新技術以及粘彈性重點照護檢驗凝血設備的臨床應用

Coagulation Monitoring: Current Techniques and Clinical Use of Viscoelastic Point-of-Care Coagulation Devices

Michael T. Ganter, MD^*, and Christoph K. Hofer, MD

From the *Department of Anesthesia and Perioperative Care University of CA San Francisco, San Francisco California; and Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Switzerland.

Anesth Analg 2008; 106:1366-1375

圍術期監測凝血功能對麻醉或手術中更好的理解出血原因、指導止血治療及預測出血的危險因素非常重要，可以。評價全血粘彈性的重點照護檢驗（POC）凝血監測設備，即血栓彈力描記圖、旋轉式血栓彈力測定法以及Sonoclot® 分析，在圍術期能夠克服常規凝血檢驗的一些局限性。這些技術的優點在於可以在床旁評估整個凝血的過程，包括從纖維蛋白形成開始一直到血塊凝縮和纖維蛋白溶解，而且得到結果只有很短的延遲。而且這些技術可以評估患者全血的凝血狀態，包括血漿凝血系統與血小板及紅細胞的相互作用，從而提供關於血小板功能的有效的額外資訊。彈性POC凝血設備越來越多的應用於臨床實踐中，尤其在心臟手術及肝臟手術中應用更為廣泛。這些技術還可以在很多臨床情況中提供有效資訊，如大出血、評估低凝和高凝狀態、指導促凝或抗凝治療及診斷手術出血。當粘彈性檢驗結果正常時，應該考慮出血的外科原因。總之，粘彈性POC凝血檢測設備可以幫助臨床醫生明確出血原因及指導促凝和抗凝治療。為確保最佳的準確性和性能，需要標準化的血液取樣及處理的操作、嚴格的品質控制以及培訓過的操作人員。

（邱鬱薇 譯 馬皓琳 李士通 校）

Perioperative monitoring of blood coagulation is critical to better understand causes of hemorrhage, to guide hemostatic therapies, and to predict the risk of bleeding during the consecutive anesthetic or surgical procedures. Point-of-care (POC) coagulation monitoring devices assessing the viscoelastic properties of whole blood, i.e., thrombelastography, rotation thrombelastometry, and Sonoclot® analysis, may overcome several limitations of routine coagulation tests in the perioperative setting. The advantage of these techniques is that they have the potential to measure the clotting process, starting with fibrin formation and continue through to clot retraction and fibrinolysis at the bedside, with minimal delays. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Viscoelastic POC coagulation devices are increasingly being used in clinical practice, especially in the management of patients undergoing cardiac and liver surgery. Furthermore, they provide useful information in a large variety of clinical scenarios, e.g., massive hemorrhage, assessment of hypo- and hypercoagulable states, guiding pro- and anticoagulant therapies, and in diagnosing of a surgical bleeding. A surgical etiology of bleeding has to be considered when viscoelastic test results are normal. In summary, viscoelastic POC coagulation devices may help identify the cause of bleeding and guide pro- and anticoagulant therapies. To ensure optimal accuracy and performance, standardized procedures for blood sampling and handling, strict quality controls and trained personnel are required.

門診手術病人監測麻醉後與快通道不可行相關的危險因素

Risk Factors Associated with Fast-Track Ineligibility After Monitored Anesthesia Care in Ambulatory Surgery Patients

Rebecca S. Twersky, MD, MPH, Svetlana Sapozhnikova, BA, and Ben Toure, MD

From the Department of Anesthesiology, SUNY Downstate Medical Center, Brooklyn, New York City, New York.

Anesth Analg 2008; 106:1421-1426

背景：門診手術麻醉後快通道被認為是在不損害病人安全和滿意度的同時提高效率和最大化利用資源的一種途徑。報導成功快通道的研究把重點主要放在麻醉技術上而不是與不成功的快通道相關的特定的病人因素、手術操作或者過程變數上。為了能夠執行改善快通道的程式、隨著時間測量變化以及鑒別出與病人監測麻醉後不能成功地到快通道相關的變數，我們完成了這個回顧性研究。

方法：指定了一個基於改良的Aldrete評分的用於所有接受監測麻醉的病人的快通道方案。它包括書面的方針變化和第一個月內醫護部門會議上的每週一次的回顧以及隨後的6個月幹預期內的每月回饋。收集的3個月基線和連續6個月幹預期的資料包括快通道狀態、外科服務和操作、手術者和麻醉者、年齡、性別、ASA評分、在手術室裏的總的時間以及總的手術後時間（手術結束到實際出院）。

結果：3個月基線期內完成了332例病例，在6個月幹預期內完成了641例病例。快通道成功率從23% 提高到了56% （P < 0.001）。多變數回歸分析得出的快通道不可行的獨立危險因素有病人年齡<60歲（與老年相比）、ASA評分III級（與I級相比）、普通外科（與整形外科和眼科相比）、實施後的月份以及總的術後時間。在快通道組總的術後時間明顯縮短了64分鐘（P < 0.001）。

結論：快通道的成功率能通過教育和病人的回饋得到提高和維持。我們鑒別出了與快通道不可行明顯相關的危險因素。如果在前瞻性的研究中發現這些因素與快通道不可行有關，那麼它們將促進用於快通道的多學科病人和程式特定的指南的制訂。

（吳進 譯 馬皓琳 李士通 校）

BACKGROUND: Fast-tracking after ambulatory anesthesia has been advocated as a pathway to improve efficiency and maximize resources without compromising patient safety and satisfaction. Studies reporting successful fast-tracking focus primarily on anesthesia techniques and not on specific patient factors, surgical procedure, or process variables associated with unsuccessful fast-tracking. We performed this retrospective study to implement a process for improving fast-tracking, measure change over time, and identify variables associated with patients unable to fast-track successfully after monitored anesthesia care.

METHODS: A fast-track protocol for all patients receiving monitored anesthesia care based on the Modified Aldrete Score was instituted. It consisted of written policy changes and weekly review at physician and nursing department meetings for the first month, followed by monthly feedback during a 6-mo intervention period. Data collected for a 3-mo baseline and the consecutive 6-mo intervention period included fast-track status, surgical service and procedure, surgeon and anesthesiology provider, age, gender, ASA status, total time in operating room, and total postoperative time (end of surgery to actual discharge).

RESULTS: Three hundred and thirty-two cases were completed during the 3-mo baseline period, and 641 cases were completed during the 6-mo intervention period. Fast-track success rate improved from 23% to 56%, P < 0.001. Independent risk factors for fast-track ineligibility identified by multivariate regression analysis were significant for patients <60 yr-old, ASA III versus I, general surgery versus orthopedics and ophthalmology, month after implementation, and total postoperative time. Total postoperative time was significantly shorter by 64 min in the fast-track group, P < 0.001.

CONCLUSION: Fast-track success rate can be improved and sustained over time by education and personnel feedback. We identified risk factors that were significantly associated with fast-track ineligibility. If those factors are found to be associated with fast-track ineligibility in a prospective investigation, they should enable development of multidisciplinary patient and procedure-specific guidelines for fast-tracking.

全麻對局麻藥的中樞神經系統和心血管系統毒性的影響

The Effects of General Anesthesia on the Central Nervous and Cardiovascular System Toxicity of Local Anesthetics

Susan E. Copeland, MVetClinStud, Leigh A. Ladd, PhD, Xiao-Qing Gu, BSc, and Laurence E. Mather, PhD

From the Department of Anaesthesia and Pain Management, University of Sydney at Royal North Shore Hospital, NSW 2065, Australia.

Anesth Analg 2008; 106:1429-1439

背景：局麻藥的毒性常常是在急性製備的麻醉實驗動物中進行研究的。我們測定了氟烷/ O2麻醉對6個醯胺類局麻藥靜脈注射後產生的心血管和中樞神經系統（CNS）毒性效應的影響。

方法：用以前作為試驗工具的母羊（約45-50kg, n = 18），測定了清醒和麻醉時分別在不同的場所，對靜脈輸注布比卡因(100 mg)、左布比卡因(125 mg)、羅呱卡因(150 mg)、利多卡因(350 mg)、甲呱卡因(350 mg)、丙胺卡因(350 mg)和鹽水（對照）3分鐘的行為、心血管和藥物代謝動力學方面的反應。

結果：局麻藥在清醒的羊中會導致驚厥，但是在全麻的羊中沒有明顯的CNS效應。在清醒的羊中，最初表現為負性收縮力和輕微心動過緩但動脈血壓不發生改變，接著在突然發作CNS興奮性中毒時表現為正性收縮力、心動過速和高血壓，伴隨QRS波群增寬。清醒的羊中輸注布比卡因、左布比卡因和羅呱卡因時致命的心律失常的發生率分別為3/11、2/12和3/13；輸注丙胺卡因時1/9發生電機械分離（接著多形性室性心動過速出現）導致死亡。在麻醉的羊中，全麻預先存在的心血管抑制在注射局麻藥後更加惡化了，增加的QRS寬度更延長了；同時血中局麻藥的濃度翻倍了。然而，所有的麻醉羊都存活了。

結論：全麻產生了生理性的干擾，加強了局麻藥的心臟抑制作用，改變了局麻藥的中毒劑量的藥代動力學。然而，局麻藥導致心血管毒性引起的死亡只發生在清醒的動物中。

（唐亮 譯 馬皓琳 李士通 校）

BACKGROUND: Local anesthetic toxicity is often studied experimentally in acutely prepared, anesthetized laboratory animals. We determined the influence of halothane/O₂ anesthesia on cardiovascular and central nervous system (CNS) toxic responses to six amide-type local anesthetics administered IV.

METHODS: Behavioral, cardiovascular, and pharmacokinetic responses were determined in previously instrumented ewes (approximately 45–50 kg, n = 18), on separate occasions when conscious and anesthetized, to bupivacaine (100 mg), levobupivacaine (125 mg), ropivacaine (150 mg), lidocaine (350 mg), mepivacaine (350 mg), prilocaine (350 mg), and saline (control) infused IV over 3 min.

RESULTS: The local anesthetics caused convulsions in conscious sheep, but no overt CNS effects in anesthetized sheep. Negative inotropy and slight bradycardia without changes in arterial blood pressure occurred initially in conscious sheep, followed by positive inotropy, tachycardia, and hypertension at the abrupt onset of CNS excitotoxicity, along with widening of QRS complexes. Fatal cardiac arrhythmias occurred in, respectively, 3 of 11, 2 of 12, and 2 of 13 conscious sheep infused with bupivacaine, levobupivacaine, and ropivacaine; in 1 of 9 with prilocaine, electromechanical dissociation (followed by polymorphic ventricular tachycardia) caused death. In anesthetized sheep, cardiovascular depression, preexisting from the general anesthesia, was exacerbated by all local anesthetics, and increased QRS width was prolonged; concurrent blood local anesthetic concentrations were doubled. Nevertheless, all anesthetized animals survived.

CONCLUSIONS: General anesthesia produced physiological perturbations, exacerbated local anesthetic-induced cardiovascular depression, and changed the pharmacokinetics of toxic doses of local anesthetics. However, cardiovascular fatalities from local anesthetics occurred only in conscious animals.

體外抑制有絲分裂原活化蛋白激酶通路對布比卡因和羅呱卡因誘發的神經毒性有保護作用

In Vitro, Inhibition of Mitogen-Activated Protein Kinase Pathways Protects Against Bupivacaine- and Ropivacaine-Induced Neurotoxicity

Philipp Lirk, MD, MSc^*, Ingrid Haller, MD^*, Hans Peter Colvin^*, Leopold Lang, Bettina Tomaselli, PhD, Lars Klimaschewski, MD, and Peter Gerner, MD^*

From the *Department of Anesthesiology and Critical Care, Division of Neuroanatomy, and Biocenter/Division of Neurobiochemistry, Medical University of Innsbruck, Austria; and Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2008; 106:1456-1464

背景：動物模型表明，特異性啟動p38有絲分裂原活化蛋白激酶（MAPK）可能是利多卡因導致神經毒性的一個關鍵步驟，但是對另外兩種應用非常廣泛的局麻藥布比卡因和羅呱卡因還未研究過。我們對如下假設進行了檢驗：（A）這些藥物的神經毒性小於其原型藥利多卡因，（B）它們對背根神經節神經元特定亞群具有選擇性毒性作用，（C）誘導p38 MAPK或相關酶如c-jun末端N-激酶（JNK）和細胞外信號調節激酶（ERK）的啟動。

方法：我們將原代培養的感覺神經元在相當於阻斷鈉電流劑量的利多卡因、布比卡因和羅呱卡因中孵育。然後，試圖找出布比卡因和羅呱卡因毒性對神經元亞群的潛在的選擇性。神經元亞群由免疫組織化學染色和細胞大小來確定。隨後，採用酶聯免疫吸附法檢驗p38 MAPK、JNK和ERK在其中的關聯性。最後，通過選擇性抑制p38 MAPK、JNK和ERK的活性確定MAPK通路在布比卡因和羅呱卡因誘導的神經毒性中的關聯性。

結果：我們發現在體外實驗中布比卡因和羅呱卡因的神經毒性效能相似，為劑量依賴性，但是對本研究涉及的神經元亞群沒有選擇性。布比卡因和羅呱卡因的神經毒性至少部分是MAPKs介導的。特別的是，我們證實了p38 MAPK和JNK途徑在布比卡因神經毒性中的關聯性，還描述了p38 MAPK途徑涉及羅呱卡因神經毒性的特徵。

結論：在等效劑量下，利多卡因在體外的神經毒性與布比卡因和羅呱卡因並沒有顯著差別。而且布比卡因和羅呱卡因對背根神經節神經元特定亞群產生的神經毒性並無不同。它們的神經毒性作用是通過啟動特定MAPKs產生的；在體外，使用特異性藥理學方法抑制這些激酶活性能夠減弱毒性作用。

（顏濤 譯， 馬皓琳 李士通 校）

BACKGROUND: Animal models show us that specific activation of the p38 mitogen-activated protein kinase (MAPK) may be a pivotal step in lidocaine neurotoxicity, but this has not been investigated in the case of two very widely used local anesthetics, bupivacaine and ropivacaine. We investigated the hypotheses that these drugs (A) are less neurotoxic than the prototype local anesthetic, lidocaine (B) are selectively toxic for subcategories of dorsal root ganglion neurons and (C) induce activation of either p38 MAPK or related enzymes, such as the c-jun terminal N-kinase (JNK) and extracellular signal-regulated kinase (ERK).

METHODS: We incubated primary sensory neuron cultures with doses of lidocaine, bupivacaine, and ropivacaine equipotent at blocking sodium currents. Next, we sought to determine potential selectivity of bupivacaine and ropivacaine toxicity on neuron categories defined by immunohistochemical staining, or size. Subsequently, the involvement of p38 MAPK, JNK, and ERK was tested using enzyme-linked immunosorbent assays. Finally, the relevance of MAPK pathways in bupivacaine- and ropivacaine-induced neurotoxicity was determined by selectively inhibiting activity of p38 MAPK, JNK, and ERK.

RESULTS: We found that the neurotoxic potency of bupivacaine and ropivacaine is dose-dependent and similar in vitro, but is not selective for any of the investigated subgroups of neurons. Neurotoxicity of bupivacaine and ropivacaine was mediated, at least in part, by MAPKs. Specifically, we demonstrated the relevance of both p38 MAPK and JNK pathways for the neurotoxicity of bupivacaine and characterized the involvement of the p38 MAPK pathway in the neurotoxicity of ropivacaine.

CONCLUSIONS: Given equipotent doses, the neurotoxic potential of lidocaine does not appear to be significantly different from that of bupivacaine and ropivacaine in vitro. Moreover, bupivacaine and ropivacaine do not exert their neurotoxicity differently on specific subsets of dorsal root ganglion neurons. Their neurotoxic effects are brought about through the activation of specific MAPKs; the specific pharmacologic inhibition of these kinases attenuates toxicity in vitro.

肝移植病人的心輸出量監測：肺動脈導管和未校準動脈壓波形分析比較

Cardiac Output Measurement in Patients Undergoing Liver Transplantation: Pulmonary Artery Catheter Versus Uncalibrated Arterial Pressure Waveform Analysis

Biais Matthieu, MD, Nouette-Gaulain Karine, MD, PhD, Cottenceau Vincent, MD, Vallet Alain, MD, Cochard Jean François, MD, Revel Philippe, MD, and Sztark François, MD, PhD

From the Service d'Anesthésie Réanimation I, Hôpital Pellegrin, Centre Hospitalo-Universitaire de Bordeaux, Place Amélie Raba-Léon, Bordeaux Cedex, France.

Anesth Analg 2008; 106:1480-1486

背景：心輸出量(CO)和創傷性血流動力學監測在肝移植中較為有用。儘管有潛在的併發症，肺動脈導管(PAC)仍常用于這些病人。近年來，開始採用一種較小創傷的設備 (Vigileo®/FloTrac^TM)，用動脈壓波形分析來估計CO，而不用體外校準。在這一研究中，我們比較了肝移植病人用自動熱稀釋PAC，暫態CO stat模式(ICO_SM) 得到的CO，和用這一新設備動脈壓波形分析（APCO）得到的CO。

方法：20例行肝移植病人，在鎮靜和機械通氣狀態下同時檢測APCO和 ICO_SM。檢測點如下：PAC插入後(T1–3)、門靜脈夾閉(T4–6)、無肝期(T7–9)、移植肝再灌注後(T10–15)和在ICU裏的術後期(T15–20)。

結果：我們登記了20例病人，獲得400個檢測值。沒有資料剔除。ICO_SM 和 APCO的偏差是0.8 L/min，一致性的95%極限是 –1.8到3.5 L/min. 百分誤差是 43%。 ICO_SM 和 APCO的偏差與全身血管阻力有相關性[r² = 0.55, P < 0.0001, y = 15.8–2.2 ln(x)] ，亞組分析發現偏差和百分誤差在低全身血管阻力的病人 (Child-Pugh B 和C級的病人)中有升高。在不同手術階段沒有差異。

結論：我們的結果提示在行肝移植的病人中Vigileo/FloTrac CO監測資料與自動熱稀釋方法得到的資料不一致，特別是全身血管阻力低的Child-Pugh B和C級病人。

（彭中美 譯 馬皓琳 李士通 校）

BACKGROUND: Cardiac output (CO) and invasive hemodynamic measurements are useful during liver transplantation. The pulmonary artery catheter (PAC) is commonly used for these patients, despite the potential complications. Recently, a less invasive device (Vigileo®/FloTrac^TM) became available, which estimates CO using arterial pressure waveform analysis without external calibration. In this study, we compared CO obtained with a PAC using automatic thermodilution, instantaneous CO stat-mode (ICO_SM), and CO obtained with the new device, arterial pressure waveform analysis (APCO) in patients undergoing liver transplantation.

METHODS: Twenty sets of simultaneous measurements of APCO and ICO_SM were determined in sedated and mechanically ventilated patients undergoing liver transplantation. Time points were as follows: after PAC insertion (T1–3), after portal clamping (T4–6), during anhepathy (T7–9), after graft reperfusion (T10–15), and in the postoperative period in the intensive care unit (T15–20).

RESULTS: We enrolled 20 patients and 400 measurements were obtained. No data were rejected. Bias between ICO_SM and APCO was 0.8 L/min, 95% limits of agreement were –1.8 to 3.5 L/min. The percentage error was 43%. Bias between ICO_SM and APCO was correlated with systemic vascular resistance [r² = 0.55, P < 0.0001, y = 15.8–2.2 ln(x)] and subgroup analysis revealed an increase in the bias and in the percentage error in patients with low systemic vascular resistance (Child-Pugh grade B and C patients). There was no difference between the different surgical periods.

CONCLUSIONS: Our results suggest that Vigileo/FloTrac CO monitoring data do not agree well with those of automatic thermodilution in patients undergoing liver transplantation, especially in Child-Pugh grade B and C patients with low systemic vascular resistance.

靜脈注射布比卡因造成心跳驟停的豬模型中複合使用腎上腺素和加壓素與脂肪乳劑比較

A Comparison of the Combination of Epinephrine and Vasopressin with Lipid Emulsion in a Porcine Model of Asphyxial Cardiac Arrest After Intravenous Injection of Bupivacaine

Viktoria D. Mayr, MD^*, Lukas Mitterschiffthaler, BS^*, Andreas Neurauter, MEng^*, Christian Gritsch, MRer.nat.^*, Volker Wenzel, MD^*, Tilko Müller, MD, Günter Luckner, MD^*, Karl H. Lindner, MD^*, and Hans-Ulrich Strohmenger, MD^*

From the Departments of *Anesthesiology and Critical Care Medicine, and Urology, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2008; 106:1566-1571

背景資料：在豬動物模型上，我們比較了複合使用腎上腺素和加壓素與脂肪乳劑對於布比卡因造成的心跳驟停後生存率的影響。

方法：在靜脈注射了0.5%布比卡因5mg/kg後，通氣停止2± 0.5min（均值±標準差）直到產生心跳驟停。在未處理的心跳驟停一分鐘後開始心肺復蘇。在心肺復蘇兩分鐘後，十個動物每隔5分鐘給予一次腎上腺素複合加壓素或4ml/kg的20%脂肪乳劑。每次給藥後三分鐘給予最多3次電擊（4、4和6 J/kg），以後的電擊均採用6 J/kg。實驗中自始至終采血以測定布比卡因的血漿濃度。

結果：在加壓素組，所有的五頭豬都存活，而脂肪乳劑組沒有一頭豬自發迴圈恢復（P<0.01）。兩組間血漿總布比卡因濃度沒有顯著性差異。

結論：在這個布比卡因導致的心跳驟停的模型中，加壓素複合腎上腺素的升壓藥與脂肪乳劑比較，在心肺復蘇中能產生更加高的冠狀動脈灌注壓並提高生存率。

(沈浩 譯 馬皓琳 李士通 校)

BACKGROUND: In a porcine model, we compared the effect of the combination of vasopressin/epinephrine with that of a lipid emulsion on survival after bupivacaine- induced cardiac arrest.

METHODS: After administration of 5 mg/kg of a 0.5% bupivacaine solution IV, ventilation was interrupted for 2 ± 0.5 (mean ± sd) min until asystole occurred. Cardiopulmonary resuscitation (CPR) was initiated after 1 min of untreated cardiac arrest. After 2 min of CPR, 10 animals received, every 5 min, either vasopressin combined with epinephrine or 4 mL/kg of a 20% lipid emulsion. Three minutes after each drug administration, up to three countershocks (4, 4, and 6 J/kg) were administered; all subsequent shocks with 6 J/kg. Blood for determination of the plasma bupivacaine concentration was drawn throughout the experiment.

RESULTS: In the vasopressor group, all five pigs survived, whereas none of five pigs in the lipid group had restoration of spontaneous circulation (P < 0.01). There was no significant difference between groups in the plasma concentration of total bupivacaine.

CONCLUSION: In this model of a bupivacaine-induced cardiac arrest, the vasopressor combination of vasopressin and epinephrine compared with lipid emulsion resulted in higher coronary perfusion pressure during CPR and survival rates.

麻醉學活躍的研究領域：麻醉學文獻的同引分析

Active Research Fields in Anesthesia: A Document Co-Citation Analysis of the Anesthetic Literature

Milan P. Jankovic, MD, Mark Kaufmann, MD, and Christoph H. Kindler, MD

Department of Anesthesia, University Hospital Basel, Basel, Switzerland.

Anesth Analg 2008; 106:1524-1533

背景：科學的發展導致了資訊流的增加以及不同研究領域間知識的連接以指數級增長。本研究中，我們使用文獻計量學方法來獲得一個形成麻醉學這個活躍的科學研究領域結構的概念網路。

方法：從《Web of Science®》（科學資訊研究所）選取2003年《Institute for Scientific Information Journal Citation Reports®》（科學資訊研究所期刊引用報告）所列的23本雜誌中主題標題為“麻醉學”的所有原始文獻（n = 3275）包括它們的參考文獻(n = 79,972)。挑選出高頻被引參考文獻(5)後，創建成對的同引參考文獻並將其用單鍵和變數水準聚類方法分組為均一結構的檔簇。另外，對每個檔簇，我們把與其相應的2003年紙類出版物區分開來，每個至少同引了簇核心的兩個文獻。然後用兩個已建立起來的簇和相應前沿論文中的檔標題檢查來命名活躍的麻醉學研究領域。這些研究領域根據該簇核心中近期文獻的比例（直接引用率指數）分類並進一步分析。

結果：確定了46個當前麻醉學研究領域。名為“食管引流型喉罩通氣道”的研究領域直接索引率指數最高（100%），而“神經性疼痛的實驗模型”及“揮發性麻醉藥引起的心肌保護作用”同引的實力水準最高（第9極）。最大的簇核心“術後噁心嘔吐”包括12篇相似的論文。《Anesthesia & Analgesia》 雜誌發表了大多數的前沿論文，而《Anesthesiology》雜誌發表了大多數的在前沿論文中作為參考文獻引用的基礎型文章。

結論：通過同引分析，我們識別出了高頻引用文獻的明顯相似的聚類表現在46個當前活躍的麻醉研究領域，並確定了其間的多重知識網路。

（朱 慧譯 馬皓琳 李士通校）

BACKGROUND: The expansion of science has resulted in an increased information flow and in an exponentially growing number of connections between knowledge in different research fields. In this study, we used methods of scientometric analysis to obtain a conceptual network that forms the structure of active scientific research fields in anesthesia.

METHODS: We extracted from the Web of Science® (Institute for Scientific Information) all original articles (n = 3275) including their references (n = 79,972) that appeared in 2003 in all 23 journals listed in the Institute for Scientific Information Journal Citation Reports® under the subject heading "Anesthesiology." After identification of highly cited references (5), pairs of co-cited references were created and grouped into uniformly structured clusters of documents using a single linkage and variable level clustering method. In addition, for each such cluster of documents, we identified corresponding front papers published in 2003, each of which co-cited at least two documents of the cluster core. Active anesthetic research fields were then named by examining the titles of the documents in both the established clusters and in their corresponding front papers. These research fields were sorted according to the proportion of recent documents in their cluster core (immediacy index) and were further analyzed.

RESULTS: Forty-six current anesthetic research fields were identified. The research field named "ProSeal laryngeal mask airway" showed the highest immediacy index (100%) whereas the research fields "Experimental models of neuropathic pain" and "Volatile anesthetic-induced cardioprotection" exhibited the highest level of co-citation strength (level 9). The research field with the largest cluster core, containing 12 homogeneous papers, was "Postoperative nausea and vomiting." The journal Anesthesia & Analgesia published most front papers while Anesthesiology published most of the fundamental documents used as references in the front papers.

CONCLUSIONS: Using co-citation analysis, we identified distinct homogenous clusters of highly cited documents representing 46 active current anesthetic research fields and determined multiple nets of knowledge among them.

關節內注射硫酸鎂和/或布比卡因用於膝關節鏡手術後的鎮痛

Intraarticular Injection of Magnesium Sulphate and/or Bupivacaine for Postoperative Analgesia After Arthroscopic Knee Surgery

Noha M. Elsharnouby^*, Hala E. Eid^*, Nahla F. Abou Elezz, and Ashraf N. Moharram

From the Departments of *Anesthesiology and Intensive Care, Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain-shams University, and Department of Orthopedic and Traumatology, Faculty of Medicine, Cairo University, Cairo, Egypt.

Anesth Analg 2008; 106:1548-1552

背景：關節內注射布比卡因經常被用於預防膝關節鏡手術後的疼痛。關節內注射鎂，一種N-甲基天冬氨酸受體阻滯劑，將在產生術後鎮痛或者增強關節內布比卡因的鎮痛效果方面引起人們特別的興趣。我們設計了該項研究以確定關節內硫酸鎂或布比卡因是否會降低VAS評分，並會減少鎮痛藥的需要量，以及二者聯合是否會較單獨應用一種藥物，更大地減少VAS評分，隨後減少鎮痛藥的需要量。

方法：108名行關節鏡下半月板切除術的病人隨機盲分入四組。鹽水安慰劑組(S組)病人注射20mL等滲鹽水，鎂組（M組）注射20ml加入了1g硫酸鎂的等滲鹽水。布比卡因組（B組）注射0.25%布比卡因20mL，而鎂和布比卡因組注射含0.25%布比卡因和1g硫酸鎂的混合液20mL。通過手術後1、2、4、6、8、12和24小時的VAS評分來評價術後鎮痛。休息和運動時病人的疼痛評分均進行評定。

結果：與其他組相比較，MB組的休息和運動時VAS評分顯著較低，首次需要術後鎮痛藥的時間顯著延遲，總的鎮痛藥的需求量也顯著較少。

結論：與單獨應用布比卡因、鎂，或鹽水安慰劑相比，鎂複合布比卡因關節內給藥會減少術後疼痛。

（黃麗娜 譯 馬皓琳 李士通 校）

BACKGROUND: Intraarticular bupivacaine is often used for prevention of pain after arthroscopic knee surgery. Intraarticular magnesium, a N-methyl-d-aspartate receptor blocker, would be of particular interest in either producing postoperative analgesia or enhancing the analgesic effect of intraarticular bupivacaine. We designed this study to determine whether intraarticular magnesium sulfate or bupivacaine results in a decrease in visual analog scale (VAS) score followed by a decrease in analgesic requirement and whether their combination would provide more reduction in VAS, and subsequently less analgesic requirement, than either drug alone.

METHODS: One-hundred and eight patients undergoing arthroscopic meniscectomy were randomized blindly into one of four parallel groups. The saline placebo group (group S) received 20 mL of isotonic saline, and the magnesium group (group M) received 20 mL of isotonic saline containing 1 g magnesium sulfate. The bupivacaine group (group B) received 0.25% (20 mL) bupivacaine, whereas the magnesium with bupivacaine group (group MB) received bupivacaine 0.25% and 1 g of magnesium sulfate in 20 mL. The postoperative analgesia was assessed using VAS recorded after surgery at 1, 2, 4, 6, 8, 12, and 24 h. Patients were evaluated at rest and with movement.

RESULTS: Group MB had a significantly reduced VAS both at rest and on movement, a significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic requirement than other groups.

CONCLUSION: Magnesium combined with bupivacaine produces a reduction in postoperative pain when given intraarticularly in comparison to either bupivacaine or magnesium alone, or to saline placebo.

比較全身複合硬膜外麻醉（0.375％羅呱卡因）和單純全麻用於上腹部手術

Combined General/Epidural Anesthesia (Ropivacaine 0.375%) Versus General Anesthesia for Upper Abdominal Surgery

Yuhong Li, MD, PhD, Shengmei Zhu, MD, PhD, and Meijuan Yan, MS

From the Department of anesthesiology, First Affiliated Hospital, School of Medicine, Zhejiang University, China.

Anesth Analg 2008; 106:1562-1565

背景：我們研究了0.375％羅呱卡因用於硬膜外複合全身麻醉下行腎切手術時對應激反應和麻醉藥用量的影響。

方法：32名ASAI-II級，因腎臟腫瘤行長約2h腎切手術的成年患者隨機分成兩組：硬膜外（生理鹽水）/全身麻醉組（C組）和硬膜外（0.375％羅呱卡因）/全身麻醉組（R組）。靶控輸注舒芬太尼和異丙酚行麻醉誘導，滴定到BIS達到40－50。靶控輸注維庫溴銨行氣管插管。插管後，用異丙酚輸注維持麻醉，滴定到BIS值保持在40－50。根據動脈血壓和心率水準調整舒芬太尼的靶濃度。分別在氣管插管前即刻、插管後2min、切皮後即刻、腹腔探查開始後即刻、手術開始後1h及拔管後即刻抽取血樣以測量血中腎上腺素、血糖和皮質醇水準。

結果：與R組相比較，C組在手術開始後1h及拔管後即刻糖和皮質醇的血漿濃度相對變化較大。兩組血中腎上腺素的水準相類似。術中用於麻醉誘導和維持所需的異丙酚用量沒有顯著差異，但是麻醉維持中舒芬太尼的用量在R組顯著減少(P < 0.05)。

結論：硬膜外0.375％羅呱卡因用於腎切手術麻醉維持可抑制圍術期應激激素反應並且減少舒芬太尼的用量。

（黃佳佳譯，馬皓琳，李士通校）

BACKGROUND: We designed this study to investigate the effect of 0.375% ropivacaine on stress hormone responses and anesthetic requirements in combined epidural/ general anesthesia for nephrectomy.

METHODS: Thirty-two adults, ASA physical status I–II, undergoing nephrectomy lasting about 2 h for renal carcinoma were randomly assigned to one of two groups: epidural (saline)/general anesthesia (group C) and epidural (0.375% ropivacaine)/ general (group R) anesthesia. Induction of anesthesia was performed with target-controlled infusion sufentanil and propofol titrated to achieve bispectral index score (define) between 40 and 50. Endotracheal intubation was facilitated by the target-controlled infusion administration of vecuronium. After intubation, anesthesia was maintained with propofol infusion titrated to maintain bispectral index between 40 and 50. The target concentration of sufentanil was titrated according to arterial blood pressure and heart rate. Plasma samples were taken immediately before, 2 min after tracheal intubation, immediately after incision, immediately after the initiation of celiac exploration, 1 h after operation, and immediately after tracheal extubation for measurements of epinephrine, glucose, and cortisol in both groups.

RESULTS: The relative changes of plasma concentrations of glucoses and cortisol were higher at 1 h after operation and immediately after extubation in group C when compared with group R. The plasma concentrations of epinephrine in both groups were similar. The requirements of propofol for induction and maintenance of anesthesia were not statistically different in the groups, but the requirement of sufentanil during maintenance was significant reduced in group R (P < 0.05).

CONCLUSIONS: Epidural ropivacaine 0.375% suppressed stress hormone responses and sufentanil requirements perioperatively during maintenance of anesthesia for nephrectomy.

.濃縮纖維蛋白原、ⅩⅢ因數和新鮮冷凍血漿對離體血液稀釋（60%）導致血凝形成障礙的影響

The In Vitro Effects of Fibrinogen Concentrate, Factor XIII and Fresh Frozen Plasma on Impaired Clot Formation After 60% Dilution

Thorsten Haas, MD^*, Dietmar Fries, MD, Corinna Velik-Salchner, MD^*, Christian Reif, Anton Klingler, MD, PhD, and Petra Innerhofer, MD^*

From the Departments of *Anaesthesiology and Critical Care Medicine, General and Surgical Critical Care Medicine, Pediatrics, General and Transplant Surgery, Division of Theoretical Surgery, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2008 106: 1360-1365.

背景：先前的研究表明提高纖維蛋白原濃度能改善稀釋性血凝塊形成。作者進行了一項離體研究來探討應用纖維蛋白原、因數ⅩⅢ（FⅩⅢ）及聯合應用是否改善血凝塊形成，以及在應用纖維蛋白原或新鮮冷凍血漿後是否產生不同的效應。

方法：採集六名健康捐獻者血液並用乳酸林格氏溶液稀釋60%。稀釋的等量血液樣本分別加入兩種不同劑量的纖維蛋白原濃聚物，FⅩⅢ濃聚物，或聯合應用，或兩種不同劑量的新鮮冷凍血漿。使用血栓彈力測定儀（ROTEM）測定血液樣本在基礎狀態（未稀釋）、血液稀釋後和補充凝血物質後凝血指標。變化由變異係數表示，比較單純應用纖維蛋白原濃聚物或聯合應用FⅩⅢ的效應及應用新鮮冷凍血漿後的效應。

結果：血液稀釋60%後，所有ROTEM參數和凝血試驗指標均出現顯著變化。單純使用FⅩⅢ後無顯著影響，聯合使用纖維蛋白原後凝血時間、α角和纖維蛋白原和纖維蛋白聚合作用得到改善並強于單用纖維蛋白原組。在應用新鮮冷凍血漿替代纖維蛋白原後，所有ROTEM變異係數的中值在正常範圍，出現劑量依賴性變化(EXTEM MCF FFP 小劑量 [38 (35, 40.3) mm)]，凝血時間縮短到近基礎值。

結論：血液稀釋後在加入纖維蛋白原可恢復所有的ROTEM參數。這種效應在聯合應用FⅩⅢ後增強，其作用強於新鮮冷凍血漿。

（胡瀟 譯 陳傑 校）

BACKGROUND: Previous investigations have shown that increasing fibrinogen concentration improves dilution-dependent impairment of clot formation. We conducted an in vitro study to explore whether substitution with fibrin-stabilizing factor XIII (FXIII) combined with fibrinogen promotes further improvement of clot formation, and whether fibrinogen administration as concentrate or fresh frozen plasma (FFP) results in comparable effects.

METHODS: Blood from six healthy donors was diluted by 60% using lactated Ringer’s solution. Aliquots of diluted blood samples were incubated with two different doses of fibrinogen concentrate, FXIII concentrate, the combination of both, or with two different doses of FFP. Using thrombelastometry (ROTEM®) blood samples were analyzed at baseline (undiluted), after dilution and after supplementation. Variables were analyzed for changes from baseline, and effects of fibrinogen concentrate alone or combined with FXIII were compared with effects observed with corresponding FFP doses.

RESULTS: After 60% in vitro dilution of blood all ROTEM parameters and global coagulation tests changed significantly. Among the substitutes tested FXIII alone had no effect, the combination with fibrinogen improved coagulation time, angle and fibrinogen/fibrin polymerization significantly more than did small-dose fibrinogen alone. After substituting fibrinogen, median values of all ROTEM variables were within the normal range, thereby showing dose dependency but also significant differences (P = 0.027) from corresponding FFP doses (EXTEM MCF FFP small dose [38 (35, 40.3) mm)], which enabled only coagulation time to be shortened to baseline levels.

CONCLUSIONS: Supplementation of fibrinogen restored all ROTEM parameters after dilution. This effect was partially enhanced by adding FXIII and was significantly stronger than for FFP substitution.

氟呱啶醇聯合地塞米松對腹腔鏡輔助下陰式子宮切除術後噁心嘔吐的預防作用

The Prophylactic Effect of Haloperidol Plus Dexamethasone on Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopically Assisted Vaginal Hysterectomy

Chin-Chen Chu, MD^*, Ja-Ping Shieh, MD, MS^*, Jann-Inn Tzeng, MD, MS^*, Jen-Yin Chen, MD, MS^*, Yi Lee, MD, Shung-Tai Ho, MD, MS, and Jhi-Joung Wang, MD, PhD^*

From the *Department of Anesthesiology, Chi-Mei Medical Center, Tainan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei; and Department of Anesthesiology, Buddhist Tzu-Chi Medical Center, Tzu-Chi University School of Medicine, Hualien, Taiwan.

Anesth Analg 2008 106: 1402-1406.

背景：氟呱啶醇，一種常用鎮靜劑，已發現具有較強的鎮吐作用而用於術後噁心嘔吐的防治，但聯合應用氟呱啶醇和地塞米松對術後噁心嘔吐的治療作用尚未評估。筆者通過與單純給與氟呱啶醇、安慰劑或氟呱利多比較評估聯合應用氟呱啶醇和地塞米松對腹腔鏡輔助下陰式子宮切除術後噁心嘔吐的預防作用。

方法：400名成年行腹腔鏡輔助下陰式子宮切除術的女性患者（n=80，分為四組）入選此隨機、雙盲、安慰劑、正性對照的研究。在麻醉誘導後15min分別給與生理鹽水（S組）、氟呱利多1.25mg(D組)、氟呱啶醇2mg( H組)、地塞米松5mg( Dx組)或氟呱啶醇2mg+地塞米松5mg( H+Dx組)。記錄術後噁心嘔吐和藥物相關的副作用。

結果：術後噁心嘔吐的發生率分別為D組36%，H組37%，Dx組38%，H+Dx組19%，均顯著低於S組65%（P<0.05），H+Dx組發生率最低（19%，P<0.05）。5組中QT間期延長、術後疼痛的程度、鎮靜深度及錐體外系症狀等副作用沒有顯著差異。

結論：同時給與氟呱啶醇2mg和地塞米松5mg較應用安慰劑及單一藥物患者術後噁心嘔吐的發生率低，且不增加副作用的發生。

（潘方立 譯 陳傑 校）

BACKGROUND: Haloperidol, a major tranquilizer, has been found to have a potent antiemetic effect on postoperative nausea and vomiting (PONV), but the prophylactic effect of haloperidol plus dexamethasone on PONV has not been evaluated. We evaluated the prophylactic effect of haloperidol plus dexamethasone to either given alone, placebo or droperidol on PONV in patients undergoing a laparoscopic-assisted vaginal hysterectomy.

METHODS: Four hundred adult women (n = 80 in each of five groups) scheduled for a laparoscopic-assisted vaginal hysterectomy were enrolled in a randomized, double-blind, placebo, and positive-control study. Fifteen minutes after the induction of anesthesia, patients received an IV injection of either saline (group S), droperidol 1.25 mg (group D), haloperidol 2 mg (group H), dexamethasone 5 mg (group Dx), or haloperidol 2 mg plus dexamethasone 5 mg (group H + Dx) to prevent PONV. The occurrence of PONV and medication-related side effects were recorded.

RESULTS: The incidences of PONV (0–24 h) in the D (36%), H (37%), Dx (38%), and H + Dx (19%) groups were significantly lower than in the S group (65%; P < 0.05 for each comparison). The H + Dx group had the lowest incidence of PONV (19%; P < 0.05 for each comparison) of the five study groups. No differences were found between the D, H, and Dx groups. Also, no differences were found among the five groups in the side effects of QT prolongation, intensity of postoperative pain, level of sedation, and occurrence of extra-pyramidal symptoms.

CONCLUSION: Prophylactic haloperidol 2 mg plus dexamethasone 5 mg produced a greater reduction in the incidence of PONV than did either drug used alone, placebo or droperidol without increasing perioperative adverse outcomes.

氟呱啶醇伍用昂丹司瓊與單用昂丹司瓊對術後噁心嘔吐預防作用的比較

Haloperidol Plus Ondansetron Versus Ondansetron Alone for Prophylaxis of Postoperative Nausea and Vomiting

Loreta Grecu, MD^*, Edward A. Bittner, MD, PhD^*, Jay Kher, MD, Sarah E. Smith, BS, and Carl E. Rosow, MD, PhD^*

From the *Department of Anesthesia and Critical Care, Massachusetts General Hospital; Tufts New England Medical Center; and Boston University School of Medicine, Boston, Massachusetts.

.Anesth Analg 2008 106: 1410-1413.

介紹：氟呱啶醇1mg與昂丹司瓊4mg對術後噁心嘔吐的預防作用及安全性是相同的。本研究比較了兩藥伍用與單用昂丹司瓊的區別。

方法：本研究為隨機、雙盲研究，共有268位成年全麻病人入組並隨機分為氟呱啶醇1mg與昂丹司瓊4mg伍用組、生理鹽水1mg與昂丹司瓊4mg伍用組。同時收集患者進入PACU480min內的有效性及安全性的相關資料。

結果：氟呱啶醇與昂丹司瓊伍用組的完整回應更多（76.2%vs59.2%）, 更少噁心、復蘇反應，但復蘇時間延長。而兩組間的鎮靜、術後住院時間、QTc延長均無差異。研究中患者未出現肌力改變、靜坐不能或嚴重心律失常。

結論：氟呱啶醇與昂丹司瓊伍用較單用昂丹司瓊對術後噁心嘔吐的預防作用更為顯著，作用時間也更長，而併發症未出現增多趨勢。

（陶穎瑩 譯 陳傑 校）

INTRODUCTION: Haloperidol 1 mg and ondansetron 4 mg are equally safe and effective for postoperative nausea and vomiting prophylaxis. We compared the combination to ondansetron alone in a mixed surgical population.

METHODS: Two-hundred and sixty-eight adults undergoing general anesthesia received 4 mg ondansetron plus 1 mg haloperidol or saline in this randomized, double-blind protocol. Efficacy and safety data were obtained until 480 min after postanesthesia care unit entry.

RESULTS: The combination had more complete responders (76.2% vs 59.2%), less nausea, less rescue, and longer time to rescue. Sedation, time to postanesthesia care unit discharge, and QTc prolongation were not different. No subject had dystonia, akathisia, or serious dysrhythmias.

CONCLUSIONS: Postoperative nausea and vomiting prophylaxis with both drugs is significantly more effective and longer lasting than ondansetron alone. There is no detectable increase in side effects

普萘洛爾增加清醒大鼠利多卡因誘導的驚厥閾值:對大腦的直接影響

Propranolol Increases the Threshold for Lidocaine-Induced Convulsions in Awake Rats: A Direct Effect on the Brain

Taketo Nakamura, MD, Yutaka Oda, MD, PhD, Ryota Takahashi, MD, PhD, Katsuaki Tanaka, MD, PhD, Ichiro Hase, MD, PhD, and Akira Asada, MD, PhD

From the Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan.

Anesth Analg 2008 106: 1450-1455.

背景：普奈洛爾是一種臨床上常用的β受體阻滯劑。局麻藥用於控制疼痛, 普奈洛爾用來治療高血壓和心動過速。然而,很少有實驗來研究普奈洛爾在局麻中的毒性作用。作者研究了在清醒自主呼吸的大鼠中,普萘洛爾對於利多卡因誘發驚厥的影響。

方法：雄性SD大鼠隨機分為6組(每組8只) 。大鼠預先在腦室內注射生理鹽水(腦室對照組:CV-C組), 10 或 30 µg/kg普奈洛爾(小劑量組:CV-S組,大劑量組:CV-L組),或者靜脈注射生理鹽水(靜脈對照組:IV-C組), 1 或 3 mg/kg普奈洛爾(小劑量組: IV -S組,大劑量組: IV -L組) 。3min後靜脈給與利多卡因（4mg/kg/min）直到發生強直陣攣性抽搐。

結果：引起抽搐的利多卡因劑量在CV-L組較CV-C組高(30.6 ± 5.1 vs 23.5 ± 2.2 mg/kg,, P = 0.008) 。 在發生抽搐時，CV-L組血漿總利多卡因濃度以及未結合蛋白的利多卡因濃度，大腦中利多卡因的濃度較CV-C組高(36.1 ± 4.8 vs 26.0 ± 3.8 µg/mL, 22.5 ± 3.5 vs 13.7 ± 2.6 µg/mL, 82.7 ± 7.1 vs 57.3 ± 5.7 µg/g, P < 0.001)。IV -L組的驚厥劑量，血漿總利多卡因濃度以及未結合蛋白的利多卡因濃度，大腦中利多卡因的濃度較IV -S組及CV-L組高。IV -L組靜脈給予利多卡因前血漿普奈洛爾的濃度相比CV-L組增高60倍(554.7 ± 104.6 和 9.3 ± 6.7 ng/mL)。

結論：普奈洛爾通過直接作用于大腦而增加利多卡因誘導驚厥的閾值。

（杜唯佳 譯 陳傑 校）

BACKGROUND: Propranolol is a β-adrenoceptor antagonist used clinically. Local anesthetics are used for controlling pain, whereas propranolol is concomitantly given to treat hypertension and tachycardia. However, there are few studies examining the effects of propranolol on the toxicity of local anesthetics. We investigated the effect of propranolol on lidocaine-induced convulsions in awake, spontaneously breathing rats.

METHODS: Male Sprague-Dawley rats were randomly divided into six groups (n = 8, each group). Rats were pretreated with intracerebroventricular saline (cerebroventricle- control: CV-C group), 10 or 30 µg/kg of (S)-(–)-propranolol (propranolol) (cerebroventricle-small dose: CV-S and cerebroventricle-large dose: CV-L groups, respectively) or IV saline (IV-control: IV-C group), 1 or 3 mg/kg of propranolol (IV-small dose: IV-S and IV-large dose: IV-L groups, respectively). Three minutes later, lidocaine was administered IV at 4 mg · kg^–1 · min^–1 until tonic-clonic convulsions occurred.

RESULTS: The convulsive dose of lidocaine in the CV-L group was significantly larger than that in the CV-C group (30.6 ± 5.1 vs 23.5 ± 2.2 mg/kg, respectively, P = 0.008). Plasma concentrations of total and protein-unbound lidocaine, concentrations of lidocaine in the brain at the onset of convulsions were also significantly higher in the CV-L group than those in the CV-C group (36.1 ± 4.8 vs 26.0 ± 3.8 µg/mL, 22.5 ± 3.5 vs 13.7 ± 2.6 µg/mL, 82.7 ± 7.1 vs 57.3 ± 5.7 µg/g, P < 0.001 for all). The convulsive dose, plasma concentrations of total and protein-unbound lidocaine, and brain lidocaine in the IV-L group were also significantly larger than those in IV-C group and comparable with those in the CV-L group. The plasma concentration of propranolol before starting an infusion of lidocaine in the IV-L group was approximately 60-fold higher than that in the CV-L group (554.7 ± 104.6 and 9.3 ± 6.7 ng/mL, respectively).

CONCLUSIONS: Propranolol increased the threshold for lidocaine-induced convulsions by directly acting on the brain.

地氟醚預處理通過靶向作用於TNF-α近端信號而抑制NF-κB的活化

Desflurane Preconditioning Inhibits Endothelial Nuclear Factor--B Activation by Targeting the Proximal End of Tumor Necrosis Factor- Signaling

Yuan Li, MD^*, Xiaonan Zhang, MSc, Biao Zhu, MD^*, and Zhanggang Xue, MD^*

From the *Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China; and Shanghai Public Health Clinical Center, Fudan University, Shanghai, China.

.Anesth Analg 2008 106: 1473-1479.

背景： 揮發性麻醉藥可干擾缺血再灌注損傷中起關鍵作用的炎症因數及粘附分子的表達。有報導顯示這一過程可抑制NF-κB，但其詳細分子機制並未闡明

方法： 用地氟醚預處理（1MAC）ECV304(人臍靜脈內皮細胞)30min，沖洗15min後，缺氧30min，再氧合60min，最後以TNF-α（10μg/ml）刺激ECV304。未進行預處理以及/或者未刺激的對照組也包括入實驗。通過蛋白質印跡法檢測IκB-α,磷酸IκB-α，磷酸IκB-α激酶（IKKα）/IKKβ以及磷酸-p38。核NF-κBp65亞基通過亞細胞分級及蛋白質印跡法測量。TNF-R1在細胞表面的表達量用流式細胞計量術來測量。受體相關的信號轉導因數如TRAF-2和IKKα則以TNF-R1的抗體和之後的蛋白質印跡法通過免疫沉澱法來測量。

結果： 預處理可抑制IκB-α的磷酸化，降解及p65的核定位。地氟醚也可影響p38的磷酸化，而p38的磷酸化在適度的炎症反應中有一定作用。IKKα/IKKβ的磷酸化可被預處理抑制，然而細胞表面大量的TNF-R1不受影響。TRAF-2和IKKα與TNF-R1的聯繫也被地氟醚所破壞。

結論： 研究結果顯示地氟醚在NF-κB途經上的分子靶點在IKK的活化以前，細胞膜表面大量的TNF-R1不受麻醉劑預處理的影響。研究顯示地氟醚預處理靶向作用於TNF-α近端信號。

（潘錢玲譯 陳傑 校）

BACKGROUND: Volatile anesthetics interfere with inflammatory cytokine production and expression of adhesion molecules which are critical for ischemia reperfusion induced injury. Nuclear factor (NF)-B has been reported to be suppressed in this process, but the detailed molecular mechanism is still unclear.

METHODS: In this study, ECV304 (a human umbilical vein endothelial cell line) was preconditioned with 30 min desflurane (1 minimal alveolar concentration), after 15 min washout, 30 min anoxia, and 60 min reoxygenation was performed. ECV304 was finally stimulated with tumor necrosis factor (TNF)- (10 ng/mL). Control groups, which were not preconditioned and/or not stimulated, were also included in the protocol. IB-, phospho-IB-, phospho-IB kinase (IKK)/IKKβ, and phopho-p38 were detected by Western blotting. The nuclear NF-B p65 subunit was measured by subcellular fractionation and Western blotting. The surface expression of TNF-R1 was measured by flow cytometry. Receptor-associated signaling adaptors, e.g., TNF receptor-associated factor 2 (TRAF2) and IKK-, were evaluated by immunoprecipitation by TNF-R1 antibody and subsequent Western blotting.

RESULTS: Desflurane preconditioning inhibits IB- phosphorylation, degradation, and p65 nuclear localization. Desflurane also affects p38 phosphorylation, which is needed for optimal inflammatory response. The phosphorylation of IKK/IKKβ was suppressed by preconditioning while the surface abundance of TNF-R1 was not affected. The association of TRAF2 and IKK- with TNF-R1 was compromised by desflurane.

CONCLUSIONS: Our results suggest that the molecular target of desflurane in the NF-B pathway is upstream of IKK activation. The abundance of TNF-R1 on the cell membrane is not affected by anesthetic preconditioning. We suggest that desflurane preconditioning targets the proximal end of TNF- signaling.

直接喉鏡法中顯示不佳和上唇咬診評分增高是GlideScope®視頻喉鏡困難氣管插管的預測因數

Poor Visualization During Direct Laryngoscopy and High Upper Lip Bite Test Score Are Predictors of Difficult Intubation with the GlideScope® Videolaryngoscope

Marie-Hélène Tremblay, MD, Stephan Williams, MD, PhD, Arnaud Robitaille, MD, FRCPC, and Pierre Drolet, MD, FRCPC

From the Department of Anesthesiology, CHUM, Hôpital Notre-Dame, University of Montréal, Montréal, Canada.

.Anesth Analg 2008 106: 1495-1500.

背景：在聲門可視性方面，GlideScope®視頻喉鏡等於或優於直接喉鏡，但GlideScope®困難插管的預測特徵尚未評定。本前瞻性研究主要評定病人困難GlideScope®插管的特徵。

方法：記錄400名進行氣管插管麻醉患者的術前人口學及形態學特徵。誘導後，在所有病人中應用直接喉鏡評估Cormack和Lehane聲門可視性，然後行GlideScope®插管。記錄插管次數及所需時間。用單變數和多變數分析法鑒定與困難GlideScope®插管相關的特點。

結果：342例患者1次插管成功，48例患者2次插管成功，9例患者3次插管成功，1名病人插管失敗。平均插管時間為21±14s. 單變數分析後發現以下特點與插管時間較長和/或多次嘗試有關：高齡、男性、打鼾史、高Mallampati氣道等級、張口度小、甲頦距離短、頸圍大、上唇咬診評分高及在直接喉鏡中高的Cormack和Lehane等級。然而，在logistic及比例風險多元回歸模型中分析這些變數發現只有直接喉鏡Cormack和Lehane等級高、上唇咬診評分高及甲頦距離短與插管時間長或多次嘗試顯著相關。

結論：儘管成功率高，在直接喉鏡Cormack和Lehane等級高、上唇咬診評分高或甲頦距離短的病人中使用GlideScope®插管可能更具挑戰性。

（張燕 譯 陳傑 校）

BACKGROUND: The GlideScope® videolaryngoscope allows equal or superior glottic visualization compared with direct laryngoscopy, but predictive features for difficult GlideScope intubation have not been identified. We undertook this prospective study to identify patient characteristics associated with difficult GlideScope intubation.

METHODS: Demographic and morphometric factors were recorded preoperatively for 400 patients undergoing anesthesia with endotracheal intubation. After induction, direct laryngoscopy was performed in all patients to assess the Cormack and Lehane grade of glottic visualization followed by GlideScope intubation. The number of attempts and time needed for intubation were recorded. Univariate and multivariate analyses were performed to identify the characteristics associated with difficult GlideScope intubation.

RESULTS: Intubation required 1, 2, and 3 attempts in 342, 48, and 9 participants, respectively, with one failure. Mean time for intubation was 21 ± 14 s. After univariate analysis, the following characteristics were significantly correlated (P < 0.05) with longer time to intubate and/or multiple attempts: older age, male sex, history of snoring, high Mallampati class, small mouth opening, short sternothyroid and manubriomental distances, large neck circumference, high upper lip bite test score, and high Cormack and Lehane grade during direct laryngoscopy. However, after introducing these variables in nominal logistic and proportional hazard multiple regression models, only high Cormack and Lehane grade during direct laryngoscopy, high upper lip bite test score, and short sternothyroid distance were significantly associated with multiple attempts or lengthier intubations.

CONCLUSION: Despite a high success rate, intubation with the GlideScope is likely to be more challenging in patients with high Cormack and Lehane grade during direct laryngoscopy, high upper lip bite test score, or short sternothyroid distance.

咪達唑侖對大鼠腦局部糖代謝具有時間依賴性的影響

The Time-Dependent Effects of Midazolam on Regional Cerebral Glucose Metabolism in Rats

Ulderico Freo, MD^*, Mauro Dam, MD, and Carlo Ori, MD^*

From the *Department of Pharmacology and Anesthesiology, University of Padova, Padova, Italy; and Istituto di Cura San Camillo, Ospedale/IRCCS, Venezia – Lido, Italy.

Anesth Analg 2008 106: 1516-1523.

背景：咪達唑侖有催眠和鎮靜作用，這可能是由不同的神經元結構介導的。作者研究催眠劑量的咪達唑侖對意識行為和腦代謝模式的影響。
方法：疼痛反射的喪失及自主運動降低被用作衡量咪達唑侖催眠和鎮靜效果的指數，腦局部糖代謝率（ rCMRglc ）作為咪唑唑侖的神經元影響指數。在靜脈注射鹽水或咪達唑侖（5 mg/kg）後2，30，60，120和180min後測定T-344大鼠62個腦區的自主運動活性（用監測儀測定）及rCMRglc（用2 -去氧葡萄糖（¹⁴C ）放射性定量測定法）。

結果：咪達唑侖注射後，大鼠在2min內麻醉，30分鐘清醒，但自主運動活性嚴重受損，此後逐漸恢復。麻醉可引起rCMRglc的普遍降低（ 59個腦區受影響，平均降低38 ％） 。意識恢復與rCMRglc在視覺，聽覺，自體感覺皮質和藍斑的正常化相關聯（ 47個腦區受影響，減少31 ％） 。活動度的恢復與rCMRglc在額部、邊緣區域、和丘腦的緩慢正常化相類似（在 60、120和180分鐘，分別有31個、17個及4個區域受影響， 導致26%、20%和15％的控制值跌幅） 。
結論：咪達唑侖的催眠作用可能是大腦覺醒和感官功能的抑制引起的，其鎮靜作用可能由皮層下功能和邊緣區域抑制所致。

（陳偉 譯 陳傑 校）

BACKGROUND: Midazolam has hypnotic and sedative activities, which may be mediated by different neuronal structures. We investigated the time course effect of a hypnotic dose of midazolam on conscious motor behavior and on patterns of brain metabolism.

METHODS: Loss of nociceptive reflexes and impairment of spontaneous locomotor activity were used as indices for the hypnotic and sedative effects of midazolam, and the regional cerebral metabolic rates for glucose (rCMRglc) were used as indices of neuronal effects of midazolam. Locomotor activity was measured with a monitor and rCMRglc were measured with the quantitative autoradiographic [¹⁴C]2-deoxyglucose procedure in 62 brain regions of Fischer-344 rats at 2, 30, 60, 120, and 180 min after IV administration of saline or midazolam 5 mg/kg.

RESULTS: After midazolam administration, rats were anesthetized at 2 min, awake but severely impaired at 30 min and slowly recovering motor activity thereafter. Anesthesia was associated with widespread rCMRglc decreases (59 areas affected, 38% mean decrease). Recovery of consciousness was associated with normalizing rCMRglc in visual, auditory, and somatosensory cortices and in the locus coeruleus (47 regions affected, 31% decrease). Recovery of motor activity was paralleled by slow rCMRglc normalization in the frontal motor, limbic, and thalamic regions (at 60, 120, and 180 min 31, 17, 4 areas affected, 26, 20, and 15% decreases from control values).

CONCLUSIONS: Whereas the hypnotic effects of midazolam may result from inhibition of brain structures involved in arousal and sensory processing, its sedative effects may result from inhibition of subcortical motor and limbic regions.

用超聲判斷頸部硬膜外阻滯穿刺針的深度

Sonographic Estimation of Needle Depth for Cervical Epidural Blocks

Soo Hwan Kim, MD^*, Kang Hun Lee, MD^*, Kyung Bong Yoon, MD, PhD^*, Woo Young Park, MD^*, and Duck-Mi Yoon, MD, PhD^*

From the Departments of *Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University Health System, Seoul, Korea.

Anesth Analg 2008 106: 1542-1547.

背景：在頸部硬膜外腔內注射類固醇類藥物可以治療面部，頸部和上肢的急慢性疼痛綜合征。超聲是神經阻滯時有價值的工具，在穿刺前可提供有用的組織資訊。本研究目的是通過比較超聲顯影下皮膚到硬脊膜之間的距離與實際皮膚到硬脊膜的距離來評估超聲的準確度和精確度。

方法：從疼痛門診選取50例需頸部硬膜外阻滯治療的患者。選取頸6/7區域的冠狀面和矢狀面超聲影像。在矢狀面超聲束引導下將硬膜外穿刺針置入，並比較各個超聲面上皮膚到硬脊膜之間的距離與實際皮膚到硬脊膜的距離。另外，檢測超聲的可見度、穿刺次數及併發症。

結果：冠狀面及矢狀面測量的間距與實際穿刺針的深度之間的相關係數分別為0.9272，0.9268。48個病人順利的完成了頸部硬膜外阻滯（96%）。兩個病人硬膜被穿破（2%）。沒有發生與硬膜外阻滯相關的血性穿刺液流出，阻滯後併發症及血流動力學的不穩定。

結論：超聲能為頸段硬膜外阻滯提供皮膚到硬膜的精確穿刺距離。在穿刺前明確皮膚至硬膜外距離及椎管的解剖結構能夠幫助我們在硬膜外穿刺時更安全的定位。

（王騰 譯 陳傑 校）

BACKGROUND: Cervical epidural steroid injections are often used to treat acute and chronic pain syndromes involving the face, neck, and upper extremities. Ultrasound has evolved as a valuable tool for performing neuraxial blocks, providing useful prepuncture information on the structure. Our goal was to evaluate the accuracy and precision of ultrasound by comparing skin to dura distance from ultrasound with the actual skin to epidural depth.

METHODS: We enrolled 50 patients undergoing cervical epidural blocks at the pain clinic. Ultrasound images with transverse and longitudinal median views of the C6/7 area were taken. The epidural needle was inserted, reproducing the direction of the ultrasound beam on the longitudinal median view. Measured distances from skin to dura on each ultrasound view were compared with the actual needle depth. Additionally, we examined ultrasound visibility, the number of puncture attempts, and any complications related to the procedure.

RESULTS: Concordance correlation coefficients between the measured distances on ultrasound and actual needle depth were 0.9272 and 0.9268 on transverse and longitudinal median view, respectively. The cervical epidural block was successfully performed on 48 patients (96%). There were two incidents (4%) of dural puncture. No bloody taps, postprocedure complications, or hemodynamic instability related to cervical epidural blocks occurred.

CONCLUSIONS: Ultrasound provides very accurate information on the skin to dura distance for epidural blocks in the cervical spine. Knowledge of skin to dura distance and a preview of spinal anatomy before puncture can more safely identify the epidural space.

全膝關節成形術後周圍神經應用左旋布比卡因和羅呱卡因的鎮痛效果：一個前瞻性的、隨機雙盲研究

Postoperative Analgesic Efficacy of Peripheral Levobupivacaine and Ropivacaine: A Prospective, Randomized Double-Blind Trial in Patients After Total Knee Arthroplasty

Florian Heid, MD^*, Nicole Müller^*, Tim Piepho, MD^*, Maren Bäres, MD^*, Markus Giesa, MD, Philipp Drees, MD, Andreas Rümelin, MD, PhD^*, and Christian Werner, MD, PhD^*

From the Departments of *Anesthesiology, and Orthopaedic Surgery, Johannes Gutenberg-University Mainz, Germany.

Anesth Analg 2008 106: 1559-1561.

背景：先前的一些研究顯示最新的局麻藥左旋布比卡因與羅呱卡因可用於術中及術後連續周圍神經阻滯。

方法：作者比較了全膝置換術患者應用0.125%的左旋布比卡因或0.2%的羅呱卡因行術後自控股神經鎮痛效果。該實驗為一雙盲、隨機、前瞻性研究，60例患者隨機接受股神經周圍輸注左旋布比卡因或羅呱卡因。通過分析術後72h局麻藥的消耗，疼痛評分，運動阻滯及阿片類藥物的需求量來評價效果。

結果：疼痛評分，運動阻滯範圍及阿片類藥物需求量均較低，組間無差異。羅呱卡因消耗量較布比卡因高67%（單位為mg）。

結論：0.125%的左旋布比卡因和0.2%的羅呱卡因在全膝置換術後有相似的止痛效果，但左旋布比卡因強于羅呱卡因。

（王鵬 譯 陳傑 校）

BACKGROUND: Several previous trials have characterized the intra- and postoperative effects of the recently introduced local anesthetics, levobupivacaine and ropivacaine, for a variety of continuous peripheral nerve blocks.

METHODS: We compared the analgesic efficacy of levobupivacaine 0.125% versus ropivacaine 0.2% via patient-controlled femoral nerve analgesia after total knee arthroplasty. In a double-blind, randomized, prospective design, 60 patients received femoral infusion with either substance. We analyzed postoperative local anesthetic consumption, pain scores, motor block, and opioid requirements over 72 h.

RESULTS: Pain scores, motor block incidence, and opioid requirements were low and not different between the groups. Ropivacaine consumption in milligrams was 67% higher than that of levobupivacaine.

CONCLUSIONS: Both levobupivacaine 0.125% and ropivacaine 0.2% provide similar analgesia after total knee arthroplasty with the latter being less potent.

乳化異氟醚對兔子缺血再灌注損傷後的心臟保護

Emulsified Isoflurane Produces Cardiac Protection After Ischemia-Reperfusion Injury in Rabbits

Yan Rao, Yan-lin Wang, Wen-sheng Zhang, and Jin Liu

Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.

Anesth Analg 2008 106: 1353-1359.

背景：在本次研究中我們將比較乳化異氟醚和吸入異氟醚對心臟的保護作用。

方法：32只兔子被暫時結紮冠狀動脈左前降支造成30分鐘的心肌缺血，接著進行3小時的再灌注。在冠狀動脈左前降支被阻斷之前，兔子被隨機分為四組（八隻為一組）：C組，沒有缺血預處理治療；IS組，吸入1.1%異氟醚；EI組，以8%的乳化異氟醚持續輸入，終末濃度為0.64%；IN組，30%甘油持續輸入30分鐘。所有治療在缺血前30分鐘進行，用異氟醚的用15分鐘洗出。3小時再灌注後測量心肌梗塞面積，乳酸脫氫酶，肌酸激酶的改變及線粒體超微結構的評估。

結果：IS 和EI組的3小時再灌注後的心梗面積比C組和IN組小(分別為20% +/- 8%, 18% +/- 8%, 39% +/- 6%, and 34% +/- 9%, P < 0.01)。IS組和EI組，C組和IN組之間的心梗面積沒有差別。3小時再灌注後IS組(456 +/- 58 U/L and 1725 +/- 230 U/L)和EI組(456 +/- 58 U/L and 1725 +/- 230 U/L)的血漿乳酸脫氫酶和肌酸激酶低於C組（676 +/- 82 U/L and 2373 +/- 529 U/L; P < 0.01)。IS，EI組和C組在線粒體超微結構的改變上沒有顯著差異。

結論：結果提示我們，在兔子的缺血再灌注損傷後，靜脈輸注乳化異氟醚和吸入異氟醚產生的心肌保護作用沒有顯著差異。

（胡豔譯 薛張剛校）

BACKGROUND: In this study, we examined the cardioprotective effects of parental emulsified isoflurane compared with inhaled isoflurane.

METHODS: Thirty-two rabbits were subjected to 30 min of myocardial ischemia induced by temporary ligation of the left anterior descending coronary artery followed by 3 h of reperfusion. Before left anterior descending coronary artery occlusion, the rabbits were randomly allocated into one of four groups (eight for each group): group C, no ischemia preconditioning treatment; group IS, inhaled isoflurane 1.1% end-tidal; group EI, a continuous infusion of 8% emulsified isoflurane to an end-tidal concentration of 0.64%; and group IN, a continuous infusion of 30% Intralipid started 30 min. Treatments were started 30 min before ischemia followed by a 15 min washout period for isoflurane groups. Myocardial infarct volume, lactate dehydrogenase, and creatine kinase levels were measured and changes in mitochondrial ultrastructure assessed after 3 h myocardial reperfusion.

RESULTS: Myocardial infarct size 3 h after reperfusion was lower in groups IS and EI compared with groups C and IN (20% +/- 8%, 18% +/- 8%, 39% +/- 6%, and 34% +/- 9%, respectively, P < 0.01). There were no differences in myocardial infarct size between groups IS and EI or between groups C and IN. Plasma lactate dehydrogenase and creatine kinase levels were lower in group IS (456 +/- 58 U/L and 1725 +/- 230 U/L) and group EI (456 +/- 58 U/L and 1725 +/- 230 U/L) 3 h after myocardial reperfusion compared with groups C (676 +/- 82 U/L and 2373 +/- 529 U/L; P < 0.01). Mitochondrial ultrastructure changes were less pronounced in groups IS and EI compared with group C.

CONCLUSIONS: Our results indicate that, in rabbits, i.v. emulsified isoflurane provides similar myocardial protection against ischemia-reperfusion injury as inhaled isoflurane.

新式麻醉通氣機能否在容積控制通氣時準確輸送小潮氣量?

Do new anesthesia ventilators deliver small tidal volumes accurately during volume-controlled ventilation?

Bachiller PR, McDonough JM, Feldman JM.

Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.

Anesth Analg 2008 106: 1392-1400.

背景：嬰兒和新生兒機械通氣時，潮氣量的小變化可導致通氣不足過度，氣壓傷，容量傷。部分是由於傳統麻醉通氣機在容量控制通氣（VCV）模式時，呼吸回路順應性和新鮮氣流會影響輸送的潮氣量。儘管PCV時輸送的潮氣量並不確定，採用迴圈呼吸系統的壓力控制通氣（PCV）模式已成為最小化機械通氣對小患者傷害的一種普遍方式。新一代麻醉通氣機通過調整新鮮氣流和呼吸環路的順應性解決了VCV的問題。此項研究中，我們評估了新式麻醉通氣機輸送小潮氣量的準確性。

方法：評估在不同呼吸回路順應性（完全擴展和收縮的回路）和肺順應性的情況下，採用VCV模式預設潮氣量分別為100ml，200ml和500ml，四台麻醉通氣機向氣道輸送容量的準確性。使用一種機械測試肺（成人和兒童）模擬容積從0.0025到0.03L/cmH2O肺的順應性，使用帶刻度屏的呼吸速率計和定制軟體測定壓力。我們測試了Smartvent 7900, Avance, and Aisys麻醉通氣機系統(GE Healthcare, Madison, WI)和Apollo 麻醉通氣機 (Draeger Medical, Telford, PA)。Smartvent 7900和Avance通氣機使用吸入流量感測器控制輸送容量，而Aisys和Apollo通氣機使用補償回路順應性方式。

結果：我們發現使用順應性補償的麻醉通氣機(Aisys和Apollo)在正常情況和低肺順應性時，使用VCV模式能準確的向測試肺氣道輸送大和小潮氣量（達預設潮氣量的95.5%-106.2%）。然而，無順應性補償的麻醉通氣機在使用VCV模式輸送預設潮氣量的準確性較差，特別是在低潮氣量和低肺順應性時（達預設潮氣量的45.6%-100.3%）。

結論：正常情況和低肺順應性時，新一代對呼吸環路順應性和新鮮氣流有補償機制的麻醉通氣機採用容量控制通氣模式能準確的向氣道輸送小潮氣量。準確的VCV由於在肺順應性改變時能確保容量，可能將成為PCV的一種有效替代手段，並使手術室內新策略如小容量/肺保護通氣成為可能。

（黃凝譯 薛張綱校）

BACKGROUND: During mechanical ventilation of infants and neonates, small changes in tidal volume may lead to hypo- or hyperventilation, barotrauma, or volutrauma. Partly because breathing circuit compliance and fresh gas flow affect tidal volume delivery by traditional anesthesia ventilators in volume-controlled ventilation (VCV) mode, pressure-controlled ventilation (PCV) using a circle breathing system has become a common approach to minimizing the risk of mechanical ventilation for small patients, although delivered tidal volume is not assured during PCV. A new generation of anesthesia machine ventilators addresses the problems of VCV by adjusting for fresh gas flow and for the compliance of the breathing circuit. In this study, we evaluated the accuracy of new anesthesia ventilators to deliver small tidal volumes.

METHODS: Four anesthesia ventilator systems were evaluated to determine the accuracy of volume delivery to the airway during VCV at tidal volume settings of 100, 200, and 500 mL under different conditions of breathing circuit compliance (fully extended and fully contracted circuits) and lung compliance. A mechanical test lung (adult and infant) was used to simulate lung compliances ranging from 0.0025 to 0.03 L/cm H(2)O. Volumes and pressures were measured using a calibrated screen pneumotachograph and custom software. We tested the Smartvent 7900, Avance, and Aisys anesthesia ventilator systems (GE Healthcare, Madison, WI) and the Apollo anesthesia ventilator (Draeger Medical, Telford, PA). The Smartvent 7900 and Avance ventilators use inspiratory flow sensors to control the volume delivered, whereas the Aisys and Apollo ventilators compensate for the compliance of the circuit.

RESULTS: We found that the anesthesia ventilators that use compliance compensation (Aisys and Apollo) accurately delivered both large and small tidal volumes to the airway of the test lung under conditions of normal and low lung compliance during VCV (ranging from 95.5% to 106.2% of the set tidal volume). However, the anesthesia ventilators without compliance compensation were less accurate in delivering the set tidal volume during VCV, particularly at lower volumes and lower lung compliances (ranging from 45.6% to 100.3% of the set tidal volume).

CONCLUSIONS: Newer generation anesthesia machine ventilators that compensate for breathing circuit compliance and for fresh gas flow are able to deliver small tidal volumes accurately to the airway under conditions of normal and low lung compliance during volume-controlled ventilation. Accurate VCV may be a useful alternative to PCV, as volume is guaranteed when lung compliance changes, and new strategies such as small volume/lung protective ventilation become possible in the operating room.

氟呱啶醇與樞複寧用於術後噁心嘔吐（短訊）

Haloperidol Versus Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting (Brief Report)
Carl E. Rosow, Kenneth L. Haspel, Sarah E. Smith, Loreta Grecu, and Edward A. Bittner

From the *Department of Anesthesia and Critical Care, Massachusetts General Hospital; Department of Anesthesiology, Yale University School of Medicine; and Boston University School of Medicine, Boston, Massachusetts.

Anesth Analg 2008 106: 1407-1409

背景：氟呱啶醇對於術後噁心嘔吐預防有效，但同5-HT₃ 受體拮抗劑比較的資料極少。

方法：全麻時244例成人病例隨機分為接受靜脈氟呱啶醇（1 mg）和樞複寧（4 mg）。採用三盲法評價每組病人的噁心、嘔吐、需要採取補救措施、鎮靜、錐體外系反應、QTc間期以及出麻醉後恢復室時間。

結果：在藥物有效性和毒性方面組間無差異性。有效率氟呱啶醇和樞複寧分別為78.2% 和 76.8%；術後QTc間期延長的發生率分別為28.9%、22.1%（無統計學差異）。

結論：在所有外科病人中，用氟呱啶醇（1 mg）預防術後噁心嘔吐的有效性和毒性與使用樞複寧（4 mg）無明顯差別。

（蔣宗明譯 薛張綱校）

BACKGROUND: Haloperidol is effective for postoperative nausea and vomiting prophylaxis, but there are almost no data comparing it to 5-HT₃ antagonists.

METHODS: Two hundred forty-four adults were randomized to receive IV haloperidol 1 mg or ondansetron 4 mg, during general anesthesia. Nausea, vomiting, need for rescue, sedation, extrapyramidal effects, QTc intervals, and time to postanesthesia care unit discharge were evaluated with a third-party blind design.

RESULTS: There was no intergroup difference in any measure of efficacy or toxicity. Haloperidol and ondansetron subjects (78.2% and 76.8%) had complete response. Postoperatively, prolonged QTc occurred in 28.9% and 22.1% (N.S.).

CONCLUSIONS: In a mixed surgical population, the efficacy and toxicity of postoperative nausea and vomiting prophylaxis with haloperidol 1 mg was not significantly different from ondansetron 4 mg.

局麻藥的中毒劑量在全麻中對其全身及局部藥代動力學的影響

The effects of general anesthesia on whole body and regional pharmacokinetics of local anesthetics at toxic doses

Copeland Susan E, Ladd Leigh A, Gu, Xiao-Qing, Mather Laurence E.

Department of Anaesthesia and Pain Management, University of Sydney at Royal North Shore Hospital, Sydney NSW 2065, Australia.

Anesth Analg 2008 106(5):1440-9

背景：局麻藥的毒性效應在對麻醉動物的實驗中已經有了廣泛研究，但臨床上所發生的毒性效應卻大都出現在清醒病人的身上。在此項研究中，我們將六種局麻藥以近似的最大推薦劑量靜注，並研究全麻對其藥代動力學的影響。

方法：我們將長期以來用作動物模型的母羊（體重約45-50 kg，n＝18），分別在清醒及氟烷麻醉狀態下在大於3分鐘的時間內緩慢靜注布比卡因100mg、左旋布比卡因125mg、羅呱卡因150mg、利多卡因350mg、甲呱卡因350mg、或丙胺卡因350mg（劑量均以其鹽酸鹽計）。然後以非旋光/光性高效液相色譜法對動脈、心臟和大腦靜脈進行連續的血藥濃度監測，我們以非房室法對全身整體性的藥代動力學進行分析，再以品質平衡的方法分析心臟和大腦局部的藥代動力學。而以體外平衡透析的方法來分析這些局麻藥分別在有或沒有氟烷麻醉狀態下的血漿結合率。

結果：局麻藥的血藥濃度在全麻狀態下增加到了兩倍，這是因為全麻減少了局麻藥的全身分佈及清除（分別減少到清醒狀態下其數值的33%和52%）。心臟和大腦的攝藥量在全麻狀態下也有所增加，導致其在這兩個區域的清除以相應減慢。右旋布比卡因的清除率大於左旋布比卡因，右旋丙胺卡因的清除率大於左旋丙胺卡因，但甲呱卡因的清除卻不受光學異構的影響。而氟烷並不影響局麻藥的血漿結合率。

結論：全麻狀態很明顯的改變了各種局麻藥的全身和局部藥代動力學效應、以及其全身效應。因此，在局麻藥的毒性研究中全麻狀態是一個極其重要卻又常被忽視的因素之一。

（劉沁譯 薛張綱校）

BACKGROUND: Local anesthetic toxicity is often studied experimentally in anesthetized subjects, but clinical toxicity usually occurs in conscious patients. In this study, we determined the influence of general anesthesia on the pharmacokinetics of six local anesthetics administered i.v. at approximately the highest recommended doses.

METHODS: Chronically instrumented ewes (approximately 45-50 kg, n = 18) were infused over 3 min with (base doses as HCl salts) bupivacaine (100 mg), levobupivacaine (125 mg), ropivacaine (150 mg), lidocaine (350 mg), mepivacaine (350 mg), or prilocaine (350 mg), on separate occasions when conscious and halothane anesthetized. Serial arterial, heart, and brain venous blood drug concentrations were measured by achiral/chiral high-performance liquid chromatography, as relevant. Whole body pharmacokinetics were assessed by noncompartmental analysis; heart and brain pharmacokinetics were assessed by mass balance. Drug blood binding, in the absence and presence of halothane, was assessed by equilibrium dialysis in vitro.

RESULTS: Blood local anesthetic concentrations were doubled with anesthesia because of decreased whole body distribution and clearance (respectively, to 33% and 52% of values when conscious). Heart and brain net drug uptake were greater under anesthesia, reflecting slower efflux from both regions. Clearances of R-bupivacaine > S-bupivacaine and R-prilocaine > S-prilocaine, but, mepivacaine clearance was not enantioselective. Halothane did not influence blood binding of the local anesthetics.

CONCLUSIONS: General anesthesia significantly changed whole body and regional pharmacokinetics of each local anesthetic as well as the systemic effects. General anesthesia is thus an important but frequently overlooked factor in studies of local anesthetic toxicity.

通過Lymnaea神經元觀察利多卡因通過Na+-H+交換增加細胞內鈉濃度的研究

Lidocaine increases intracellular sodium concentration through a Na+-H+ exchanger in an identified Lymnaea neuron.

Onizuka S, Kasaba T, Tamura R, Takasaki M.

Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, Kiyotake-Cho, Miyazaki 889-1692, Japan.

Anesth Analg 2008 106: 1473-1479.

背景：細胞內鈉離子濃度與神經元活性有關。對細胞內鈉離子來說，鈉氫交換起重要作用，而它又受細胞內PH值的影響。然而，利多卡因對細胞內PH及鈉氫交換的影響並不明確。我們用椎實螺屬神經元來測定利多卡因如何影響細胞內PH值、鈉氫交換及細胞內鈉離子濃度。

方法：細胞內鈉濃度可由sodium-binding苯並呋喃間苯二甲酸反映，而細胞內PH值由2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein反映，它們被用來測定細胞內鈉濃度及PH。細胞內鈉離子的測定包括正常鈉離子，鈉鹽中的鈉離子，修正過細胞外PH後細胞內鈉離子及鈉氫交換拮抗劑的預處理下測定的游離鈉離子。此外，細胞內鈉離子與PH同時被記錄。從0.1-10mm,利多卡因、馬比佛卡因、布比卡因，普魯卡因及QX-314被分別評價。

結果：利多卡因、馬比佛卡因、普魯卡因使細胞內鈉離子濃度增加成劑量依賴性。對比下QX-314每次加劑量並不都改變鈉離子細胞內濃度。利多卡因在鈉鹽及鈉氫交換拮抗劑的預處理下不能增加細胞內鈉離子濃度，利多卡因、馬比佛卡因、普魯卡因在基礎水準上引起了明顯的細胞內PH值的下降。相比下QX-314不引起細胞內PH值改變。這些結果證明利多卡因通過蛋白捕獲使細胞呈酸性，啟動鈉氫交換而增加細胞內鈉離子濃度。細胞內鈉濃度增加及PH改變導致細胞毒性。

結論：利多卡因通過蛋白捕獲啟動鈉氫交換而增加細胞內鈉離子濃度。

（劉婷潔譯 薛張鋼校）

BACKGROUND: The intracellular sodium concentration ([Na(+)]in) is related to neuron excitability. For [Na(+)]in, a Na(+)-H(+) exchanger plays an important role, which is affected by intracellular pH ([pH]in). However, the effect of lidocaine on [pH]in and a Na(+)-H(+) exchanger is unclear. We used neuron from Lymnaea stagnalis to determine how lidocaine affects [pH]in, Na(+)-H(+) exchanger, and [Na(+)]in.

METHODS: Intracellular sodium 4imaging by sodium-binding benzofuran isophthalate and intracellular pH imaging by 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein were used to measure [Na(+)]in and [pH]in. Measurements for [Na(+)]in were made in normal, Na(+) free saline, with modified extracellular pH, and a Na(+)-H(+) exchanger antagonist [(5-N-ethyl-N-isopropyl amiloride, N-methylisopropylamiloride, and 5-(N,N-hexamethylene)-amiloride) pretreatment trials. Furthermore, [Na(+)]in and [pH]in were recorded simultaneously. From 0.1 to 10 mM, lidocaine, mepivacaine, bupivacaine, prilocaine, and QX-314 were evaluated.

RESULTS: Lidocaine, mepivacaine, and prilocaine increased the [Na(+)]in in a dose-dependent manner. In contrast, QX-314 did not change the [Na(+)]in at each dose. In the Na(+) free saline or in the presence of each Na(+)-H(+) exchanger antagonist, lidocaine failed to increase [Na(+)]in. Lidocaine, mepivacaine, and prilocaine induced a significant decrease in [pH]in below baseline with an increase in [Na(+)]in. In contrast, QX-314 did not change the [pH]in. These results demonstrated that lidocaine increases [Na(+)]in through Na(+)-H(+) exchanger activated by intracellular acidification, which is induced by the proton trapping of lidocaine. This [Na(+)]in increase and [pH]in change induces cell toxicity.

CONCLUSION: Lidocaine increases the [Na(+)] through a Na(+)-H(+) exchanger by proton trapping.

不同吸入氧分數的單增量變化對使用氧氣洗出技術測定機械通氣病人的功能潮氣量的影響

The Impact of Different Step Changes of Inspiratory Fraction of Oxygen on Functional Residual Capacity Measurements Using the Oxygen Washout Technique in Ventilated Patients

Heinze, Hermann MD; Sedemund-Adib, Beate MD; Heringlake, Matthias MD; Gosch, Ulrich W. MD; Gehring, Hartmut MD; Eichler, Wolfgang MD

From the Department of Anaesthesiology, University of Luebeck, Luebeck, Germany.

Anesth Analg 2008 106: 1491-1494

背景：功能殘氣量（FRC）的測定能指導我們調整通氣治療方法。使用氧氣洗出技術，能夠在床旁測定自主呼吸病人的功能殘氣量。但是，對於監測來說至關重要的高度可重複性，卻沒有在機械通氣的病人中表現出來。較大的吸入氧分數單增量變化（⊿FiO2）會影響高吸入氧分數的機械通氣患者的臨床應用。我們要研究的是這種FRC測量方法的可重複性，以及不同的⊿FiO2對於這種可重複性的影響。

方法：LUFU系統（Draeger Medical，Luebeck ，德國）使用氧氣洗出來估測FRC，即快速⊿FiO2過程中的多次呼吸氮洗出技術的一個參數。在20個心血管外科的術後患者中，使用⊿FiO2為0.1，0.2，0.6，來重複測定這些患者的FRC。

結果：重複測定對於FRC的測出並無不同，同樣使用的⊿FiO2是0.1，0.2或者0.6也對結果沒有影響（⊿0.1: 2.62 L±0.58, 2.62 L ±0.59, P =0.995; ⊿0.2: 2.70 L±0.59, 2.66 L ±0.56, P =0.258; ⊿0.6: 2.61 L ±0.58, 2.59 L ±0.58, P =0.639)。它們各自的變異係數分別為6.6%，5.6%，6.6%。

結論：機械化通氣的病人可以用氧氣洗出技術來測定FRC，具有臨床上能接受的可重複性。

並且使用的⊿FiO2為0.1，0.2或者0.6，對於這種可重複性的影響並沒有統計學意義。

（秦敏菊譯 薛張綱校）

BACKGROUND: Functional residual capacity (FRC) measurements may help to guide respiratory therapy. Using the oxygen washout technique, FRC can be assessed at bedside during spontaneous breathing. High repeatability, crucial for monitoring, has not been shown in ventilated patients. A large step change of inspiratory fraction of oxygen (Fio2) （⊿Fio2) may impede the clinical use in patients ventilated with high Fio2. We investigated the repeatability of FRC measurements and the impact of different ⊿Fio2 on this repeatability.

METHODS: The LUFU system (Draeger Medical, Luebeck, Germany) estimates FRC by oxygen washout, a variant of multiple-breath-nitrogen-washout during a fast ⊿Fio2. In 20 postoperative cardiac surgery patients, FRC was measured in duplicate using ⊿Fio2 of 0.1, 0.2, and 0.6.

RESULTS: There were no differences between repeated measurements of FRC, neither using a ⊿Fio2 of 0.1, 0.2 nor 0.6(⊿0.1: 2.62 L ± 0.58, 2.62 L ± 0.59, P = 0.995; ⊿0.2: 2.70 L ± 0.59, 2.66 L ± 0.56, P = 0.258; ⊿0.6: 2.61 L ± 0.58, 2.59 L ± 0.58, P = 0,639). Coefficients of variation were 6.6%, 5.6%, and 6.6%, respectively.

CONCLUSIONS: FRC can be measured in ventilated patients using the oxygen washout technique with a clinically acceptable repeatability. Repeatability is not significantly influenced whether using a ⊿Fio2 of 0.1, 0.2, or 0.6.

關於產痛評估的動態模型的建立與驗證

The Development and Validation of a Dynamic Model to Account for the Progress of Labor in the Assessment of Pain

Jessamyn Conell-Price, BA, Jennifer B. Evans, Daewha Hong, MS, Steven Shafer, MD, and Pamela Flood, MD

From the Department of Anesthesiology, Columbia University, New York City, New York.

Anesth Analg 2008 106: 1509-1515.

背景：產痛常被描述為女性生命中最嚴重的疼痛，且充滿變數。雖然與產痛相關的已知因素有許多，但仍難以估計這些因素對個體的影響，因為分娩是一個動態的過程，所產生的疼痛亦不斷改變。以往的研究往往使用平均疼痛評分，本研究的目的是建立和驗證一個模型，分析整個分娩過程中影響疼痛的因素。

方法：我們回溯建庫，連續選取2006年10月至2007年1月在紐約長老會醫院分娩的200名初產婦進行研究。評定量表包括：宮縮痛（0-10級）、宮頸擴張度及鎮痛前催產素的使用。用S形方程的非線性效應建模描述疼痛與宮頸擴張之間的關係。91例初產婦的資料用於建模，95例初產婦的資料用於驗證（所有初產婦疼痛評分均大於零）。使用由此產生的模型分析催產素應用對疼痛的影響。

結果：由訓練集得出的模型對驗證集有預測價值（P<0.001）。疼痛預測分數為實際測量分數的平均值。將催產素作為協變進行分析，結果表明：48%應用催產素的婦女，在分娩開始時承受更多的痛苦，但與未應用催產素的婦女相比，疼痛的增長率及最大強度並無增加，並且擁有更緩慢的早期產程及更迅速的後期產程。

結論：我們建立並驗證了用於描述產痛的動態模型。該模型適用於統計分析影響因素的協方差，並可用於比較各影響因素對產痛及其變化的影響。

(施穎譯 薛張綱校)

BACKGROUND: Labor pain is often described as the worst pain in a woman's life, but the experience is highly variable. Although many factors have been linked to labor pain, it has been difficult to assess the individual effects of these factors because labor is a dynamic process and pain intensity changes over the course of labor. Previous studies have used average pain scores. The aim of this study was to develop and validate a model that would allow for the statistical analysis of factors that affect pain throughout labor.

METHODS: We conducted this study with a retrospective database drawn from the medical records of 200 consecutive nulliparous parturients who delivered at New York Presbyterian Hospital between October 2006 and January 2007. Numerical rating scale scores for pain with contractions (0–10 scale), cervical dilation, and oxytocin use before analgesia request were recorded. Nonlinear effects modeling with a sigmoid equation was used to describe the relationship between reported pain and cervical dilation. The modeling technique was developed with data from 91 parturients and validated with an independent set of 95 parturients (all parturients with pain scores more than zero). The resulting model was used to analyze the effect of a sample covariate, oxytocin administration, on reported pain in the entire data set.

RESULTS: The model derived from our training set was predictive of the data from our validation set (P < 0.001). Predicted pain scores were on average two numerical rating scale points above or below measured pain scores. Analyzing oxytocin as a covariant showed that women treated with oxytocin reported 48% more pain at the start of labor but did not have a significantly more rapid increase in pain or higher maximal pain when compared with women not treated with oxytocin. Women treated with oxytocin had slower early labor and more rapid late labor.

CONCLUSION: We have developed and validated a model for describing pain over the course of labor. Our model is suited to the statistical analysis of covariance and could potentially be used to compare the effects of covariants on labor pain and the rate of change of pain.

麻醉後監護室中嚴重疼痛的有關因素

Predictive Factors of Severe Postoperative Pain in the Postanesthesia Care Unit

Frédéric Aubrun, MD, PhD^*, Nathalie Valade, MD^*, Pierre Coriat, MD^*, and Bruno Riou, MD, PhD

From the Departments of *Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University Health System, Seoul, Korea.

Anesth Analg 2008 106: 1535-1541.

背景：麻醉後監護室中廣泛使用靜滴嗎啡（IMT ）來控制疼痛。術後疼痛和嗎啡用量的差異性有很多因素構成。我們把IMT >0.15 mg/kg或IMT失敗看作嚴重的術後疼痛，來分析與之有關的術前和術中因素。

方法：評估有關疼痛，治療的術前資訊和術中事件，以及他們在術後疼痛中扮演的角色。IMT以後病人分為兩組：嚴重疼痛（SP）組和非嚴重疼痛組。資料用均數±標準差來表示。

結果：該研究包括342名病人：200名(58%)在非嚴重疼痛組，142名(42%)在嚴重疼痛組。運用單變數分析的方法，兩組在用藥和手術史方面沒有顯著差別，而SP組的術前治療更多(P < 0.05)。SP組的手術和麻醉時間更長(P < 0.001)， 在IMT之前和之後的舒芬太尼以及類似物用量更高。運用多變數分析的方法，術中阿片類藥物大量使用（舒芬太尼量>0.6 µg/kg）(比值比= 2.68, P < 0.001) ，術中採用全麻(比值比 = 3.96, P = 0.03)，術前麻醉藥物的使用(比值比 = 1.91, P < 0.01)都是和嚴重術後疼痛有關的獨立因素。

結論：術中舒芬太尼的大量使用，全麻和術前使用過麻醉藥物治療明顯和嚴重術後疼痛有關。

（孫鵬飛譯 薛張綱校）

BACKGROUND: IV morphine titration (IMT) is widely used in the postanesthesia care unit to achieve pain relief. Numerous factors contribute to variability in postoperative pain or morphine consumption. We analyzed prospectively the pre- and intraoperative predictive factors of severe postoperative pain defined as a dose of IMT >0.15 mg/kg or a failure of IMT.

METHODS: We assessed the role of preoperative information about pain, medical treatments, and intraoperative events and their role on postoperative pain. After IMT, patients were divided into two groups: severe pain (SP) and nonsevere pain. Data are expressed as mean ± sd.

RESULTS: Three hundred forty-two patients were included in the study: 200 (58%) in the nonsevere pain group and 142 (42%) in the SP group. Using a univariate analysis, there was no significant difference between groups related to medical or surgical history except for more frequent preoperative treatments in the SP group (P < 0.05). Duration of the surgical procedure and anesthesia were longer in the SP group (P < 0.001). The dose of sufentanil and visual analog scale scores before and at the end of IMT were higher in the SP group (P < 0.001). Using a multivariate analysis, a high dose of intraoperative opioid (sufentanil dose >0.6 µg/kg) (Odds ratio = 2.68, P < 0.001), a general anesthetic procedure (Odd ratio = 3.96, P = 0.03), and the use of preoperative analgesic drugs (Odds ratio = 1.91, P < 0.01) were independent factors associated with severe postoperative pain.

CONCLUSION: A higher intraoperative dose of sufentanil, general anesthesia, and preoperative treatment with analgesics were significantly associated with severe postoperative pain.

一項關於超聲及神經刺激聯合定位膕窩－坐骨神經阻滯的前瞻性隨機對照研究

Combined Ultrasound and Neurostimulation Guidance for Popliteal Sciatic Nerve Block: A Prospective, Randomized Comparison with Neurostimulation Alone

Eric Dufour, Patrick Quennesson, Anne Laure Van Robais, Françoise Ledon, Pierre-Antoine Laloë, Ngai Liu, and Marc Fischler

From the *Department of Anesthesiology, Hôpital Foch, Suresnes, France; Departments of Anesthesiology, and Surgery, Clinique La Montagne, Courbevoie, France.

Anesth Analg 2008 106: 1553-1558.

背景：作為定位周圍神經的有效工具，超聲定位使得神經阻滯的實施更為容易。但是其在膕窩－坐骨神經阻滯中的效果尚未得到肯定。

方法：在這項隨機單盲前瞻性研究中，我們對比了解剖結構聯合神經刺激定位（NS組，n＝30）與超聲引導下神經刺激定位（US-NS組，n＝30）實施膕窩－坐骨神經阻滯所需要的時間（以主要終點為准）。每例阻滯都是由一位操作者單獨完成的。正確的針位由最小刺激電流</=0.5 mA來確定，或者，在US-NS組是由針柄引起神經活動來確定，即使此時最小刺激電流>0.5 mA。在US-NS組，分別於脛神經和腓總神經處給予10ml 0.5%左布比卡因，並且為了提高麻醉效果，沒有調整進針位置。所有操作都有影像記錄，並且要求在7分鐘內完成。成功的阻滯定義為：30分鐘後，神經分佈區域內冷感覺完全消失，足背及足蹠屈曲消失。

結果：NS組的5個病人，US-NS組的3個病人退出了研究。兩組的阻滯需要時間沒有顯著差異。US-NS組的穿刺針通過次數只有在探測第一根神經時較低(1 [1-2] vs 2 [1-6]; P < 0.01)。US-NS組的30分鐘成功率明顯較高(65% vs 16%; P < 0.001)。

結論：超聲及神經刺激聯合定位並不減少阻滯所需時間，但是提高了膕窩－坐骨神經阻滯的30分鐘成功率。

(夏俊明譯 薛張綱校)

BACKGROUND: Ultrasound imaging, an effective tool to localize peripheral nerves, may facilitate block performance. However, its usefulness during popliteal sciatic nerve block has not been assessed.

METHODS: In this prospective, randomized, patient-blinded study, we compared the block time (as the primary end-point) of a popliteal sciatic nerve block with double-injection performed using anatomical landmarks and neurostimulation (NS group; n = 30) versus combined ultrasound and neurostimulation guidance (US-NS group; n = 30). Each block procedure was performed by a single operator. Correct needle placement was defined by a minimal stimulating current 0.5 mA, or, in the US-NS group, by mobilization of the nerve by the needle shaft even if the minimal stimulating current >0.5 mA. Ten milliliter levobupivacaine 0.5% was administered separately on the tibial and common peroneal nerves without needle adjustment to improve the spread of anesthetic in the US-NS group. All procedures were video-recorded, and a maximum of 7 min was allowed to perform the block. Successful block was defined as complete loss of cold sensation in the sciatic distribution and an inability to perform a plantar and dorsal flexion of the foot at 30 min.

RESULTS: Five patients in the NS group and three in US-NS group were excluded from the study for prolonged procedure. Block time was not significantly different between groups. The number of needle passes was lower only for the detection of the first nerve in the US-NS group (1 [1–2] vs 2 [1–6]; P < 0.01). A greater success rate was observed at 30 min in the US-NS group (65% vs 16%; P < 0.001).

CONCLUSIONS: Combined ultrasound and neurostimulation guidance does not decrease block time but increases the success rate of popliteal sciatic nerve block observed at 30 min.