Table of Contents
November 2008
CARDIOVASCULAR
ANESTHESIOLOGY:
胡豔譯 薛張剛校
A Thromboelastometric
Evaluation of the Effects of Hypothermia on the Coagulation System
Malin Rundgren and Martin Engström
Anesth Analg 2008 107: 1465-1468.
心臟手術中止血環酸和抑肽酶：一項220例心臟手術病人的應用分析
丁俊雲 譯 陳傑 校
Tranexamic Acid and Aprotinin in Primary Cardiac Operations: An Analysis of 220 Cardiac Surgical Patients Treated with Tranexamic Acid or Aprotinin
Wulf Dietrich, Michael Spannagl, Johannes Boehm, Katharina Hauner, Siegmund Braun, Tibor Schuster, and Raimund Busley
Anesth
Analg 2008 107: 1469-1478.
江繼宏 譯
馬皓琳 李士通 校
Tranexamic Acid
Reduces Perioperative Blood Loss in Adult Patients Having Spinal Fusion Surgery
Jean Wong, Hossam El Beheiry, Yoga Raja Rampersaud, Stephen Lewis, Henry Ahn, Yoshani De Silva, Amir Abrishami, Naseer Baig, Robert J. McBroom, and Frances Chung
Anesth Analg 2008 107: 1479-1486.
黃凝譯 薛張綱校
A Randomized
Controlled Trial of Cell Salvage in Routine Cardiac Surgery
Andrew A. Klein, Samer A. M. Nashef, Linda Sharples, Fiona Bottrill, Matthew Dyer, Johanna Armstrong, and Alain Vuylsteke
Anesth Analg 2008 107: 1487-1495.
合併低蛋白血症的老年心臟手術患者使用白蛋白對炎症反應，內皮細胞活化，以及長期腎功能是否有好處？
舒慧剛 譯 陳傑 校
Is Albumin
Administration in Hypoalbuminemic Elderly Cardiac Surgery Patients of Benefit
with Regard to Inflammation, Endothelial Activation, and Long-Term Kidney
Function?
Joachim Boldt, Ch Brosch, K. Röhm, A. Lehmann, A. Mengistu, and S. Suttner
Anesth Analg 2008 107: 1496-1503.
PEDIATRIC
ANESTHESIOLOGY:
右美托咪定：治療先天性心臟病手術圍術期房性和交界性心動過速的新藥：一項初步的研究
周雅春 譯 馬皓琳 李士通 校
Dexmedetomidine: A
Novel Drug for the Treatment of Atrial and Junctional Tachyarrhythmias During
the Perioperative Period for Congenital Cardiac Surgery: A Preliminary Study
Constantinos Chrysostomou, Lee Beerman, Dana Shiderly, Donald Berry, Victor O. Morell, and Ricardo Munoz
Anesth Analg 2008 107: 1514-1522.
蔣宗明譯 薛張綱校
A Prospective,
Randomized Comparison of Cobra Perilaryngeal Airway and Laryngeal Mask Airway
Unique in Pediatric Patients
Peter Szmuk, Oscar Ghelber, Maria Matuszczak, Marry F. Rabb, Tiberiu Ezri, and Daniel I. Sessler
Anesth Analg 2008 107: 1523-1530.
用於兒童外周靜脈置管的一種靜脈通路指示裝置：一項前瞻性、隨機、對照試驗
張磊 譯 陳傑 校
A Vein Entry Indicator Device for Facilitating Peripheral Intravenous Cannulation in Children: A Prospective, Randomized, Controlled Trial
Eliahu Simhi, Ludmyla Kachko, Elhanan Bruckheimer, and Jacob Katz
Anesth Analg 2008 107:
1531-1535.
容積描記脈搏波幅對七氟醚麻醉的兒科病人靜脈內注射含腎上腺素的硬膜外試驗劑量是有效的指示劑
王宏 譯 馬皓琳 李士通校
Plethysmographic Pulse
Wave Amplitude Is an Effective Indicator for Intravascular Injection of
Epinephrine-Containing Epidural Test Dose in Sevoflurane-Anesthetized Pediatric
Patients
Hany A. Mowafi, Samer A. Arab, Salah A. Ismail, Abdulmohsin A. Al-Ghamdi, and Roshdi R. Al-Metwalli
Anesth Analg 2008 107: 1536-1541.
AMBULATORY
ANESTHESIOLOGY:
一篇關於阻塞性睡眠呼吸暫停綜合症的系統綜述及其對麻醉師的啟示
劉沁譯
薛張綱校
A Systemic Review of
Obstructive Sleep Apnea and Its Implications for Anesthesiologists
Sharon A. Chung, Hongbo Yuan, and Frances Chung
Anesth Analg 2008 107: 1543-1563.
ANESTHETIC
PHARMACOLOGY:
葉樂 譯 陳傑 校
The Influence of Age
on the Dynamic Relationship Between End-Tidal Sevoflurane Concentrations and
Bispectral Index
Luis I. Cortínez, Iñaki F. Trocóniz, Ricardo Fuentes, Pedro Gambús, Yung-Wei Hsu, Fernando Altermatt, and Hernán R. Muñoz
Anesth Analg 2008 107:
1566-1572.
兒童麻醉中的呼末七氟醚濃度、腦電雙頻指數及腦狀態指數之間的動態關係
唐亮 譯
馬皓琳 李士通 校
The
Dynamic Relationship Between End-Tidal Sevoflurane Concentrations, Bispectral
Index, and Cerebral State Index in Children
Ricardo Fuentes, Luis I. Cortínez, Michel M. R. F. Struys, Alejandro Delfino, and Hernán Muñoz
Anesth Analg 2008 107: 1573-1578.
在非洲蟾蜍卵母細胞中芳香族揮發性麻醉藥對鈉離子電壓門控通道的效應
劉婷潔譯 薛張綱校
The Effects of
Volatile Aromatic Anesthetics on Voltage-Gated Na+ Channels
Expressed in Xenopus Oocytes
Takafumi Horishita, Edmond I. Eger, II, and R. Adron Harris
Anesth Analg 2008 107:
1579-1586.
劉世文 譯 陳傑 校
Low-Dose Systemic
Bupivacaine Prevents the Development of Allodynia After Thoracotomy in Rats
Jin Woo Shin, Carlo Pancaro, Chi Fei Wang, and Peter Gerner
Anesth Analg 2008 107:
1587-1591.
利多卡因通過提高細胞週期蛋白依賴激酶抑制劑1A (p21)的表達從而抑制NIH-3T3細胞增殖
張瑩譯 馬皓琳 李士通校
Lidocaine Inhibits NIH-3T3 Cell
Multiplication by Increasing the Expression of Cyclin-Dependent Kinase
Inhibitor 1A (p21)
Sukumar P. Desai, Koji Kojima, Charles A. Vacanti, and Shohta Kodama
Anesth Analg 2008 107: 1592-1597.
TECHNOLOGY,
COMPUTING, AND SIMULATION:
秦敏菊譯 薛張綱校
Anesthesia
Information Management System Implementation: A Practical Guide (Special Article)
Stanley Muravchick, James E. Caldwell, Richard H. Epstein, Maria Galati, Warren J. Levy, Michael O'Reilly, Jeffrey S. Plagenhoef, Mohamed Rehman, David L. Reich, and Michael M. Vigoda
Anesth Analg 2008 107: 1598-1608.
一種新穎的神經肌肉阻滯諮詢系統以改善神經肌肉阻滯：一個隨機，對照，臨床的實驗
懷曉蓉 譯 陳傑 校
Improved
Neuromuscular Blockade Using a Novel Neuromuscular Blockade Advisory System: A
Randomized, Controlled, Clinical Trial (Special Article)
Terence J. Gilhuly, Bernard A. MacLeod, Guy A. Dumont, Alex M. Bouzane, and Stephan K. W. Schwarz
Anesth Analg 2008 107: 1609-1617.
PATIENT
SAFETY:
姜旭暉譯，馬皓琳，李士通校
Body Temperature
Change During Anesthesia for Electroconvulsive Therapy: Implications for
Quality Incentives in Anesthesiology
Jerome H. Modell, Nikolaus Gravenstein, and Timothy E. Morey
Anesth Analg 2008 107: 1618-1620.
電阻聚合物與強熱空氣加溫：志願者的熱能傳遞和核心溫度複溫速度的比較
施穎譯
薛張綱校
Resistive Polymer
Versus Forced-Air Warming: Comparable Heat Transfer and Core Rewarming Rates in
Volunteers
Oliver Kimberger, Christine Held, Karin Stadelmann, Nikolaus Mayer, Corinne Hunkeler, Daniel I. Sessler, and Andrea Kurz
Anesth Analg 2008 107:
1621-1626.
CRITICAL
CARE AND TRAUMA:
在嚴重膿毒症中早期使用高劑量抗凝血酶：來自KyberSept試驗的單中心結果
朱紫瑜 譯 陳傑 校
Early Administration
of High-Dose Antithrombin in Severe Sepsis: Single Center Results from the
KyberSept-Trial
Alain Eid, Christian J. Wiedermann, and Gary T. Kinasewitz
Anesth Analg 2008 107:
1633-1638.
裘毅敏譯，馬皓琳 李士通校
Tracheostomy in the
Intensive Care Unit: A Nationwide Survey
Stefan Kluge, Hans Jörg Baumann, Claudia Maier, Hans Klose, Andreas Meyer, Axel Nierhaus, and Georg Kreymann
Anesth Analg 2008 107: 1639-1643.
OBSTETRIC
ANESTHESIOLOGY:
孫鵬飛譯 薛張綱校
A Randomized Trial of
Dural Puncture Epidural Technique Compared with the Standard Epidural Technique
for Labor Analgesia
Eric Cappiello, Nollag O'Rourke, Scott Segal, and Lawrence C. Tsen
Anesth Analg 2008 107:
1646-1651.
周姝婧 譯 陳傑 校
The Anesthetic
Management for Cesarean Delivery in a Patient with Shone's Syndrome (Case Report)
Kathleen Sachse and Medhat Hannallah
Anesth Analg 2008 107: 1652-1654.
ECONOMICS,
EDUCATION, AND POLICY:
顏濤 譯， 馬皓琳 李士通 校
A
Simulation Model for Determining the Optimal Size of Emergency Teams on Call in
the Operating Room at Night
Jeroen M. van Oostrum, Mark Van Houdenhoven, Manon M. J. Vrielink, Jan Klein, Erwin W. Hans, Markus Klimek, Gerhard Wullink, Ewout W. Steyerberg, and Geert Kazemier
Anesth
Analg 2008 107: 1655-1662.
NEUROSURGICAL
ANESTHESIOLOGY AND NEUROSCIENCE:
夏俊明譯 薛張綱校
Increased Oxygen
Administration Improves Cerebral Oxygenation in Patients Undergoing Awake
Carotid Surgery
Mark D. Stoneham, Omer Lodi, Thearina C. D. de Beer, and John W. Sear
Anesth Analg 2008 107:
1670-1675.
腦電雙頻譜指數在嚴重腦損傷合併難治性顱高壓患者巴比妥酸昏迷中的應用
趙嫣紅 譯 陳傑 校
The Use of Bispectral
Index to Monitor Barbiturate Coma in Severely Brain-Injured Patients with
Refractory Intracranial Hypertension
Vincent Cottenceau, Laurent Petit, Françoise Masson, Dominique Guehl, Julien Asselineau, Jean-François Cochard, Catherine Pinaquy, Alain Leger, and François Sztark
Anesth Analg 2008 107: 1676-1682.
青少年脊柱側彎手術中應用異丙酚-瑞芬太尼麻醉進行術中喚醒試驗時混合聽覺誘發電位指數和BIS的比較
朱 慧譯 馬皓琳 李士通校
A Comparison in
Adolescents of Composite Auditory Evoked Potential Index and Bispectral Index
During Propofol-Remifentanil Anesthesia for Scoliosis Surgery with
Intraoperative Wake-Up Test
Heleen J. Blussé van Oud-Alblas, Jeroen W. B. Peters, Tom G. de Leeuw, Kris T. A. Vermeylen, Luuk W. L. de Klerk, Dick Tibboel, Jan Klein, and Frank Weber
Anesth Analg 2008 107: 1683-1688.
宣麗真譯 薛張綱校
The Howling Cortex:
Seizures and General Anesthetic Drugs (Review Article)
Logan J. Voss, James W. Sleigh, John P. M. Barnard, and Heidi E. Kirsch
Anesth Analg 2008 107:
1689-1703.
GENERAL
ARTICLES:
潘錢玲 譯 陳傑 校
Effectiveness of
Noninvasive Positive Pressure Ventilation to Enhance Preoxygenation in Morbidly
Obese Patients: A Randomized Controlled Study
Jean-Marc Delay, Mustapha Sebbane, Boris Jung, David Nocca, Daniel Verzilli, Yvan Pouzeratte, Moez El Kamel, Jean-Michel Fabre, Jean-Jacques Eledjam, and Samir Jaber
The Anesth Analg 2008 107: 1707-1713.
ANALGESIA:
黃麗娜 譯 馬皓琳 李士通 校
Postoperative Pain
and Analgesic Requirements After Anesthesia with Sevoflurane, Desflurane or
Propofol
Argyro Fassoulaki, Aikaterini Melemeni, Anteia Paraskeva, Ioanna Siafaka, and Constantine Sarantopoulos
Anesth Analg 2008 107: 1715-1719.
章一靜譯 薛張綱校
Gabapentin Attenuates Late but Not Early
Postoperative Pain After Thyroidectomy with Superficial Cervical Plexus Block
Nicolas Brogly, Jean-Michel Wattier, Grégoire Andrieu, Daliana Peres, Emanuel Robin, Eric Kipnis, Laurent Arnalsteen, Béatrice Thielemans, Bruno Carnaille, François Pattou, Benoît Vallet, and Gilles Lebuffe
Anesth Analg 2008 107: 1720-1725.
在體內高或低皮質醇對人體單核細胞介導的炎症反應途徑有雙相影響
陳偉 譯 陳傑 校
In Vivo Exposure to High or Low Cortisol Has
Biphasic Effects on Inflammatory Response Pathways of Human Monocytes
Mark P. Yeager, Patricia A. Pioli, Kathleen Wardwell, Michael L. Beach, Peter Martel, Hong K. Lee, Athos J. Rassias, and Paul M. Guyre
Anesth Analg 2008 107: 1726-1734.
泰國的脊髓麻醉後心搏停止：40,271例麻醉的多中心前瞻性記錄：
張曦 譯，馬皓琳 李士通 校
Cardiac Arrest After
Spinal Anesthesia in Thailand: A Prospective Multicenter Registry of 40,271
Anesthetics
Somrat Charuluxananan, Somboon Thienthong, Mali Rungreungvanich, Thavat Chanchayanon, Thitima Chinachoti, Oranuch Kyokong, and Yodying Punjasawadwong
Anesth Analg 2008 107: 1735-1741.
對土耳其一家私人醫院34109名行硬膜外阻止的婦產科病人的回顧性研究
陳珺珺譯 薛張綱校
A Retrospective Review of 34,109 Epidural Anesthetics for Obstetric and Gynecologic Procedures at a Single Private Hospital in Turkey (Brief Report)
Kaan Katircioglu, Levent Hasegeli, H. Fehmi Ibrahimhakkioglu, Berkay Ulusoy, and Huseyin Damar
Anesth Analg 2008 107:
1742-1745.
3%氯普魯卡追加0.5%布比卡因和2%利多卡因追加0.5%布比卡因在肌間溝臂叢神經阻滯中的比較：一項隨機、前瞻、雙盲對照試驗：
王騰 譯 陳傑 校
A Randomized,
Prospective, Double-Blind Trial Comparing 3% Chloroprocaine Followed by 0.5%
Bupivacaine to 2% Lidocaine Followed by 0.5% Bupivacaine for Interscalene
Brachial Plexus Block
Soheila Jafari, Allison I. Kalstein, Habib M. Nasrullah, Mehrdad Hedayatnia, Joel M. Yarmush, and Joseph SchianodiCola
Anesth Analg 2008 107: 1746-1750.
彭中美 譯 馬皓琳 李士通 校
Single Injection
Peribulbar Anesthesia with a Short Needle Combined with Digital Compression (Brief Report)
Waleed Riad and Nauman Ahmed
Anesth Analg 2008 107:
1751-1753.
Tranexamic Acid
Reduces Perioperative Blood Loss in Adult Patients Having Spinal Fusion Surgery
Jean Wong, MD,
FRCPC*, Hossam El Beheiry, MBBCh, PhD, FRCPC*, Yoga Raja
Rampersaud, MD, FRCSC_files/image002.gif){kind=small}
, Stephen Lewis, MD, FRCSC_files/image003.gif){kind=small}
, Henry Ahn, MD, FRCSC_files/image005.gif){kind=small}
, Yoshani De Silva, BSc*, Amir
Abrishami, MD*, Naseer Baig, MD, FRCPC_files/image007.gif){kind=small}
, Robert J. McBroom, MD, FRCSC||,
and Frances Chung, MD, FRCPC*
From the
Departments of *Anesthesia, and _files/image008.gif){kind=small}
Orthopaedics, Toronto Western Hospital,
University Health Network, Toronto, Ontario, _files/image009.gif){kind=small}
Department of Orthopaedics, St. Michael's
Hospital, Toronto, Ontario, Departments of _files/image010.gif){kind=small}
Anesthesia, and ||Orthopaedics, Trillium
Hospital, Mississauga, Ontario, Canada.
Anesth Analg 2008;
107:1479-1486
背景:成年病人行脊柱重建手術往往伴隨大量出血,以致常常需要輸入異體血製品。本研究選取行擇期後路胸/腰椎內固定脊柱融合術的成年病人，採用隨機、前瞻、雙盲、多中心的方法，探討氨甲環酸（TXA）減少圍手術期間失血及輸血的效能。
方法：151名成年病人隨機分為2組。TXA組：麻醉誘導後靜脈推注10 mg/kg TXA,隨後以1 mg/kg/hr TXA維持輸注。安慰劑組：給予等容積安慰劑（生理鹽水）。主要結果是手術中和手術後24 h內估計失血量及計算失血量。次要結果是異體輸血的發生率和病人住院時間。
結果：4名病人皆因可識別的外科性出血被排除研究，因此147名病人納入統計分析。與安慰劑組相比，TXA組病人總的估計失血量和計算失血量比安慰劑組分別降低大約25%和30% (1592 ± 1315 mL比2138
± 1607 mL, P = 0.026; 3079 ± 2558比4363 ± 3030, P = 0.017)。兩組中，輸入的血製品量和住院時間沒有差異。TXA、手術持續時間、椎骨融合的數目是影響圍術期失血的獨立因素。輸注異體紅細胞需考慮病人的ASA分級、手術持續時間及脊柱融合數目。
結論：對於擇期行後路胸/腰椎內固定脊柱融合手術的成年病人，TXA明顯減少圍術期估計及計算的總失血量。
(江繼宏 譯
馬皓琳 李士通 校）
BACKGROUND: Spinal reconstructive surgery in adults can
be associated with significant blood loss, often requiring
allogeneic blood transfusion. The objective of this randomized,
prospective, double-blind, multicenter study was to evaluate the
efficacy of tranexamic acid (TXA) in reducing perioperative blood
loss and transfusion in adult patients having elective posterior
thoracic/lumbar instrumented spinal fusion surgery.
METHODS: One hundred fifty-one adult patients were
randomized to receive either a bolus of 10 mg/kg IV of TXA after
induction followed by a maintenance infusion of 1 mg/kg/hr of TXA,
or an equivalent volume of placebo (normal saline). The primary
outcome was the total perioperative estimated and calculated blood
loss intraoperatively and 24 h postoperatively. Secondary outcomes
were incidence of allogeneic blood exposure, and duration of
hospital stay.
RESULTS: Four patients were withdrawn for
identifiable surgical bleeding, therefore 147 patients were included
in the analysis. The total estimated and calculated perioperative
blood loss was approximately 25% and 30% lower in patients given TXA
versus placebo (1592 ± 1315 mL vs 2138 ± 1607 mL, P = 0.026; 3079 ± 2558 vs 4363 ±
3030, P = 0.017), respectively.
There was no difference in the amounts of blood products transfused,
and length of stay between the two groups. TXA, surgical duration,
and number of vertebrae fused were independent factors related to
perioperative blood loss. Predictors for the need for allogeneic red
blood cell transfusion were ASA classification, surgical duration
and number of levels fused.
CONCLUSIONS: TXA significantly reduced the estimated and
calculated total amount of perioperative blood loss in adult patients
having elective posterior thoracic/lumbar instrumented spinal fusion
surgery.
右美托咪定：治療先天性心臟病手術圍術期房性和交界性心動過速的新藥：一項初步的研究
Dexmedetomidine:
A Novel Drug for the Treatment of Atrial and Junctional Tachyarrhythmias During
the Perioperative Period for Congenital Cardiac Surgery: A Preliminary Study
Constantinos
Chrysostomou, MD, Lee Beerman, MD, Dana Shiderly, BSN, RN, CCRN, Donald Berry,
RPh, Victor O. Morell, MD, and Ricardo Munoz, MD
From the Department
of Cardiology, Cardiac Intensive Care Unit, Children’s Hospital of
Pittsburgh–University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Anesth Analg 2008;
107:1514-1522
研究背景：先天性心臟病手術圍術期經常出現房性和交界性心動過速，且可使致病率和死亡率升高。上述節律失常雖然可被正常心臟良好耐受，但是在先天性心臟病患者中可引起嚴重的血流動力學不穩定，在心肺轉流術後階段尤為嚴重。由於目前可用的抗心律失常藥物可能無效或耐受性差，故對這些心律失常的治療頗為棘手。本研究檢驗了右美托咪定這一最初用於鎮靜的藥物對於房性和交界性心動過速可能具有的療效。儘管一些動物實驗的資料顯示該藥可預防某種類型的室性心動過速，但尚無關於該藥對房性和交界性心動過速治療作用的研究。
研究目的：此為回顧性、非隨機、非對照研究。研究包括了進入心臟病監護室的14名患者，右美托咪定用於鎮靜/鎮痛和治療交界性異位心動過速（JET）、房性異位性心動過速（AET）、折返型室上性心動過速（Re-SVT）、心房撲動（AF）或交界性加速性節律（JAR）。使用右美托咪定作為首選治療藥物或其他抗心律失常藥物治療失敗後的補救措施。主要研究終點為(a) Re-SVT 在3分鐘之內轉為正常竇性心律（NSR），其他心律失常在2小時內轉為正常竇性心律或 (b) 心率（HR）減慢使得血流動力學改善；JET _files/image012.gif){kind=small}
170 bpm, AET _files/image014.gif){kind=small}
20%, AF _files/image015.gif){kind=small}
150 bpm 且預防JAR進展為JET。
研究結果：患者平均年齡為2 ± 3月，平均體重為4 ± 1.5千克。大多數心律失常（79％）出現在術後。9名患者接受右美托咪定作為首選治療藥物，5名患者接受該藥作為補救藥物。10名患者（71％）接受1.1 ± 0.5 µg/kg初始負荷劑量。12名患者接受0.9 ± 0.3 µg · kg–1 · h–1 持續靜脈輸注。13名患者接受機械通氣。4名患者（28％）出現不良反應。3名患者出現低血壓但輸注液體後好轉，1名患者可能出現了短暫的完全性房室（AV）傳導阻滯。14名患者中有9名患者接受了臨時心房起搏（7名患者）或AV順序起搏（2名患者）以改善AV同步性。13名患者（93％）達到了心律和/或HR得到控制的初步結果。在給予右美托咪定後67 ±
75 min之內JET心率從 197 ± 22 降至165 ± 17 bpm。這些患者中有5名患者在39 ± 31小時後轉為NSR，有1名患者維持JAR。4名Re-SVT患者經治療後此類心動過速均得以終止。3名患者轉為NSR，一名患者轉為JAR。一名AET（220–270 bpm）患者對右美托咪定反應良好，在35分鐘內HR降至120 bpm 並且在85分鐘內轉為NSR。一名AF患者對該藥沒有反應。2名JAR患者均未進展為JET且HR從158 ± 11bpm降至129 ± 1 bpm。
結論：這一初步的觀察性研究結果提示右美托咪定可能對於圍術期房性和交界性心動過速的急性期具有潛在的治療作用，可控制HR或使心律轉為NSR。
（周雅春 譯 馬皓琳 李士通 校）
BACKGROUND: Atrial and junctional tachyarrhythmias occur
frequently during the perioperative period for congenital cardiac
surgery and can be a cause of increased morbidity and mortality.
These rhythm disturbances that may be well tolerated in a normal
heart can cause significant hemodynamic instability in patients with
congenital heart defects, particularly during the postcardiopulmonary
bypass period. Management of these arrhythmias presents more of
a challenge, since currently available antiarrhythmic drugs can be
ineffective and poorly tolerated. In this study, we examined the
possible effect of dexmedetomidine, a primarily sedative drug, on
atrial and junctional tachyarrhythmias. Though some animal data have
shown that it can prevent certain types of ventricular tachycardia,
its therapeutic role during these types of arrhythmias has not been
studied.
METHODS: This was a retrospective, nonrandomized,
noncontrolled study. Fourteen patients admitted to the cardiac
intensive care unit and who received dexmedetomidine for both,
sedation/analgesia and for junctional ectopic tachycardia (JET),
atrial ectopic tachycardia (AET), reentry type supraventricular
tachycardia (Re-SVT), atrial flutter (AF) or junctional accelerated
rhythm (JAR) were included. Dexmedetomidine was used as a primary
drug or as a rescue if other antiarrhythmics had been used. Our primary
end-points were (a) conversion to normal sinus rhythm (NSR) within
3 min for Re-SVT, and 2 h for all other arrhythmias or (b) heart
rate (HR) reduction to improve hemodynamics; JET _files/image016.gif){kind=small}
170 bpm, AET _files/image017.gif){kind=small}
20%, AF _files/image018.gif){kind=small}
150 bpm and for JAR prevention of progression
to JET.
RESULTS: The mean age and weight were 2 ± 3 mo and 4
± 1.5 kg, respectively. Most of the arrhythmias (79%) occurred
during the postoperative period. Dexmedetomidine was used as a
primary treatment in nine and as a rescue in five patients. Ten
patients (71%) received an initial loading dose of 1.1 ± 0.5 µg/kg.
A continuous infusion, 0.9 ± 0.3 µg · kg–1 · h–1 was
administered in 12 patients. Thirteen patients’ lungs were
mechanically ventilated. Adverse effects were seen in four patients
(28%). Three had hypotension that responded to fluid administration
and one had a possible brief complete atrioventricular (AV) block.
Nine of the 14 patients were transiently paced with atrial (seven)
or AV sequential (two) pacing to improve AV synchrony. The primary
outcome with rhythm and/or HR control was achieved in 13 patients
(93%). JET rate decreased from 197 ± 22 to 165 ± 17 bpm within 67 ±
75 min of dexmedetomidine administration. Five of these patients
converted to NSR in 39 ± 31 h and one remained in JAR. All four
patients with Re-SVT had resolution of their tachyarrhythmia. Three
converted to NSR and one to JAR. One patient with AET (220–270 bpm)
responded well with decreasing HR to 120 bpm within 35 min and to
NSR in 85 min. One patient with AF failed to respond. In two
patients with JAR, neither progressed to JET and HR decreased from
158 ± 11 to 129 ± 1 bpm.
CONCLUSION: This preliminary, observational report
suggests that dexmedetomidine may have a potential therapeutic role
in the acute phase of perioperative atrial and junctional
tachyarrhythmias for either HR control or conversion to NSR.
容積描記脈搏波幅對七氟醚麻醉的兒科病人靜脈內注射含腎上腺素的硬膜外試驗劑量是有效的指示劑
Plethysmographic
Pulse Wave Amplitude Is an Effective Indicator for Intravascular Injection of
Epinephrine-Containing Epidural Test Dose in Sevoflurane-Anesthetized Pediatric
Patients
Hany A. Mowafi,
MBBch, MSc, MD, Samer A. Arab, MBBch, MD, Salah A. Ismail, MBBch, MSc, MD,
Abdulmohsin A. Al-Ghamdi, MBBch, MD, and Roshdi R. Al-Metwalli, MBBch, MSc, MD
From the Department
of Anesthesiology, Faculty of Medicine, King Faisal University, Saudi Arabia.
Anesth Analg 2008;
107:1536-1541
背景：體積描記脈搏波幅(PPWA)在成人可有效地檢測靜脈內注射硬膜外試驗劑量，敏感性和特異性為100%。我們在七氟醚麻醉的兒科病人評價PPWA對靜脈內注射模擬硬膜外試驗劑量的檢測功效。
方法：80個嬰兒和兒童隨機地分組，吸入含0.5 MAC或1 MAC和氧化亞氮的氧氣，每組病人進一步隨機地靜脈注射含1:200,000腎上腺素 (0.5 µg/kg )的1%利多卡因0.1 mL/kg以模擬靜脈內注射硬膜外試驗劑量或注射生理鹽水。注射後檢測心率(HR)，收縮壓(SBP)和PPWA 5分鐘，以HR增快超過10次/分鐘、SBP升高超過15 mm Hg和PPWA減小超過10%定義為陽性實驗反應。
結果：注射試驗劑量後，0.5 MAC和1 MAC七氟醚組PPWA在79 ± 22和 80 ± 19 s平均最大降幅為69% ± 18% 和58% ± 14%。兩個七氟醚組PPWA的敏感性、特異性、陽性預計值和陰性預計值都是100%，但是以HR和SBP作為檢測標準時，0.5 MAC七氟醚組的敏感性分別是90%和95%，1 MAC七氟醚組都是85%。
結論：PPWA在兒科病人能有效地檢測靜脈內注射模擬的含腎上腺素的硬膜外試驗劑量。
（王宏 譯 馬皓琳 李士通校）
BACKGROUND: Plethysmographic pulse wave amplitude (PPWA)
was effective in detecting intravascular injection of epidural test
dose with 100% sensitivity and specificity in adults. We evaluated the
efficacy of PPWA in detecting intravascular injection of a simulated
epidural test dose during sevoflurane anesthesia in pediatric
patients.
METHODS: Eighty infants and children were randomized
to receive either 0.5 minimal alveolar concentration (MAC) or 1 MAC
sevoflurane and nitrous oxide in oxygen. Patients in each anesthesia
group were further randomized to receive either 0.1 mL/kg of 1%
lidocaine with 1:200,000 epinephrine (0.5 µg/kg of epinephrine)
IV to simulate the intravascular injection of epidural test dose
or saline. Heart rate (HR), systolic blood pressure (SBP), and PPWA
were monitored for 5 min after injection. A positive test response
was defined as HR increase _files/image019.gif){kind=small}
10 bpm, SBP increase _files/image020.gif){kind=small}
15 mm Hg, and PPWA decrease _files/image021.gif){kind=small}
10%.
RESULTS: Injecting the test dose resulted in an
average maximum PPWA decrease by 69% ± 18% and 58% ± 14% at 79 ±
22 and 80 ± 19 s in the 0.5 MAC and 1 MAC sevoflurane groups,
respectively. The sensitivity, specificity, positive predictive, and
negative predictive values for PPWA were 100% in both sevoflurane
groups, whereas by using HR and SBP criteria, the sensitivity was
90% and 95% respectively during 0.5 MAC sevoflurane anesthesia and
85% for both during 1 MAC sevoflurane anesthesia.
CONCLUSION: PPWA is effective for detection of an
intravascular injection of a simulated epidural
epinephrine-containing test dose in pediatric patients.
兒童麻醉中的呼末七氟醚濃度、腦電雙頻指數及腦狀態指數之間的動態關係
The Dynamic
Relationship Between End-Tidal Sevoflurane Concentrations, Bispectral Index,
and Cerebral State Index in Children
Ricardo Fuentes, MD*,
Luis I. Cortínez, MD*, Michel M. R. F. Struys, MD, PhD_files/image022.gif){kind=small}
_files/image023.gif){kind=small}
, Alejandro Delfino, MD*, and
Hernán Muñoz, MD, MSc*
From the
*Departamento de Anestesiología, Facultad de Medicina, Pontificia Universidad
Católica de Chile, Santiago, Chile; _files/image024.gif){kind=small}
Department of Anesthesia, University Medical
Center Groningen, Groningen, The Netherlands, and _files/image025.gif){kind=small}
Department of Anesthesia, Ghent University,
Ghent, Belgium.
Anesth Analg 2008;
107:1573-1578
背景：為了在兒童麻醉中使用腦電圖監測儀來指導麻醉藥的給予，就需要這些監測儀在這個人群中測得的麻醉藥效應的足夠特點。我們試圖定量和比較用腦電雙頻指數（BIS）及腦狀態指數（CSI）在兒童測得的七氟醚效應的動態變化。
方法：前瞻性研究15例擇期行較小手術的健康兒童，年齡在3-15歲。在CSI和BIS同步記錄過程中，七氟醚揮發器先設置為6%，持續5 min，然後降低。測定呼末濃度(CET)。對CET-七氟醚效應部位濃度平衡和藥效學進行建模。比較兩者之間的吻合度。資料為典型值（變異係數）。
結果：在研究的麻醉深度範圍內，用效應部位平衡半衰期（t1/2 ke0）來表示的七氟醚效應的變化速度，CSI [2.0 (14) min]比BIS[1.2 (53) min]變化慢(P < 0.05)。在七氟醚給予 (E0) 之前BIS和CSI的估計基線效應，CSI為84 (39)而BIS為87 (7)（無顯著意義）。七氟醚的催眠效應的敏感性用C50表示[最大效應(Emax)一半時穩態CET]，CSI為2.1 (68) %而BSI為2.1 (16)%（無顯著意義）。CSI為45（0）時的最大效應)高於BIS為27（39）時的最大效應27 (39) (P < 0.05)。人群預計誤差BIS (–0.7 ± 26.9)優於CSI
(–3.0 ± 178.6) (P < 0.05)。
結論：在兒童中，七氟醚的t1/2 ke0和藥效動力學的定量和結果完全取決於測定其催眠作用所用的監測儀。在所研究的麻醉深度範圍內，七氟醚效應的變化速度慢於CSI。為了在這些監測儀的監測下，適當地指導七氟醚在兒童中給藥，這些差異必需要進行考慮。
（唐亮 譯 馬皓琳 李士通 校）
BACKGROUND: To guide anesthetic administration with
electroencephalogram monitors in children, an adequate
characterization of the anesthetic effect measured by these monitors
in this population is needed. We sought to quantify and compare the
dynamic profile of sevoflurane’s effect measured with the cerebral
state index (CSI) and the bispectral index (BIS) in children.
METHODS: Fifteen healthy children, aged 3–15 yr,
scheduled to undergo minor surgery were prospectively studied.
During the simultaneous recording of CSI and BIS, the sevoflurane vaporizer
was set at 6 vol % for 5 min and then decreased. End-tidal concentrations
(CET)
were measured. The CET–sevoflurane
effect–site concentration equilibration and pharmacodynamics were
modeled. Goodness of fit between models was compared. Data are typical
value (coefficient of variation).
RESULTS: Within the anesthetic depth range studied,
the rate of change of sevoflurane’s effect expressed as the
effect–site equilibration half-life (t1/2 ke0) was slower with the CSI [2.0
(14) min] than with BIS [1.2 (53) min] (P < 0.05). The estimated baseline
effect of BIS and CSI before sevoflurane administration (E0) was 84 (39) for CSI and 87 (7)
for BIS (NS). The sensitivity to sevoflurane hypnotic effect
expressed in the C50
[steady-state CET
eliciting half of the maximum response (Emax)] was 2.1 (68) % with CSI and 2.1 (16)% with
BIS (NS). The Emax
with CSI 45 (0) was higher than that with BIS 27 (39) (P < 0.05). The population
prediction error was significantly better for BIS (–0.7 ± 26.9) than
for CSI (–3.0 ± 178.6) (P < 0.05).
CONCLUSIONS: In children, the t1/2 ke0 of sevoflurane and the pharmacodynamics
of sevoflurane were quantified and the results were entirely
dependent on the monitor used to measure its hypnotic effect. Within
the anesthetic depth range studied, the rate of change of
sevoflurane’s effect was slower with the CSI. To adequately guide
sevoflurane administration with these monitors in children, these
differences should be considered.
利多卡因通過提高細胞週期蛋白依賴激酶抑制劑1A (p21)的表達從而抑制NIH-3T3細胞增殖
Lidocaine
Inhibits NIH-3T3 Cell Multiplication by Increasing the Expression of
Cyclin-Dependent Kinase Inhibitor 1A (p21)
Sukumar P. Desai,
MD, Koji Kojima, MD, PhD, Charles A. Vacanti, MD, and Shohta Kodama, MD, PhD
From the Department
of Anesthesiology, Perioperative and Pain Medicine, Laboratory for Tissue
Engineering and Regenerative Medicine, Brigham and Women’s Hospital, Harvard
Medical School, Boston, Massachusetts.
Anesth Analg 2008;
107:1592-1597
背景：我們發現了利多卡因抑制鼠類胚胎成纖維細胞系NIH-3T3生長的分子機制。局部麻醉藥能在體外抑制細胞的生長。它們對傷口癒合的影響存在爭議。我們研究了利多卡因在體外對鼠類成纖維細胞系NIH-3T3增殖的影響及其新機制。
方法：在NIH-3T3細胞培養液中加入利多卡因[0、0.05、0.5、1、2和5
mM]一起培養。接下來的幾天內通過細胞計數測定細胞的增殖，測定溴去氧尿苷的攝取、用多聚酶鏈反應陣列測定基因的表達，以及蛋白印跡分析來檢驗受影響蛋白的增高水準，以探討利多卡因抑制細胞增殖的發生機制。
結果：利多卡因呈劑量依賴地抑制NIH-3T3細胞的增殖。0.05和0.5
mM利多卡因對細胞增殖沒有影響，1 mM利多卡因有輕度影響，2和5
mM利多卡因嚴重抑制細胞的增殖(P = 0.006)。培養液中加入2
mM利多卡因後3.5天，2 mM利多卡因抑制溴去氧尿苷的攝取(與對照組相比P =
0.02，與1 mM利多卡因相比P =
0.0495)。培養液中加入利多卡因1.5天后，利多卡因上調細胞週期蛋白-D1和細胞週期蛋白依賴激酶抑制劑1A
[p21]的表達。培養液中加入利多卡因後2.5天，利多卡因使p21蛋白水準增加。
結論：脊麻、硬膜外麻醉或神經叢阻滯後在血漿中可見低濃度利多卡因，不會明顯影響成纖維細胞的增殖。而更高濃度的利多卡因通過使細胞增殖強效抑制劑p21合成增加，從而在細胞生長週期S相抑制成纖維細胞的增殖。較高濃度可見於組織浸潤後，可以明顯抑制成纖維細胞的增殖，因而可能妨礙傷口的癒合。
（張瑩譯 馬皓琳 李士通校）
BACKGROUND: We explored molecular mechanisms by which
lidocaine inhibits growth in the murine embryonic fibroblast cell
line NIH-3T3. Local anesthetics can adversely affect cell growth
in vitro. Their
effects on wound healing are controversial. We examined the effects
and novel mechanisms by which lidocaine affects in vitro multiplication of the murine fibroblast
cell line NIH-3T3.
METHODS: NIH-3T3 cells were grown in culture with
lidocaine [0, 0.05, 0.5, 1, 2, and 5 mM]. Cell multiplication was
assessed by determining cell counts on subsequent days, while
mechanisms by which inhibition occurred were evaluated by
bromodeoxyuridine uptake, gene expression using polymerase chain
reaction array, and Western blot analysis to verify increased levels
of affected proteins.
RESULTS: Lidocaine caused dose-dependent inhibition
of multiplication of NIH-3T3 cells. Effects ranged from no
inhibition [0.05 and 0.5 mM] and mild inhibition [1 mM], to severe
inhibition [2 and 5 mM] [P = 0.006]. Lidocaine 2 mM inhibited bromodeoxyuridine uptake
at day 3.5 [P = 0.02
versus control, and P =
0.0495 vs 1 mM lidocaine]. On day 1.5, lidocaine upregulated
expression of cyclin-D1 and cyclin-dependent kinase inhibitor 1A
[p21]. On day 2.5, lidocaine increased the levels of p21 protein.
CONCLUSIONS: Low concentrations of lidocaine, as would be
seen in plasma after spinal, epidural, or plexus anesthesia, do not
significantly affect multiplication of fibroblasts. Higher doses of
lidocaine arrest cell multiplication at the S-phase of the growth
cycle by upregulation of p21, an extremely potent inhibitor of cell
multiplication. Higher concentrations, as would be seen after tissue
infiltration, severely inhibit fibroblast multiplication and thus
may impair wound healing.
Body Temperature
Change During Anesthesia for Electroconvulsive Therapy: Implications for
Quality Incentives in Anesthesiology
Jerome H. Modell,
MD, DSc (Hon.), Nikolaus Gravenstein, MD, and Timothy E. Morey, MD
From the Department
of Anesthesiology, University of Florida College of Medicine, Gainesville,
Florida.
Anesth Analg 2008;
107:1618-1620
背景：美國麻醉學家學會已經對外宣佈圍手術期維持正常體溫是麻醉學品質的體現。我們檢驗了是否可以在單一人群（接受電驚厥治療（ECT）的病人）中達到這種麻醉品質激勵。
方法：我們比較了麻醉前經紅外測得的耳溫和經過101種順序的便於ECT的較短麻醉藥後到達麻醉後復蘇室（PACU）時的耳溫。
結果：共有35例病人在麻醉前耳溫測得<36°C，18例病人在麻醉後送到PACU時耳溫<36°C。30種麻醉藥使病人的體溫在麻醉過程中降低，64種麻醉藥使病人的體溫在麻醉期間升高，7種不改變病人體溫。所有的資料檢查都表明病人麻醉前後的體溫之間沒有相關性。
討論：我們得到了結論是當給予麻醉以便於ECT時，我們研究中的病人在麻醉期間的溫度變化並不一致。如果送到PACU時病人的鼓室溫度低於36°C，我們也不可以推測病人在麻醉過程中的體溫管理是低於標準的。而且目前的體溫測量方法也不足以確定病人在手術後是否低體溫。由於避免低體溫是一個有價值的目標，如果體溫被用作為一種麻醉品質激勵，麻醉科就必須保證體溫監測設備可以準確測量術後體溫。
（姜旭暉譯，馬皓琳，李士通校）
BACKGROUND: The American Society of Anesthesiologists
has announced that perioperative normothermia is a "Quality
Incentive in Anesthesiology." We examined whether we could meet
this quality incentive in a simple population: patients undergoing
anesthesia for electroconvulsive therapy (ECT).
METHODS: We compared infrared-measured ear
temperature before anesthesia to temperature upon delivery of
patients to the postanesthesia care unit (PACU) after 101
consecutive brief anesthetics to facilitate ECT.
RESULTS: For 35 procedures, the patients had an
infrared ear thermometer temperature of <36°C before anesthesia
was administered, and 18 had a temperature of <36°C after anesthesia
when transferred to the PACU. For 30 anesthetics, the patients'
temperature decreased during anesthesia, for 64 anesthetics it
increased during anesthesia, and for 7 it did not change. Overall
examination of the data demonstrated no correlation between
preprocedure and postprocedure temperature.
DISCUSSION: We conclude that there was no consistent
change in temperature during anesthesia between our study patients
when anesthesia was administered to facilitate ECT. If patients' tympanic
temperatures were below 36°C upon admission to the PACU, it would be
incorrect to conclude that intraprocedural temperature management
measures were substandard. Also, current methods of measuring
temperature may be inadequate to ascertain if patients are
hypothermic after surgery. As the avoidance of hypothermia is a
meritorious goal, anesthesia departments need to ensure that their
temperature monitoring equipment is adequate to ensure accurate
measurement of postanesthetic temperature if this variable is to be
used as a quality incentive.
ICU內的氣管切開術：一項全國範圍的調查
Tracheostomy in
the Intensive Care Unit: A Nationwide Survey
Stefan Kluge, MD*,
Hans Jörg Baumann, MD_files/image026.gif){kind=small}
, Claudia Maier, MD*, Hans Klose,
MD_files/image027.gif){kind=small}
, Andreas Meyer, MD_files/image028.gif){kind=small}
, Axel Nierhaus, MD*, and Georg
Kreymann, MD*
From the
Departments of *Intensive Care; and _files/image029.gif){kind=small}
Pulmonary Medicine, University Medical
Center, Hamburg-Eppendorf, Germany.
Anesth Analg 2008;
107:1639-1643
背景：近幾年來氣管切開術的指征、時機及技巧發生了改變。我們開展了一項調查以評估當前德國重症監護病房(ICUs)內氣管切開術的實施。
方法：將問卷郵寄給513位德國ICU（包括小兒ICU）的醫師負責人，。
結果：在513個ICU中，我們獲得了455份回饋結果（89%）。在90%的ICU中，在機械通氣的最初14天中實施氣管切開術。86%的ICU常規實施經皮擴張氣管切開術；改良的Ciaglia技術是最流行的經皮穿刺技術(69%)。絕大部分(98%)的經皮穿刺操作是在支氣管鏡控制下完成的。通常由一位外科醫生(61%)在手術室內(72%)完成外科氣管切開術，而經皮擴張氣管切開術則是由一位重症護理醫生(93%)在ICU (98%)患者的床邊完成的。26%的ICU常規隨訪氣管切開的病人，45%的ICU有關於氣管切開的指征、時機及技術操作的指南。
結論：在德國，經皮擴張氣管切開術是危重病人氣管切開的一種選擇。改良的Ciaglia技術是更好的經皮穿刺技術，幾乎所有的內科醫生都常規使用支氣管鏡引導。大多數氣管切開術都在機械通氣的第二周完成。
（裘毅敏譯，馬皓琳 李士通校）
BACKGROUND: The indication, timing and technique of
tracheostomy have changed over the last several years. We performed
a survey to assess the current practice of tracheostomy in German
intensive care units (ICUs).
METHODS: A postal questionnaire was sent to the head
physicians of 513 German ICUs, excluding pediatric ICUs.
RESULTS: We obtained responses from 455 of the 513
ICUs (89%). In 90% of the ICUs, tracheostomies were performed during
the first 14 d of mechanical ventilation. Eighty-six percent of
the ICUs routinely performed percutaneous dilatational tracheostomy;
the modified Ciaglia technique was the most popular percutaneous technique
(69%). The majority (98%) of the percutaneous procedures were
performed under bronchoscopic control. Surgical tracheostomy is
usually performed in the operating room (72%) by a surgeon (61%),
whereas percutaneous dilatational tracheostomies are usually performed
at the patient's bedside in the ICU (98%) by an intensivist (93%).
Tracheostomized patients were followed up routinely in 26% of the
ICUs, and in 45% of the ICUs there were guidelines regarding the
indication, the timing and the technique of tracheostomy.
CONCLUSION: Percutaneous dilatational tracheostomy is
the procedure of choice for tracheostomy in critically ill patients
in Germany. The modified Ciaglia technique is the preferred
percutaneous technique, and nearly all physicians routinely use bronchoscopic
guidance. Most tracheostomies are done during the second week of
mechanical ventilation.
A
Simulation Model for Determining the Optimal Size of Emergency Teams on Call in
the Operating Room at Night
Jeroen M. van
Oostrum, MSc*, Mark Van Houdenhoven, PhD*_files/image030.gif){kind=small}
, Manon M. J. Vrielink, MSc*, Jan
Klein, MD, PhD_files/image031.gif){kind=small}
, Erwin W. Hans, PhD_files/image032.gif){kind=small}
, Markus Klimek, MD, DEAA_files/image033.gif){kind=small}
, Gerhard Wullink, PhD*_files/image034.gif){kind=small}
, Ewout W. Steyerberg, PhD_files/image035.gif){kind=small}
, and Geert Kazemier, MD, PhD*||
From the
Departments of *Operating Rooms; _files/image036.gif){kind=small}
Anesthesiology, Erasmus University Medical
Center, Rotterdam, The Netherlands; _files/image037.gif){kind=small}
Department of Operational Methods for
Production and Logistics, School of Business, Public Administration and
Technology, University of Twente, The Netherlands; Departments of _files/image038.gif){kind=small}
Public Health; and ||Surgery, Erasmus University
Medical Center, Rotterdam, The Netherlands.
Anesth Analg 2008;
107:1655-1662
背景:在夜間(如晚11:00至晨7:30)開展急診手術的醫院面臨確定最佳手術室人員的問題。為減少急診病人併發症的發生和促進病人的完全恢復，需要在預定的安全時間視窗內開始手術。我們開發了一種程式來確定最佳的夜間手術室團隊構成，以使得人員開支最少而又能提供足夠的資源使手術能在安全的時間範圍內開始。
方法：應用離散事件類比結合安全時限模型。允許安全地推遲急診手術。採用Erasmus大學醫學中心主手術室資料進行驗證該模型。計算下列兩種結果：超過安全時限的急診手術和手術室及麻醉護士被從家中呼叫來的頻率。我們使用下列Erasmus醫學中心的輸入資料來估計本模型中所有相關參數的分佈：急診病人到達的次數、外科手術時長、在麻醉後恢復室停留時間和轉運次數。此外，由Erasmus醫學中心的外科醫生和手術室工作人員確定安全時限。
結果：與基準情況相比，將手術室內人員從9人減至5人導致延誤處理病人的比例增加2.5％。當需要時被從家裏呼叫到醫院的手術室和麻醉護士有相當大的增加。
結論：採用安全時限有益於夜間手術室的管理。安全時限模型顯著影響得到及時處置的急診病人人數。我們的研究表明，通過對安全時限模型和電腦類比方法的應用，手術室可以減少值班人員數量而不危害病人安全。
（顏濤 譯， 馬皓琳 李士通 校）
BACKGROUND: Hospitals that perform emergency surgery
during the night (e.g., from 11:00 pm to 7:30 am) face decisions on
optimal operating room (OR) staffing. Emergency patients need to
be operated on within a predefined safety window to decrease morbidity
and improve their chances of full recovery. We developed a process
to determine the optimal OR team composition during the night, such
that staffing costs are minimized, while providing adequate
resources to start surgery within the safety interval.
METHODS: A discrete event simulation in combination
with modeling of safety intervals was applied. Emergency surgery was
allowed to be postponed safely. The model was tested using data from
the main OR of Erasmus University Medical Center (Erasmus MC). Two
outcome measures were calculated: violation of safety intervals and
frequency with which OR and anesthesia nurses were called in from
home. We used the following input data from Erasmus MC to estimate
distributions of all relevant parameters in our model: arrival times
of emergency patients, durations of surgical cases, length of stay
in the postanesthesia care unit, and transportation times. In
addition, surgeons and OR staff of Erasmus MC specified safety
intervals.
RESULTS: Reducing in-house team members from 9 to 5
increased the fraction of patients treated too late by 2.5% as
compared to the baseline scenario. Substantially more OR and
anesthesia nurses were called in from home when needed.
CONCLUSION: The use of safety intervals benefits OR
management during nights. Modeling of safety intervals substantially
influences the number of emergency patients treated on time. Our
case study showed that by modeling safety intervals and applying
computer simulation, an OR can reduce its staff on call without
jeopardizing patient safety.
青少年脊柱側彎手術中應用異丙酚-瑞芬太尼麻醉進行術中喚醒試驗時混合聽覺誘發電位指數和BIS的比較
A Comparison in
Adolescents of Composite Auditory Evoked Potential Index and Bispectral Index
During Propofol-Remifentanil Anesthesia for Scoliosis Surgery with
Intraoperative Wake-Up Test
Heleen J. Blussé
van Oud-Alblas, MD*, Jeroen W. B. Peters, PhD*, Tom G. de
Leeuw, MD*, Kris T. A. Vermeylen, MD*, Luuk W. L. de
Klerk, MD, PhD_files/image039.gif){kind=small}
, Dick Tibboel, MD, PhD_files/image040.gif){kind=small}
, Jan Klein, MD, PhD*, and Frank
Weber, MD*
From the
Departments of *Anesthesiology, _files/image041.gif){kind=small}
Orthopedics, and _files/image042.gif){kind=small}
Pediatric Surgery, Erasmus Medical
Center–Sophia Children’s Hospital, Rotterdam, The Netherlands.
Anesth Analg 2008;
107:1683-1688
背景：腦電雙頻譜指數（BIS）和來源於腦電圖和聽覺誘發電位的混合A系ARX指數(cAAI)，已被用來作為麻醉深度監測。在兒童和青少年脊柱側彎手術應用異丙酚-瑞芬太尼麻醉的術中喚醒試驗中，我們用密西根大學鎮靜評分比較兩個指數在區別不同催眠狀態方面的表現。同時評估術後顯性回憶的情況。
方法：選取20名患者（10～20歲）。誘導時、喚醒試驗和恢復時計算預期概率。在喚醒試驗開始時、對指令能有目的的體動時和患者再麻醉後比較BIS和cAAI。在喚醒試驗過程中，患者按指示記住一種顏色，隨後進行顯性回憶的調查。
結果：誘導時BIS和cAAI的預期概率是0.82 和 0.63 (P < 0.001)，喚醒試驗時為0.78和0.79 (P < 0.001)，恢復時為0.74和0.78 (P < 0.001)。在喚醒試驗過程中，BIS和cAAI均值在有目的的體動時有顯著升高，再麻醉後顯著降低。
結論：在誘導時，BIS表現比cAAI好。在統計學上儘管cAAI在喚醒試驗和恢復時更好地鑒別意識清醒水準，但這些差異似乎並沒有臨床意義。兩個指數在喚醒試驗時均升高，指示更高的清醒水準。沒有證明存在顯性回憶。
（朱 慧譯 馬皓琳 李士通校）
BACKGROUND: The electroencephalogram-derived Bispectral
Index (BIS), and the composite A-line ARX index (cAAI), derived from
the electroencephalogram and auditory evoked potentials, have been
promoted as anesthesia depth monitors. Using an intraoperative wake-up
test, we compared the performance of both indices in distinguishing
different hypnotic states, as evaluated by the University of
Michigan Sedation Scale, in children and adolescents during
propofol-remifentanil anesthesia for scoliosis surgery. Postoperative
explicit recall was also evaluated.
METHODS: Twenty patients (aged 10–20 yr) were
enrolled. Prediction probabilities were calculated for induction,
wake-up test, and emergence. BIS and cAAI were compared at the start
of the wake-up test, at purposeful movement to command, and after
the patient was reanesthetized. During the wake-up test, patients
were instructed to remember a color, and were then interviewed for
explicit recall.
RESULTS: Prediction probabilities of BIS and cAAI for
induction were 0.82 and 0.63 (P < 0.001), for the wake-up test, 0.78 and 0.79 (P < 0.001), and 0.74 and 0.78 for
emergence (P <
0.001). During the wake-up test, a significant increase in mean BIS
and cAAI (P < 0.05)
was demonstrated at purposeful movement, followed by a significant
decline after reintroduction of anesthesia.
CONCLUSIONS: During induction, BIS performed better than
cAAI. Although cAAI was statistically a better discriminator for the
level of consciousness during the wake-up test and emergence, these
differences do not appear to be clinically meaningful. Both indices
increased during the wake-up test, indicating a higher level of
consciousness. No explicit recall was demonstrated.
Postoperative
Pain and Analgesic Requirements After Anesthesia with Sevoflurane, Desflurane
or Propofol
Argyro Fassoulaki,
MD, PhD, DEAA*, Aikaterini Melemeni, MD, DESA*, Anteia
Paraskeva, MD, DESA*, Ioanna Siafaka, MD*, and
Constantine Sarantopoulos, MD, PhD, DEAA_files/image043.gif){kind=small}
From the
*Department of Anesthesiology, Aretaieio Hospital, Medical School, University
of Athens; and _files/image044.gif){kind=small}
Department of Anesthesiology, Medical
College of Wisconsin, Milwaukee, Wisconsin.
Anesth Analg 2008;
107:1715-1719
背景：全身麻醉藥可能有會引起影響術後疼痛的感受傷害性作用。在評估術後疼痛的研究中，全身麻醉藥對止痛藥的需要量的影響還沒有研究過，除了最近一個研究表明異丙酚麻醉較異氟醚麻醉，能提供更好的術後鎮痛。
方法：在這個前瞻性、盲法、隨機的研究中，我們記錄了行(腹式)子宮切除術或子宮肌瘤切除術的病人術後2、4、8和24小時鎮痛藥的需要量（嗎啡的mg數），和疼痛評分（VAS評分，單位mm），這些病人分別用七氟醚、地氟烷或異丙酚維持麻醉，並且維持腦電雙頻指數（BIS）值在35-45之間。進入麻醉後監護室後立即記錄病人的疼痛評分。
結果：這三組間在術後2、4、8和24小時嗎啡的累積消耗量並無差異（P = 0.50）。術後24小時之內，七氟醚組嗎啡的消耗量為28 ± 13.8 mg，而地氟烷組和異丙酚組的消耗量分別為25 ±
11.7 mg和27 ± 16.1 mg。病人在轉運至麻醉後恢復室即刻處於靜息或咳嗽後、手術後2、4、8和24小時的VAS評分在三組間沒有差異（靜息時P 分別為0.40、0.39、0.50、0.47、0.06， 咳嗽後P分別為0.67、0.45、0.22、0.26、0.29）。
結論：七氟醚、地氟烷或異丙酚組嗎啡的需要量和術後24小時的疼痛沒有差異。
（黃麗娜 譯 馬皓琳 李士通 校）
BACKGROUND: General anesthetics may have nociceptive
actions that affect postoperative pain. In studies evaluating
postoperative pain, the effect of general anesthetics on analgesic
requirements has not been considered except for one recent study
suggesting that propofol anesthesia provides better analgesia after
surgery than isoflurane.
METHODS: In this prospective, blind, randomized trial
we recorded postoperative analgesic requirements (mg of morphine)
and pain scores (visual analog scale in mm) 2, 4, 8, and 24 h
postoperatively in patients undergoing abdominal hysterectomy or
myomectomy under sevoflurane, desflurane or propofol anesthesia,
titrated to maintain Bispectral Index values between 35 and 45. Pain
scores were also recorded immediately after transfer to the postanesthesia
care unit.
RESULTS: Cumulative morphine consumption did not
differ among the three groups 2, 4, 8, or 24 h postoperatively (P = 0.50). The morphine consumed
within 24 h postoperatively was 28 ± 13.8 mg in the sevoflurane
group, 25 ± 11.7 mg in the desflurane group and 27 ± 16.1 mg in the
propofol group. The visual analog scale values at rest or after
cough immediately after patient transport to the postanesthesia care
unit and 2, 4, 8, and 24 h after surgery did not differ among the
three groups (P
= 0.40, 0.39, 0.50, 0.47, 0.06 at rest and P = 0.67, 0.45, 0.22, 0.26, 0.29 after
cough respectively).
CONCLUSION: Morphine consumption and pain 24 h
postoperatively did not differ among the sevoflurane, desflurane,
and propofol groups.
泰國的脊髓麻醉後心搏停止：40,271例麻醉的多中心前瞻性記錄：
Cardiac Arrest
After Spinal Anesthesia in Thailand: A Prospective Multicenter Registry of
40,271 Anesthetics
Somrat
Charuluxananan, MD*, Somboon Thienthong, MD_files/image045.gif){kind=small}
, Mali Rungreungvanich, MD_files/image046.gif){kind=small}
, Thavat Chanchayanon, MD_files/image047.gif){kind=small}
, Thitima Chinachoti, MD||,
Oranuch Kyokong, MD*, and Yodying Punjasawadwong, MD¶
From the
*Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, _files/image048.gif){kind=small}
Khon-Kaen University, _files/image049.gif){kind=small}
Ramathibodi Hospital Mahidol University, _files/image050.gif){kind=small}
Prince of Songkla University, ||Siriraj
Hospital Mahidol University, and ¶Chiang Mai University, Thailand.
Anesth Analg 2008;
107:1735-1741
背景和目的：作為泰國麻醉事故研究的部分，我們評估脊髓麻醉過程中，心搏停止的發生率和原因。
方法：在一個12月週期內(2003年3月1日到2004年2月28日)， 一個前瞻性多中心研究，記錄泰國20家醫院（7所大學醫院，5所三級醫院，4所綜合性醫院，4所區醫院）接受麻醉的病人。麻醉人員報告病人、外科和麻醉的相關因素和不良結果，包括脊髓麻醉過程中的心搏停止(時間程序定義為脊髓麻醉誘導到手術結束)。麻醉操作24 h內每當發生特別的不良事件時，記錄不良事件的特殊表格。用單變數和多元分析來識別脊髓麻醉中與心搏停止有關的因素。P<0.05被認為有統計學意義。
結果：在記錄的40,271例脊髓麻醉中，有11例心搏停止，相應的發生率是每10,000例中2.73 (95% CI:
1.12–4.34)。發生心搏停止的死亡率為90.9%。在這11個心搏停止的病人中，5個剖宮產，6個肢體手術，包括髖部手術。4個病人(36.3%)，麻醉直接導致了心搏停止（高位交感神經阻滯、局麻藥過量或缺乏心電監護），反之，其他心搏停止與特殊事件有關（假體粘合劑、大量出血、可疑肺栓塞和可疑心肌梗塞）。從多元分析，麻醉中心搏停止的危險是身材矮小(優勢比0.944 [95% CI: 0.938–0.951], P < 0.001)、長時間手術(優勢比1.003 [95% CI: 1.001–1.005], P = 0.002)及由外科醫生進行的脊髓麻醉(優勢比23.508 [95% CI: 6.112–90.415], P < 0.001)。
結論：脊髓麻醉中心搏停止是不常發生的，但是發生的死亡率很高。如果外科醫生進行脊髓麻醉，這是心搏停止的一個顯著性相關因素。增加麻醉醫師人數、改善脊髓麻醉監護的指南及改善麻醉護士培訓計畫，可以減少心搏停止的發生率和/或改善病人的結局。
（張曦 譯，馬皓琳 李士通 校）
BACKGROUND AND
OBJECTIVES: As part of the
Thai Anesthesia Incidents Study of anesthetic adverse outcomes, we
evaluated the incidence and factors related to cardiac arrest during
spinal anesthesia.
METHODS: During a 12-mo period (March 1, 2003, to
February 28, 2004), a prospective, multicenter registry of patients
receiving anesthesia was initiated in 20 hospitals (7 university, 5
tertiary, 4 general, and 4 district hospitals) across Thailand.
Anesthesia personnel reported patient-, surgery-, and
anesthetic-related variables and adverse outcomes, including cardiac
arrest during spinal anesthesia (defined as the time period from
induction of spinal anesthesia until the end of operation). Adverse
event specific forms were recorded within 24 h of an anesthetic
procedure whenever a specific adverse event occurred. Univariate and
multivariate analysis were used to identify factors related to
cardiac arrest during spinal anesthesia. A P value <0.05 was considered significant.
RESULTS: In the registry of 40,271 cases of spinal
anesthesia, there were 11 cardiac arrests, corresponding to an
incidence of 2.73 (95% CI: 1.12–4.34) per 10,000 anesthetics. The
mortality rate was 90.9% among patients who arrested. Among 11
patients who arrested, there were 5 cases of cesarean delivery and 6
cases of extremity surgery, including hip surgery. In 4 patients
(36.3%), the anesthetic contributed directly to the arrest (high
sympathetectomy, local anesthetic overdose, or lack of
electrocardiography monitoring), whereas some arrests were
associated with specific events (cementing of prosthesis, massive
bleeding, suspected pulmonary embolism, and suspected myocardial
infarction). From multivariate analysis, the risks of cardiac arrest
during anesthesia were shorter stature (odds ratio 0.944 [95% CI:
0.938–0.951], P <
0.001), longer duration of surgery (odds ratio 1.003 [95% CI:
1.001–1.005], P
= 0.002), and spinal anesthesia administered by the surgeon (odd
ratio 23.508 [95% CI: 6.112–90.415], P < 0.001), respectively.
CONCLUSION: The incidence of cardiac arrest during
spinal anesthesia was infrequent, but was associated with a high
mortality rate. If the surgeon performed the spinal anesthetic, this
was a significant factor associated with cardiac arrest. Increasing
the number of anesthesiologists, improving monitoring guidelines for
spinal anesthesia and improving the nurse-anesthetist training
program may decrease the frequency of arrest and/or improve patient
outcome.
Single Injection
Peribulbar Anesthesia with a Short Needle Combined with Digital Compression
Waleed Riad, AB,
SB, MD, KSUF, and Nauman Ahmed, FCPS
From the Department
of Anaesthesia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.
Anesth Analg 2008;
107:1751-1753
背景：我們比較用15毫米針和標準的25毫米針用於眼球周阻滯的效果。
方法：用15或25毫米長的針對150例病人行阻滯。在用15毫米針時，應用拇指和食指指壓針頭介面周圍。注射麻醉藥直到注意到眼瞼發脹。增強不充分的阻滯。
結果：就局部麻醉藥容量、補充給藥和制動方面，在兩組之間沒有明顯差異。
結論：用15毫米針眼球周阻滯加上指壓的效果與25毫米針相當。
（彭中美 譯 馬皓琳 李士通 校）
BACKGROUND: We compare the efficacy of using a 15 mm to
the standard 25 mm needle for performing peribulbar blockade.
METHODS: Blocks were performed on 150 patients using
15 or 25 mm needle length. Digital compression was applied by the
thumb and index finger around the needle hub during injection with
15 mm needle. Anesthetic was injected until lid fullness was noted.
Inadequate block was augmented.
RESULTS: No significant differences were noted
between groups with respect to local anesthetic volume,
supplementation, and akinesia.
CONCLUSION: Peribulbar blockade performed with a 15 mm
needle with digital pressure is comparable to blockade using a 25 mm
needle.
心臟手術中止血環酸和抑肽酶：一項220例心臟手術病人的應用分析
Tranexamic
Acid and Aprotinin in Primary Cardiac Operations: An Analysis of 220 Cardiac
Surgical Patients Treated with Tranexamic Acid or Aprotinin
Wulf
Dietrich, MD, PhD*, Michael Spannagl, MD_files/image051.gif){kind=small}
, Johannes Boehm, MD_files/image052.gif){kind=small}
, Katharina Hauner, MD_files/image053.gif){kind=small}
, Siegmund Braun, MD_files/image054.gif){kind=small}
, Tibor Schuster, MS||,
and Raimund Busley, MD¶
From
the *Institute for Research in Cardiac Anesthesia; _files/image055.gif){kind=small}
Department of
Hemostasiology, Ludwig Maximilian University, Munich; Departments of _files/image056.gif){kind=small}
Cardiac Surgery and _files/image057.gif){kind=small}
Clinical Chemistry,
German Heart Center Munich; ||Department of Medical Statistics and
Epidemiology, Klinikum Rechts der Isar; and ¶Department of Anesthesiology,
Behandlungszentrum Vogtareuth, Vogtareuth, Germany.
Anesth
Analg 2008 107: 1469-1478.
背景：抗纖溶藥物已廣泛用於心臟手術中以減少出血。異體血輸注，即使是在出血較少的心臟手術中使用率也非常高。本研究中作者對比了止血環酸和抑肽酶在減少心臟手術病人術中出血的效果。
方法：這一前瞻性、隨機、雙盲研究選擇了220例冠脈搭橋術（CABG）或主動脈換瓣術(AVR)。患者隨機接受止血環酸（約6g）或足劑量的抑肽酶（約5-6 x 106KU）。在嚴格的輸注系統指導下進行輸注，通過分子標記物來評估這兩種藥物在作用方式上的區別。主要觀察項目為同種異體的紅細胞輸注率和手術後24小時血液丟失量。資料根據意向性分析原則通過方差分析和U檢驗來分析比較.
結果： 研究包括了220名患者(CABG: 134, AVR: 86)，抑肽酶組中47%的患者住院期間輸注了異體血，止血環酸組為61%（p=0.036），抑肽酶的使用使得異體血輸注的危險性下降23%（RR 0.77, 95% CI 0.53–0.88）。雖然總的術後出血的組間無顯著差異，但抑肽酶處理的冠脈搭橋病人中術後24小時內出血量減少 〔分別為500ml（350–750 mL） 、650 mL（475–875 mL ），中位數, 25th–75th百分位數; P = 0.039〕。抑肽酶組中輸血率減少和術後第一天血紅蛋白的濃度升高(11.3, 9.9–12.1 、 10.6, 9.9–11.6 mg/dL; P
= 0.023)。在手術結束時纖溶酶啟動通過D-二聚體比較(分別為抑肽酶組0.15, 0.11–0.17 mg/L
，止血環酸組為 0.18, 0.12–0.24 mg/L)。在抑肽酶組當肝素的需要量減少後，部分凝血酶啟動時間延長到了術後4小時。19%的抑肽酶組病人和45%的止血環酸組病人在心肺分流術中至少追加了一次肝素，在止血環酸組術後和術後第一天肌鈣蛋白T水準明顯升高(P = 0.017)。兩組病人在腎臟、心臟併發症的發生率或死亡率無顯著差異。
結論：止血環酸組行冠脈搭橋術病人紅細胞輸注率略降低，主動脈換瓣膜病人沒有差異。在止血環酸在冠脈搭橋術中出血量增加的影響有限，臨床價值取決於特殊的病人和特定的機構。
（丁俊雲 譯 陳傑 校）
BACKGROUND:
Antifibrinolytics
are widely used in cardiac surgery to reduce bleeding. Allogeneic
blood transfusion, even in primary cardiac operations with low blood
loss, is still high. In the present study we evaluated the impact of
tranexamic acid compared to aprotinin on the transfusion incidence
in cardiac surgical patients with low risk of bleeding.
METHODS:
This
prospective, randomized, double-blind study included 220 patients
undergoing primary coronary artery revascularization (coronary
artery bypass grafting [CABG]) or aortic valve replacement (AVR).
Randomized in blocks of 20, patients received either tranexamic acid
(approximately 6 g) or full-dose aprotinin (approximately 5–6 x 106
Kallikrein Inhibiting Units). Transfusion was guided by a strict
transfusion algorithm. Molecular markers of hemostasis were
determined to assess differences in the mode of action of the two
drugs. Primary end-points were the incidence of allogeneic red cell
transfusion and 24-h postoperative blood loss. Data were analyzed
according to the intention-to-treat principle and compared using the
_files/image059.gif){kind=small}
2 and
Mann-Whitney U-test.
RESULTS:
Two-hundred-twenty
patients were enrolled (CABG: 134, AVR: 86). In the aprotinin Group
47% of patients received allogeneic blood during the hospital stay
as compared to 61% in the tranexamic acid group (P = 0.036). Aprotinin
conferred a 23% reduction in allogeneic transfusion risk (RR 0.77,
95% CI 0.53–0.88). Overall, no significant difference in
postoperative bleeding was observed, although 24-h blood loss was
reduced in aprotinin-treated CABG patients (500, 350–750 mL vs 650,
475–875 mL (median, 25th–75th percentile); P = 0.039). Despite the
lower transfusion rate, the hemoglobin concentration on the first
postoperative day was higher in the aprotinin group (11.3, 9.9–12.1
vs 10.6, 9.9–11.6 mg/dL; P = 0.023). The fibrinolytic activity at
the end of operation determined by D-Dimer was comparable in both
groups. (0.15, 0.11–0.17 mg/L [aprotinin] versus 0.18, 0.12–0.24
mg/L [tranexamic acid]). The activated partial thromboplastin time
was prolonged up to 4 h postoperatively in the aprotinin group,
while the heparin requirement was reduced: 19% of the patients in
the aprotinin group and 45% in the tranexamic acid group received
at least one additional bolus heparin during cardiopulmonary bypass
(P
< 0.001). Troponin T levels postoperatively and on postoperative
day 1 were significantly higher in the tranexamic acid group (P = 0.017). No differences
in renal, cardiac, or mortality outcomes were observed.
CONCLUSION:
Considering
the rate of transfusion of red blood cells, tranexamic acid was
slightly inferior in patients undergoing CABG, but there was no
difference in patients receiving AVR. Tranexamic acid seems to be
less effective in operations with increased bleeding such as CABG.
Clinical benefit depends on specific patient and institution
characteristics (ClinicalTrials.gov NCT00396760).
合併低蛋白血症的老年心臟手術患者使用白蛋白對炎症反應，內皮細胞活化，以及長期腎功能是否有好處？
Is
Albumin Administration in Hypoalbuminemic Elderly Cardiac Surgery Patients of
Benefit with Regard to Inflammation, Endothelial Activation, and Long-Term
Kidney Function?
Joachim
Boldt, MD, Ch Brosch, MD, MD, K. Röhm, MD, A. Lehmann, MD, A. Mengistu, MD, and
S. Suttner, MD
From
the Department of Anesthesiology and Intensive Care Medicine, Klinikum der
Stadt Ludwigshafen, Ludwigshafen, Germany.
Anesth
Analg 2008 107: 1496-1503.
背景：由於輸注人血白蛋白對低白蛋白患者有益，因此，作者使用人血白蛋白糾正接受心臟手術的老年患者的低血容量的研究。
方法：在一項前瞻性隨機的試驗中，50名年齡>80歲，術前血清白蛋白濃度<3.5mg/dl的患者，在體外迴圈下接受心臟手術，25名給予5%的人血白蛋白，另外25名給予羥乙基澱粉。
開始輸注量為500ml，然後持續輸注至術後第二天的早晨，維持肺毛細血管壓或者中心靜脈壓在12到14mmHg之間.
結果：在麻醉誘導後，術後5小時，術後第一天和術後第二天，分別檢測炎症反應（白細胞介素-6，-10），內皮細胞活化（細胞間粘附分子-1），以及腎功能（包括谷胱甘肽轉移酶-_files/image061.gif){kind=small}
和中性粒細胞明膠酶相關載脂蛋白）。隨訪至出院後約60天。給予2980±430mL人血白蛋白和3060±680mL羥乙基澱粉。給予人血白蛋白組血清白蛋白濃度顯著增高（至4.5±0.3mg/dL）。給予人血白蛋白的患者與給予羥乙基澱粉的患者相比，血肌酐，腎小球濾過率，以及尿中谷胱甘肽轉移酶和中性粒細胞明膠酶相關載脂蛋白的水準無差別。炎症反應在兩組也很相似，而內皮細胞活化在羥乙基澱粉組裏發生更少。沒有患者發展為腎衰而需要腎臟替代療法。
結論：年齡>80歲，低蛋白血症，接受心臟手術的患者使用人血白蛋白，和使用羥乙基澱粉相比，對於炎症反應、內皮細胞活化和腎功能並無優勢。
（舒慧剛 譯 陳傑 校）
BACKGROUND:
Because
patients with low albumin levels may benefit from human albumin (HA)
administration, we studied correction of hypovolemia with HA in
hypoalbuminic elderly cardiac surgery patients.
METHODS:
In a
prospective, randomized study, 50 patients aged >80 yr undergoing
cardiac surgery using cardiopulmonary bypass with a preoperative
serum albumin concentration of <3.5 mg/dL, received either 5% HA
(n =
25) or hydroxyethyl starch (6% HES 130/0.4) (n = 25). Volume was added
to the priming (500 mL) and given until the morning of the second
postoperative day to keep pulmonary capillary wedge pressure or
central venous pressure between 12 and 14 mm Hg.
RESULTS:
Inflammatory
response (interleukins-6, -10), endothelial activation
(intercellular adhesion molecule-1), and kidney function (including
glutathione transferase-_files/image062.gif){kind=small}
and neutrophil
gelatinase-associated lipocalin) were measured after induction of
anesthesia, 5 h after surgery, and the first and second
postoperative day. A follow-up, approximately 60 days after
discharge from the hospital, was done.
Two
thousand nine hundred eighty ± 430 mL of HA and 3060 ± 680 mL of HES
130/0.4 were given. Serum albumin concentration was significantly
increased by HA (to 4.5 ± 0.3 mg/dL). Serum creatinine, glomerular
filtration rate, and urinary levels of _files/image063.gif){kind=small}
-glutathione transferase
and neutrophil gelatinase-associated lipocalin were not different in
the HA-compared to the HES-treated patients. The inflammatory
response was similar in both groups, whereas endothelial activation
was less in the HES group. None of the patients developed renal
failure requiring renal replacement therapy.
CONCLUSION:
Use of
HA in hypoalbuminemic cardiac surgery patients aged >80 yr was
without benefit with regard to inflammatory response, endothelial
activation, and renal function compared to 6% HES 130/0.4.
用於兒童外周靜脈置管的一種靜脈通路指示裝置：一項前瞻性、隨機、對照試驗
A Vein Entry Indicator
Device for Facilitating Peripheral Intravenous Cannulation in Children: A
Prospective, Randomized, Controlled Trial
Eliahu
Simhi, MD*_files/image064.gif){kind=small}
, Ludmyla Kachko, MD*,
Elhanan Bruckheimer, MD_files/image065.gif){kind=small}
, and Jacob Katz, MD*
From
the *Department of Anesthesia, Schneider Children’s Medical Center of Israel,
Petah Tiqwa and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv,
Israel; _files/image066.gif){kind=small}
Department of
Anesthesiology and Critical Care Medicine, Children’s Hospital of Pittsburgh,
Pittsburgh, Pennsylvania; and _files/image067.gif){kind=small}
Department of Pediatric
Cardiology, Schneider Children’s Medical Center of Israel, Petah Tiqwa and Sackler
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Anesth
Analg 2008 107: 1531-1535.
背景：兒童由於靜脈口徑小和難於觸及，血管通路的建立往往存在技術上的困難。本研究中，作者試圖確定使用靜脈通路指標裝置（ VEIDTM ）是否有利於建立兒童外周靜脈通路。
方法：在以色列的一個較大的三級醫院行相同擇期手術的202名健康兒童（ASA I－II 級），隨機分配接受VEID協助或標準外周靜脈插管。所有病例均使用22號套管行上肢靜脈置管。主要結果檢測指標為：嘗試插管次數，第一次嘗試的成功率，和插管時間。取這些資料的均數，使用方差分析和Pearson 2檢驗或Fisher’s精確檢驗進行組間比較;逐步logis回歸被用來確定三個變數（年齡，靜脈評估類別，使用靜脈進入指標裝置 ）與第一次成功插管的顯著相關性。P值〈=0.05被認為具有顯著性。
結果：兩組患者中的大部分第一次嘗試插管即取得成功。VEID組中8 ％，對照組中28 ％的患者需要兩次嘗試，需要3次嘗試的比例則分別為1 ％和3 ％（ P < 0.01 ） 。通過靜脈評估分類分析發現，對於容易置管的患者兩組第一次置管成功率相似。然而，困難和中等類別，VEID組成功率為89.7 ％，而對照組的成功率為23.3 ％，（ P < 0.01 ）。
使用VEID組嘗試次數較少與從尋求合適的靜脈開始到插管成功的時間較短相關。（ 9.1秒對比對照組的22.5秒）。
結論：靜脈通路指示裝置有利於健康兒童困難靜脈置管，減少了嘗試次數和穿刺時間。
（張磊 譯 陳傑 校）
BACKGROUND:
Vascular
access is often technically difficult in children because of the
small caliber and impalpability of the veins. In this study, we sought
to determine if use of the Vein Entry Indicator Device (VEIDTM)
in children facilitates peripheral venous access.
METHODS:
Two-hundred-two
healthy (ASA grade I and II) children scheduled for same-day surgery
at a major tertiary hospital in Israel were randomly allocated to
undergo VEID-assisted or standard peripheral venous cannulation. All
cases involved the insertion of a 22-gauge cannula into an upper
limb vein. Primary outcome measures were number of attempts to
successful cannulation, rate of success at first attempt, and time
required for insertion. The data were presented as mean (sd).
Analyses of variance and Pearson _files/image068.gif){kind=small}
2 test or
Fisher’s exact test were used to compare the groups; forward
stepwise logistic regression was used to identify the three
variables (age, vein assessment category, use of the VEID)
significantly associated with a successful first attempt. A P value of _files/image069.gif){kind=small}
0.05 was considered
significant.
RESULTS:
Successful
cannulation was achieved at the first attempt in the majority of
patients in both groups. Two attempts were needed in 8% of the VEID
group and 28% of the control group, and 3 attempts were needed in 1%
and 3%, respectively (P < 0.01). Analysis by vein assessment
category yielded a similar rate of successful first-attempt
cannulations in the two groups for easy veins. However, for the
difficult and intermediate categories, the rate was 89.7% in the
VEID group compared to 23.3% in the control group (P < 0.001). The fewer
number of attempts in the study group was associated with a shorter
time from the start of the search for an appropriate vein to successful
cannulation (9.1 s versus 22.5 s in the control group).
CONCLUSIONS:
The VEID
facilitates the insertion of peripheral venous cannulas in healthy
children with intermediate/difficult veins undergoing same-day
surgery, reducing the number of attempts and the overall time
required.
年齡對呼末七氟醚濃度和BIS指數動態關係的影響
The
Influence of Age on the Dynamic Relationship Between End-Tidal Sevoflurane
Concentrations and Bispectral Index
Luis
I. Cortínez, MD*, Iñaki F. Trocóniz, PhD_files/image070.gif){kind=small}
, Ricardo Fuentes, MD*,
Pedro Gambús, MD_files/image071.gif){kind=small}
, Yung-Wei Hsu, MD_files/image072.gif){kind=small}
, Fernando Altermatt, MD*,
and Hernán R. Muñoz, MD, MSc*
From
the *Departamento de Anestesiología, Escuela de Medicina, Pontificia
Universidad Católica de Chile. Santiago, Chile; _files/image073.gif){kind=small}
Department of Pharmacy;
School of Pharmacy; University of Navarra; Pamplona, Spain; _files/image074.gif){kind=small}
Department of Anesthesiology,
Hospital CLINIC, Universidad de Barcelona, CIBERehd, IDIBAPS, Barcelona, Spain;
and _files/image075.gif){kind=small}
Department of
Anesthesiology, Mackay Memorial Hospital, Taiwan.
Anesth
Analg 2008 107: 1566-1572.
背景：年齡是吸入麻醉藥的藥物代謝動力學的一個重要的因素。然而，年齡對七氟醚動態分佈的影響尚未得到詳細描述。作者進行此項研究來描繪年齡與其他相關變數對呼末七氟醚濃度(CET)和其用效能（用BIS指數來表示）的動態關係。
方法： 對50名，年齡3—71歲，行小手術的患者進行前瞻性研究。研究期間持續監測呼末七氟醚濃度(CET)和BIS。麻醉維持期間，待BIS值穩定於60–65間後，令吸入七氟醚濃度增加至5%維持5min，直至BIS <40後減低濃度。在此期間對呼末七氟醚濃度和其用效能（用BIS來表示）的動態關係的變化，利用種群藥代學和藥效學方法通過非線型混合效應模型V建立最大效能抑制模型。一個有預測性的檢查方法被用於確認最終模型。
結果：七氟醚效應通過監測BIS值，由C50表示（穩態呼末半數有效濃度），伴隨年齡增大而增加。由效應靶點的平衡半衰期（ t1 / 2為ke0 ）所表示的七氟醚效應的變化速度，在老年人中增加。預測分析證實這一模型是恰當的。
結論：年齡對呼末七氟醚濃度和用BIS表示的效應之間動態關係有顯著的影響。
（葉樂 譯 陳傑 校）
BACKGROUND:
Age is
an important determinant of the pharmacokinetic profile of inhaled
anesthetics. The influence of age on the dynamic profile of
sevoflurane’s effect has not been well described. We performed this
study to characterize the influence of age and other covariates on
the dynamic relationship between sevoflurane end-tidal concentration
(CET)
and its effect measured by bispectral index (BIS).
METHODS:
Fifty
patients, aged 3–71 yr, scheduled for minor surgery were
prospectively studied. The BIS and sevoflurane CET were
continuously measured during the study period. During maintenance of
anesthesia and after stable BIS values of 60–65 were obtained, the
inspired concentration of sevoflurane was increased to 5 vol % for 5
min or until BIS <40 and then decreased. The dynamic relationship
between sevoflurane CET and its effect as measured by BIS during this
transition period were modeled with an inhibitory Emax model
using a population pharmacokinetic–pharmacodynamic approach with
NONMEM V. A predictive check method was used to validate the final
model.
RESULTS:
The
sensitivity to sevoflurane’s effect as measured by BIS expressed in
the C50
[steady-state CET eliciting half of maximum response (Imax)]
increased with age. The speed of change of sevoflurane’s effect,
expressed as the effect–site equilibration half-life (t1/2 ke0), increased
at older ages. The predictive check analysis confirmed the adequacy
of the model.
CONCLUSIONS:
Age
significantly affects the dynamic relationship between sevoflurane CET and its
effect measured with BIS.
全身低劑量布比卡因預防大鼠開胸術後異常性疼痛的發生
Low-Dose
Systemic Bupivacaine Prevents the Development of Allodynia After Thoracotomy in
Rats
Jin
Woo Shin, MD, PhD_files/image076.gif){kind=small}
, Carlo Pancaro, MD*,
Chi Fei Wang, PhD*, and Peter Gerner, MD*
From
the *Pain Research Center, Department of Anesthesiology, Brigham and Women’s
Hospital, Harvard Medical School, Boston, MA; and _files/image077.gif){kind=small}
Department of
Anesthesiology and Pain Medicine, College of Medicine, University of Ulsan,
Asan Medical Center, Seoul, South Korea.
Anesth
Analg 2008 107: 1587-1591.
背景：最近，開胸手術後慢性疼痛的模型在大鼠上已被複製用來觀察可能減少開胸手術後異常性疼痛發病率的藥物作用。以往的研究表明，在大鼠模型鞘內注射或全身嗎啡，可樂定，新斯的明，和加巴噴丁可減少開胸的術後疼痛，本研究目的是測試肋間和全身注射布比卡因是否能在慢性肋間神經痛動物模型上阻止疼痛的發生。
方法：雄性SD大鼠麻醉後，暴露右邊第4和第5肋骨。開胸、關胸1小時，手術前後或手術前肋間注射或全身注射布比卡因1毫克（ 0.2毫升0.5 ％ ），對照組關胸前不注射任何藥物，手術後3周在大鼠切口周圍預定區域測試機械痛。
結果：對照組 43 ％的動物發生疼痛，手術前、手術後肋間注射、術前全身各自注射布比卡因的實驗組疼痛的發生率只有6%，12%，12%。
結論：以往的研究表明，阿片類藥物，2 -腎上腺素受體激動劑，新斯的明，和加巴噴丁可以防止關胸後疼痛的發生。目前的結果表明，手術前後肋間注射或者手術前全身給予布比卡因，能有效地防止機械痛。
（劉世文 譯 陳傑 校）
BACKGROUND:
Chronic
pain after thoracotomy has been recently reproduced in a rat model
that allows investigation of the effect of drugs that might reduce
the incidence of allodynia after thoracotomy. Previous studies
suggest that intrathecal or systemic morphine, clonidine,
neostigmine, and gabapentin reduce the incidence of allodynia in the
rat postthoracotomy pain model. Our purpose was to test whether
intercostal and systemic injection of bupivacaine prevented the
development of allodynia in an animal model of chronic intercostal
neuropathic pain.
METHODS:
Male
Sprague-Dawley rats were anesthetized and the right 4th and 5th ribs
surgically exposed. The pleura were opened and the ribs were
retracted for 1 h. Intercostal or systemic bupivacaine 1 mg (0.2 mL
at 0.5%) was injected before and after surgery, or before surgery; a
control group underwent rib retraction and did not receive any drug.
Rats were tested for mechanical allodynia at a predetermined area
around the incision site during the 3 wk after surgery.
RESULTS:
Allodynia
developed in 43% of the animals that did not receive bupivacaine
(control group); in contrast, allodynia developed in only 6%, 12%,
and 12% of those animals that received intercostal bupivacaine
before surgery, after surgery, or systemically before surgery,
respectively.
DISCUSSION:
Previous
studies suggest that allodynia after rib retraction can be prevented
by opioids, _files/image079.gif){kind=small}
2-adrenergic agonists,
neostigmine, and gabapentin. The current results suggest that bupivacaine
is effective in preventing mechanical allodynia, whether given by
intercostal injection before or after surgery, or systemically
before surgery.
一種新穎的神經肌肉阻滯諮詢系統以改善神經肌肉阻滯：一個隨機，對照，臨床的實驗
Improved
Neuromuscular Blockade Using a Novel Neuromuscular Blockade Advisory System: A
Randomized, Controlled, Clinical Trial
Terence
J. Gilhuly, MASc*_files/image080.gif){kind=small}
, Bernard A. MacLeod, MD,
FRCPC*, Guy A. Dumont, PhD_files/image081.gif){kind=small}
, Alex M. Bouzane, MSc,
MD*, and Stephan K. W. Schwarz, MD, PhD, FRCPC*_files/image082.gif){kind=small}
From
the *Department of Anesthesiology, Pharmacology & Therapeutics, Hugill
Anesthesia Research Centre, _files/image083.gif){kind=small}
Department of Electrical
and Computer Engineering, and _files/image084.gif){kind=small}
Department of Anesthesia,
St. Paul's Hospital, The University of British Columbia, Vancouver, B.C.,
Canada.
Anesth
Analg 2008 107: 1609-1617.
背景：傳統單次給予神經肌肉阻滯劑常與術中控制受限，復蘇延長以及麻醉後的阻滯作用的殘餘效應有關。為了克服這些限制，作者研發了一個新穎的自適應電腦控制程式--肌肉阻滯諮詢系統（NMBAS）。NMBAS根據於一個六個序列的模型和病人肌電圖描記，給予麻醉醫生有關給藥時間和劑量的建議。在此，檢驗了相對於標準管理NMBAS能夠改善NMB的假說。
方法：作者設計了這項前瞻性、隨機的、對照的、雙盲的、平行對照的臨床實驗， 選擇ASA I-III，應用羅庫溴銨神經肌肉阻滯，麻醉時間≥1.5h，腹部手術的患者73例。這些患者隨機分配到標準管理組或者NMBAS引導的羅庫溴銨給藥組。主要結果變數是手術中反映NMB不充分的發生率。次要結果變數包括在手術結束時逆轉之前的四個成串刺激（TOF）比值，羅庫溴銨的總劑量，逆轉藥物，麻醉劑和其他藥物，術後副反應的發生率，以及NMBAS介紹的麻醉學上不配合的發生率。
結果：73個入組的患者中，每個組n=30的適合分析。統計的患者進行組間比較。與標準管理組相比較，NMBAS組中手術中與NMB不充分相關事件的總發生率顯著降低（8/30vs19/30;p=0.004）。TOF比值的平均值在手術結束時尚未逆轉前在NMBAS組更高（0.59[95%Cl,0.48-0.69]vs0.14[95%Cl,0.04-0.24];p<0.0001）。羅庫溴銨總的給藥劑量，逆轉藥物，以及其他藥物，和術後副反應的發生率沒有明顯區別。
結論:與常規相比，NMBAS引導的管理與改善NBM品質和提高手術結束時TOF比值相關，可能降低NMB殘餘效應的風險和提高病人手術期間的安全性。
（懷曉蓉 譯 陳傑 校）
BACKGROUND:
Conventional
incremental bolus administration of neuromuscular blocking (NMB)
drugs is associated with limitations in intraoperative control,
potential delays in recovery, and residual blockade in the
postanesthetic period. To overcome such limitations, we developed a
novel adaptive control computer program, the Neuromuscular Blockade
Advisory System (NMBAS). The NMBAS advises the anesthesiologist on
the timing and dose of NMB drugs based on a sixth-order Laguerre
model and the history of the patient's electromyographic responses.
Here, we tested the hypothesis that the use of the NMBAS improves
NMB compared to standard care.
METHODS:
We
conducted a prospective, randomized, controlled, blinded,
parallel-group, clinical trial with n = 73 patients (ASA physical
status I-III) undergoing abdominal surgery under general anesthesia _files/image085.gif){kind=small}
1.5 h with NMB using
rocuronium. Patients were allocated to standard care or NMBAS-guided
rocuronium administration. The primary outcome variable was the
incidence of intraoperative events reflecting inadequate NMB.
Secondary outcome variables included train-of-four (TOF) ratios at
the end of surgery before reversal, the total doses of rocuronium,
reversal agents, anesthetics and other drugs, the incidence of
postoperative adverse events, and the incidence of anesthesiologist
noncompliance with NMBAS recommendations.
RESULTS:
Of 73
enrolled patients, n = 30 per group were eligible for analysis. Patient
demographics were comparable between the groups. The incidence in
total intraoperative events associated with inadequate NMB was
significantly lower in the NMBAS group compared to standard care
(8/30 vs 19/30; P = 0.004). Mean TOF ratios at the end of surgery before
reversal were higher in the NMBAS group (0.59 [95% CI, 0.48–0.69] vs
0.14 [95% CI, 0.04–0.24]; P < 0.0001). Total administered doses
of rocuronium, reversal drugs, and other drugs, and the incidence of
postoperative adverse events were not different.
CONCLUSIONS:
Compared
to standard practice, NMBAS-guided care was associated with improved
NMB quality and higher TOF ratios at the end of surgery, potentially
reducing the risk of residual NMB and improving perioperative
patient safety.
在嚴重膿毒症中早期使用高劑量抗凝血酶：來自KyberSept試驗的單中心結果
Early
Administration of High-Dose Antithrombin in Severe Sepsis: Single Center
Results from the KyberSept-Trial
Alain
Eid, MD*, Christian J. Wiedermann, MD_files/image086.gif){kind=small}
, and Gary T. Kinasewitz,
MD_files/image087.gif){kind=small}
From
the *Division of Pulmonary and Critical Care, CO Springs Memorial Hospital, CO
Springs, Colorado; _files/image088.gif){kind=small}
Division of Internal
Medicine, Department of Medicine, Central Hospital of Bolzano, Bolzano, Italy;
and _files/image089.gif){kind=small}
Pulmonary and Critical
Care Medicine, University of Oklahoma Health Science Center, Oklahoma.
Anesth
Analg 2008 107: 1633-1638.
背景：在KyberSept試驗的全部的結果中，對嚴重膿毒症中使用高劑量抗凝血酶的非治療效應與主要結果——28天死亡率不一致的可能原因是由於異質性。控制的非治療效應的KB試驗結果與其主要成果，28天死亡率互相矛盾，可能是由於患者個體差異造成。目前還沒有早期使用（微循環紊亂但還沒有出現不可逆器官損害）抗凝血酶治療嚴重膿毒症的相關作用的報導。
目標：作者報導KS試驗中嚴重膿毒症患者出現新的器官衰竭早期在單中心的接受了治療及由此產生的結果。
方法：所有參加者都來自美國某三級醫院重症監護室。患者隨機1：1分配（空白對照：n=41；抗凝血酶AT：n=40），在48小時內接受抗凝血酶治療（30000IU靜注，超過四天）或安慰劑治療。
結果：組間原始變數基線穩定。80%的患者（n=65）在發生嚴重膿毒症的24小時內接受研究藥物治療；94%的患者（n=76）在48小時內接受研究藥物。AT組的40名參與者中的9名（22.5%）在最初的7天內出現了新的器官功能障礙，而相較於39名空白對照組患者中的17名患者（43.6%），空白對照組的原始變數基線並無不同（P=0.058；2名患者最初就患有多器官功能障礙而被排除）。在28天時，40名接受AT治療的患者中有16名（40%）死亡，而41名接受空白對照治療的患者有22名（54%）死亡[明顯減少，14%；優勢比（95%可信區間），0.58（0.24-1.39）]。在接受AT治療的患者中，出血的發生率明顯增加（40名AT組患者中8名出現（20.0%），同時，空白對照組41名患者中有1名出現（2.4%）；P<0.015）。
結論：由此分析的資料證實抗凝血酶治療的患者出血的風險增加。當在嚴重膿毒症早期給予抗凝血酶，儘管統計學差異不明顯，抗凝血酶治療的器官衰竭和死亡率的絕對風險相應降低21%和14%，這顯示抗凝血酶治療對於有選擇的膿毒症患者還是具有潛在益處的。此研究提示我們需要進一步進行抗凝血酶治療膿毒症的研究，並側重于減少患者個體差異性。
（朱紫瑜 譯 陳傑 校）
BACKGROUND:
The
overall finding in the KyberSept trial of no treatment effect of
high-dose antithrombin (AT) in severe sepsis was inconsistent for
the primary outcome, 28-day mortality, possibly because of patient
heterogeneity. No data have been reported on the effects of AT
therapy administered early in severe sepsis when microcirculation is
disturbed but irreversible organ damage has not yet developed.
OBJECTIVE:
We report
the post hoc results of the KyberSept trial in patients with severe
sepsis treated at a single center early after new onset organ
failure.
METHODS:
All
study participants from a United States tertiary care intensive care
unit were analyzed. Patients had been randomized 1:1 (placebo: n = 41; AT: n = 40) to receive AT
(30,000 IU IV over a period of four days) or placebo within 48 h.
RESULTS:
Baseline
variables were well balanced between groups. Eighty percent of
patients (n = 65) received study drug within 24 h after onset of severe
sepsis; 94% (n = 76) received study drug within 48 h. Nine of 40
participants in the AT group (22.5%) had new organ dysfunction
during the first 7 days which was not present at baseline compared
with 17 of 39 subjects (43.6%) in the placebo group (P = 0.058; two
participants had dysfunction of all organs at baseline and were
therefore excluded). At 28 days, 16 of 40 patients (40%) treated
with AT died versus 22 of 41 (54%) with placebo [absolute reduction,
14%; odds ratio (95% confidence interval), 0.58 (0.24–1.39)]. In
patients receiving AT, a significantly increased bleeding incidence
was observed (any bleeding, 8 of 40 (20.0%) for AT group vs 1/41
(2.4%) for placebo group; P < 0.015).
CONCLUSIONS:
Data
from this post hoc analysis confirm an increased bleeding risk seen with AT
treatment in these patients. When given early in severe sepsis,
though statistically not significant, absolute risk reductions with
AT of 21% and 14% for organ failure and mortality, respectively, indicate
a potential for treatment benefit in selected sepsis patients. This
observation may have implications for continuing sepsis trials with
AT that focus on reduced patient heterogeneity.
合併有Shone’s綜合征的產婦行剖宮產時的麻醉管理
The
Anesthetic Management for Cesarean Delivery in a Patient with Shone's Syndrome
Kathleen
Sachse, MD, and Medhat Hannallah, MD, FFARCS
From
the Department of Anesthesiology, Georgetown University School of Medicine,
Washington, DC.
Anesth
Analg 2008 107: 1652-1654.
Shone’s綜合征是一種罕見的先天性心臟病，主要包含多達4種左心的梗阻性損傷。本文作者報導一位元17歲合併有Shone’s綜合征的產婦接受剖宮產術。該產婦合併有輕度二尖瓣狹窄和輕度左室流出道梗阻。作者嘗試對其實施硬膜外腔阻滯麻醉，但患者出現了嚴重的低血壓及與之相關的胎兒心動過緩，而需要立即在全麻下實施剖宮產術。文中還討論了此類患者的圍產期麻醉用藥及管理要點。
（周姝婧 譯 陳傑 校）
Shone's
syndrome is a rare congenital cardiac condition that consists of up
to four obstructive left-sided cardiac lesions. We report a
17-yr-old nullipara with Shone's syndrome who presented for cesarean
delivery. She had mild mitral stenosis and mild left ventricular
outflow tract obstruction. Epidural anesthesia was attempted, but
the patient developed severe hypotension associated with fetal
bradycardia necessitating immediate cesarean delivery under general
anesthesia. The peripartum anesthetic and management considerations
for these patients are discussed.
腦電雙頻譜指數在嚴重腦損傷合併難治性顱高壓患者巴比妥酸昏迷中的應用
The
Use of Bispectral Index to Monitor Barbiturate Coma in Severely Brain-Injured
Patients with Refractory Intracranial Hypertension
Vincent
Cottenceau, MD*, Laurent Petit, MD*, Françoise Masson, MD*,
Dominique
Guehl, MD, PhD_files/image090.gif){kind=small}
, Julien Asselineau, MS_files/image091.gif){kind=small}
, Jean-François Cochard,
MD*, Catherine Pinaquy, MD*, Alain Leger, MD*,
and François Sztark, MD, PhD*
From
the *Departments of Anesthesia and Intensive Care Unit, _files/image092.gif){kind=small}
Clinical Neurophysiology,
and _files/image093.gif){kind=small}
Clinical Epidemiology
Unit, Centre Hospitalo-Universitaire de Bordeaux, Bordeaux, France; Université
Victor Segalen Bordeaux 2, Bordeaux, France.
Anesth
Analg 2008 107: 1676-1682.
背景：嚴重創傷性腦損傷（TBI）病人應用巴比妥藥物治療通常需要監測腦電圖（EEG）爆發-抑制模式。而腦電雙頻譜指數（BIS）是來源於腦電圖且考慮了皮層靜息。作者試圖探討BIS的變化是否預示著特異性的爆發-抑制模式。
方法：對11位接受巴比妥治療的創傷性腦損傷（TBI）病人進行前瞻性研究。每天記錄一小時的腦電圖。爆發/抑制比值（腦電圖抑制率「SREEG」：60秒大腦皮層靜息百分率）每5分鐘在原腦電圖上計算1分鐘，並且與同步測得的BIS-XPTM相對比（腦電雙頻譜指數與抑制率「SRBIS」）。巴比妥昏迷的最適合腦電圖水準定義為2-5次爆發/分鐘。巴比妥昏迷的最合適BIS範圍通過實驗資料預測，在每一個實驗中都將研究其精確度。
結果：測得的SREEG
與SRBIS一致性很高（組內相關係數0.94「95%可信區間：0.90-0.96」）。SREEG與BIS呈顯著性相關。在一些實驗中出現顯著不一致。預測巴比妥昏迷的最佳BIS範圍為6-15.
結論：在使用巴比妥藥物治療的創傷性腦損傷（TBI）病人中，SREEG
與BIS的相關性很高。當BIS指數小於6時，巴比妥類藥物的輸注速度將要減慢。當BIS指數大於15時，巴比妥類藥物的輸注速度將要加快。需要通過對腦電圖相似信號的觀察（正如BIS-XPTM所顯示）定時檢查腦電雙頻譜指數與腦電圖抑制模式的對應關係
（趙嫣紅 譯 陳傑 校）
BACKGROUND:
Barbiturate
therapy in severely traumatic brain-injured (TBI) patients is
usually monitored by an electroencephalogram (EEG) with
burst-suppression pattern as a target. The Bispectral Index (BIS) is
derived from EEG and considers cortical silence. We sought to
determine whether a BIS range could predict a specific burst-suppression
pattern.
METHODS:
Eleven
TBI patients treated with barbiturate were included prospectively.
EEG was recorded daily for 1 h. Every 5 min, the number of bursts
and the suppression ratio (suppression ratio from EEG [SREEG]:
percentage of last 60 s in cortical silence) was calculated for 1
min on the raw EEG and compared to concomitant data from the BIS-XPTM
(BIS and suppression ratio [SRBIS]). The optimal level of
barbiturate coma was defined as 2–5 bursts/min in the EEG. A BIS
range predictive of optimal level was determined from all data and
its accuracy was studied for each examination.
RESULTS:
Agreement
between SREEG and SRBIS was high (interclass correlation
coefficient 0.94 [95% confidence interval: 0.90–0.96]). There was a
significant association between SREEG and BIS. Significant disagreements
were observed in some examinations. The best accuracy to predict
optimal pattern was obtained with a BIS range from 6 to 15.
CONCLUSION:
The
relationship between BIS and SREEG was high in TBI
patients treated with barbiturates. The rate of barbiturate infusion
might be decreased if BIS is <6 or increased if BIS is >15.
Correspondence between BIS and suppression pattern should
periodically be checked by observation of the EEG analogical signal
(as displayed by BIS-XPTM).
The
Effectiveness of Noninvasive Positive Pressure Ventilation to Enhance
Preoxygenation in Morbidly Obese Patients: A Randomized Controlled Study
Jean-Marc
Delay, MD*, Mustapha Sebbane, MD*, Boris Jung, MD*,
David Nocca, MD_files/image094.gif){kind=small}
, Daniel Verzilli, MD*,
Yvan Pouzeratte, MD*, Moez El Kamel, MD*, Jean-Michel
Fabre, MD, PhD_files/image095.gif){kind=small}
, Jean-Jacques Eledjam,
MD, PhD*, and Samir Jaber, MD, PhD*
From
the Departments of *Anesthesia and Critical Care B (DAR B), and _files/image096.gif){kind=small}
Digestive Surgery,
Saint-Eloi University Hospital of Montpellier, Montpellier, France.
Anesth
Analg 2008 107: 1707-1713.
背景：配合壓力支持通氣和呼氣末正壓通氣的無創正壓通氣（NPPV）能有效地為插管時存在低氧的病人提供氧氣。作者假設使用NPPV給氧要比自發通氣（SV）進行預氧化能更快增加病態肥胖病人的呼氣末氧濃度（ETO2）。
方法：28名病態肥胖患者參加了這一前瞻性地隨機研究。使用SV或者NPPV（壓力支援=8cmH2o,PEEP=6cmH2o）(NPPV組)給氧5 min。ETO2可以使用麻醉呼吸回路測量，也可表示為大氣濃度的一小部分。主要終點是在給氧最後ETO2>95%的病人數量。次要終點包括達到最大ETO2的時間和給氧結束時的ETO2值。
結果：與SV組相比NPPV組中有更大比例的患者在5 min時ETO2達到95%(13/14 vs 7/14, P =
0.01)。在NPPV組ETO2達到最大值的時間明顯少於SV組（185±46 vs 222±42 s，P=0.02）。在給氧結束時的平均ETO2值NPPV組比SV更大(96.9 ± 1.3 vs 94.1 ±
2.0%, P < 0.001)。NPPV組可見中等程度的胃擴張。但兩組均未見明顯不良後果。
結論：在手術室對病態肥胖病人通過面罩進行NPPV給氧是安全、可行和有效的。對於這類人NPPV能提供更快速的給氧，達到更高的ETO2。
（潘錢玲 譯 陳傑 校）
BACKGROUND:
Noninvasive
positive-pressure ventilation (NPPV) with pressure
support-ventilation and positive end-expiratory pressure are
effective in providing oxygenation during intubation in hypoxemic
patients. We hypothesized administration of oxygen (O2)
using NPPV would more rapidly increase the end-tidal O2 concentration
(ETo2) than preoxygenation using spontaneous ventilation (SV)
in morbidly obese patients.
METHODS:
Twenty-eight
morbidly obese patients were enrolled in this prospective randomized
study. Administration of O2 for 5 min was performed
either with SV group or with NPPV (pressure support = 8 cm H2O,
positive end-expiratory pressure = 6 cm H2O) (NPPV
group). ETo2 was measured using the anesthesia breathing circuit,
and is expressed as a fraction of atmospheric concentration. The
primary end-point was the number of patients with an ETo2 >95%
at the end of O2 administration. Secondary end-points included
the time to reach the maximal ETo2 and the ETo2 at the
conclusion of O2 administration.
RESULTS:
A larger
proportion of patients achieved a 95% ETo2 at 5 min with
NPPV than SV (13/14 vs 7/14, P = 0.01). The time to reach the maximal
ETo2 was significantly less in the NPPV than in the SV
group (185 ± 46 vs 222 ± 42 s, P = 0.02). The mean ETo2
at the conclusion of O2 administration was larger in the
NPPV group than the SV group (96.9 ± 1.3 vs 94.1 ± 2.0%, P < 0.001). A modest,
although significant, increase in gastric distension was observed in
the NPPV group. No adverse effects were observed in either group.
CONCLUSION:
Administration
of O2 via a facemask with NPPV in the operating room is
safe, feasible, and efficient in morbidly obese patients. In this
population NPPV provides a more rapid O2 administration,
achieving a higher ETo2.
在體內高或低皮質醇對人體單核細胞介導的炎症反應途徑有雙相影響
In Vivo Exposure to High or
Low Cortisol Has Biphasic Effects on Inflammatory Response Pathways of Human
Monocytes
Mark
P. Yeager, MD*, Patricia A. Pioli, PhD_files/image097.gif){kind=small}
, Kathleen Wardwell, BS_files/image098.gif){kind=small}
, Michael L. Beach, MD,
PhD*, Peter Martel, MS_files/image099.gif){kind=small}
, Hong K. Lee, PhD_files/image100.gif){kind=small}
, Athos J. Rassias, MD*,
and Paul M. Guyre, PhD_files/image101.gif){kind=small}
From
the Departments of *Anesthesiology, _files/image102.gif){kind=small}
Physiology, and _files/image103.gif){kind=small}
Pathology, Dartmouth
Medical School, Hanover, New Hampshire and the Dartmouth-Hitchcock Medical Center,
Lebanon, New Hampshire.
Anesth
Analg 2008 107: 1726-1734.
背景：最近的研究表明，糖皮質激素對免疫反應有支持（刺激）和抑制性影響，這取決於糖皮質激素濃度。由於一些糖皮質激素對炎症的刺激，作者推測糖皮質激素在體內急性缺失將減少人單核細胞介導的炎症反應。
方法：分離健康志願者參加在體治療前和後的單核細胞; 1 ）注射生理鹽水， 2 ）注射高劑量氫化可的松（8 µg·kg–1·min–1） ，其次是隔夜口服氫化可的松，以及3 ）口服米非司酮（200 mg 在04：00和16：00 點）為阻止細胞內的糖皮質激素受體和注射依託咪酯（1.5 mg·kg–1·h–1 ）12小時，以防止代償性合成腎上腺皮質醇。連續測量血漿促腎上腺皮質激素，血漿和唾液皮質醇。測試單核細胞為： 1 ）細胞因數反應， 2 ）CD163 ， CD119和CD54 的表達，3） mRNA水準的糖皮質激素反應炎症介質。所有資料測試均在離體有或沒有脂多糖刺激單核細胞下進行。
結果：皮質醇和促腎上腺皮質激素的測量證明有效控制體內皮質醇。體內皮質醇增多和糖皮質激素的消耗對單核細胞mRNA水準4個重要的 糖皮質激素反應分子（糖皮質激素受體， CD163 ，白細胞介素-10 ，和細胞因數合成- 3抑制因數）有相互的影響。單核細胞因數反應和蛋白表達沒有受到糖皮質激素缺失的影響。皮質醇增多增強了 CD163的表達 。
結論：短期糖皮質激素缺失影響糖皮質激素反應分子的mRNA水準，但並不影響單核細胞蛋白的表達或細胞因數反應。
（陳偉 譯 陳傑 校）
BACKGROUND:
Recent
studies demonstrate that glucocorticoids (GCs) have both supportive
(stimulatory) and suppressive effects on immune responses, depending
upon the GC concentration. Since some GC effects on inflammation are
stimulatory, we hypothesized that acute in vivo GC depletion would
decrease inflammatory responses of human monocytes.
METHODS:
Monocytes
were isolated from healthy volunteer participants before and after in
vivo
treatment with; 1) IV saline, 2) IV high dose hydrocortisone (8
µg·kg–1·min–1) followed by oral hydrocortisone
overnight, and 3) oral RU486 (200 mg at 0400 and 1600 h) to block
the intracellular GC receptor and IV etomidate (1.5 mg·kg–1·h–1)
for 12 h to prevent compensatory adrenal cortisol synthesis. Plasma
adrenocorticotropic hormone, plasma, and salivary cortisol were
measured serially. Monocytes were tested for; 1) cytokine responses,
2) expression of CD163, CD119, and CD54, and 3) mRNA levels of
GC-responsive inflammatory mediators. All measurements were made
with and without in vitro stimulation of monocytes by
lipopolysaccharide.
RESULTS:
Cortisol
and adrenocorticotropic hormone measurements demonstrated effective
manipulation of in vivo cortisol. In vivo hypercortisolemia and in
vivo GC
depletion had reciprocal effects on monocyte mRNA levels of 4
important GC-responsive molecules: 1) GC receptor, CD163,
interleukin-10, and suppressor of the cytokine synthesis-3. Monocyte
cytokine responses and protein expression were not affected by GC
depletion. CD163 expression was increased by hypercortisolemia.
CONCLUSIONS:
Short-term
GC depletion affects mRNA levels of GC-responsive molecules but does
not affect monocyte protein expression or cytokine responses.
3%氯普魯卡追加0.5%布比卡因和2%利多卡因追加0.5%布比卡因在肌間溝臂叢神經阻滯中的比較：一項隨機、前瞻、雙盲對照試驗：
A
Randomized, Prospective, Double-Blind Trial Comparing 3% Chloroprocaine Followed
by 0.5% Bupivacaine to 2% Lidocaine Followed by 0.5% Bupivacaine for
Interscalene Brachial Plexus Block
Soheila
Jafari, MD, Allison I. Kalstein, DO, Habib M. Nasrullah, MD, Mehrdad
Hedayatnia, MD, Joel M. Yarmush, MD, and Joseph SchianodiCola, MD
From
the Department of Anesthesiology, New York Methodist Hospital, Brooklyn, New
York.
Anesth
Analg 2008 107: 1746-1750.
背景：2-氯普魯卡因加布比卡因(C/B)後可用於區域麻醉，但由於其效果不是很顯著，並沒有能夠得到廣泛應用。在這項隨機、前瞻、雙盲對照試驗中，作者比較了使用(C/B)和使用利多卡因加布比卡因（L/B）在肌間溝阻滯中的效用。
方法：30例準備在肌間溝臂叢神經阻滯下行肩膀關節手術的病人隨機分成兩組，每組15例。一組（C/B）使用3%氯普魯卡因混合碳酸氫鹽和腎上腺素，緊接著使用0.5%布比卡因和腎上腺素。另一組（L/B）使用2%利多卡因代替3%氯普魯卡因。運動神經和感覺神經阻滯每15秒測試一次。主要評定的結束點是完全運動神經阻滯的出現。運用Time-to-event統計方法分析。
結果：一名L/B組的病人沒有出現阻滯，不做分析。C/B組和L/B組出現運動神經阻滯的平均時間分別是90秒（15-575）和180（15-3720）秒（P=0.0325）。兩組的感覺神經阻滯的平均時間分別是90（30-600）秒和12（30-3900）秒（P=0.0185）。統計顯示，在5分鐘內C/B組的15例病人中有13例有運動神經阻滯，L/B組14例病人中只有7例有運動神經阻滯。十分鐘內，C/B組15名病人全部實現運動神經阻滯，L/B組只有10名。在L/B組中最長等待了60分鐘來評估是不是完成了阻滯。
結論：研究表明：在肌間溝阻滯時，使用C/B藥物比使用L/B能更快完成阻滯。
（王騰 譯 陳傑 校）
BACKGROUND:
The
combination of 2-chloroprocaine and bupivacaine (C/B) for regional
anesthesia has been described, but its use was largely abandoned due
to equivocal results in efficacy. In this prospective, double-blind,
randomized study, we compared the onset of an interscalene block
using C/B versus a combination of lidocaine and bupivacaine (L/B).
METHODS:
Thirty
patients scheduled for shoulder arthroscopy under interscalene block
were divided into two groups of 15 each. One group (C/B) received 3%
2-chloroprocaine combined with bicarbonate and epinephrine,
immediately followed by 0.5% bupivacaine and epinephrine, whereas
the other group (L/B) received 2% lidocaine instead of 3%
2-chloroprocaine. Motor and sensory block were assessed every 15 s.
The primary end-point was the time of onset to complete motor block.
Time-to-event (survival) statistical analysis tests were applied.
RESULTS:
One L/B
patient had a failed block, and was excluded. The median time to
motor block for C/B and L/B was 90 (15–575) and 180 (15–3720) s,
respectively (P = 0.0325), and to sensory block for C/B and L/B was 90
(30–600) and 210 (30–3900) s, respectively (P = 0.0185). Survival
analysis showed that in 5 min, 13 of 15 patients from the C/B group
but only 7 of 14 from the L/B group had a successful motor block.
In 10 min, 15 of 15 patients from the C/B group but only 10 of
14 from the L/B group had a successful motor block. It took as long
as 60 min to assess block success/failure for blocks in the L/B
group.
CONCLUSIONS:
This
study demonstrates that a successful block was more rapid using C/B
than L/B for interscalene blocks.
A
Thromboelastometric Evaluation of the Effects of Hypothermia on the Coagulation
System
Malin
Rundgren and Martin Engström
Department
of Anaesthesia and Intensive Care, Halmstad Central Hospital, Halmstad, Sweden.
Anesth
Analg 2008 107: 1465-1468.
背景：低溫可分為意外和治療性的。治療性低溫越來越多的被用於不同的情況，例如：心臟停搏後的神經保護等。低溫會導致凝血系統的損害，但損害的程度很難評估。大部分的研究著眼於血漿而不是全血。我們用全血在一個寬範圍的溫度（25-40攝氏度）內研究低溫對凝血系統的影響。
方法：從6個健康的志願者采血，保存在檸檬酸鹽試管中。在輪流用凝血彈性度評價凝血系統前，將樣本放在25-40攝氏度的水中水浴30分鐘。接觸啟動劑（鞣花酸）用於觸發最初的凝血。測量凝血時間、血塊形成時間、生理角及最大血塊強度。所有的試驗持續60分鐘然後在與水浴溫度相同的溫度下進行測量。
結果：在研究的溫度範圍內，凝血功能的損害隨溫度的降低而加重。所有的測量值都呈階梯式的下降，有顯著差異（P<0.0001）。
結論：全血的檢測分析提示低溫進行性的損害凝血系統。
（胡豔譯 薛張剛校）
BACKGROUND: Hypothermia may be accidental
or therapeutic. Therapeutic hypothermia is increasingly used as treatment for
various conditions, e.g., neuroprotection after cardiac arrest. Hypothermia
leads to an impairment of the coagulation system, but the degree of impairment
has been difficult to determine. Most studies have been performed on plasma
instead of whole blood. We therefore evaluated whole blood investigating the
effects of hypothermia on the coagulation system over a wide range of
temperatures (25-40 degrees C).
METHODS: Blood was drawn from six
healthy volunteers into citrated test tubes. Samples were then placed in water
baths with temperatures ranging from 25 to 40 degrees C for 30 min before the
coagulation system was studied using rotational thromboelastometry. A contact
activator (Ellagic acid) was used for initiation of coagulation. Clotting time,
clot formation time, alpha angle, and maximum clot strength were measured. All
tests were run for 60 min and they were performed at the same temperature as
the temperature in the water bath.
RESULTS: Coagulation was increasingly
impaired with decreasing temperatures in the temperature range studied. All
variables measured were significantly impaired in a stepwise pattern (P <
0.0001).
CONCLUSIONS: Evauation using a whole blood
analysis shows that hypothermia progressively impairs the coagulation system.
A
Randomized Controlled Trial of Cell Salvage in Routine Cardiac Surgery
Andrew
A. Klein, Samer A. M. Nashef, Linda Sharples, Fiona Bottrill, Matthew Dyer,
Johanna Armstrong, and Alain Vuylsteke
Department
of Anaesthesia, Papworth Hospital, Cambridge, CB23 3RE, UK.
Anesth
Analg 2008 107: 1487-1495.
背景：之前的研究表明血液回收可能減少心臟手術的異體輸血，但這些研究有局限性，包含了其他節約輸血策略使用的不一致。我們設計了一項隨機對照研究以確定對擇期非複雜心臟手術行常規血液回收能否減少輸血，以及在嚴格輸血方案和常規使用抗纖維蛋白酶的設定下行常規血液回收的成本效益分析。
方法：230名首次行冠脈搭橋術和/或心臟瓣膜手術的患者預先隨機分為對照組和血液回收組。後一組通過細胞回收設備行術中和術後6小時內胸腔引流液的血液回收並行自體血回輸。所有患者均使用氨甲環酸並按規定演算法接受紅細胞和凝血因數輸注。
結果：兩組間患者輸異體血的比例沒有差異（兩組均為32％，相對危險因數1.0, P = 0.89）。以目前的血製品和細胞回收設備的價格，使用血液回收至少增加每個病人的花費103美元。當患者因出血再次行胸腔探查時予以排除（按方案計畫），血液回收組患者輸異體血單位量明顯少於對照組（65vs100U，相對危險因數0.71, P = 0.04）。
結論：首次行常規心臟手術的患者在具有嚴格血液保存計畫的醫療機構中，常規使用血液回收並不能減少患者輸異體血的比例。然而，術後出血過多的患者卻可通過血液回收明顯減少輸血的單位量。儘管使用血液回收能明顯減少血製品的需要量，但會增加醫療機構的成本。
（黃凝譯 薛張綱校）
BACKGROUND:
Previous trials have indicated that cell salvage may reduce allogeneic blood
transfusion during cardiac surgery, but these studies have limitations, including
inconsistent use of other blood transfusion-sparing strategies. We designed a
randomized controlled trial to determine whether routine cell salvage for
elective uncomplicated cardiac surgery reduces blood transfusion and is cost
effective in the setting of a rigorous transfusion protocol and routine
administration of antifibrinolytics.
METHODS:
Two-hundred-thirteen patients presenting for first-time coronary artery bypass
grafting and/or cardiac valve surgery were prospectively randomized to control
or cell salvage groups. The latter group had blood aspirate during surgery and
mediastinal drainage the first 6 h after surgery processed in a cell saver
device and autotransfused. All patients received tranexamic acid and were
subjected to an algorithm for red blood cell and hemostatic blood factor
transfusion.
RESULTS:
There was no difference between the two groups in the proportion of patients
exposed to allogeneic blood (32% in both groups, relative risk 1.0 P = 0.89). At current blood products and cell saver
prices, the use of cell salvage increased the costs per patient by a minimum of
$103. When patients who had mediastinal re-exploration for bleeding were
excluded (as planned in the protocol), significantly fewer units of allogeneic
red blood cells were transfused in the cell salvage compared with the control
group (65 vs 100 U, relative risk 0.71 P =
0.04).
CONCLUSION:
In patients undergoing routine first-time cardiac surgery in an institution
with a rigorous blood conservation program, the routine use of cell salvage
does not further reduce the proportion of patients exposed to allogeneic blood
transfusion. However, patients who do not have excessive bleeding after surgery
receive significantly fewer units of blood with cell salvage. Although the use
of cell savage may reduce the demand for blood products during cardiac surgery,
this comes at an increased cost to the institution.
兒童病人眼鏡蛇式喉周氣道與Unique喉罩前瞻性隨機研究
A
Prospective, Randomized Comparison of Cobra Peri laryngeal Airway and Laryngeal
Mask Airway Unique in Pediatric Patients
Szmuk
P,Ghelber O, Matuszczak M, Rabb, MF, Ezri T, Sessler D
From the *Department of Anesthesiology,
University of Texas Southwestern Medical School and Children’s Medical Center
at Dallas, Texas; _files/image104.gif){kind=small}
Department of Anesthesiology, University of
Texas Medical School at Houston, Texas; _files/image105.gif){kind=small}
Department of Anesthesia, Wolfson Medical
Center, Holon, Affiliated to Tel Aviv University, Israel; and _files/image106.gif){kind=small}
Department of Outcomes Research, The
Cleveland Clinic, Ohio; ¶Member Outcomes Research Consortium.
Anesth
Analg 2008 107: 1523-1530
背景：成人正壓通氣時眼鏡蛇式喉周氣道（CobraPLA）比Unique喉罩更能夠提供有效的氣道封閉壓。因此，我們比較