Table of Contents
March 2009
CARDIOVASCULAR
ANESTHESIOLOGY:
肌鈣蛋白I水平在預測絕經後婦女行心血管手術後發生不良心血管事件預後的價值
單嘉琪譯 薛張綱校
Prognostic Value of
Troponin I Levels for Predicting Adverse Cardiovascular Outcomes in Postmenopausal
Women Undergoing Cardiac Surgery
Joshua D. Stearns, Victor G. Dávila-Román, Benico Barzilai, Richard E. Thompson, Kelly L. Grogan, Betsy Thomas, and Charles W. Hogue, Jr
Anesth Analg 2009 108:
719-726.
鄭麗 譯 陳傑 校
Fast-Track Anesthesia
and Cardiac Surgery: A Retrospective Cohort Study of 7989 Patients
Vesna Svircevic, Arno P. Nierich, Karel G. M. Moons, George J. Brandon Bravo Bruinsma, Cor J. Kalkman, and Diederik van Dijk
Anesth Analg 2009 108:
727-733.
一篇就文獻進行的系統性回顧：血栓彈性描計法可以預測術後血栓栓塞的發生麽？
姜旭暉譯，馬皓琳，李士通校
Does
Thromboelastography Predict Postoperative Thromboembolic Events? A Systematic
Review of the Literature
Yue Dai, Anna Lee, Lester A.
H. Critchley, and Paul F. White
Anesth Analg 2009 108: 734-742.
血栓彈性測定法（ROTEM）檢測體外迴圈術後肝素和魚精蛋白的試點研究及結果
范羽譯 薛張綱校
Detection of
Protamine and Heparin After Termination of Cardiopulmonary Bypass by
Thrombelastometry (ROTEM®): Results of a Pilot Study
Markus Mittermayr, Corinna Velik-Salchner, Berndt Stalzer, Josef Margreiter, Anton Klingler, Werner Streif, Dietmar Fries, and Petra Innerhofer
Anesth Analg 2009 108:
743-750.
劉世文 譯 陳傑 校
The Effects of
Fibrinogen Levels on Thromboelastometric Variables in the Presence of
Thrombocytopenia
Thomas Lang, Kai Johanning, Helfried Metzler, Siegfried Piepenbrock, Cristina Solomon, Niels Rahe-Meyer, and Kenichi A. Tanaka
Anesth Analg 2009 108: 751-758.
裘毅敏譯，馬皓 琳 李士通校
Noninfectious Serious
Hazards of Transfusion
(Review Article)
Jeanne E. Hendrickson and Christopher D. Hillyer
Anesth Analg 2009 108:
759-769.
葉樂 譯 陳傑 校
Transfusion-Related
Acute Lung Injury: Current Concepts for the Clinician (Review Article)
Darrell J. Triulzi
Anesth Analg 2009 108: 770-776.
周雅春 譯
馬皓琳 李士通 校
Cardiac Surgery in
the Parturient (Review
Article)
Shobana Chandrasekhar, Christopher R. Cook, and Charles D. Collard
Anesth Analg 2009 108: 777-785.
PEDIATRIC
ANESTHESIOLOGY:
兒科手術室外異丙酚行鎮靜/麻醉治療的不良反應及其發生率：來自兒科鎮靜研究協會的報道
黃劍譯 薛張綱校
The Incidence and Nature of Adverse Events
During Pediatric Sedation/Anesthesia With Propofol for Procedures Outside the
Operating Room: A Report From the Pediatric Sedation Research Consortium
Joseph P. Cravero, Michael L.
Beach, George T. Blike, Susan M. Gallagher, James H. Hertzog, and Pediatric
Sedation Research Consortium
Anesth Analg 2009 108:
795-804.
張磊 譯 陳傑 校
Relative Analgesic
Potencies of Levobupivacaine and Ropivacaine for Caudal Anesthesia in Children
Pablo Ingelmo, Geoff Frawley, Marinella Astuto, Chris Duffy, Susan Donath, Nicola Disma, Giuseppe Rosano, Roberto Fumagalli, and Antonio Gullo
Anesth Analg 2009 108:
805-813.
李瑩譯 薛張綱校
The Reliability of
Continuous Noninvasive Finger Blood Pressure Measurement in Critically Ill
Children
Joris Lemson, Charlotte M. Hofhuizen, Olaf Schraa, Jos J. Settels, Gert Jan Scheffer, and Johannes G. van der Hoeven
Anesth Analg 2009 108:
814-821.
張瑩譯 李士通 馬皓琳 校
Real-Time Assessment of Perioperative
Behaviors and Prediction of Perioperative Outcomes (Brief Report)
Senthilkumar Sadhasivam, Lindsey L. Cohen, Alexandra Szabova, Anna Varughese, Charles Dean Kurth, Paul Willging, Yu Wang, Todd G. Nick, and Joel Gunter Anesth
Analg 2009 108: 822-826.
AMBULATORY
ANESTHESIOLOGY:
姚敏敏譯 薛張綱校
Manual Versus
Target-Controlled Infusion Remifentanil Administration in Spontaneously
Breathing Patients
Annelies T. Moerman, Luc L. Herregods, Martine M. De Vos, Eric P. Mortier, and Michel M. R. F. Struys
Anesth Analg 2009 108: 828-834.
ANESTHETIC
PHARMACOLOGY:
張燕 譯 陳傑 校
Methemoglobinemia
Related to Local Anesthetics: A Summary of 242 Episodes
Joanne Guay
Anesth Analg 2009 108: 837-845.
黃麗娜 譯 馬皓琳 李士通 校
The Effect of
Residual Neuromuscular Blockade on the Speed of Reversal with Sugammadex
Paul F. White, Burcu Tufanogullari, Ozlem Sacan, Edward G. Pavlin, Oscar J. Viegas, Harold S. Minkowitz, and M. E. Hudson
Anesth Analg 2009 108: 846-851.
俞佳譯 薛張綱校
A Comparison of
Propofol and Remifentanil Target-Controlled Infusions to Facilitate Fiberoptic
Nasotracheal Intubation
Alexandre Lallo, Valerie Billard, and Jean-Louis Bourgain
Anesth Analg 2009 108:
852-857.
大鼠氙氣預處理：促存活信號、線粒體滲透性轉變和生物能學的作用
舒慧剛 譯 陳傑 校
Xenon Preconditioning:
The Role of Prosurvival Signaling, Mitochondrial Permeability Transition and
Bioenergetics in Rats
Yasushi Mio, Yon Hee Shim, Ebony Richards, Zeljko J. Bosnjak, Paul S. Pagel, and Martin Bienengraeber
Anesth Analg 2009 108: 858-866.
江繼宏 譯
馬皓琳 李士通 校
Proprioceptive
Function Is More Sensitive than Motor Function to Desflurane Anesthesia
Linda S. Barter, Laurie O. Mark, and Joseph F. Antognini
Anesth Analg 2009 108: 867-872.
TECHNOLOGY,
COMPUTING, AND SIMULATION:
張玥琪譯，薛張綱校
An Evaluation of a
Novel Software Tool for Detecting Changes in Physiological Monitoring
J. Mark Ansermino, Jeremy P. Daniels, Randy T. Hewgill, Joanne Lim, Ping Yang, Chris J. Brouse, Guy A. Dumont, and John B. Bowering
Anesth Analg 2009 108:
873-880.
丁俊雲 譯 陳傑 校
Noninvasive Cardiac
Output Measurement in Heart Failure Subjects on Circulatory Support
Rob Phillips, Peter Lichtenthal, Julie Sloniger, Darryl Burstow, Malcolm West, and Jack Copeland
Anesth Analg 2009 108:
881-886.
周姝婧 譯 陳傑 校
Minimally Invasive
Cardiac Output Monitoring in the Perioperative Setting (Review Article)
Duane J. Funk, Eugene W. Moretti, and Tong J. Gan
Anesth Analg 2009 108: 887-897.
CRITICAL
CARE AND TRAUMA:
張釗譯 薛張綱校
Changes in Functional
Residual Capacity During Weaning from Mechanical Ventilation: A Pilot Study
Hermann Heinze, Beate Sedemund-Adib, Matthias Heringlake, Torsten Meier, and Wolfgang Eichler
Anesth Analg 2009 108: 911-915.
王宏翻譯，馬皓琳，李士通校正
Alcohol Use Disorder
and Perioperative Immune Dysfunction (Review Article)
Alexandra Lau, Vera von Dossow, Michael Sander, Martin MacGuill, Nadine Lanzke, and Claudia Spies
Anesth Analg 2009 108: 916-920.
OBSTETRIC ANESTHESIOLOGY:
黃佳佳譯，馬皓琳 李士通校
Patient-Controlled
Epidural Analgesia for Labor (Review Article)
Stephen H. Halpern and Brendan Carvalho
Anesth Analg 2009 108: 921-928.
ECONOMICS,
EDUCATION, AND POLICY:
朱蘭芳譯 薛張綱
The Teaching of
Professionalism During Residency: Why It Is Failing and a Suggestion to Improve
Its Success (Review
Article)
Robert R. Gaiser
Anesth Analg 2009 108: 948-954.
NEUROSURGICAL
ANESTHESIOLOGY AND NEUROSCIENCE:
混合皮層神經元-神經膠質細胞培養遭受氧糖缺失時的早期麻醉預處理：在七氟醚誘導時産生的神經保護作用中，三磷酸腺苷依賴性鉀通道和活性氧所起的作用
黃丹 譯 陳傑 校
Early Anesthetic
Preconditioning in Mixed Cortical Neuronal-Glial Cell Cultures Subjected to
Oxygen-Glucose Deprivation: The Role of Adenosine Triphosphate Dependent
Potassium Channels and Reactive Oxygen Species in Sevoflurane-Induced
Neuroprotection
Lionel J. Velly, Paula T. Canas, Benjamin A. Guillet, Christelle N. Labrande, Frédérique M. Masmejean, André L. Nieoullon, François M. Gouin, Nicolas J. Bruder, and Pascale S. Pisano
Anesth Analg 2009 108: 955-963.
環磷腺苷反應單元結合蛋白磷酰化和4-苯基-1（4-苯丁基）呱啶（PPBP）的神經保護作用
顔濤 譯 馬皓琳 李士通 校
Cyclic
Adenosine Monophosphate Response Element-Binding Protein Phosphorylation and
Neuroprotection by 4-Phenyl-1-(4-Phenylbutyl) Piperidine (PPBP)
Sufang Yang, Nabil J. Alkayed, Patricia D. Hurn, and Jeffrey R. Kirsch
Anesth Analg 2009 108:
964-970.
陳珺珺譯 薛張綱校
Cerebral
Resuscitation After Cardiocirculatory Arrest (Review Article)
Andreas Schneider, Bernd W. Böttiger, and Erik Popp
Anesth Analg 2009 108: 971-979.
ANALGESIA:
8%定量利多卡因噴霧泵對創傷後外周神經病變的鎮痛作用：一項初步研究
周姝婧 譯 陳傑 校
The Analgesic Effect
of a Metered-Dose 8% Lidocaine Pump Spray In Posttraumatic Peripheral
Neuropathy: A Pilot Study
Akifumi Kanai, Yuka Segawa, Takashi Okamoto, Masanori Koto, and Hirotsugu Okamoto
Anesth Analg 2009 108:
987-991.
唐李雋 譯
馬皓琳 李士通
校
Capsicum Plaster at
the Hegu Point Reduces Postoperative Analgesic Requirement After Orthognathic
Surgery
Kyo S. Kim, Kyu N. Kim, Kyung G. Hwang, and Chang J. Park
Anesth Analg 2009 108:
992-996.
陳珺珺譯 薛張綱校
Cytotoxicity of Local
Anesthetics in Human Neuronal Cells
Rosalia Perez-Castro, Sohin Patel, Zayra V. Garavito-Aguilar, Andrew Rosenberg, Esperanza Recio-Pinto, Jin Zhang, Thomas J. J. Blanck, and Fang Xu
Anesth Analg 2009 108: 997-1007.
一種新型異二氫吲哚衍生物JM-1232(-)的鎮痛效應和藥理特性
黃施偉 譯，馬皓琳 李士通 校
The Antinociceptive Effects and
Pharmacological Properties of JM-1232(-): A Novel Isoindoline Derivative
Shunsuke Chiba, Tomoki Nishiyama, and Yoshitsugu Yamada
Anesth Analg 2009 108:
1008-1014.
苄呱酚醇導致的抗傷害感覺和降低慢性後根神經節壓縮小鼠的脊髓背角NR2B亞單位的表達
陳珺珺譯 薛張綱校
Ifenprodil Induced
Antinociception and Decreased the Expression of NR2B Subunits in the Dorsal
Horn After Chronic Dorsal Root Ganglia Compression in Rats
Wei Zhang, Chang-Xi Shi, Xiao-ping Gu, Zheng-Liang Ma, and Wei Zhu
Anesth Analg 2009 108: 1015-1020.
朱 慧譯 馬皓琳 李士通校
Lidocaine Injection
into the Rat Dorsal Root Ganglion Causes Neuroinflammation
Livia Puljak, Sanja Lovric Kojundzic, Quinn H. Hogan, and Damir Sapunar
Anesth Analg 2009 108:
1021-1026.
懷曉蓉 譯 陳傑 校
An Absorbable Local
Anesthetic Matrix Provides Several Days of Functional Sciatic Nerve Blockade
Chi-Fei Wang, Alimorad G. Djalali, Ankur Gandhi, David Knaack, Umberto De Girolami, Gary Strichartz, and Peter Gerner
Anesth Analg 2009 108:
1027-1033.
趙嫣紅 譯 陳傑 校
The Efficacy of Skin
Temperature for Block Assessment After Infraclavicular Brachial Plexus Block
Vincent Minville, Agnés Gendre, Jan Hirsch, Stein Silva, Benoît Bourdet, Carole Barbero, Olivier Fourcade, Kamran Samii, and Hervé Bouaziz
Anesth Analg 2009 108:
1034-1036.
陳珺珺譯 薛張綱校
Ultrasound-Guided
Obturator Nerve Block: A Sonoanatomic Study of a New Methodologic Approach
Taylan Akkaya, Emine Ozturk, Ayhan Comert, Yesim Ates, Haluk Gumus, Halil Ozturk,
Ibrahim Tekdemir, and Alaittin Elhan
Anesth Analg 2009 108:
1037-1041.
肌鈣蛋白I水平在預測絕經後婦女行心血管手術後發生不良心血管事件預後的價值
Prognostic Value
of Troponin I
Levels for Predicting Adverse Cardiovascular
Outcomes in Postmenopausal Women
Undergoing Cardiac Surgery
Stearns,
Joshua D. MD; Davila-Roman, Victor G. MD; Barzilai, Benico MD; Thompson,
Richard E. PhD; Grogan, Kelly L. MD; Thomas, Betsy RN; Hogue, Charles W. Jr MD
From the
*Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical
Institutions, Baltimore, Maryland; _files/image003.gif){kind=small}
Cardiovascular Division, Department of
Medicine, Washington University School of Medicine, St. Louis, Missouri; _files/image005.gif){kind=small}
Department of Biostatistics, Johns Hopkins
Bloomberg School of Public Health, Baltimore, Maryland; and _files/image007.gif){kind=small}
Department of Clinical Research, Washington
University School of Medicine, St. Louis, Missouri.
Anesthesia &
Analgesia March
2009.108(3):719-726,
背景：心血管手術後的不良心血管事件是影響婦女圍手術期發病率和死亡率的重要因素。肌鈣蛋白I提供了一個心血管損傷敏感的檢測指標，但其在心血管手術後的水平因性別而異。我們此次研究的目的就是評估肌鈣蛋白I水平在預測絕經後婦女行心血管手術後産生心血管並發症上的價值。
方法：此次研究的佇列來自於先前一個已報道的臨床試驗，那個研究旨在評估老年婦女中17[beta]-雌二醇的神經保護潛能。在那個研究中，175名未接受雌激素替代治療且將擇期行冠脈旁路移植術（有無瓣膜手術均可）的絕經後婦女經雙盲隨機分成兩組，分別自手術前一天開始接受17[beta]-雌二醇或安慰劑治療，至術後五天。在術前，術後入重症監護室當日以及術後頭四天分別進行連續十二導聯心電圖及血清肌鈣蛋白I濃度檢測。我們這次研究的主要終檢值是重大的心血管不良事件（MACE），即Q波型心肌梗死，低心排量以及術後三十天內死亡。Q波型心肌梗死的診斷需有兩位內科醫生分別獨立進行評估，兩者意見一致方爲最終診斷。低心排量狀態是指在不考慮具體治療的情況下心臟指數小於2.0 L · min-1 · m-2超過八個小時。
結果：術後第一天的肌鈣蛋白I水平被用於預測重大的心血管不良事件（MACE）（受試者曲線下面級=0.862）。將肌鈣蛋白I的終檢值定於>7.6 ng/mL（95%可信區間，6.4–10.8）可提供鑒別患者是否存在發生重大心血管不良事件（MACE）風險的最佳敏感性和特異性。由肌鈣蛋白水平來識別一個患者是否合併有心血管事件，其陰性預測價值很高（96%），而陽性預測價值卻一般（40%）。圍手術期接受17[beta]-雌二醇治療的婦女與安慰劑組比較，術後肌鈣蛋白I的水平並無差異；並且重大心血管不良事件（MACE）的發生率並不受17[beta]-雌二醇治療的影響。
結論：對於絕經後婦女而言，術後第一天肌鈣蛋白I水平升高預示著重大心血管不良事件（MACE）發生的可能。監測圍手術期的肌鈣蛋白I水平也許可以作爲預測患者不良心血管事件發生風險的一種手段。
（單嘉琪譯 薛張綱校）
BACKGROUND: Adverse cardiac events that
follow cardiac surgery
are an important source of perioperative morbidity and mortality for women. Troponin I provides a sensitive
measure of cardiac injury, but the levels after cardiac surgery may vary
between sexes. Our purpose in this study was to evaluate the prognostic value of troponin I levels for predicting cardiovascular complications in postmenopausal women undergoing cardiac surgery.
METHODS: The cohort of this study
were women enrolled in a
previously reported clinical trial evaluating the neuroprotective potential of
17[beta]-estradiol in elderly women.
In that study, 175 postmenopausal
women not receiving estrogen
replacement therapy and scheduled to undergo coronary artery bypass graft (with
or without valve surgery) were prospectively randomized to receive
17[beta]-estradiol or placebo in a double-blind manner beginning the day before
surgery and continuing for 5 days postoperatively. Serial 12-lead
electrocardiograms were performed and serum troponin I concentrations were
measured before surgery, after surgery on arrival in the intensive care unit,
and for the first four postoperative days. The primary end-point of the present
study was major adverse cardiovascular events (MACE)
defined as a Q-wave myocardial infarction, low cardiac output state or death
within 30 days of surgery. The diagnosis of Q-wave myocardial infarction was
made independently by two physicians blinded to treatment and patient outcomes
with the final diagnosis requiring consensus. Low cardiac output state was
defined as cardiac index <2.0 L [middle dot] min-1 [middle dot] m-2 for
>8 h regardless of treatment.
RESULTS: Troponin I levels on postoperative
day 1 were predictive of MACE (area under the receiver operator curve = 0.862).
A cutoff point for troponin
I of >7.6 ng/mL (95% confidence interval, 6.4-10.8) provided the optimal
sensitivity and specificity for identifying patients at risk for MACE. The
negative predictive value
of a troponin I level for
identifying a patient with a composite cardiovascular outcome was high
(96%) and the positive predictive value
moderate (40%). Postoperative troponin
I levels were not different between women receiving perioperative
17[beta]-estradiol treatment compared with placebo and the frequency of MACE
was not influenced by 17[beta]-estradiol treatment.
CONCLUSIONS: In postmenopausal women, elevated troponin I levels on
postoperative day 1 are predictive of MACE. Monitoring of perioperative troponin I levels might provide a
means for stratifying patients at risk for adverse cardiovascular events.
血栓彈性測定法（ROTEM）檢測體外迴圈術後肝素和魚精蛋白的試點研究及結果
Detection of
protamine and heparin after termination of cardiopulmonary bypass by
thrombelastometry (ROTEM): results of a pilot study.
Mittermayr M,
Velik-Salchner C, Stalzer B, Margreiter J, Klingler A, Streif W, Fries D,
Innerhofer PFrom the *Department of Anesthesiology and Critical Care Medicine,
Innsbruck Medical University, Innsbruck, Austria; _files/image008.gif){kind=small}
Assign Data Management and Biostatistics
GmbH, Innsbruck, Austria; and _files/image009.gif){kind=small}
Department of Pediatrics, Innsbruck Medical
University, Innsbruck, Austria.
Anesth Analg 2009
Mar; 108(3):743-50.
背景：此次研究的目的爲確定血栓彈性測定法（ROTEM）是否可檢出魚精蛋白對於凝血功能的影響以及其區別於肝素的不同之處。
方法：爲了逆轉體外迴圈術後肝素的效應，22名相繼行主動脈或冠狀動脈手術的患者被選取入組。依據臨床慣例，所有入組病人按手術時所被給予的肝素總量接受其初始對應的魚精蛋白用量。若患者啟動凝固時間（ACT）延長或出現彌漫性出血的臨床徵兆，則可繼續給予其額外劑量的魚精蛋白（70U/kg）。同時須完成常規ACT測定、ROTEM分析（包括肝素敏感性[INTEM]測試和肝素酶包含性[HEPTEM]測試）及標準凝固試驗，並測量凝血因數和抗凝因數Xa的活性。
結果：比較肝素敏感性（INTEM）測試的結果（均數[+/-標準差]）：219.8（+/-19.1）秒至241.1（+/-21.7）秒（P<0.001）和肝素酶包含性（HEPTEM）測試的結果:210.2（+/-19.9）秒至226.8（+/-21.8）秒（P<0.001），兩者均顯示額外使用魚精蛋白（n=16）對於延長患者凝血時間具有顯著的統計學意義；而在僅給予單次魚精蛋白劑量的患者中（n=6）這些變化並沒有被發現。此外，運用INTEM測試與HEPTEM測試的比率，可成功地從58名不含殘餘肝素的患者中檢出56例；從僅有的6名在體外迴圈術後抗凝因數Xa升高的患者中檢出3例。
結論：初步資料顯示體外迴圈術後額外使用魚精蛋白可導致凝血時間在INTEM測試與HEPTEM測試中短暫延長。而在ACT延長的病例中，ROTEM分析對於檢出殘餘肝素可能有效。
（范羽譯 薛張綱校）
BACKGROUND: Our goal of this study was to determine
whether protamine's effects on coagulation can be detected and differentiated
from those of heparin when using thrombelastometry (ROTEM).
METHODS: To reverse the effects of heparin after
cardiopulmonary bypass (CPB), 22 consecutive patients undergoing aortocoronary
bypass graft surgery were included. According to clinical routine, all patients
received a first dose of protamine calculated from the total amount of heparin
given; additional protamine (70 U/kg) was administered to patients with
activated clotting time (ACT) above baseline and clinical signs of diffuse
bleeding. Simultaneously, routine ACT measurements, ROTEM assays
(heparin-sensitive INTEM, and heparinase-containing HEPTEM test) and standard
coagulation tests were performed, and the activity of coagulation factors as
well as antifactor Xa activity measured.
RESULTS: Administration of additional protamine (n =
16) resulted in a statistically significant increase in coagulation times on
the intrinsically activated test (INTEM-CT), namely from (mean [+/-SD]) 219.8
(+/-19.1) s to 241.1 (+/-21.7) s (P < 0.001), and on the
heparinase-containing test (HEPTEM-CT), namely from 210.2 (+/-19.9) s to 226.8
(+/-21.8) s (P < 0.001). These changes were not observed in patients
receiving a single protamine dose (n = 6). The INTEM-CT:HEPTEM-CT ratio correctly
identified 56 of the 58 samples as not containing residual heparin and
correctly detected residual heparin in 3 of the only 6 samples showing elevated
antifactor Xa values after CPB.
CONCLUSION: Our preliminary data show that at
termination of CPB administration of additional protamine results in a brief
prolongation of coagulation times on the INTEM and HEPTEM test and that ROTEM
might be useful in excluding residual heparin in cases showing prolonged ACT.
兒科手術室外異丙酚行鎮靜/麻醉治療的不良反應及其發生率：來自兒科鎮靜研究協會的報道
The incidence and nature of
adverse events during pediatric sedation/anesthesia with propofol for
procedures outside the operating room: a report from the Pediatric Sedation
Research Consortium.
Joseph P. Cravero,
Michael L. Beach, George T. Blike, Susan M. Gallagher, James H. Hertzog, and
Pediatric Sedation Research Consortium
From the
*Department of Anesthesiology and Pediatrics; _files/image010.gif){kind=small}
Department of Anesthesiology and Community
and Family Medicine, Dartmouth Hitchcock Medical Center, One Medical Center
Drive, Lebanon, New Hampshire; and _files/image011.gif){kind=small}
Department of Anesthesiology, Division of Critical
Care Medicine, Alfred I duPont Hospital for Children, Wilmington, Delaware.
Anesth Analg 2009 108: 795-804.
目標：研究異丙酚的鎮靜/麻醉作用的特性及其不良事件的發生率。爲此我們使用了一個由專業的兒科工作者提供的關於兒科手術室外鎮靜/麻醉的大樣本前瞻性資料庫。
病例選擇和方法：資料由兒科鎮靜研究協會(Pediatric
Sedation Research Consortium,PSRC)收集。這一國際性的協會致力於改進鎮靜/麻醉在兒童中的應用。協會的成員們按一定的規程前瞻性持續收集接受鎮靜及鎮靜/麻醉治療的病例資料。主要的入選標準是在手術室外診療中對某些形式的鎮靜/麻醉的需求度，無排除標準。統計資料，主要疾病，並存疾病，治療方法，所用藥物，治療和恢復時間，麻醉藥物劑量效用關係，氣道控制及惡性事件都由網路化的資料收集工具進行收集匯總。本研究中，我們評價了所有以異丙酚爲主要鎮靜/麻醉治療藥物的情況。
結果：37個地區彙報了自2004.6.1至2007.9.1間共49836例以異丙酚行鎮靜/麻醉的病例。無死亡病例，需心肺復蘇2例，鎮靜/麻醉狀態下發生誤吸4例。稍輕的不良事件還有O2飽和度低於90%超過30s，其發生率爲154:10000。窒息或氣道阻塞發生率爲575:10000。喘鳴，喉痙攣，分泌物過多及嘔吐的發生率分別爲50,96,341和49:10000。預期外的住院治療(所需治療級別上升)發生率在7.1:10000。據粗略分析，肺部不良事件的發生率在麻醉科和其他科室間無顯著性差異。
結論：我們報道了最大數量的兒科手術室外異丙酚鎮靜/麻醉的病例分析。由一些較偏好並且較有組織計劃進行鎮靜/麻醉治療的組織提供的資料顯示使用異丙酚進行鎮靜/麻醉嚴重不良反應的發生率並不高。但是這一操作的安全性還取決於處理一些相對較輕微的不良反應的能力。希望我們的資料能爲使用異丙酚進行鎮靜/麻醉治療的培訓教育提供一定的參考價值以促進更加安全的使用這一藥物。
（黃劍譯 薛張綱校）
OBJECTIVE: We used a large database of prospectively
collected data on pediatric sedation/anesthesia outside the operating room
provided by a wide range of pediatric specialists to delineate the nature and
frequency of adverse events associated with propofol-based sedation/anesthesia
care.
PATIENTS AND METHODS: Data were collected by the Pediatric Sedation Research Consortium, a collaborative group of institutions dedicated to improving sedation/anesthesia care for children internationally. Members prospectively enrolled consecutive patients receiving sedation or sedation/anesthesia for procedures. The primary inclusion criterion was the need for some form of sedation/anesthesia to perform a diagnostic or therapeutic procedure outside the operating room. There were no exclusion criteria. Data on demographics, primary illness, coexisting illness, procedure performed, medications used, procedure and recovery times, medication doses outcomes of anesthesia, airway interventions and adverse events were collected and reported using web-based data collection tool. For this study, we evaluated all instances where propofol was used as the primary drug in the sedation/anesthesia technique.
RESULTS: Thirty-seven locations submitted data on 49,836 propofol sedation/anesthesia encounters during the study period from July 1, 2004 until September 1, 2007. There were no deaths. Cardiopulmonary resuscitation was required twice. Aspiration during sedation/anesthesia occurred four times. Less serious events were more common with O(2) desaturation below 90% for more than 30 s, occurring 154 times per 10,000 sedation/anesthesia administrations. Central apnea or airway obstruction occurred 575 times per 10,000 sedation/anesthesia administrations. Stridor, laryngospasm, excessive secretions, and vomiting had frequencies of 50, 96, 341, and 49 per 10,000 encounters, respectively. Unexpected admissions (increases in levels of care required) occurred at a rate of 7.1 per 10,000 encounters. In an unadjusted analysis, the rate of pulmonary adverse events was not different for anesthesiologists versus other providers.
CONCLUSIONS: We report the largest series of pediatric propofol sedation/anesthesia for procedures outside the operating room. The data indicate that propofol sedation/anesthesia is unlikely to yield serious adverse outcomes in a collection of institutions with highly motivated and organized sedation/anesthesia services. However, the safety of this practice is dependent on a system's ability to manage less serious events. We propose that our data suggest variables for training and credentialing providers of propofol sedation/anesthesia and the system characteristics that promote safe use of this drug.
The Reliability
of Continuous Noninvasive Finger Blood Pressure Measurement in Critically Ill
Children
Joris Lemson, MD*,
Charlotte M. Hofhuizen, MD_files/image012.gif){kind=small}
, Olaf Schraa, MSc_files/image013.gif){kind=small}
, Jos J. Settels, MSc_files/image014.gif){kind=small}
, Gert Jan Scheffer, MD, PhD_files/image015.gif){kind=small}
, and Johannes G. van der Hoeven, MD, PhD*
From the
Departments of *Intensive Care Medicine, _files/image016.gif){kind=small}
Anesthesiology, Radboud University Nijmegen
Medical Centre, Nijmegen, The Netherlands; and _files/image017.gif){kind=small}
BMEYE BV, Amsterdam, The Netherlands.
Anesth Analg 2009
108: 814-821.
介紹：使用有特殊裝置的充氣指套（FINAP），通過指尖動脈可以對成人進行持續無創血壓測定，並且它的可行性和可靠性均較高。在重症患兒，我們使用標準的兒童指套並經軟體計算，對這種無創血壓測定的方法與有創動脈測定（IAP）進行比較。
方法：我們的研究物件是鎮靜及呼吸機輔助通氣的送入重症監護室的患兒。在血流動力學相對平穩期間，分別使用三種方法測定血壓，從而比較FINAP、IAP和無創振動測壓裝置的結果。我們還比較了IAP和由指尖血壓換算的肱動脈血壓的值。
結果：試驗包括了35名2至22kg的患兒。總共測定了152個FINAP，其中4.6％沒有成功。比較FINAP和IAP，收縮壓、舒張壓、平均動脈壓的偏差分別是–16.2, –7.7, and –10.2 mm Hg。置信區間（LOA）分別是26.1%, 30.1%,和22.6%.。經指尖血壓換算的肱動脈血壓與IAP相比較，偏差分別是–11.8, 0.6和–0.9
mm Hg ，LOA分別是21.7%, 8.9%, 8.9% 。無創的振動法血壓測定與IAP相比偏差分別是–6.8, –0.9,–3.8 mm Hg，LOA分別是18.2%, 38.6%, 22.1% 。
結論：在血流動力學穩定的重症患兒，使用Beta型指套測定指尖血壓並換算成肱動脈血壓進行的持續無創血壓監測的結果是可靠的。
（李瑩譯 薛張綱校）
INTRODUCTION: Continuous noninvasive arterial blood
pressure can be measured in finger arteries using an inflatable
finger cuff (FINAP) with a special device and has proven to be
feasible and reliable in adults. We studied prototype pediatric
finger cuffs and pediatric software to compare this blood pressure
measurement with intraarterially measured blood pressure (IAP) in
critically ill children.
METHODS: We included sedated and mechanically
ventilated children admitted to our pediatric intensive care unit.
We performed simultaneous arterial blood pressure measurements
during a relatively stable hemodynamic period and compared FINAP,
IAP, and the noninvasive blood pressure oscillometric technique. We
also compared IAP to a reconstruction of brachial pressure from
finger pressure.
RESULTS: Thirty-five children between 2 and 22 kg
body weight were included. In total, 152 attempts to record a FINAP
pressure were performed of which 4.6% were unsuccessful. When
comparing FINAP to IAP, bias was –16.2, –7.7, and –10.2 mm
Hg for systolic arterial blood pressure, diastolic arterial blood
pressure, and mean arterial blood pressure. Limits of agreement (LOA) were respectively
26.1%, 30.1%, and 22.6%. When reconstruction of brachial pressure
from finger pressure was compared to IAP, these results were –11.8,
0.6, and –0.9 mm Hg for bias and 21.7%, 8.9%, and 8.9% for LOA. When
noninvasive blood pressure oscillometric technique was compared to
IAP, the results were: –6.8, –0.9, and –3.8 mm Hg for
bias and 18.2%, 38.6%, and 22.1% for LOA.
CONCLUSION: Beta type continuous noninvasive arterial
blood pressure monitoring using a finger cuff with brachial arterial
waveform reconstruction seems reliable in hemodynamically stable critically
ill children.
Manual Versus
Target-Controlled Infusion Remifentanil Administration in Spontaneously
Breathing Patients
Annelies T.
Moerman, MD*, Luc L. Herregods, MD, PhD*, Martine M. De
Vos, MD, PhD_files/image018.gif){kind=small}
, Eric P. Mortier, MD, Dsc*, and Michel M. R. F. Struys, MD,
PhD
From the
Departments of *Anesthesiology and Gastro-Enterology, Ghent University
Hospital; Department of Anesthesiology, Ghent University, Gent, Belgium; and
Department of Anesthesiology, University Medical Center Groningen, University
of Groningen, Groningen, The Netherlands.
Anesth Analg 2009
108: 828-834
背景：聯合輸注丙泊酚及瑞芬太尼進行深度鎮靜時一項顯著的特點就是其頻繁發生的副作用，特別是呼吸抑制。這些副作用有可能是聯合應用這兩種藥物引起，也有可能是由輸注技術引起。而靶控輸注（TCI）可以將輸注技術最優化。我們希望在進行腸鏡檢查的病人中通過隨機雙盲對照來回答這樣兩個問題：第一，加用瑞芬太尼是否會增加其副作用？第二：同手控輸注相比，靶控輸注瑞芬太尼是否能減少副作用的發生？
方法：進行腸鏡檢查的病人被隨機分配接受人工控制輸注瑞芬太尼（MCI）（0.125µg每公斤每分鐘的速度輸注兩分鐘，然後以0.05µg每公斤每分鐘的速度持續輸注）、靶控輸注瑞芬太尼（1 ng/mL）或安慰劑（普通生理鹽水靶控輸注或同樣的速度手控輸注）。所有的病人都接受靶控輸注丙泊酚，靶濃度調整至能提供深度鎮靜，病人對口頭指令沒有反應，但是在沒有幫助的情況下保持自主通氣。
結果：很明顯，接受安慰劑組的病人更多地出現了體動、咳嗽、和呃逆，短暫的影響了檢查。三組間在血流動力學及恢復期的差異沒有臨床意義。通過靶控輸注瑞芬太尼減少了丙泊酚的用量。同人工控制輸注瑞芬太尼相比，靶控輸注瑞芬太尼時通氣不足及呼吸暫停的發生率下降。（TCI n = 7, MCI n =
16, P < 0.05）
結論：同單用丙泊酚相比，在保持自主呼吸的深度鎮靜病人中，聯用瑞芬太尼和丙泊酚能爲腸鏡檢查提供更好的條件。同人工控制輸注相比，靶控輸注瑞芬太尼減少了丙泊酚的用量，同時呼吸暫停和呼吸抑制的發生率更低（TCI n = 7, MCI n = 16,
P < 0.05）。
（姚敏敏譯 薛張綱校）
BACKGROUND: The combination of propofol-remifentanil for
procedural deep sedation in spontaneously breathing patients is
characterized by the frequent incidence of side effects, especially
respiratory depression. These side effects may be due to either the
drug combination or the drug delivery technique. Target-controlled
infusion (TCI) might optimize drug delivery. In this prospective, randomized,
double-blind study in patients undergoing elective colonoscopy, we
thus tried to answer two questions: first, if adding remifentanil to
propofol surpasses the disadvantages of the combination of these two
products, and second, if administration of remifentanil via TCI
decreases the incidence of side effects, compared to manually
controlled administration.
METHODS: Patients undergoing elective colonoscopy
were randomly assigned to receive remifentanil via manually
controlled continuous infusion (MCI) (0.125 µg · kg–1 ·
min–1 for 2 min followed by a continuous infusion of 0.05
µg · kg–1 · min–1), TCI remifentanil (1
ng/mL), or placebo (normal saline either as TCI or manual infusion
of equivalent rate). All patients received TCI propofol, adjusted to
a target concentration level that provided deep sedation in which
patients were not responsive to verbal commands, but maintained
spontaneous ventilation without assistance.
RESULTS: Significantly more patients in the placebo
group showed movement, cough and hiccup, which transiently
interfered with the examination. There were no clinically
significant differences in hemodynamic or recovery variables among
all groups. Remifentanil administered via TCI resulted in a decrease
in propofol requirements. The incidence of hypopnea and apnea was
less frequent when remifentanil was administered via TCI compared to
MCI (TCI n = 7, MCI n = 16, P < 0.05).
CONCLUSION: The combination of remifentanil and propofol
for deep sedation in spontaneously breathing patients, offered
better conditions for colonoscopy than propofol used as a single
drug. Remifentanil administered via TCI resulted in a decrease in
propofol dosing and in a lower incidence in apnea and respiratory depression
(TCI n = 7, MCI n = 16, P < 0.05), compared to manually
controlled administration of remifentanil.
A
Comparison of Propofol and Remifentanil Target-Controlled Infusions to
Facilitate Fiberoptic Nasotracheal Intubation
Alexandre Lallo,
MD, FRCPC*_files/image019.gif){kind=small}
, Valerie Billard, MD*, and Jean-Louis
Bourgain, MD*
From the
*Department of Anesthesiology, Institut Gustave Roussy, Villejuif, France; and _files/image020.gif){kind=small}
Department of Anesthesiology, Centre
Hospitalier de l’université de Montréal, Hopital Notre-Dame. Montréal, Quebec,
Canada.
Anesth Analg 2009
108: 852-857
介紹：成功的光纖下插管要求患者的舒適和良好的插管條件。在這個研究中我們比較異丙酚（P）和瑞芬太尼（R）靶控輸注（TCI）在光纖下氣管插管的效果和舒適程度。
方法：60名需要光纖下經鼻氣管插管的患者經隨機分配接受P或R靶控輸注。局部麻醉後，TCI一開始設置爲2.5 µg/mL (P) 和 1.5 ng/mL (R)，然後根據患者的反應增量，每次1 µg/mL (P) 和0.5 ng/mL (R)。目標血藥濃度和鎮靜水平在每一步都被記錄，以及在手術以後評估總藥量，調整次數，插管條件，患者不舒適和回憶。
結果：插管持續時間，成功率和藥物增加的次數在兩組之間並無差異。最終血藥濃度在3.9 ± 1.4 µg/mL (P)或2.4
± 0.8 ng/mL (R)(各自總量142 ± 55 mg 和77 ± 27 µg)之時,插管條件在兩組中同樣好。插管後最低的spO2和最高的呼末CO2沒有差別。沒有觀察到喉痙攣和重大的血流動力學改變。在P組中出現了一例由於阻塞性呼吸暫停引起的缺氧。P組的患者顯著的更鎮靜和不合作。在R組中回憶發生更頻繁，而疼痛分數在兩組中同樣低。
結論：R和P靶控輸注可以迅速滴定，取得良好的插管條件和患者的舒適。R使患者更合作，在保持自主呼吸非常重要時使氣管插管更安全。
（俞佳譯 薛張綱校）
INTRODUCTION: Successful fiberoptic intubation requires
both patient comfort and good intubating conditions. In this study we compared
the efficacy and ease of titration of propofol (P) and remifentanil (R) target-controlled
infusions (TCI) during fiberoptic intubation.
METHODS: Sixty patients requiring fiberoptic
nasotracheal intubation were randomized to receive (P) or (R) effect-site TCI.
After topical anesthesia, TCI was set to 2.5 µg/mL (P) or 1.5 ng/mL (R) then
titrated by 1 µg/mL (P) or 0.5 ng/mL (R) increments according to patient
reactions. Targets and level of sedation were recorded at each step as well as
total dose, number of adjustments, intubating conditions, discomfort, and
recall assessed after surgery.
RESULTS: Intubation duration, success rate, and
number of increments did not differ between groups. Intubating conditions were
good in both groups, with a final
target of 3.9 ± 1.4 µg/mL (P) or 2.4 ± 0.8 ng/mL (R) (total dose 142 ± 55 mg
and 77 ± 27 µg, respectively). There was no difference in minimal Spo2 and
maximal end-tidal CO2 after intubation. No laryngospasm or significant
hemodynamic instability was observed. There was one major hypoxemia due to
obstructive apnea in group P. Patients in group P were significantly more
sedated and less cooperative. Recall was more frequent in group R, whereas pain
scores were equally low in both groups.
CONCLUSION: Both R and P TCI can be rapidly titrated
to achieve good intubating conditions and patient comfort. R allows for more
patient cooperation, making it safer when spontaneous ventilation is paramount.
An Evaluation of
a Novel Software Tool for Detecting Changes in Physiological Monitoring
J. Mark Ansermino,
Jeremy P. Daniels, Randy T. Hewgill, Joanne Lim, Ping Yang, Chris J. Brouse,
Guy A. Dumont, and John B. Bowering From the *Department of Anesthesiology,
Pharmacology and Therapeutics, and _files/image021.gif){kind=small}
Electrical and Computer Engineering,
University of British Columbia, Vancouver, Canada.
Anesth Analg 2009
108: 873-880.
背景：我們已經開發了一種軟體工具（iAssist）協助臨床醫生在麻醉過程中監測生理資料以指導其醫療行爲。這個系統有跟蹤多種動態生理過程的統計性能和識別新的動態趨勢的能力。我們報道我們對這個工具的最新探索（在非第一時間）並將其對動態變化的探測結果與事後對動態變化的總體回顧進行了比較。我們假設了一個評價的綜合體，這個綜合體評價了旨在增強動態探測功能的監測設備。
方法：19名兒童和38名成人進入試驗，接受超過68小時的麻醉。在每個手術病例中，麻醉師在第一時間報告所有的監視器中已知的臨床變化。一個訓練有素的觀察者同時記錄口頭報告的變化和每個麻醉師的醫療行爲。同一個病例隨後由新型軟體工具（iAssist）離線評價。心率、呼末二氧化碳，潮氣量和呼吸頻率被用一個動態線性增長模型來模仿，這個模型的噪音分佈由一個適應性的卡爾曼濾波通過一個遞迴的期望最大化方法來估計。變化由自適應累積求和試驗來探測。無創平均動脈血壓和氧飽和度的變化通過一個從指數級重量移動平均濾波分離出來的濾波的自適應累積求和試驗來探測。在事後分析中，每個由iAssist探測到的變化被兩名臨床醫生用一個完整病例圖表的方式來獨立分級。遺漏的變化被記錄下來。
結果：iAssist軟體工具探測到896例真陽性變化（平均12.76/小時），敏感度0.91，陽性預測值0.87.事後回顧鑒定出91個遺漏的變化（平均1.34/小時），真陽性率與假陰性率的總比例爲9.55。臨床醫生第一時間報導了209個變化趨勢（平均3.07/小時）。
結論：該演算法與視覺觀測整個趨勢相比較執行起來更有優勢。需要進一步的研究，以確定何時以及如何提請臨床醫師注意這些變化。
（張玥琪譯，薛張綱校）
BACKGROUND: We have developed a software tool (iAssist)
to assist clinicians as they monitor the physiological data that guide their
actions during anesthesia. The system tracks the statistical properties of
multiple dynamic physiological processes and identifies new trend patterns. We
report our initial evaluation of this tool (in pseudo real-time) and compare
the detection of trend changes to a post hoc visual review of the full trend.
We suggest a combination of criteria by which to evaluate the performance of
monitoring devices that aim to enhance trend detection.
METHODS: Nineteen children and 28 adults consented
to be included in the study, encompassing more than 68 h of anesthesia. In each
surgical case, an anesthesiologist reported all perceived clinical changes in
monitoring in real-time. A trained observer simultaneously documented the
verbally reported changes and every anesthesiologist action. The same cases
were subsequently evaluated offline (in pseudo real-time) by a novel software
tool (iAssist). Heart rate, end-tidal carbon dioxide, exhaled minute
ventilation, and respiratory rate were modeled using a dynamic linear growth
model whose noise distribution was estimated by an adaptive Kalman filter based
on a recursive expectation-maximization method. Changes were detected by
adaptive local Cumulative Sum testing. Changes in the mean arterial noninvasive
blood pressures and oxygen saturation were detected using adaptive Cumulative
Sum testing on a filtered residual from an exponentially weighted moving
averaging filter. In post hoc analysis, each change detected by iAssist was
graded independently by two clinicians using a graphical display of the whole
case. Missed changes were recorded.
RESULTS: The iAssist software tool detected 869
true positive changes (at an average of 12.76/h) with a sensitivity of 0.91 and
positive predictive value of 0.87. The post hoc review identified 91 missed
changes (at an average of 1.34/h), resulting in an overall ratio of true
positive rates to false-negative rates of 9.55. The clinicians in real-time
reported 209 changes in trend (at an average of 3.07/h).
CONCLUSION: The algorithms perform favorably compared
with a visual inspection of the complete trend. Further research is needed to
identify when and how to draw the clinician's attention to these changes.
Changes in
functional residual capacity during weaning from mechanical ventilation: a
pilot study.
Heinze H, Sedemund-Adib B, Heringlake M, Meier T, Eichler W
.From the
*Department of Anesthesiology, Pharmacology and Therapeutics, and _files/image022.gif){kind=small}
Electrical and Computer Engineering,
University of British Columbia, Vancouver, Canada.
Anesth Analg 2009
108: 911-915.
背景：降低壓力支援（PSV）下呼氣末正壓（PEEP）水平的通氣模式常在氣管插管危重病人拔管前使用，但是PSV對於功能殘氣量（FRC）的有何影響尚不清楚。在這項研究中，我們試圖探尋心臟手術病人術後脫機期FRC和肺功能的變化。
方法：LUFU系統(Dräger Medical, Lübeck, Germany)通過使用旁流氧氣分析儀分析混有氮氣的呼出氣體中的氧氣來估計FRC。心臟手術病人術後首先使用雙相正壓通氣(BiPAP)，並附加10 mbar的PEEP。適當調整供氣壓力上限使潮氣量達到of 6-8 mL/kg (BIPAP 10)。30分鐘後，上壓和下壓限值均降低3 mbar (BIPAP 7)。當可測得患者自主呼吸時，將機械通氣模式轉換爲PSV下的持續氣道正壓通氣 (CPAP) 模式，並且使用之前與BIPAP相符合的壓力支援及壓力下限作爲CPAP的壓力水平。30分鐘後重復測量(CPAP 7_2)。
結果：10名患者入組研究，FRC減少(BIPAP 10: 3.6 [1.0]
L; BIPAP 7: 3.1 [0.9] L; CPAP 7_1: 2.9 [0.9] L; CPAP 7_2: 2.7 [0.6] L [Mean
(SD)]; 方差多變數分析: P = 0.017), PF率 (BIPAP 10: 420 [114] mm Hg; BIPAP 7: 405
[110] mm Hg; CPAP 7_1: 353 [70] mm Hg; CPAP 7_2: 340 [70] mm Hg [Mean (SD)]; 方差多變數分析: P = 0.045)。全程PaCO(2)無顯著性變化(P = 0.221)。
結論：在心臟手術脫管期間FRC的下降最終可以（部分） 用肺泡不張的原因來解釋。這種變化能否對脫管期間有指導意義仍然需要進一步研究。
（張釗譯 薛張綱校）
BACKGROUND: Reduction of high positive end-expiratory
pressure levels and pressure support ventilation (PSV) are frequently used
before tracheal extubation in critically ill patients, but the impact of PSV on
functional residual capacity (FRC) is unknown. In this study, we sought to
detect the changes of FRC and pulmonary function during a weaning protocol in
patients ventilated after cardiac surgery.
METHODS: The LUFU system (Dräger Medical, Lübeck,
Germany) estimates FRC by oxygen washout, a variant of multiple breath nitrogen
washout, using a sidestream O(2) analyzer. Postoperative cardiac surgery
patients were initially ventilated using biphasic positive airway pressure
ventilation (BiPAP) with a positive end-expiratory pressure of 10 mbar. The
upper pressure limit was adjusted to deliver a tidal volume of 6-8 mL/kg (BIPAP
10). After 30 min, the upper and lower pressure limits were both reduced by 3
mbar (BIPAP 7). When spontaneous breathing efforts were detected, ventilation mode
was switched to continuous positive airway pressure (CPAP) with PSV using the
former lower pressure limit as the CPAP level and the corresponding pressure
support of the former BIPAP adjustment (CPAP 7_1). Measurements were repeated
after 30 min (CPAP 7_2).
RESULTS: Ten patients were studied. FRC decreased
(BIPAP 10: 3.6 [1.0] L; BIPAP 7: 3.1 [0.9] L; CPAP 7_1: 2.9 [0.9] L; CPAP 7_2:
2.7 [0.6] L [Mean (SD)]; MANOVA: P = 0.017), as did PF ratio (BIPAP 10: 420
[114] mm Hg; BIPAP 7: 405 [110] mm Hg; CPAP 7_1: 353 [70] mm Hg; CPAP 7_2: 340
[70] mm Hg [Mean (SD)]; MANOVA: P = 0.045). PaCO(2) did not change
significantly over time (P = 0.221).
CONCLUSION: Decreasing FRC during the weaning process
after cardiac surgery may, at least in part, be explained by alveolar
derecruitment. Whether this variable could help guide a weaning protocol has to
be studied further.
The Teaching of
Professionalism During Residency: Why It Is Failing and a Suggestion to Improve
Its Success (Review
Article)
Robert R. Gaiser
From the Department
of Anesthesiology and Critical Care, Hospital of the University of
Pennsylvania, Philadelphia, Pennsylvania.
Anesth Analg 2009
108: 948-954.
專業化是住院醫師期間需要學習和被考核的主要內容之一。有綜述性文獻指出，專業化培訓並未得到完全地理解和實施。專業化培訓已經納入住院醫師教育計劃。但是，住院醫師有兩種學習途徑：明確安排的課程和潛移默化地學習。後者指住院醫師通過觀察院內同事所學到的行爲。這種潛移默化地學習對住院醫師專業行爲影響很大。針對這種情況，一項可以改進專業化培訓的措施不僅要包括主題學習，還應該給予個人思考各自知識和行爲的時間。這種自我反思有利於對專業的真正理解和實踐的發展，並可能提高專業能力。
（朱蘭芳譯 薛張綱）
Professionalism is
one of the core competencies to be taught and evaluated during residency.
A review of the literature suggests that professionalism is not
completely understood or practiced. The teaching of professionalism
has been incorporated into the educational programs for residents.
However, residents learn from two curriculums: the stated curriculum
and a hidden curriculum. The hidden curriculum represents the
actions observed by the resident of the faculty in the hospital. The
impact of this hidden curriculum upon professional behavior by the
resident is significant. Due to the hidden curriculum, a possible
means of improving professionalism involves the development of a
program for faculty. This program must include not only topics but
time for personal reflection of one’s knowledge and actions. Self-reflection
allows for the development of a true understanding and practice of
professionalism and may improve professional behavior.
Cerebral
Resuscitation After Cardiocirculatory Arrest
Andreas Schneider,
MD*, Bernd W. Böttiger, MD*, and Erik Popp, MD_files/image023.gif){kind=small}
From the
*Department of Anesthesiology and Postoperative Intensive Care Medicine,
University of Cologne, Germany; and _files/image024.gif){kind=small}
Department of Anesthesiology, University of
Heidelberg, Germany.
Anesth Analg 2009
108: 971-979.
對於心臟驟停的病人，經心肺復蘇可以恢復50％的自主迴圈。然而大多數病人在復蘇後最終仍然死亡了。死亡原因主要是由於全腦的缺血。因此有必要在心跳停止後進行一些針對保護和保存腦功能的治療。幾年前，低溫治療被用於臨床。在一項隨機臨床試驗中，上述方法是可以改善心跳停止病人的生存率及神經系統結局。除了低溫治療，臨床或試驗中還有其他一些治療方法。這些方法包括血栓溶解治療，輸注特殊藥物，抗細胞凋亡藥物。在這篇文獻中，我們回顧了不同方法的病理生理背景及對大腦復蘇的療效。
（陳珺珺譯 薛張綱校）
Cardiopulmonary
resuscitation can restore spontaneous circulation in up to 50% of
patients suffering from cardiac arrest. However, most of these
patients still die during the postresuscitation period. Mortality is
largely due to neuronal injury after global cerebral ischemia. There
is, therefore, a clear need for therapies, which restore and protect
brain function after cardiac arrest. Several years ago, mild
therapeutic hypothermia was introduced into clinical practice. It
represents the first treatment to improve both survival and
neurological outcome of patients after out-of-hospital cardiac
arrest, according to randomized clinical trials. In addition to
therapeutic hypothermia, various other therapeutic options are
currently being investigated experimentally and/or clinically. These
include thrombolytic therapy, specific infusion regimens, or
antiapoptotic drugs. In this article, we review both the
pathophysiological background and the efficacy of different measures that might be useful for
cerebral resuscitation.
Cytotoxicity of
Local Anesthetics in Human Neuronal Cells
Rosalia
Perez-Castro, MS*, Sohin Patel, MD*, Zayra V.
Garavito-Aguilar, BS*, Andrew Rosenberg, MD_files/image025.gif){kind=small}
, Esperanza Recio-Pinto, PhD*,
Jin Zhang, MD*, Thomas J. J. Blanck, MD, PhD*, and Fang
Xu, PhD*
From the
*Department of Anesthesiology, New York University School of Medicine; and _files/image026.gif){kind=small}
Department of Anesthesiology, NYU Hospital
for Joint Diseases, New York, New York.
Anesth Analg 2009
108: 997-1007.
背景：除了抑制外周神經的興奮傳導，局麻藥對中樞神經系統、心血管系統、神經肌接頭和細胞代謝有毒性作用。術後不同的神經系統的並發症與局麻藥的細胞毒性有關，但根本機制尚不清楚。由於臨床上應用局麻藥的濃度遠高於抑制離子通道的EC50，因此離子通道被阻滯不能解釋局麻藥所致的細胞死亡，應該有其他作用參與了細胞死亡。在我們的研究中，我們比較了6種我們常用的局麻藥的細胞毒性作用，從而討論其根本的毒性機制。
方法：人SH-SY5Y神經瘤細胞暴露於六種局麻藥（布比卡因、羅派卡因、甲派卡因、利多卡因、普魯卡因和氯普魯卡因），通過MTT-(3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl
tetra-odium bromide) 比色法測定生存的數量，通過熒光成像的方法，測定LIVE/DEAD®反應物(calcein/AM and ethidium homodimer-1)評估質量。 此外，通過FLICATM測定與細胞凋亡相關的caspase-3/-7的啟動。此外，還評估了局麻藥介導的去極化和氯化氨甲酰膽鹼激動引起的胞內Ca2+的反應。
結果：1）治療十分鐘後，所有六種局麻藥均可以濃度依賴性的降低細胞的存活率。它們的致死的能力爲普魯卡因≤甲派卡因＜利多卡因＜氯普魯卡因＜羅派卡因＜布比卡因（LD50，指50％的細胞死亡的濃度）。在這六種局麻藥中，只有布比卡因和利多卡因在增加濃度的情況下可以殺滅所有的細胞。2）布比卡因和利多卡因都可以啟動caspase-3/-7。Caspase的激動依賴于高濃度的利多卡因和布比卡因。此外，布比卡因啟動caspase的速率低於利多卡因。高濃度的利多卡因可以立刻啟動caspase，但是在濃度低於10mM時，不能顯著激動caspase。3）普魯卡因和氯普魯卡因可以濃度依賴性地抑制由去極化和受體激動介導的胞漿Ca2+的反應，這一現象在先前的有關布比卡因、羅派卡因、甲派卡因的利多卡因的研究中也觀察到。沒有一種局麻藥可以顯著增加基礎或Ca2+誘導胞漿Ca2+水平。
結論：局麻藥可以造成細胞的快速死亡，主要的原因是壞死。利多卡因和布比卡因可以時間或濃度依賴性的觸發細胞凋亡。這可能與術後神經系統損傷有關。利多卡因可以導致短暫的神經系統症狀，但並不是毒性最大的局麻藥；而布比卡因很少導致暫時的神經系統症狀卻是毒性最大的局麻藥。這提示了不同的局麻藥的細胞毒性導致的神經系統損傷有多種機制參與。
（陳珺珺譯 薛張綱校）
BACKGROUND: In addition to inhibiting the excitation
conduction process in peripheral nerves, local anesthetics (LAs)
cause toxic effects on the central nervous system, cardiovascular
system, neuromuscular junction, and cell metabolism. Different postoperative
neurological complications are ascribed to the cytotoxicity of LAs,
but the underlying mechanisms remain unclear. Because the clinical
concentrations of LAs far exceed their EC50 for
inhibiting ion channel activity, ion channel block alone might not
be sufficient to explain LA-induced cell death. However, it may
contribute to cell death in combination with other actions. In this
study, we compared the cytotoxicity of six frequently used LAs and
will discuss the possible mechanism(s) underlying their toxicity.
METHODS: In human SH-SY5Y neuroblastoma cells,
viability upon exposure to six LAs (bupivacaine, ropivacaine,
mepivacaine, lidocaine, procaine, and chloroprocaine) was
quantitatively determined by the MTT-(3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl
tetra-odium bromide) colorimetry assay and qualitatively confirmed by
fluorescence imaging, using the LIVE/DEAD® assay reagents (calcein/AM
and ethidium homodimer-1). In addition, apoptotic activity was
assessed by measuring the activation of caspase-3/-7 by imaging
using a fluorescent caspase inhibitor (FLICATM). Furthermore,
LA effects on depolarization- and carbachol-stimulated intracellular
Ca2+-responses were also evaluated.
RESULTS: 1) After a 10-min treatment, all six LAs
decreased cell viability in a concentration-dependent fashion. Their
killing potency was procaine _files/image028.gif){kind=small}
mepivacaine < lidocaine <
chloroprocaine < ropivacaine < bupivacaine (based on LD50,
the concentration at which 50% of cells were dead). Among these six
LAs, only bupivacaine and lidocaine killed all cells with increasing
concentration. 2) Both bupivacaine and lidocaine activated
caspase-3/-7. Caspase activation required higher levels of lidocaine
than bupivacaine. Moreover, the caspase activation by bupivacaine
was slower than by lidocaine. Lidocaine at high concentrations
caused an immediate caspase activation, but did not cause
significant caspase activation at concentrations lower than 10 mM.
3) Procaine and chloroprocaine concentration-dependently inhibited
the cytosolic Ca2+-response evoked by depolarization or
receptor-activation in a similar manner as a previous observation
made with bupivacaine, ropivacaine, mepivacaine, and lidocaine. None
of the LAs caused a significant increase in the basal and Ca2+-evoked
cytosolic Ca2+-level.
CONCLUSION: LAs can cause rapid cell death, which is
primarily due to necrosis. Lidocaine and bupivacaine can trigger
apoptosis with either increased time of exposure or increased
concentration. These effects might be related to postoperative
neurologic injury. Lidocaine, linked to the highest incidence of
transient neurological symptoms, was not the most toxic LA, whereas
bupivacaine, a drug causing a very low incidence of transient
neurological symptoms, was the most toxic LA in our cell model. This
suggests that cytotoxicity-induced nerve injury might have different
mechanisms for different LAs and different target(s) other than neurons.
苄呱酚醇導致的抗傷害感覺和降低慢性後根神經節壓縮小鼠的脊髓背角NR2B亞單位的表達
Ifenprodil
Induced Antinociception and Decreased the Expression of NR2B Subunits in the
Dorsal Horn After Chronic Dorsal Root Ganglia Compression in Rats
Wei Zhang, MD, Chang-Xi Shi, MD, Xiao-ping Gu, MD, PhD, Zheng-Liang Ma, MD, PhD, and Wei Zhu, MD
From the Department of Anesthesiology, Drum Tower Hospital, Medical Department of Nanjing University, Jiangsu Province, China.
Anesth Analg 2009
108: 1015-1020.
背景：脊髓N-右旋甲基－天冬氨酸在神經性疼痛的發病機制中起了重要的作用，給予N-右旋甲基－天冬氨酸受體拮抗劑可以減弱這種痛覺過敏。苄呱酚醇是N-右旋甲基－天冬氨酸受體2B(NR2B)的選擇性拮抗劑。有一些研究證明，在動物實驗中，苄呱酚醇對神經性疼痛有鎮痛作用。我們將這方面的研究延伸至後根神經節慢性壓縮（CCD）引起的反應。
方法：我們通過測試小鼠手掌對機械刺激和溫度刺激反應閾值變化，來評估CCD小鼠在鞘內注射苄呱酚醇後對機械刺激和溫度痛覺過敏的情況。我們使用了免疫組化和免疫印迹的方法來研究苄呱酚醇對CCD小鼠NR2B亞單位表達的影響。
結果：這些資料揭示了，在CCD小鼠上，脊髓背角表面NR2B的表達有所增加。我們發現，除了抑制對溫度和機械刺激的痛覺反應，鞘內注射苄呱酚醇還可以抑制脊髓NR2B的表達。
結論：這些資料表明，在CCD小鼠身上，苄呱酚醇可以對抗傷害性感覺，並進一步證明NR2B與神經性疼痛有關。
（陳珺珺譯 薛張綱校）
BACKGROUND: Spinal N-methyl d-aspartate receptors play an important role in the pathogenesis of neuropathic pain, and administration of N-methyl d-aspartate receptor antagonists can attenuate this hyperpathia. Ifenprodil is an antagonist selective for N-methyl d-aspartate receptor 2B (NR2B) subunits. Several researches have reported effective analgesia of ifenprodil in animal models of neuropathic pain. We extended this work to include chronic compression of the dorsal root ganglia (CCD).
METHODS: The paw withdrawal mechanical threshold and paw withdrawal thermal latency tests were used to assess mechanical allodynia and thermal hyperalgesia after a CCD operation and intrathecal injection of ifenprodil. We used immunohistochemistry and immunoblotting to investigate the effect of ifenprodil on NR2B subunits expression in CCD rats.
RESULTS: The data revealed increased expression of NR2B subunits in the superficial dorsal horn in CCD rats. We found that, in addition to a marked suppression of thermal hyperalgesia and mechanical allodynia, intrathecal injection ifenprodil treatment causes a decreased expression of NR2B in the spinal cord.
CONCLUSIONS: These data suggest that ifenprodil induced anti nociception in CCD rats and provided further evidence for the important role of NR2B subunits in the development of neuropathic pain.
Ultrasound-Guided
Obturator Nerve Block: A Sonoanatomic Study of a New Methodologic Approach
Taylan Akkaya, MD*,
Emine Ozturk, MD_files/image030.gif){kind=small}
, Ayhan Comert, MD_files/image032.gif){kind=small}
, Yesim Ates, MD_files/image034.gif){kind=small}
, Haluk Gumus, MD*, Halil Ozturk,
MD_files/image035.gif){kind=small}
, Ibrahim Tekdemir, MD_files/image036.gif){kind=small}
, and Alaittin Elhan, MD_files/image037.gif){kind=small}
From the
Departments of *Anesthesia and Pain Unit, _files/image038.gif){kind=small}
Radiology, Ministry of Health Diskapi Y_files/image040.jpg){kind=small}
ld_files/image041.jpg){kind=small}
r_files/image042.jpg){kind=small}
m Beyaz_files/image043.jpg){kind=small}
t Research and Educational Hospital,
Ankara-Turkey; Departments of _files/image044.gif){kind=small}
Anatomy, and _files/image045.gif){kind=small}
Anesthesiology and Reanimation, Ankara
University, Ankara-Turkey.
Anesth Analg 2009
108: 1037-1041.
背景：閉孔神經阻滯是對技術有最高挑戰性的區域阻滯中的一種。最近，通過超聲手段描述了神經的特性。然而，臨床上尚沒有應用超聲引導下對病人進行閉孔神經阻滯的報道。在我們的研究中，我們使用了超聲手段，分別對屍體、志願者及病人的閉孔神經及其兩分支的解剖位置進行描述。
方法：通過超聲對屍體進行研究，高回聲三角區由恥骨支上緣，恥骨肌內側緣和閉孔肌的外側緣組成，其中包括閉孔血管和神經。在八名志願者中，我們獲得了兩根閉孔神經的影像學及其到特定標誌的距離（股動脈、股靜脈和恥骨結節）。通過先前確定的進路，在超聲引導下對15名病人進行了閉孔神經阻滯。我們記錄了針尖到股動脈的距離，穿刺點到恥骨結節的距離和進針深度。
結果：在志願者上，通過超聲可見閉孔神經主幹、前後分支的的比例分別是12/16,13/16和7/16。在志願者身上獲得的特定標誌間的距離分別是：閉孔神經-股靜脈爲12.9 ± 2.9 mm ，閉孔神經-恥骨結節爲19.9 ± 2.6 mm。在病人身上獲得的測量資料爲：股動脈-針尖距離爲 18.5 ± 2.4 mm,進針深度爲 48.3 ± 10.4 mm,恥骨結節- 穿刺點的水平距離爲 18.8 ± 2.0 mm,恥骨結節-穿刺點的垂直距離爲 21.1 ± 2.9 mm。與基礎值相比，在病人處得到的直觀類比標度計分較低。93%的病人（15人中14人）對阻滯的效果表示滿意。
結論：在超聲引導下，可以通過標誌對病人進行閉孔神經阻滯。
（陳珺珺譯 薛張綱校）
BACKGROUND: Obturator nerve block is one of the most
technically challenging regional anesthesia techniques. Recently,
the characteristics of the nerve have been described using
ultrasound. However, clinical application of proximal
ultrasound-guided obturator nerve block on patients has not been
reported. In this study, we used ultrasound to describe the
anatomical localization of the obturator nerve and its two branches
in cadavers, volunteers, and also patients.
METHODS: A hyperechoic triangular shape formed by the
superior pubic ramus,
posterior margin of the pectineus muscle and anterior aspect of the
external obturator muscle containing the obturator vessels and nerve
was defined by ultrasound imaging in cadavers. In eight volunteers,
bilateral obturator nerve images were obtained and the distances to
specific landmarks (femoral artery, femoral vein, and pubic
tubercle) were recorded. Ultrasound-guided obturator nerve block was
further performed in 15 patients by using the previously defined
approach. The final distance of the needle tip to the femoral
artery, distances between the needle insertion point to the pubic
tubercle and the depth of needle insertion were recorded.
RESULTS: The rates of common obturator nerve,
anterior and branching obturator nerve pattern visibility with
ultrasound were determined in 12/16, 13/16, and 7/16 sites in
volunteers, respectively. Mean (sd) values of critical landmarks
obtained from volunteers were obturator nerve-femoral vein 12.9 ± 2.9 mm and obturator nerve-pubic tubercle
19.9 ± 2.6 mm.
Mean measurements obtained from patients were: femoral artery- needle
tip 18.5 ± 2.4 mm, needle depth
48.3 ± 10.4 mm, pubic tubercle- needle insertion
point (horizontal) 18.8 ± 2.0 mm, and pubic tubercle- needle insertion point (vertical)
21.1 ± 2.9 mm. Visual analog
scale scores obtained from patients at 1 and 24 h were lower
compared to baseline values (P < 0.001). Ninety-three percent (14 of 15) of the patients
reported satisfaction from the block.
CONCLUSIONS: Landmarks defined in this clinical trial can
be used in patients for obturator nerve block with ultrasound
guidance.
快通道麻醉與心臟手術：7989例患者的回顧性佇列研究
Fast-Track
Anesthesia and Cardiac Surgery: A Retrospective Cohort Study of 7989 Patients
Vesna Svircevic, MD*,
Arno P. Nierich, MD, PhD_files/image046.gif){kind=small}
, Karel G. M. Moons, PhD*_files/image047.gif){kind=small}
, George J. Brandon Bravo Bruinsma, MD, PhD_files/image048.gif){kind=small}
, Cor J. Kalkman, MD, PhD*, and
Diederik van Dijk, MD, PhD*||
From the
*Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The
Netherlands; _files/image049.gif){kind=small}
Department of Anesthesiology, Isala Clinics,
Groot Weezenland 20, Zwolle, The Netherlands; _files/image050.gif){kind=small}
Julius Center for Health Sciences and
Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; _files/image051.gif){kind=small}
Department of Cardiothoracic Surgery, Isala
Clinics, Groot Weezenland 20, Zwolle, The Netherlands; and ||Department of
Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Anesth Analg 2009
108: 727-733.
背景：快通道心臟麻醉（FTCA）已被廣泛地應用於臨床，但它的安全性還沒有得到強有力的研究支援。
方法：作者比較了FTCA患者及既往常規大劑量阿片類藥物心臟麻醉（CCA）的患者的預後。主要預後指標爲住院期間死亡率。次要預後指標爲住院期間急性心肌梗死、腎衰及中風的發生率。同時比較機械通氣的持續時間，ICU住院天數以及術後住院天數。
結果： CCA組4020例，FTCA組3969例。FTCA組病人年齡略大，較多並存疾病及較多的換瓣手術。住院期間死亡率CCA組爲1.9%，FTCA2.3%。FTCA組CCA組與死亡率比值爲1.20（95%區間，0.65-1.32，P=0.66），調整後比值爲0.92。住院期間心肌梗死率CCA組5.2%，FTCA組5.5%（P=0.61）,中風發生率CCA組0.9%,FTCA組1.3%(P=0.06),腎衰發生率組間相當（0.8%，P=0.84）。FTCA組機械通氣時間短於CCA組（6vs12h，P _files/image052.gif){kind=small}
0.001），但ICU入駐時間平均值要比CCA組長1小時（23vs22h，P _files/image053.gif){kind=small}
0.001）。雖然兩組的住院時間平均值都是6 天，但CCA組第90百分位病人的住院天數爲13 天，FTCA組爲18 天（P _files/image054.gif){kind=small}
0.001）。
結論： 源自7989例心臟手術病人的資料顯示沒有證據表明應用FTCA增加不良後果的風險。
（鄭麗 譯 陳傑 校）
BACKGROUND: Fast-track cardiac anesthesia (FTCA) has
been widely implemented but its safety has not been evaluated in
sufficiently powered studies.
METHODS: We compared outcomes of patients undergoing
FTCA with a historical control group undergoing conventional
high-dose opioid cardiac anesthesia (CCA). The primary outcome measure
was the incidence of in-hospital mortality. Secondary outcome measures
were the incidence of in-hospital acute myocardial infarction, renal
failure, and stroke. We also compared duration of mechanical
ventilation and length of hospitalization in the intensive care unit
and postoperative ward.
RESULTS: The CCA group comprised 4020 patients and
the FTCA Group 3969 patients. The patients in the FTCA group were
slightly older, had more comorbidities, and were more likely to
undergo valve surgery than the CCA group. The incidence of
in-hospital mortality was 1.9% in the CCA group and 2.3% in the FTCA
group. Compared with the CCA group, the crude odds ratio for
mortality in the FTCA group was 1.20 (95% confidence interval
0.88–1.64, P
= 0.25) and the adjusted odds ratio was 0.92 (95% confidence interval,
0.65–1.32, P = 0.66).
The incidence of myocardial infarction and stroke in the CCA and
FTCA groups were 5.2% and 5.5% (P = 0.61), and 0.9% and 1.3%, (P = 0.06), respectively, whereas
the incidence of acute renal failure was similar in both groups
(0.8%, P = 0.84). The
duration of mechanical ventilation was shorter in the FTCA patients
compared with the CCA group (6 vs 12 h, P _files/image055.gif){kind=small}
0.001), but their median intensive care stay
was 1 h longer (23 vs 22 h, P _files/image056.gif){kind=small}
0.001). Although the median duration of
hospitalization was 6.0 days in both groups, the 90th percentile of
the hospitalization time was 13 days in the CCA group and 18 days in
the FTCA group (P _files/image057.gif){kind=small}
0.001).
CONCLUSIONS: These data from 7989 cardiac surgical
patients showed no evidence of an increased risk of adverse outcomes
in patients undergoing FTCA.
The Effects of
Fibrinogen Levels on Thromboelastometric Variables in the Presence of
Thrombocytopenia
Thomas Lang, MD*_files/image058.gif){kind=small}
, Kai Johanning, MD*, Helfried
Metzler, MD_files/image059.gif){kind=small}
, Siegfried Piepenbrock, MD*,
Cristina Solomon, MD*, Niels Rahe-Meyer, MD, PhD*, and
Kenichi A. Tanaka, MD, MSc_files/image060.gif){kind=small}
From the
*Department of Anesthesiology, Medical School, Hannover, Germany; _files/image061.gif){kind=small}
Werlhof Institut, Hannover, Germany, _files/image062.gif){kind=small}
Department of Anesthesiology, University
Medical School, Graz, Austria; and _files/image063.gif){kind=small}
Department of Anesthesiology, Emory
University School of Medicine, Atlanta, GA.
Anesth Analg 2009
108: 751-758.
背景：纖維蛋白原和纖維蛋白與血小板結合在正常的止血過程中非常重要。ROTEM法常用於測量血凝塊粘彈性強度以衡量血小板纖維蛋白結合的程度。在這個研究中，作者用ROTEM法研究纖維蛋白原濃度及其在總血塊強度中的作用。
方法：採集健康志願者血液標本。血小板計數對血凝塊強度〔通過測量血凝塊最大彈性（MCE）〕的影響通過ROTEM評估。富含血小板血漿（PRP）用自體血漿調節到一般水平血小板計數再測量。PRPs被調整爲10 x 103 mm–3 ，50 x 103 mm–3，100 x 103 mm–3，纖維蛋白原濃度集中在550和780mg/dl。用FIBTEM法在不依賴血小板附著作用下分析纖維蛋白對血塊的聚合作用。另外回顧性分析兩組中血小板減少患者血塊強度（MCE）。
結果：血塊強度在血小板計數低於100 x 103 mm–3時減少，計數多於400 x 103 mm–3時血塊強度增強。即使在低血小板計數(10 x 103 mm–3)時，增加纖維蛋白原濃度呈濃度依賴性增加血凝塊強度。在904例血小板減少患者分析獲得的資料證實了血凝塊強度和血漿纖維蛋白原水平呈正相關。
結論：用ROTEM法分析體外及臨床資料表明：纖維蛋白原濃度是獨立於血小板計數之外的血栓強度影響因素。在血小板減少症的患者中維護纖維蛋白原濃度是至關重要。EXTEM和FIBTEM在指導纖維蛋白原補充治療中有重要意義。
（劉世文 譯 陳傑 校）
BACKGROUND: The binding of fibrinogen and fibrin to
platelets is important in normal hemostasis. The extent of
platelet-fibrin interaction can be measured as the viscoelastic
strength of clot by rotational thromboelastometry (ROTEM®). In this
study, we investigated the effect of fibrinogen concentration and
its relative contribution to overall clot strength using ROTEM.
METHODS: Blood samples were collected from healthy
volunteers. The effects of platelet count on clot strength,
determined by maximum clot elasticity (MCE), were evaluated on ROTEM
using platelet-rich plasma (PRP) adjusted with autologous plasma to
generate a range of platelet counts. PRPs were adjusted to 10 x
103 mm–3, 50 x 103 mm–3, and 100 x
103 mm–3 and spiked with fibrinogen concentrates at 550
and 780 mg/dL. The effect of fibrin polymerization on clot strength,
independent of platelet attachment, was analyzed by the cytochalasin
D-modified thromboelastometry (FIBTEM®) method. Additional
retrospective analysis of clot strength (MCE) in two groups of
thrombocytopenic patients was conducted.
RESULTS: Clot strength (MCE) decreased at a platelet
count below 100 x 103 mm–3, whereas increases
in MCE peaked and reached a plateau at platelet counts from 400 x 103
mm–3. Increasing fibrinogen concentrations in PRP
increased clot strength in a concentration-dependent manner, even at
low platelet counts (10 x 103 mm–3). The
positive correlation between clot strength and plasma fibrinogen
level was also confirmed in the analysis of the data obtained from
904 thrombocytopenic patients.
CONCLUSIONS: These in vitro and clinical data indicate that the
clot strength increases in a fibrinogen concentration-dependent manner
independent of platelet count, when analyzed by ROTEM. The
maintenance of fibrinogen concentration is critical in the presence
of thrombocytopenia. EXTEM® (extrinsic activation) and FIBTEM may be
useful in guiding fibrinogen repletion therapy.
Transfusion-Related
Acute Lung Injury: Current Concepts for the Clinician
Darrell J. Triulzi,
MD
From the Department
of Pathology, Division of Transfusion Medicine, University of Pittsburgh
Medical Center, Institute for Transfusion Medicine, Pittsburgh, Pennsylvania.
Anesth Analg 2009
108: 770-776.
在美國輸血相關的發病率和死亡率的首要原因是輸血相關的急性肺損傷(TRALI)。TRALI診斷標準爲：在可以排除心衰或血管容量負荷過重的情況下，輸血6小時內的發生的缺氧和雙肺水腫。主要的鑒別診斷是輸血相關迴圈超負荷。支援治療的方法包括給氧和機械通氣。利尿並無特效，激素的作用也未證實。患者通常數天內痊愈。所有類型的血液製品都曾與急性肺損傷相關。但是，富含血漿成分的製品，如新鮮冰凍血漿和血漿分離置換法血小板，最常發生。目前尚不能完全解釋急性肺損傷的發病機制。多數情況下與針對人類白細胞抗原（ HLA ） I類/人類白細胞抗原II類或中性粒細胞特異性抗原[尤其是HNA- 3A型]的抗體， 和供血者血漿裏的白細胞抗體有關。肺血管內皮細胞的活化是導致急性肺損傷的重要因素，可能解釋了手術或重症監護病房裏觀察到的患者的大多數情況。輸血中的白細胞凝集抗體結合肺血管內皮細胞局部的中性粒細胞，導致啟動和釋放氧化酶和其他有害生物活性物質，造成毛細血管滲漏。在少數急性肺損傷中下，不能證實存在抗體，則假定輸注的血液成分裏的中性粒細胞促發因素可以調節急性肺損傷患者肺血管內皮活化，所謂的“兩次打擊”的機制。對抗白細胞抗體作用的進一步認識，以減少了引起急性肺損傷風險。曾經懷孕過一次的女性血液中常常帶有HLA抗體，總患病率爲24 ％，其發生概率隨曾經懷孕的次數而遞增。自從認識到HLA抗體同急性肺損傷有關，中心血站已採取策略是主要從男性的捐助者獲取血漿成分。爲了降低機采血小板相應的風險，採取事先檢測女性血小板捐助者的HLA抗體。需要更進一步的研究來瞭解導致急性肺損傷相關血液成分和患者的危險因素，推廣新的治療方案和措施，以減少發生急性肺損傷的風險。
（葉樂 譯 陳傑 校）
The leading cause
of transfusion-related morbidity and mortality in the United States
is transfusion-related acute lung injury (TRALI). Diagnostic
criteria for TRALI have recently been developed and primarily
consist of hypoxia and bilateral pulmonary edema occurring during or
within 6 h of a transfusion in the absence of cardiac failure or
intravascular volume overload. The primary differential diagnosis is
transfusion-associated circulatory overload and differentiation can
be difficult. Treatment is supportive with oxygen and mechanical
ventilation. Diuresis is not indicated and the role of steroids is
unproven. Patients typically recover within a few days. All types of
blood products have been associated with TRALI, however, the plasma-rich
components, such as fresh frozen plasma and apheresis platelets,
have been most frequently implicated. The pathogenesis of TRALI is
not completely understood. Leukocyte antibodies in donor plasma
have been implicated in most cases with antibodies directed at
human leukocyte antigen (HLA) class I, HLA class II or neutrophil-specific
antigens, particularly HNA-3a. Activation of pulmonary endothelium is
important in the development of TRALI and may account for most cases
being observed in surgical or intensive care unit patients.
Transfused leukoagglutinating antibodies bind to recipients’ neutrophils
localized to pulmonary endothelium resulting in activation and
release of oxidases and other damaging biologic response modifiers
that cause capillary leak. In a minority of TRALI cases, no
antibodies are identified and it is postulated that neutrophil
priming factors in the transfused component can mediate TRALI in a
patient with pulmonary endothelial activation, the so called
"two hit" mechanism. Recognition of the role of anti-leukocyte
antibodies has led to new strategies to reduce the risk of TRALI.
Female blood donors with a previous pregnancy frequently have HLA
antibodies with an overall prevalence of 24% and increasing
prevalence related to the number of previous pregnancies. Since HLA
antibodies have been implicated in TRALI, blood centers have adopted
policies to produce plasma components primarily from male donors.
Strategies to reduce the risk from apheresis platelets are
problematic and are likely to involve testing female apheresis
platelet donors for HLA antibodies. Much more research is needed to
understand the blood component and patient risk factors for TRALI so
that novel strategies for treatment and additional measures to
reduce the risk of TRALI can be developed.
4左旋布比卡因和羅呱卡因用於小兒骶管麻醉的相對鎮痛效應
Relative
Analgesic Potencies of Levobupivacaine and Ropivacaine for Caudal Anesthesia in
Children
Pablo Ingelmo, MD*,
Geoff Frawley, MD_files/image064.gif){kind=small}
, Marinella Astuto, MD*, Chris
Duffy, MD_files/image065.gif){kind=small}
, Susan Donath, PhD_files/image066.gif){kind=small}
, Nicola Disma, MD_files/image067.gif){kind=small}
, Giuseppe Rosano, MD_files/image068.gif){kind=small}
, Roberto Fumagalli, MD*, and
Antonio Gullo, MD_files/image069.gif){kind=small}
From the
*Department of Perioperative Medicine and Intensive, A.O. San Gerardo, Monza,
Dipartimento di medicina sperimentale ambientale e biotecnologie mediche, Università
degli Studi Milano Bicocca, Milan, Italy; _files/image070.gif){kind=small}
Department of Paediatric Anesthesia and Pain
Management, Royal Children’s Hospital. Melbourne Australia; _files/image071.gif){kind=small}
Clinical Epidemiology and Biostatistics
Unit, Murdoch Children’s Research Institute, University of Melbourne Australia;
and _files/image072.gif){kind=small}
Department of Anesthesia, A.O.U. Policlinico
Catania, Università degli Studi di Catania, Italy.
Anesth Analg 2009
108: 805-813.
背景：目前尚無新型局部麻醉劑左旋布比卡因和羅呱卡因骶管麻醉最小鎮痛濃度的相對效應比較研究。本文作者進行了一項前瞻性，隨機，雙盲研究，以確定在兒童骶管單次羅呱卡因和左旋布比卡因最低鎮痛濃度和劑量反應曲線。
方法：前瞻性、隨機、雙盲研究比較兒童骶管羅呱卡因和左旋布比卡因鎮痛的劑量反應曲線。第一部分， 80名男童隨機接受羅呱卡因或左旋布比卡因。第二部分，32名患者隨機接受劑量爲ED50-ED95 範圍內50%有效劑量以描繪劑量反應曲線。
結果：以羅呱卡因和左旋布比卡因行骶管阻滯的ED50無顯著差異。以狄克遜法估計左旋布比卡因ED50是0.069 ％ （ 95 ％ CI爲0.056 ％ -0.082 ％ ）和羅呱卡因是0.075 ％ （ 95 ％ CI爲0.058 ％ -0.092 ％ ） 。左旋布比卡因等張回歸法ED50和ED95分別爲0.068（ 0.04-0.09 ）和0.20 ％ （ 95 ％ CI爲0.16 ％ -0.24 ％ ） 。羅呱卡因ED50和ED95分別爲0.066 （ 0.033-0.098 ）和0.225 ％ （ 95 ％ CI爲0.21 ％ -0.24 ％ ） 。
結論：兒童接受一個MAC的七氟醚下，左旋布比卡因和羅呱卡因骶管阻滯ED50沒有顯著性差異的。ED50藥效比爲0.92和ED95藥效比爲0.89 ，表明左旋布比卡因和羅呱卡因在骶管麻醉時有相似的效力。
（張磊 譯 陳傑 校）
BACKGROUND: Comparing relative potency of new local
anesthetics, such as levobupivacaine and ropivacaine, by the minimum
local analgesic concentration model has not been described for
caudal anesthesia. Therefore, we performed a prospective,
randomized, double-blind study to determine the minimum local
analgesic concentrations of a caudal single shot of ropivacaine and
levobupivacaine in children and to describe the upper dose-response
curve.
METHODS: We performed a two-stage prospective,
randomized, double-blind study comparing the dose-response curves of
caudal ropivacaine and levobupivacaine in children. In phase 1, 80
boys were randomized to receive either ropivacaine or levobupivacaine.
In the second phase a further 32 patients were randomly allocated to
receive caudal anesthesia with doses designed to delineate the upper
dose-response range (the 50% effective dose [ED50]-ED95
range).
RESULTS: There were no significant differences in ED50
values for caudal ropivacaine and levobupivacaine. The ED50
for levobupivacaine estimated from the Dixon Massey method was
0.069% (95% CI 0.056%-0.082%) and for ropivacaine was 0.075% (95% CI
0.058%-0.092%). Estimated by isotonic regression the ED50
and ED95 respectively of levobupivacaine were 0.068
(0.04-0.09) and 0.20% (95% CI 0.16%-0.24%). For ropivacaine ED 50
and ED95 were 0.066 (0.033-0.098) and 0.225% (95% CI 0.21%-0.24%).
CONCLUSIONS: In children receiving one minimum alveolar
anesthetic concentration of sevoflurane, there were no significant
differences in the ED50 for caudal levobupivacaine and
ropivacaine. The potency ratio at ED50 was 0.92 and 0.89
at ED95, indicating that caudal levobupivacaine and
ropivacaine have a similar potency.
高鐵血紅蛋白症與局麻藥關係：242例個案的總結
Methemoglobinemia
Related to Local Anesthetics: A Summary of 242 Episodes
Joanne Guay, MD,
FRCPC
From the Department
of Anesthesia, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal
Canada.
Anesth Analg 2009
108: 837-845.
背景：本文的目的是總結在醫學文獻中有關局部麻醉劑相關高鐵血紅蛋白血症的個案。
方法：作者用以下的關鍵字：“局部麻醉劑”和“高鐵血紅蛋白血症”在美國國立圖書館的醫學文獻中進行了檢索。
結果：共有242個個案（ 40.1 ％刊登在2000年或之後）。紅褐色的血液表明高鐵血紅蛋白血症，但其他顔色可能會被發現。在91.8%的個案中脈搏血氧儀飽和度（ 小於或等於 90
％ ）與動脈血氧分壓（ 大於或等於 70毫米汞柱）存在偏差。用脈搏血氧儀測定的血氧飽和度和共同血氧飽和度之間的差異從-6.2
％至44.7
％ 。6個月以上的兒童使用劑量超過2.5 mg/kg的單純丙胺卡因可誘導高鐵血紅蛋白血症。在成人，丙胺卡因的劑量應低於5.0mg/kg.，存在腎功能不全時減少到3.2 mg/kg.和如果同時使用其他氧化藥物時減少到1.3 mg/kg.。一個單純苯佐卡因噴霧劑可能導致高鐵血紅蛋白血症。在相對較低的血紅蛋白值時可以觀察到臨床症狀，包括32.2%的兒童和29.1 ％的成人出現昏迷。在給予亞甲藍後，59.9
％患者出現反彈性高鐵血紅蛋白血症並持續18h。高鐵血紅蛋白血症的並發症包括缺氧性腦病，心肌梗塞和死亡。
結論：苯佐卡因不應繼續使用；丙胺卡因不應使用於6個月以下兒童，孕婦，或服用其他氧化藥物的病人。其他患者應用劑量應限制在2.5 mg/kg以內。
（張燕 譯 陳傑 校）
BACKGROUND: The purpose of this article is to summarize
all episodes of local anesthetic-related methemoglobinemia found
in the medical literature.
METHODS: I performed a search of the American
National Library of Medicine's PubMed with the following key words:
"local anesthetic" and "methemoglobinemia."
RESULTS: Two-hundred-forty-two episodes (40.1%
published in year 2000 or after) were found. Chocolate-colored blood
suggests methemoglobinemia but other colors may be found. A
discrepancy between the pulse oximeter saturation (_files/image073.gif){kind=small}
90%) and the arterial oxygen partial
pressure (_files/image075.gif){kind=small}
70 mm Hg) was present in 91.8% of the episodes.
The difference between oxygen saturation measured by pulse oximetry
and co-oximetry varied from –6.2% to 44.7%. Plain prilocaine may
induce clinically symptomatic methemoglobinemia in children older
than 6 mo at doses exceeding 2.5 mg/kg. In adults, the dose of
prilocaine should be kept lower than 5.0 mg/kg, which is reduced to
3.2 mg/kg in the presence of renal insufficiency and to 1.3 mg/kg if
other oxidizing drugs are used concurrently. A single spray of
benzocaine may induce methemoglobinemia. Clinical symptoms may be
observed at relatively low methemoglobin values, including coma at
32.2 and 29.1% in children and adults, respectively. Rebound
methemoglobinemia (benzocaine on mucous membranes) with
methemoglobin values as high as 59.9% may occur up to 18 h after
methylene blue administration. Complications of methemoglobinemia
include hypoxic encephalopathy, myocardial infarction, and death.
CONCLUSION: Benzocaine should no longer be used.
Prilocaine should not be used in children younger than 6-mo-old, in
pregnant women, or in patients taking other oxidizing drugs. The
dose should be limited to 2.5 mg/kg.
大鼠氙氣預處理：促存活信號、線粒體滲透性轉變和生物能學的作用
Xenon
Preconditioning: The Role of Prosurvival Signaling, Mitochondrial Permeability
Transition and Bioenergetics in Rats
Yasushi Mio, MD*_files/image076.gif){kind=small}
, Yon Hee Shim, MD*, Ebony
Richards, BS*, Zeljko J. Bosnjak, PhD*, Paul S. Pagel,
MD, PhD*, and Martin Bienengraeber, PhD*_files/image077.gif){kind=small}
From the
*Department of Anesthesiology, Medical College of Wisconsin, Milwaukee,
Wisconsin; _files/image078.gif){kind=small}
Department of Anesthesiology, Jikei
University School of Medicine, Tokyo, Japan; and _files/image079.gif){kind=small}
Department of Pharmacology and Toxicology,
Medical College of Wisconsin, Milwaukee; Wisconsin.
Anesth Analg 2009
108: 858-866.
背景：揮發性麻醉惰性氣體氙氣對心臟缺血/再灌注損傷具有保護作用，但對這一現象的機制並不完全理解。作者測試了氙氣啟動促存活信號激酶這一目標線粒體來誘發心肌保護這一假設。
方法：雄性Wistar大鼠在血流動力學監測下接受30min左冠狀動脈前降支阻塞和2 h再灌注。大鼠隨機接受70 ％ 氮氣/30 ％的氧氣（對照組）或三個周期的吸入70 ％ 氙氣/30 ％氧氣5min間隙吸入氧/氮混合氣體5min。使用三苯染色測量心肌梗死面積。對照組和氙氣處理組大鼠的離體心臟用於磷酸化Akt和GSK - 3β的Western免疫印迹和孤立的線粒體。線粒體缺氧/複氧前後的氧耗決定了線粒體通透性轉換孔的開放。
結果：與對照組相比，氙氣顯著減少心肌梗死面積（ 32
± 4和59 ％ ± 4 ％，P < 0.05 ）和增加磷酸化Akt和GSK- 3β 。與對照組相比，氙氣預處理保存分離線粒體的呼吸狀態。氙氣預處理組誘導線粒體膜去極化所需的Ca2 +濃度較大（分別爲 78 ± 17和56 ± 17 μm） 。磷酸肌醇-3激酶的抑制劑wortmannin阻止了氙氣對梗死面積和呼吸的效應。
結論：結果表明，氙氣預處理減少心肌梗死面積， 磷酸化 Akt和GSK-3β，維護線粒體功能，抑制鈣離子誘導的線粒體通透性轉換孔開放。這些資料表明，氙氣誘導心臟保護的發生，是因爲啟動促存活線粒體，並使它們更不容易受到缺血再灌注損傷。
（舒慧剛 譯 陳傑 校）
BACKGROUND: Similar to volatile anesthetics, the
anesthetic noble gas xenon protects the heart from
ischemia/reperfusion injury, but the mechanisms responsible for this
phenomenon are not fully understood. We tested the hypothesis that
xenon-induced cardioprotection is mediated by prosurvival signaling
kinases that target mitochondria.
METHODS: Male Wistar rats instrumented for
hemodynamic measurements were subjected to a 30 min left anterior
descending coronary artery occlusion and 2 h reperfusion. Rats were
randomly assigned to receive 70% nitrogen/30% oxygen (control) or
three 5-min cycles of 70% xenon/30% oxygen interspersed with the
oxygen/nitrogen mixture administered for 5 min followed by a 15 min
memory period. Myocardial infarct size was measured using
triphenyltetrazolium staining. Additional hearts from control and
xenon-pretreated rats were excised for Western blotting of Akt and
glycogen synthase kinase 3 β (GSK-3β) phosphorylation and isolation
of mitochondria. Mitochondrial oxygen consumption before and after
hypoxia/reoxygenation and mitochondrial permeability transition pore
opening were determined.
RESULTS: Xenon significantly (P < 0.05) reduced myocardial infarct
size compared with control (32 ± 4 and 59% ± 4% of the left
ventricular area at risk; mean ± sd) and enhanced phosphorylation of
Akt and GSK-3β. Xenon pretreatment preserved state 3 respiration of
isolated mitochondria compared with the results obtained in the
absence of the gas. The Ca2+ concentration required to induce
mitochondrial membrane depolarization was larger in the presence
compared with the absence of xenon pretreatment (78 ± 17 and 56 ± 17
µM, respectively). The phosphoinositol-3-kinase-kinase inhibitor
wortmannin blocked the effect of xenon on infarct size and
respiration.
CONCLUSIONS: These results indicate that xenon
preconditioning reduces myocardial infarct size, phosphorylates Akt,
and GSK-3β, preserves mitochondrial function, and inhibits Ca2+-induced
mitochondrial permeability transition pore opening. These data suggest
that xenon-induced cardioprotection occurs because of activation of
prosurvival signaling that targets mitochondria and renders them
less vulnerable to ischemia-reperfusion injury.
Noninvasive
Cardiac Output Measurement in Heart Failure Subjects on Circulatory Support
Rob Phillips, MPhil*,
Peter Lichtenthal, MD_files/image080.gif){kind=small}
, Julie Sloniger, MS_files/image081.gif){kind=small}
, Darryl Burstow, MD*, Malcolm West,
MD*, and Jack Copeland, MD_files/image082.gif){kind=small}
From the
*Department of Medicine, The University of Queensland, Brisbane, Australia; _files/image083.gif){kind=small}
Department of Anesthesiology, and _files/image084.gif){kind=small}
Department of Surgery, The University of
Arizona College of Medicine, Tucson, Arizona.
Anesth Analg 2009
108: 881-886.
背景：儘管存在效力不明、使用困難、安全性等問題，肺動脈導管（PAC）監測仍廣泛用於圍術期心臟外科重症監護室病人血流動力學的監測和管理。 USCOM是一種無創性連續多普勒波直接測量心輸出量（ CO ）的裝置，可作爲PAC的替代者。 儘管USCOM的可靠性未獲公認，相對於PAC該方法在心臟外科重症監護病房中有著更好的可用性。作者在應用完全型人工心臟 (TAH)控制心衰患者中比較了應用USCOM與CardioWest監測心輸出量的差別。
方法：使用CardioWest和USCOM裝置來雙盲監測心衰行TAH患者的心輸出量、每搏輸出量（SV）和心率（ HR ） 。CardioWest 通過18項7個專案的測試獲得了508個不同的配對資料。用Bland-Altman法分析比較。
結果：CardioWest 和 USCOM測得的心輸出量、每搏輸出量和心率的平均值及標準差（ ±標準差）分別爲7.33 ± 0.46和7.34 ± 0.51L/min、 56.2 ± 3.8和56.6 ± 3.8 mL及131 ± 3和130 ± 4bpm。心輸出量在5.2至9.3 L/min之間。兩種方法對測量心輸出量、每搏輸出量和心率的平均差分別是-0.01 ± 0.23 L/min， -0.34 ± 1.97 mL和0.9 ± 2.3bpm，平均百分比差異分別爲-0.3 ％ ， -0.6 ％和0.7 ％ 。心輸出量、每搏輸出量和心率的一致性百分比分別爲6.4 ％ ， 7.1 ％和3.6 ％ 。
結論： 對心衰行TAH的患者USCOM是一種可行的、準確的測量和監測心輸出量的方法，可能在心血管疾病診斷和處理上有更廣泛地的應用價值。
（丁俊雲 譯 陳傑 校）
BACKGROUND: Pulmonary artery catheter (PAC) thermodilution
is commonly used in the perioperative cardiac surgical intensive care
unit for measurement and management of central hemodynamics despite
questions about effectiveness, difficulty of use, and safety. USCOM
is a noninvasive continuous wave Doppler device for direct
measurement of cardiac output (CO) and is an alternative to PAC.
USCOM validation has predominantly been in the cardiac surgical
intensive care unit against PAC, despite the recognized limitations
in reliability of the method. We compared USCOM CO measurements with
the CardioWest, an orthotopic total artificial heart (TAH), in heart
failure (HF) subjects during controlled interventions.
METHOD: CO, stroke volume (SV), and heart rate (HR)
were measured in a blinded fashion using the CardioWest and the
USCOM device in TAH HF patients. Five-hundred eight paired measures
from 18 examinations of seven subjects were acquired as flow was
varied by the CardioWest controller. Bland-Altman analysis was used
to compare agreement.
RESULTS: Mean values and standard deviations (±sd)
for CO, SV, and HR by CardioWest and USCOM were 7.33 ± 0.46 and
7.34 ± 0.51 L/min, 56.2 ± 3.8 and 56.6 ± 3.8 mL, and 131 ± 3 and 130
± 4 bpm, respectively. CO ranged from 5.2 to 9.3 L/min. The mean
differences between methods for CO, SV, and HR were –0.01 ± 0.23
L/min, –0.34 ± 1.97 mL, and 0.9 ± 2.3 bpm, respectively, with
mean percentage differences of –0.3%, –0.6%, and 0.7%. The
percentage limits of agreement for CO, SV, and HR were 6.4%, 7.1%,
and 3.6%.
DISCUSSION: USCOM is a feasible and accurate method for
noninvasive measurement and monitoring of CO in TAH HF patients and
may have a wider application in diagnosis and management of
cardiovascular disease.
Minimally
Invasive Cardiac Output Monitoring in the Perioperative Setting
Duane J. Funk,
MD, FRCPC, Eugene W. Moretti, MD, MHsc, and Tong J. Gan, MB, MHS, FRCA,
FFARCS(I)
From the Department
of Anesthesiology, Division of Critical Care, Duke University Medical Center,
Durham, North Carolina.
Anesth Analg 2009
108: 887-897.
隨著患者年齡的增長及其並存病的升高，我們日益需求圍術期對患者的生理學指標，如心排出量（cardiac output，CO）、液體治療後的回應性和組織灌注情況進行跟蹤監測的設備。 麻醉醫師所持有的用於監測患者CO的工具 是肺動脈導管或者經食管超聲心動圖。這些裝置都存在著一定的缺陷，並且可能會引起並發症。最近，已有一些新的裝置投入市場（包括食管多普勒監測、脈搏波形分析、指示劑稀釋、胸部生物電阻抗和部分無重復吸入系統等），它們能夠無創監測CO，並且在某些情況下評估患者對液體治療的反應。在這篇綜述中，作者描述了這些新裝置所涉及的技術，有關應用的研究，以及它們在應用過程中的缺陷。
（周姝婧 譯 陳傑 校）
With advancing age
and increased co-morbidities in patients, the need for monitoring
devices during the perioperative period that allow clinicians to
track physiologic variables, such as cardiac output (CO), fluid
responsiveness and tissue perfusion, is increasing. Until recently,
the only tool available to anesthesiologists to monitor CO was
either a pulmonary artery catheter or transesophageal echocardiograph.
These devices have their limitations and potential for morbidity.
Several new devices (including esophageal Doppler monitors, pulse
contour analysis, indicator dilution, thoracic bioimpedance and
partial non-rebreathing systems) have recently been marketed which
have the ability to monitor CO noninvasively and, in some cases,
assess the patient’s ability to respond to fluid challenges. In this
review, we will describe these new devices including the technology,
studies on their efficacy and the limitations of their use.
混合皮層神經元-神經膠質細胞培養遭受氧糖缺失時的早期麻醉預處理：在七氟醚誘導時産生的神經保護作用中，三磷酸腺苷依賴性鉀通道和活性氧所起的作用
Early Anesthetic
Preconditioning in Mixed Cortical Neuronal-Glial Cell Cultures Subjected to
Oxygen-Glucose Deprivation: The Role of Adenosine Triphosphate Dependent
Potassium Channels and Reactive Oxygen Species in Sevoflurane-Induced
Neuroprotection
Lionel J. Velly, MD*_files/image085.gif){kind=small}
, Paula T. Canas, MD*, Benjamin
A. Guillet, PhD_files/image086.gif){kind=small}
;, Christelle N. Labrande, PhD_files/image087.gif){kind=small}
, Frédérique M. Masmejean, BS_files/image088.gif){kind=small}
, André L. Nieoullon, PhD_files/image089.gif){kind=small}
, François M. Gouin, MD*, Nicolas
J. Bruder, MD*, and Pascale S. Pisano, PhD_files/image090.gif){kind=small}
From the
*Department of Anesthesia, Centre Hospitalier Universitaire Timone Adultes,
Marseille, France; _files/image091.gif){kind=small}
Laboratory of Pharmacodynamic, UMR INSERM
608, Marseille, France; and _files/image092.gif){kind=small}
Laboratory IC2N, UMR6186 CNRS, Université
de la Méditerranée, Marseille, France.
Anesth Analg 2009
108: 955-963.
背景：這項關於混合皮層神經元-神經膠質細胞培養遭受短時氧糖缺失（OGD）的研究的目的是 ：1）比較在氧糖缺失之前（預處理）或期間（直接神經保護）增加七氟醚所産生的神經保護作用。2）探討在七氟醚的早期預處理作用機制中，三磷酸腺苷敏感性鉀（KATP）通道參與的可能性和細胞內活性氧(ROS)的水平。
方法：成熟的混合皮層神經元-神經膠質細胞在厭氧培養室裏暴露90min的氧糖缺失，隨後複氧。OGD前隨機給予七氟醚（0.03-3.4Mm）90min和停用60min（早期預處理）或 OGD期間應用七氟醚90min（直接神經保護作用）。在乳酸脫氫酶釋放到培養基法量化24小時細胞死亡數。用2’-7’ 二氯熒光素乙酰乙酸鹽來評估七氟醚預處理後細胞內活性氧的産生。
結果：七氟醚濃度高於0.07Mm的預處理産生強大的閾值依賴性神經保護作用，氧糖缺失時七氟醚引起劑量依賴性神經保護作用。三磷酸腺苷敏感性鉀通道阻滯劑（格列本脲0.3μM和5羥基癸酸50μM），或者活性氧清除劑（N-2-巰丙酰氨基乙酸100μM和N-乙酰半胱氨酸50μM），儘管它們不影響細胞活力，但抵消了由七氟醚早期預處理産生的神經保護作用。在預處理期間的七氟醚暴露使得活性氧水平顯著提高，而這可以被活性氧清除劑和三磷酸腺苷敏感性鉀通道阻滯劑所阻止。
結論：早期的七氟醚預處理産生混合皮層神經元-神經膠質細胞培養的閾值依賴性保護，可能通過打開三磷酸腺苷敏感性鉀通道，從而産生活性氧的機制來對抗氧糖缺失。
（黃丹 譯 陳傑 校）
BACKGROUND: The purpose of the present study, on mixed
cortical neuronal-glial cell cultures subjected to transient
oxygen-glucose deprivation (OGD) was: i) to compare the
neuroprotection afforded by sevoflurane added either before
(preconditioning) or during (direct neuroprotection) the OGD and ii)
to explore the possible involvement of adenosine
triphosphate-sensitive potassium (KATP) channels and intracellular
reactive oxygen species (ROS) levels in the mechanism of the early
preconditioning effect of sevoflurane.
METHODS: Mature mixed cortical neuronal-glial cell
cultures were exposed to 90-min OGD in an anaerobic chamber followed
by reoxygenation. Sevoflurane (0.03–3.4 mM) was randomly administered
for 90 min and discontinued 60 min before OGD (early preconditioning)
or during the 90-min OGD (direct neuroprotection). Cell death was
quantified 24 h after the OGD by lactate dehydrogenase release into
the bathing medium. Intracellular ROS generation was assessed at the
end of sevoflurane preconditioning using 2',7'-dichlorofluorescin
diacetate.
RESULTS: Sevoflurane preconditioning elicited a
potent threshold-dependent neuroprotective effect at concentrations
higher than 0.07 mM and sevoflurane added during OGD elicited a dose
dependent neuroprotective effect. Blockers of KATP channels
(glibenclamide 0.3 µM and 5 hydroxydecanoic acid 50 µM), or
ROS-scavengers (N-2-mercaptopropionyl glycine 100 µM and
N-acetylcysteine 50 µM), although they did not affect cell
viability, counteracted the neuroprotection produced by early
sevoflurane preconditioning. Sevoflurane exposure during
preconditioning induced a significant increase in ROS levels which
was prevented by both ROS scavengers and blockers of KATP channels.
CONCLUSION: Early sevoflurane preconditioning induced a
threshold-dependent protection of mixed cortical neuronal-glial cell
cultures against OGD by mechanisms that seem to involve opening KATP
channels, thereby leading to generation of ROS.
8%定量利多卡因噴霧泵對創傷後外周神經病變的鎮痛作用：一項初步研究
The Analgesic
Effect of a Metered-Dose 8% Lidocaine Pump Spray In Posttraumatic Peripheral
Neuropathy: A Pilot Study
Akifumi Kanai, MD,
PhD, Yuka Segawa, MD, Takashi Okamoto, MD, Masanori Koto, MD, and Hirotsugu
Okamoto, MD, PhD
From the Department
of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Japan.
Anesth Analg 2009
108: 987-991.
背景：利多卡因表面貼片能夠有效地治療創傷後外周神經病變（posttraumatic peripheral neuropathy，PTPN），但由於需要額外使用，它不適用於爆發性疼痛。在這裏，作者評估了8%利多卡因噴霧泵（Xylocaine pump spray，XPS）對由手術或損傷所致的外周神經病理性疼痛的效果。
方法：31位PTPN患者被隨機分爲2組，一組接受XPS，另一組接受生理鹽水噴霧泵作爲空白對照組，將藥物噴灑于兩組患者疼痛部位的皮膚表面。噴灑的最佳劑量爲能夠完全覆蓋疼痛區域，據個人情況而定，最多可達30噴（0.1ml/噴，30次）。7天後，將兩組患者交叉接受另一噴劑的治療。用視覺類比評分評估患者的疼痛情況。
結果：XPS而不是空白噴霧泵能夠顯著地降低持續疼痛和觸覺異常的視覺類比評分。應用後，其鎮痛效果平均可持續5h（範圍，2-60h）。在3位元應用XPS的患者中發生了輕微的並發症，包括局部激惹症狀（n=3）和局部燒灼感（n=1）。這些並發症無需藥物治療而在數小時後消失。
結論：目前的研究顯示，XPS可以有效地改善PTPN，能夠迅速鎮痛，沒有全身性的副作用，且使用方便。
（周姝婧 譯 陳傑 校）
BACKGROUND: A topical lidocaine patch is effective in
the treatment of posttraumatic peripheral neuropathy (PTPN), but it
is not suited for breakthrough pain because of difficulty with an
additional application. Here, we examined the effect of 8% lidocaine
pump spray (Xylocaine pump spray®, XPS) on peripheral neuropathic
pain caused by surgery or injury.
METHODS: Thirty-one patients with PTPN were
randomized to receive either XPS or saline placebo pump spray
applied to painful skin areas. The optimal dose of up to 30 sprays
(0.1 mL/single spray, 30 times) was individually determined as the
dose which completely covered the painful site. After a 7-day
period, the patients were crossed over to receive the optimal dose
of the alternative spray. Pain was assessed with a visual analog
scale.
RESULTS: XPS, but not placebo pump spray,
significantly decreased the visual analog scale for continuing pain
and tactile allodynia. The effect persisted for a median of 5 h
(range, 2–60 h) after application. Mild side effects were reported
in three patients with XPS consisting of local irritation (n = 3) and local flare (n = 1). All adverse events disappeared
without medication within a few hours.
CONCLUSIONS: The present study suggests that XPS provides
a significant improvement in PTPN due to its prompt analgesia, lack
of systemic side effects and convenience.
An Absorbable
Local Anesthetic Matrix Provides Several Days of Functional Sciatic Nerve
Blockade
Chi-Fei Wang, MD*,
Alimorad G. Djalali, MD, PhD*, Ankur Gandhi, PhD_files/image093.gif){kind=small}
, David Knaack, PhD_files/image094.gif){kind=small}
, Umberto De Girolami, MD_files/image095.gif){kind=small}
, Gary Strichartz, PhD*, and
Peter Gerner, MD*
From the *Pain
Research Center, Department of Anesthesiology, Perioperative and Pain Medicine,
Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; _files/image096.gif){kind=small}
Orthocon, Inc., North Brunswick, New Jersey;
and _files/image097.gif){kind=small}
Division of Neuropathology, Department of
Pathology, Brigham and Women’s Hospital Harvard Medical School, Boston,
Massachusetts.
Anesth Analg 2009
108: 1027-1033.
背景：周圍神經的功能性阻滯是局部麻醉的基本目的，期待其作用持久，涵蓋或超過整個手術期。現有的局麻藥在一個單劑量給藥後提供的有效鎮痛時間小於8—12h。作者報告了一個可用於骨科，植入性的、可控制釋放的藥物給予裝置， 包括一個FDA批准的包含利多卡因基質），能夠局部釋放幾天之久。
方法：Xybrex，一個可吸收，控制釋放的給藥裝置，包括16%（w/w）利多卡因，在雄性大鼠(300-350 gm)中植入在坐骨神經附近，每只大鼠的利多卡因劑量分別爲5.3、10.6、16和32mg。作爲對照，鹽酸利多卡因溶液（0.2 mL， 2% = 4 mg）注射在非常靠近坐骨神經的地方。通過用鑷子夾捏外側腳趾的行爲來評估大鼠痛覺，同時通過量化伸肌的推力來評估運動阻滯。在植入後24h、4d和4wk評估可能的坐骨神經的神經毒性。在體外測量利多卡因從裝置中釋放動力學。在2.5，6.5，10和24.25h時收集樣本測定利多卡因。
結果：Xybrex在高劑量（分別爲300和600mg/ka，包含16和32mg的利多卡因游離堿）提供了對於一個強烈的夾捏完全的鎮痛分別爲7.0 ± 2.0 h, 6.9± 1.7 h ，和一個不完全的鎮痛分別爲60.0 ± 5.4 h, 58.8 ±4.2 h，相對於由2%的利多卡因溶液（包含4mg利多卡因）引起的坐骨神經阻滯完全鎮痛爲
0.61± 0.03 h 和不完全鎮痛爲0.96 ±0.03 h 。這些同樣高劑量的Xybrex 産生了完全的運動阻滯分別爲17.0± 3.3 h, 17.6 ± 3.3 h ，並且完全恢復分別爲352.0 ± 55.7 h (14.7 ± 2.3 d)， 579.0 ±36.1 h (24.1 ± 1.5 d)。資料以平均 ± SE的形式記錄。所有的Xybrex 組和2%利多卡因組相比時P < 0.001 。在靠近坐骨神經0.1mm的結締組織和肌肉中小的局部組織炎症/病狀，兩組動物中均能觀察到。實驗中沒有全身中毒徵象。離體研究顯示藥物釋放呈指數動力學特徵，對比無時程性傷害缺乏意味著持續傷害性刺激在神經與該藥裝置間利多卡因直接的、局部作用，而無先前釋放藥物的累積效應
結論：Xybrex是一個可吸收的，控制釋放的藥物給予裝置，能夠提供大鼠周圍神經數天的鎮痛，無顯著的局部神經毒性或者系統性毒性。
（懷曉蓉 譯 陳傑 校）
BACKGROUND: Functional blockade of peripheral nerves is
the primary objective of local anesthesia, and it is often desirable
to have a persistent blockade, sustained throughout and beyond a
surgical procedure. Current local anesthetics give effective analgesia
for <8–12 h after a single bolus injection. We report on an
implantable, controlled-release drug delivery system intended for
use in bone and consisting of a Food and Drug
Administration-approved matrix containing lidocaine that is capable
of local delivery for several days.
METHODS: XybrexTM, an absorbable,
controlled-release delivery system containing 16% (w/w) lidocaine,
was implanted next to the sciatic nerve of male rats (300–350 gm),
at lidocaine doses of 5.3, 10.6, 16, and 32 mg lidocaine per rat.
For comparison, a lidocaine HCl solution (0.2 mL, 2% = 4 mg) was
injected in close proximity to the sciatic nerve. Rats were assessed
behaviorally for analgesia by a forceps pinch of the lateral digits,
and for motor block by quantifying the extensor postural thrust.
Potential neurotoxicity of sciatic nerves was evaluated histologically
at 24 h, 4 days, and 4 wk after implantation. The kinetics of lidocaine’s
release from the matrix was measured in vitro by ultraviolet detection of
lidocaine in samples collected at 2.5, 6.5, 20, and 24.25 h.
RESULTS: Xybrex at the highest doses (300 and 600
mg/kg, containing 16 and 32 mg of lidocaine free base, respectively)
provided complete analgesia to an intense pinch for 7.0 ± 2.0 h,
6.9 ± 1.7 h and partial analgesia for 60.0 ± 5.4 h, 58.8 ± 4.2 h,
respectively, compared to 0.61 ± 0.03 h of complete analgesia and
0.96 ± 0.03 h of partial analgesia by sciatic block from the 2%
lidocaine solution (containing 4 mg lidocaine). These same high
doses of Xybrex produced complete motor block for 17.0 ± 3.3 h, 17.6
± 3.3 h with full recovery in 352.0 ± 55.7 h (14.7 ± 2.3 days),
579.0 ± 36.1 h (24.1 ± 1.5 days) respectively. Data are
reported as mean ± se. P
< 0.001 for all Xybrex groups compared to the 2% lidocaine group.
Minor local tissue inflammation/pathology, primarily in the
connective tissue and muscle 0.1 mm adjacent to the nerve, was
observed equally in animals treated with Xybrex and 2% lidocaine
solution. There were no behavioral signs of systemic toxicity. The in
vitro release
followed exponential kinetics and。its comparison to the time-course of functional nociceptive
deficit implied that the duration of nociception represented the
local, immediate interaction of lidocaine between the nerve and the
matrix and not a cumulative effect of previously released drug.
CONCLUSIONS: Xybrex is an absorbable, controlled-release
drug delivery system that provides several days of analgesia for
rat peripheral nerves without apparent significant local neurotoxicity
or systemic toxicity.
The Efficacy of
Skin Temperature for Block Assessment After Infraclavicular Brachial Plexus
Block
Vincent Minville,
MD*, Agnés Gendre, MD*, Jan Hirsch, MD_files/image098.gif){kind=small}
, Stein Silva, MD*, Benoît
Bourdet, MD*, Carole Barbero, MD*, Olivier Fourcade, MD,
PhD*, Kamran Samii, MD*, and Hervé Bouaziz, MD, PhD_files/image099.gif){kind=small}
From the *Department
of Anesthesiology and Intensive Care, University Hospital of Toulouse,
University Paul Sabatier, Toulouse, France; _files/image100.gif){kind=small}
Cardiovascular Research Institute, University
of California, San Francisco, California; and _files/image101.gif){kind=small}
Department of Anesthesiology and Intensive
Care, University Hospital of Nancy, Nancy, France.
Anesth Analg 2009
108: 1034-1036.
背景：儘管有研究表明應用皮溫升高來評估神經阻滯效果比應用針刺覺及溫度覺改變來評估具有更高的特異性和敏感性，但原先應用的方法需要電腦輔助紅外熱成像，該方法價格昂貴且需要嚴格的專業培訓。在本前瞻性觀察研究中，作者使用簡易紅外溫度儀評估鎖骨下臂叢神經阻滯效果是否可靠。
方法：選擇應用鎖骨下臂叢神經阻滯行上肢手術的患者30名。自局麻藥注射後起，在四個主要神經分佈區域進行皮膚溫度測量，同時在注藥後30min內每隔5min測量感覺阻滯（痛溫覺喪失評分爲0，正常痛溫覺爲2）。本研究中神經阻滯成功的定義爲：在局麻藥注射後30min內，四個主要神經分佈區域（橈神經，尺神經，正中神經，肌皮神經）的溫度覺（酒精棉球擦拭）和痛覺（針刺覺）評分爲0。以非接觸式溫度探頭測量皮膚溫度。
結果：被阻滯神經總數爲120（30位患者，每位患者4根神經）。其中25例患者神經阻滯成功，4例由於阻滯失敗需要靜脈麻醉輔助，1例患者實施全麻。不同神經分佈區域的皮膚溫度變化無顯著性差異。同一區域的皮膚溫度在神經阻滯後升高，與阻滯前相比有顯著性差異(T5到T30，P < 0.0001)。同一時間神經阻滯區域與非神經阻滯區域的平均皮膚溫度有顯著性差異(T5，P < 0.05 ；T10到T30，P< 0.0001)。當阻滯後5分鐘和10分鐘，特定感覺區域的皮膚溫度升高≥1°C，則對應的神經被阻滯（評分=0）。因此，當阻滯後5分鐘和10分鐘四條神經區域的皮膚溫度都發生變化，那麽在30分鐘後神經成功阻滯。本研究中，患者的對側上肢和中心體溫無變化。
結論：使用簡易紅外溫度儀通過測定皮膚溫度來評估神經阻滯效果，這一方法簡單、可靠，且能在早期預示神經阻滯的成功。
（趙嫣紅 譯 陳傑 校）
BACKGROUND: Although it has been reported that an
increase in skin temperature indicates block success with higher
specificity and sensibility than skin sensitivity to pinprick and
cold, the methodology previously used computer-assisted infrared
thermography, a technique that is expensive and requires substantial
personnel training. In this prospective observational study, we
evaluated whether a simple infrared thermometer can reliably predict
block effectiveness after infraclavicular brachial plexus blockade.
METHODS: Thirty consecutive patients undergoing upper
limb surgery under infraclavicular block were enrolled. From the
end of the local anesthetic injection, skin temperature was measured
in all four major nerve distribution areas, and the sensory block
onset (using cold and pinprick with 0 = no sensation to 2 = normal)
were evaluated every 5 min for 30 min. A successful block was
defined as the absence of sensation to cold (swab soaked with
alcohol) and pinprick (needle) with a score of "0" within
30 min after the injection in the 4 major nerve distribution areas
(radial, ulnar, median and musculocutaneous). Skin temperature measurements
were performed using a noncontact temperature probe.
RESULTS: One-hundred-twenty nerves (30 patients, 4
nerves per patient) were anesthetized. Twenty-five patients had a
successful block. Four patients required supplementation for block
failure. General anesthesia was performed in one patient. Skin
temperature variation was not different among different nerves.
There was a statistically significant increase in cutaneous
temperature after nerve block compared to the same skin area before
the procedure (P < 0.0001 from T5 to T30). Average temperature variations
in blocked versus unblocked nerves at the same time were
significantly different (P
< 0.05 at T5 then P <
0.0001 from T10 to T30). When temperature in a specific sensory territory
increased 1°C or more, at 5 and 10 min, the specific nerve was
blocked (the score was "0"). Thus, when temperature changes
in all 4 nerves were noted at 5 and 10 min, the block was successful
at 30 min. No change in temperature in the contralateral arm or in
the core temperature was observed.
CONCLUSION: Skin temperature assessment with an infrared
thermometer is a reliable, simple and early indicator of a
successful nerve block.
一篇就文獻進行的系統性回顧：血栓彈性描計法可以預測術後血栓栓塞的發生麽？
Does
Thromboelastography Predict Postoperative Thromboembolic Events? A Systematic
Review of the Literature
Yue Dai, MB, MSc*,
Anna Lee, PhD*, Lester A. H. Critchley, MD*, and Paul F.
White, PhD, MD_files/image102.gif){kind=small}
From the
*Department of Anaesthesia and Intensive Care, The Chinese University of Hong
Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, China; and _files/image103.gif){kind=small}
Department of Anesthesiology and Pain
Management, University of Texas Southwestern Medical Center, Dallas, Texas.
Anesth Analg 2009;
108:734-742
背景：由於血栓彈性描計法（TEG）可以檢測出高凝狀態，因此它可以作爲預測術後血栓栓塞發生的有效方法，就此我們系統性地回顧了文獻來評估TEG預測術後血栓發生的準確性。
方法：兩位互不干擾的研究人員分別搜索了PUBMED和EMBASE電子資料庫，查找出包含圍術期進行TEG測試並用參考標準判斷結果的成年手術病人的前瞻性研究。評價包括的研究的質量並評估包括的每一項研究的診斷性測試準確性值。
結果：本次分析有10篇研究入選（共1056位病人），但是只有5篇文獻報道了TEG測試的準確性
值
。研究的總體質量和診斷評估的水平從好到差
變
異很大。由於血液高凝的定義、TEG方法、病人的特
征、
所用
的參考標準和測得的結果有變異性，所以沒有採用薈萃分析。敏感度和特異性的範圍分別從0%到100%和62%到92%。診斷優勢比從1.5到27.7，曲線下面積從0.57到0.91。在TEG的各變數中，最大振幅可以作爲鑒別
血液高凝狀態和預測血栓栓塞發生的最好參數。
結論：TEG預測術後血栓栓塞的發生的準確性變異較大。爲了確定TEG是否是高危外科手術人群中臨床上有用的篩選試驗，我們還需要進行更多的前瞻性研究。
（姜旭暉譯，馬皓琳，李士通校）
BACKGROUND: Since thromboelastography (TEG) can detect
hypercoagulable states, it is a potentially useful test for
predicting postoperative thromboembolic complications. Therefore, we
performed a systematic review of the literature to evaluate the
accuracy of TEG in predicting postoperative thromboembolic events.
METHODS: PUBMED and EMBASE electronic databases were
searched by two independent investigators to identify prospective
studies involving adult patients undergoing operative procedures in
which a TEG test was performed perioperatively and outcomes were
measured by reference standards. The quality of included studies was
assessed and measures of diagnostic test accuracy were estimated for
each included study.
RESULTS: Ten studies (with a total of 1056 patients)
were included in this analysis; however, only five reported measures
of TEG test accuracy. The overall quality of the studies and level
of diagnostic evaluation of the studies were highly variable, from
poor to good. As there were variations in the definition of
hypercoagulability, TEG methodology and patient characteristics, reference
standards used and outcomes measured, a meta-analysis was not
undertaken. The sensitivity and specificity ranged from 0% to 100%
and 62% to 92%, respectively. The diagnostic odds ratio ranged from
1.5 to 27.7; area under the curve ranged from 0.57 to 0.91. Of the
TEG variables, maximum amplitude seems to be the best parameter to
identify hypercoagulable states and to predict thromboembolic
events.
CONCLUSIONS: The predictive accuracy of TEG for
postoperative thromboembolic events is highly variable. To determine
if the TEG is a clinically useful screening test in high-risk
surgical populations, more prospective studies are needed.
Noninfectious
Serious Hazards of Transfusion
Jeanne E.
Hendrickson, MD*_files/image104.gif){kind=small}
, and Christopher D. Hillyer, MD*
From the
*Department of Pathology and Laboratory Medicine, Center for Transfusion and
Cellular Therapies, and _files/image105.gif){kind=small}
AFLAC Cancer Center and Blood Disorders
Service, Children’s Healthcare of Atlanta, Division of Pediatric
Hematology/Oncology, Emory University School of Medicine, Atlanta, Georgia.
Anesth Analg 2009;
108:759-769
由於獻血者問卷的改良及尖端的感染性疾病的血液篩選技術，非感染性嚴重風險(NISHOTs)已成爲輸血最常見的並發症。NISHOTs的種類很廣泛，包括從能恰當描述的
且已歸類的輸血反應（溶血、發熱
、膿毒血症和變應/ 蕁麻疹/過敏）到更罕見的並發症。這些包括誤輸血、輸血相關的急性肺損傷
、輸血相關的迴圈超負荷、輸血後紫癜、輸血相關的移植物抗宿主病、微嵌合狀態、輸血相關的免疫調製、同種異體免疫、代謝紊亂、大量輸血導致的凝血障礙、紅細胞存儲損傷引起的並發症、輸血過多或輸血不足導致的並發症及鐵超負荷。
近幾年，NISHOTs在出版社及科學界均比以前受到更多關注。由於輸血引起的潛在並發症越來越多，研究者們已
關注自由與限制紅細胞輸注的發病率及病死率比較，及輸注“陳舊血”與“新鮮血”潛在危險的對比。本文回顧了集中於最近的關注和文獻的NISHOTs。
（裘毅敏譯，馬皓
琳 李士通校）
As infectious
complications from blood transfusion have decreased because of
improved donor questionnaires and sophisticated infectious disease
blood screening, noninfectious serious hazards of transfusion (NISHOTs)
have emerged as the most common complications of transfusion. The
category of NISHOTs is very broad, including everything from
well-described and categorized transfusion reactions (hemolytic, febrile,
septic, and allergic/urticarial/anaphylactic) to lesser known
complications. These include mistransfusion, transfusion-related acute
lung injury, transfusion-associated circulatory overload, posttransfusion
purpura, transfusion-associated graft versus host disease,
microchimerism, transfusion-related immunomodulation, alloimmunization,
metabolic derangements, coagulopathic complications of massive
transfusion, complications from red cell storage lesions, complications
from over or undertransfusion, and iron overload.
In recent years,
NISHOTs have attracted more attention than ever before, both in the
lay press and in the scientific community. As the list of potential
complications from blood transfusion grows, investigators have
focused on the morbidity and mortality of liberal versus restrictive
red blood cell transfusion, as well as the potential dangers of
transfusing "older" versus "younger" blood. In
this article, we review NISHOTs, focusing on the most recent
concerns and literature.
Cardiac Surgery
in the Parturient
Shobana
Chandrasekhar, MD, Christopher R. Cook, DO, and Charles D. Collard, MD
From the Division
of Cardiovascular Anesthesiology, Department of Anesthesiology, Baylor College
of Medicine, Texas Heart® Institute, St. Luke’s Episcopal Hospital, Houston,
TX.
Anesth Analg 2009;
108:777-785
心臟疾病爲妊娠期非産科性死亡的主要原因，在産婦中的發病率爲1％-3%，由此引起的孕産婦死亡率爲10％—15％。先天性心臟病在育齡婦女已越來越多見，占妊娠期心臟疾病的比例越來越高（可達75％）。孕産婦未經治療的心臟疾病使得胎兒也處於危險之中。新生兒並發症的獨立預測因素包括産婦紐約心臟協會心衰分級>2、妊娠期抗凝藥物的運用、吸煙史，多胎妊娠和左室流出道梗阻。由於産婦心外科手術發病率和死亡率高於非妊娠患者，故大多數有心臟疾病的産婦首先接受藥物治療，同時準備在藥物治療失敗後接受心外科手術治療。心外科手術期産婦死亡的危險因素包括血管活性藥物、年齡、手術類型、二次手術和産婦心功能分級。胎兒死亡的危險因素包括産婦年齡>35歲、心功能分級、二次手術、急診手術、心肌保護的類型和缺氧時間。雖然如此，通過如下措施可達到可以接受的産婦和胎兒圍術期死亡率：術前早期發現産婦心血管失代償狀態、採用胎兒監護、在手術前分娩可存活胎兒以及在妊娠4月到6月時安排擇期手術。此外，體外迴圈期間使産婦攜氧能力和子宮血流量達到最佳狀態也可降低胎兒死亡率。目前産婦體外迴圈的建議包括：1）維持泵流量>2.5 L · min–1 · m–2 、灌注壓 >70 mm Hg；2）維持血細胞比容> 28%；3）如果可行，採用常溫灌注；4）採用搏動血流；5）採用α－pH穩態管理。
（周雅春 譯
馬皓琳 李士通 校）
Heart disease is
the primary cause of nonobstetric mortality in pregnancy, occurring
in 1%–3% of pregnancies and accounting for 10%–15% of maternal
deaths. Congenital heart disease has become more prevalent in women
of childbearing age, representing an increasing percentage (up to
75%) of heart disease in pregnancy. Untreated maternal heart disease
also places the fetus at risk. Independent predictors of neonatal
complications include a maternal New York Heart Association heart
failure classification >2, anticoagulation use during pregnancy,
smoking, multiple gestation, and left heart obstruction. Because cardiac
surgical morbidity and mortality in the parturient is higher than
nonpregnant patients, most parturients with cardiac disease are
first managed medically, with cardiac surgery being reserved when
medical management fails. Risk factors for maternal mortality during
cardiac surgery include the use of vasoactive drugs, age, type of
surgery, reoperation, and maternal functional class. Risk factors
for fetal mortality include maternal age >35 yr, functional
class, reoperation, emergency surgery, type of myocardial
protection, and anoxic time. Nonetheless, acceptable maternal and
fetal perioperative mortality rates may be achieved through such
measures as early preoperative detection of maternal cardiovascular
decompensation, use of fetal monitoring, delivery of a viable fetus
before the operation and scheduling surgery on an elective basis
during the second trimester. Additionally, fetal morbidity may be
reduced during cardiopulmonary bypass by optimizing maternal
oxygen-carrying capacity and uterine blood flow. Current maternal
bypass recommendations include: 1) maintaining the pump flow rate
>2.5 L · min–1 · m–2 and perfusion pressure
>70 mm Hg; 2) maintaining the hematocrit > 28%; 3) using
normothermic perfusion when feasible; 4) using pulsatile flow; and
5) using _files/image107.gif){kind=small}
-stat pH management.
Real-Time
Assessment of Perioperative Behaviors and Prediction of Perioperative Outcomes
Senthilkumar
Sadhasivam, MD, MPH*, Lindsey L. Cohen, PhD_files/image108.gif){kind=small}
, Alexandra Szabova, MD*, Anna
Varughese, MD*, Charles Dean Kurth, MD*, Paul Willging,
MD_files/image109.gif){kind=small}
, Yu Wang, MS_files/image110.gif){kind=small}
, Todd G. Nick, PhD_files/image111.gif){kind=small}
, and Joel Gunter, MD*
From the
*Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio; _files/image112.gif){kind=small}
Department of Psychology, Georgia State
University, Atlanta, Georgia; _files/image113.gif){kind=small}
Department of Otorhinolaryngology, and _files/image114.gif){kind=small}
Division of Biostatistics and Epidemiology,
Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.
Anesth Analg 2009;
108:822-826
背景和目的：