Time Table of Contents

May 2009

 

CARDIOVASCULAR ANESTHESIOLOGY:

在有腦自身調節異常風險的病人中行低溫心肺旁路期間的頸靜脈氧合：-固定計與pH-固定計血氣處理的影響比較

彭中美 譯 馬皓琳 李士通 校

Jugular Venous Oxygenation During Hypothermic Cardiopulmonary Bypass in Patients at Risk for Abnormal Cerebral Autoregulation: Influence of -Stat Versus pH-Stat Blood Gas Management (Brief Report)

Lance R. Hoover, Radhika Dinavahi, Wei-Ping Cheng, John R. Cooper, Jr, Maria Rosa Marino, Tyler C. Spata, Gaile L. Daniels, William K. Vaughn, and Nancy A. Nussmeier

Anesth Analg 2009 108: 1389-1393.

體外迴圈期間的最佳灌注：一項循證研究

懷曉蓉　譯　陳傑　校

Optimal Perfusion During Cardiopulmonary Bypass: An Evidence-Based Approach (Review Article)

Glenn S. Murphy, Eugene A. Hessel, II, and Robert C. Groom

Anesth Analg 2009 108: 1394-1417.

心臟手術病人術中應用經食道超聲心動描記術測量腎血流量的可行性研究

單嘉琪譯 薛張綱校

The Feasibility of Measuring Renal Blood Flow Using Transesophageal Echocardiography in Patients Undergoing Cardiac Surgery

Ping-Liang Yang, David T. Wong, Shuang-Bo Dai, Hai-Bo Song, Ling Ye, Jin Liu, and Bin Liu

Anesth Analg 2009 108: 1418-1424.

由TEG®血小板圖^TM測得的米力農對血小板活化的作用

裘毅敏譯，馬皓琳、李士通校

The Effect of Milrinone on Platelet Activation as Determined by TEG® Platelet Mapping^TM

Mark C. Wesley, Francis X. McGowan, Robert A. Castro, Sheahan Dissanayake, David Zurakowski, and James A. DiNardo

Anesth Analg 2009 108: 1425-1429.

使用旋轉血栓彈力測定儀評估血小板輸注的效果

朱紫瑜　譯　陳傑　校

The Effects of Platelet Transfusions Evaluated Using Rotational Thromboelastometry (Brief Report)

Per Flisberg, Malin Rundgren, and Martin Engström

Anesth Analg 2009 108: 1430-1432.

血液凝固：止血措施與凝血酶的調節

範羽譯 薛張綱校

Blood Coagulation: Hemostasis and Thrombin Regulation (Review Article)

Kenichi A. Tanaka, Nigel S. Key, and Jerrold H. Levy

Anesth Analg 2009 108: 1433-1446

在止血中組織因數和VIIa因數的作用

唐亮 譯  馬皓琳 李士通 校

The Role of Tissue Factor and Factor VIIa in Hemostasis (Review Article)

Nigel Mackman

Anesth Analg 2009 108: 1447-1452.

經導管內主動脈瓣移植：麻醉學方面的思考

周姝婧　譯　陳傑　校

Transcatheter Aortic Valve Implantation: Anesthetic Considerations (Review Article)

Frederic T. Billings, IV, Susheel K. Kodali, and Jack S. Shanewise

Anesth Analg 2009 108: 1453-1462.

PEDIATRIC ANESTHESIOLOGY:

兒童喉部度量的年齡相關分析

黃劍譯 薛張綱校

Pediatric Laryngeal Dimensions: An Age-Based Analysis

Priti G. Dalal, David Murray, Anna H. Messner, Angela Feng, John McAllister, and David Molter

Anesth Analg 2009 108: 1475-1479.

全麻藥對耳蝸植入手術患兒電激發鐙骨肌反射的劑量依賴抑制作用

張瑩譯  馬皓琳 李士通校

Dose-Dependent Suppression of the Electrically Elicited Stapedius Reflex by General Anesthetics in Children Undergoing Cochlear Implant Surgery

Mark W. Crawford, Michelle C. White, Evan J. Propst, Christian Zaarour, Sharon Cushing, Carolyne Pehora, Adrian L. James, Karen A. Gordon, and Blake C. Papsin

Anesth Analg 2009 108: 1480-1487.

超聲引導技術與體表標誌定位技術用於小兒髂腹股溝-髂腹下神經阻滯：羅呱卡因血漿濃度的意義

黃丹　譯　陳傑　校

Ultrasound Versus Landmark-Based Technique for Ilioinguinal-Iliohypogastric Nerve Blockade in Children: The Implications on Plasma Levels of Ropivacaine

Marion Weintraud, Märit Lundblad, Stephan C. Kettner, Harald Willschke, Stephan Kapral, Per-Arne Lönnqvist, Karl Koppatz, Klaus Turnheim, Adrian Bsenberg, and Peter Marhofer

Anesth Analg 2009 108: 1488-1492.

腹股溝壓迫，瓦耳薩耳瓦氏手法以及反向特倫德倫伯氏臥位對兒童股動脈橫截面積的影響

李瑩譯 薛張綱校

The Effect of Inguinal Compression, Valsalva Maneuver, and Reverse Trendelenburg Position on the Cross-Sectional Area of the Femoral Vein in Children

Jin-Tae Kim, Chun-Soo Park, Hyun Jung Kim, Jung-Man Lee, Hee-Soo Kim, Chong-Sung Kim, and Seong-Deok Kim

Anesth Analg 2009 108: 1493-1496.

AMBULATORY ANESTHESIOLOGY:

比較經皮吸收東莨菪堿複合昂丹司瓊和單獨使用昂丹司瓊對預防門診病人手術後噁心和嘔吐的一個隨機、雙盲、多中心試驗

王宏 譯，馬皓琳 李士通 校

A Randomized, Double-Blind, Multicenter Trial Comparing Transdermal Scopolamine Plus Ondansetron to Ondansetron Alone for the Prevention of Postoperative Nausea and Vomiting in the Outpatient Setting

Tong J. Gan, Ashish C. Sinha, Anthony L. Kovac, R. Kevin Jones, Stephen A. Cohen, Jean P. Battikha, Jonathan S. Deutsch, Joseph V. Pergolizzi, Jr, the TDS Study Group, and Peter S. A. Glass

Anesth Analg 2009 108: 1498-1504.

使用瑞芬太尼有利於插入Cobra喉周通氣道(Cobra PLA)

潘錢玲　譯　陳傑　校

The Use of Remifentanil to Facilitate the Insertion of the Cobra Perilaryngeal Airway

Woo Jae Jeon, Kyoung Hun Kim, Jung Kook Suh, and Sang Yun Cho

Anesth Analg 2009 108: 1505-1509.

ANESTHETIC PHARMACOLOGY:

志願者中聯合應用腦電圖和聽覺誘發電位鑒別麻醉深度

姚敏敏譯 薛張綱校

A Combination of Electroencephalogram and Auditory Evoked Potentials Separates Different Levels of Anesthesia in Volunteers

Bettina Horn, Stefanie Pilge, Eberhard F. Kochs, Gudrun Stockmanns, Andreas Hock, and Gerhard Schneider

Anesth Analg 2009 108: 1512-1521.

咪達唑侖對丙泊酚藥動學影響的混合效應模型的建立

江繼宏 譯  馬皓琳 李士通 校

Mixed-Effects Modeling of the Influence of Midazolam on Propofol Pharmacokinetics

Jaap Vuyk, Bart Jan Lichtenbelt, Erik Olofsen, Jack W. van Kleef, and Albert Dahan

Anesth Analg 2009 108: 1522-1530.

蝌蚪實驗顯示異戊酸、甲基丙二酸及丙酸能減少麻醉藥物EC50值，調節甘氨酸受體功能以及與二棕櫚酸磷脂酰膽鹼相互作用

（趙嫣紅　譯　陳傑　校）

Yun Weng, Tienyi Theresa Hsu, Jing Zhao, Stefanie Nishimura, Gerald G. Fuller, and James M. Sonner

Isovaleric, Methylmalonic, and Propionic Acid Decrease Anesthetic EC₅₀ in Tadpoles, Modulate Glycine Receptor Function, and Interact with the Lipid 1,2-Dipalmitoyl-Sn-Glycero-3-Phosphocholine

Anesth Analg 2009 108: 1538-1545

TECHNOLOGY, COMPUTING, AND SIMULATION:

通過報警延遲和臨床表現改善重症監護室的報警

俞佳譯 薛張綱校

Improving Alarm Performance in the Medical Intensive Care Unit Using Delays and Clinical Context

Matthias Görges, Boaz A. Markewitz, and Dwayne R. Westenskow

Anesth Analg 2009 108: 1546-1552.

在健康志願者中心臟指數的無創評估：比較胸廓阻抗心動描記法和多普勒超聲心動描記法

周雅春 譯 李士通 馬皓琳 校

Noninvasive Assessment of Cardiac Index in Healthy Volunteers: A Comparison Between Thoracic Impedance Cardiography and Doppler Echocardiography

Jean-Luc Fellahi, Vincent Caille, Cyril Charron, Pierre-Hervé Deschamps-Berger, and Antoine Vieillard-Baron

Anesth Analg 2009 108: 1553-1559.

PATIENT SAFETY:

局部麻醉和監護下麻醉時的意識水平:患者的期望和體驗

張燕 譯 陳傑 校

Levels of Consciousness During Regional Anesthesia and Monitored Anesthesia Care: Patient Expectations and Experiences (Brief Report)

Roy K. Esaki and George A. Mashour

Anesth Analg 2009 108: 1560-1563.

圍手術期麻醉醫師關於口腔問題的考慮

張玥琪譯，薛張綱校

Perioperative Dental Considerations for the Anesthesiologist (Review Article)

Jeffrey S. Yasny

Anesth Analg 2009 108: 1564-1573.

現代的快速可降解的羥乙基澱粉：最近的概念

唐李雋 譯  馬皓琳  李士通 校

Modern Rapidly Degradable Hydroxyethyl Starches: Current Concepts (Review Article)

Joachim Boldt

Anesth Analg 2009 108: 1574-1582.

CRITICAL CARE AND TRAUMA:

在類比未插管呼吸驟停患者的臺式模型上研究氣道阻塞時的通氣策略

張磊　譯　陳傑　校

Ventilation Strategies in the Obstructed Airway in a Bench Model Simulating a Nonintubated Respiratory Arrest Patient (Technical Communication)

Holger Herff, Peter Paal, Achim von Goedecke, Thomas Mitterlechner, Christian A. Schmittinger, and Volker Wenzel

Anesth Analg 2009 108: 1585-1588.

OBSTETRIC ANESTHESIOLOGY:

在脊麻剖宮産中應用單一膠體擴容與晶膠合用相比對母體心輸出量的影響

張釗譯 薛張綱校

Colloid Preload Versus Coload for Spinal Anesthesia for Cesarean Delivery: The Effects on Maternal Cardiac Output

Wendy H. L. Teoh and Alex T. H. Sia

Anesth Analg 2009 108: 1592-1598.

羊水栓塞

黃佳佳譯，馬皓琳 李士通校

Amniotic Fluid Embolism (Review Article)

Richard S. Gist, Irene P. Stafford, Andrew B. Leibowitz, and Yaakov Beilin

Anesth Analg 2009 108: 1599-1602.

ECONOMICS, EDUCATION, AND POLICY:

兒科診斷成像和使用鎮靜的增長率

舒慧剛　譯　陳傑　校

Growth Rates in Pediatric Diagnostic Imaging and Sedation

Ruth E. Wachtel, Franklin Dexter, and Angella J. Dow

Anesth Analg 2009 108: 1616-1621.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

一致聲明：首屆麻醉藥與阿爾海默茨病國際研討會                        

朱蘭芳譯 薛張綱校

Consensus Statement: First International Workshop on Anesthetics and Alzheimer’s Disease (Special Article)

Dmitri Baranov, Philip E. Bickler, Gregory J. Crosby, Deborah J. Culley, Maryellen F. Eckenhoff, Roderic G. Eckenhoff, Kirk J. Hogan, Vesna Jevtovic-Todorovic, András Palotás, Misha Perouansky, Emmanuel Planel, Jeffrey H. Silverstein, Huafeng Wei, Robert A. Whittington, Zhongcong Xie, and Zhiyi Zuo

Anesth Analg 2009 108: 1627-1630.

在一側頸動脈完全性結紮加嚴重低血壓的小鼠模型中去氧腎上腺素可以改善大腦細胞毒性水腫並減少腦梗塞體積

姜旭暉譯，馬皓琳，李士通校

Phenylephrine Ameliorates Cerebral Cytotoxic Edema and Reduces Cerebral Infarction Volume in a Rat Model of Complete Unilateral Carotid Artery Occlusion with Severe Hypotension

Seiji Ishikawa, Hiroyuki Ito, Kuninori Yokoyama, and Koshi Makita
Anesth Analg 2009 108: 1631-1637.

引導或可曲纖維支氣管鏡引導經口氣管插管對頸椎移動影響的比較

丁俊雲　譯　陳傑　校

A Comparison of Cervical Spine Motion During Orotracheal Intubation with the Trachlight® or the Flexible Fiberoptic Bronchoscope

Bryan J. Houde, Stephan R. Williams, Alexandre Cadrin-Chênevert, François Guilbert, and Pierre Drolet

Anesth Analg 2009 108: 1638-1643.

ANALGESIA:

腦卒中後神經痛：關於其病理生理機制及治療的綜述

陳珺珺譯 薛張綱校

Central Poststroke Pain: A Review of Pathophysiology and Treatment

Bishwanath Kumar, Jayantee Kalita, Gyanendra Kumar, and Usha K. Misra

Anesth Analg 2009 108: 1645-1657.

透視引導下正中入路頸段硬膜外注射：硬膜外腔造影圖分析

葉樂　譯　陳傑　校

Fluoroscopically Guided Cervical Interlaminar Epidural Injections Using the Midline Approach: An Analysis of Epidurography Contrast Patterns (Brief Report)

Kwang Su Kim, Sung Sik Shin, Tae Sam Kim, Chang Young Jeong, Myung Ha Yoon, and Jeong Il Choi

Anesth Analg 2009 108: 1658-1661.

大轉子疼痛綜合征：關於解剖、診斷和治療方面的綜述

陳珺珺譯 薛張綱校

Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment (Review Article)

Bryan S. Williams and Steven P. Cohen

Anesth Analg 2009 108: 1662-1670.

阿米替林在一種大鼠神經性疼痛模型中對L5背根初級傳入纖維異位放電的影響

顔濤 譯， 馬皓琳  李士通 校

The Effect of Amitriptyline on Ectopic Discharge of Primary Afferent Fibers in the L5 Dorsal Root in a Rat Model of Neuropathic Pain

Xin Su, Annie H. Liang, and Mark O. Urban

Anesth Analg 2009 108: 1671-1679.

急性炎性疼痛模型中外周給予胞二磷膽鹼（CDP－膽鹼）的效應：7煙鹼乙酰膽鹼受體的作用

宋翠俠　譯　陳傑　校

The Effect of Peripherally Administered CDP-Choline in an Acute Inflammatory Pain Model: The Role of 7 Nicotinic Acetylcholine Receptor

Mine Sibel Gurun, Renee Parker, James C. Eisenach, and Michelle Vincler

Anesth Analg 2009 108: 1680-1687.

在超聲引導下持續肌間溝臂叢神經阻滯:一項隨機、三盲、安慰劑對照研究

陳珺珺譯 薛張綱校

Continuous Interscalene Brachial Plexus Block via an Ultrasound-Guided Posterior Approach: A Randomized, Triple-Masked, Placebo-Controlled Study

Edward R. Mariano, Robert Afra, Vanessa J. Loland, NavParkash S. Sandhu, Richard H. Bellars, Michael L. Bishop, Gloria S. Cheng, Lynna P. Choy, Rosalita C. Maldonado, and Brian M. Ilfeld

Anesth Analg 2009 108: 1688-1694.

一項比較超聲和神經刺激作爲穿刺針引導行肌間溝導管放置的前瞻性隨機試驗

黃施偉 譯，馬皓琳 李士通 校

A Prospective Randomized Comparison of Ultrasound and Neurostimulation as Needle End Points for Interscalene Catheter Placement

Michael J. Fredrickson, Craig M. Ball, Adam J. Dalgleish, Alistair W. Stewart, and Tim G. Short

Anesth Analg 2009 108: 1695-1700.

大鼠側路經皮星狀神經節阻滯技術

張燕　譯　陳傑　校）

A Lateral Percutaneous Technique for Stellate Ganglion Blockade in Rats

Nebahat Gulcu, Ersoz Gonca, and Hasan Kocoglu

Anesth Analg 2009 108: 1701-1704.

體表解剖標誌判斷棘突節段用來行胸段硬膜外穿刺

陳珺珺譯 薛張綱校

Surface Anatomy as a Guide to Vertebral Level for Thoracic Epidural Placement

Desiree A. Teoh, Kristi L. Santosham, Carmen C. Lydell, Dean F. Smith, and Michael T. Beriault

Anesth Analg 2009 108: 1705-1707.

在健康志願者應用磁共振成像進行骶旁阻滯的解剖學研究

朱 慧譯 馬皓琳 李士通校

An Anatomical Study of the Parasacral Block Using Magnetic Resonance Imaging of Healthy Volunteers

Maeve O'Connor, Margaret Coleman, Fintan Wallis, and Dominic Harmon

Anesth Analg 2009 108: 1708-1712.

心臟手術病人術中應用經食道超聲心動描記術測量腎血流量的可行性研究

The Feasibility of Measuring Renal Blood Flow Using Transesophageal Echocardiography in Patients Undergoing Cardiac Surgery

Ping-Liang Yang, David T. Wong, Shuang-Bo Dai, Hai-Bo Song, Ling Ye, Jin Liu, and Bin Liu

From the *Department of Anesthesiology, West China Second University Hospital, Sichuan University, People's Republic of China; Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada; and Department of Anesthesiology, West China Hospital, Sichuan University, People's Republic of China.

Anesth Analg 2009 108: 1418-1424.

 

背景：現在尚沒有可在術中監控腎血流量的可靠方法。在本次研究中，我們評估了在心臟手術術中應用經食道超聲心動描記術進行左腎血流量測量的可行性及其可重復性。

方法：此次前瞻性研究應用經食道超聲心動描記術對行心臟手術的60位患者進行左腎血流量的測量，並無人爲干預因素，共有三個測量時間點（分別爲心肺動脈分流術術前，術中和術後）。六份超聲圖樣本是通過雙盲的方法由兩位獨立的技術員在測量即刻及六個月之後分別進行分析解釋獲得的。各個測量組內及組間的可重復性已通過計算變異率和層級相關係數的方法進行了量化。

結果：多普勒角度大於30度的病人（60個樣本中有20個）被排除在這次腎血流量測量研究之外。在所有的60個樣本中有36個樣本（60%）的左腎血流量被成功的測量分析。各個測量組內及組間的變異率均小於10%。左腎血流量測量組內及組間的可重復性也達到好甚至極好的水平（層級相關係數爲0.604-0.999）。心肺動脈分流術術前，術中和術後三個階段的左腎動脈管腔直徑範圍爲3.8—4.1mm，腎動脈血流速度範圍爲25—35cm/s，腎血流量爲192—299mL/min。

結論：在行心臟手術的病人中，應用經食道超聲心動描記術測量左腎血流量的方法對於60%的病例具有可行性。各個腎血流量測量組內及組間的可重復性也已達到好甚至

（單嘉琪譯 薛張綱校）

BACKGROUND: There is no reliable method to monitor renal blood flow intraoperatively. In this study, we evaluated the feasibility and reproducibility of left renal blood flow measurements using transesophageal echocardiography during cardiac surgery.

METHODS: In this prospective noninterventional study, left renal blood flow was measured with transesophageal echocardiography during three time points (pre-, intra-, and postcardiopulmonary bypass) in 60 patients undergoing cardiac surgery. Sonograms from 6 subjects were interpreted by 2 blinded independent assessors at the time of acquisition and 6 mo later. Interobserver and intraobserver reproducibility were quantified by calculating variability and intraclass correlation coefficients.

RESULTS: Patients with Doppler angles of >30[degrees] (20 of 60 subjects) were eliminated from renal blood flow measurements. Left renal blood flow was successfully measured and analyzed in 36 of 60 (60%) subjects. Both interobserver and intraobserver variability were <10%. Interobserver and intraobserver reproducibility in left renal blood flow measurements were good to excellent (intraclass correlation coefficients 0.604-0.999). Left renal arterial luminal diameter for the pre, intra, and postcardiopulmonary bypass phases, ranged from 3.8 to 4.1 mm, renal arterial velocity from 25 to 35 cm/s, and left renal blood flow from 192 to 299 mL/min.

CONCLUSION: In patients undergoing cardiac surgery, it was feasible in 60% of the subjects to measure left renal blood flow using intraoperative transesophageal echocardiography. The interobserver and intraobserver reproducibility of renal blood flow measurements was good to excellent.

 

血液凝固：止血措施與凝血酶的調節

Blood coagulation: hemostasis and thrombin regulation.

Tanaka KA, Key NS, Levy JH

From the *Division of Cardiothoracic Anesthesia and Critical Care, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia; and Division of Hematology, Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Anesth Analg 2009 108: 1433-1446.

                                                                          

隨著越來越多的強效抗凝藥物在臨床使用，控制圍手術期出血顯然已成爲一項重要挑戰。瞭解最新的血液凝固概念對於在術前探討患者的出血風險和制定圍手術期止血措施是十分重要的。絲氨酸蛋白凝血酶在其他絲氨酸蛋白酶原（無效酶前體）、輔助因數及細胞表面受體的啟動過程中起著決定性作用。當創傷發生後，凝血酶被就近調節生成並迅速達到局部産生止血作用，但其卻不會導致全身失控性的血栓形成。出血/血液稀釋、輸血和外科手術壓迫是手術過程中干擾血液凝固和炎症系統的最主要因素。術後出血往往需要異體輸血，異體輸血不僅提供止血措施，更可促成凝血酶的生成。然而，由於術後促凝活性物質和炎症反應的增加，抗栓治療可能被用於預防圍手術期血栓並發症。隨著新型止血藥物和抗凝藥物的引入，實施圍手術期止血及預防血栓形成的方法已取得重要進展。可由於傳統的血凝試驗並不能完整反映血液凝固的生理過程，故目前的治療局限了最佳的藥理學療法的實施。瞭解凝血酶的體內調節機制和藥理學變化可有助於控制圍手術期出血，並顯著減少血栓形成的危險性。此篇綜述運用多個簡化的血液凝固模型來關注止血措施和凝血酶形成的調節機制。

（范羽譯 薛張綱校）

Perioperative bleeding is a major challenge particularly because of increasing clinical use of potent antithrombotic drugs. Understanding current concepts of coagulation is important in determining the preoperative bleeding risk of patients, and in managing hemostatic therapy perioperatively. The serine protease thrombin plays pivotal roles in the activation of additional serine protease zymogens (inactive enzymatic precursors), cofactors, and cell-surface receptors. Thrombin generation is closely regulated to locally achieve rapid hemostasis after injury without causing uncontrolled systemic thrombosis. During surgery, there are major disturbances in coagulation and inflammatory systems because of hemorrhage/hemodilution, blood transfusion, and surgical stresses. Postoperative bleeding often requires allogeneic blood transfusions, which support thrombin generation and hemostasis. However, procoagulant activity and inflammation are increased postoperatively; thus, antithrombotic therapy may be required to prevent perioperative thrombotic complications. There have been significant advances in the management of perioperative hemostasis and thrombosis because of the introduction of novel hemostatic and antithrombotic drugs. However, a limitation of current treatment is that conventional clotting tests do not reflect the entire physiological processes of coagulation making optimal pharmacologic therapy difficult. Understanding the in vivo regulatory mechanisms and pharmacologic modulation of thrombin generation may help control bleeding without potentially increasing prothrombotic risks. In this review, we focus on the regulatory mechanisms of hemostasis and thrombin generation using multiple, simplified models of coagulation.

 

兒童喉部度量的年齡相關分析

Pediatric laryngeal dimensions: an age-based analysis.

Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D.

From the *Department of Anesthesiology, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania; Department of Anesthesiology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri; Department of Otolaryngology/Head and Neck Surgery Lucile Packard Children's Hospital, Stanford University, Palo Alto, California; ||Kaiser Foundation Hospital, Oakland, California; ¶Department of Anesthesiology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri; and #Department of Otolaryngology, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri.

Anesth Analg 2009 108: 1475-1479

 

背景：在兒童，環狀軟骨是漏斗狀氣道的最狹窄部分。隨著生長發育，它逐漸轉變成爲成人的圓筒狀氣道。許多的兒童氣道評估正是基於這種氣道轉變過程的理論。本研究的主要目標是測量各年齡兒童的氣道。我們通過測量聲門和環狀軟骨區，來觀察用可視支氣管鏡圖像是否可以分辨由兒童的漏斗狀氣道向成人的圓筒狀氣道轉化的過程。

方法：年齡在6個月至13歲，共135名ASA分級在1~2級的兒童在全麻下經由可視支氣管鏡接受了喉部測量。測量資料包括聲門和環狀軟骨水平的橫斷面積(C-CSA)，前後徑和橫徑。

結果：在135名接受檢測的兒童中，有7例由於檢測所得圖像質量較差而被剔除。實際參與研究的兒童有128名，其中男孩79名和女孩49名。平均年齡5.9+/-3.3歲，平均身高爲113.5+/-22.2cm，平均體重爲23.5+/-13Kg。C-CSA平均值爲48.9+/-15.5mm，大於G-CSA的平均值30+/-16.5mm，且在自6月齡開始(P<0.001,r=0.45,power=1)的所有研究物件中，C-CSA值均大於G-CSA。C-CSA:G-CSA的平均率爲2.1+/-1.2。G-CSA和C-CSA的具有正相關性，相對於與年齡(r=0.36,P<0.001;r=0.27,P=0.001),身高(r=0.34,P<0.001;r =0.29,P<0.001)及體重(r=0.35,P<0.001;r=0.25,P=0.003).未觀察到研究資料中在不同性別間存在顯著差異。

結論：本次關於嬰幼兒的研究中，與環狀軟骨相比，聲門才是兒童氣道最狹窄的部位。由支氣管鏡圖像可看出，兒童氣道與成人相似，更爲接近圓筒狀而不是漏斗狀。還需要進一步的研究來證實，這些麻醉狀態下對氣道的靜態測量是否可以反應兒童聲門和環狀軟骨的動態特性。

（黃劍譯 薛張綱校）

BACKGROUND: In children, the cricoid is considered the narrowest portion of the "funnel-shaped" airway. Growth and development lead to a transition to the more cylindrical adult airway. A number of airway decisions in pediatric airway practice are based on this transition from the pediatric to the adult airway. Our primary aim in this study was to measure airway dimensions in children of various ages. The measures of the glottis and cricoid regions were used to determine whether a transition from the funnel-shaped pediatric airway to the cylindrical adult airway could be identified based on images obtained from video bronchoscopy.

METHODS: One hundred thirty-five children (ASA physical status 1 or 2) aged 6 mo to 13 yr were enrolled for measurement of laryngeal dimensions, including cross-sectional area (G-CSA), anteroposterior and transverse diameters at the level of the glottis and the cricoid (C-CSA), using the video bronchoscopic technique under general anesthesia.

RESULTS: Of the 135 children enrolled in the study, seven patients were excluded from the analysis mainly because of poor image quality. Of the 128 children studied (79 boys and 49 girls), mean values (+/-standard deviation) for the demographic data were age 5.9 (+/-3.3) yr, height 113.5 (+/-22.2) cm and weight 23.5 (+/-13) kg. Overall, the mean C-CSA was larger than the G-CSA (48.9 +/- 15.5 mm(2) vs 30 +/- 16.5 mm(2), respectively). This relationship was maintained throughout the study population starting from 6 mo of age (P < 0.001, r = 0.45, power = 1). The mean ratio for C-CSA: G-CSA was 2.1 +/- 1.2. There was a positive correlation between G- and the C-CSA versus age (r = 0.36, P < 0.001; r = 0.27, P = 0.001, respectively), height (r = 0.34, P < 0.001; r = 0.29, P < 0.001, respectively), and weight (r = 0.35, P < 0.001; r = 0.25, P = 0.003, respectively). No significant gender differences in the mean values of the studied variables were observed.

CONCLUSION: In this study of infants and children, the glottis rather than cricoid was the narrowest portion of the pediatric airway. Similar to adults, the pediatric airway is more cylindrical than funnel shaped based on these video bronchoscopic images. Further studies are needed to determine whether these static airway measurements in anesthetized and paralyzed children reflect the dynamic characteristics of the glottis and cricoid in children.

 

 

腹股溝壓迫，瓦耳薩耳瓦氏手法以及反向特倫德倫伯氏臥位對兒童股動脈橫截面積的影響

The effect of inguinal compression, Valsalva maneuver, and reverse Trendelenburg position on the cross-sectional area of the femoral vein in children.

Jin-Tae Kim, Chun-Soo Park, Hyun Jung Kim, Jung-Man Lee, Hee-Soo Kim, Chong-Sung Kim, and Seong-Deok Kim

From the Departments of *Anesthesiology and Pain Medicine, and Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea.

Anesth Analg 2009 108: 1493-1496.

     

背景： 對於簡易化股靜脈插管術，更大橫斷面積(CSA)的靜脈是有利的，並且可以通過腹股溝壓迫、瓦耳薩耳瓦氏手法或者反向特倫德倫伯臥位來獲得。在本研究中，我們通過超生波檢查評估了這些方法在兒童中應用的效果。

方法：用超聲檢查測量50位已麻醉小兒科患者的股靜脈橫截面積(小組L：25名患者大於2歲；小組S：25名患者小於2歲)。分別測量了以下六種情況下的股靜脈橫截面：1)仰臥位元(控制)，2)用手指壓迫腹股溝韌帶，3)15度的特倫德倫伯臥位，4)15度特倫德倫伯臥位加腹股溝壓迫，5)瓦耳薩耳瓦氏手法，6)在反向15度的特倫德倫伯臥位。我們定義20%的橫截面積改變爲具有臨床意義。

結果： 腹股溝壓迫在小組L增加了股靜脈40%的橫截面積，而在小組S增加了57% (P < 0.001)。腹股溝壓迫加特倫德倫伯臥位在小組L也增加了43%的橫截面，在小組S則增加了73%(P < 0.001)。 瓦耳薩耳瓦氏手法對於股靜脈橫截面積的增加在小組S中比小組L更有效。特倫德倫伯臥位或者反向特倫德倫伯臥位對於股靜脈橫截面積的改變都不具有臨床意義。

結論： 腹股溝壓迫可有效地增加股靜脈的橫截面積，並且在特倫德倫伯臥位時它的作用也是顯著的。瓦耳薩耳瓦氏手法對2歲以下兒童更有效。而重心位置改變對兒童股靜脈橫截面的改變影響很小。

（李瑩譯 薛張綱校）

BACKGROUNDS: For facilitation of femoral venous cannulation, the larger cross-sectional area (CSA) of the vein is helpful and can be achieved by inguinal compression, Valsalva maneuver, or the reverse Trendelenburg position. In this study, we evaluated these methods using ultrasonography in children.

METHODS: Ultrasound was used to measure the CSA of the common femoral vein of 50 anesthetized pediatric patients (Group L: 25 patients more than 2 yr, Group S: 25 patients younger than 2 yr). The following six measurements of the CSA of the femoral vein were made: 1) in the supine position (control), 2) with digital compression above the inguinal ligament, 3) in the Trendelenburg position 15 degrees , 4) in the Trendelenburg position 15 degrees plus inguinal compression, 5) with Valsalva maneuver, and 6) in the reverse Trendelenburg position 15 degrees . We defined 20% change of the CSA as clinically significant.

RESULTS: Inguinal compression increased the CSA of the femoral vein by 40% in Group L and by 57% in Group S (each P < 0.001). Inguinal compression during the Trendelenburg position also increased the CSA by 43% in Group L and by 73% in Group S (each P < 0.001). Valsalva maneuver for increasing the CSA of the femoral vein was more effective in Group S (increased by 35%) than in Group L (by 19%). The changes in the CSA were not clinically significant during the Trendelenburg position or the reverse Trendelenburg position.

CONCLUSIONS: Inguinal compression effectively increases the CSA of the femoral vein and its effect is also prominent in the Trendelenburg position. Valsalva maneuver is more effective in small children. Gravitational position changes have little effect on the size of the femoral vein in children.

 

 

志願者中聯合應用腦電圖和聽覺誘發電位鑒別麻醉深度

A Combination of Electroencephalogram and Auditory Evoked Potentials Separates Different Levels of Anesthesia in Volunteers

Bettina Horn, MD^*, Stefanie Pilge, MD^*, Eberhard F. Kochs, MD^*, Gudrun Stockmanns, PhD, Andreas Hock, MSc^*, and Gerhard Schneider, MD^*

From the *Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich; and Institute of Information Logistics, Department of Computer Science and Applied Cognitive Science, University of Duisburg-Essen, Germany.

Anesth Analg 2009 108: 1512-1521.

 

背景：研究顯示聯合應用腦電圖和聽覺誘發電位能很好的鑒別有意識和無意識狀態。在這個研究中，我們找到一種結合腦電圖和聽覺誘發電位的指示器，不但能鑒別有意識和無意識，同時能區分出不同的麻醉深度。

方法：十五名試驗前未用藥的志願者在這個隨機化交叉對照試驗的兩個連續試驗階段中分別接受七氟醚或者異丙酚單純麻醉。意識喪失和腦電爆發抑制分別作爲全麻的起點和終點。除了這兩個極點外，兩個介於意識消失和腦電爆發抑制之間的麻醉深度將整個過程分成三個等分的階段。這樣的資訊設計用於檢測先前描述過的聯合腦電聽覺誘發電位指示器（意識檢測器）能否區別出清醒狀態和腦電爆發抑制之間不同的麻醉狀態。還有，一個在現有研究基礎上改進的聯合腦電和聽覺誘發電位的指示器隨後在同樣的病人資訊下用於檢測區別清醒和意識消失的能力。

結果：先前的意識指示器在本次研究中區分不同麻醉深度的預測概率（P_K）爲0.77，改進後的新的指示器的預測概率爲0.94。這個新的指示器應用於先前的研究中的預測概率爲0.89。

結論：這些結果顯示結合了腦電圖和聽覺誘發電位的新型指示器能夠區分出從清醒狀態至深度麻醉（即腦電爆發抑制）之間不同的麻醉深度。

（姚敏敏譯 薛張綱校）

BACKGROUND: It has been shown that the combination of electroencephalogram (EEG) and auditory evoked potentials (AEP) allows a good separation of consciousness from unconsciousness. In the present study, we sought a combined EEG/AEP indicator that allows both separation of consciousness from unconsciousness and discrimination among different levels of sedation and hypnosis over a wider range of anesthesia.

METHODS: Fifteen unpremedicated volunteers received mono-anesthesia with sevoflurane or propofol in a randomized crossover design in two consecutive sessions. Loss of consciousness (LOC) and EEG burst suppression (BSP) defined end-points from the upper and lower range of general anesthesia. In addition to those two extremes, the difference between anesthetic concentration at BSP and LOC was divided into three equal intervals, resulting in two intermediate levels which divided the concentration from LOC (minimum) to BSP (maximum) into three equal steps. This data set was used to test whether a previously described combined EEG/AEP indicator "detector of consciousness" can also discriminate among degrees of anesthetic effects from the awake state to BSP. Furthermore, a new improved combined EEG/AEP indicator was developed on the basis of the data from the current study, and subsequently this new indicator was tested for its ability to separate consciousness from unconsciousness with the patient data set.

RESULTS: The former "detector of consciousness" showed a prediction probability (P_K) of 0.77 to separate different levels of anesthesia from the current study, whereas for the new combined EEG/AEP indicator, P_K was 0.94. The new indicator was further applied to the previous study and achieved a P_K of 0.89.

CONCLUSIONS: These results show that with the new indicator presented here, a combination of EEG and AEP parameters can be used to differentiate degrees of anesthetic effects over a wide range of hypnosis, from the conscious state to deep anesthesia (i.e., BSP).

 

 

通過報警延遲和臨床表現改善重症監護室的報警

Improving Alarm Performance in the Medical Intensive Care Unit Using Delays and Clinical Context

Matthias Görges, MS, Boaz A. Markewitz, MD, and Dwayne R. Westenskow, PhD

From the Department of Anesthesiology, University of Utah; and Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah.

Anesth Analg 2009 108: 1546-1552.

 

介紹：在重症監護室，報警器用來引起對病人的注意，警惕病人的生理學變化，或者對醫學設備故障發出警告；然而，高達94%的報警器是錯誤的。我們在這項研究中的目的是確定一種方法以減少錯誤報警的數量。

方法：一個觀察員記錄警報計時列印資訊和健康監護組員在病人房間裏出場的情況；每個警報反應被分類成有效（5分鐘之內採取行動），無效（對警報無反應），和忽略（警報被有意忽略或者靜音）。

結果：在200個小時的研究期間，1271個單獨個體進入被觀察的房間，發生1214次警報以及2344次任務被執行。平均而言，警報每小時發生6.07次，每小時中有3.28分鐘處於報警狀態；23%是有效的，36%無效，41%被忽略。報警持續時間平均爲17秒。14秒的報警延遲可以減少50%的被忽略和無效報警，而19秒的延遲可以減少67%。吸引器，洗滌，重新配置和口腔護理引發152次被忽略或者無效呼吸機報警。

討論：介紹了19秒的報警延遲和自動檢測吸引器，重新配置，口腔護理和洗滌器可以將無效和被忽略報警次數從934減少到274。更多可靠的報警可以引起計時的反應，減少工作負擔，減輕噪音污染，潛在的提高病人的安全。

（俞佳譯 薛張綱校）

INTRODUCTION: In an intensive care unit, alarms are used to call attention to a patient, to alert a change in the patient's physiology, or to warn of a failure in a medical device; however, up to 94% of the alarms are false. Our purpose in this study was to identify a means of reducing the number of false alarms.

METHODS: An observer recorded time-stamped information of alarms and the presence of health care team members in the patient room; each alarm response was classified as effective (action taken within 5 min), ineffective (no response to the alarm), and ignored (alarm consciously ignored or actively silenced).

RESULTS: During the 200-h study period, 1271 separate entries by an individual to the room being observed were recorded, 1214 alarms occurred and 2344 tasks were performed. On average, alarms occurred 6.07 times per hour and were active for 3.28 min per hour; 23% were effective, 36% were ineffective, and 41% were ignored. The median alarm duration was 17 s. A 14-s delay before alarm presentation would remove 50% of the ignored and ineffective alarms, and a 19-s delay would remove 67%. Suctioning, washing, repositioning, and oral care caused 152 ignored or ineffective ventilator alarms.

DISCUSSION: Introducing a 19-s alarm delay and automatically detecting suctioning, repositioning, oral care, and washing could reduce the number of ineffective and ignored alarms from 934 to 274. More reliable alarms could elicit more timely response, reduce workload, reduce noise pollution, and potentially improve patient safety.

 

 

圍手術期麻醉醫師關於口腔問題的考慮

Perioperative Dental Considerations for the Anesthesiologist

Jeffrey S. Yasny

From the Department of Anesthesiology, The Mount Sinai School of Medicine, New York.

Anesth Analg 2009 108: 1564-1573.

 

儘管麻醉醫師一貫在病人口腔裏進行操作，但他們可能並沒有接受過有關牙齒及其周圍組織以及口腔修復的系統性的教育。由於圍手術期口腔損傷是最常見的麻醉相關性不良事件之一並且是衆多針對麻醉醫師的醫療事故投訴的元兇，所以一系列口腔問題的考慮是值得的。圍手術期口腔創傷的可能性隨著病人牙齒最弱性和相關麻醉危險因素出現的增加而增加。減少口腔損傷始于麻醉醫師術前對病人牙齒和口腔組織狀況的評估。清楚地記錄病人術前口腔條件並告知病人口腔損害的可能性將減少相關的術後口腔治療。基於發現一個潛在的危險的口腔條件，外科處理前需考慮求助口腔科醫生提供解決之道。在做諸如喉鏡檢查和氣管內插管等刺激性操作時實施謹慎的措施可幫助預防口腔損傷。在一個這樣的損傷事件中，數種處理策略可提供一個快速有效的解決方法。給予口內條件和相關圍術期風險因素更多的關注可減少發生口腔損傷的幾率和經濟代價。

（張玥琪譯，薛張綱校）

Although anesthesiologists consistently work in the mouth of patients, they may not have been exposed to a comprehensive education of teeth, surrounding tissues, and intraoral prostheses. Since perioperative dental damage is one of the most common anesthesia-related adverse events and is responsible for the greatest number of malpractice claims against anesthesiologists, several dental considerations are warranted. The likelihood of perioperative dental trauma increases with the vulnerability of a patient's dentition and the presence of associated anesthesia risk factors. Minimizing dental injuries begins with the anesthesiologist's preoperative assessment of the patient's dentition and intraoral tissues. Clear documentation of the patient's preoperative dental condition and notifying the patient of the potential dental damage will diminish costs for any related postoperative dental treatment. Upon discovery of a potentially hazardous dental condition, a consultation with a dentist should be considered before proceeding with the surgical procedure. Exercising cautionary measures during provocative events, such as laryngoscopy and tracheal extubation, can aid in the prevention of dental trauma. In the event of such an injury, several management tactics can promote a swift and reasonable resolution. Establishing an increased awareness of intraoral conditions and the related perioperative risk factors may diminish the incidence of dental damage and financial costs.

 

 

在脊麻剖宮産中應用單一膠體擴容與晶膠合用相比對母體心輸出量的影響

Colloid preload versus coload for spinal anesthesia for cesarean delivery: the effects on maternal cardiac output.

Teoh WH, Sia AT.

Department of Women's Anesthesia, KK Women's and Children's Hospital, Singapore.

Anesth Analg 2009 108: 1592-1598.

 

背景：脊麻對於剖宮産病人可引發嚴重的母體低血壓，心輸出量（ＣＯ）減少和胎盤血流量降低。由於快速的組織再分佈，預先輸入晶體液對脊麻的副作用無效。在脊麻過程回抽到腦脊液的同時給予晶膠混合擴容可能有更好的效果。這裏所說的無效假設是：給予脊麻剖宮産婦膠體擴容（15 mL/kg羥乙基澱粉（賀斯）130/0.4 [Voluven 6%]）和同等量的晶膠混合擴容對於母體心排量和低血壓的發生率無區別。其次研究分娩後新生兒體內酸堿平衡及分娩前血管升壓藥的需要量。

方法：募集40名ASA評分I 和 II的擇期剖宮産婦，隨機分配到P組（給予15 mL/kg 賀斯擴容）或C組（在確認回抽到腦脊液時給予晶膠混合擴容）。使用USCOM超聲心排量監測儀記錄患者心率、動脈血壓、每搏輸出量、和心排血量基線，每分鐘記錄一次連續10分鐘，後每2.5分鐘記錄一次連續10分鐘。脊麻需右側臥位於腰3/4椎間隙實施。彈丸式注射新福林維持動脈血壓在基線的90%-100% 。

結果：人口學特徵、麻醉劑以及外科特點相似。基線收縮壓、心率和膠體容量無組間差異。脊麻後5分鐘內P組病人的心排量和每搏輸出量顯著增加(P = 0.01) ，但心排量的增加維持不到10分鐘。而低血壓的發生率、絕對動脈血壓值(P = 0.73)、分娩前新福林需要量（P組需要量中位元值300毫克（0－1000mg），C組中位值150毫克（0－850mg），P = 0.24），新生兒出生後的Apgar評分以及臍動脈和臍靜脈的血氣分析均無顯著差異。

結論：靜脈使用15 mL/kg賀斯130/0.4擴容增加前負荷相對於晶膠混合使用可使脊麻剖宮産病人的心排量在麻醉後5分鐘內有顯著增加，然而，對於母體和新生兒的影響無差異。

（張釗譯 薛張綱校）

BACKGROUND: Spinal anesthesia for cesarean delivery may cause severe maternal hypotension, and a decrease in cardiac output (CO) and blood flow to the placenta. Fluid preloading with crystalloid is ineffective due to rapid redistribution. A "coload" given at the time of cerebrospinal fluid identification may be more effective. Our null hypothesis was that there would be no difference between the effect of a colloid preload (15 mL/kg hydroxyethyl starch (HES) 130/0.4 [Voluven 6%]) and an identical coload on maternal CO and the incidence of hypotension after spinal anesthesia for cesarean delivery. Secondary outcomes studied were neonatal acid- base status and predelivery vasopressor requirements.

METHODS: Forty ASA PS I and II women scheduled for elective cesarean delivery were recruited. Patients were randomized to Group P (preload of 15 mL/kg HES) or Group C (coload, given when cerebrospinal fluid identified). Heart rate, arterial blood pressure, stroke volume and CO measurements were recorded at baseline, every minute for 10 min, and every 2.5 min interval for 10 min with the USCOM ultrasonic CO monitor. Spinal anesthesia was performed at the L3/4 interspace in the right lateral position. Arterial blood pressure was maintained at 90%-100% of baseline values using IV phenylephrine boluses.

RESULTS: Demographic, anesthetic, and surgical characteristics were similar. There were no between-group differences in baseline systolic blood pressure, heart rate, and colloid volume. CO and stroke volume were significantly increased in Group P (P = 0.01) in the 5 min after spinal anesthesia. This increase in CO was not sustained at 10 min. There were no significant between-group differences in the incidence of hypotension, absolute arterial blood pressure values (P = 0.73), predelivery median (range) phenylephrine requirements (300[0-1000] in Group P versus 150 [0-850]microg in Group C, P = 0.24), or neonatal outcome as measured by Apgar scores and umbilical arterial and venous blood gas values.

CONCLUSION: Intravascular volume expansion with 15 mL/kg HES 130/0.4 given as a preload, but not coload, significantly increased maternal CO for the first 5 min after spinal anesthesia for cesarean delivery, however, maternal and neonatal outcomes were not different.

 

 

一致聲明：首屆麻醉藥與阿爾海默茨病國際研討會                        

Consensus Statement: First International Workshop on Anesthetics and Alzheimer’s Disease 
Dmitri Baranov, Philip E. Bickler, Gregory J. Crosby, Deborah J. Culley, Maryellen F. Eckenhoff, Roderic G. Eckenhoff, Kirk J. Hogan, Vesna Jevtovic-Todorovic, András Palotás, Misha Perouansky, Emmanuel Planel, Jeffrey H. Silverstein, Huafeng Wei, Robert A. Whittington, Zhongcong Xie, and Zhiyi Zuo

From the *Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Anesthesia, University of California San Francisco Medical Center, San Francisco, California; Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin; ||Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia; ¶Asklepios-Med Bt, Szeged, Hungary; #Department of Pathology, Taub Institute for Alzheimer’s Disease Research, Columbia University Medical Center; **Department of Anesthesiology, Mount Sinai School of Medicine of New York University; Department of Anesthesiology, Columbia University Medical Center, New York City, New York; and Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2009 108: 1627-1630.

 

爲了綜合考查麻醉藥與阿爾還默茨病潛在關係研究的目前狀況，一些科學家最近在費城開了整天的會來陳述和討論相關內容。這篇文章提出了阿爾還默茨病與麻醉藥可能存在關聯的一致觀點，並指出了接下來爲決定性測試這一結論所需要的措施。

（朱蘭芳譯 薛張綱校）

In order to review the current status of the potential relationship between anesthesia and Alzheimer’s disease, a group of scientists recently met in Philadelphia for a full day of presentations and discussions. This special article represents a consensus view on the possible link between Alzheimer’s disease and anesthesia and the steps required to test this more definitively.

 

 

腦卒中後神經痛：關於其病理生理機制及治療的綜述

Central Poststroke Pain: A Review of Pathophysiology and Treatment

Bishwanath Kumar, MD, Jayantee Kalita, DM, Gyanendra Kumar, MD, and Usha K. Misra, DM

From the Department of Neurology Sanjay Gandhi PGIMS, Lucknow, India.

Anesth Analg 2009 108: 1645-1657

 

背景：腦卒中後神經痛（CPSP）可以導致患者勞動力喪失，它在腦卒中病人中的發生率是8%–14%。這種現象沒有得到重視且沒有很好的治療方法。

目的：我們系統的回顧了CPSP的病理生理及治療。

方法：我們使用Medline，輸入關鍵字" central post-stroke pain," "post-stroke pain," "CPSP and basic studies," "CPSP and clinical features," "CPSP and pharmacological treatment," "CPSP and nonpharmacological treatment" 和"CPSP and treatment guideline." 文章分成幾類：臨床表現、病理生理和治療，然後系統地復習。

結果：腦卒中後一段時間，通常是1-2月，腦卒中引起的脊髓丘腦束通路受損可引起CPSP。CPSP可以是自發的或是有誘因的，它的嚴重程度不盡相同。隨著時間它的症狀回有所緩解。CPSP的症狀可以是輕度的運動障礙或是關節的位置覺和振動覺受損。CPSP的病理生理尚不是十分清楚，但是和中樞去抑制、中樞刺激和致敏的失衡有關。關於治療有I和II兩種。阿米替林和拉莫三嗪（IIB類）是一線用藥，慢心律、氟甲沙明和加巴噴丁是二線用藥。對於産生耐藥的病人，反復的經顱磁刺激和深部腦刺激是可選的方法

結論：CPSP的病人會出現不同的感覺症狀，它發生的病理生理機制尚不是十分清楚。阿米替林和拉莫三嗪是有效的治療藥物。我們尚需要進一步研究其發生的病理生理機制，並探索新的治療方法。

（陳珺珺譯 薛張綱校）

BACKGROUND: Central poststroke pain (CPSP) is a disabling morbidity occurring in 8%–14% of patients with stroke. It is infrequently recognized and difficult to manage.

OBJECTIVE: We systematically reviewed the pathophysiology and treatment of CPSP.

METHODS: We conducted a Medline search using the key words "central post-stroke pain," "post-stroke pain," "CPSP and basic studies," "CPSP and clinical features," "CPSP and pharmacological treatment," "CPSP and nonpharmacological treatment" and "CPSP and treatment guideline." The articles related to CPSP were categorized into clinical features, pathophysiology and treatment, and then systematically reviewed.

RESULTS: Stroke along the spinothal amocortical pathway may result in CPSP after a variable period, usually after 1–2 mo. CPSP may be spontaneous or evoked, variable in intensity and quality. It tends to improve with time. CPSP is associated with mild motor symptoms with relative sparing of joint position and vibration sensations. The pathophysiology of CPSP is not well understood, but central disinhibition, imbalance of stimuli and central sensitization have been suggested. There are few class I and class II studies regarding its management. Amitriptyline and lamotrigine (class IIB) are recommended as first-line and  mexiletine, fluvoxamine and gabapentin as second-line drugs. In pharmacoresistant patients, repetitive transcranial magnetic stimulation and deep brain stimulation have been beneficial.

CONCLUSIONS: CPSP patients present with diverse sensory symptoms and its pathophysiology is still poorly understood. Amitriptyline and lamotrigine are effective treatments. Further studies are needed to understand the pathophysiology and investigate newer therapeutic modalities.

大轉子疼痛綜合征：關於解剖、診斷和治療方面的綜述

Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment

Bryan S. Williams, MD, MPH^*, and Steven P. Cohen, MD

From the *Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, and Walter Reed, Army Medical Center, Washington, DC.

Anesth Analg 2009 108: 1662-1670

 

大轉子疼痛綜合征（GTPS）指的是髖部外側部的慢性疼痛。這種局部疼痛症狀曾在轉子窩滑囊炎中被描述，它與其他來源的疼痛的表現相仿，包括關節盤痛、關節退行性病變和脊柱病理性疼痛。GTPS的發生率大約是每年每1000分之1.8，女性、合併腰背痛、骨關節炎、髂脛帶觸痛和肥胖的病人發生率較高。

GTPS的症狀包括髖外側持續疼痛，並放射到大腿到膝關節外側，偶爾也會放射到膝關節以下或臀部。理學檢查提示大轉子後外側區域觸痛。大多數GTPS是自限性的，一些保守治療如理療、減肥、非甾體類抗炎治療和行爲矯正可以緩解症狀。其他的治療方法包括關節囊或髖關節內注射皮質激素或局麻藥。當保守治療無效時可以採用有創的手術治療來減輕疼痛症狀。

（陳珺珺譯 薛張綱校）

Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity.

Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative  measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.

在超聲引導下持續肌間溝臂叢神經阻滯:一項隨機、三盲、安慰劑對照研究

Continuous Inter scalene Brachial Plexus Block via an Ultrasound-Guided Posterior Approach: A Randomized, Triple-Masked, Placebo-Controlled Study

Edward R. Mariano, MD, MAS^*, Robert Afra, MD, Vanessa J. Loland, MD^*, NavParkash S. Sandhu, MD^*, Richard H. Bellars, MD^*, Michael L. Bishop, MD^*, Gloria S. Cheng, MD^*, Lynna P. Choy, MD^*, Rosalita C. Maldonado, BS^*, and Brian M. Ilfeld, MD, MS^*

From the Departments of *Anesthesiology, and Orthopedic Surgery, University of California, San Diego Medical Center, San Diego, California.

Anesth Analg 2009 108: 1688-1694

 

背景：關於經後路在肌間溝放置持續輸注導管尚沒有進行過對照研究。在一項隨機、三盲、安慰劑對照研究中，我們試圖驗證了一下假設：對於肩關節手術引起的中度疼痛，超聲引導下的經後路在肌間溝持續神經阻滯的鎮痛效果優於單次給予羅呱卡因的效果。

方法：術前，受試者在超聲引導下經斜角肌間隙放置了導管。所有的受試者接受了初始劑量的羅呱卡因。術後兩天，受試者按需給予口服阿片類藥物，實驗組和對照組分別給予裝有0.2%的羅呱卡因或生理鹽水的裝置。原始結果指的是術後第一天（POD1）平均疼痛評分，用0-10表示。其他結果包括最重及最輕疼痛評分，口服阿片藥物的需要量，睡眠障礙、病人的滿意度及並發症的發生率。

結果：試驗者共有32名受試者，記錄了30根周圍神經導管。相比于給予初始劑量的羅呱卡因後持續給予生理鹽水組，持續輸注羅呱卡因在POD1可以提供很好的鎮痛效果（n=15）（疼痛分數分別是0.0 [0.0–5.0] versus 3.0 [0.0–6.0], P < 0.001)。在POD1和POD2，比較口服阿片類藥物的消耗量，羅呱卡因組低於對照組。接受羅呱卡因的受試者較少有睡眠障礙，與生理鹽水組相比對於鎮痛的滿意度較高。

結論：對於肩關節手術引起的中到重度疼痛的額病人，相比于肌間溝內單次給藥神經組織，術後兩天持續神經阻滯可以減緩疼痛，降低阿片類藥物的需要量，提高睡眠質量，增加病人的滿意度。

（陳珺珺譯 薛張綱校）

BACKGROUND: The posterior approach for placing continuous interscalene  catheters has not been studied in a controlled investigation. In this randomized, triple-masked, placebo-controlled study, we tested the hypothesis that an ultrasound-guided continuous posterior interscalene block provides superior postoperative analgesia compared to a single-injection ropivacaine interscalene block after moderately painful shoulder surgery.

METHODS: Preoperatively, subjects received a stimulating interscalene catheter using an ultrasound-guided, in-plane posterior approach. All subjects received an initial bolus of ropivacaine. Postoperatively, subjects were discharged with oral analgesics and a portable infusion device containing either ropivacaine 0.2% or normal saline programmed to deliver a perineural infusion over 2 days. The primary outcome was average pain on postoperative day (POD) 1 (scale: 0–10). Secondary outcomes included least and worst pain scores, oral opioid requirements, sleep disturbances, patient satisfaction, and incidence of complications.

RESULTS: Of the 32 subjects enrolled, 30 perineural catheters were placed per protocol. Continuous ropivacaine perineural infusion (n = 15) produced a statistically and clinically significant reduction in average pain (median [10th–90th percentile]) on POD 1 compared with saline infusion (n = 15) after initial ropivacaine bolus (0.0 [0.0–5.0] versus 3.0 [0.0–6.0], respectively; P < 0.001). Median oral opioid consumption (oxycodone) was lower in the ropivacaine group than in the placebo group on POD 1 (P = 0.002) and POD 2 (P = 0.002). Subjects who received a ropivacaine infusion suffered fewer sleep disturbances than those in the placebo group (P = 0.005 on POD 0 and 1 nights) and rated their satisfaction with analgesia higher than subjects who received normal saline (P < 0.001).

CONCLUSIONS: Compared to a single-injection interscalene block, a 2-day continuous posterior interscalene block provides greater pain relief, minimizes supplemental opioid requirements, greatly improves sleep quality, and increases patient satisfaction after moderate-to-severe painful outpatient shoulder surgery

 

 

體表解剖標誌判斷棘突節段用來行胸段硬膜外穿刺

Surface Anatomy as a Guide to Vertebral Level for Thoracic Epidural Placement

Desiree A. Teoh, FRPC, MD^*, Kristi L. Santosham, MD^*, Carmen C. Lydell, MD, Dean F. Smith, FRCPC, MD, and Michael T. Beriault, FRCPC, MD^*

From the Departments of *Anesthesia, and Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.

Anesth Analg 2009 108: 1705-1707.

 

背景：術後最佳鎮痛及最小副作用要求胸段硬膜外導管位置能準確放置。先前的研究表明，麻醉醫生依靠體表解剖定位來判斷脊椎的節段是不準確的。在這項研究中，我們比較了兩種不同的體表標誌物來判斷第七胸椎（T7）的位置。

方法：210名行胸片檢查的病人隨機分爲兩組。患者取直立位，通過C7和肩胛骨假定的T7用不透光的標誌固定。放射醫生通過盲法判斷標誌實際確定的棘突的位置。然後通過Fisher’精確檢驗的統計學方法進行統計。並且準確判斷了病人的一般特點（年齡、性別、BMI、身高、體重）。

結果：病人的一般情況是相似的。第七頸椎橫突作爲確定T7的骨性標誌，它的準確性是29%，而通過肩胛骨確定的準確性是10%（P < 0.001)。如果確定的是T7  ± 1水平，它的準確性分別是78%和42%(P = 5.84 x 10^–8)。越向尾部，出錯的可能越大（比如確定T8或 T9）。C7作爲標誌在BMI<25的病人準確性較高（P = 6.51 x 10^–5)。在那些BMI 25的病人，兩種標誌的準確性都不是很高 (P = 0.312)。

結論：對於BMI<25的病人，通過第七頸椎橫突確定的T7棘突的位置在78%的病人是準確的。對於BMI25的病人，第七頸椎橫突和肩胛下角都不能準確確定T7的位置。

(陳珺珺譯 薛張綱校)

BACKGROUND: Precise placement of thoracic epidural catheters is required to optimize postoperative analgesia and minimize adverse effects. Previous research demonstrated that anesthesiologists are inaccurate when using surface anatomy to locate vertebral levels. In this study, we compared the accuracy of two different landmarks to identify the seventh thoracic (T7) spinous process.

METHODS: Two-hundred-ten patients referred for chest radiography were randomized to two groups. With patients in the anatomic (upright) position, one investigator identified and placed a radioopaque marker over the presumed T7 spinous process using either the vertebra prominens (C7) or the inferior scapular tip as a surface landmark. A radiologist, blinded to the identification technique, reported the spinous process corresponding to the radioopaque label. Marker positions were then compared using the Fisher's exact test. The influence of patient characteristics (age, gender, Body Mass Index [BMI], and height and weight) on accuracy was also examined.

RESULTS: Patient characteristics were similar between groups. The T7 spinous process was identified correctly 29% of the time with the C7 landmark and 10% of the time with the scapular landmark (P < 0.001). Accuracy improved for T7 ± 1 level to 78% and 42%, respectively (P = 5.84 x 10^–8). Errors were more common in the caudal direction (i.e., T8 or T9 identified). The C7 landmark was more accurate among those with a BMI <25 (P = 6.51 x 10^–5). In those with a BMI 25, both landmarking methods were frequently inaccurate (P = 0.312).

CONCLUSIONS: For patients with a BMI <25, the T7 spinous process can be reliably identified to within one interspace in 78% of patients using the C7 (vertebra prominens) surface landmark. Neither the vertebra prominens nor the tip of scapula is a reliable landmark to identify T7 in patients with a BMI 25.

在有腦自身調節異常風險的病人中行低溫心肺旁路期間的頸靜脈氧合：-固定計與pH-固定計血氣處理的影響比較

Jugular Venous Oxygenation During Hypothermic Cardiopulmonary Bypass in Patients at Risk for Abnormal Cerebral Autoregulation: Influence of -Stat Versus pH-Stat Blood Gas Management

Lance R. Hoover, MD^*, Radhika Dinavahi, MD, Wei-Ping Cheng, MD, John R. Cooper, Jr, MD, Maria Rosa Marino, MD^||, Tyler C. Spata, BA, Gaile L. Daniels, EMT, William K. Vaughn, PhD^¶, and Nancy A. Nussmeier, MD^#

From the *Department of Cardiothoracic Anesthesia, San Antonio Uniform Health Education Consortium, San Antonio, Texas; Division of Cardiovascular Anesthesiology, the Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas; Department of Anesthesiology, The Cardiovascular Institute and Fu Wai Hospital at the Chinese Academy of Medical Sciences, Beijing; Department of Anesthesiology, Baylor College of Medicine, Houston, Texas; ||Department of Cardiovascular Anaesthesia, Centro Cardiologico Monzino IRCCS, Milano, Italy; ¶Department of Biostatistics and Epidemiology, the Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas; and #Department of Anesthesiology, SUNY Upstate Medical University, Syracuse, New York.

Anesth Analg 2009; 108:1389-1393

在一項對有腦血流自身調節受損風險的心臟手術病人的前瞻性、隨機研究中，我們比較了-固定計和pH-固定計下血氣處理。選擇40例年齡〉70歲、糖尿病、以前有中風史或未控制的高血壓病人。在低溫和複溫早期，-固定計病人（n = 12）的頸靜脈氧分壓明顯低於pH-固定計病人(n = 19; P < 0.05)。在複溫期間，頸靜脈去飽和(如 SjvO₂ <50%)在-固定計病人中的發生率6/12，而pH-固定計病人沒有發生(P = 0.0006)。如果在心肺旁路期間用pH-固定計血氣處理，有腦自身調節功能較差風險的病人可有較高的氧分壓和氧飽和度。

（彭中美 譯 馬皓琳 李士通 校）

In a prospective, randomized study of cardiac surgical patients at risk for impaired cerebral blood flow autoregulation, we compared -stat and pH-stat blood gas management. The 40 patients enrolled had age >70 yr, diabetes, prior stroke, or uncontrolled hypertension. During hypothermia and early rewarming, jugular oxygen tensions were significantly lower in -stat patients (n = 12) than pH-stat patients (n = 19; P < 0.05). During rewarming, jugular venous desaturation (i.e., SjvO₂ <50%) occurred in 6 of 12 -stat patients, but no pH-stat patients (P = 0.0006). Patients at risk for poor cerebral autoregulation have higher oxygen tensions and saturations if pH-stat blood gas management is used during cardiopulmonary bypass.

 

由TEG®血小板圖^TM測得的米力農對血小板活化的作用

The Effect of Milrinone on Platelet Activation as Determined by TEG® Platelet Mapping^TM

 

Mark C. Wesley, MD^*, Francis X. McGowan, MD^*, Robert A. Castro, MT^*, Sheahan Dissanayake, MT^*, David Zurakowski, PhD, and James A. DiNardo, MD^*

From the Departments of *Anesthesia, Perioperative and Pain Medicine, and Orthopaedic Surgery and Biostatistics, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2009; 108:1425-1429

背景：米力農是一種磷酸二酯酶III的抑制劑，通過增加細胞內的環磷腺苷來改善心室功能及血管擴張。細胞內環磷腺苷水平的增高也可抑制二磷酸腺苷(ADP)及花生四烯酸(AA)誘導的血小板凝集。我們假設通過TEG®血小板圖^TM.測繪法的監測，可定量地評價血液治療濃度的米力農對ADP及AA誘導的血小板活化的抑制作用。

方法：在15位無抗血小板用藥史的健康成人身上抽取血樣。加入米力農到全血中達到三個臨床相關的濃度(30、100和300 ng/mL)。在無米力農及以上三個濃度的全血中實施傳統的凝血彈力描記法(TEG®)及TEG血小板測繪法。

結果：米力農血濃度的增加伴隨著對ADP及AA誘導的血小板活化的抑制作用增大(P < 0.0001)。當米力農濃度達到300 ng/mL時，可明顯破壞對ADP及AA的血小板活化反應。

結論：通過TEG血小板^TM.測繪法可發現治療性血藥濃度的米力農顯著抑制ADP及AA誘導的血小板活化作用，而對傳統的陶土-活化的TEG無影響。

我們建議：對於使用米力農及其它改變血小板環核苷酸濃度的藥物的患者，須謹慎解釋TEG血小板測繪法的結果。

（裘毅敏譯，馬皓琳、李士通校）

BACKGROUND: Milrinone is a phosphodiesterase III inhibitor that increases intracellular cyclic adenosine monophosphate resulting in improved ventricular function and vasodilation. Increased intracellular levels of cyclic adenosine monophosphate also inhibit adenosine diphosphate (ADP) and arachidonic acid (AA)-induced platelet aggregation. We hypothesized that inhibition of ADP and AA-induced platelet activation by therapeutic blood concentrations of milrinone could be quantified using TEG® Platelet Mapping^TM.

METHODS: Blood was taken from 15 healthy adults who had not been taking antiplatelet medications. Milrinone was added to whole blood in three clinically relevant concentrations (30, 100, and 300 ng/mL). Conventional thromboelastography (TEG®) and TEG Platelet Mapping were performed on whole blood without milrinone and at each of these three concentrations.

RESULTS: Increased blood concentrations of milrinone were associated with increased inhibition of ADP and AA-induced platelet activation (P < 0.0001). Milrinone at a blood concentration of 300 ng/mL markedly impaired the platelet activation response to ADP and AA.

CONCLUSIONS: Therapeutic blood concentrations of milrinone exhibit a significant inhibitory effect on ADP and AA-induced platelet activation as determined by TEG Platelet Mapping, without affecting the conventional kaolin-activated TEG.

We suggest that TEG Platelet Mapping results be interpreted with caution in patients being treated with milrinone, and other drugs that modify platelet cyclic nucleotide concentrations.

 

在止血中組織因數和VIIa因數的作用

The Role of Tissue Factor and Factor VIIa in Hemostasis

Nigel Mackman, PhD

From the Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Anesth Analg 2009; 108:1447-1452

組織因數(TF)是VII/VIIa 因數(FVII/VIIa)的一個跨膜受體。它在血管周圍的細胞構成性表達。內皮將這個強效的“啟動劑”與迴圈中的配體FVII/FVIIa完全分隔開來，防止不適當的啟動凝血途徑。內皮屏障的破壞導致血管外TF的暴露和迅速啟動凝血途徑。TF還在其他的一些組織中表達，如心臟和大腦，且能提供這些組織更多的凝血功能的保障。少量的TF還以微粒的形式存在於血液中，這些微粒是從活化的和凋亡的細胞出來的小膜囊。微粒TF的濃度在許多疾病中會增加，如敗血症和癌症，且這種所謂的“血源傳染性”TF可能促成這些疾病伴隨的血栓形成。已開發出了重組FVIIa作爲有抑制性抗體的血友病患者的一個有效止血藥物。此外，它可用於對於常規治療沒有反應的出血患者。然而，重組FVIIa恢復止血的機制尚未清楚地確定。總之，TF:FVIIa複合物對於止血是非常必要的，重組FVIIa是一個非常有效的止血藥物。

（唐亮 譯  馬皓琳 李士通 校）      

Tissue factor (TF) is a transmembrane receptor for Factor VII/VIIa (FVII/VIIa). It is constitutively expressed by cells surrounding blood vessels. The endothelium physically separates this potent "activator" from its circulating ligand FVII/FVIIa and prevents inappropriate activation of the clotting cascade. Breakage of the endothelial barrier leads to exposure of extravascular TF and rapid activation of the clotting cascade. TF is also expressed in certain tissues, such as the heart and brain, and provides additional hemostatic protection to these tissues. Small amounts of TF are also present in blood in the form of microparticles, which are small membrane vesicles derived from activated and apoptotic cells. Levels of microparticle TF increase in a variety of diseases, such as sepsis and cancer, and this so-called "blood-borne" TF may contribute to thrombosis associated with these diseases. Recombinant FVIIa has been developed as an effective hemostatic drug for the treatment of hemophilia patients with inhibitory antibodies. In addition, it is used for patients with bleeding that do not respond to conventional therapy. However, the mechanism by which recombinant FVIIa restores hemostasis has not been clearly defined. In conclusion, the TF:FVIIa complex is essential for hemostasis and recombinant FVIIa is an effective hemostatic drug.

全麻藥對耳蝸植入手術患兒電激發鐙骨肌反射的劑量依賴抑制作用

Dose-Dependent Suppression of the Electrically Elicited Stapedius Reflex by General Anesthetics in Children Undergoing Cochlear Implant Surgery

Mark W. Crawford, MBBS, FRCPC^*, Michelle C. White, MBChB, DCH, FRCA^*, Evan J. Propst, MSc, MD, Christian Zaarour, MD^*, Sharon Cushing, MD, Carolyne Pehora, RN, MN^*, Adrian L. James, DM, FRCS, Karen A. Gordon, PhD, and Blake C. Papsin, MD, FRCSC

From the Departments of *Anesthesia and Pain Medicine, and Otolaryngology/Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2009; 108:1480-1487

背景： 耳蝸植入物可以刺激聽神經産生聽覺。確定刺激合適的上下限是耳蝸植入手術成功所必須的。術中激發鐙骨肌反射的閾值(ESRT)和激發複合動作電位(ECAP)常用於確定植入物刺激的極限。在本研究中，我們評估了七氟烷、地氟烷、異氟烷和丙泊酚對術中 ESRT和ECAP的劑量相關作用。

方法： 44 名行耳蝸植入手術患兒，年齡6個月至17歲，隨機分組接受七氟烷、地氟烷、異氟烷或丙泊酚麻醉。由一位不知分組的研究者在呼氣末麻醉藥濃度爲經年齡校正、隨機順序的0、0.75和1.5倍最低肺泡有效濃度，或丙泊酚的血液靶濃度爲0、1.5和3.0 µg/mL時的激發反應。使用單因素重復測量方差分析資料，P < 0.05爲差異有統計學意義。

結果：ESRT呈濃度依賴地隨揮發性麻醉藥濃度的升高而升高(P < 0.01)。有超過半數的患兒吸入揮發性麻醉藥後鐙骨肌反射消失。丙泊酚對ESRT影響最小。與ESRT相反，ECAP不受麻醉的影響。

結論：揮發性麻醉藥呈濃度依賴地抑制鐙骨肌反射，表明術中使用了揮發性麻醉藥測定得到的ESRT值會過高估計最大舒適水平，這將會導致患兒術後的不適，妨礙患兒對植入物的適應。我們建議在耳蝸植入手術需要測定鐙骨肌反射閾值時，不要使用揮發性麻醉藥。

（張瑩譯  馬皓琳 李士通校）

 BACKGROUND: Cochlear implants stimulate the auditory nerve to enable hearing. Determining appropriate upper and lower limits of stimulation is essential for successful cochlear implantation. The intraoperative evoked stapedius reflex threshold (ESRT) and evoked compound action potential (ECAP) are commonly used to determine the limits of implant stimulation. In this study, we evaluated the dose-related effects of sevoflurane, desflurane, isoflurane, and propofol on the intraoperative ESRT and ECAP.

METHODS: Forty-four children aged 6 mo to 17 yr undergoing cochlear implantation were recruited. Each child was randomly assigned to receive sevoflurane, desflurane, isoflurane, or propofol. Evoked responses were measured by a blinded investigator at end-tidal anesthetic concentrations corresponding to 0, 0.75, and 1.5 age-adjusted minimum alveolar concentration administered in random sequence and at targeted blood concentrations of propofol of 0, 1.5, and 3.0 µg/mL. Data were analyzed using one-way repeated-measures analysis of variance. P < 0.05 was considered statistically significant.

RESULTS: The ESRT increased dose dependently with increasing volatile anesthetic concentration (P < 0.01). The stapedius reflex was completely abolished by volatile anesthesia in more than half of children. Propofol minimally affected the ESRT. In contrast, the ECAP was unaffected by anesthesia.

CONCLUSIONS: Volatile anesthetics suppress the stapedius reflex in a dose-dependent manner, suggesting that ESRT measurements acquired during volatile anesthesia will overestimate the maximum comfort level, which may cause discomfort postoperatively and adversely affect the child’s adaptation to the implant. We advise against the use of volatile anesthetics for measurement of the stapedius reflex threshold during cochlear implant surgery.

比較經皮吸收東莨菪堿複合昂丹司瓊和單獨使用昂丹司瓊對預防門診病人手術後噁心和嘔吐的一個隨機、雙盲、多中心試驗

A Randomized, Double-Blind, Multicenter Trial Comparing Transdermal Scopolamine Plus Ondansetron to Ondansetron Alone for the Prevention of Postoperative Nausea and Vomiting in the Outpatient Setting

Tong J. Gan, MD^*, Ashish C. Sinha, MD, PhD, Anthony L. Kovac, MD, R. Kevin Jones, MD, CPI, Stephen A. Cohen, MD, MBA^||, Jean P. Battikha, MS^¶, Jonathan S. Deutsch, MD^¶, Joseph V. Pergolizzi, Jr, MD^#, the TDS Study Group^**, and Section Editor Peter S. A. Glass

From the *Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; University of Pennsylvania, Philadelphia, Pennsylvania; University of Kansas Medical Center, Kansas City, Kansas; Accurate Clinical Trials Inc./Saddleback Memorial Medical Center, Laguna Hills, California; ||Beth Israel Deaconess Medical Center, Boston, Massachusetts; ¶Baxter Healthcare Corporation, New Providence, New Jersey; #Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and **The TDS Study Group consists of the following members: Gregory H. Adkisson (St. Agnes Healthcare Inc., Baltimore, MD, St. Agnes Healthcare Inc. Clinical Research Center, Baltimore, MD), Keith Candiotti (University of Miami School of Medicine, Jackson Health Systems, Miami, FL), Stephen A. Cohen (Beth Israel Deaconess Medical Center, Boston, MA), Neil R. Connelly (Baystate Medical Center, Springfield, MA), Patricia L. Dalby (Magee Women's Hospital of UPMC, Pittsburgh, PA), Robert D'Angelo (Forsyth Medical Center, Winston-Salem, NC), Albert R. Davis (Loyola University Medical Center, Chicago, IL), David R. Drover (Stanford Hospital and Clinics, Stanford, CA), Tong J. Gan, Fernando Altermatt, Dianne Scott (Duke University Medical Center, Durham, NC, Duke Health Raleigh Hospital, Raleigh, NC, and Duke Center for Aesthetic Services, Durham, NC), Joseph S. Gimbel (AZ Research Center, John C. Lincoln Hospital, North Mountain, and John C. Lincoln Hospital, Deer Valley, Phoenix, AZ), R. Kevin Jones (Saddleback Memorial Medical Center, Laguna Hills, CA), Anthony L. Kovac (University of Kansas Medical Center, Kansas City, Kansas, KS), John B. Leslie (Mayo Clinic Hospital, Phoenix, AZ), Robert A. McKinney, Jr. (Trinity Clinic, North Park, Mother Frances Hospital, and Tyler Square, Tyler, TX), Tricia A. Meyer (Scott and White Hospital, Temple, TX), Joseph Pergolizzi (Physicians Day Surgery Center, Naples, FL), Beverly K. Philip (Brigham and Women's Hospital, Boston, MA), Martin J. Redmond (State University of New York at Stony Brook Ambulatory Surgical Center, Stony Brook, NY), Denise A. Scaringe (Cooper University Hospital, Camden, NJ, Cooper Surgery Center, Voorhees, NJ), Ashish C. Sinha (Hospital of the University of Pennsylvania, Philadelphia, PA), Jeffrey M. Varga (The Western Pennsylvania Hospital-Forbes Regional Campus, Monroeville, PA), Eugene R. Viscusi (Thomas Jefferson University Hospital and Jefferson Surgical Center, Philadelphia, PA), Elliott C. Wohlner (St. Anthony Central Hospital, Denver, CO), and Mark C. Ziegler (Mercy Hospital Anderson and Mercy Anderson Ambulatory Surgery Center, Cincinnati, OH).

Anesth Analg 2009; 108:1498-1504

背景：術後噁心和嘔吐（PONV）是門診手術後常見的並發症。我們想檢測是否使用東莨菪堿經皮吸收劑（TDS）聯合靜脈注射昂丹司瓊（OND）較單獨使用OND更能減少門診病人的PONV。

方法：在隨機、雙盲、多中心試驗中，620例接受門診腹腔鏡檢查或隆胸手術有PONV風險的女性病人進入手術室前2h給予活性的TDS貼片或無TDS的貼片。所有病人在全麻誘導前2-5分鐘靜脈注射OND 4 毫克，隨後進行全麻。完全止吐反應的定義爲無嘔吐/幹嘔或無解救藥物治療使用，在術後24小時和48小時判斷完全止吐反應。還收集了病人嘔吐/幹嘔、噁心或使用解救藥物治療的比例、手術結束到第一次上述反應發作的時間、離開醫院/外科中心的時間、嘔吐/幹嘔和噁心發作的次數和嚴重性以及病人對止吐治療的滿意度。

結果：相對于單獨使用OND，聯合使用TDS和OND顯著地減少術後24小時噁心和嘔吐/幹嘔，但在術後48小時沒有顯著性差異出現。聯合使用TDS和OND的病人沒有出現嘔吐/幹嘔和沒有使用解救藥物治療的比例是48%，而單獨使用OND 的病人的比例是39%（P < 0.02）。相對於單獨使用OND組，聯合使用TDS和OND組完全反應（沒有噁心，沒有嘔吐/幹嘔以及沒有使用解救藥物治療）的比例顯著更高(35%比25%, P < 0.01)。相對於單獨使用OND組，聯合使用TDS和OND組第一次噁心、嘔吐/幹嘔或解救治療的時間顯著更晚(P < 0.05)。相對于OND組，聯合使用TDS和OND組不良事件的累積總發生率更低(36.7%比49%, P < 0.01)。

結論：聯合使用TDS和OND較單獨使用OND更能減少PONV,並能減少不良事件的發生。

（王宏 譯，馬皓琳 李士通 校）

BACKGROUND: Postoperative nausea and vomiting (PONV) are common complications after ambulatory surgery. We sought to determine whether the use of transdermal scopolamine (TDS) in combination with IV ondansetron (OND) is more effective than one alone for reducing PONV in outpatient settings.

METHODS: In a randomized, double blind, multicenter trial, 620 at-risk female patients undergoing outpatient laparoscopic or breast augmentation surgery received either an active TDS patch or a similar appearing sham 2 h before entering the operating room. All patients received IV OND (4 mg) 2–5 min before induction of anesthesia followed by a general anesthetic regimen. Complete antiemetic response, defined as no vomiting/retching or rescue medication use, was measured through 24 h and 48 h after surgery. The proportion of patients with vomiting/retching, nausea, or use of rescue medication, the time from the end of surgery to the first episode of these events and the time to discharge from the hospital/surgery center, as well as the number and severity of vomiting/retching and nausea episodes, and patient satisfaction with antiemetic therapy were also collected.

RESULTS: The combination of TDS + OND statistically significantly reduced nausea and vomiting/retching compared with OND alone 24 h after surgery but not at 48 h. The proportion of patients who did not experience vomiting/retching and did not use rescue medication was 48% for TDS + OND and 39% for OND alone (P < 0.02). Total response (no nausea, no vomiting/retching, and no use of rescue medication) was also statistically higher for the TDS + OND group compared with the OND-only group (35% vs 25%, P < 0.01). The time to first nausea, vomiting/retching, or rescue episode was statistically significantly longer for the TDS + OND group compared with the OND-only group (P < 0.05). The cumulative overall incidence of adverse events was lower in the TDS + OND group compared with the OND group (36.7% vs 49%, P < 0.01).

CONCLUSIONS: TDS + OND reduces PONV compared with OND alone. This is achieved with a reduction in adverse events.

咪達唑侖對丙泊酚藥動學影響的混合效應模型的建立

Mixed-Effects Modeling of the Influence of Midazolam on Propofol Pharmacokinetics

Jaap Vuyk, MD, PhD^*, Bart Jan Lichtenbelt, MD, Erik Olofsen, MSc^*, Jack W. van Kleef, MD, PhD^*, and Albert Dahan, MD, PhD^*

From the Department of Anesthesiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands; and Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

Anesth Analg 2009; 108:1522-1530

背景：混合使用麻醉藥産生藥物動力學相互作用導致藥物濃度變化高達30%。咪達唑侖常在基於丙泊酚的麻醉前用作術前鎮靜藥。我們在本研究中明確了咪達唑侖對丙泊酚藥動學的影響。

方法：我們採用隨機交叉的方式在兩個時段對8名健康男性志願者進行研究。在A期間，1 min內給予志願者1 mg/kg丙泊酚，隨後59 min連續輸注2.5 mg · kg^–1 · h^–1丙泊酚。在B期間，除按A方案輸注丙泊酚外，輸注丙泊酚前15 min至停止輸注後6 h採用靶控輸注咪達唑侖 (常數C_t: 125 ng/mL)。採集動脈血標本分析血液丙泊酚和血漿咪達唑侖濃度，直到丙泊酚輸注停止後6 h。採用Akaike模型選擇準則建立非線性混合效應模型研究咪達唑侖和血液動力學參數對丙泊酚藥動學的影響。

結果：與單獨輸注丙泊酚相比，聯合輸注咪達唑侖(C_blood: 224.8 ± 41.6 ng/mL)時丙泊酚血藥濃度增加25.1% ± 13.3%。咪達唑侖(C_blood: 225 ng/mL)使得丙泊酚Cl₁從1.94 下降至1.61 L/min，Cl₂從2.86下降至1.52 L/min, 而Cl₃從0.95下降至0.73 L/min。包含平均動脈壓進一步改良了丙泊酚藥動學模型。

結論：咪達唑侖降低了丙泊酚的代謝和快慢分佈清除率。此外，平均動脈壓的降低産生丙泊酚藥動學變化而導致其血液濃度增加。

(江繼宏 譯  馬皓琳 李士通 校）

BACKGROUND: The combined administration of anesthetics has been associated with pharmacokinetic interactions that induce concentration changes of up to 30%. Midazolam is often used as a preoperative sedative in advance of a propofol-based anesthetic. In this study, we identified the influence of midazolam on the pharmacokinetics of propofol.

METHODS: Eight healthy male volunteers were studied on two occasions in a random crossover manner. During Session A, volunteers received propofol 1 mg/kg in 1 min followed by an infusion of 2.5 mg · kg^–1 · h^–1 for 59 min. During Session B, in addition to this propofol infusion scheme, a target-controlled infusion of midazolam (constant C_t: 125 ng/mL) was given from 15 min before the start until 6 h after termination of the propofol infusion. Arterial blood samples for blood propofol and plasma midazolam concentration analysis were taken until 6 h after termination of the propofol infusion. Nonlinear mixed-effects models examining the influence of midazolam and hemodynamic variables on propofol pharmacokinetics were constructed using Akaike criterion for model selection.

RESULTS: In the presence of midazolam (C_blood: 224.8 ± 41.6 ng/mL), the blood propofol concentration increased by 25.1% ± 13.3% compared with when propofol was given as single drug. Midazolam (C_blood: 225 ng/mL) reduced propofol Cl₁ from 1.94 to 1.61 L/min, Cl₂ from 2.86 to 1.52 L/min, and Cl₃ from 0.95 to 0.73 L/min. Inclusion of mean arterial blood pressure further improved the propofol pharmacokinetic model.

CONCLUSIONS: Midazolam reduces the metabolic and rapid and slow distribution clearances of propofol. In addition, a reduction in mean arterial blood pressure is associated with propofol pharmacokinetic alterations that increase the blood propofol concentration.

在健康志願者中心臟指數的無創評估：比較胸廓阻抗心動描記法和多普勒超聲心動描記法

Noninvasive Assessment of Cardiac Index in Healthy Volunteers: A Comparison Between Thoracic Impedance Cardiography and Doppler Echocardiography

Jean-Luc Fellahi, MD, PhD^*, Vincent Caille, MD, Cyril Charron, MD, Pierre-Hervé Deschamps-Berger, MD, and Antoine Vieillard-Baron, MD, PhD

From the *Department of Anesthesiology, Centre Hospitalier Privé Saint-Martin, Caen, France; The Intensive Care Unit, Centre Hospitalier Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne, France; and The Department of Cardiology, Polyclinique, Deauville, France.

Anesth Analg 2009; 108:1553-1559

背景：胸廓生物阻抗心動描記法（ICG）被認爲是一種無創、持續、不依賴操作者且信價比高的一種心輸出量監測方法。本研究比較採用ICG（Niccomo^TM設備）和經胸多普勒心動超聲法在健康志願者靜息狀態下接受血流動力學負荷挑戰時的心臟指數（CI）的測定結果。

方法：25名健康志願者（男性7名，女性18名，平均年齡36 ± 6歲，體表面積1.75 ± 0.17 m²）在下述三種實驗狀態下接受測定：基礎狀態，呼氣末正壓+ 10 cm H₂O和通過將醫用抗休克褲腹部部分充氣至30cm H₂O使得下體産生正壓。

結果：ICG信號質量>89%超過所有測量設定。觀察到CI_TTE 和CI_ICG之間有微弱但有顯著意義的聯繫(r = 0.36; P = 0.002)。兩種技術之間的一致性爲0.94 L · min^–1 · m^–2 (95% CI: 0.77–1.11)，一致性的界限爲–0.47～2.35 L · min^–1 · m^–2，而百分誤差爲53％。在採用呼氣末正壓+ 10 cm H₂O (r = 0.21; P = 0.31)和醫用抗休克褲(r = 0.22; P = 0.30)後CI_TTE 和CI_ICG的百分比改變之間的聯繫不具有統計學意義。

結論：靜息狀態下健康志願者採用ICG和經胸多普勒超聲心動法測定的CI絕對值之間關聯性弱且缺乏一致性。Niccomo設備對於監測處於血流動力負荷挑戰狀態下CI的變化並不可靠。

（周雅春 譯 李士通 馬皓琳 校）

BACKGROUND: Thoracic bioimpedance cardiography (ICG) has been proposed as a noninvasive, continuous, operator-independent, and cost-effective method for cardiac output monitoring. In the present study, we compared cardiac index (CI) measurements with ICG (Niccomo^TM device) and transthoracic Doppler echocardiography in resting healthy volunteers undergoing hemodynamic load challenge.

METHODS: Twenty-five healthy volunteers (7 men and 18 women, mean age 36 ± 6 yr, body surface area 1.75 ± 0.17 m²) were investigated during three experimental conditions: baseline, positive end-expiratory pressure + 10 cm H₂O and lower body positive pressure by means of medical antishock trousers inflated to 30 cm H₂O in the abdominal compartment.

RESULTS: ICG signal quality was >89% over all sets of measurements. A weak but significant relationship was observed between CI_TTE and CI_ICG (r = 0.36; P = 0.002). Agreement between both techniques was 0.94 L · min^–1 · m^–2 (95% CI: 0.77–1.11), limits of agreement were –0.47 to 2.35 L · min^–1 · m^–2, and percentage error was 53%. No statistically significant relationships were found between percent changes in CI_TTE and CI_ICG after applications of positive end-expiratory pressure + 10 cm H₂O (r = 0.21; P = 0.31) and medical antishock trousers (r = 0.22; P = 0.30).

CONCLUSIONS: Poor correlation and lack of agreement between absolute values of CI measured by ICG and transthoracic Doppler echocardiography were found in resting healthy volunteers. The Niccomo device was also unreliable for monitoring changes in CI during hemodynamic load challenge.

現代的快速可降解的羥乙基澱粉：最近的概念

Modern Rapidly Degradable Hydroxyethyl Starches: Current Concepts

Joachim Boldt, MD

From the Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.

Anesth Analg 2009; 108:1574-1582

羥乙基澱粉（HES）是一種被廣泛應用於糾正圍手術期血容量過低的血漿替代物。HES製劑是由濃度、摩爾取代度（MS）、平均分子量(M_w)、C₂/C₆取代比、溶劑和起源定義的。HES可能存在的不願見到的副作用是過敏反應、凝血功能的改變導致的出血增加、腎功能障礙、蓄積和瘙癢症。基於潛在副作用的考慮，區分不同HES製劑很重要，因爲HES製劑不盡相同。第一代HES製劑表現出的高M_w (>450 kD)和高MS (>0.7) 産生了與凝血、器官功能和蓄積有關的不良作用。本綜述聚焦於M_w (130 kD)和MS (<0.5)較低的現代（第三代）、降解更快的HES製劑是否更安全及副作用較少。幾項研究證明了這類現代HES製劑在凝血、腎功能、瘙癢和蓄積等方面顯示出安全性。現代HES製劑能溶解於適合於血漿的平衡溶液，不含非生理含量的鈉和氯，因此適用於糾正低血容量。

（唐李雋 譯  馬皓琳  李士通 校）

Hydroxyethyl starch (HES) is a widely used plasma substitute for correcting perioperative hypovolemia. HES preparations are defined by concentration, molar substitution (MS), mean molecular weight (M_w), the C₂/C₆ ratio of substitution, the solvent, and the origin. The possible unwanted side effects of HES are anaphylactic reactions, alterations of hemostasis resulting in increased bleeding, kidney dysfunction, accumulation, and pruritus. In view of the potential side effects, it is crucial to distinguish among the different HES preparations; all HES preparations are not the same. The first generation of HES preparation showing a high M_w (>450 kD) and a high MS (>0.7) was associated with negative effects with regard to coagulation, organ function, and accumulation. This review is focused on whether modern (third generation), more rapidly degradable HES preparations with a lower M_w (130 kD) and a lower MS (<0.5) are safer and have fewer side effects. Several studies demonstrated that such modern HES preparations appear to be safe with regard to hemostasis, kidney function, itching, and accumulation. Modern HES preparations are dissolved in balanced, plasma-adapted solutions that no longer contain unphysiological amounts of sodium and chloride and are thus suitable for correcting hypovolemia.

羊水栓塞

Amniotic Fluid Embolism

 

Richard S. Gist, MD^*, Irene P. Stafford, MD, Andrew B. Leibowitz, MD^*, and Yaakov Beilin, MD^*

From the *Department of Anesthesiology, Mount Sinai School of Medicine of New York University, New York City, New York; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas; and Department of Obstetrics and Gynecology, Mount Sinai School of Medicine of New York University, New York City, New York.

Anesth Analg 2009; 108:1599-1602

羊水栓塞是懷孕期間最具災難性的並發症之一。首次描述羊水栓塞是在1941年，發生羊水栓塞的情況非常少見，其確切的病理生理學機制還不是很清楚。原本以爲病原學的本質是血栓，但是更多最近的證據提示可能和免疫有關。臨床症狀多表現爲：呼吸困難、胎兒狀況不可靠、低血壓、驚厥以及彌漫性血管內凝血。早期發現羊水栓塞對於成功的預後非常重要。然而，即使及時搶救，嬰兒和母親的預後常常都很差。目前已報道的有創且成功搶救羊水栓塞的方法包括重組VIIa因數的應用、心室輔助裝置、吸入NO、心肺轉流和主動脈內球囊泵和體外膜式氧合，應該考慮在某些特定病例中使用。

（黃佳佳譯，馬皓琳 李士通校）

Amniotic fluid embolism is one of the most catastrophic complications of pregnancy. First described in 1941, the condition is exceedingly rare and the exact pathophysiology is still unknown. The etiology was thought to be embolic in nature, but more recent evidence suggests an immunologic basis. Common presenting symptoms include dyspnea, nonreassuring fetal status, hypotension, seizures, and disseminated intravascular coagulation. Early recognition of amniotic fluid embolism is critical to a successful outcome. However, despite intensive resuscitation, outcomes are frequently poor for both infant and mother. Recently, aggressive and successful management of amniotic fluid embolism with recombinant factor VIIa and a ventricular assist device, inhaled nitric oxide, cardiopulmonary bypass and intraaortic balloon pump with extracorporeal membrane oxygenation have been reported and should be considered in select cases.

在一側頸動脈完全性結紮加嚴重低血壓的小鼠模型中去氧腎上腺素可以改善大腦細胞毒性水腫並減少腦梗塞體積

Phenylephrine Ameliorates Cerebral Cytotoxic Edema and Reduces Cerebral Infarction Volume in a Rat Model of Complete Unilateral Carotid Artery Occlusion with Severe Hypotension

Seiji Ishikawa, MD, Hiroyuki Ito, MD, Kuninori Yokoyama, PhD, and Koshi Makita, MD

From the Department of Anesthesiology, Tokyo Medical and Dental University, Graduate School of Medicine, Yushima, Bunkyo-ku, Tokyo, Japan.

Anesth Analg 2009; 108:1631-1637

背景：去氧腎上腺素是一種選擇性₁腎上腺素能受體激動劑，通過外周血管收縮來升高動脈血壓。但是當頸內動脈存在疾病的病人發生出血性休克時去氧腎上腺素是否可以改善腦缺血的預後還不清楚。

方法：（實驗1）21只成年雄性斯普拉-道來大鼠吸入異氟烷進行麻醉，肺部機械通氣。在右側頸總動脈被結紮後，抽取動脈血直至平均動脈壓（MAP）低至30 mm Hg以造成腦缺血。當平均動脈壓在30 mm Hg持續10分鐘後小鼠被隨機分成三組（每組7只）。去氧腎上腺素組靜脈注射去氧腎上腺素來維持平均動脈壓至70 ± 3 mm Hg維持5分鐘，安慰劑組與苯腎同等體積的生理鹽水持續給予5分鐘，對照組什麽藥都不給予，維持平均動脈壓在30 mm Hg。驅血後30分鐘，以0.25 mL/min的速度重新靜脈輸注抽取的血液。連續獲得彌散加權的磁共振成像，建立表現彌散係數圖像來測定細胞毒性水腫的量。（實驗2）爲了分析去氧腎上腺素對右大腦中動脈範圍中局部腦血流量(rCBF)的影響，另外添加的15只小鼠（每組5只）用鐳射多普勒血流儀測得rCBF。

結果：（實驗1）在驅血後10分鐘，去氧腎上腺素組(357.5 ± 93.5 mm³)、安慰劑組(333.5 ± 69.6 mm³)和對照組(303.1 ± 85.8 mm³)的細胞毒性水腫量之間沒有顯著區別。對照組隨著時間延長，低表現彌散係數的區域顯著擴大，然而在去氧腎上腺素組去氧腎上腺素輸注後這種區域開始減小，而且在30分鐘內就幾乎全部消失了。去氧腎上腺素組最終的腦梗塞量（3.9 ± 2.6 mm³）比安慰劑組(341.5 ± 213.7 mm³)和對照組(509.1 ± 197.0 mm³)都明顯要小（P < 0.01）。（實驗2）雖然在10分鐘驅血後rCBF 比減少到了基礎值的40%–50%，但是去氧腎上腺素立即增加了rCBF值超過基礎水平。在安慰劑組rCBF顯著增加，但是和去氧腎上腺素組相比稍有滯後。

結論：在一側頸動脈完全性結紮加嚴重低血壓的大鼠模型中去氧腎上腺素可以改善大腦細胞毒性水腫並減少梗塞量。這些發現提示了在出血性休克時去氧腎上腺素可以瞬間升高CBF而不增加大腦血管的強直性痙攣。

（姜旭暉譯，馬皓琳，李士通校）

BACKGROUND: Phenylephrine is a selective ₁ adrenergic receptor agonist that increases arterial blood pressure by peripheral vasoconstriction. However, whether phenylephrine improves the outcome of cerebral ischemia in patients with internal carotid artery disease during hemorrhagic shock is unclear.

METHODS: (Experiment 1) Twenty-one adult male Sprague-Dawley rats were anesthetized with isoflurane and their lungs mechanically ventilated. After the right common carotid artery was ligated, arterial blood was withdrawn until mean arterial blood pressure (MAP) reached 30 mm Hg to induce cerebral ischemia. After MAP was maintained at 30 mm Hg for 10 min, the animals were randomly allocated to three groups (n = 7 each). In the phenylephrine group, phenylephrine was administered IV to maintain a MAP of 70 ± 3 mm Hg for 5 min. In the saline group, an identical volume of normal physiologic saline was continuously administered for 5 min. In the control group, neither phenylephrine nor saline was administered and MAP was maintained at 30 mm Hg. At 30 min of exsanguination, the withdrawn blood was reinfused IV at a rate of 0.25 mL/min. Diffusion-weighted magnetic resonance images were serially acquired and apparent diffusion coefficient maps were created to determine the volume of cytotoxic edema. (Experiment 2) To analyze the effect of phenylephrine on the regional cerebral blood flow (rCBF) in the right middle cerebral artery territory, rCBF was measured using laser Doppler flowmetry in 15 additional rats (n = 5 each).

RESULTS: (Experiment 1) At 10 min of exsanguination, there were no significant differences in the volume of cytotoxic edema among the phenylephrine (357.5 ± 93.5 mm³), saline (333.5 ± 69.6 mm³), and control (303.1 ± 85.8 mm³) groups. Low apparent diffusion coefficient regions significantly expanded with time in the control group, whereas they started to decrease just after phenylephrine infusion and almost all had disappeared within 30 min in the phenylephrine group. The final infarction volume in the phenylephrine group (3.9 ± 2.6 mm³, P < 0.01) was significantly lower than that in the saline group (341.5 ± 213.7 mm³) and control group (509.1 ± 197.0 mm³). (Experiment 2) Although rCBF decreased to 40%–50% of the baseline at 10 min of exsanguination, phenylephrine immediately increased rCBF over the baseline level. In the saline group, rCBF increased significantly, but there was some delay compared with the phenylephrine group.

CONCLUSIONS: Phenylephrine ameliorated cytotoxic edema and decreased the infarction volume in a rat model of complete unilateral carotid artery occlusion with severe hypotension. These findings suggest that phenylephrine transiently increased CBF without increasing the tonus of cerebral vasculature during hemorrhagic shock.

阿米替林在一種大鼠神經性疼痛模型中對L5背根初級傳入纖維異位放電的影響

The Effect of Amitriptyline on Ectopic Discharge of Primary Afferent Fibers in the L5 Dorsal Root in a Rat Model of Neuropathic Pain

Xin Su, MD, Annie H. Liang, MD, and Mark O. Urban, PhD

From the Department of Pain Research, Merck Research Laboratories, West Point, Pennsylvania.

Anesth Analg 2009; 108:1671-1679

背景：已有研究顯示鈉通道阻滯劑阿米替林能夠抑制受損神經的異位放電。在本研究中，我們描述了在L5/L6脊神經結紮（SNL）大鼠的L5背根傳入纖維異位放電的電生理學特性以及對阿米替林抑制作用的敏感性特徵。

方法：本研究選擇在SNL後縮爪閾值<4.0g的大鼠。在戊巴比妥麻醉的大鼠行椎板切除後，在接近進入脊髓處將L5背根纖維分散，在外周分別記錄靜脈注射阿米替林前後的單個單位自發電活動。測量傳入纖維的平均放電頻率和瞬間頻率。

結果：由瞬間頻率和放電峰間隙的分佈來看，未手術大鼠的傳入纖維具有高頻(35.23 ± 6.63 Hz)和模式化自發放電。在SNL手術後大鼠，傳入神經纖維呈無規律模式自發放電（平均11.05 ± 3.66 Hz）或在某些動物呈短暫爆發活動。未手術大鼠僅5/13(38%)傳入纖維在應用阿米替林(2 mg/kg, IV)後自發電活動減少，而阿米替林顯著抑制SNL大鼠13/18(72%)傳入纖維的異位放電(ID₅₀ = 1.66 ± 0.17 mg/kg)。而且，阿米替林的最大抑制效應總是出現於具有低頻(<20 Hz)和/或爆發放電的傳入纖維。

結論：這些結果爲臨床上用於治療神經性疼痛的藥物阿米替林可選擇性抑制神經性疼痛模型大鼠的低頻異位放電和爆發放電提

（顔濤 譯， 馬皓琳  李士通 校）

BACKGROUND: The sodium channel blocker amitriptyline has been shown to inhibit ectopic discharge in injured nerves. In the present study, we characterized ectopic discharges of afferent fibers following L5/L6 spinal nerve ligation (SNL) by their electrophysiological properties and sensitivities to inhibition by amitriptyline in the decentralized L5 dorsal root in SNL rats.

METHODS: Rats exhibiting withdrawal thresholds <4.0 g after SNL were selected for the present study. After laminectomy in pentobarbital-anesthetized rats, the L5 dorsal root was decentralized close to its entry to the spinal cord, and the spontaneous activities of single units were recorded peripherally before and after IV administration of amitriptyline. The mean frequency of afferent fiber activity and instantaneous frequency were measured.

RESULTS: The spontaneous activities of afferent fibers in naïve rats had high frequency (35.23 ± 6.63 Hz) and pattern discharge based on their instantaneous frequencies and interspike interval distributions. In rats that had received SNL, afferent fibers exhibited spontaneous discharge (mean of 11.05 ± 3.66 Hz) with an irregular discharge pattern or short bursting activity in some cases. Only 5/13 (38%) afferent fibers from naïve rats showed reduced spontaneous activities after amitriptyline (2 mg/kg, IV), whereas amitriptyline significantly inhibited ectopic discharge in 13/18 (72%) afferent fibers from SNL rats (ID₅₀ = 1.66 ± 0.17 mg/kg). Furthermore, the greatest inhibitory effect of amitriptyline was consistently observed on those afferent fibers exhibiting low frequency (<20 Hz) and/or bursting discharge.

CONCLUSION: These results provide direct evidence that amitriptyline, which is used clinically for the treatment of neuropathic pain, selectively inhibits ectopic discharge of low frequency and bursting discharge in the rat neuropathic pain model.

一項比較超聲和神經刺激作爲穿刺針引導行肌間溝導管放置的前瞻性隨機試驗

A Prospective Randomized Comparison of Ultrasound and Neurostimulation as Needle End Points for Interscalene Catheter Placement

Michael J. Fredrickson, MD^*, Craig M. Ball, MD, Adam J. Dalgleish, MD, Alistair W. Stewart, BSc, and Tim G. Short, MD^*

From the Departments of *Anesthesia and Orthopedic Surgery, Auckland City Hospital; Department of Anesthesiology, Faculty of Medical and Health Sciences, The University of Auckland, Grafton, Auckland, New Zealand; and Department of Orthopedic Surgery, Middlemore Hospital, Manukau City, Auckland, New Zealand.

Anesth Analg 2009; 108:1695-1700

背景：在本前瞻性、隨機試驗中，我們對假設進行驗證：肌間溝導管放置用於肩部手術術後鎮痛時，採用超聲與神經刺激引導穿刺時效果相似。次級終點包括針在皮膚下的時間、操作相關的疼痛以及早期神經並發症的發生率。

方法：招募行肩部手術的患者。套管針進針一開始在out-of-plane超聲成像的引導下進行，隨後前瞻性隨機分爲超聲下將針放至肌間溝交界面的側方(n = 41)或在電流 <0.5 mA 時獲得合適的運動反應(n = 40)。然後導管被盲目地送入超過針尖2-3cm的部位。所有手術在全麻下進行。手術結束時，設置0.2%羅呱卡因2mL/h輸注，並按需隨時給予5mL的單次輸注量，在家持續2-5天。記錄針在皮膚下的時間以及進針時數位等級疼痛評分（NRPS）。病人記錄術後第1天和第2天最嚴重的NRPS以及追加的羅呱卡因單次輸注和曲馬多的需要量。第10天，就新的神經症狀詢問所有病人。

結果：術後48h內，靜息下和活動時最差的NRPS和追加羅呱卡因單次輸注或曲馬多的需要量均無顯著差別。在超聲組，有一例未獲得滿意的超聲成像。在神經刺激組，所有病人獲得合適的運動反應。針在皮膚下時間的中位數（四分位數）在超聲組爲78 (65–101) s，而在神經刺激組爲108 (94–129) s (P < 0.001)。穿刺時NRPS的中位數（四分位數）在超聲組爲2 (0–4)，而在神經刺激組爲3 (1–5) (P < 0.048)。兩組間神經並發症的發生率沒有差別。

結論：肌間溝導管放置用於肩部手術術後鎮痛時，採用超聲與神經刺激引導穿刺效果相似。超聲引導減少針在皮膚下的時間和操作相關的疼痛。

（黃施偉 譯，馬皓琳 李士通 校）

BACKGROUND: In this prospective, randomized study, we tested the hypothesis that interscalene catheters placed for shoulder surgery using an ultrasound needle end point provide postoperative analgesia similar in quality to those placed using a neurostimulation needle end point. Secondary end points included needle time under the skin, procedure-related pain, and the incidence of early neurological complications.

METHODS: Patients presenting for shoulder surgery were recruited. Needles introduced for catheter insertion were initially guided with out-of-plane ultrasound imaging but were prospectively randomized to either sonographic placement immediately lateral to the interscalene interface (n = 41) or to an appropriate motor response at <0.5 mA (n = 40). Catheters were then advanced blindly 2–3 cm beyond needle tip. All surgery was conducted under general anesthesia. At the end of surgery, an infusion of ropivacaine 0.2% 2 mL/h with as-required hourly 5 mL boluses was instituted and continued at home for 2–5 days. Needle time under the skin and numerical rating pain score (NRPS) during insertion were recorded. Patients recorded worst NRPS, the need for supplementary ropivacaine boluses and tramadol on postoperative days 1 and 2. All patients were questioned at Day 10 for new neurological symptoms.

RESULTS: There was no significant difference in the worst NRPS at rest and on movement and the requirement for supplementary ropivacaine boluses or tramadol during the first 48 postoperative hours. In one patient in group ultrasound, a satisfactory ultrasound image was unobtainable. An appropriate motor response was obtained in all subjects in group neurostimulation. The median (quartiles) needle time under the skin was 78 (65–101) s in group ultrasound and 108 (94–129) s in group neurostimulation (P < 0.001). The median (quartiles) insertion NRPS was 2 (0–4) in group ultrasound and 3 (1–5) in group neurostimulation (P < 0.048). There was no difference in the frequency of neurological complications between groups.

CONCLUSIONS: Interscalene catheters placed for shoulder surgery using an ultrasound needle end point provide postoperative analgesia that is of similar quality to that obtained when using a neurostimulation needle end point. The ultrasound end point was associated with a reduction in needle under the skin time and procedure-related pain.

在健康志願者應用磁共振成像進行骶旁阻滯的解剖學研究

An Anatomical Study of the Parasacral Block Using Magnetic Resonance Imaging of Healthy Volunteers

Maeve O'Connor, MB, BCh, BAO^*, Margaret Coleman, FFARCSI^*, Fintan Wallis, FRCR, and Dominic Harmon, MD, FCARCSI^*

From the Departments of *Anesthesia and Intensive Care Medicine, and Radiology, Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland.

Anesth Analg 2009; 108:1708-1712

背景：據報道骶旁入路進行坐骨神經阻滯是易學易操作的，成功率高，並發症少。

方法：在10名志願者身上使用磁共振成像來評估類比針（垂直於皮膚）以骶旁入路到達骶叢。還同時記錄類比骶旁阻滯過程中所遇到的盆內結構。

結果：10名志願者中4名用類比針到達了骶叢，1名志願者到達了坐骨神經。骶叢精確地位於多種內臟結構旁，包括小腸、血管和卵巢。剩下的5名志願者（第一次進針入路未接觸骶叢）遇到了小腸、直腸、血管、精囊和骨性結構。以前，沒有碰到骶叢的話，推薦重新調整進針點使其靠近尾部。我們發現這樣的調整會導致盆內臟器穿孔或肛周凹陷。

結論：這些發現對骶旁阻滯解剖標誌的可靠性提出了質疑，提高了使用這項技術造成常見內臟穿孔的可能性。

（朱 慧譯 馬皓琳 李士通校）

 

BACKGROUND: The parasacral approach to sciatic blockade is reported to be easy to learn and perform, with a high success rate and few complications.

METHODS: Using magnetic resonance imaging, we evaluated the accuracy of a simulated needle (perpendicular to skin) in contacting the sacral plexus with this approach in 10 volunteers. Intrapelvic structures encountered during the simulated parasacral blocks were also recorded.

RESULTS: The sacral plexus was contacted by the simulated needle in 4 of the 10 volunteers, and the sciatic nerve itself in one volunteer. The plexus was accurately located adjacent to a variety of visceral structures, including small bowel, blood vessels, and ovary. In the remaining five volunteers (in whom the plexus was not contacted on first needle pass), small bowel, rectum, blood vessels, seminal vesicles, and bony structures were encountered. Historically, when plexus is not encountered, readjustment of the needle insertion point more caudally has been recommended. We found that such an adjustment resulted in simulated perforation of intrapelvic organs or the perianal fossa.

CONCLUSIONS: These findings question the reliability of the anatomical landmarks of the parasacral block and raise the possibility of frequent visceral puncture using this technique.

 

體外迴圈期間的最佳灌注：一項循證研究

Optimal Perfusion During Cardiopulmonary Bypass: An Evidence-Based Approach

Glenn S. Murphy, MD^*, Eugene A. Hessel, II, MD, and Robert C. Groom, MS, CCP

From the *Department of Anesthesiology, Evanston Northwestern Healthcare and Northwestern University Feinberg School of Medicine, Evanston, Illinois; Department of Anesthesiology and Surgery (Cardiothoracic), University of Kentucky College of Medicine, Lexigton Kentucky; and Department of Cardiovascular Perfusion, Maine Medical Center, Portland, Maine.

Anesth Analg 2009 108: 1394-1417.

 

在這個綜述中，作者總結了現有的最佳證據以指導成人體外迴圈（CPB）時達到“最佳”灌注。目前，有關體外迴圈期間生理變化這一問題上存在較大爭議。儘管有少數的資料提示高風險患者可能維持平均動脈血壓>70mmHg更有利，但是低風險患者能夠耐受平均動脈血壓在50-60mmHg而無明顯的並發症。體外迴圈時最佳的血細胞比容尚未界定，以大量資料資料爲基礎的研究表明，嚴重的血液稀釋和輸注濃縮紅細胞均可增加術後不良結果的風險。氧輸送取決於泵流量和動脈血氧含量。因此，在更嚴重的血液稀釋時通過增加泵流量可能避免器官損傷。此外，體外迴圈期間最佳溫度可能隨生理目標變化而改變，近來資料表明過度的複溫可能導致神經損傷。體外迴圈回路組成的設計也可能影響組織灌注和結局。儘管從理論講離心式血泵優於滾柱泵，但是尚難以說明使用離心泵能改善臨床結局。體外迴圈回路肝素預充可能減輕炎症反應和凝血途徑，但難以明確其可以減少主要不良反應的發病率和死亡率。同樣，與封閉系統相比，開放式靜脈儲血器無明顯的臨床優勢。總之，目前關於如何實施最佳的體外迴圈能夠作出強烈推薦的證據依然有限。迫切需要隨機試驗來評價患者，特別是高風險患者臨床結局的差異。

（懷曉蓉　譯　陳傑　校）

In this review, we summarize the best available evidence to guide the conduct of adult cardiopulmonary bypass (CPB) to achieve "optimal" perfusion. At the present time, there is considerable controversy relating to appropriate management of physiologic variables during CPB. Low-risk patients tolerate mean arterial blood pressures of 50–60 mm Hg without apparent complications, although limited data suggest that higher-risk patients may benefit from mean arterial blood pressures >70 mm Hg. The optimal hematocrit on CPB has not been defined, with large data-based investigations demonstrating that both severe hemodilution and transfusion of packed red blood cells increase the risk of adverse postoperative outcomes. Oxygen delivery is determined by the pump flow rate and the arterial oxygen content and organ injury may be prevented during more severe hemodilutional anemia by increasing pump flow rates. Furthermore, the optimal temperature during CPB likely varies with physiologic goals, and recent data suggest that aggressive rewarming practices may contribute to neurologic injury. The design of components of the CPB circuit may also influence tissue perfusion and outcomes. Although there are theoretical advantages to centrifugal blood pumps over roller pumps, it has been difficult to demonstrate that the use of centrifugal pumps improves clinical outcomes. Heparin coating of the CPB circuit may attenuate inflammatory and coagulation pathways, but has not been clearly demonstrated to reduce major morbidity and mortality. Similarly, no distinct clinical benefits have been observed when open venous reservoirs have been compared to closed systems. In conclusion, there are currently limited data upon which to confidently make strong recommendations regarding how to conduct optimal CPB. There is a critical need for randomized trials assessing clinically significant outcomes, particularly in high-risk patients.

 

 

使用旋轉血栓彈力測定儀評估血小板輸注的效果

The Effects of Platelet Transfusions Evaluated Using Rotational Thromboelastometry

Per Flisberg, MD, PhD^*, Malin Rundgren, MD^*, and Martin Engström, MD, PhD

From the *Department of Anaesthesia and Intensive Care, Lund University Hospital, Lund, Sweden; and Department of Anaesthesia and Intensive Care, Halmstad Central Hospital, Halmstad, Sweden.

Anesth Analg 2009 108: 1430-1432.

 

背景：此研究中，作者評估了血小板輸注對全血凝固産生的即刻效應。

方法：對10位元血小板減少的患者輸注一個單位200-300×10⁹的血小板，並使用旋轉血栓彈力測定儀測量輸注前及輸注時的凝血狀態。

結果：輸注使血小板計數的中位數從31.5×10⁹上升至43.5×10⁹。血凝塊形成時間縮短了32%（P=0.005），然而最大凝結強度卻增加了47%（P=0.005）。

結論：在這些患者中，輸注血小板後血小板計數平均上升12×10⁹與旋轉血栓彈力測定儀的相關資料的提高的相關性在統計學上有意義。

（朱紫瑜　譯　陳傑　校）

BACKGROUND: In this study, we assessed the immediate effects of platelet transfusion on whole blood coagulation.

METHODS: Ten thrombocytopenic patients given a single unit platelet transfusion of 200–300 x 10⁹ platelets had their coagulation status assessed before and immediately after transfusion using rotational thromboelastometry.

RESULTS: Transfusion increased the median platelet count from 31.5 to 43.5 x 10⁹/L. Clot formation time decreased by 32% (P = 0.005), whereas maximum clot strength increased by 47% (P = 0.005).

CONCLUSION: Statistically significant improvements in rotational thromboelastometry-measured parameters were observed in association with a mean increase of 12 x 109/L in platelet count after platelet transfusion in these patients.

 

 

經導管內主動脈瓣移植：麻醉學方面的思考

Transcatheter Aortic Valve Implantation: Anesthetic Considerations

Frederic T. Billings, IV, MD^*, Susheel K. Kodali, MD, and Jack S. Shanewise, MD^*

From the Departments of *Anesthesiology, and Internal Medicine, College of Physicians and Surgeons of Columbia University, New York, New York.

Anesth Analg 2009 108: 1453-1462.

 

主動脈瓣狹窄仍然是最常見的心臟瓣膜疾病。儘管主動脈瓣（AV）置換術對患者有益，但許多高危患者卻不能耐受手術。AV移植術能夠治療主動脈狹窄，而患者不需行胸骨切開、體外迴圈（CPB）以及主動脈鉗閉。這一經導管的操作是通過左心室（LV）尖穿刺或經皮股動脈或股靜脈導管穿刺完成的。患者接受全身麻醉，術中需對其血流動力學進行嚴密調控，並接受經食管的心臟超聲檢查（TEE）。

作者通過回顧文獻結合他們的經歷探討了在經導管內AV移植術中麻醉醫生的角色，重點關注麻醉監護、術中特殊事件、TEE和圍術期並發症。

目前有兩種方法可以到達主動脈瓣口：經股動脈逆行和經心尖順行。可根據每一位元患者的髂動脈內徑大小和迂曲度、主動脈弓內粥樣板塊的形成情況和心尖的病變情況選擇不同的入路。

精心設計全身麻醉以便在操作結束後順利拔管，而靜脈通路和藥物支援確保在緊急情況下實施胸骨切開並開始CPB。快速心室起搏和停止機械通氣阻斷心臟射血，並減少瓣膜成形術和假體移植過程中的心臟移位。儘管這些方法有利於操作者將假體放至受體的確切位置，但同時它們會引起低血壓和心律失常。在起搏和心臟複律前應用血管加壓藥可恢復足夠的血流動力學。

借助TEE可判斷主動脈瓣口面積、主動脈病理變化、心室功能和二尖瓣返流情況。TEE和X線熒光還可用於對主動脈瓣內的導引管進行定位。假體固定于瓣膜成形術的球囊導管上，通過充氣後進行移植。TEE可迅速測量主動脈瓣的返流情況，同時評估是否存在主動脈夾層。縫合股血管或LV尖後，即可對患者實施復蘇和拔管。

作者所觀察到的以及文獻報道的並發症包括主動脈瓣返流尽管那个表明、假體栓塞、二尖瓣破裂、出血、主動脈夾層、CPB、中風和死亡。

經導管內AV移植術的成功離不開術中的血流動力學調控。採用經股和經髂血管的入路時，需注意血流動力學管理方面的一些問題。但是總的來說兩種入路都需要快速心室起搏、在不停跳心瓣膜移植期間處理好低血壓和心律失常，以及實施TEE。麻醉醫師應嚴密監測接受經導管AV移植的主動脈瓣狹窄的患者。

（周姝婧　譯　陳傑　校）

Aortic valvular stenosis remains the most common debilitating valvular heart lesion. Despite the benefit of aortic valve (AV) replacement, many high-risk patients cannot tolerate surgery. AV implantation treats aortic stenosis without subjecting patients to sternotomy, cardiopulmonary bypass (CPB), and aorta cross-clamping. This transcatheter procedure is performed via puncture of the left ventricular (LV) apex or percutaneously, via the femoral artery or vein. Patients undergo general anesthesia, intense hemodynamic manipulation, and transesophageal echocardiography (TEE).

To elucidate the role of the anesthesiologist in the management of transcatheter AV implantation, we review the literature and provide our experience, focusing on anesthetic care, intraoperative events, TEE, and perioperative complications.

Two approaches to the aortic annulus are performed today: transfemoral retrograde and transapical antegrade. Iliac artery size and tortuosity, aortic arch atheroma, and pathology in the area of the (LV) apex help determine the preferred approach in each patient.

A general anesthetic is tailored to achieve extubation after procedure completion, whereas IV access and pharmacological support allow for emergent sternotomy and initiation of CPB. Rapid ventricular pacing and cessation of mechanical ventilation interrupts cardiac ejection and minimizes heart translocation during valvuloplasty and prosthesis implantation. Although these maneuvers facilitate exact prosthesis positioning within the native annulus, they promote hypotension and arrhythmia. Vasopressor administration before pacing and cardioversion may restore adequate hemodynamics.

TEE determines annulus size, aortic pathology, ventricular function, and mitral regurgitation. TEE and fluoroscopy are used for positioning the introducer catheter within the aortic annulus. The prosthesis, crimped on a valvuloplasty balloon catheter, is implanted by inflation. TEE immediately measures aortic regurgitation and assesses for aortic dissection. After repair of femoral vessels or LV apex, patients are allowed to emerge and assessed for extubation.

Observed and published complications include aortic regurgitation, prosthesis embolization, mitral valve disruption, hemorrhage, aortic dissection, CPB, stroke, and death.

Transcatheter AV implantation relies on intraoperative hemodynamic manipulation for success. Transfemoral and transapical approaches pose unique management challenges, but both require rapid ventricular pacing, the management of hypotension and arrhythmias during beating-heart valve implantation, and TEE. Anesthesiologists will care for debilitated patients with aortic stenosis receiving transcatheter AV implantation.

超聲引導技術與體表標誌定位技術用於小兒髂腹股溝-髂腹下神經阻滯：羅呱卡因血漿濃度的意義

Ultrasound Versus Landmark-Based Technique for Ilioinguinal-Iliohypogastric Nerve Blockade in Children: The Implications on Plasma Levels of Ropivacaine

Marion Weintraud, MD^*, Märit Lundblad, MD, Stephan C. Kettner, MD^*, Harald Willschke, MD^*, Stephan Kapral, MD^*, Per-Arne Lönnqvist, MD, Karl Koppatz, Klaus Turnheim, MD, Adrian Bsenberg, MD, and Peter Marhofer, MD^*

From the *Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria; Department of Anesthesia and Intensive Care, Karolinska Hospital/Astrid Lindgren Hospital, Stockholm, Sweden; Department of Pharmacology, Medical University of Vienna, Vienna, Austria; and Department of Anesthesia, University Cape Town, Red Cross Children Hospital, Cape Town, South Africa.

Anesth Analg 2009 108: 1488-1492.

 

背景：小兒髂腹股溝-髂腹下神經阻滯(INB)常見局部麻醉藥(LAs)血漿濃度較高。超聲引導可以在解剖上準確地注射局部麻醉藥，其可能改變血藥濃度。因此，作者比較了超聲引導與體表標誌定位下行髂腹股溝-髂腹下神經阻滯後的血漿羅呱卡因濃度。

方法： 全身麻醉下66名擬行腹股溝疝修補術的兒童（8-84個月）使用0.5%的羅呱卡因0.25ml/kg（1.25mg/kg）行髂腹股溝-髂腹下神經阻滯。這些兒童接受體表標誌定位技術（n=31）或超聲引導技術（n=35）。在注射局部麻醉藥之前（0）以及注射後5、10、20、30分鐘後採用高效液相色譜法測量羅呱卡因的血藥濃度。測定血漿峰濃度（C_max），達到血漿峰濃度的時間（t_max），吸收速率常數（k_a），血藥濃度上升速率(dC₀/dt)以及曲線下面積值（AUC）。  

 結果：與體表標誌爲基礎的定位技術相比，超聲引導技術導致了較高的C_max (sd), k_a, dC₀/dt和曲線下面積值（AUC），以及較短的t_max。(C_max: 1.78 [0.62] vs 1.23 [0.70] µg/mL, P < 0.01; k_a: 14.4 [10.7] vs 11.7 [11.4] h^–1, P < 0.05; dC₀/dt: 0.26 [0.12] vs 0.15 [0.03] µg/mL · min, P < 0.01; AUC: 42.4 [15.9] vs 27.2 [18.1] µg · 30 min/mL, P < 0.001; t_max: 20.4 [8.6] vs 25.3 [7.6] min, P < 0.05).

結論：藥代動力學資料顯示，與體表標誌爲基礎的定位技術相比，使用超聲引導技術行髂腹股溝-髂腹下神經阻滯後，局部麻醉藥吸收更快，血藥濃度更高。因此，超聲引導下行髂腹股溝-髂腹下神經阻滯時，應考慮減少局部麻醉藥的用量。

（黃丹　譯　陳傑　校）

BACKGROUND: Ilioinguinal-iliohypogastric nerve blockade (INB) is associated with high plasma concentrations of local anesthetics (LAs) in children. Ultrasonographic guidance enables exact anatomical administration of LA, which may alter plasma levels. Accordingly, we compared plasma levels of ropivacaine after ultrasonographic versus landmark-based INB.

METHODS: After induction of general anesthesia, 66 children (8–84 mo) scheduled for inguinal hernia repair received INB with 0.25 mL/kg of ropivacaine 0.5% (1.25 mg/kg) either by a landmark-based (n = 31) or by an ultrasound-guided technique (n = 35). Ropivacaine plasma levels were measured before (0) and 5, 10, 20, and 30 min after the LA injection, using high-performance liquid chromatography. Maximum plasma concentrations (C_max), time to C_max (t_max), the absorption rate constant (k_a), the speed of rise of the plasma concentration at Time 0 (dC₀/dt), and area under the curve value (AUC) were determined.

RESULTS: The ultrasound-guided technique resulted in higher C_max (sd), k_a, dC₀/dt, and AUC values and shorter t_max compared with the landmark-based technique (C_max: 1.78 [0.62] vs 1.23 [0.70] µg/mL, P < 0.01; k_a: 14.4 [10.7] vs 11.7 [11.4] h^–1, P < 0.05; dC₀/dt: 0.26 [0.12] vs 0.15 [0.03] µg/mL · min, P < 0.01; AUC: 42.4 [15.9] vs 27.2 [18.1] µg · 30 min/mL, P < 0.001; t_max: 20.4 [8.6] vs 25.3 [7.6] min, P < 0.05).

CONCLUSIONS: The pharmacokinetic data indicate faster absorption and higher maximal plasma concentration of LA when ultrasound was used as a guidance technique for INB compared with the landmark-based technique. Thus, a reduction of the volume of LA should be considered when using an ultrasound-guided technique for INB.

使用瑞芬太尼有利於插入Cobra喉周通氣道(Cobra PLA)

The Use of Remifentanil to Facilitate the Insertion of the Cobra Perilaryngeal Airway

Woo Jae Jeon, MD, Kyoung Hun Kim, MD, Jung Kook Suh, MD, and Sang Yun Cho, MD

From the Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea.

Anesth Analg 2009 108: 1505-1509.

 

背景：在使用異丙酚前給瑞芬太尼利於喉罩插入。作者設計本研究以確定在給予異丙酚時瑞芬太尼是否也利於喉周通氣道（ CobraPLA ）的插入。

方法：芬太尼和異丙酚都通過效應室靶控輸注給予。實驗分四組