Anesthesia & Analgesia
November 2006
Table of Content
CARDIOVASCULAR ANESTHESIA:
心臟手術中大量肽酶的使用:如此大量足夠嗎?對8281例心臟手術病人使用肽酶後的分析
宋翠俠 譯 陳傑 校
High-Dose Aprotinin in Cardiac Surgery: Is High-Dose High Enough?: An Analysis of 8281 Cardiac Surgical Patients Treated with Aprotinin
Wulf Dietrich, Raimund Busley, and Monika Kriner
Anesth Analg 2006 103: 1074-1081.
冠狀動脈旁路移植手術中使用足量酞酶：圍手術期藥物治療與患者預後分析
金琳 譯，薛張綱 審校
Full-Dose Aprotinin Use in Coronary Artery Bypass Graft Surgery: An Analysis of Perioperative Pharmacotherapy and Patient Outcomes
David Royston, Jerrold H. Levy, Jane Fitch, Wulf Dietrich, Simon C. Body, John M. Murkin, Bruce D. Spiess, and Andrea Nadel
Anesth Analg 2006 103: 1082-1088.
裘毅敏譯，馬皓琳 李士通校
Reduction in Air Bubble Size Using Perfluorocarbons During Cardiopulmonary Bypass in the Rat
Kenji Yoshitani, Fellery de Lange, Qing Ma, Hilary P. Grocott, and G. Burkhard Mackensen
Anesth Analg 2006 103: 1089-1093
波 譯 陳傑 校
The Vasodilatory Effects of Levosimendan on the Human Internal Mammary Artery
Félix R. Montes, Darío Echeverri, Lorena Buitrago, Isabel Ramírez, Juan C. Giraldo, Javier D. Maldonado, and Juan P. Umaña
Anesth Analg 2006 103: 1094-1098.
擇期行心臟外科手術的ASA III-IV患者術前口服碳水化合物
孫敏莉譯 薛張綱校
Preoperative Oral Carbohydrate Administration to ASA III-IV Patients Undergoing Elective Cardiac Surgery
Jan-P. Breuer, Vera von Dossow, Christian von Heymann, Markus Griesbach, Michael von Schickfus, Elise Mackh, Cornelia Hacker, Ulrike Elgeti, Wolfgang Konertz, Klaus-D. Wernecke, and Claudia D. Spies
Anesth Analg 2006 103: 1099-1108.
彭中美 譯 馬皓琳 李士通 校
Nonlinear Heart Rate Variability Analysis May Predict Atrial Fibrillation After Coronary Artery Bypass Grafting (Brief Report)
Dmitri Chamchad, George Djaiani, Hyun Ju Jung, Lev Nakhamchik, Jo Carroll, and Jay C. Horrow
Anesth Analg 2006 103: 1109-1112.
PEDIATRIC ANESTHESIA:
阻塞性睡眠呼吸暫停綜合征患兒進行增殖腺扁桃體切除術的圍術期併發症
詹慧 譯 陳傑 校
Perioperative Complications of Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome
John C. Sanders, Melinda A. King, Ronald B. Mitchell, and James P. Kelly
Anesth Analg 2006 103: 1115-1121.
吳德華譯 薛張綱校
An Evaluation of the Retromolar Space for Oral Tracheal Tube Placement for Maxillofacial Surgery in Children
Suman Arora, Vidya Rattan, and Neerja Bhardwaj
Anesth Analg 2006 103: 1122-1125.
張瑩 譯 馬皓琳 李士通校
Pediatric Airway and Esophageal Profiles with Acoustic Reflectometry
Gligor Gucev, David T. Raphael, Shlomo Elspas, and Gary Glass
Anesth Analg 2006 103: 1126-1130.
周懿之 譯 陳傑 校
Clinical Measures of Heparin’s Effect and Thrombin Inhibitor Levels in Pediatric Patients with Congenital Heart Disease
Nina A. Guzzetta, Bruce E. Miller, Kathy Todd, Fania Szlam, Renee H. Moore, Keith K. Brosius, Elizabeth C. Wilson, Anna M. Cohen, and Steven R. Tosone
Anesth Analg 2006 103: 1131-1138.
王麗珺譯 薛張綱校
Segmental Wall-Motion Abnormalities After an Arterial Switch Operation Indicate Ischemia
Kathryn Rouine-Rapp, Kenneth P. Rouillard, Wanda Miller-Hance, Norman H. Silverman, Kathryn K. Collins, Michael K. Cahalan, Alan Bostrom, and Isobel A. Russell
Anesth Analg 2006 103: 1139-1146.
AMBULATORY ANESTHESIA:
胡湘譯 李士通 馬皓琳校
Airway Responses During Desflurane Versus Sevoflurane Administration via a Laryngeal Mask Airway in Smokers
Rachel Eshima McKay, Alan Bostrom, Michel C. Balea, and Warren R. McKay
Anesth Analg 2006 103: 1147-1154.
李惟一 譯 陳傑 校
The Additive Interactions Between Ondansetron and Droperidol for Preventing Postoperative Nausea and Vomiting
Matthew T. V. Chan, Kai C. Choi, Tony Gin, Po Tong Chui, Timothy G. Short, Pong Mo Yuen, Amy H. Y. Poon, Christian C. Apfel, and Tong J. Gan
Anesth Analg 2006 103: 1155-1162.
ANESTHETIC PHARMACOLOGY:
用聽覺誘發電位和腦電圖評價右旋美托咪啶/雷米太尼和咪達唑侖/雷米太尼對健康人輕到中度鎮靜的效果
鐘靜譯 薛張綱校
The Effects of Dexmedetomidine/Remifentanil and Midazolam/Remifentanil on Auditory-Evoked Potentials and Electroencephalogram at Light-to-Moderate Sedation Levels in Healthy Subjects
Matthias Haenggi, Heidi Ypparila, Kathrin Hauser, Claudio Caviezel, Ilkka Korhonen, Jukka Takala, and Stephan M. Jakob
Anesth Analg 2006 103: 1163-1169.
唐李雋 譯 馬皓琳 李士通 校
The Effects of Paracetamol and Parecoxib on Kidney Function in Elderly Patients Undergoing Orthopedic Surgery
Wolfgang Koppert, Katrin Frötsch, Nilofar Huzurudin, Wolfgang Böswald, Norbert Griessinger, Volker Weisbach, Roland E. Schmieder, and Jürgen Schüttler
Anesth Analg 2006 103: 1170-1176.
丁震敏 譯 陳傑 校
Do Dopamine Receptors Mediate Part of MAC?
Yasumasa Tanifuji, Yi Zhang, Mark Liao, Edmond I. Eger, II, Michael J. Laster, and James M. Sonner
Anesth Analg 2006 103: 1177-1181.
TECHNOLOGY, COMPUTING, AND SIMULATION:
周 荻譯 薛張綱校
Variations in Arterial Blood Pressure and Photoplethysmography During Mechanical Ventilation
Giuseppe Natalini, Antonio Rosano, Maria E. Franceschetti, Paola Facchetti, and Achille Bernardini
Anesth Analg 2006 103: 1182-1188.
姜旭暉 譯 馬皓琳 李士通 校
Does Cerebral Monitoring Improve Ophthalmic Surgical Operating Conditions During Propofol-Induced Sedation?
Vivian L. B. Oei-Lim, Marcel G. W. Dijkgraaf, Marc D. de Smet, Martin White, and Cor J. Kalkman
Anesth Analg 2006 103: 1189-1195.
衛紅 譯 陳傑 校
The Problem of Artifacts in Patient Monitor Data During Surgery: A Clinical and Methodological Review (Review Article)
George Takla, John H. Petre, D. John Doyle, Mayumi Horibe, and Bala Gopakumaran
Anesth Analg 2006 103: 1196-1204.
CRITICAL CARE AND TRAUMA:
陸文清譯 薛張綱校
The Effect of Tracheal Gas Insufflation on Gas Exchange Efficiency
Michael R. Pinsky, Edgar Delgado, and Bernard Hete
Anesth Analg 2006 103: 1213-1218.
黃佳佳 譯，馬皓琳 李士通 校
Initial and Delayed Onset of Acute Respiratory Failure: Factors Associated with Development and Outcome
Suzana M. Lobo, Francisco R. M. Lobo, Flavio Lopes-Ferreira, Daliana Peres Bota, Christian Melot, and Jean-Louis Vincent
Anesth Analg 2006 103: 1219-1223.
NEUROSURGICAL ANESTHESIA:
右旋美托咪啶用於震顫性麻痹病人深部腦刺激物植入術的臨經驗
宋金超 譯 陳傑 校
Clinical Experience with Dexmedetomidine for Implantation of Deep Brain Stimulators in Parkinson's Disease
Irene Rozet, Saipin Muangman, Monica S. Vavilala, Lorri A. Lee, Michael J. Souter, Karen J. Domino, Jefferson C. Slimp, Robert Goodkin, and Arthur M. Lam
Anesth Analg 2006 103: 1224-1228.
徐麗穎譯 薛張綱校
Computed Tomography-Estimated Specific Gravity of Noncontused Brain Areas as a Marker of Severity in Human Traumatic Brain Injury
Vincent Degos, Thomas Lescot, Abderrezak Zouaoui, Harold Hermann, Françoise Préteux, Pierre Coriat, and Louis Puybasset
Anesth Analg 2006 103: 1229-1236.
神經外科手術中以雷米太尼為基礎的麻醉後頭皮神經阻滯與嗎啡用於過渡性鎮痛的對比研究
黃麗娜 譯 馬皓琳 李士通 校
A Comparison Between Scalp Nerve Block and Morphine for Transitional Analgesia After Remifentanil-Based Anesthesia in Neurosurgery
Christian Ayoub, François Girard, Daniel Boudreault, Philippe Chouinard, Monique Ruel, and Robert Moumdjian
Anesth Analg 2006 103: 1237-1240.
OBSTETRIC ANESTHESIA:
鄭麗 譯 陳傑 校
The Effects of Spinal Anesthesia on QT Interval in Preeclamptic Patients
Selda Sen, Galip Ozmert, Hakan Turan, Eray Caliskan, Alper Onbasili, and Duran Kaya
Anesth Analg 2006 103: 1250-1255
GENERAL ARTICLES:
頭頸部過伸可增Mallampati氣道評估的特異性和預測價值
王慧琳譯 薛張綱校
Craniocervical Extension Improves the Specificity and Predictive Value of the Mallampati Airway Evaluation
George A. Mashour and Warren S. Sandberg
Anesth Analg 2006 103: 1256-1259.
王慧琳譯 薛張綱校
The Twenty-Degree Reverse-Trendelenburg Position Decreases the Incidence and Severity of Postoperative Nausea and Vomiting After Thyroid Surgery
Kiyo Tominaga and Toshiyuki Nakahara
Anesth Analg 2006 103: 1260-1263.
喉罩通氣道和探條插管失敗：Combitube是用於住院病人急症氣道處理的第二個解救設備
邱郁薇 譯 馬皓琳 李士通 譯
Laryngeal Mask Airway and Bougie Intubation Failures: The Combitube as a Secondary Rescue Device for In-Hospital Emergency Airway Management (Brief Report)
Thomas C. Mort
Anesth Analg 2006 103: 1264-1266.
ANALGESIA:
塞來昔布（Celecoxib），普瑞巴林（Pregabalin）其聯合使用在柱融合手術中的鎮痛效果
周密 譯 陳傑 校
The Analgesic Efficacy of Celecoxib, Pregabalin, and Their Combination for Spinal Fusion Surgery
Scott S. Reuben, Asokumar Buvanendran, Jeffrey S. Kroin, and Karthik Raghunathan
Anesth Analg 2006 103: 1271-1277.
經斜角肌間溝臂叢神經阻滯行肩關節鏡手術病人術前給予單次量巴噴丁（800mg）不能增術後鎮痛效果
金 路譯 薛張綱校
A Single Preoperative Dose of Gabapentin (800 Milligrams) Does Not Augment Postoperative Analgesia in Patients Given Interscalene Brachial Plexus Blocks for Arthroscopic Shoulder Surgery
Frédéric Adam, Christophe Ménigaux, Daniel I. Sessler, and Marcel
Chauvin
Anesth Analg 2006 103: 1278-1282.
張曦 譯，馬皓琳 李士通 校
Experimental Heat Pain for Detecting Pregnancy-Induced Analgesia in Humans
Brendan Carvalho, Martin S. Angst, Andrea J. Fuller, Eric Lin, Anbu D. Mathusamy, and Edward T. Riley
Anesth Analg 2006 103: 1283-1287.
王震虹 譯 陳傑 校
A Pain Model After Gynecologic Surgery: The Effect of Intrathecal
and Systemic Morphine
Chuanyao Tong, Dawn Conklin, and James C. Eisenach
Anesth Analg 2006 103: 1288-1293.
已有外周感覺運動神經疾病或糖尿病性多發性神經病的患者軸索麻醉或鎮痛後神經系統併發症
周雅春 譯 馬皓琳 李士通 校
Neurologic Complications After Neuraxial Anesthesia or Analgesia in Patients with Preexisting Peripheral Sensorimotor Neuropathy or Diabetic Polyneuropathy
James R. Hebl, Sandra L. Kopp, Darrell R. Schroeder, and Terese T. Horlocker
Anesth Analg 2006 103: 1294-1299.
脛後神經阻滯中一個近端阻滯點的評估和神經刺激導向裝置針的使用
顧新宇 譯 陳傑 校
Evaluation of a Proximal Block Site and the Use of Nerve-Stimulator-Guided Needle Placement for Posterior Tibial Nerve Block
Robert Doty, Jr, Radha Sukhani, Mark C. Kendall, Edward Yaghmour, Antoun Nader, Alina Brodskaia, Tripti C. Kataria, and Robert McCarthy
Anesth Analg 2006 103: 1300-1305.
韓曉丹譯 薛張綱校
Lumbosacral Cerebrospinal Fluid Volume in Humans Using Three-Dimensional Magnetic Resonance Imaging
John T. Sullivan, Sharon Grouper, Matthew T. Walker, Todd B. Parrish, Robert J. McCarthy, and Cynthia A. Wong
Anesth Analg 2006 103: 1306-1310.
顏濤 譯， 馬皓琳 李士通 校
Postoperative Analgesia After Major Spine Surgery: Patient-Controlled Epidural Analgesia Versus Patient-Controlled Intravenous Analgesia
Michael R. Schenk, Michael Putzier, Bjoern Kügler, Stephan Tohtz, Kristina Voigt, Tania Schink, Wolfgang J. Kox, Claudia Spies, and Thomas Volk
Anesth Analg 2006 103: 1311-1317.
比較中胸段和低胸段硬膜外間隙硬膜外壓和低於大氣壓的硬膜外壓的發生率的差異
曹瑜 譯 陳傑 校
A Comparison of Epidural Pressures and Incidence of True Subatmospheric Epidural Pressure Between the Mid-Thoracic and Low-Thoracic Epidural Space
W. Anton Visser, Mathieu J. M. Gielen, Janneke L. P. Giele, and Gert J. Scheffer
Anesth Analg 2006 103: 1318-1321.
局部麻醉藥物的心臟毒性：一項麻醉院系關於當代臨實踐的調查研究
韓曉丹譯 薛張綱校
Local Anesthetic-Induced Cardiac Toxicity: A Survey of Contemporary Practice Strategies Among Academic Anesthesiology Departments
William Corcoran, John Butterworth, Robert S. Weller, Jonathan C. Beck, J. C. Gerancher, Timothy T. Houle, and Leanne Groban
Anesth Analg 2006 103: 1322-1326.
使用全氟化碳減小大鼠體外迴圈中的氣泡大小
Reduction in Air Bubble Size Using Perfluorocarbons During Cardiopulmonary Bypass in the Rat
Kenji Yoshitani, MD*, Fellery de
Lange, MD*_files/image001.gif){kind=small}
, Qing Ma, MD*,
Hilary P. Grocott, MD, FRCPC*, and G. Burkhard Mackensen, MD*
From the *Department of Anesthesiology,
Duke University Medical Center; and _files/image002.gif){kind=small}
Division
of Perioperative Care and Emergency Medicine, University Medical Center, Utrecht,
the Netherlands.
Anesth Analg 2006;103:1089-1093
背景：全氟化碳 (PFC) 乳是人造的攜氧化合物，對氣體有很高的溶解性，實驗已顯示能改善腦氣栓。腦氣栓與用體外迴圈(CPB)的心臟手術後的腦部不良反應有關。我們設計本研究的目的是測試PFC乳是否能減少CPB回路中氣泡的體積。方法：將進行60 min常溫非搏動性CPB的雄性Sprague-Dawley大鼠隨機分為3組。PFC組(n = 10)通過膜肺接受60% O2/36% N2/4% CO2進入靜脈儲液罐的2.7 g/kg (4.5 mL/kg) 的 PFC；對照組(n = 10)接受同樣的混合氣體4.5 mL/kg的生理鹽水。N2O 組(n = 6)暴露於36% N2O/60% O2/4% CO2中，並接受4.5 mL/kg的生理鹽水。CPB10min 35 min後400 µL的空氣注入CPB回路中的氣泡室。20 min後去除氣泡作容積分析。結果：與基礎值比較，PFC組的氣泡體積減小了13% ± 5%，N2O 組的氣泡體積增大了46% ± 9%，這兩組的化與對照組相比均有顯著性差異(P < 0.0001)。結論：結果提示給予PFC對減小CPB中出現的氣泡體積可能是有用的。
（裘毅敏譯，馬皓琳 李士通校）
BACKGROUND: Perfluorocarbon (PFC) emulsions are artificial oxygen-carrying compounds with a high solubility for gases that have experimentally been shown to ameliorate cerebral air embolism. Cerebral air embolism has been associated with adverse cerebral outcomes after cardiac surgery using cardiopulmonary bypass (CPB). We designed this study to test whether PFC emulsions could reduce the volume of bubbles within the CPB circuit.
METHODS: Male Sprague-Dawley rats undergoing 60 min of normothermic nonpulsatile CPB were randomized to one of the three groups. The PFC group (n = 10) received 60% O2/36% N2/4% CO2 via the membrane oxygenator and 2.7 g/kg (4.5 mL/kg) of PFC into the venous reservoir; the control group (n = 10) received the same gas mixture and 4.5 mL/kg of saline; the N2O group (n = 6) was exposed to 36% N2O/60% O2/4% CO2 and received 4.5 mL/kg of saline. After 10 min and 35 min of CPB, 400 µL of air was injected into a bubble chamber in the CPB circuit. After 20 min, the bubble was removed for volumetric analysis.
RESULTS: Compared with baseline, the bubble decreased 13% ± 5% in size in the PFC group and increased 46% ± 9% in the nitrous oxide group, both of these changes significantly different from the control group (P < 0.0001).
CONCLUSION: The results suggest that PFC administration may be useful in reducing the volume of gaseous bubbles present during CPB.
Nonlinear Heart Rate Variability Analysis May Predict Atrial Fibrillation After Coronary Artery Bypass Grafting
Dmitri Chamchad, MD*, George
Djaiani, MD_files/image003.gif){kind=small}
, Hyun Ju Jung,
MD_files/image004.gif){kind=small}
, Lev Nakhamchik,
MSc_files/image005.gif){kind=small}
, Jo Carroll, RN_files/image006.gif){kind=small}
, and Jay C.
Horrow, MD, MS_files/image007.gif){kind=small}
From the *Department of Anesthesia,
Lankenau Hospital, Wynnewood, Pennsylvania; _files/image008.gif){kind=small}
Department
of Anesthesia, Toronto General Hospital, Toronto, Ontario, Canada; and _files/image009.gif){kind=small}
Department of
Anesthesia, Drexel University College of Medicine, Philadelphia, Pennsylvania.
Anesth Analg 2006;103:1109-1112
背景：心率異性可能預示冠脈搭橋術後的心律失常。方法：對患者連續10分鐘心電圖記錄的脫機處理通過逐步多元對數回歸提供了R-R間期的時域、頻域、Poincaré，和點相關分析隨後與術後房顫的相關性。結果：符合入圍標準的88例患者中，13例發生房顫。峰值點關聯維數(優勢比 3.985/單位, P = 0.0096)和年齡(優勢比 1.144/yr, P = 0.0019) 與房顫有獨立的相關性 (c-統計值 = 0.839)。結論：進一步的研究應該確定峰值點關聯維數能預示體外迴圈下行冠脈搭橋術後房顫的發生。
（彭中美 譯 馬皓琳 李士通 校）
BACKGROUND: Heart rate variability might predict arrhythmias after coronary artery bypass grafting.
METHODS: Off-line processing of 10-min electrocardiogram recordings of consecutive patients provided R–R intervals for time domain, frequency domain, Poincaré, and point correlation analyses and subsequent association with postoperative atrial fibrillation by stepwise multivariate logistic regression.
RESULTS: Of 88 patients who met entry criteria, 13 developed atrial fibrillation. Peak point correlation dimension (odds ratio 3.985/unit, P = 0.0096) and age (odds ratio 1.144/yr, P = 0.0019) were independently associated with atrial fibrillation (c-statistic = 0.839).
CONCLUSIONS: Further study should confirm the ability of peak point correlation dimension to predict atrial fibrillation after coronary artery surgery with cardiopulmonary bypass.
Pediatric Airway and Esophageal Profiles with Acoustic Reflectometry
Gligor Gucev, MD*, David T.
Raphael, MD, PhD*, Shlomo Elspas, MD*, and Gary Glass_files/image010.gif){kind=small}
From the *Department of Anesthesiology,
Keck School of Medicine, University of Southern California, Los Angeles,
California; and _files/image011.gif){kind=small}
E. Benson Hood
Laboratories, Pembroke, Massachusetts.
Anesth Analg 2006;103:1126-1130
用聲學反射計的激素檢查可以以面積－深度剖面的形式，評估一個空腔的三維特徵。我們進行了一個初步研究在21名2-12歲兒童中得到與放置和定位呼吸管（氣管導管，ETT，內徑4.5–6 mm）有關的聲學反射計（AR）成像。與以往在成人中記錄的相同，在兒童也得到了特徵性AR剖面可用於氣道和食道插管。兩種剖面都顯示在整個氣管內導管長度的面積是恒定的，在之後的遠端，氣道面積有快速增，但食道面積降低到近乎零水準。與氣管剖面相比，支氣管插管顯示隆突遠端氣道面積減少。隨氣管內插管深，氣管內導管和支氣管壁將發生密相貼，使深度的氣道面積減少。我們討論了兒童和新生兒中氣管內導管貼壁的發生，以其可能的AR發現和治療。
（張瑩 譯 馬皓琳 李士通校）
Acoustic reflectometry is a technique by which the dimensions of a cavity can be estimated in the form of an area–distance profile. We conducted a pilot study to obtain the acoustic reflectometry (AR) images associated with breathing tube (endotracheal tube, ETT) placement (inner diameter 4.5–6 mm) and positioning in 21 (n = 21) children, aged 2–12 yr. Characteristic AR profiles, as previously noted in adults, were obtained for tracheal and esophageal intubations in children. Both types of profiles showed constant area throughout the ETT length, followed distally by either a rapid area increase (tracheal) or an area decrease to a near zero value (esophageal). Relative to a tracheal profile, a bronchial intubation exhibits a decrease in area distal to the carina position. With deeper ETT insertion, abutment of the ETT against the bronchial wall can occur, with a possible profound area decrease. The occurrence of ETT abutment in children and neonates, and its possible AR detection and treatment, is discussed.
Airway Responses During Desflurane Versus Sevoflurane Administration via a Laryngeal Mask Airway in Smokers
Rachel Eshima McKay, MD*, Alan
Bostrom, PhD_files/image012.gif){kind=small}
, Michel C.
Balea, MS*, and Warren R. McKay, MD*
From the *Department of Anesthesia and
Perioperative Care, University of California, San Francisco, California; and _files/image013.gif){kind=small}
Department of
Epidemiology and Biostatistics; University of California San Francisco, San
Francisco, California.
Anesth Analg 2006;103:1147-1154
與不吸煙者比較，吸煙者在麻醉中發生呼吸道併發症的概率更大。不知道一個吸入性麻醉藥的相對刺激性是否會增吸煙者的這些呼吸道併發症的發生率。在本研究中，我們測試了是否使用更刺激的麻醉（地氟醚）會導致吸煙者咳嗽、憋氣、喉痙攣或者氧飽和度下降的發生率更高。我們隨機分配了110名吸煙者應用地氟醚（n=55）或者七氟醚（n=55）麻醉，經由喉罩通氣道給予。5個接受地氟醚的病人(9%)與9個接受七氟醚的病人(16%)有咳嗽(P = 0.39)。絕大多數的咳嗽發生在誘導過程中(33%)或在氣道操作與低濃度麻醉中出現(56%)。憋氣、喉痙攣或者氧飽和度下降的發生率在接受地氟醚與七氟醚對比的患者之間是相近的。回顧性的比較這一組110位吸煙者與以前接受同樣的麻醉方法的一組包括100名非吸煙者和27名吸煙者顯示使病人呼吸系統併發症的風險增的是吸煙而不是麻醉藥物的選擇。
（胡湘譯 李士通 馬皓琳校）
Cigarette smokers have a greater risk of respiratory complications during anesthesia compared with nonsmokers. It is not known whether the relative pungency of an inhaled anesthetic further contributes to the smokers’ increased rate of such complications. In the present study, we tested whether the use of a more pungent anesthetic (desflurane) would result in a higher rate of coughing, breath holding, laryngospasm, or desaturation among patients who smoke. We randomly assigned 110 smokers to anesthesia with desflurane (n = 55) or sevoflurane (n = 55), administered via a laryngeal mask airway. Five patients (9%) receiving desflurane and nine patients (16%) receiving sevoflurane coughed (P = 0.39). Most coughing occurred during induction (33%) or emergence (56%), in the setting of airway manipulation and low anesthetic concentration. The rate of breath holding, laryngospasm, and desaturation was similar between those receiving desflurane versus sevoflurane. A retrospective comparison of this cohort of 110 smokers to a previous group consisting of 100 nonsmokers and 27 smokers receiving an identical anesthetic regimen indicates that cigarette smoking, but not choice of anesthetic, places patients at increased risk of respiratory complications.
The Effects of Paracetamol and Parecoxib on Kidney Function in Elderly Patients Undergoing Orthopedic Surgery
Wolfgang Koppert, MD, Priv.-Doz.*,
Katrin Frötsch, MD*, Nilofar Huzurudin, MD*, Wolfgang
Böswald, MD*, Norbert Griessinger, MD*, Volker Weisbach,
MD, Priv.-Doz._files/image014.gif){kind=small}
, Roland E.
Schmieder, MD, Professor_files/image015.gif){kind=small}
, and Jürgen
Schüttler, MD, Professor*
From the Departments of *Anesthesiology, _files/image016.gif){kind=small}
Transfusion Medicine
and Haemostaseology, _files/image017.gif){kind=small}
Nephrology and
Hypertension, University Hospital Erlangen, D-91054 Erlangen, Germany.
Anesth Analg 2006;103:1170-1176
傳統非甾體類炎藥對腎能的一般不良作用通常包括腎血流量、腎小球濾過率和鈉鉀排泄的減少，主要通過制腎環氧合酶起作用。我們設計了本研究以確定對靜脈注射乙醯氨基酚或帕瑞考昔對進行整形手術的老年患者腎能的影響。75例行髖關節置換或股骨幹手術的患者（76 ± 8 歲,均數 ±標準差）完成了該項隨機化的安慰對照研究。患者進入麻醉後監護室後，就給予研究藥物的初始量：對乙醯氨基酚1000 mg 靜脈注射(n = 25)，帕瑞考昔 40 mg 靜脈注射 (n = 25)，或鹽水靜脈注射 (n = 25)；追量在之後的三天內給予。阿片類作為補救藥物供給。在術前術後採集血、尿樣本，並測定腎能標記物。在給予帕瑞考昔初始量後的前兩小時內，肌酐清除率略微減少(125 ± 83至 86 ± 45 mL/min, P < 0.05)，而在安慰組和對乙醯氨基酚組中觀察到肌酐清除率無明顯減少。在所有的處理之後，鈉、鉀、尿白蛋白、α
-1-微球蛋白的排泄短暫升高（組間差異無顯著性）。總之，整形手術後所有患者的球管能皆有短暫受累，然而，不同處理組間的差異很小，且無臨相關性。進一步的研究應致於用此類藥物更長期治療的腎臟不良反應，尤其是那些有腎能減退或合併症的患者。
（唐李雋 譯 馬皓琳 李士通 校）
The common adverse effects of traditional
nonsteroidal antiinflammatory drugs on renal function include
reductions in renal blood flow, glomerular filtration rate, and
sodium and potassium excretion, mainly via inhibition of renal
cyclooxygenase. We designed the present study to determine the
effects of IV paracetamol or parecoxib on renal function in elderly
patients undergoing orthopedic surgery. Seventy-five patients (76 ±
8 yr, mean ± sd) undergoing hip replacement or surgery of the
femoral shaft completed this randomized and placebo-controlled
study. After their arrival in the postanesthesia care unit, patients
received an initial dose of the study medication, paracetamol 1000
mg IV (n = 25), parecoxib 40 mg IV (n = 25), or saline IV (n = 25);
subsequent doses were administered for the next 3 days. Opioids were
provided as rescue medication. Blood and urine samples were
collected before and after surgery, and markers of renal function
were determined. During the first 2 h after the initial dose of
parecoxib, creatinine clearance was slightly diminished (125 ± 83 to
86 ± 45 mL/min, P < 0.05), whereas
no significant decrease of creatinine clearance was observed in the
placebo and paracetamol groups. After all treatments, sodium and
potassium excretion as well as urine albumin and _files/image018.gif){kind=small}
-1-microglobulin were transiently increased (group differences:
not signicifant). In conclusion, glomerular and tubular functions
were transiently affected in all patients after orthopedic surgery;
however, the differences between the treatment groups were small and
not clinically relevant. Further studies are warranted to determine
adverse renal effects of longer-lasting therapy with these drugs,
especially in patients with renal impairment or concomitant
diseases.
Does Cerebral Monitoring Improve Ophthalmic Surgical Operating Conditions During Propofol-Induced Sedation?
Vivian L. B. Oei-Lim, MD, PhD*,
Marcel G. W. Dijkgraaf, PhD_files/image019.gif){kind=small}
, Marc D. de
Smet, MDCM, PhD_files/image020.gif){kind=small}
, Martin White,
MD, PhD*, and Cor J. Kalkman, MD, PhD_files/image021.gif){kind=small}
From the Departments of *Anesthesiology, _files/image022.gif){kind=small}
Clinical Epidemiology
& Biostatistics, _files/image023.gif){kind=small}
Ophthalmology,
Academic Medical Center, University of Amsterdam, Amsterdam; and _files/image024.gif){kind=small}
Department of Anesthesiology, University Medical Center, University of
Utrecht, Utrecht, Netherlands.
Anesth Analg 2006;103:1189-1195
眼科手術中病人從深度鎮靜條件中突然發生體動將對眼睛造成損害。有報導指出雙譜指數（BIS）和中潛伏期聽覺誘發電位（腋生的AEP指數，AAI）是鎮靜水準和意識消失的準確指標。我們在鎮靜過程中評估這些監測指標，特別強調防止過度鎮靜。100例排定行擇期眼科手術的病人用靶控輸注異丙酚進行鎮靜，並隨機地分入BIS指導組、AAI指導組、BIS/AAI指導組或臨指導組(每組n =25)。超過70歲的病人的異丙酚初始靶濃度是0.5 µg · mL–1，其餘所有病人1.0 µg · mL–1。每3分鐘分別增靶濃度0.1 or 0.2 µg · mL–1，直到病人的BIS值達到75(70—90)或AAI達到40(35—60)。不知分組的眼科醫生在術後評價處理品質。有四位病人因為過多的頭動而改為全身麻醉。BIS值在7%的手術時間中超出了範圍，AAI值在58%的時間超出了範圍。四組病人之間的處理品質沒有顯著性差別。我們得出結論，用BIS或AAI監測指導的異丙酚鎮靜和單純的臨觀測指導的鎮靜相比，並不改善眼科手術的操作條件。
（薑旭暉 譯 馬皓琳 李士通 校）
Sudden movements from over-sedation during ophthalmic surgery can be detrimental to the eye. Bispectral index (BIS) and middle-latency auditory-evoked potentials (Alaris AEP index, AAI) were reported to be accurate indicators for the level of sedation and loss of consciousness. We assessed these monitors during sedation with special emphasis on preventing over-sedation. One-hundred patients scheduled for elective eye surgery were sedated with target-controlled propofol infusion and randomly allocated to BIS-guided, AAI-guided, BIS/AAI-guided, or clinically guided groups (n = 25 each). The initial target concentration was 0.5 µg · mL–1 in patients >70 yr and 1.0 µg · mL–1 in all other patients. The concentration was increased every 3 min by 0.1 or 0.2 µg · mL–1, respectively until the patient had reached a BIS value of 75 (range 70–90) or an AAI of 40 (range 35–60). The surgeon who was blinded to group allocation assessed treatment quality after the procedure. Sedation was converted into general anesthesia in four patients because of excessive head movements. BIS was out of range 7% of the time vs 58% for AAI. No significant differences in treatment quality were observed among the four groups. We conclude that propofol sedation, guided by BIS or AAI monitoring, did not enhance ophthalmic surgical operating conditions over sedation guided by clinical observation only.
Initial and Delayed Onset of Acute Respiratory Failure: Factors Associated with Development and Outcome
Suzana M. Lobo, MD, Francisco R. M. Lobo, MD, Flavio Lopes-Ferreira, MD, Daliana Peres Bota, MD, Christian Melot, MD, PhD, and Jean-Louis Vincent, MD, PhD
From the Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, Belgium.
Anesth Analg 2006;103:1219-1223
在對31內外科重症監護室（ICU）中收入的1038例成年患者的前瞻性觀察研究中發現，入住ICU的時間超過48小時的313例患者中有182例（58%）發生急性呼吸衰竭（ARF，定義為Pao2/Fio2 _files/image025.gif){kind=small}
200 mm Hg並且需要呼吸支援）。其中，133例（42%）患者發生始髮型ARF（入住ICU後48小時內發生）；49例（16%）患者發生遲髮型ARF（入住ICU48小時以後發生）。在收入ICU時，心血管序貫性器官能衰竭評估 （SOFA）分數在始髮型ARF 患者中比 遲髮型ARF患者高(1.1 ± 1.5 vs 0.6 ± 1.2, P < 0.05)。 另外，高血漿C-反應蛋白濃度(OR 1.08,
95% CI 1.04–1.12, P = 0.0001)和高SOFA評分(OR 1.20, 95%
CI 1.08–1.33, P = 0.0007)是始髮型ARF的獨立相關因素，低Glasgow
昏迷等級（GCS）評分(OR 1.13, 95% CI 1.04–1.21, P = 0.0018)與遲髮型ARF相關。在始髮型ARF中收入ICU時的高 SOFA 評分(OR 1.24, 95%
CI 1.12–1.38, P = 0.0001)和低 GCS 評分 (OR 0.89,
95% CI 0.83–0.96, P = 0.0013)以遲髮型ARF中48 h
時的低 GCS 評分（OR 0.67, 95% CI 0.54–0.84, P =
0.0011)是獨立的死亡相關因素。兩者的死亡率是相似的。
（黃佳佳 譯，馬皓琳 李士通 校）
In a prospective observational study of
1038 adult admissions to a 31-bed medical/surgical intensive care
unit (ICU), acute respiratory failure (ARF, defined as a Pao2/Fio2
ratio _files/image026.gif){kind=small}
200 mm Hg and the
need for respiratory support) occurred in 182 (58%) of the 313
admissions with an ICU stay of more than 48 h. Initial ARF (onset
within 48 h of ICU admission) occurred in 133 (42%) patients, and
delayed onset ARF (onset >48 h after ICU admission) in 49 (16%).
On admission, the cardiovascular sequential organ failure assessment
(SOFA) score was higher in initial than in delayed onset ARF (1.1 ±
1.5 vs 0.6 ± 1.2, P < 0.05). High
admission serum C-reactive protein concentrations (OR 1.08, 95% CI
1.04–1.12, P = 0.0001) and SOFA scores (OR
1.20, 95% CI 1.08–1.33, P = 0.0007) were the
factors independently associated with initial ARF, and a low Glasgow
coma scale (GCS) score (OR 1.13, 95% CI 1.04–1.21, P = 0.0018) was associated with delayed onset ARF. In
initial ARF, a high SOFA score (OR 1.24, 95% CI 1.12–1.38, P = 0.0001) and a low GCS score (OR 0.89, 95% CI
0.83–0.96, P = 0.0013) on admission,
and in delayed onset ARF, a low GCS score at 48 h (OR 0.67, 95% CI
0.54–0.84, P = 0.0011) were independently associated
with death. The mortality rate was similar for initial and delayed
onset ARF.
神經外科手術中以雷米太尼為基礎的麻醉後頭皮神經阻滯與嗎啡用於過渡性鎮痛的對比研究
A Comparison Between Scalp Nerve Block and Morphine for Transitional Analgesia After Remifentanil-Based Anesthesia in Neurosurgery
Christian Ayoub, MD, B. Pharm*,
François Girard, MD, FRCPC*, Daniel Boudreault, MD, FRCPC*,
Philippe Chouinard, MD, FRCPC*, Monique Ruel, RN*, and
Robert Moumdjian, MD, FRCS(C)_files/image027.gif){kind=small}
From the *Department of Anesthesiology, and
_files/image028.gif){kind=small}
Neurosurgery division,
CHUM, Hôpital Notre-Dame, Montréal, Canada.
Anesth Analg 2006;103:1237-1240
我們比較了以雷米太尼為基礎的麻醉的神經外科手術後頭皮神經阻滯（SNB）與嗎啡提供的過渡性鎮痛。50例顱骨切開術病人隨機分入兩組：嗎啡組和阻滯組。嗎啡組在硬膜關閉後靜脈注射0.1 mg · kg–1嗎啡，手術結束時用20mL生理鹽水行SNB；阻滯組在硬膜關閉後用10mL生理鹽水替代嗎啡，手術結束時用0.5％布比卡因與2％利多卡因的1：1混合液行SNB。用10分數位化等級量表評定術後1、2、4、8、12、1624小時的疼痛程度。鎮痛包括皮下注射可待因。數位化等級量表評分的平均值在兩組間每一個時間間隔是相似的。除了術後4小時阻滯組的可待因量較大外，兩組總的可待因量也是相似的。可待因首量注射前的滯時在兩組間也無統計學差異：阻滯組和嗎啡組的中位數和範圍分別為45 分鐘 (20–2880) 比30 分鐘(10–2880)。兩組間術後血流動學相似。噁心嘔吐的發生率在嗎啡組略高，但是意識混亂的發生在兩組間沒有差異。總之，頭皮神經阻滯可以提供與嗎啡相似的過渡性鎮痛品質，並且兩者術後的血流動學化相同。
（黃麗娜 譯 馬皓琳 李士通 校）
We compared transitional analgesia provided by scalp nerve block (SNB) or morphine after remifentanil-based anesthesia in neurosurgery. Fifty craniotomy patients were randomly divided into two groups: morphine (morphine 0.1 mg · kg–1 IV after dural closure and an SNB performed with 20 mL of 0.9% saline at the end of surgery) and block (10 mL of 0.9% saline instead of morphine after dural closure and an SNB performed with a 1:1 mixture of bupivacaine 0.5% and lidocaine 2% at the end of surgery). Postoperative pain was assessed at 1, 2, 4, 8, 12, 16, and 24 h using a 10-point numerical rating scale. Analgesia consisted of subcutaneous codeine. Average numerical rating scale scores were similar between the two groups at each time interval. Total codeine dosage was also similar, except at 4 h postoperatively when it was higher in the block group. The delay before administration of the first dose of codeine was not statistically different between groups: 45 min (20–2880) vs 30 min (10–2880), median and range for the block and morphine group, respectively. Postoperative hemodynamics were similar for both groups. The incidence of nausea and vomiting was slightly more frequent in the morphine group, but the occurrence of confusion did not differ between groups. In conclusion, SNB provides a quality of transitional analgesia that is similar to that of morphine with the same postoperative hemodynamic profile.
喉罩通氣道和探條插管失敗：Combitube是用於住院病人急症氣道處理的第二個解救設備
Laryngeal Mask Airway and Bougie Intubation Failures: The Combitube as a Secondary Rescue Device for In-Hospital Emergency Airway Management
Thomas C. Mort, MD*_files/image029.gif){kind=small}
From the *Department of Anesthesiology,
Simulation Center, Hartford Hospital, Hartford and _files/image030.gif){kind=small}
Department of Anesthesiology, University of Connecticut School
of Medicine, Farmington, Connecticut.
Anesth Analg 2006;103:1264-1266
當傳統插管方法失敗時，備用的搶救氣道設施必須時可行且迅速協臨醫師控制氣道。我回顧了急診插管資料庫，從而明確哪個導氣管設施是用作搶救初步搶救設備失敗時的後備設備。探條和喉罩通氣道均有自身的失敗率。在住院情況當探條和喉罩通氣道失敗時，常用於急診未住院病人的Combitube®看來是一種有用的二級搶救設備。
（邱鬱薇 譯 馬皓琳 李士通 譯）
When conventional intubation methods fail, an accessory rescue airway device must be immediately available and rapidly deployed to assist the clinician in managing the airway. I reviewed an emergency intubation database to determine what airway devices were used as a backup to rescue the primary rescue device failures. The bougie and the laryngeal mask airway each have an intrinsic failure rate. The Combitube®, commonly used in the emergency prehospital setting, appeared to be a useful secondary rescue device in the hospital setting when the bougie and laryngeal mask airway failed.
Experimental Heat Pain for Detecting Pregnancy-Induced Analgesia in Humans
Brendan Carvalho, MBBCh, FRCA*,
Martin S. Angst, MD*, Andrea J. Fuller, MD_files/image031.gif){kind=small}
, Eric Lin, MD_files/image032.gif){kind=small}
,
Anbu D. Mathusamy, MD_files/image033.gif){kind=small}
, and Edward T. Riley,
MD*
From the *Department of Anesthesia,
Stanford University School of Medicine, Stanford, Californi; at Northern
Colorado Anesthesia Professional Consultants, Fort Collins, Colorado; _files/image034.gif){kind=small}
University of
California San Francisco, San Francisco, California; and _files/image035.gif){kind=small}
Bronx-Lebanon
Hospital, Bronx, New York.
Anesth Analg 2006;103:1283-1287
動物實驗提示，增迴圈中的雌激素和黃體酮活化內啡肽系統產生娠引起的傷害感受效應。人類的研究已提供了不一致的結果，而且常常缺少一個非娠對照組。在這個研究中，我們比較娠婦女和非娠婦女對試驗性熱和冷疼痛的敏感度。選入19個健康的非娠女性志願者和20個娠足月婦女。用實驗性熱導致的疼痛和冷壓疼痛模型，檢測疼痛的閾值和耐受。分別在分娩前和分娩後1-2天（娠組）或連續幾天（非娠組）評估受試者。比較非娠對照組，分娩前和分娩後娠婦女的熱疼痛的耐受性較顯著增（49.0 ± 1.2 對50.0 ± 1.0 和49.2 ± 1.2對50.1 ± 0.7°C；平均數±標準差）。然而，冷壓試驗導致的疼痛在兩個研究組忍受了相似的時間。足月娠導致的止痛效應可以通過實驗性熱疼痛檢測。這種效應持續到產後24-48小時。實驗性熱疼痛是用於進一步描述人類娠導致止痛現象的一個合適的模式。
（張曦 譯，馬皓琳 李士通 校）
Animal studies suggest that increased circulating estrogen and progesterone, and activation of the endorphin system cause prenancy-induced antinociceptive effects. Human studies have provided inconsistent results and have often lacked a nonpregnant control group. In this study, we compared sensitivity to experimental heat and cold pain in pregnant and nonpregnant women. Nineteen healthy nonpregnant female volunteers and 20 pregnant women at term were enrolled. Pain threshold and tolerance were examined using experimental heat-induced pain and cold pressor pain models. Subjects were evaluated pre- and 1–2 days post-delivery (pregnant), or on consecutive days (nonpregnant). Heat pain tolerance was significantly increased in the pregnant women during pre and postdelivery when compared with nonpregnant controls (50.0 ± 1.0 vs 49.0 ± 1.2 and 50.1 ± 0.7 vs 49.2 ± 1.2°C; mean ± sd). However, pain induced by the cold pressor test was endured for a similar amount of time by both study groups. Pregnancy-induced analgesic effects at term can be detected in a model of experimental heat pain. These effects persist during the first 24–48 h after delivery. Experimental heat pain is a suitable modality for further characterizing the phenomenon of pregnancy-induced analgesia in humans.
已有外周感覺運動神經疾病或糖尿病性多發性神經病的患者軸索麻醉或鎮痛後神經系統併發症
Neurologic Complications After Neuraxial Anesthesia or Analgesia in Patients with Preexisting Peripheral Sensorimotor Neuropathy or Diabetic Polyneuropathy
James R. Hebl, MD*, Sandra L.
Kopp, MD*, Darrell R. Schroeder, MS_files/image036.gif){kind=small}
, and Terese T. Horlocker, MD*
From the *Department of Anesthesiology; and
_files/image037.gif){kind=small}
Section of
Biostatistics, Department of Health Sciences Research, Mayo Clinic College of
Medicine, Rochester, Minnesota.
Anesth Analg 2006;103:1294-1299
背景：軸索阻滯後嚴重神經系統併發症的風險在普通人群中非常罕見。但是原先有神經系統損害的患者在軸索麻醉或鎮痛後進一步發生神經損害後遺症的風險性可能增。方法：我們回顧性調查了567名在軸索麻醉或鎮痛前患有外周感覺運動神經疾病或糖尿病性多發性神經病的患者。收集每個患者的人口統計學資、神經系統病史、軸索阻滯的適應症類型、併發症和阻滯預後。結果：大部分病人在接受阻滯時具有穩定的慢性神經系統體征或症狀，只有很少部分病人報在接受阻滯前六個月內神經系統症狀進一步重。軸索阻滯的種類包括：325名患者麻（57％）、214名患者硬膜外麻醉或鎮痛（38％）、24名患者連續麻（4％）4名患者腰硬聯合麻醉（1％）。在所有患者中，2名患者（0.4%; 95% 可信限 0.1%–1.3%）在手術後出現新的或重的神經能缺失。此2名患者軸索阻滯操作過程中無特事件發生。在這些患者中，軸索阻滯可能促成繼發於已受損神經周圍直接創傷和局麻藥神經毒性的損傷。63名患者中發生了65項（11.5%）與術操作有關的併發症。最常見的併發症是無意中引發的感覺異常（7.6%），其次是有出血證據的損傷性置針（1.6%）和意外穿破硬膜（0.9）。沒有發生感染或血液學性併發症。結論：我們發現接受軸索麻醉或鎮痛的外周感覺運動神經疾病或糖尿病多發神經病患者嚴重術後神經能障礙的發生率為0.4%（95% 可信限0.1%–1.3%）。臨醫師在開展和實施區域麻醉性監護計畫時應該意識到這一潛在的高危性亞人群。
(周雅春 譯 馬皓琳 李士通 校）
BACKGROUND: The risk of severe neurologic injury after neuraxial blockade is extremely rare among the general population. However, patients with preexisting neural compromise may be at increased risk of further neurologic sequelae after neuraxial anesthesia or analgesia.
METHODS: We retrospectively investigated 567 patients with a preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy who subsequently underwent neuraxial anesthesia or analgesia. Patient demographics, neurologic history, the indication and type of neuraxial blockade, complications, and block outcome were collected for each patient.
RESULTS: The majority of patients had chronically stable neurologic signs or symptoms at the time of block placement, with very few reporting progression of their symptoms within the last 6 mo. The type of neuraxial technique included spinal anesthesia in 325 (57%) patients, epidural anesthesia or analgesia in 214 (38%) patients, continuous spinal anesthesia in 24 (4%) patients, and a combined spinal-epidural technique in four (1%) patients. Overall, two (0.4%; 95% CI 0.1%–1.3%) patients experienced new or progressive postoperative neurologic deficits, in the setting of an uneventful neuraxial technique. In these patients, the neuraxial block may have contributed to the injury secondary to direct trauma or local anesthetic neurotoxicity around an already vulnerable nerve. Sixty-five (11.5%) technical complications occurred in 63 patients. The most common complication was unintentional elicitation of a paresthesia (7.6%), followed by traumatic (evidence of blood) needle placement (1.6%) and unplanned dural puncture (0.9%). There were no infectious or hematologic complications.
CONCLUSIONS: The risk of severe postoperative neurologic dysfunction in patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing neuraxial anesthesia or analgesia was found to be 0.4% (95% CI 0.1%–1.3%). Clinicians should be aware of this potentially high-risk subgroup of patients when developing and implementing a regional anesthetic care plan.
Postoperative Analgesia After Major Spine Surgery: Patient-Controlled Epidural Analgesia Versus Patient-Controlled Intravenous Analgesia
Michael R. Schenk, MD*, Michael
Putzier, MD_files/image038.gif){kind=small}
, Bjoern Kügler*,
Stephan Tohtz, MD_files/image039.gif){kind=small}
, Kristina Voigt*,
Tania Schink_files/image040.gif){kind=small}
, Wolfgang J.
Kox, FRCP*, Claudia Spies, MD*, and Thomas Volk, MD*
From the Departments of *Anesthesiology and
Intensive Care, _files/image041.gif){kind=small}
Orthopedics; and _files/image042.gif){kind=small}
Institute of Medical
Biometry, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany.
Anesth Analg 2006;103:1311-1317
背景：柱融合術可導致嚴重的術後疼痛，妨礙康復。我們用一項前瞻、雙盲、隨機對照的研究比較了病人自控硬膜外鎮痛（PCEA）與病人自控靜脈鎮痛（PCIA）的有效性。方法：在腰椎前-後融合術術中放置硬膜外導管後，72位病人使用了PCEA(羅呱卡因0.125%和舒太尼1.0µg/mL，輸注速度14mL/h，單次量5mL，鎖定時間15min)和靜脈安慰或者PCIA（嗎啡2.0mg/mL，單次量3mg，鎖定時間15min）和硬膜外安慰。評估疼痛水準（視覺類比評分 0-10）、活動能（翻身、站立和行走）、鎮痛藥消耗量以不良反應至術後72h。結果：按照事先確定的標準，14位病人被排除，剩下58位元病人進行資料分析。在整個研究階段內，PCEA組病人在休息和活動時的疼痛水平均明顯低於PCIA組病人（所有病例P < 0.0001）。PCEA組病人能在翻身的時間較早（P < 0.05）。PCEA病人對疼痛治療滿意度更高（P < 0.01）。結論：我們結論是，在柱融合術後，利用術中放置的硬膜外導管，使用羅呱卡因和舒太尼行PCEA相比PCIA能提供更好的鎮痛和更高的病人滿意度。
（顏濤 譯， 馬皓琳 李士通 校）
BACKGROUND: Spinal fusion surgery causes severe postoperative pain, hampering reconvalescense. We investigated the efficacy of patient-controlled epidural analgesia (PCEA) in a prospective, double-blind, randomized, controlled comparison with patient-controlled IV analgesia (PCIA).
METHODS: After lumbar anterior-posterior fusion receiving an epidural catheter intraoperatively, 72 patients were given either PCEA (ropivacaine 0.125% and sufentanil 1.0 µg/mL at 14 mL/h; bolus: 5 mL; lockout time: 15 min) and IV placebo or PCIA (morphine 2.0 mg/mL; bolus: 3 mg; lockout time: 15 min) and epidural placebo. Pain levels (visual analog scale 0-10), functional capabilities (turning in bed, standing, and walking), analgesic consumption, and side effects were evaluated until 72 h after surgery.
RESULTS: Fourteen patients were excluded by predetermined criteria, leaving 58 patients for data analysis. Pain levels at rest and during mobilization were significantly lower in the PCEA when compared with that in the PCIA group throughout the study period (P < 0.0001 in all cases). Time until able to turn in bed was achieved earlier in the PCEA group (P < 0.05). Patients in the PCEA group were significantly more satisfied with pain therapy (P < 0.01).
CONCLUSION: We conclude that PCEA with ropivacaine and sufentanil, using intraoperatively placed epidural catheters, provides superior analgesia and higher patient satisfaction when compared with PCIA after spinal fusion surgery.
冠狀動脈旁路移植手術中使用足量酞酶：圍手術期藥物治療與患者預後分析
Full-Dose Aprotinin Use in Coronary Artery Bypass Graft Surgery: An Analysis of Perioperative Pharmacotherapy and Patient Outcomes
David Royston, FRCA*, Jerrold H. Levy, MD_files/image043.gif){kind=small}
, Jane Fitch, MD_files/image044.gif){kind=small}
, Wulf Dietrich, MD_files/image045.gif){kind=small}
, Simon C. Body, MBChB, MPH||,
John M. Murkin, MD¶, Bruce D. Spiess, MD#, and Andrea Nadel, PhD**
From the *Department of Anesthesia,
Harefield Hospital, London, UK; _files/image046.gif){kind=small}
Department of
Anesthesiology, Emory University, Atlanta, Goergia; _files/image047.gif){kind=small}
Department of Anesthesiology, University of Oklahoma, Oklahoma
City, Oklahoma; _files/image048.gif){kind=small}
Department of Anesthesiology,
German Heart Center Munich, Munich, Germany; ||Department of Anesthesiology,
Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical
School, Boston, Massachusetts; ¶Department of Anesthesia, University of Western
Ontario, London, Ontario, Canada; #Department of Anesthesiology, VCURES Shock
Center, Virginia Commonwealth University/Medical College of Virginia Campus,
Richmond, Virginia; and **Global Statistics, Bayer Pharmaceuticals Corporation,
West Haven, Connecticut.
Anesth Analg 2006 103: 1082-1088
背景：不恰當地啟動止血和炎症反應可能與術後發病率和死亡率相關。既往實驗室研究和動物試驗研究表明絲氨酸蛋白酶制——酞酶——可以預防組織和器官損傷。在這篇回顧分析中，我們評估了人類冠狀動脈旁路移植手術（CABG）中使用酞酶治療與器官能不全的關係。方法：使用評估足量酞酶（負荷量為2×109 IU，之後泵推初始量為2×109 IU，維持量為0.5×109 IU/h）減少行CABG患者（安慰組，n＝861；酞酶組，n＝862）術中血液丟失和輸血量的安全性和有效性的前瞻性隨機雙盲安慰對照研究的資料進行回顧性分析。原始研究終點是死亡、不良的腦血管事件、心肌梗塞（MI）與藥物干預（正性肌藥物、血管活性藥物與心律失常藥物）。結果：單一數分析顯示與安慰相比，足量酞酶治療對減少不良的腦血管事件的發生（比值比[OR] 0.42，95％可性區間[CI] 0.19-0.93；P = 0.03）和正性肌藥物（OR 0.79，95% CI 0.65-0.97；P = 0.02）、血管活性藥物（OR 0.74，95% CI 0.61-0.90；P < 0.01）與心律失常藥物（OR 0.79，95% CI 0.65-0.96；P = 0.02）有明顯的作用，但與死亡（OR 1.00，95% CI 0.54-1.85；P = 1.0）和心肌梗塞（OR 0.92，95% CI 0.64-1.31；P = 0.6）無關。多數分析證明了單一數分析的結果。結論：這項回顧性分析研究利用了行CABG患者的前瞻性隨機雙盲安慰對照研究的資料，結果表明使用全量酞酶可以降低不良的腦血管事件的發生率、減少血管活性藥物的使用；但對死亡和圍手術期心肌梗塞的危險性沒有影響。
（金琳 譯，薛張綱 審校）
BACKGROUND: Inappropriate activation of hemostasis and inflammation may contribute to postoperative morbidity and mortality. The serine protease inhibitor, aprotinin, has been shown to prevent tissue and organ injury in laboratory and animal studies. In this retrospective analysis, we evaluated the relationship of aprotinin therapy with organ dysfunction in humans undergoing coronary artery bypass graft surgery (CABG).METHODS: Data from prospective randomized, double-blind, placebo-controlled studies evaluating the safety and efficacy of full-dose aprotinin (2 million KIU load, 2 million KIU pump prime, and 0.5 million KIU/h continuous infusion) to reduce blood loss and transfusion requirements in patients undergoing CABG (placebo, n = 861; aprotinin, n = 862) were examined retrospectively. Primary end-points were death, adverse cerebrovascular outcome, myocardial infarction (MI), and pharmacological interventions (inotropic drugs, vasopressors, and antiarrhythmics). RESULTS: Univariate analysis showed that relative to placebo, full-dose aprotinin therapy was associated with significant effects on the incidence of adverse cerebrovascular outcome (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.19–0.93; P = 0.03) and use of inotropic drugs (OR 0.79, 95% CI 0.65–0.97; P = 0.02), vasopressors (OR 0.74, 95% CI 0.61–0.90; P < 0.01), and antiarrhythmics (OR 0.79, 95% CI 0.65–0.96; P = 0.02), but not death (OR = 1.00, 95% CI 0.54–1.85; P = 1.0) or MI (OR 0.92, 95% CI 0.64–1.31; P = 0.6). Multivariate analysis confirmed results of univariate analysis. CONCLUSIONS: This retrospective analysis of data collected from prospective, randomized, placebo-controlled studies in CABG shows that full-dose aprotinin use was associated with a lower risk of adverse cerebrovascular outcomes and a reduced need for use of vasoactive drugs; the risk of death and perioperative MI was not affected by aprotinin therapy.
擇期行心臟外科手術的ASA III-IV患者術前口服碳水化合物
Preoperative Oral Carbohydrate Administration to ASA III-IV Patients Undergoing Elective Cardiac Surgery
Breuer, Jan-P. MD *; von Dossow, Vera MD *; von Heymann, Christian MD *; Griesbach, Markus MD *; von Schickfus, Michael Cand med *; Mackh, Elise Cand med *; Hacker, Cornelia Cand med *; Elgeti, Ulrike MD +; Konertz, Wolfgang MD +; Wernecke, Klaus-D. PhD ++; Spies, Claudia D. MD *
From the *Department of Anesthesiology and Intensive Care Medicine, Campus Charite Mitte and Campus Virchow-Klinikum; +Department of Cardiovascular Surgery; and ++Institute of Medical Statistics and Biometry, Campus Charite Mitte, CHARITE University Medicine Berlin, Berlin, Germany
Anesthesia & Analgesia. 103(5):1099-1108, November 2006
在這項研究中，我們調查研究了擇期行心臟外科手術ASA體格狀態III-IV的患者術前口服碳水化合物對術後胰島素（PIR）、胃液容量、術前不適合和器官機能障礙的影響,其中包括非胰島素依賴2型糖尿病患者。外科手術前，188患者隨機接受清澈的12.5%碳水化合物飲品（CHO）、有滋味的水（安慰），或整夜禁食（對照）。CHO和安慰採用雙盲的方法在夜間給予800ml和術前2小時給予400ml相應的飲品。患者從全麻誘導開始到手後24小時予以監測。控制血糖≤10.0mmol/L的外用胰島素需要量作為PIR的標示。胃液容量通過被動胃引流（passive gastric reflux）來測量，術前不適使用目視評分表來評價。記錄術後臨和外科資料。血糖水準和胰島素需要量各組之間無差別。患者接受CHO和安慰與對照組相比更少出現口渴症狀（分別為，P < 0.01 和 P = 0.06）。飲用液體不引起胃容量增或其他副作用。術中CHO組在心肺轉流術開始後較少需要收縮性支援（(P < 0.05）。結論是，在心臟外科手術之前使用碳水化合物對PIR無影響。清澈的液體減少患者口渴，而且是對於ASA III-IV的患者是安全可推薦的方法。進一步的研究將是探討術前口服CHO可能的心臟保護效應。
（孫敏莉譯 薛張綱校）
In this study we investigated the effects of preoperative oral carbohydrate administration on postoperative insulin resistance (PIR), gastric fluid volume, preoperative discomfort, and variables of organ dysfunction in ASA physical status III-IV patients undergoing elective cardiac surgery, including those with noninsulin-dependent Type-2 diabetes mellitus. Before surgery, 188 patients were randomized to receive a clear 12.5% carbohydrate drink (CHO), flavored water (placebo), or to fast overnight (control). CHO and placebo were treated in double-blind format and received 800 mL of the corresponding beverage in the evening and 400 mL 2 h before surgery. Patients were monitored from induction of general anesthesia until 24 h postoperatively. Exogenous insulin requirements to control blood glucose levels <=10.0 mmol/L were used as a marker for PIR. Gastric fluid volume was measured by passive gastric reflux and preoperative discomfort using visual analog scales. Postoperative clinical and surgical data were recorded. Blood glucose levels and insulin requirements did not differ between groups. Patients receiving CHO and placebo were less thirsty compared with controls (P < 0.01 and P = 0.06, respectively). Ingested liquids did not cause increased gastric fluid volume or other adverse events. The CHO group required less intraoperative inotropic support after initiation of cardiopulmonary bypass weaning (P < 0.05). In conclusion, preoperative CHO administration before cardiac surgery does not affect PIR. Clear fluids reduce thirst and may be recommended as a safe procedure in ASA III-IV patients. Further research is indicated to investigate possible cardioprotective effects of preoperative CHO intake.
An evaluation of the retromolar space for oral tracheal tube placement for maxillofacial surgery in children.
Department of Anaesthesia and Intensive Care, Oral Health Sciences Center, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.
Anesth Analg. 2006 Nov;103(5):1122-5.
背景：第一二恒臼齒的萌出可能影響臼齒後空間的大小。本研究我們評估了小兒臼齒後空間大小對臼齒後氣管導管的放置是否充足和第一二橫臼齒對此空間的影響。方法：評估3-15歲行非面部手術的患兒臼齒後空間大小。標準經口氣管插管後，移動氣管導管至臼齒後空間，下頜緩慢閉合至中央合攏。同時注意是否有氣道阻增和氧飽和度降低。研究的第二部分是經臼齒後氣管插管在小兒齶面外科行術中頜間固定術的可行性評估。結果：臼齒後空間足夠用來放置氣管導管。第一二恒臼齒的萌發不影響氣管插管。在80個臼齒後放置氣管導管的患兒中間有79例可達到牙齒中央閉合。6例行頜間固定術和齶面外科手術的患兒成地進行了臼齒後氣管插管。結論：臼齒後空間可安全的用於術中頜間固定患兒的氣管插管，同時可讓出更多的鼻腔和口腔的空間。
（吳德華譯 薛張綱校）
BACKGROUND: The eruption of the first and second permanent molar teeth may influence the size of the retromolar space. In this study we evaluated the adequacy of the retromolar space for retromolar intubation and any effect of eruption of the first and second permanent molar teeth on this space in children. METHODS: Children 3-15 yr of age, undergoing surgery other than facial surgery were included for evaluation of the retromolar space. After standard oral tracheal intubation, the endotracheal tube was shifted to the retromolar space and the mandible was slowly closed to achieve centric occlusion. At the same time, any increase in airway resistance or decrease in oxygen saturation was noted. In the second part of the study, the feasibility of retromolar intubation in pediatric patients undergoing maxillofacial surgery with intraoperative maxillomandibular fixation was assessed. RESULTS: There was enough space for endotracheal tube placement in the retromolar region. The eruption of the first and second permanent molar teeth did not affect intubation. It was possible to achieve centric occlusion in 79 of 80 children with the endotracheal tube positioned in the retromolar space. Retromolar intubation was successfully accomplished in six pediatric patients undergoing maxillomandibular fixation and maxillofacial surgery. CONCLUSION: The retromolar space can be safely used for intubation in children when intraoperative maxillomandibular fixation, and simultaneous access to the nose and oral cavity are needed.
Segmental wall-motion abnormalities after an arterial switch operation indicate ischemia
Kathryn Rouine-Rapp, Kenneth P. Rouillard, Wanda Miller-Hance, Norman H. Silverman, Kathryn K. Collins, Michael K. Cahalan, Alan Bostrom, and Isobel A. Russell
Department of Anesthesia, University of California-San Francisco, 94143-0648, USA. Anesth Analg 2006 103: 1139-1146.
我們前瞻性地選擇了29名行動脈轉接手術的新生兒，研究異常的節段性壁運動(SWMA) 是否代表了心肌缺血。術中，經食管超聲心動圖在基線時測定一次，心肺轉流後測定兩次。分別在胸骨開前和主動脈鉗鬆開後3, 6, 12, 24, 48和72小時測定心肌肌鈣蛋白(cTnI)水準。
術後即時Holter和15導聯心電圖（ECG）用於評價缺血。出院前進行經食管超聲心動圖評價。轉流結束，給予魚精蛋白後即時，9名新生兒的節段性壁運動正常，20名異常。其中，5名新生兒的SWMA是暫時的，另外15名出現在關胸時。後者相關的節段多於前者(P > 0.001)。關胸時出現SWMA的新生兒，術後cTnI水準高於正常壁運動的新生兒(P = 0.02)。26名新生兒均獲得了術後心電圖資料。心電圖顯示：8名壁運動正常的新生兒中的2名、5名出現暫時SWMA中的1名、13名關胸時出現SWMA中的9名，存在心肌缺血。12, 24和 48 h的CtnI水準術中SWMA均可預測術後SWMA。我們認為，這些資料提示了持續至動脈轉接術結束的SWMA出現於多個心肌節段的SWMA，與心肌缺血有關。需要對這些患者進行進一步隨訪以明確術中心肌缺氧的增是否與長期預後有關。
（王麗珺譯 薛張綱校）
We prospectively studied 29 consecutive neonates undergoing an arterial switch operation to determine if segmental wall motion abnormalities (SWMA) represented myocardial ischemia. Intraoperative transesophageal echocardiogram was recorded at baseline and twice after cardiopulmonary bypass. Cardiac troponin I (cTnI) levels were measured before sternal incision and 3, 6, 12, 24, 48, and 72 h after removal of the aortic cross-clamp. Immediate postoperative Holter and 15-lead electrocardiograms (ECG) were evaluated for ischemia. Transthoracic echocardiograms were obtained before hospital discharge. At bypass termination, immediately after protamine administration, segmental wall motion was normal in nine neonates and abnormal in 20. SWMA were transient in five and present at the time of chest closure in 15 neonates. Neonates in whom SWMA were present at chest closure had more segments involved than those in whom SWMA were transient (P > 0.001). Neonates with SWMA at chest closure had higher cTnI levels postoperatively versus neonates with normal wall motion (P = 0.02). Postoperative ECG data were available in 26 neonates. There was ECG evidence of myocardial ischemia in two of eight neonates with normal wall motion, one of five with transient SWMA, and nine of 13 with SWMA at chest closure. CTnI levels at 12, 24, and 48 h and intraoperative SWMA were predictive of postoperative SWMA. We believe these data indicate that SWMA, which persist at the completion of an arterial switch operation, and which are present in multiple myocardial segments, correlate with myocardial ischemia. Further follow-up of these patients is needed to determine if increased intraoperative myocardial ischemia correlates with long-term outcomes.
用聽覺誘發電位和腦電圖評價右旋美托咪啶/雷米太尼和咪達唑侖/雷米太尼對健康人輕到中度鎮靜的效果
The effects of dexmedetomidine/remifentanil and midazolam/remifentanil on auditory-evoked potentials and electroencephalogram at light-to-moderate sedation levels in healthy subjects.
Haenggi M, Ypparila H, Hauser K, Caviezel C, Korhonen I, Takala J, Jakob SM.
Department of Intensive Care Medicine, University Hospital of Bern, Bern, Switzerland.
Anesth Analg 2006 103: 1163-1169.
避免過度鎮靜是ICU病人的一個重要問題。電生理檢測也許能解決這個問題。既然腦電圖能反映不同的鎮靜深度，我們用它來評估10個健康病人對兩種鎮靜藥的反應。右旋美托咪啶/雷米太尼和咪達唑侖/雷米太尼被隔7天輸注，分段給藥，以達到2，3，4度鎮靜，並分別用腦電圖，BIS，ERP來監測。右旋美托咪啶/雷米太尼組的腦電圖以象徵深度鎮靜的高能低頻的波形為特徵。只有右旋美托咪啶/雷米太尼組的BIS值均一地下降，從94+/- 3到58 +/- 14，而咪達唑侖/雷米太尼組的BIS值從94 +/- 2 到76 +/- 10。咪達唑侖/雷米太尼組的ERP從5.3 +/- 1.3 到 0.4 +/- 1.1。我們得出結論：用右旋美托咪啶/雷米太尼鎮靜的志願者，其ERP值表明其對聽覺刺激有皮質反應，即使其鎮靜深度已很深。ERP能反映咪達唑侖的鎮靜深度但不能反映右旋美托咪啶的鎮靜深度。BIS則能反映右旋美托咪啶的鎮靜深度但不能反映咪達唑侖的鎮靜深度。
（鐘靜譯 薛張綱校）
Avoidance of excessively deep sedation levels is problematic in intensive care patients. Electrophysiologic monitoring may offer an approach to solving this problem. Since electroencephalogram (EEG) responses to different sedation regimens vary, we assessed electrophysiologic responses to two sedative drug regimens in 10 healthy volunteers. Dexmedetomidine/remifentanil (dex/remi group) and midazolam/remifentanil (mida/remi group) were infused 7 days apart. Each combination of medications was given at stepwise intervals to reach Ramsay scores (RS) 2, 3, and 4. Resting EEG, bispectral index (BIS), and the N100 amplitudes of long-latency auditory-evoked potentials (ERP) were recorded at each level of sedation. During dex/remi, resting EEG was characterized by a recurrent high-power low-frequency pattern which became more pronounced at deeper levels of sedation. BIS Index decreased uniformly in only the dex/remi group (from 94 +/- 3 at baseline to 58 +/- 14 at RS 4) compared to the mida/remi group (from 94 +/- 2 to 76 +/- 10; P = 0.029 between groups). The ERP amplitudes decreased from 5.3 +/- 1.3 at baseline to 0.4 +/- 1.1 at RS 4 (P = 0.003) in only the mida/remi group. We conclude that ERPs in volunteers sedated with dex/remi, in contrast to mida/remi, indicate a cortical response to acoustic stimuli, even when sedation reaches deeper levels. Consequently, ERP can monitor sedation with midazolam but not with dexmedetomidine. The reverse is true for BIS.
Variations in Arterial Blood Pressure and Photoplethysmography During Mechanical Ventilation
Giuseppe Natalini, Antonio Rosano, Maria E. Franceschetti, Paola Facchetti, and Achille Bernardini
From the Department of Anesthesia, Intensive Care and Emergency, Poliambulanza Hospítal, Brescí, Italy.
Anesth Analg 2006 103:1182-1188
我們分析了機械通氣引起的動脈血壓化和從監測在手術室和重症監護室裏的57位病人的波形得來的光學體積描記圖。分析在正壓通氣時的收縮壓和脈壓化，_files/image049.gif){kind=small}
Up, _files/image050.gif){kind=small}
Down，在動脈和光學體積描記波形中的噴射前化在49(86%)個病人中存在。當同時使用動脈血壓和光學體積描記圖來計算時，脈搏壓化和噴射前期相似，否則兩者的化則不同。光學體積描記圖的脈搏化〉9%說明患者的動脈壓化〉13%（ROC曲線下面積＝0.85）或_files/image051.gif){kind=small}
Down >5 mm Hg ( ROC
曲線下面積 = 0.85)。在低血壓的患者中，光學體積描記圖的脈搏化〉9%仍然是最佳的域值（脈壓化>13%：ROC曲線下面積=0.90；_files/image052.gif){kind=small}
Down >5 mm
Hg：ROC曲線下面積=0.93)來預計液體反應性。總之，這項研究顯示了在動脈壓波形中觀察到的脈搏化和光學體積描記圖在對正壓機械通氣的反應是相似的。而且，光學體積描記圖的脈搏化>9%顯示了機械通氣導致動脈壓化的患者可能對液體管理有反應。
（周 荻譯 薛張綱校）
We analyzed
ventilation-induced changes in arterial blood pressure and
photoplethysmography from waveforms obtained by monitoring 57
patients in the operating room and intensive care unit. Analysis of
systolic and pulse pressure variations during positive pressure ventilation,
_files/image053.gif){kind=small}
Up, _files/image054.gif){kind=small}
Down, and changes in the preejection period on both
arterial and photoplethysmographic waveforms were possible in 49
(86%) patients. The pulse pressure variation and preejection period
were similar when calculated using both arterial blood pressure and
photoplethysmography, whereas the other variables were different.
Photoplethysmographic pulse variation >9% identified patients
with arterial pulse pressure variation >13% (area under ROC curve
= 0.85) or _files/image055.gif){kind=small}
Down >5 mm Hg (area
under ROC curve = 0.85). In hypotensive patients,
photoplethysmographic pulse variation >9% remained the best
threshold value (pulse pressure variation >13%: area under ROC
curve = 0.90; _files/image056.gif){kind=small}
Down >5 mm
Hg: area under ROC curve = 0.93) for predicting fluid responsiveness.
In conclusion, this study showed that pulse variations observed in
the arterial pressure waveform and photoplethysmogram are similiar
in response to positive pressure ventilation. Furthermore, photoplethysmographic
pulse variation > 9% identifies patients with ventilation-induced
arterial blood pressure variation that is likely to respond to fluid
administration.
The Effect of Tracheal Gas Insufflation on Gas Exchange Efficiency
Michael R. Pinsky, MD*_files/image057.gif){kind=small}
, Edgar Delgado, RRT_files/image058.gif){kind=small}
,
and Bernard Hete, PhD_files/image059.gif){kind=small}
Department of Critical Care Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261.
Anesth Analg 2006;103:1213-1218
經氣管的注氣通氣法(TGI)可以改善氣體交換的效率，但同時會伴有肺的過度膨脹，通常需要調整呼吸機來代償增的氣體流量。雖然雙向TGI (Bi-TGI)將肺的過度膨脹減到最少，但它還是需要降低潮氣量預防肺的過度膨脹。由Respironics (Murrysville, PA)發明的一種流量代償系統可以匹配TGI的流量，然而，兩者的效率都沒有在活體中得到證實。我們驗證假設：流量代償可以使用一個不的分鐘通氣量；Bi-TGI比非雙向TGI(Uni-TGI)產生更少的過度膨脹，在TGI期間氣管導管的大小會影響過度膨脹的程度。我們研究七隻麻醉的狗，用Respironics的流量代償系統進行正壓通氣。在持續穩定情況下進行測量，同時監測CO2 的產生。氣體交換效率（通過測量呼出氣體）和過度膨脹（通過測量胸腔壓的增）在Bi-TGI和 Uni-TGI以7 到10F的氣管導管之間比較。在有流量代償系統下，Bi-TGI和 Uni-TGI可以不改分鐘通氣量。在各大小的氣管導管中，Uni-TGI比Bi-TGI產生更多的過度膨脹。7.5F以的氣管導管普遍產生過度膨脹。我們得出結論，這種新的流量代償系統使TGI在使用中不需要調整呼吸參數，並且Bi-TGI比Uni-TGI產生更少的過度膨脹，在小直徑的氣管導管中也是如此。
（陸文清譯 薛張綱校）
Transtracheal gas insufflation (TGI) improves gas exchange efficiency, but is associated with hyperinflation, and usually requires ventilator adjustment to compensate for the increased gas flow. Although bidirectional TGI (Bi-TGI) minimizes hyperinflation, it does not preclude the need to reduce tidal volumes to prevent hyperinflation. A flow-compensation system was developed by Respironics (Murrysville, PA) to match TGI flows; however, neither that nor the efficacy of Bi-TGI have been tested in vivo. We tested the hypotheses that flow compensation allows for a constant minute ventilation; Bi-TGI produces less hyperinflation than does unidirectional TGI (Uni-TGI), and endotracheal tube size influences the degree of hyperinflation during TGI.Seven anesthetized intact dogs were studied during positive-pressure ventilation using the Respironics flow compensation system. Measurements were made during steady-state conditions at constant and measured levels of CO2 production. Gas exchange efficiency (assessed by expired gas analysis for dead space) and hyperinflation (measured as an increase in pleural pressure) were compared during Bi- and Uni-TGI and for endotracheal tube sizes varying from 7 to 10F. Bi- and Uni-TGI could be delivered at constant minute ventilation without adjusting ventilatory setting when the flow compensation circuit was present. Uni-TGI produced more hyperinflation than did Bi-TGI with all sizes of endotracheal tube, and hyperinflation was universally present as tube size decreased to 7.5F. We conclude that this new flow compensation system allows for the delivery of TGI without the need for adjustments to the ventilator settings, and that Bi-TGI produces less hyperinflation than does Uni-TGI, even with small diameter endotracheal tubes.
CT估測非挫傷腦區比重在外傷性腦損傷中作為嚴重程度的標誌
Computed tomography-estimated specific gravity of noncontused brain areas as a marker of severity in human traumatic brain injury
Degos V, Lescot T, Zouaoui A, Hermann H, Preteux F, Coriat P, Puybasset L.
Department of Anesthesiology and Critical Care, Centre Hospitalo-Universitaire (CHU) Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris, France.
Anesth Analg. 2006 Nov;103(5):1229-36.
在這項研究中，我們評估了外傷性腦損傷(TBI)患者中腦估測比重和臨症狀、治療強度水準結局的關係。在120名嚴重TBI患者中用初始CT（5 +/- 6 h) DICOM影像測定了非挫傷球腦重量、體積、和eSG。由40名健康患者中得到對照值。TBI患者非挫傷球腦區的eSG明顯高於對照組。Marshall CT分級3或4級，或起初的Glasgow昏迷評分較低的患者eSG更高。根據非挫傷球區eSG分兩個組：小於(n = 83, 69%) 或大於 (n = 37, 31%)正常閾值（確定為1.96 sd above normal = 1.0355 g/mL）。eSG增組中發生瞳孔散大、事故現場應用滲透治療、和治療強度水準更高。eSG增高的病人出ICU時的結局更差，而一年時的差異無顯著性。CT分析eSG在TBI早期管理中的作用可能是切實可行的。
(徐麗穎譯 薛張綱校)
In this study, we assessed the relationship between brain estimated specific gravity (eSG) and clinical symptoms, therapeutic intensity level, and outcome in human traumatic brain injury (TBI). Brain weight, volume, and eSG of the noncontused hemispheric areas were measured from computed tomography (CT) DICOM images on the initial (5 +/- 6 h) CT of 120 patients with severe TBI. Control values were obtained from 40 healthy patients. The eSG of the noncontused hemispheric areas was significantly higher in TBI patients than in controls. eSG was higher in patients having a Marshall CT classification of 3 or 4 or a low initial Glasgow coma score. Two groups were defined according to the eSG of the noncontused hemispheric areas: less than (n = 83, 69%) or more than (n = 37, 31%) the threshold of normality (defined as 1.96 sd above normal = 1.0355 g/mL). The occurrence of mydriasis, use of osmotherapy at the scene of the accident, and therapeutic intensity level were higher in the increased eSG group. The outcome at intensive care unit discharge was worse in patients with an increased eSG although the difference was no longer significant at 1 yr. eSG determination by CT analysis might be relevant in the early management of TBI.
頭頸部過伸可增Mallampati氣道評估的特異性和預測價值
Craniocervical Extension Improves the Specificity and Predictive Value of the Mallampati Airway Evaluation
George A. Mashour and Warren S. Sandberg
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, USA.
Anesth Analg 2006 103: 1256-1259.
研究背景:改良的Mallampati(MMP)分級是評估張口度和口腔內結構的標準氣道檢查.最近的資料指出最大張口度(通過齒間距來測定)出現在頭頸過伸時.MMP檢查時患者頭呈中立位,未達到最大齒間距,故氣道條件會顯得差一些.我們設想在MMP評分中增頭頸過伸,它與傳統的MMP檢查相比是否會增張口度,降低評分以減少假陽性率.方法:數名有著至少1年氣道管理經驗的臨醫生採用MMP檢查(被檢查者頭呈中立位)評估60位成人的氣道條件.同樣的檢查在入頸部過伸(EMS)後重複一次.結果:總體而言,頭頸過伸降低了MMP分級(p<0.002).EMS和傳統的MMP相比使特異性從70%增到80%,陽性預測值從24%增到31%.兩者的靈敏度相同(83%).結論:頭頸過伸可增MMP氣道評估的特異性和陽性預測值,但靈敏度不.應當考慮將EMS引入到臨實踐中.
(王慧琳譯 薛張綱校)
BACKGROUND: The modified Mallampati (MMP) classification is a standard airway examination that assesses mouth opening and structures within the oral cavity. Recent data suggest that maximal mouth opening (as measured by interdental distance) is possible only with extension of the craniocervical junction. Because the MMP examination is performed with the head in a neutral position, the airway may appear worse because of submaximal interdental distance. We hypothesized that adding craniocervical extension to the MMP would allow for greater mouth opening, lower scores, and less false positives than the traditional MMP examination. METHODS: Multiple clinicians with at least 1 yr of airway experience evaluated adult airways (n = 60) with the MMP examination (with head in neutral position). The same examination was then repeated with the addition of craniocervical extension (Extended Mallampati Score, EMS). RESULTS: On average, craniocervical extension decreased the MMP class (P < 0.002). The EMS improved specificity from 70% to 80% and positive predictive value from 24% to 31% when compared with the traditional MMP. The sensitivity (83%) was the same for MMP and EMS. CONCLUSIONS: Craniocervical extension improves the specificity and positive predictive value of the MMP airway evaluation while retaining sensitivity of the traditional MMP examination. The introduction of the EMS into clinical practice should be considered.
20°頭高位能減少甲狀腺手術後噁心嘔吐的發生率和嚴重程度
The twenty-degree reverse-Trendelenburg position decreases the incidence and severity of postoperative nausea and vomiting after thyroid surgery.
Department of Anesthesiology, Tokushima Municipal Hospital, Tokushima, Japan. Anesth Analg. 2006 Nov;103(5):1260-3
研究背景：在這個隨機、單盲、控制實驗中，我們評價了20°頭高位對甲狀腺手術後噁心嘔吐的作用。方法：病人(n = 224)給與標準的異丙酚全麻。在整個手術過程中，病人被隨機的分為兩組：一組為頭過伸位元20°頭高位，另一組為頭過伸位水準位。術後24小時所有的不良事件將被記錄包括術後噁心、嘔吐、噁心程度評分、嘔吐次數止吐藥物的使用次數。我們將這段時間分為0-3小時、3-24小時兩個階段。結果：在術後0-3小這個時間段內兩組的不良事件是可比的。但在20°頭高位組不論是在3-24小時還是整個術後24小時，噁心和/或嘔吐，噁心程度評分，嘔吐次數都顯著下降。結論：20°頭高位能改善術後噁心嘔吐。
(王慧琳譯 薛張綱校)
BACKGROUND: In this randomized, single-blind, controlled study, we evaluated whether the 20 degrees reverse-Trendelenburg position had an effect on postoperative nausea and vomiting in patients undergoing thyroid surgery. METHODS: Patients (n = 224) were given a standardized propofol anesthetic. Intraoperatively, patients were randomly assigned into two groups according to the tilt of the table maintained during surgery: patients were positioned with the neck extended and the table tilted with 20 degrees reverse-Trendelenburg or with the neck extended and the table positioned at a horizontal tilt. All episodes of postoperative nausea, vomiting, nausea severity score, frequency of vomiting, and the use of antiemetics were recorded during the first 24 h after anesthesia. We divided this time period into 0-3 h and 3-24 h. RESULTS: During the 0-3 h postoperative period, all observed episodes were comparable between groups. However, during the 3-24 h and the overall postoperative period, the incidence of nausea and/or vomiting, the nausea severity score, and frequency of vomiting were significantly less in the 20 degrees reverse-Trendelenburg position. CONCLUSION: The 20 degrees reverse-Trendelenburg position effectively ameliorates postoperative nausea and/or vomiting.
經斜角肌間溝臂叢神經阻滯行肩關節鏡手術病人術前給予單次量巴噴丁（800mg）不能增術後鎮痛效果
A Single Preoperative Dose of Gabapentin (800 Milligrams) Does Not Augment Postoperative Analgesia in Patients Given Interscalene Brachial Plexus Blocks for Arthroscopic Shoulder Surgery
Frédéric Adam, MD*, Christophe
Ménigaux, MD*, Daniel I. Sessler, MD_files/image060.gif){kind=small}
_files/image061.gif){kind=small}
, and Marcel
Chauvin, MD_files/image062.gif){kind=small}
From the *Department of Anesthesia, Hôpital
Ambroise Paré, Assistance Publique-Hôpitaux de Paris; _files/image063.gif){kind=small}
Department of Outcomes Research, The Cleveland Clinic,
Cleveland, Ohio; _files/image064.gif){kind=small}
Outcomes Research
Institute, University of Louisville, Louisville, KY; and _files/image065.gif){kind=small}
Department
of Anesthesia and INSERM E 332, Hôpital Ambroise Paré.
Anesth Analg 2006 103: 1278-1282.
背景：肩關節鏡手術後鎮痛不足比較常見。在多種情況下，同時行斜角肌間溝阻滯和給予巴噴丁石是治療疼痛的有效方法。我們檢驗在門診關節鏡手術中通過斜角肌間溝臂叢神經阻滯並給予巴他丁是否可以增術後鎮痛效果。方法：60例病人隨機分為兩組，於術前2小時通過口服分別給予巴他丁800mg和安慰。然後用0.5%羅呱卡因0.3mL/kg行經斜角肌間溝臂叢神經阻滯。全麻維持採用七氟烷，並給予單次量瑞太尼1µg/kg。術後鎮痛起始給予嗎啡，隨後給予可多普洛菲（150mg口服，每日兩次），需要時合併使用對乙醯氨基酚400mg和右丙氧30mg。疼痛評分、鎮痛需求和副作用在門診手術室和家中觀察48小時。結果：全麻後蘇醒時間兩組相似。兩組間在疼痛評分、首次術後鎮痛要求和口服鎮痛藥的用量方面也無顯著差別。除了巴他丁組頭痛發生率稍低以外，兩組間副作用的發生率也基本相當。結論：術前單次給予巴他丁800mg不能增在經斜角肌間溝臂叢神經阻滯下行肩關節鏡手術病人的術後鎮痛效果。
（金 路譯 薛張綱校）
BACKGROUND: Inadequate analgesia is common after shoulder arthroscopy. Both interscalene blocks and gabapentin are effective methods of pain management under various circumstances. We tested the hypothesis that gabapentin augments postoperative analgesia provided by interscalene brachial plexus block in patients having ambulatory arthroscopic shoulder surgery. METHODS: Sixty patients were randomly assigned to receive oral gabapentin, 800 mg, or placebo 2 h before surgery. An interscalene brachial plexus block with 0.3 mL/kg of 0.5% ropivacaine was performed. General anesthesia was maintained with sevoflurane and included a single 1-µg/kg dose of remifentanil. Postoperative analgesia was initially provided with morphine and subsequently with ketoprofene (150 mg orally twice daily) and a combination of 400 mg acetaminophen and 30 mg dextropropoxyphene as needed. Pain scores, analgesic requirements, and side effects were assessed in the ambulatory unit and at home for 48 h. RESULTS: Emergence from general anesthesia was similar in both groups. There were no significant differences in pain scores, first postoperative request for analgesia, or oral analgesic consumption. The incidence of side effects was comparable in both groups, except that headaches were less frequent in the gabapentin group. CONCLUSION: A single preoperative dose of gabapentin (800 mg) does not augment postoperative analgesia in patients given interscalene brachial plexus blocks for arthroscopic shoulder surgery.
Lumbosacral Cerebrospinal Fluid Volume in Humans Using Three-Dimensional Magnetic Resonance Imaging
John T. Sullivan, Sharon Grouper, Matthew T. Walker, Todd B. Parrish, Robert J. McCarthy, and Cynthia A. Wong
From the Departments of *Anesthesiology and
_files/image066.gif){kind=small}
Radiology, Northwestern
University Feinberg School of Medicine, Chicago, IL.
Anesth Analg 2006 103: 1306-1310
背景： 蛛網膜下腔麻醉的臨反應與腰段腦液容量有關，它在病人中是多的。方法：71個病人用長回聲波（TE = 198 msec）、快速自旋回波程式時間來做腰段的磁性共振成像制脂肪成像。建立三維成像，腰段的CSF容量用a threshold-based region產生的運算法則來計算。結果： 用水槽法和屍體腦液來證實的實驗是精確的。異係數是0.42%。計算的平均容量是 35.8 ± 10.9ml，範
圍是10.6-61.3ml。腰段CSF容量在病人中化很大，而且與BMI成反比例。椎管狹窄做放射診斷的病人腰段CSF容量要比其他組小，與疝氣病人相比是不同
的。結論： 這項術的應用將會使我們對於蛛網膜下腔麻醉有更深的瞭解。
（韓曉丹譯 薛張綱校）
BACKGROUND: The clinical response to spinal anesthesia is influenced by lumbosacral cerebrospinal fluid (CSF) volume, which is highly variable among patients. METHODS: Lumbosacral magnetic resonance images were obtained in 71 patients using a long echo time (TE = 198 msec), fast spin echo sequence with fat suppression. Three-dimensional images were created and lumbosacral CSF volume was estimated using a threshold-based region growing algorithm.RESULTS: A validation experiment using a water bath and cadaveric spinal cord demonstrated that the technique was accurate (1.4 ± 0.4% difference between estimated and measured). The coefficient of variance was 0.42% among the three estimated CSF values per subject. The mean calculated volume was 35.8 ± 10.9 mL with a range of 10.6-61.3 mL. Lumbosacral CSF volume was widely variable among patients and was inversely proportional to body mass index (r = –.276, P = 0.02). Mean calculated lumbosacral CSF volumes were smaller in the group of subjects that had radiographic diagnoses of spinal stenosis when compared with subjects with no diagnosis (mean difference –8.4 mL, 95% CI of the difference, –16.1 to –0.8 mL, P = 0.03) and were not different when compared with those with herniated disk disease (mean difference –6.4 mL, 95% CI of the difference –14.7 to 1.9 mL, P = 0.19). CONCLUSIONS: Application of this technique to clinical investigations may further enhance our understanding of spinal anesthesia.
局部麻醉藥物的心臟毒性：一項麻醉院系關於當代臨實踐的調查研究
Local Anesthetic-Induced Cardiac Toxicity: A Survey of Contemporary Practice Strategies Among Academic Anesthesiology Departments
Corcoran, William
Department of Anesthesiology, Wake Forest
University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
27157-1009, USA.
Anesth Analg 2006 103: 1322-1326
雖然有新的局麻藥(LA) 、有效的實驗量、還有新的局麻術提高了局部麻醉的安全性，但是由局麻藥引起的心臟毒性作用仍是存在的。所以，我們評估了美國麻醉學會中對於LA引起的心臟毒性的最新處理措施。一份有19個問題的關於局麻藥的調查問卷被發往135個麻醉學會。我們收到了91份匿名的文卷，占到了總數的67％。根據每個月外周神經阻滯的次數我們將應答者分組：>70 （38％），51－70（13％），31－50（20％） ，11－30（23％），<10（6％）。與較低的局麻術使用組相比，在局麻例數>70的組中外周神經阻滯使用羅派卡因是低使用組的1.7倍，輸注脂肪乳用於復蘇是其3.9倍，同樣，高局麻術使用組更傾向于有一套建立有創心肺復蘇支持方案。我們的結論是在調察機構中對於LA引起的毒性反應的處理和準備有差別，這些差別意示著局麻藥引起的安全性問題還沒解決。
（韓曉丹譯 薛張綱校）
Though new local anesthetics (LA), effective test-dosing, and new regional anesthetic techniques may have improved the safety of regional anesthesia, the optimal management plan for LA-induced cardiac toxicity remains uncertain. Accordingly, we evaluated current approaches to LA cardiotoxicity among academic anesthesiology departments in the United States. A 19-question survey regarding regional anesthesia practices and approaches to LA cardiac toxicity was sent to the 135 academic anesthesiology departments listed by the Society of Academic Anesthesiology Chairs-Association of Anesthesiology Program Directors. Ninety-one anonymously completed questionnaires were returned, at a response rate of 67%. The respondents were categorized into groups according to the number of peripheral nerve blocks (PNBs) performed each month: >70 PNBs (38%), 51–70 PNBs (13%), 31–50 PNBs (20%), 11–30 PNBs (23%), and <10 PNBs (6%). Anesthesia practices administering >70 PNBs were 1.7-times more likely to use ropivacaine (NS), 3.9-times more likely to consider lipid emulsion infusions for resuscitation (P = 0.008), and equally as likely to have an established plan for use of invasive mechanical cardiopulmonary support in the event of LA cardiotoxicity (NS) than low-PNB volume centers. We conclude that there are differences in the management and preparedness for treatment of LA toxicity among institutions, but the safety implications of these differences are undetermined.
心臟手術中大量肽酶的使用:如此大量足夠嗎?對8281例心臟手術病人使用肽酶後的分析
High-Dose Aprotinin in Cardiac Surgery: Is High-Dose High Enough?
An Analysis of 8281 Cardiac Surgical Patients Treated with Aprotinin
Wulf
Dietrich, MD, PhD*, Raimund Busley, MD*, and Monika
Kriner, MSc_files/image067.gif){kind=small}
From the *Department of Anesthesiology,
German Heart Center Munich; and _files/image068.gif){kind=small}
Institute for
Statistics and Epidemiology, Medical Faculty, Technical University, Munich,
Germany.
Anesth Analg 2006 103: 1074-1081.
本文回顧性分析並以驗證如下假設：使用大於6×106 KIU量的肽酶較使用5-6×106KIU肽酶更有效地減少出血。在8281例成年心臟手術病例中，肽酶的使用量與體重、手術時間相聯繫並計算每分鐘每公斤使用量（KIU/Kg/Min）。確定線性和邏輯回歸曲線以監測肽酶量與術後出血、輸血量以其他因素的關係。6小時胸引流量在小量組（最小四分位數）為447 ± 319ml，而作為對照的大量組（最大四分位數）則為360 ± 290ml(p<0.01)。需要輸異體血的病人比例為小量組55%，而大量組為47%。肽酶量也是術後開胸止血手術的一個獨立危險因數(低量組數為2.4%，大量組為1.9%)。腎衰需要透析（大量組2.3％，低量組3.3％，P < 0.01）或腎損（術後肌酐升高_files/image069.gif){kind=small}
2 mg/dL，大量組6.4％，低量組10％，P < 0.01）的風險在大量組較小。因此肽酶的量和腎能之間並沒有關係（原文）。作者的結果證實了如下假設：心臟手術中個體化量偏高些的肽酶有可能更有效。
（宋翠俠 譯 陳傑 校）
In this retrospective analysis we tested the
hypothesis that aprotinin doses of more than 6 x 106
kallikrein inhibiting units (KIU) per patient may be more effective
in reducing bleeding compared with the high-dose regimen of 5–6 x 106
KIU aprotinin. The aprotinin doses administered for 8281 adult
cardiac surgical patients were correlated to body weight and time of
operation and calculated in KIU per kg body weight and minute of
operation. Linear and logistic regression models were designed to
detect potential associations between dose and postoperative
bleeding, transfusion, and other covariates. The 6-h chest tube
drainage in the lowest quartile dosing group was 447 ± 319 mL (mean
± sd) compared with 360 ± 290 mL in the highest quartile dosing
group (P < 0.001). The proportion of
patients requiring allogeneic blood transfusion was reduced from 55%
to 47% comparing the lowest with the highest dosing group (P < 0.01). Aprotinin dose was also an independent predictor
for rethoracotomy for surgical hemostasis (1.9% in the highest
quartile to 2.4% in the lowest dosing quartile; P < 0.01). The risk of renal failure requiring dialysis (2.3%
in the highest dosing group vs 3.3% in the lowest dosing group; P < 0.01) or impairment of renal function (creatinine increase
of _files/image070.gif){kind=small}
2 mg/dL postoperatively, 6.4%
in the highest dosing group vs 10.0% in the lowest dosing group; P < 0.01) was lower with higher doses of aprotinin.
Thus, there was no association between aprotinin dose and renal
function. Our results support the hypothesis that a more
individualized aprotinin regimen with potentially higher doses may
optimize the effectiveness of aprotinin therapy in cardiac surgery.
The Vasodilatory Effects of Levosimendan on the Human Internal Mammary Artery
Félix R. Montes, MD*, Darío
Echeverri, MD_files/image071.gif){kind=small}
, Lorena
Buitrago, MB_files/image072.gif){kind=small}
, Isabel
Ramírez, IE_files/image073.gif){kind=small}
, Juan C. Giraldo, MD*,
Javier D. Maldonado, MD||, and Juan P. Umaña, MD||
From the Departments of *Anesthesiology, _files/image074.gif){kind=small}
Cardiology,
||Cardiovascular Surgery, _files/image075.gif){kind=small}
Laboratory of Vascular
Function, Fundación CardioInfantil, Instituto de Cardiología; and _files/image076.gif){kind=small}
Facultad de Ingeniería
Industrial, Universidad de Los Andes, Bogota, Colombia, South America.
Anesth Analg 2006 103: 1094-1098
.
背景：左西孟旦是一種強心藥，能通過增強心肌鈣離子敏感性而增強心肌收縮性，通過開放ATP-依賴性 K+通道引起周圍血管擴張。此藥能否用於冠狀動脈旁路移植術中治療移植血管的痙攣，目前尚不確定。
方法：觀察左西孟旦對取自冠狀動脈旁路移植術病人的乳內動脈（IMA）的作用。將IMA仔細製成環狀，用兩根金屬鉤固定並置於器官浴箱，並用去甲腎腺素和促凝血素 A2 同型物(U46619)使IMA環明顯收縮。將硝酸甘油、米農他和左西孟旦分別作用於動脈環，並繪製動脈舒張濃度反應曲線。評估左西孟旦對有能性內皮的動脈環和無能性內皮的動脈環的作用。另外評估左西孟旦在防止去甲腎腺素誘發的動脈痙攣的作用。
結果：硝酸甘油、米農和左西孟旦完全逆轉了U46619和去甲腎腺素引起的IMA收縮。左西孟旦對去甲腎腺素誘發的IMA收縮能產生有效的濃度依賴性的效應。左西孟旦對有或無能性內皮的動脈的作用是相似的。
（波 譯 陳傑 校）
BACKGROUND: Levosimendan, an inotropic drug that enhances myocardial contractility through myofilment calcium sensitazion, induces peripheral vasodilation via opening ATP-dependent K+ channels. It is unknown whether this drug can be used for the treatment of perioperative vasospasm of arterial conduits used for coronary artery bypass grafting.
METHODS: We investigated the effects of levosimendan on human internal mammary artery (IMA) specimens taken from patients undergoing coronary artery bypass surgery. The rings were carefully prepared and placed between two wire hooks in organ bath chambers and then constricted submaximally with norepinephrine and thromboxane A2 analog (U46619). Nitroglycerin, milrinone, and levosimendan were separately added in a cumulative fashion and concentration response curves for relaxation were constructed. In parallel experiments, the response to levosimendan was evaluated on rings with and without functional endothelium. Levosimendan prevention of norepinephrine-induced contraction was also estimated.
RESULTS: Nitroglycerin, milrinone, and levosimendan completely reversed the contraction of the IMA segments induced by U46619 and norepinephrine. Levosimendan produced a potent, concentration-dependent preventive effect on the norepinephrine-induced contraction of IMA. The responses to levosimendan were similar in preparations with or without endothelium.
阻塞性睡眠呼吸暫停綜合征患兒進行增殖腺扁桃體切除術的圍術期併發症
Perioperative Complications of Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome
John C. Sanders, MB, BS, FRCA*,
Melinda A. King, MD*, Ronald B. Mitchell, MD, FRCS_files/image077.gif){kind=small}
_files/image078.gif){kind=small}
, and James P. Kelly, PhD_files/image079.gif){kind=small}
From the *Departments of Anesthesiology and
Critical Care, _files/image080.gif){kind=small}
Surgery, _files/image081.gif){kind=small}
Pediatrics, University of New Mexico, School of Medicine,
Albuquerque, New Mexico.
Anesth Analg 2006 103: 1115-1121.
作者評估了阻塞性睡眠呼吸暫停綜合症(OSAS)患兒在進行增殖腺扁桃體切除術後發生併發症的比率，以這些患兒使用常規麻醉方式的安全性和併發症術前預測因數。61位經多導睡眠描記法所確診的OSAS患兒和21位復發性扁桃體炎的患兒進行了常規標準的麻醉（年齡為2～16歲，ASA I～III），記錄圍手術期併發症的發生次數和藥物治療量，以OSAS的嚴重程度。術中OSAS患兒發生呼吸系統併發症的比例多於非OSAS患兒（5.7比2.9，P<0.0001），包括麻醉誘導和蘇醒時聲門阻塞、呼吸暫停等是最常見的併發症。體重輕、年齡小、OSAS嚴重併發症的發生比例高。在麻醉蘇醒恢復時給OSAS患兒藥物治療比OSAS患兒更為必要（17/61比1/21,P<0.05）。但是兩組患兒在阿片類藥物的需求和恢復室內的復蘇時間方面無明顯差異。述結果表明OSAS患兒在腺體樣扁桃體切除術後，更易發生呼吸系統併發症，但是這些併發症並不延長他們在恢復室內的復蘇時間。
（詹慧 譯 陳傑 校）
We evaluated the rate of complications experienced by children who undergo adenotonsillectomy for obstructive sleep apnea syndrome (OSAS), the safety of a standard anesthetic protocol for these children, and preoperative predictors of complications. Sixty-one children with OSAS, confirmed by polysomnography, and 21 children with recurrent tonsillitis were anesthetized using a standard protocol before adenotonsillectomy (ages 2–16 yr, ASA 1–3). The number of complications and medical interventions in the perioperative period were recorded and correlated with the presence and severity of OSAS. Children with OSAS had more respiratory complications per operation than non-OSAS children (5.7 vs 2.9, P < 0.0001). Supraglottic obstruction, breath holding, and desaturation on anesthetic induction and emergence were the most common complications. Increased severity of OSAS, low weight, and young age are correlated with an increased rate of complications. Medical intervention was necessary in more children with OSAS during recovery and emergence than in the non-OSAS group (17/61 vs 1/21, P < 0.05). Both groups of children had similar opioid requirements and time to discharge from the recovery room. These findings suggest that children with OSAS are at risk for respiratory complications after adenotonsillectomy, but that these complications do not prolong the time to discharge.
Clinical Measures of Heparin’s Effect and Thrombin Inhibitor Levels in Pediatric Patients with Congenital Heart Disease
Nina A.
Guzzetta, MD*, Bruce E. Miller, MD*, Kathy Todd, RN, BA,
CCRC_files/image082.gif){kind=small}
, Fania Szlam, MMSc*, Renee H.
Moore, MS_files/image083.gif){kind=small}
, Keith K. Brosius, MD*, Elizabeth C. Wilson, MD*,
Anna M. Cohen, MD*, and Steven R. Tosone, MD*
From the *Department of Anesthesiology, Emory
University School of Medicine; _files/image084.gif){kind=small}
Cardiac Research
Department, Children’s Healthcare of Atlanta at Egleston; and _files/image085.gif){kind=small}
Department of Biostatistics, Emory University, Atlanta,
Georgia.
Anesth Analg 2006 103: 1131-1138.
本研究中，作者研究了小兒先天性心臟病患者心肺轉流期間三種凝血酶制：凝血酶Ⅲ（ATⅢ），肝素輔因數Ⅱ（HCⅡ）和α－2－巨球蛋白（α2M）監測肝素效果的幾種方法之間的關係。118名兒童分為6個年齡組：<1月；1－3月；3－6月；6－12月；12－24月；和>10歲。測定ATⅢ，HCⅡ和α2M的基礎濃度，同時測定矽藻土和白陶土啟動的凝血酶時間（ACT）的基礎值，給予標準肝素400U/kg後3分鐘複測。計算每個病人給予肝素前後的ACT化和肝素的量－反應關係。與矽藻土相比，白陶土啟動的ACT測試在其給予肝素後異性較小。而成人的結果則相反，ATⅢ與肝素作用的臨實驗之間以其他凝血酶制間並沒有正相關關係。此外，小於1月齡的病人α2M的水準意外的低，同時伴隨ATⅢ和HCⅡ的低水準。作者的發現在於應當關注新生兒心肺轉流期間肝素是否有足夠的凝作用。因此，ACT延長是否真實反映其凝作用需進一步研究。
（周懿之 譯 陳傑 校）
In this investigation, we examined the
relationship among three thrombin inhibitors, antithrombin III
(ATIII), heparin cofactor II (HCII), and _files/image086.gif){kind=small}
-2-macroglobulin (_files/image087.gif){kind=small}
2M), and several
clinical tests of heparin’s effect in pediatric patients with
congenital heart disease undergoing cardiopulmonary bypass. One
hundred eighteen children were stratified into six age groups: <1
mo, 1–3 mo, 3–6 mo, 6–12 mo, 12–24 mo, and >10 yr. Baseline
ATIII, HCII, and _files/image088.gif){kind=small}
2M values were measured.
Baseline celite- and kaolin-activated clotting times (ACT) were also
measured and repeated 3 min after a standard heparin dose of 400
U/kg. Differences in ACT values before and after heparin administration
and a heparin dose–response relationship were calculated for each
patient. Kaolin-activated ACT tests showed less variation after
heparin administration than celite-activated tests. In contrast to
what has been demonstrated in adults, ATIII showed no positive
correlation with the clinical tests of heparin’s effect nor did the
other thrombin inhibitors. Additionally, patients <1 mo old had
unexpectedly low levels of _files/image089.gif){kind=small}
2M
accompanying their expected low levels of ATIII and HCII. Our
findings raise concerns about the ability of heparin to adequately
anticoagulate these neonates during cardiopulmonary bypass and,
consequently, challenge the accuracy of ACT prolongation to truly
reflect the extent of their anticoagulation.
The Additive Interactions Between Ondansetron and Droperidol for Preventing Postoperative Nausea and Vomiting
Matthew T. V. Chan, MBBS, FANZCA*,
Kai C. Choi, PhD_files/image090.gif){kind=small}
, Tony Gin, MD,
FRCA, FANZCA*, Po Tong Chui, MBBS, FANZCA*, Timothy G.
Short, MD, FANZCA_files/image091.gif){kind=small}
, Pong Mo Yuen,
MBChB, FRCOG_files/image092.gif){kind=small}
, Amy H. Y. Poon, MBChB,
FANZCA*, Christian C. Apfel, MD, PhD||, and Tong J. Gan,
MD, FRCA¶
From the *Department of Anaesthesia and
Intensive Care; _files/image093.gif){kind=small}
Centre for Epidemiology
and Biostatistics; _files/image094.gif){kind=small}
Department of Obstetrics and
Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital,
Shatin, Hong Kong Special Administrative Region; _files/image095.gif){kind=small}
Department of Anaesthesia, Auckland City Hospital and Auckland
School of Health Sciences, Auckland University; ||Department of Anesthesia and
Perioperative Care, University of California at San Francisco, San Francisco,
California; and ¶Department of Anesthesiology, Duke University Medical Center,
Durham, North Carolina.
Anesth Analg 2006 103: 1155-1162.
預防性使用樞複寧和氟呱利多能夠減少術後噁心嘔吐的發生率。前瞻性研究表明同時使用這兩種藥物所產生的止吐效果比單獨使用任何一種的效果更好。作者使用一種非參數的方法來證明樞複寧和氟呱利多之間的相互作用是否具有可性，並且比較二者的混合製的實際作用和預期值（兩種藥物的單獨作用標準化後的相值）之間有何不同。選取400例婦科腔鏡病人，在麻醉誘導前5分鐘隨機接受如下藥物的靜脈注射：1.生理鹽水；2.樞複寧4mg；3，氟呱利多1.25mg；4，樞複寧4mg和氟呱利多1.25mg的混合液。這些患者術中所用麻醉藥物方法和術後鎮痛均一致。患者術前48h內和靜脈注射藥物後5分鐘接受心電圖QT間期的檢查。在含有160名患者的一組中，術後2-3h重複測量QT間期。在術後2天內，對照組術後噁心嘔吐發生率高達68%，（95%CI 58-77），而單獨使用樞複寧和氟呱利多能減少術後噁心嘔吐發生率至30%（95%CI 21-40）和28%（95%CI 20-38）。混合製的實際效果12.1%(95%CI 6.4-20.2)和預期值11.8%(95% CI 7.1-11.9)相似（P=0.94），相似性分別為87.9%和88.2%。靜脈注射樞複寧，氟呱利多或混合製後，患者的QT間期有輕微的一過性的延長。這種化在實驗組之間相近。結論：樞複寧和氟呱利多的作用具有可性的，兩種藥物的藥理機制各不相同，混合使用並不增QT間期延長的發生率。
（李惟一 譯 陳傑 校）
Prophylactic ondansetron or droperidol reduces the incidence of postoperative nausea and vomiting (PONV). Previous studies showed that the combination of these two drugs produced better antiemetic effect than either drug alone. We present a nonparametric method to determine the pharmacologic interaction between ondansetron and droperidol and compared the observed response of the drug combination with that predicted from additivity. This is calculated as the product of the individual drug response, normalized to that of the controls. Five minutes before induction of anesthesia, 400 patients scheduled for laparoscopic gynecologic surgery were randomly assigned to receive 1) saline IV; 2) ondansetron 4 mg IV; 3) droperidol 1.25 mg IV; or 4) a combination of droperiodol 1.25 mg and ondansetron 4 mg IV. A standardized anesthetic technique and postoperative analgesic regimen were used. Patients were reviewed regularly for 48 h. Changes in the heart rate adjusted QT (QTc) interval were measured from electrocardiograms recorded before and 5 min after study drug administration. In a subgroup of 160 patients, QTc intervals were measured again at 2–3 h after surgery. During the first 48 h after the surgery, the proportion of patients experiencing PONV was 68% (95% CI 58–77) in the control group. A single dose of ondansetron or droperidol decreased the incidence of PONV to 30% (95% CI 21–40) and 28% (95% CI 20–38), respectively. The predicted incidence of PONV after drug combination, 11.8% (7.1–11.9), was similar to that observed, 12.1% (6.4–20.2), P = 0.94. The corresponding predicted and observed treatment responses in the combination group were 88.2% and 87.9%, respectively. There was a modest and transient increase in QTc interval after administration of ondansetron, droperidol, or their combination. The changes were however similar among groups. We conclude that the interaction between ondansetron and droperiodol was additive. Both drugs acted independently of each other through their specific mechanisms of action. The incidence of QTc prolongation did not increase with the drug combination.
MAC多巴胺受體是否部分介導了？
Do Dopamine Receptors Mediate Part of MAC?
Yasumasa
Tanifuji, MD*, Yi Zhang, MD_files/image096.gif){kind=small}
, Mark Liao, BS_files/image097.gif){kind=small}
, Edmond I. Eger, II, MD_files/image098.gif){kind=small}
, Michael J. Laster, DVM_files/image099.gif){kind=small}
, and James M. Sonner, MD_files/image100.gif){kind=small}
From the _files/image101.gif){kind=small}
Department
of Anesthesia and Perioperative Care, University of California, San Francisco,
CA; *Department of Anesthesiology, The Jikei University School of Medicine,
Tokyo, Japan; and _files/image102.gif){kind=small}
Department of
Anesthesiology, Fuwai Hospital and Cardiovascular Institute, Beijing, People’s
Republic of China.
Anesth Analg 2006 103: 1177-1181.
背景：中樞神經系統兒茶酚胺耗竭，包括多巴胺的缺失，可降低MAC；中樞神經系統兒茶酚胺釋放，包括多巴胺的釋放，能增MAC；紋狀體中游離多巴胺濃度的升高能減少MAC。這些發現提示多巴胺受體可部分介導吸入麻醉藥的效能以提供對傷害刺激的制動作用。方法：作者研究了多巴胺D2受體的阻滯氟呱利多0.3 mg/kg or 3.0 mg/kg對鼠吸入環丙烷、地氟烷、氟烷、異氟烷或七氟醚的MAC的影響，以氟呱利多（3.0 mg/kg）對依託咪酯（一種主要通過增強γ-氨基丁酸受體對γ-氨基丁酸的反應而起作用的一種麻醉藥）對制傷害刺激的體動反應效應需要的濃度或量的影響。結果：多巴胺D2受體阻滯氟呱利多（量為0.3 mg/kg或 3.0 mg/kg）對鼠吸入環丙烷、地氟烷、氟烷、異氟烷或七氟醚或等量的依託咪酯的MAC並沒有減少作用。結論：述結果其他關於多巴胺D1受體研究的資料顯示多巴胺受體並不介導由吸入麻醉藥產生的制動作用。
（丁震敏 譯 陳傑 校）
BACKGROUND: Depletion of central nervous system catecholamines, including dopamine, can decrease MAC (the minimum alveolar concentration of an inhaled anesthetic required to suppress movement in response to a noxious stimulus in 50% of test subjects); release of central nervous system catecholamines, including dopamine, can increase MAC; and increased free dopamine concentrations in the striatum can decrease MAC. Such findings suggest that dopamine receptors might mediate part of the capacity of inhaled anesthetics to provide immobility in the face of noxious stimulation.
METHODS: We
measured the effect of blockade of D2 dopamine-mediated transmission
with 0.3 mg/kg or 3.0 mg/kg droperidol on the MAC of cyclopropane,
desflurane, halothane, isoflurane, or sevoflurane in rats, and the
effect of 3.0 mg/kg droperidol on the dose or concentration of
etomidate (an anesthetic known to act principally by enhancing the
response of _files/image103.gif){kind=small}
-aminobutyric acidA
receptors to _files/image104.gif){kind=small}
-aminobutyric acid)
required to suppress movement in response to noxious stimulation.
RESULTS: Blockade of D2 dopamine-mediated transmission with droperidol does not decrease the MAC of cyclopropane, desflurane, halothane, isoflurane, or sevoflurane or its equivalent for etomidate in rats.
CONCLUSIONS: These data, plus data from studies by others about D1 dopamine receptors, indicate that dopamine receptors do not mediate the immobility produced by inhaled anesthetics.
The Problem of Artifacts in Patient Monitor Data During Surgery: A Clinical and Methodological Review
George Takla, MS, John H. Petre, PhD, D. John Doyle, MD, PhD, Mayumi Horibe, MD, and Bala Gopakumaran, PhD
From the Division of Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio.
Anesth Analg 2006 103: 1196-1204.
監測儀資料不實影響在手術中正確獲取監測資的問題已經引起了廣泛的關注，這亦是引起虛假報警的原因之一。第二個問題是自動保存系統會記錄下錯誤的監測資。儘管目前大部分的監測儀已採取了許多措施來減少監測儀資料不實的發生，但是，他們的作用是有限的。作者回顧了在手術期間病人監測儀資料不實的病例，討論了目前市的病人監測儀採用的消除和最小化不實數據的措施包括術方面和環境因數等，也探討了正在研究中的檢測和校正方法。這些將會用於檢測和消除監測儀資料不實，提高監測儀的準確性和特異性。
（衛紅 譯 陳傑 校）
Artifacts are a significant problem affecting the accurate display of information during surgery. They are also a source of false alarms. A secondary problem is the inadvertent recording of artifactual and inaccurate information in automated record keeping systems. Though most of the currently available patient monitors use techniques to minimize the effect of artifacts, their success is limited. We reviewed the problem of artifacts affecting patient monitor data during surgical cases. Methods adopted by currently marketed patient monitors to eliminate and minimize artifacts due to technical and environmental factors are reviewed and discussed. Also discussed are promising artifact detection and correction methods that are being investigated. These might be used to detect and eliminate artifacts with improved accuracy and specificity.
右旋美托咪啶用於震顫性麻痹病人深部腦刺激物植入術的臨經驗
Clinical Experience with Dexmedetomidine for Implantation of Deep Brain Stimulators in Parkinson's Disease
Irene
Rozet, MD*, Saipin Muangman, MD*, Monica S. Vavilala, MD*_files/image105.gif){kind=small}
_files/image106.gif){kind=small}
, Lorri A. Lee, MD*_files/image107.gif){kind=small}
, Michael J. Souter, MB, ChB, FRCA*_files/image108.gif){kind=small}
, Karen J. Domino, MD*_files/image109.gif){kind=small}
, Jefferson C. Slimp, PhD_files/image110.gif){kind=small}
, Robert Goodkin, MD_files/image111.gif){kind=small}
, and Arthur M. Lam, MD, FRCPC*_files/image112.gif){kind=small}
From the Departments of *Anesthesiology, _files/image113.gif){kind=small}
Pediatrics, _files/image114.gif){kind=small}
Rehabilitation
Medicine, and _files/image115.gif){kind=small}
Neurological Surgery,
University of Washington, Seattle, Washington.
Anesth Analg 2006 103: 1224-1228.
_files/image116.gif){kind=small}
-2受體激動右旋美托咪啶(Dex)的藥理學特性表明它有可能是一種理想的鎮靜藥物用於深部腦刺激物植入術。作者將2001年到2004年實施深部腦刺激物植入術的病人的麻醉記錄進行了一項回顧性的分析。2003年開始，應用Dex作為鎮靜藥用於深部腦刺激物植入術。比較兩組病人間人口統計學資料、高血壓藥物的使用連續腦電圖，一組病人給予Dex (11 名患者/13 次操作) ，另一組病人不給予任何的鎮靜藥 (對照組: 8名患者/9次操作)。兩組病人的疾病嚴重程度沒有差異。Dex使病人舒適外科滿意，並顯著降低了高血壓藥物的使用(在Dex組為54%, 對照組為100%, P = 0.048)。深部腦刺激物植入術中，用Dex
鎮靜沒有干擾腦電圖, 能使血液動學穩定病人舒適。因此。這些手術中應常規使用Dex。
（宋金超 譯 陳傑 校）
The pharmacologic profile of the _files/image117.gif){kind=small}
-2 agonist
dexmedetomidine (Dex) suggests that it may be an ideal sedative drug
for deep brain stimulator (DBS) implantation. We performed a
retrospective chart review of anesthesia records of patients who
underwent DBS implantation from 2001 to 2004. In 2003, a clinical
protocol with Dex sedation for DBS implantation was initiated.
Demographic data, use of antihypertensive medication, and duration
of mapping were compared between patients who received Dex (11
patients/13 procedures) and patients who did not receive any
sedation (controls: 8 patients/9 procedures). There were no
differences in severity of illness between the two groups. Dex
provided patient comfort and surgical satisfaction with mapping in
all cases, and significantly reduced the use of antihypertensive
medication (54% in the Dex group, versus 100% in controls, P = 0.048). In DBS implantation, sedation with Dex did not
interfere with electrophysiologic mapping, and provided hemodynamic
stability and patient comfort. Routine use of Dex in these
procedures may be indicated.
先兆子癇病人行麻對QT間期的影響
The Effects of Spinal Anesthesia on QT Interval in Preeclamptic Patients
Selda Sen,
MD*, Galip Ozmert, MD_files/image118.gif){kind=small}
, Hakan Turan, MD_files/image119.gif){kind=small}
, Eray Caliskan, MD_files/image120.gif){kind=small}
, Alper Onbasili, MD_files/image121.gif){kind=small}
, and Duran Kaya, MD_files/image122.gif){kind=small}
From the Departments of *Anaesthesiology and _files/image123.gif){kind=small}
Cardiology, Adnan
Menderes University, Aydin, Turkey; _files/image124.gif){kind=small}
Department
of Obstetric and Gynecology, SSK Ankara Maternity and Women's Health Teaching
Hospital; and _files/image125.gif){kind=small}
Department of Internal
Medicine, Ankara University, Ankara, Turkey.
Anesth Analg 2006 103: 1250-1255.
本文作者研究麻對嚴重先兆子癇的孕婦QT間期的影響。25位先兆子癇的病人（先兆子癇組）和25位有著正常動脈血壓和QT間期的健康的娠婦女（對照組）進行前瞻性、病例對照研究。麻醉前，以麻起效之後的5，10，20，30，60，和120分鐘分別記錄動脈壓，心率和QT間期（基線值）。同時記錄麻黃素使用總量，感覺阻滯所需時間，以Apgar評分。麻前，先兆子癇組的QT間期（452 ±17.5）明顯長於對照組（376 ±21.4）。然而在先兆子閑組中，麻後QT間期縮短，而對照組沒有顯著化。結論：QT間期在有高血壓和低血鈣的重度先兆子閑病人可能延長。麻能使QT間期延長的剖腹產產婦QT間期正常，可能由於交感阻滯所致。
（鄭麗 譯 陳傑 校）
In this study, we measured the effects of spinal anesthesia on the corrected QT (QTc) interval in women with severe preeclampsia. Twenty-five preeclamptic (preeclamptic group) and 25 healthy pregnant women with normal arterial blood pressure and QTc interval (control group) were enrolled in this prospective, case-controlled study. Arterial blood pressure, heart rate, and QTc interval values were obtained before (baseline value) and at 5, 10, 20, 30, 60, and 120 min after initiation of spinal anesthesia. Total ephedrine dose, time elapsed until sensory block, and Apgar scores were recorded. Prior to spinal anesthesia, QTc interval values were significantly higher in the preeclamptic group (452 ± 17.5 ms) when compared with that in controls (376 ± 21.4 ms). Although the QTc interval shortened during spinal anesthesia when compared with baseline value in the preeclamptic group (P < 0.05), it showed no significant change in the control group. In conclusion, the QTc interval may be prolonged in severe preeclamptic patients who have hypertension and hypocalcemia. Spinal anesthesia for cesarean delivery may normalize that prolonged QTc interval due to sympathetic blockade.
塞來昔布（Celecoxib），普瑞巴林（Pregabalin）其聯合使用在柱融合手術中的鎮痛效果
The Analgesic Efficacy of Celecoxib, Pregabalin, and Their Combination for Spinal Fusion Surgery
Scott S.
Reuben, MD*, Asokumar Buvanendran, MD_files/image126.gif){kind=small}
, Jeffrey S. Kroin, PhD_files/image127.gif){kind=small}
, and Karthik Raghunathan, MD*
From the *Department of Anesthesiology,
Baystate Medical Center, Springfield, Massachusetts; and _files/image128.gif){kind=small}
Department of Anesthesiology, Rush Medical College, Chicago,
Illinois.
Anesth Analg 2006 103: 1271-1277.
背景：最佳的術後鎮痛效果很難通過使用單一藥物來實現。因此，許多專家建議應用兩種或兩種以的藥物合用以降低藥物的副作用。在這個試驗中，作者評估了圍手術期使用塞來昔布，普瑞巴林或兩者合用時在柱融合手術術後鎮痛效果。方法：80位患有柱融合後擇期行腰椎間盤減壓手術的病人隨機口服給藥：術前1h和術後12h分別給予安慰；術前1h給予塞來昔布400mg術後12h給予塞來昔布200mg；術前1h和術後12h分別給予普瑞巴林150mg；或術前1h給予合（塞來昔布/普瑞巴林400mg/150mg）和術後12h給予合（塞來昔布/普瑞巴林200mg/150mg）。結果：塞來昔布/普瑞巴林組病人自控鎮痛的嗎啡消耗量最少。單獨給予塞來昔布或普瑞巴林組的阿片用量較安慰組也有減少，但是不如聯合使用減少的多。在圍手術期的24h中，無論是病人休息還是活動狀態下，聯合使用塞來昔布和普瑞巴林是最有效的緩解疼痛的方法。但是四組的血流動學和呼吸頻率沒有顯著差異。聯合用藥組嘔吐的發生率低於安慰組。
結論：相對于柱融合術後單獨使用塞來昔布或普瑞巴林，圍手術期聯合使用塞來昔布和普瑞巴林能改善鎮痛效果且副作用小。
（周密 譯 陳傑 校）
BACKGROUND: As optimal pain relief after surgery is difficult to achieve with the use of just one drug, many pain experts advocate the use of two or more classes of medications so as to reduce the side effects from any one drug. In this trial, we assessed the analgesic efficacy of administering perioperative celecoxib, pregabalin, or both after spinal fusion surgery.
METHODS: Eighty patients scheduled to undergo elective decompressive lumbar laminectomy with posterior spinal fusion were randomized to receive oral medications: placebo 1 h before and 12 h after surgery, celecoxib 400 mg 1 h before and celecoxib 200 mg 12 h after surgery, pregabalin 150 mg 1 h before and 12 h after surgery, or a pregabalin/celecoxib combination of 400 mg/150 mg 1 h before and 200 mg/150 mg 12 h after surgery.
RESULTS: The pregabalin/celecoxib group consumed the least patient-controlled morphine. Celecoxib alone or pregabalin alone also reduced opioid use compared with placebo, but not as much as when combined. The pregabalin/celecoxib combination was the most effective treatment for reducing pain both at rest and with movement over the 24-h postoperative time period. Hemodynamics and respiratory rate did not differ among the four treatment groups. Fewer patients experienced nausea in the pregabalin/celecoxib group compared with that in the placebo group.
CONCLUSION: The perioperative administration of the combination of celecoxib and pregabalin improved analgesia and caused fewer side effects, than either analgesic drug alone after spinal fusion surgery.
A Pain Model After Gynecologic Surgery: The Effect of Intrathecal and Systemic Morphine
Chuanyao Tong, MD, Dawn Conklin, BA, and James C. Eisenach, MD
From the Department of Anesthesiology, Pain Mechanisms Laboratory, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Anesth Analg 2006 103: 1288-1293.
背景：儘管最近的研究證實內臟痛和軀體痛在神經病理基礎和治療均不同，但是對術後疼痛的大多數實驗研究都採用軀體表面痛的模型，而且沒有產科手術後疼痛的模型。作者描述了大鼠剖腹術後有或無子宮和宮頸的不良刺激的自發行為，以求得對產科術後疼痛的專項描繪。方法：雌SD大鼠採用分別只吸入麻醉，僅在麻醉後剖腹術或剖腹術後對低位子宮和宮頸進行60 min的張性擴張，然後觀察其行為。結果：與僅吸入麻醉的大鼠比較剖腹術的大鼠的自發性活動（飲水，整理，探察）減少。剖腹術宮頸的操作進一步減少了這些活動，增了異常活動（甜下腹部和骨盆位置壓在地面）。鞘內注射和全身用嗎啡可以恢復自發活動和減少異常活動，兩種不同的用藥方式有微小的不同。結論：這些資料表明一些特的行為直接反映了產科術後疼痛軀體和內臟痛的組成，同時這個模型可用於檢驗減輕疼痛的新的治療方案。
（王震虹 譯 陳傑 校）
BACKGROUND: Despite recent recognition that visceral pain differs from somatic pain in its neurophysiologic basis and treatment modalities, most laboratory studies of postoperative pain use a model of superficial somatic injury, and there is no model of postoperative pain after gynecologic surgery. We describe spontaneous behavior in rats after laparotomy with or without noxious stimulation of the uterus and cervix to more specially address pain after gynecologic surgery.
METHODS: Female Sprague-Dawley rats received inhaled anesthesia only, anesthesia with laparotomy, or laparotomy plus 60 min of tonic distension of the lower uterine segment and cervix, followed by video observation of spontaneous behavior.
RESULTS: Compared with anesthesia alone, laparotomy decreased some spontaneous behaviors (drinking water, grooming, and exploration). Laparotomy plus uterocervical manipulation further decreased these behaviors and increased abnormal behaviors (licking of the lower abdomen and squashing posture of the pelvis to the floor). Intrathecal and systemic morphine restored spontaneous behavior and reduced abnormal behaviors, with minor differences between routes of administration.
CONCLUSIONS: These data suggest that specific behaviors may distinctly reflect somatic and visceral components of postoperative gynecologic pain, and that this model may be used to test novel therapies to relieve pain in this setting.
脛後神經阻滯中一個近端阻滯點的評估和神經刺激導向裝置針的使用
Evaluation of a Proximal Block Site and the Use of Nerve-Stimulator-Guided Needle Placement for Posterior Tibial Nerve Block
Robert Doty, Jr, MD, Radha Sukhani, MD, Mark C. Kendall, MD, Edward Yaghmour, MD, Antoun Nader, MD, Alina Brodskaia, MD, Tripti C. Kataria, MD, and Robert McCarthy, DPharm
From the Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
Anesth Analg 2006 103: 1300-1305
.
背景：在沒有神經刺激器（NS）引導的情況下，脛後神經（PTN）阻滯傳統是在旁正中踝區域完成的。PTN還可以在拇長屈肌腱和趾長屈肌腱之間的筋膜下平面內踝向大約7cm處阻滯。在這項研究中，作者比較了使用和不使用NS嚮導的情況下，在傳統的遠中心端（D）（內踝2cm）成實施PTN阻滯的頻率。還比較了D位點和近中心位點（P）的阻滯的成率和潛伏時間。方法：受試者隨機分到P-NS組(n=45)，D-NS組(n=45)或D不使用NS組(n=45)。所有阻滯都使用0.625%左布比卡因0.15mL/kg。在足底內側神經，足底外側神經和跟骨內側神經的分佈區域評價針刺感覺的麻痹。如果PTN的所有分佈區域都達到了手術麻醉效果則認為PTN阻滯成。結果：和D組（73.3%）相比，D-NS組(100%)和P-NS組(93.5%)的PTN阻滯成率更高(P=0.02)。D-NS組達到阻滯的平均潛伏時間(8min，95% CI 7-9min)比D組(20min，95% CI 13-26min)(P<0.01)和P-NS組(15min，95% CI 12-18min)(P=0.04)短。結論：NS導向裝置針提高了D位元點阻滯成率並減少了D位點達到PTN阻滯的潛伏時間。用P位點來阻滯PTN可能是另一個有效的選擇，特別是對那些無法接近D位點的病人。
（顧新宇 譯 陳傑 校）
BACKGROUND: Posterior tibial nerve (PTN) block has traditionally been performed in the para-medial malleolar area without nerve stimulator (NS) guidance. The PTN can also be blocked proximally (7 cm) above the medial malleolus in the subfascial plane between the flexor hallucis longus and flexor digitorum longus tendons. In this study we compared the frequency of successful PTN block at the traditional distal (D) site (2 cm above the medial malleolus) with and without NS guidance. We also compared block success and latency at the D site versus the proximal (P) block site.
METHODS: Subjects were randomized to P-NS (n = 45), D-NS (n = 45), or D without NS (n = 45). Levobupivacaine 0.625%, 0.15 mL/kg was used for all blocks. Pinprick sensory anesthesia was evaluated in the distribution of the medial plantar, lateral plantar, and medial calcaneal nerves. PTN block was considered successful if surgical anesthesia was achieved in all PTN distributions.
RESULTS: The frequency of successful PTN block was greater for D-NS (100%) and P-NS (93.5%), compared with D (73.3%) (P = 0.02). Median latency to complete block was less for D-NS (8 min, 95% CI 7-9 min) than D (20 min, 95% CI 13-26 min) (P < 0.01) and P-NS (15 min, 95% CI 12-18 min) (P = 0.04).
CONCLUSIONS: NS-guided needle placement improves the success and decreases the latency to onset of complete PTN block at the D site. The P approach to PTN block may be a useful alternative to the traditional D site approach, particularly in patients with restricted access to the D site.
比較中胸段和低胸段硬膜外間隙硬膜外壓和低於大氣壓的硬膜外壓的發生率的差異
A Comparison of Epidural Pressures and Incidence of True Subatmospheric Epidural Pressure Between the Mid-Thoracic and Low-Thoracic Epidural Space
W. Anton
Visser, MD*, Mathieu J. M. Gielen, MD, PhD_files/image129.gif){kind=small}
, Janneke L. P. Giele, MSc_files/image130.gif){kind=small}
, and Gert J. Scheffer, MD, PhD_files/image131.gif){kind=small}
From the *Department of Anesthesiology,
Intensive Care and Pain Management, Amphia Hospital, 4800 RL Breda, The
Netherlands; and _files/image132.gif){kind=small}
Department of
Anesthesiology, University Medical Center Nijmegen, 6500 HB Nijmegen, The
Netherlands.
Anesth Analg 2006 103: 1318-1321.
背景：硬膜外壓的差異可能會影響胸段硬膜外阻滯麻藥的擴散。作者評估了中胸段和下胸段硬膜外間隙壓是否存在差異以低於大氣壓的硬膜外壓發生率的差異。方法：兩組分別在胸3-5（中胸段組，n=20）和胸7-10（低胸段組，n=20）椎間隙放置了硬膜外導管。確認硬膜外腔的方法是使用連接感測器的針，從而測得硬膜外壓。結果：有三位病人無法確定硬膜外腔從而從研究中剔出。硬膜外壓資料以中位數（中四分位範圍）表述。中胸段組中位硬膜外壓是1mmHg（-1到4.5），低胸段是4mmHg（2-7.8）（P=0.04）。硬膜外壓低於0mmHg的發生率中胸段組是8/17，低胸段組是2/20。（P=0.02）。結論：中胸段硬膜外腔的壓低於低胸段組，而低於大氣壓的硬膜外壓的發生率高於低胸段組。但是，硬膜外壓的中位數兩組都是正值。這種壓梯度是否會影響胸段硬膜外阻滯的擴散仍需要經一步的研究。
（曹瑜 譯 陳傑 校）
BACKGROUND: Differences in epidural pressure (EP) may influence the spread of blockade in thoracic epidural anesthesia. We evaluated if EP and the incidence of subatmospheric EP differ between the mid- and low-thoracic epidural space.
METHODS: Patients received an epidural catheter at the T3-5 (MID group, n = 20) or T7-10 (LOW group, n = 20) intervertebral space, respectively. The epidural space was identified using a Tuohy needle connected to a pressure transducer, after which EP was measured.
RESULTS: The
epidural space could not be identified in three patients who were
excluded from the study. EP data are presented as median value
(interquartile range). Median EP was 1 mm Hg (–1 to 4.5) in the MID
group, and 4 mm Hg (2-7.8) in the LOW group (P = 0.04). The incidence of an EP _files/image133.gif){kind=small}
0 mm Hg was
8 of 17 patients in the MID group and 2 of 20 patients in the LOW
group (P = 0.02).
CONCLUSIONS: We conclude that EP is lower, and the incidence of subatmospheric EP is higher in the mid-thoracic epidural space when compared with that in the low-thoracic epidural space. However, median EP was positive in both groups. It remains to be investigated whether this pressure gradient is sufficient to influence the spread of thoracic epidural blockade.