Anesthesia & Analgesia

March 2007

 

CARDIOVASCULAR ANESTHESIA:

有關超聲介導中心靜脈置管應用的調查

邱郁薇 譯 馬皓琳 李士通校

A Survey of the Use of Ultrasound During Central Venous Catheterization

Peter L. Bailey, Laurent G. Glance, Michael P. Eaton, Bob Parshall, and Scott McIntosh

Anesth Analg 2007 104: 491-497.

PEDIATRIC ANESTHESIA:

嬰兒兒童的麻醉藥物使用

王時來譯 薛張綱校

Use of Anesthetic Agents in Neonates and Young Children (Special Article)

R. Daniel Mellon, Arthur F. Simone, and Bob A. Rappaport

Anesth Analg 2007 104: 509-520.

肺動脈高壓患兒行非心臟手術或心導管術的圍術期併發症

丁震敏 譯 陳傑 校

Perioperative Complications in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheterization

Mario J. Carmosino, Robert H. Friesen, Aimee Doran, and Dunbar D. Ivy

Anesth Analg 2007 104: 521-527.

在小兒麻醉用於拔除喉罩通氣道的七氟醚最低肺泡濃度

胡湘 譯 馬皓琳 李士通 校

Minimum Alveolar Concentration of Sevoflurane for Laryngeal Mask Airway Removal in Anesthetized Children

Jeong-Rim Lee, Seong-Deok Kim, Chong-Sung Kim, Tae-Gyoon Yoon, and Hee-Soo Kim

Anesth Analg 2007 104: 528-531.

可樂定對兒童術後外周神經阻滯鎮痛的影響

陳勇柱譯 薛張綱校

The Effects of Clonidine on Postoperative Analgesia After Peripheral Nerve Blockade in Children

Giovanni Cucchiaro and Arjunan Ganesh

Anesth Analg 2007 104: 532-537.

AMBULATORY ANESTHESIA:

圍術期耳電針法對第三磨牙拔除術後的疼痛和鎮痛藥用量沒有影響

顧新宇 譯 陳傑 校

Perioperative Auricular Electroacupuncture Has No Effect on Pain and Analgesic Consumption After Third Molar Tooth Extraction

Andrea Michalek-Sauberer, Harald Heinzl, Sabine M. Sator-Katzenschlager, Gabriel Monov, Erich Knolle, and Hans Georg Kress

Anesth Analg 2007 104: 542-547.

比較樞複寧和異丙嗪治療用樞複寧預防失敗的患者術後噁心和嘔吐的效果:一項回顧性資料庫分析

彭中美 譯 馬皓琳 李士通 校

A Comparison of Ondansetron with Promethazine for Treating Postoperative Nausea and Vomiting in Patients Who Received Prophylaxis with Ondansetron: A Retrospective Database Analysis (Brief Report)

Ashraf S. Habib, Johnatan Reuveni, Akiko Taguchi, William D. White, and Tong J. Gan

Anesth Analg 2007 104: 548-551.

接受經尿道操作的老年病人的鞘內麻醉：一項為了尋找合適量的研究（簡要的報）

周時蓓譯 薛張綱校

Intrathecal Anesthesia for Elderly Patients Undergoing Short Transurethral Procedures: A Dose-Finding Study (Brief Report)

Edna Zohar, Yossi Noga, Uri Rislick, Ilan Leibovitch, and Brian Fredman

Anesth Analg 2007 104: 552-554.

ANESTHETIC PHARMACOLOGY:

一項有關選擇性肌松藥結合——速克美松安全逆轉羅庫溴深度神經肌肉阻滯的隨機量探究的II期研究

衛紅 譯 陳傑 校

A Randomized, Dose-Finding, Phase II Study of the Selective Relaxant Binding Drug, Sugammadex, Capable of Safely Reversing Profound Rocuronium-Induced Neuromuscular Block

Scott B. Groudine, Roy Soto, Cynthia Lien, David Drover, and Kevin Roberts

Anesth Analg 2007 104: 555-562.

新藥Sugammadex逆轉羅庫溴引起的神經肌肉阻滯在異丙酚或七氟醚麻醉維持下同樣有效

唐李雋 譯 馬皓琳 李士通 校

Reversal of Rocuronium-Induced Neuromuscular Block with the Novel Drug Sugammadex Is Equally Effective Under Maintenance Anesthesia with Propofol or Sevoflurane

Bernard F. Vanacker, Karel M. Vermeyen, Michel M. R. F. Struys, Henk Rietbergen, Eugene Vandermeersch, Vera Saldien, Alain F. Kalmar, and Martine E. Prins

Anesth Analg 2007 104: 563-568.

Sugammadex逆轉羅庫溴誘導的神經肌肉阻滯,與使用新斯的明-格隆溴或騰喜龍-阿托品的比較.

施 譯 薛張綱校

Sugammadex Reversal of Rocuronium-Induced Neuromuscular Blockade: A Comparison with Neostigmine–Glycopyrrolate and Edrophonium–Atropine

Ozlem Sacan, Paul F. White, Burcu Tufanogullari, and Kevin Klein

Anesth Analg 2007 104: 569-574.

速克美松：臨神經肌肉藥理學的另一個里程碑

衛紅 譯 陳傑 校

Sugammadex: Another Milestone in Clinical Neuromuscular Pharmacology (Medical Intelligence)

Mohamed Naguib

Anesth Analg 2007 104: 575-581.

高碳酸血症性過度通氣可以縮短異氟醚麻醉後蘇醒時間

姜旭暉譯 馬皓琳，李士通校

Hypercapnic Hyperventilation Shortens Emergence Time from Isoflurane Anesthesia

Derek J. Sakata, Nishant A. Gopalakrishnan, Joseph A. Orr, Julia L. White, and Dwayne R. Westenskow

Anesth Analg 2007 104: 587-591.

TECHNOLOGY, COMPUTING, AND SIMULATION:

電子提示儀能增程式文檔記錄依從性以專業費用的報

陳佳莉譯 薛張綱校

Electronic Reminders Improve Procedure Documentation Compliance and Professional Fee Reimbursement

Sachin Kheterpal, Ruchika Gupta, James M. Blum, Kevin K. Tremper, Michael O’Reilly, and Paul E. Kazanjian

Anesth Analg 2007 104: 592-597.

自主呼吸期間氧氣清除術用於測定能殘氣量的準確性研究。

衛紅 譯 陳傑 校

The Accuracy of the Oxygen Washout Technique for Functional Residual Capacity Assessment During Spontaneous Breathing

Hermann Heinze, Bernhard Schaaf, Jochen Grefer, Karl Klotz, and Wolfgang Eichler

Anesth Analg 2007 104: 598-604.

腦狀態指數在異丙酚麻醉深度遞增過程中的表現：與雙譜指數比較

黃佳佳 譯，馬皓琳 李士通 校

Performance of the Cerebral State Index During Increasing Levels of Propofol Anesthesia: A Comparison with the Bispectral Index

Luis I. Cortínez, Alejandro E. Delfino, Ricardo Fuentes, and Hernán R. Muñoz

Anesth Analg 2007 104: 605-610.

用超聲術評價聲門下管徑的可行性

陳珺珺譯 薛張綱校

The Feasibility of Ultrasound to Assess Subglottic Diameter (Technical Communication)

Karim Lakhal, Xavier Delplace, Jean-Philippe Cottier, François Tranquart, Xavier Sauvagnac, Colette Mercier, Jacques Fusciardi, and Marc Laffon

Anesth Analg 2007 104: 611-614.

ECONOMICS, EDUCATION, AND POLICY:

關於麻醉前門診，資整合手術室內滯留:對執業麻醉醫師的調查結果

印潔敏 譯 陳傑 校

Preanesthesia Clinics, Information Management, and Operating Room Delays: Results of a Survey of Practicing Anesthesiologists

Natalie F. Holt, David G. Silverman, Ravindra Prasad, James Dziura, and Keith J. Ruskin

Anesth Analg 2007 104: 615-618.

CRITICAL CARE AND TRAUMA:

由急症科醫生完成的院外病人食道支氣管插管

裘毅敏譯，馬皓琳 李士通校

The Out-of-Hospital Esophageal and Endobronchial Intubations Performed by Emergency Physicians

Arnd Timmermann, Sebastian G. Russo, Christoph Eich, Markus Roessler, Ulrich Braun, William H. Rosenblatt, and Micheal Quintel

Anesth Analg 2007 104: 619-623.. 

D-甲羥基澱粉在大鼠模型中對伴毛細血管滲漏的多菌性膿毒症的炎性作用

秦 佳譯 薛張綱校

Hydroxyethyl Starch, but Not Modified Fluid Gelatin, Affects Inflammatory Response in a Rat Model of Polymicrobial Sepsis with Capillary Leakage

Xiaomei Feng, Jian Liu, Min Yu, Sihai Zhu, and Jianguo Xu

Anesth Analg 2007 104: 624-630.

慢性態反應哮喘模型中七氟醚麻醉對肺學與組織學的影響

宋翠俠 譯 陳傑 校

Lung Mechanics and Histology During Sevoflurane Anesthesia in a Model of Chronic Allergic Asthma

Shirley Moreira Burburan, Debora Gonçalves Xisto, Halina Cidrini Ferreira, Douglas dos Reis Riva, Giovanna Marcella Cavalcante Carvalho, Walter Araujo Zin, and Patricia Rieken Macêdo Rocco

Anesth Analg 2007 104: 631-637.

七氟醚對受內毒素損傷肺泡皮細胞的免疫調製作用

周雅春 譯 馬皓琳 李士通 校

The Immunomodulatory Effect of Sevoflurane in Endotoxin-Injured Alveolar Epithelial Cells

Dominik Suter, Donat R. Spahn, Stephan Blumenthal, Livia Reyes, Christa Booy, Birgit Roth Z'graggen, and Beatrice Beck-Schimmer

Anesth Analg 2007 104: 638-645.

針刺足三裏（ST36）能減弱脂多糖誘導的大鼠急性腎損傷但不能減弱肝損傷

羅 璿譯 薛張綱校

Acupuncture Stimulation of ST36 (Zusanli) Attenuates Acute Renal but Not Hepatic Injury in Lipopolysaccharide-Stimulated Rats

Chin-Liang Huang, Pei-Shan Tsai, Tao-Yeuan Wang, Li-Ping Yan, Heng-Ze Xu, and Chun-Jen Huang

Anesth Analg 2007 104: 646-654

NEUROSURGICAL ANESTHESIA:

靜注尼卡地平和前列腺素E1對兔主動脈鉗閉開放後引起的大腦軟腦膜微動脈收縮效應作用的比較研究　　

鄭麗 譯 陳傑 校

The Comparative Effects of Intravenous Nicardipine and Prostaglandin E1 on the Cerebral Pial Arteriolar Constriction Seen After Unclamping of an Aortic Cross-Clamp in Rabbits

Masahiko Kumazawa, Hiroki Iida, Masayoshi Uchida, Mami Iida, Motoyasu Takenaka, and Shuji Dohi

Anesth Analg 2007 104: 659-665.

OBSTETRIC ANESTHESIA:

分析剖宮產手術中血紅細胞回收再利用的輸注實踐和作用

張曦 譯，馬皓琳 李士通 校

An Analysis of Transfusion Practice and the Role of Intraoperative Red Blood Cell Salvage During Cesarean Delivery

Jill Fong, Edith D. Gurewitsch, Hey-Joo Kang, Lisa Kump, and Patricia Fogarty Mack

Anesth Analg 2007 104: 666-672.

使用背景量輸注機控指令單次給藥孕婦自控硬膜外鎮痛的對照試驗

王光妍譯 薛張綱校

A Comparison of a Basal Infusion with Automated Mandatory Boluses in Parturient-Controlled Epidural Analgesia During Labor

Alex T. Sia, Yvonne Lim, and Cecilia Ocampo

Anesth Analg 2007 104: 673-678.

麻下行剖宮產患者中預防性使用格拉司並不能預防產後噁心嘔吐

李惟一 譯 陳傑 校

The Prophylactic Granisetron Does Not Prevent Postdelivery Nausea and Vomiting During Elective Cesarean Delivery Under Spinal Anesthesia

Mrinalini Balki, Shilpa Kasodekar, Sudhir Dhumne, and Jose C. A. Carvalho

Anesth Analg 2007 104: 679-683.

GENERAL ARTICLE:

實施血液細胞回收時修正吸引導致的溶血

張瑩 譯 馬皓琳 李士通 校

Modification of Suction-Induced Hemolysis During Cell Salvage

Jonathan H. Waters, Brandon Williams, Mark H. Yazer, and Marina V. Kameneva

Anesth Analg 2007 104: 684-687.

ANALGESIA:

術後鎮痛對手術後主要併發症的影響：一項系統的最新的證據

張 儷譯 薛張鋼校

Effect of Postoperative Analgesia on Major Postoperative Complications: A Systematic Update of the Evidence

Spencer S. Liu and Christopher L. Wu

Anesth Analg 2007 104: 689-702.

10. 慢性疼痛醫學中有關健康的生活品質的入門文書

張美榮 譯 陳傑 校

A Primer on Health-Related Quality of Life in Chronic Pain Medicine (Medical Intelligence)

Thomas R. Vetter

Anesth Analg 2007 104: 703-718.

大鼠福馬林試驗中大麻酯受體激動WIN55,212-2和布比卡因之間傷害的協同作用

黃施偉 譯，馬皓琳、李士通 校

Antinociceptive Synergy Between the Cannabinoid Receptor Agonist WIN 55,212-2 and Bupivacaine in the Rat Formalin Test

Sinyoung Kang, Chi Hyo Kim, Heeseung Lee, Dong Yeon Kim, Jong In Han, Rack Kyung Chung, and Guie Yong Lee

Anesth Analg 2007 104: 719-725.

地塞米松對嗎啡耐受大鼠髓穀氨醯胺合成酶谷氨酸脫氫酶表達的影響

孫 霞譯 薛張綱校

The Effect of Dexamethasone on Spinal Glutamine Synthetase and Glutamate Dehydrogenase Expression in Morphine-Tolerant Rats

Gong-Jhe Wu, Zhi-Hong Wen, Wu-Fu Chen, Yi-Chen Chang, Chen-Hwan Cherng, and Chih-Shung Wong

nesth Analg 2007 104: 726-730.

雙側髂腹股溝神經阻滯可以減少非腹腔鏡婦科手術的女性患者的嗎啡用量

詹慧 譯 陳傑 校

Bilateral Ilioinguinal Nerve Block Decreases Morphine Consumption in Female Patients Undergoing Nonlaparoscopic Gynecologic Surgery

Fabienne Oriola, Yannick Toque, Anne Mary, Odile Gagneur, Sadek Beloucif, and Hervé Dupont

Anesth Analg 2007 104: 731-734.

 

有關超聲介導中心靜脈置管應用的調查

A Survey of the Use of Ultrasound During Central Venous Catheterization

Peter L. Bailey, MD*, Laurent G. Glance, MD*, Michael P. Eaton, MD*, Bob Parshall, BS*, and Scott McIntosh, PhD{dagger}

From the Departments of *Anesthesiology and {dagger}Community and Preventive Medicine, University of Rochester, Rochester, New York.

Anesth Analg 2007;104:491-497

背景：中心靜脈置管（CVC）過程中的併發症並不罕見，而且可能相當嚴重。一些人推薦在CVC過程中使用超聲（US）來提高患者安全性。我們進行了一項調查來評估US使用的頻率和影響它使用的因素。

方法：我們對心血管麻醉醫師協會的所有成員進行了一項電子調查。採用單數和多數對數回歸來分析US使用的機率與醫院醫師等因素之間的關係。所有檢驗採用雙側檢驗，P值<0.05為差異有統計學意義。

結果：4235名會員中，1494名進行了答復（答復率＝35.3％）。2/3的答復者中從未或幾乎從未使用過US，而僅有15％的應答者經常或幾乎經常使用US。33％的答復者從來或幾乎從來沒有US設備，而41％的答復者稱始終或幾乎始終擁有US設備。US設備的可用性與CVC中使用超聲的機率密切相關（校正OR = 18.9；P <0.001）。最常見的不使用US的原因是“沒有明顯必要使用US”（46％）。在US的使用中，作為援救或螢幕檢查進路（72％）比即時應用（26％）更為普遍。

結論：CVC過程中US的使用還很局限，而且它的使用率與設備的擁有率最密切相關。作為螢幕檢查進路和援救原因使用US比即時導向更為常見。我們的調查提示目前在CVC過程中US的使用與循證醫學的推薦還有差距。

（邱鬱薇 譯 馬皓琳 李士通校）

BACKGROUND: Complications during central venous catheterization (CVC) are not rare and can be serious. The use of ultrasound (US) during CVC has been recommended to improve patient safety. We performed a survey to evaluate the frequency of, and factors influencing, US use.

METHODS: We conducted an electronic survey of all members of the Society of Cardiovascular Anesthesiologists. Univariate and multivariate logistic regressions were used to assess the association between the frequency of US use and hospital and physician factors. All tests were two-sided, and a P value <0.05 was considered statistically significant.

RESULTS: Of the 4235 members, 1494 responded (response rate = 35.3%). Two-thirds of the respondents never, or almost never, use US, whereas only 15% always, or almost always, use US. Thirty-three percent of the respondents never, or almost never, have US available, whereas 41% stated that US is always, or almost always, available. Availability of US equipment was strongly associated with US use for CVC (adj OR = 18.9; P value <0.001). The most common reason cited for not using US was "no apparent need for the use of US" (46%). When US was used, rescue or screening approaches were more common (72%) than real-time use (26%).

CONCLUSIONS: The use of US during CVC remains limited and is most strongly associated with the availability of equipment. Screening and rescue use of US are more common than real-time guidance. Our survey suggests that current use of US during CVC differs from existing evidence-based recommendations.

 

 

在小兒麻醉用於拔除喉罩通氣道的七氟醚最低肺泡濃度

Minimum Alveolar Concentration of Sevoflurane for Laryngeal Mask Airway Removal in Anesthetized Children

Jeong-Rim Lee, MD, Seong-Deok Kim, MD, PhD, Chong-Sung Kim, MD, PhD, Tae-Gyoon Yoon, MD, PhD, and Hee-Soo Kim, MD, PhD

From the Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Korea.

Anesth Analg 2007;104:528-531

背景：在兒童，當病人還處於麻醉狀態時拔除喉罩通氣道（LMA）是比較適合的。我們嘗試測定在兒童中可以拔除LMA的最佳七氟醚的最低肺泡濃度（MAC），而又無氣道併發症。

方法：我們研究了25個無術前用藥的7月-10歲、ASA I級、接受泌尿外科或整形外科手術的兒童。全麻誘導採用經面罩給予氧氣混合七氟醚。插入LMA以氧氣混合七氟醚維持麻醉。術畢在呼氣末七氟醚濃度減少到預期的水準時拔除LMA，用下序貫方法（每步增減0.2%）來確定七氟醚的濃度。成的拔除標誌為拔除時或拔除後一分鐘內無咳嗽、牙關閉、有目的的大體動、屏氣或者喉痙攣。

結果：50%成拔除LMA的七氟醚MAC為1.84%（95%可信區間1.45%-1.96%），成拔除95%的有效濃度為2.17%（95%可信區間2.02%-3.48%）。

結論：七氟醚呼氣末濃度為1.84%時，在50%的麻醉兒童中可達到安全的LMA拔除且無咳嗽、體動或任何其他氣道併發症。

（胡湘 譯 馬皓琳 李士通 校）

BACKGROUND: In children, it is preferable to remove the laryngeal mask airway (LMA) when the patient is still anesthetized. We sought to determine the optimal minimum alveolar concentration of sevoflurane that would allow removal of the LMA in children without airway complications.

METHODS: We studied 25 unpremedicated children between 7 mo and 10 yr of age, ASA Status I, undergoing urologic or plastic surgery. General anesthesia was induced with sevoflurane and oxygen given via mask. The LMA was inserted and anesthesia was maintained with sevoflurane in oxygen. The LMA was removed at the end of surgery when the end-tidal sevoflurane concentration had reduced to a predetermined level, determined by the up-and-down method, with 0.2% as a step size. A removal accomplished without coughing, teeth clenching, gross purposeful movement, breath holding or laryngospasm, during or within 1 min after removal, was considered to be successful.

RESULTS: The minimum alveolar concentration of sevoflurane at which 50% of LMA removals were successful was 1.84% (95% confidence limits, 1.45%–1.96%), and the 95% effective dose for successful removal was 2.17% (95% confidence limits, 2.02%–3.48%).

CONCLUSIONS: LMA removal may be accomplished without coughing, moving, or any other airway complication at 1.84% end-tidal sevoflurane concentration in 50% of anesthetized children.

 

 

比較樞複寧和異丙嗪治療用樞複寧預防失敗的患者術後噁心和嘔吐的效果:一項回顧性資料庫分析

A Comparison of Ondansetron with Promethazine for Treating Postoperative Nausea and Vomiting in Patients Who Received Prophylaxis with Ondansetron: A Retrospective Database Analysis

 

Ashraf S. Habib, MBBCh, MSc, FRCA, Johnatan Reuveni, Akiko Taguchi, MD, PhD, William D. White, MPH, and Tong J. Gan, MB, FRCA, FFARCS(I)

From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2007;104:548-551

背景：對於止吐藥治療接受術後噁心嘔吐（PONV）預防患者PONV的效果的資料很少。

方法：在這個回顧性資料分析中，我們比較了異丙嗪和樞複寧在接受全身麻醉且樞複寧預防失敗的成人中治療PONV的有效性。

結果：在樞複寧預防性治療失敗後，3062例患者接受樞複寧，752例患者接受異丙嗪治療。應用異丙嗪後的完全有效率(無PONV和進一步解救藥)是68%，樞複寧是50% (P < 0.0001)。6.26mg異丙嗪和較大量異丙嗪之間無差異。

結論：異丙嗪治療樞複寧預防無效後的PONV比樞複寧顯著有效。異丙嗪6.25mg同較大量一樣有效.

(彭中美 譯 馬皓琳 李士通 校)

BACKGROUND: There are little data on the efficacy of antiemetics for treating postoperative nausea and vomiting (PONV) in patients who received prior PONV prophylaxis.

METHODS: In this retrospective database analysis, we compared the efficacy of ondansetron with that of promethazine for treating PONV in adults receiving general anesthesia who failed ondansetron prophylaxis.

RESULTS: Three thousand sixty-two patients received ondansetron and 752 received promethazine after failure of ondansetron prophylaxis. The complete response (no PONV and no further rescue) was 68% after administration of promethazine and 50% after ondansetron administration (P < 0.0001). There was no difference in complete response between 6.25 mg and higher doses of promethazine.

CONCLUSIONS: Promethazine was significantly more effective than ondansetron for treating PONV after failed ondansetron prophylaxis. Promethazine 6.25 mg was as effective as higher doses.

 

 

新藥Sugammadex逆轉羅庫溴引起的神經肌肉阻滯在異丙酚或七氟醚麻醉維持下同樣有效

Reversal of Rocuronium-Induced Neuromuscular Block with the Novel Drug Sugammadex Is Equally Effective Under Maintenance Anesthesia with Propofol or Sevoflurane

Bernard F. Vanacker, MD, PhD*, Karel M. Vermeyen, MD, PhD{dagger}, Michel M. R. F. Struys, MD, PhD{ddagger}, Henk Rietbergen, MSc, Eugene Vandermeersch, MD, PhD*, Vera Saldien, MD{dagger}, Alain F. Kalmar, MD{ddagger}, and Martine E. Prins, MSc

From the *University Hospitals Leuven, KU Leuven, Belgium; {dagger}University Hospital Antwerp, Antwerp, Belgium; {ddagger}Ghent University Hospital, Ghent, Belgium; NV Organon, Oss, The Netherlands.

Anesth Analg 2007;104:563-568
在本研究中我們調查了新藥sugammadex逆轉羅庫溴引起的神經肌肉阻滯（NMB）在異丙酚或七氟醚麻醉維持的患者中是否同樣有效。用異丙酚誘導後，將患者隨機分為異丙酚組(n = 21)和七氟醚組(n = 21)。給予羅庫溴0.6 mg/kg用以氣管插管。速度描記法監測NMB。當四個成串刺激比率中的第二個肌顫搐再現時，單次靜脈注入sugammadex 2.0 mg/kg。主要終點是從開始給予sugammadex到四個成串刺激比率恢復至0.9。異丙酚和七氟醚麻醉後的平均恢復時間都是1.8分鐘。兩組恢復時間差異的95％可信區間 (–0.5 到 +0.4 min)在預定義的等價間期(–1 到 +1 min)內，表明NMB恢復不受麻醉維持的影響。13名患者(異丙酚n = 4; 七氟醚n = 9)出現不良事件，其中治療相關性的有4例(異丙酚n = 3; 七氟醚n = 1)。沒有治療相關的嚴重不良事件、停藥或死亡。未發生殘餘性麻痹。某種程度Sugammadex的安全性在異丙酚麻醉下較七氟醚更滿意。

（唐李雋 譯 馬皓琳 李士通 校）

In this study we investigated whether the novel reversal drug, sugammadex, is equally effective at reversing rocuronium-induced neuromuscular block (NMB) in patients under propofol or sevoflurane maintenance anesthesia. After receiving propofol for induction, patients were randomized to propofol (n = 21) or sevoflurane (n = 21). Rocuronium 0.6 mg/kg was administered for tracheal intubation. NMB was monitored using acceleromyography. At reappearance of the second twitch of the train-of-four ratio, sugammadex 2.0 mg/kg was administered by IV bolus. The primary end-point was time from start of sugammadex administration to recovery of train-of-four ratio to 0.9. Mean recovery time was 1.8 min after both propofol and sevoflurane anesthesia. The 95% confidence interval for the difference in recovery time between the 2 groups (–0.5 to +0.4 min) was well within the predefined equivalence interval (–1 to +1 min), indicating that recovery from NMB was unaffected by maintenance anesthesia. Thirteen patients (propofol n = 4; sevoflurane n = 9) experienced adverse events; these were treatment-related in 4 patients (propofol n = 3; sevoflurane n = 1). There were no treatment-related serious adverse events and no discontinuations or deaths. No residual paralysis occurred. The safety profile of sugammadex was somewhat more favorable under propofol than under sevoflurane anesthesia.

 

 

高碳酸血症性過度通氣可以縮短異氟醚麻醉後蘇醒時間

Hypercapnic Hyperventilation Shortens Emergence Time from Isoflurane Anesthesia

 

Derek J. Sakata, MD, Nishant A. Gopalakrishnan, BS, Joseph A. Orr, PhD, Julia L. White, RN, BS, CCRC, and Dwayne R. Westenskow, PhD

From the Department of Anesthesiology, University of Utah, Salt Lake City, Utah.

Anesth Analg 2007;104:587-591

背景：最近的調查發現，為了縮短用揮發性麻醉的手術後蘇醒時間，78%的麻醉醫師使用過度通氣來將麻醉從肺內快速洗出。過度通氣的做法還沒有在臨 廣泛運用，這是因為過度通氣造成的低動脈血二氧化碳分壓會減少腦血流且制呼吸驅動。通過增病人的氣道死腔量可以在過度通氣時簡單安全地維持正常或輕微增高的動脈血二氧化碳分壓值。

方法：我們讓二十個外科手術病人接受1個MAC的異氟醚吸入麻醉，一組輕度高碳酸血症（ETCO2約為28mmHg），一組輕度低碳酸血症（ETCO2約為55mmHg），然後比較他們之間異氟醚洗出時間的區別。一病人在洗出時分鐘通氣量倍，通過插入額外氣道死腔量來維持ETCO2在過度通氣時接近55mmHg。活性碳吸附罐吸附死腔裏的麻醉氣體。所有病人在洗出時新鮮氣體流量都增到10L/min。

結果：每當用重複呼吸和麻醉吸附維持的高碳酸血症性過度通氣時，從關閉揮發罐到睜開眼睛嘴巴的時間、氣管拔管時間標準化BIS達到0.95的時間均較快（P<0.001）。拔管時間平均縮短59%。

結論：通過過度通氣來將麻醉從肺內快速洗出以通過CO2重複呼吸來誘發過度通氣過程中的高碳酸血症，可以顯著縮短異氟醚麻醉的蘇醒時間。當提供揮發性麻醉快速洗出很重要時，尤其是一直到術畢都維持高濃度揮發性麻醉或者無預的手術突然結束的情況下，應該考慮採用以這種方法。

（姜旭暉譯 馬皓琳，李士通校）

BACKGROUND: To shorten emergence time after a procedure using volatile anesthesia, 78% of anesthesiologists recently surveyed used hyperventilation to rapidly clear the anesthetic from the lungs. Hyperventilation has not been universally adapted into clinical practice because it also decreases the Paco2, which decreases cerebral bloodflow and depresses respiratory drive. Adding deadspace to the patient’s airway may be a simple and safe method of maintaining a normal or slightly increased Paco2 during hyperventilation.

METHODS: We evaluated the differences in emergence time in 20 surgical patients undergoing 1 MAC of isoflurane under mild hypocapnia (ETco2 approximately 28 mmHg) and mild hypercapnia (ETco2 approximately 55 mmHg). The minute ventilation in half the patients was doubled during emergence, and hypercapnia was maintained by insertion of additional airway deadspace to keep the ETco2 close to 55 mmHg during hyperventilation. A charcoal canister adsorbed the volatile anesthetic from the deadspace. Fresh gas flows were increased to 10 L/min during emergence in all patients.

RESULTS: The time between turning off the vaporizer and the time when the patients opened their eyes and mouths, the time of tracheal extubation, and the time for normalized bispectral index to increase to 0.95 were faster whenever hypercapnic hyperventilation was maintained using rebreathing and anesthetic adsorption (P < 0.001). The time to tracheal extubation was shortened by an average of 59%.

CONCLUSIONS: The emergence time after isoflurane anesthesia can be shortened significantly by using hyperventilation to rapidly clear the anesthetic from the lungs and CO2 rebreathing to induce hypercapnia during hyperventilation. The device should be considered when it is important to provide a rapid emergence, especially after surgical procedures where a high concentration of the volatile anesthetic was maintained right up to the end of the procedure, or where surgery ends abruptly and without warning.

 

 

腦狀態指數在異丙酚麻醉深度遞增過程中的表現：與雙譜指數比較

Performance of the Cerebral State Index During Increasing Levels of Propofol Anesthesia: A Comparison with the Bispectral Index

Luis I. Cortínez, MD, Alejandro E. Delfino, MD, Ricardo Fuentes, MD, and Hernán R. Muñoz, MD, MSc

From the Departamento de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile. Santiago, Chile.

Anesth Analg 2007;104:605-610

背景：腦狀態監測儀是測量麻醉深度的一種新型儀器。在這項研究中，我們比較了異丙酚麻醉中腦狀態監測與雙譜指數（BIS）監測。

方法：15位健康患者接受持續異丙酚輸注麻醉(300 mL/h)。記錄腦狀態指數(CSI)和BIS直至爆發性制比60%。評價基線異率、預測概率兩指數間的吻合度。同時評估意識喪失的臨標誌。

結果：平均BISCSI喚醒值分別為95.6和91.6 (P = 0.01)。估計的BIS和CSI的預測概率值分別為0.87 ± 0.08和0.86 ± 0.08(平均值±標準差)（NS）。當估計的效應部位異丙酚濃度從5 µg/mL增到 8 µg/mL時，CSI趨於穩定在60－40。效應部位異丙酚濃度從7 µg/mL增到 10 µg/mL時，BIS穩定在40－20。平均BIS-CSI差異為–7.4，95%吻合限22.2～–36.9。與爆發性制比相關的BIS和CSI分別為–0.60和–0.97(P < 0.01)。預計的50%和95%病人睫毛反射消失時的BIS和CSI值不同(P < 0.05)。

結論：異丙酚誘導過程中兩種監測總體的表現是相似的。然而，這兩種監測不同的動學特性顯示，BIS可能是評價中等麻醉深度較為有效的指數，而CSI用於評價更深的麻醉深度較好。

（黃佳佳 譯，馬皓琳 李士通 校）

BACKGROUND: The cerebral state monitor is a new device to measure depth of anesthesia. In this study we compared the cerebral state monitor with the bispectral index (BIS) monitor during propofol anesthesia.

METHODS: Fifteen healthy patients received a continuous infusion of propofol (300 mL/h). The cerebral state index (CSI) and the BIS values were recorded until burst suppression ratio 60%. Baseline variability, prediction probability, and agreement analysis between indices were evaluated. Clinical markers of loss of consciousness were also assessed.

RESULTS: Mean awake BIS and CSI values were 95.6 and 91.6, respectively (P = 0.01). BIS and CSI prediction probability values (mean ± sd) were estimated to be 0.87 ± 0.08 and 0.86 ± 0.08, respectively (NS). The CSI tended to stabilize at values of 60–40 when estimated propofol concentrations at the effect site increased from 5 to 8 µg/mL. The BIS stabilized at values of 40–20 when the propofol concentrations at the effect site increased from 7 to 10 µg/mL. The mean BIS-CSI difference was –7.4 with 95% limits of agreement of 22.2 and –36.9. The BIS and CSI correlation with the burst suppression ratio was –0.60 and –0.97, respectively (P < 0.01). Predicted BIS and CSI values for loss of eyelash reflex in 50% and 95% of the patients were different (P < 0.05).

CONCLUSION: The overall performance of both monitors during propofol induction was similar. However, the different dynamic profiles of these monitors indicate that BIS may be a more useful index for evaluating intermediate anesthetic levels, whereas CSI may be better for evaluating deeper anesthetic levels.

 

 

由急症科醫生完成的院外病人食道支氣管插管

The Out-of-Hospital Esophageal and Endobronchial Intubations Performed by Emergency Physicians

Arnd Timmermann, MD, DEAA*, Sebastian G. Russo, MD*, Christoph Eich, MD, DEAA*, Markus Roessler, MD, DEAA*, Ulrich Braun, MD, PhD*, William H. Rosenblatt, MD, PhD{dagger}, and Micheal Quintel, MD, PhD*

From the *Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August University, Goettingen, Germany; and {dagger}Department of Anesthesiology, School of Medicine, Yale University, New Haven, Connecticut.

Anesth Analg 2007;104:619-623

背景：對於危重或創傷病人而言，氣道的快速建立是院前急救人員的首要問題。院外病人的氣管插管是頗具挑戰性的。未被認識到的插管誤入食道是臨的災難。

方法：我們持續地對需空運並由初級急症科醫生完成院外氣管插管的病人進行了一個觀察性的前瞻性研究，以測定未被認識到的食道支氣管內插管的數目。研究醫生通過結合直接明視、呼氣末二氧化碳檢測、食道檢測裝置體檢來確定氣管導管的位置。

結果：在５年的研究階段，初級急症科醫生連續對１４９位患者實行了院外氣管插管，並隨後由研究醫生進行評估。患者平均年齡為57.0 (±22.7) 歲，９９位(66.4%)患者為男性。研究醫生確定16例（10.7%）和10例（6.7%）氣管導管已分別置於右支氣管主幹和食道內。所有誤入食道的插管都被檢測到並由研究醫生予糾正，但１０位患者中有７位在治療的最初２４小時內死亡。

結論：未被認識到誤入食道的插管是常見的，且與高死亡率相關。插管入食道可通過呼氣末二氧化碳監測食道檢測裝置來發現。院外醫務人員需在氣道處理方面接受持續的培訓，並需要提供額外的驗證設備來幫確定氣管導管的位置。

（裘毅敏譯，馬皓琳 李士通校）

 

BACKGROUND: Rapid establishment of a patent airway in ill or injured patients is a priority for prehospital rescue personnel. Out-of-hospital tracheal intubation can be challenging. Unrecognized esophageal intubation is a clinical disaster.

METHODS: We performed an observational, prospective study of consecutive patients requiring transport by air and out-of-hospital tracheal intubation, performed by primary emergency physicians to quantify the number of unrecognized esophageal and endobronchial intubations. Tracheal tube placement was verified on scene by a study physician using a combination of direct visualization, end-tidal carbon dioxide detection, esophageal detection device, and physical examination.

RESULTS: During the 5-yr study period 149 consecutive out-of-hospital tracheal intubations were performed by primary emergency physicians and subsequently evaluated by the study physicians. The mean patient age was 57.0 (±22.7) yr and 99 patients (66.4%) were men. The tracheal tube was determined by the study physician to have been placed in the right mainstem bronchus or esophagus in 16 (10.7%) and 10 (6.7%) patients, respectively. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment.

CONCLUSION: The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. Esophageal intubation can be detected with end-tidal carbon dioxide monitoring and an esophageal detection device. Out-of-hospital care providers should receive continuing training in airway management, and should be provided additional confirmatory adjuncts to aid in the determination of tracheal tube placement.

 

 

七氟醚對受內毒素損傷肺泡皮細胞的免疫調製作用

The Immunomodulatory Effect of Sevoflurane in Endotoxin-Injured Alveolar Epithelial Cells

Dominik Suter, MD*{dagger}, Donat R. Spahn, MD*, Stephan Blumenthal, MD, Livia Reyes{dagger}, Christa Booy{dagger}, Birgit Roth Z'graggen, PhD{dagger}, and Beatrice Beck-Schimmer, MD*{dagger}

From the Institutes of *Anesthesiology, {dagger}Physiology and Zurich Center for Integrative Human Physiology, University of Zurich, Zurich; and Department of Anesthesiology, Orthopedic University Clinic Zurich Balgrist, Zurich, Switzerland.

Anesth Analg 2007;104:638-645

背景：內毒素所致肺損傷是用於描述急性肺損傷免疫病理學機制的一個有效實驗體系。儘管揮發性麻醉藥直接接觸到肺泡皮細胞（AEC），但是關於麻醉藥對此類細胞作用的資非常有限。本實驗研究了吸入麻醉藥七氟醚預處理對受脂多糖（LPS）損傷的AEC的作用。

方法：AEC用1.1vol%的七氟醚孵育0.5小時後用LPS刺激5小時。分析單核細胞趨化蛋白－1（MCP-1）、巨噬細胞炎性蛋白－1β（MIP-1ß）、巨噬細胞炎性蛋白－2（MIP-2）、細胞因數誘導中性粒細胞趨化物－1（CINC-1）和細胞間黏附分子－1（ICAM-1）的表達。同時通過趨化和黏附試驗進行能測試以闡明檢測結果之間的生物學聯繫。

結果：七氟醚－LPS組中，經七氟醚預處理的AEC的MCP-1蛋白表達較無七氟醚－LPS細胞下調50％(P < 0.05)。七氟醚使LPS刺激過的細胞中的MIP-1ß濃度降低32％(P < 0.05)，MIP-2濃度降低29% (P < 0.05)，CINC-1濃度降低20% (P < 0.05)，ICAM-1蛋白表達減弱36％(P < 0.05)。此種制使得中性粒細胞炎症應答產生本質化。七氟醚處理的LPS細胞中的趨化活性減少33％(P < 0.001)且中性粒細胞對AEC的黏附也減少47％(P < 0.001)。

結論：本研究顯示七氟醚可改LPS－誘導的炎症應答，該作用不僅與炎性介質表達方式有關，還與其減少中性粒細胞等效應細胞聚集的生物學效應有關。

（周雅春 譯 馬皓琳 李士通 校）

BACKGROUND: Endotoxin-induced lung injury is a useful experimental system for the characterization of immunopathologic mechanisms in acute lung injury. Although alveolar epithelial cells (AEC) are directly exposed to volatile anesthetics, there is limited information about the effect of anesthetics on these cells. In this study we investigated the effect of pretreatment with the inhaled anesthetic sevoflurane on lipopolysaccharide (LPS)-injured AEC.

METHODS: AEC were incubated with 1.1 vol % sevoflurane for 0.5 h, followed by LPS stimulation for 5 h. Expression of monocyte chemoattractant protein-1 (MCP-1), macrophage inflammatory protein-1ß (MIP-1ß), macrophage inflammatory protein-2 (MIP-2), cytokine-induced neutrophil chemoattractant-1 (CINC-1), and intercellular adhesion molecule-1 (ICAM-1) was analyzed. In addition, functional tests were performed through chemotaxis and adherence assays to underline the biological relevance of the findings.

RESULTS: Exposure of AEC to sevoflurane resulted in a 50% downregulation of MCP-1 protein in the sevoflurane-LPS group when compared with non-sevoflurane- LPS cells (P < 0.05). MIP-1ß concentration in LPS-stimulated cells decreased by 32% with sevoflurane (P < 0.05), MIP-2 by 29% (P < 0.05), and CINC-1 by 20% (P < 0.05). ICAM-1 protein expression was attenuated by 36% (P < 0.05). This inhibition caused substantial changes in the inflammatory response of neutrophils. 33% less chemotactic activity was seen in sevoflurane-treated LPS cells (P < 0.001) as well as 47% decreased adhesion of neutrophils to AEC (P < 0.001).

CONCLUSIONS: This study shows that sevoflurane alters the LPS-induced inflammatory response, not only with respect to the expression pattern of inflammatory mediators, but also regarding the biological consequences with less accumulation of effector cells such as neutrophils.

 

 

分析剖宮產手術中血紅細胞回收再利用的輸注實踐和作用

An Analysis of Transfusion Practice and the Role of Intraoperative Red Blood Cell Salvage During Cesarean Delivery

Jill Fong, MD*, Edith D. Gurewitsch, MD{dagger}, Hey-Joo Kang, MD{ddagger}, Lisa Kump, MD, and Patricia Fogarty Mack, MD*

From the *Departments of Anesthesiology and {ddagger}Obstetrics and Gynecology, New York Presbyterian Hospital-Weill Cornell Medical Center; {dagger}Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine; and Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York.

Anesth Analg 2007;104:666-672

背景：我們尋求確定手術中回收的紅細胞（RBC）輸注理論可能減少剖宮產病人恰當的輸同種異體的紅細胞到何種程度。

方法：回顧了1992年1月1日到1996年6月30日和1998年6月1日到2003年6月30日需要血液輸注的剖宮產病人的醫療記錄。對於每位病人，我們都計算了如果進行術中自體輸血，理論可以避免的同種異體紅細胞的單位數。計算基於估計血液丟失量、術前紅細胞壓積和產生一個紅細胞單位所需的回收血量。紅細胞輸注的恰當性用推薦的紅細胞輸注指南來確定，即在持續出血的病人是否血紅蛋白<7 gm/dL。

結果：小百分比的剖宮產病人(1.8%)接受了血液製品的輸注。接受了血液輸注的207位病人中，回收利用紅細胞可以理論減少115位病人(55.6%)進行同種異體紅細胞輸注。這115位病人中只有75.7%是恰當地輸注了紅細胞。

結論：理論，基於最好、平均和最差的紅細胞回收計算，分別有25.1%、21.2% 或者14.5%的恰當輸血的患者可以完全避免同種異體紅細胞的輸注。

（張曦 譯，馬皓琳 李士通 校）

BACKGROUND: We sought to determine to what extent intraoperative salvaged red blood cells (RBC) might theoretically reduce exposure to appropriately transfused allogenic erythrocytes in Cesarean delivery patients.

METHODS: Medical records of Cesarean delivery patients requiring blood transfusions from January 1, 1992 to June 30, 1996 and June 1, 1998 to June 30, 2003 were reviewed. For each patient, we calculated the number of allogenic RBC units that could have theoretically been avoided had intraoperative autotransfusion been performed, based upon estimated blood loss, preoperative hematocrit, and the amount of retrieved blood needed to yield a single RBC unit. RBC transfusion appropriateness was determined using the recommended guideline of transfusing RBCs if the hemoglobin is <7 gm/dL in a patient with continuing bleeding.

RESULTS: A small percentage of Cesarean delivery patients (1.8%) received blood product transfusions. Of 207 patients receiving blood transfusions, salvaged erythrocytes could have theoretically decreased exposure to allogenic RBCs in 115 (55.6%) patients. Only 75.7% of these 115 patients were appropriately transfused with erythrocytes.

CONCLUSION: Theoretically, based on best, average, and worst RBC salvage recovery calculations, 25.1%, 21.2%, or 14.5% of the appropriately transfused patients, respectively, could have completely avoided allogenic RBC transfusion.

 

 

實施血液細胞回收時修正吸引導致的溶血

Modification of Suction-Induced Hemolysis During Cell Salvage

Jonathan H. Waters, MD*, Brandon Williams, BS{dagger}, Mark H. Yazer, MD, FRCPC{ddagger}, and Marina V. Kameneva, PhD{dagger}||

From the *Department of Anesthesiology, Magee Womens Hospital of University of Pittsburgh Medical center; Departments of {dagger}Bioengineering and {ddagger}Pathology, The Institute for Transfusion Medicine; and ||McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA.

Anesth Analg 2007;104:684-687

背景：實施血液細胞回收時收集紅細胞的有效程度取決於多種因素，包括吸引壓。本研究中，我們試圖確定吸引壓對有效收集紅細胞的影響，並且鑒定吸引對回收血液的影響最小化的方法。

方法：將60mL全血等分放置于燒杯或平皿中，用100或300mm Hg負壓吸引。測定並比較不同條件下的溶血量。將血液用生理鹽水1:1稀釋，重複同樣實驗。

結果：溶血量由0.21%至2.29%不等。用300mmHg負壓從平皿中吸引時，溶血量最大。血液用生理鹽水稀釋後，溶血量降低。因此，從外科手術野吸引回收血液應使用最小的吸引負壓，並儘量減小血液和空氣的接觸面積。

結論：從手術野吸引回收血液時用生理鹽水稀釋，可以明顯減少血液損傷。雖然吸引直接導致的溶血並不多，但吸引時動態血液和空氣接觸面導致的紅細胞損傷，從而不利地影響血液細胞回收的有效性。

（張瑩 譯 馬皓琳 李士通 校）

BACKGROUND: The efficiency of red blood cell collection during cell salvage is dictated by multiple variables, including suction pressure. In this study, we attempted to determine the influence of suction pressure on the efficiency of cell salvage and to identify methods for minimizing the impact of suction on salvaged blood.

METHODS: Whole blood was placed in 60-mL aliquots either in a beaker or on a flat surface and suctioned at 100 and 300 mm Hg. The amount of hemolysis was measured and compared under the varying conditions. The experiments were repeated with the blood diluted with normal saline solution in a 1:1 mix.

RESULTS: Hemolysis ranged from 0.21% to 2.29%. Hemolysis was greatest when whole blood was suctioned from a flat surface at 300 mm Hg. It was reduced when the blood was diluted with saline. Blood suctioned from a surgical field during cell salvage should be done with minimal suction pressures and with the goal of minimizing blood–air interfaces.

CONCLUSIONS: Significant reduction of blood damage can be obtained by diluting blood with normal saline while suctioning it from the surgical field. Although immediate hemolysis due to suctioning was not very high, the red blood cell damage from suctioning produced by a dynamic blood–air interface might adversely affect the efficiency of cell salvage.

 

 

大鼠福馬林試驗中大麻酯受體激動WIN55,212-2和布比卡因之間傷害的協同作用

Antinociceptive Synergy Between the Cannabinoid Receptor Agonist WIN 55,212-2 and Bupivacaine in the Rat Formalin Test

Sinyoung Kang, MD, PhD, Chi Hyo Kim, MD, PhD, Heeseung Lee, MD, Dong Yeon Kim, MD, PhD, Jong In Han, MD, PhD, Rack Kyung Chung, MD, PhD, and Guie Yong Lee, MD, PhD

From the Department of Anesthesiology and Pain Medicine, Ewha Womans University Medical College, Seoul, Korea.

Anesth Analg 2007;104:719-725

背景：大麻酯類和局麻藥之間的鎮痛協同作用尚無研究。我們通過使用福馬林試驗試圖判定鞘內注射大麻酯受體激動(WIN 55,212-2)和布比卡因之間相互作用的特性。

方法：在雄性SD大鼠置入腰段鞘內導管。在鞘內注射WIN 55,212-2、布比卡因或二者混合液之後，將50μL5％的福馬林注入大鼠後爪皮下。繪製量－反應曲線，並確定每一單用藥物各自的ED50 (50％有效量)值。測試固定比例的WIN 55,212-2和布比卡因混合液在福馬林試驗中的聯合傷害效應，並使用等輻射分析法來確定二者的藥理學相互作用。

結果：鞘內注射WIN 55,212-2、布比卡因或二者混合液可在福馬林試驗的1期和2期產生量依賴的退縮數量減少。等輻射分析發現鞘內注射WIN 55,212-2和布比卡因在福馬林試驗的兩個期內都呈協同作用。聯合應用後，ED50值明顯小於理論的相效應值（P<0.05）。

結論：這些結果提示鞘內聯合應用WIN 55,212-2和布比卡因在福馬林兩期均產生協同的傷害相互作用。

（黃施偉 譯，馬皓琳、李士通 校）

BACKGROUND: The analgesic interaction between cannabinoids and local anesthetics has not been investigated. We sought to determine the nature of the interaction between the intrathecal cannabinoid receptor agonist (WIN 55,212-2) and bupivacaine using the formalin test.

METHODS: Lumbar intrathecal catheters were implanted in male Sprague-Dawley rats. After intrathecal administration of WIN 55,212-2, bupivacaine, or their combination, 50 µL of 5% formalin was injected subcutaneously into the hindpaw. Dose–response curves were established and the respective ED50 (50% effective dose) values were determined for each agent alone. Fixed-ratio combinations of WIN 55,212-2 and bupivacaine were tested for combined antinociceptive effects in the formalin test and an isobolographic analysis was performed to characterize the pharmacologic interaction of both drugs.

RESULTS: Intrathecally administered WIN 55,212-2, bupivacaine, or their combination produced a dose-dependent decrease in the number of flinches during Phase 1 and 2 of the formalin test. Isobolographic analysis revealed a synergistic interaction between intrathecal WIN 55,212-2 and bupivacaine in both phases of the formalin test. In combination, the ED50 value was significantly smaller than the theoretical additive value (P < 0.05).

CONCLUSIONS: These results demonstrate that intrathecally coadministered WIN 55,212-2 and bupivacaine provide synergistic antinociceptive interaction in both phases of the formalin test.

 

肺動脈高壓患兒行非心臟手術或心導管術的圍術期併發症

Perioperative Complications in Children with Pulmonary Hypertension Undergoing Noncardiac Surgery or Cardiac Catheterization

Mario J. Carmosino, MD*, Robert H. Friesen, MD*, Aimee Doran, CPNP{dagger}, and Dunbar D. Ivy, MD{dagger}

From the Departments of *Anesthesiology; and {dagger}Pediatrics (Cardiology), The Children’s Hospital and University of Colorado School of Medicine, Denver, Colorado.

Anesth Analg 2007 104: 521-527.

 

背景：肺動脈高壓可導致嚴重的心能不全，被認為與圍術期心血管併發症發生的危險增相關。

方法：作者回顧分析1999年到2004年期間肺動脈高壓患兒行非心臟手術或心導管術期間麻醉或鎮靜的醫學記錄。研究其術中至術後48h之內發生併發症的誘因、類型和相關因素。

結果： 156名患兒（平均年齡4.0歲）共進行了256次手術操作。引起PAH的病因包括特發性的（原發）（56%），先心病（21%），慢性肺病（14%），慢性氣道阻塞（4%）和慢性肝病（4%）。68%病人基礎肺動脈高壓是亞系統的，19%是系統性的，13%是超系統的。麻醉方法：鎮靜（22%），全麻吸入麻醉（58%），全身靜脈麻醉（20%）。8名患兒（5.1%，總運算元的3.1%）發生了較小的併發症。而在行心導管術時有7名患兒（總患兒的4.5%，的心導管運算元的5.0%，占所有操作的2.7%）發生了較嚴重的併發症，包括心臟驟停和肺高壓危象。其中有兩個患兒（患兒的1.3%，操作的0.8%）死于肺高壓危象。通過多數回歸分析顯示超系統肺動脈高壓是較大併發症的重要預測因素（OR=8.1，P=0.02）。而併發症與年齡，PAH的病因，麻醉類型和氣道管理沒有明顯相關性。

結論：患有超系統的PAH患兒圍術期嚴重併發症的風險較大，包括心臟停止和肺高壓危象。

（丁震敏 譯 陳傑 校）

BACKGROUND: Pulmonary arterial hypertension (PAH) can lead to significant cardiac dysfunction and is considered to be associated with an increased risk of perioperative cardiovascular complications.

METHODS: We reviewed the medical records of children with PAH who underwent anesthesia or sedation for noncardiac surgical procedures or cardiac catheterizations from 1999 to 2004. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined.

RESULTS: Two hundred fifty-six procedures were performed in 156 patients (median age 4.0 yr). PAH etiology was 56% idiopathic (primary), 21% congenital heart disease, 14% chronic lung disease, 4% chronic airway obstruction, and 4% chronic liver disease. Baseline pulmonary artery pressure was subsystemic in 68% patients, systemic in 19%, and suprasystemic in 13%. The anesthetic techniques were 22% sedation, 58% general inhaled, 20% general IV. Minor complications occurred in eight patients (5.1% of patients, 3.1% of procedures). Major complications, including cardiac arrest and pulmonary hypertensive crisis, occurred in seven patients during cardiac catheterization procedures (4.5% of patients, 5.0% of cardiac catheterization procedures, 2.7% of all procedures). There were two deaths associated with pulmonary hypertensive crisis (1.3% of patients, 0.8% of procedures). Baseline suprasystemic PAH was a significant predictor of major complications by multivariate logistic regression analysis (OR = 8.1, P = 0.02). Complications were not significantly associated with age, etiology of PAH, type of anesthetic, or airway management.

CONCLUSION: Children with suprasystemic PAH have a significant risk of major perioperative complications, including cardiac arrest and pulmonary hypertensive crisis.

 

圍術期耳電針法對第三磨牙拔除術後的疼痛和鎮痛藥用量沒有影響

Perioperative Auricular Electroacupuncture Has No Effect on Pain and Analgesic Consumption After Third Molar Tooth Extraction

Andrea Michalek-Sauberer, MD*, Harald Heinzl, PhD{dagger}, Sabine M. Sator-Katzenschlager, MD*, Gabriel Monov, MD{ddagger}, Erich Knolle, MD*, and Hans Georg Kress, MD, PhD*

From the *Department of Anesthesiology and General Intensive Care Medicine (B); {dagger}Core Unit for Medical Statistics and Informatics; and {ddagger}Bernhard Gottlieb Department of Oral Surgery, Medical University of Vienna, Austria.

Anesth Analg 2007 104: 542-547.

 

背景：既往研究顯示耳針（AA）能夠緩解急性和慢性疼痛。作者前瞻性、隨機的、雙盲、對照研究了149位患者耳電針（AE）對局麻下行單側下頜第三磨牙拔除術後第一個48小時鎮痛和止痛藥用量的影響。

方法：患者接受耳電針（AE，n=76）或耳針（無電刺激）（AA，n=37），採用2/100Hz的交替電刺激或用金屬盤替代針的假電刺激或無無針電刺激（NN，n=36）。在整個研究過程中AA點為牙穴（1），聲門穴（55），口腔穴（84）。用5級評分法評定疼痛並記錄撲熱息痛500mg片需要量和額外鎮痛藥物甲滅酸500mg的需要量。

結果：疼痛為中等度或更嚴重的平均中位數數(四分位數、下四分位數)分別為：AE組：33%（12%，64%），AA組：22%（6%，56%），NN組：30%（7%，53%），組間無顯著差異。需要撲熱息痛500mg片的平均值（AE組：5.2片（0-12），AA組：4.6片（0-11），NN組：5.4片（0-10）需要額外鎮痛藥甲滅酸的患者比例（AE組:19%，AA組:18%，NN組:19%）也均無明顯差異。

結論：不論AE或AA都不能減輕第三磨牙拔除術的急性疼痛的疼痛度和減少鎮痛藥用量。

（顧新宇 譯 陳傑 校）

BACKGROUND: Auricular acupuncture (AA) has been shown to alleviate acute and chronic pain. We investigated the effects of auricular electroacupuncture (AE) on pain and analgesic drug consumption in the first 48 h after unilateral mandibular third molar tooth extraction under local anesthesia in a prospective, randomized, double-blind, placebo-controlled study in 149 patients.

METHODS: Patients received either AA with electrical stimulation (AE, n = 76) or without (AA, n = 37) electrical stimulation at an alternating frequency of 2/100 Hz or a sham AE with metal plates instead of needles and no electrical stimulation, no-needle (NN, n = 36) at the AA points 1 (tooth), 55 (Shen men) and 84 (mouth) during the entire study period. Regularly rated pain intensity (five-point verbal rating scale), consumption of acetaminophen 500 mg tablets and additional rescue medication with mefenamic acid 500 mg were assessed.

RESULTS: The median fraction of time when pain was rated as moderate or worse (upper and lower quartile): AE: 33% (12%, 64%), AA: 22% (6%, 56%), NN: 30% (7%, 53%) did not differ significantly among the treatment groups. There were no significant differences in mean number of acetaminophen 500 mg tablets (range): AE: 5.2 (0–12), AA: 4.6 (0–11), NN: 5.4 (0–10) or percentage of patients requiring additional mefenamic acid: AE: 19%, AA: 18%, NN: 19%.

CONCLUSION: We conclude that neither AE nor AA alone reduce either pain intensity or analgesic consumption in a molar tooth extraction model of acute pain.

 

一項有關選擇性肌松藥結合——速克美松安全逆轉羅庫溴深度神經肌肉阻滯的隨機量探究的II期研究

A Randomized, Dose-Finding, Phase II Study of the Selective Relaxant Binding Drug, Sugammadex, Capable of Safely Reversing Profound Rocuronium-Induced Neuromuscular Block

Scott B. Groudine, MD*, Roy Soto, MD{dagger}, Cynthia Lien, MD{ddagger}, David Drover, MD, and Kevin Roberts, MD*

From the *Department of Anesthesiology, Albany Medical Center, Albany, New York; {dagger}Health Sciences Center, Stony Brook University Hospital, Stony Brook, New York; {ddagger}Department of Anesthesiology, Weill Medical College of Cornell University/New York Presbyterian Hospital, New York, New York; and Department of Anesthesia, Stanford Medical Center, Stanford, California.

Anesth Analg 2007 104: 555-562.

 

背景：逆轉深度神經肌肉阻滯仍是臨一個重要的課題。速克美松是一個改良的γ環精，與甾體類神經肌肉阻滯藥結合，促其從煙鹼樣受體解離。速克美松是第一個選擇性肌松藥結合。

方法： 50名患者入選速克美松II期的效能和安全範圍的研究。受試者接受氧化亞氮和丙酚麻醉，隨機分組分別給予羅庫溴0.6mg/kg或1.2mg/kg，並給予0.5，1.0，2.0，4.0或8.0mg/kg之一量的速克美松。使用的神經肌肉監測儀是TOF Watch SX®速度儀。TOF≥0.9定義為肌松恢復。均在強直後計數為1或2的深度阻滯狀態下應用速克美松。

結果：除了低量的組（0.5－1.0mg/kg）部分受試者肌松未能充分逆轉外，其餘應用速克美松的受試者的神經肌肉阻滯作用均被逆轉。在速克美松2mg/kg組中，所有的受試者均得以充分逆轉，但恢復時間具有明顯的異性（1.8－15.20min）。肌松逆轉有量依賴性時間異性減小和逆轉速度提高。大量組（8mg/kg）平均恢復時間為1.2min（範圍0.8－2.1min）。研究中無嚴重副作用。

結論：速克美松耐受良好、可迅速有效地逆轉深度羅庫溴神經肌肉阻滯。隨著量的增，平均恢復時間縮短。羅庫溴誘導的深度神經肌肉阻滯可被速克美松（≥2mg/kg）有效逆轉。

（衛紅 譯 陳傑 校）

BACKGROUND: The reversal of a deep neuromuscular blockade remains a significant clinical problem. Sugammadex, a modified {gamma}-cyclodextrin, encapsulates steroidal neuromuscular blocking drugs, promoting their rapid dissociation from nicotinic receptors. Sugammadex is the first drug that acts as a selective relaxant binding agent.

METHODS: We enrolled 50 patients into a Phase II dose-finding study of the efficacy and safety of sugammadex. Subjects, anesthetized with nitrous oxide and propofol, were randomized to one of two doses of rocuronium (0.6 or 1.2 mg/kg) and to one of five doses of sugammadex (0.5, 1.0, 2.0, 4.0, or 8.0 mg/kg). Neuromuscular monitoring was performed using the TOF Watch SX® acceleromyograph. Recovery was defined as a train-of-four ratio 0.9. Sugammadex was administered during profound block when neuromuscular monitoring demonstrated a posttetanic count of one or two.

RESULTS: Reversal of neuromuscular block was obtained after administration of sugammadex in all but the lowest dose groups (0.5–1.0 mg/kg) where several subjects could not be adequately reversed. At the 2 mg/kg dose all patients were reversed with sugammadex, but there was significant variability (1.8–15.2 min). Patient variability decreased and speed of recovery increased in a dose-dependent manner. At the highest dose (8 mg/kg), mean recovery time was 1.2 min (range 0.8–2.1 min). No serious adverse events were reported during this trial.

CONCLUSIONS: Sugammadex was well tolerated and effective in rapidly reversing profound rocuronium-induced neuromuscular block. The mean time to recovery decreased with increasing doses. Profound rocuronium-induced neuromuscular block can be reversed successfully with sugammadex at doses 2 mg/kg.


速克美松：臨神經肌肉藥理學的另一個里程碑

Sugammadex: Another Milestone in Clinical Neuromuscular Pharmacology

Mohamed Naguib, MB, BCh, MSc, FFARCSI, MD

From the Department of Anesthesiology and Pain Medicine, Unit 409, Anderson Cancer Center, The University of Texas M. D., Houston, Texas.

Anesth Analg 2007 104: 575-581.

近期正在進行III期臨試驗的速克美松，作為革命性的處於實驗研究的拮藥物，引入臨實踐可能會改臨神經肌肉藥理學的局面。速克美松——一種經修飾的γ－環精——與甾體類神經肌肉阻斷以1比1比例（羅庫溴>維庫溴>>潘庫溴）形成相當緻密的水溶性複合物來發揮作用。在羅庫溴誘發的神經肌肉阻斷中，靜脈給予速克美松會形成一濃度梯度化使羅庫溴分子從神經肌接頭重新進入血漿，使神經肌接頭快速恢復活性。速克美松沒有生物學活性，不與血漿蛋白結合，使用安全而且有很好的耐受性。此外，其對乙醯膽鹼酯酶或體內其他任何受體系統都不起作用。作為一拮該複合物的效能並不取決於該環精複合物的經腎臟排泄率。人體與動物研究證實，在不存在肌無的情況下，速克美松能逆轉由羅庫溴生產的程度相當深的神經肌肉阻斷，因而對增患者安全有利。速克美松同樣有利於使用羅庫溴進行的快速麻醉誘導，它能提供比1.0mg/kg琥珀醯膽鹼更好的快速的起效和終效。而且不需要另膽鹼酯酶制和膽鹼能藥來拮殘餘神經肌肉阻斷作用，意味著不會產生由於使用這些藥物而生產的心血管和其他的一些副作用。臨使用速克美松能避免羅庫溴和甾體類神經肌肉阻斷的拮所產生的缺點。

（衛紅 譯 陳傑 校）

Sugammadex is a revolutionary investigational reversal drug currently undergoing Phase III testing whose introduction into clinical practice may change the face of clinical neuromuscular pharmacology. A modified {gamma}-cyclodextrin, sugammadex exerts its effect by forming very tight water-soluble complexes at a 1:1 ratio with steroidal neuromuscular blocking drugs (rocuronium > vecuronium >> pancuronium). During rocuronium-induced neuromuscular blockade, the IV administration of sugammadex creates a concentration gradient favoring the movement of rocuronium molecules from the neuromuscular junction back into the plasma, which results in a fast recovery of neuromuscular function. Sugammadex is biologically inactive, does not bind to plasma proteins, and appears to be safe and well tolerated. Additionally, it has no effect on acetylcholinesterase or any receptor system in the body. The compound's efficacy as an antagonist does not appear to rely on renal excretion of the cyclodextrin-relaxant complex. Human and animal studies have demonstrated that sugammadex can reverse very deep neuromuscular blockade induced by rocuronium without muscle weakness. Its future clinical use should decrease the incidence of postoperative muscle weakness, and thus contribute to increased patient safety. Sugammadex will also facilitate the use of rocuronium for rapid sequence induction of anesthesia by providing a faster onset-offset profile than that seen with 1.0 mg/kg succinylcholine. Furthermore, no additional anticholinesterase or anticholinergic drugs would be needed for antagonism of residual neuromuscular blockade, which would mean the end of the cardiovascular and other side effects of these compounds. The clinical use of sugammadex promises to eliminate many of the shortcomings in our current practice with regard to the antagonism of rocuronium and possibly other steroidal neuromuscular blockers.

 

自主呼吸期間氧氣清除術用於測定能殘氣量的準確性研究。

The Accuracy of the Oxygen Washout Technique for Functional Residual Capacity Assessment During Spontaneous Breathing

Hermann Heinze, MD*, Bernhard Schaaf, MD{dagger}, Jochen Grefer, MD*, Karl Klotz, MD*, and Wolfgang Eichler, MD*

From the Departments of *Anesthesiology and {dagger}Medicine III, University of Luebeck, Luebeck, Germany.

Anesth Analg 2007 104: 598-604.

 

背景:能殘氣量（FRC）的測定對於肺損傷病人監測有著重要意義。儀器的缺乏妨礙了常規FRC的測定。最近有一種簡易自動的利用氧氣清除的FRC測定方法。本研究擬評估氧氣清除術用於測定FRC的準確性。

方法：LUFU系統（Draeger，Luebeck，Germany）用於評估氧氣清除術測定FRC，是一種可的多重呼吸氮清除儀。這種術使用一種旁流氧氣分析儀測定從吸氣末到呼氣末期間的FiO2快速化來計算FRC。運用了三種方法測定23名健康的、自主呼吸的、坐姿的志願者的FRC：1）氦氣稀釋法（FRC－He），2）軀體體積描計法（FRC－bp），3）氧氣清除法（FRC－O2）。

結果：FRC－O2（平均4.1±1.1L，範圍2.4－6.9L）與FRC－He（平均4.0±1.0L，範圍2.4－6.2L；偏移FRC－O2：－0.2±0.4L）和FRC－bp（平均4.2±1.0L，範圍2.8－6.1L；偏移FRC－O2：0.1±0.6L）化一致。

結論：在自主呼吸的健康志願者中，與FRC－He、FRC－bp比較，使用LUFU系統的氧氣清除術測定FRC的偏移和精確度可被臨接受。

（衛紅 譯 陳傑 校）

BACKGROUND: Measurement of functional residual capacity (FRC) is of considerable interest for monitoring patients with lung injury. The lack of instruments has impeded routine bedside FRC measurement. Recently, a simple automated method for FRC assessment by O2 washout has been introduced. We designed this study to evaluate the accuracy of FRC measurement using the O2 washout technique.

METHODS: The LUFU system (Draeger, Luebeck, Germany) estimates FRC by O2 washout, a variant of multiple breath nitrogen washout. This technique uses a sidestream O2-analyzer to calculate FRC from end-inspired and end-expired O2 concentrations during fast changes of Fio2. We measured FRC in 23 healthy, spontaneously breathing volunteers in the sitting position using three techniques: 1) helium dilution (FRC-He), 2) body plethysmography (FRC-bp), 3) oxygen washout (FRC-O2).

RESULTS: FRC-O2 (mean 4.1 ± 1.1 L, range 2.4–6.9 L) corresponds with FRC-He (mean 4.0 ± 1.0 L, range 2.4–6.2 L; bias of FRC-O2: –0.2 ± 0.4 L) and FRC-bp (mean 4.2 ± 1.0 L, range 2.8–6.1 L; bias of FRC-O2: 0.1 ± 0.6 L).

CONCLUSIONS: The bias and precision of the O2 washout technique using the LUFU system were clinically acceptable when compared with FRC-He and FRC-bp for FRC assessment in spontaneously breathing volunteers.


關於麻醉前門診，資整合手術室內滯留:對執業麻醉醫師的調查結果

Preanesthesia Clinics, Information Management, and Operating Room Delays: Results of a Survey of Practicing Anesthesiologists

Natalie F. Holt, MD, MPH*, David G. Silverman, MD*, Ravindra Prasad, MD{dagger}, James Dziura, PhD, MPH{ddagger}, and Keith J. Ruskin, MD*

From the Departments of *Anesthesiology and Neurosurgery, Yale University School of Medicine; {ddagger}Department of Biostatistics, General Clinical Research Center, Yale University School of Medicine, New Haven, Connecticut; {dagger}Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and ||ASA Committee on Electronic Media and Information Technology, American Society of Anesthesiologists, Park Ridge, Illinois.

Anesth Analg 2007 104: 615-618.

 

背景：麻醉前門診（PECs）的目的之一是確保病人做好充分的術前準備，從而降低日間手術延遲或臨時取消的發生率。在一些單中心研究中，已證實了PECs的積極作用。然而，關於其整體的使用和有效性的資料尚有限。

方法：作者給參2005年美國麻醉學年會的出席者分發了一份調查問卷。問卷介紹了PECs在國內的普率其最常見的工作方式，並要求應答者論述PEC訪視對降低因患者資缺失而造成的日間手術延誤的發生率的影響。

結果：有1857份問卷返回。其中79％的應答者在設有PEC的醫療機構工作。57％的應答者指出，在沒有進行麻醉前評估的日間手術病人中，每10人中至少有1人手術延遲。而在術前進行麻醉前PEC訪視的病人中，有23％的應答者報了相同的手術延誤率。

結論：無論是否進行麻醉前評估，由於病人資的缺失導致日間手術延遲的發生仍較為普遍。導致手術延遲的原因可能包括資傳遞有誤，對於術前準備缺乏一致的標準或其他制度的因素。

（印潔敏 譯 陳傑 校）

BACKGROUND: One purpose of preanesthesia evaluation clinics (PECs) is to decrease the incidence of day-of-surgery delays and cancellations by ensuring that patients are medically ready for surgery. In several single-center studies, PECs have been shown to have a positive impact. However, limited information is available regarding their overall use and perceived effectiveness.

METHODS: A survey was distributed to attendees of the 2005 Annual Meeting of the American Society of Anesthesiologists. The survey addressed the national prevalence of PECs and the most common methods for referral to them. Respondents were also asked to address the impact of PEC visits on perceived prevalence of day-of-surgery delays caused by missing patient information.

RESULTS: One thousand eight hundred fifty-seven surveys were returned. Sixty- nine percent of respondents worked at institutions with a PEC. Fifty-seven percent of respondents indicated that delays occur in at least 1 in 10 patients not seen for preanesthesia evaluation prior to the day of surgery. For patients who had a PEC visit prior to surgery, the same frequency of delays was reported by 23% of respondents.

CONCLUSIONS: Day-of-surgery delays caused by missing information remain relatively common despite preanesthesia evaluation. Possible causes for these delays include failures of information transfer, lack of consensus on criteria for surgical readiness, or other institutional factors.


慢性態反應哮喘模型中七氟醚麻醉對肺學與組織學的影響

Lung Mechanics and Histology During Sevoflurane Anesthesia in a Model of Chronic Allergic Asthma

Shirley Moreira Burburan, MD, MSc*{dagger}, Debora Gonçalves Xisto, RRT{dagger}, Halina Cidrini Ferreira, RRT{ddagger}, Douglas dos Reis Riva{ddagger}, Giovanna Marcella Cavalcante Carvalho{ddagger}, Walter Araujo Zin, MD, PhD{ddagger}, and Patricia Rieken Macêdo Rocco, MD, PhD{dagger}

From the *Division of Anesthesiology, Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro; and Laboratories of {dagger}Pulmonary Investigation and {ddagger}Respiration Physiology, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.

Anesth Analg 2007 104: 631-637.

 

背景：尚沒有研究證實七氟醚在慢性炎症和氣道重塑中的作用，例如哮喘發作中出現的情況，本文作者研究了七氟醚麻醉在慢性態反應性哮喘中對呼吸的影響，研究肺學並分析肺的形態改，從而判定生理學的改是否可以反映潛在的形態改。

方法： 36例BALB/c小鼠（重為20-25g）隨機分為4組。在卵清蛋白（OVA）組，卵清蛋白致敏小鼠接受反復卵清蛋白刺激；SAL組，用生理鹽水替代卵清蛋白。在最後一次刺激之後的24h，小鼠接受巴比妥鈉（PENTO，20mg/Kg i.p.）或七氟醚(SEVO,1MAC)麻醉。用肺膨脹末阻斷法分析肺的靜態順應性（Est），阻（{Delta}P1），粘彈性/異性（{Delta}P2），最後將肺臟固定和染色以分析其組織學的化。

結果：在OVASEVO組的動物{Delta}P1（38%），{Delta}P2（24%）和Est（22%）均低於OVAPENTO組。在組織學方面，OVASEVO組的動物氣道擴張（16%）更明顯，而肺泡塌陷度（25%）則較後組低。在SALSEVO組的動物{Delta}P1（35%）低於SALPENTO組，而前者的氣道直徑（12%）則大於後者。

結論；對於慢性態反應哮喘，七氟醚作用於主氣道與肺周圍氣道，降低{Delta}P 1，{Delta}P 2與Est。

（宋翠俠 譯 陳傑 校）

BACKGROUND: There are no studies examining the effects of sevoflurane on a chronically inflamed and remodeled airway, such as that found in asthma. In the present study, we sought to define the respiratory effects of sevoflurane in a model of chronic allergic asthma. For this purpose, pulmonary mechanics were studied and lung morphometry analyzed to determine whether the physiological modifications reflected underlying morphological changes.

METHODS: Thirty-six BALB/c mice (20–25 g) were randomly divided into four groups. In OVA groups, mice were sensitized with ovalbumin and exposed to repeated ovalbumin challenges. In SAL groups, mice received saline using the same protocol. Twenty-four hours after the last challenge, the animals were anesthetized with pentobarbital sodium (PENTO, 20 mg/kg i.p.) or sevoflurane (SEVO, 1 MAC). Lung static elastance (Est), resistive ({Delta}P1) and viscoelastic/inhomogeneous ({Delta}P2) pressure decreases were analyzed by an end-inflation occlusion method. Lungs were fixed and stained for histological analysis.

RESULTS: Animals in the OVASEVO group showed lower {Delta}P1 (38%), {Delta}P2 (24%), and Est (22%) than animals in the OVAPENTO group. Histology demonstrated greater airway dilation (16%) and a lower degree of alveolar collapse (25%) in the OVASEVO compared with OVAPENTO group. {Delta}P1 was lower (35%) and airway diameters larger (12%) in the SALSEVO compared with SALPENTO group.

CONCLUSION: Sevoflurane anesthesia acted both at airway level and lung periphery reducing ({Delta}P1 and {Delta}P2 pressures, and Est in chronic allergic asthma.


靜注尼卡地平和前列腺素E1對兔主動脈鉗閉開放後引起的大腦軟腦膜微動脈收縮效應作用的比較研究　　

The Comparative Effects of Intravenous Nicardipine and Prostaglandin E1 on the Cerebral Pial Arteriolar Constriction Seen After Unclamping of an Aortic Cross-Clamp in Rabbits

Masahiko Kumazawa, MD*, Hiroki Iida, MD*, Masayoshi Uchida, MD{dagger}, Mami Iida, MD{ddagger}, Motoyasu Takenaka, MD*, and Shuji Dohi, MD*

From the Departments of *Anesthesiology and Pain Medicine, and {ddagger}Cardiology, Gifu University Graduate School of Medicine, Gifu City, Gifu; {dagger}Department of Anesthesia, Chubu Rosai Hospital, Nagoya; and Department of Nutrition and Food Science, Faculty of Home Economics, Gifu Women's University, Gifu, Japan.

Anesth Analg 2007 104: 659-665. [

 

背景：主動脈手術期間，強血管擴張尼卡地平和前列腺素E1常用於處理系統性高血壓或肺高壓。

方法：通過閉合兔顱腦窗分別在以下時間點測量軟腦膜微動脈地直徑：在用藥前、用藥後15min、主動脈鉗閉即刻、鉗閉後20min主動脈開放後0-60min。分別用以下藥物：靜注0.9%生理鹽水（對照組）；尼卡地平（量分別為在0.1，1.0，或10ug.kg-1.min-1），或PGE1（量分別為0.1，1.0，或10ug.kg-1.min-1）。

結果：在開放夾閉的主動脈後，大腦微動脈地直徑在對照組顯著縮小，且持續了至少60min，在60min時，與基礎相比，大的微動脈（R＞75um）的直徑縮小了16%，小的微動脈（R＜75um）的直徑縮小了27%。小量的尼卡地平對主動脈開放後引起地反射性血管收縮效應沒有影響，大量地尼卡地平顯著地弱了大小微動脈的血管收縮作用（在60min時，大的微動脈直徑縮小6%－10%，小的微動脈直徑收縮10%－18%）。而在開放夾閉的主動脈之後的5分鐘甚至更長時間內，相對於對照組靜注PGE1對軟腦膜大小微動脈收縮效應無顯著影響。

結論：大量的尼卡地平可以弱主動脈開放引起的軟腦膜微動脈的收縮作用，而PGE1無此效應。

（鄭麗 譯 陳傑 校）

BACKGROUND: The potent vasodilators nicardipine and prostaglandin E1 (PGE1) are useful for the treatment of systemic hypertension or pulmonary hypertension during aortic surgery.

METHODS: We measured cerebral pial arteriolar diameters, using a rabbit closed cranial window preparation: before (baseline) and 15 min after the start of an IV infusion (preclamp) (0.9% saline [control group], nicardipine [at 0.1, 1.0, or 10 µg·kg–1·min–1], or PGE1 [at 0.1 or 1.0 µg·kg–1·min–1]), just after aortic clamping, 20 min after clamping, and at 0–60 min after unclamping.

RESULTS: In the control group, a significant decrease in diameter persisted for at least 60 min after unclamping (maximum [at 60 min], –16% for large [75 µm], and –27% for small [<75 µm] arterioles versus baseline). Although the aortic unclamping-induced vasoconstriction was unaffected under the smallest dose of nicardipine, it was significantly attenuated under larger doses in both large and small arterioles (residual vasoconstriction, –10% and –6% for large and –18% and –10% for small arterioles; at 60 min). The pial arteriolar constriction observed at 5 min or more after unclamping in the control group was not altered by PGE1 in either large or small arterioles.

CONCLUSIONS: The larger doses of nicardipine, but neither dose of PGE1, attenuated aortic unclamping-induced sustained cerebral pial arteriolar constriction.



麻下行剖宮產患者中預防性使用格拉司並不能預防產後噁心嘔吐

The Prophylactic Granisetron Does Not Prevent Postdelivery Nausea and Vomiting During Elective Cesarean Delivery Under Spinal Anesthesia

Mrinalini Balki, MD, Shilpa Kasodekar, MD, Sudhir Dhumne, MD, and Jose C. A. Carvalho, MD, PhD

From the Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Ontario, Canada.

Anesth Analg 2007 104: 679-683.

背景：區域麻醉下剖宮產患者圍手術期的噁心嘔吐受諸多因素影響，預防性嘔吐措施是否有效仍有爭論。在這個實驗中，作者嘗試著嚴格控制其他誘發因素來確定預防性使用格拉司是否對於麻下行剖宮產的患者能起到預防圍手術期噁心嘔吐的作用。

方法：這個隨機，雙盲，安慰對照研究中，共入組176名產婦。在靜脈輸入10ml/kg的林格氏平衡液後，用0.75%重比重布比卡因15mg,，太尼10ug，嗎啡100ug進行麻。通過使用一定量的新福林，將患者的血壓維持在基礎水準。分娩後靜注縮宮素0.5IU並持續靜脈輸注。在鉗閉臍帶後，給予格拉司1mg或等量的生理鹽水。如果出現持續的噁心嘔吐則靜注苯海拉明50mg。統計產後噁心嘔吐的發生率，需要急嘔吐、低血壓、疼痛和其他副作用的發生率。

結果：在使用格拉司嘔吐組中，產後噁心嘔吐發身生率為20.4%，對照組為17.0%(P=0.56，NS)。術中低血壓的發生率，分娩前為9.6%，分娩後為6.2%,兩組相近。術中疼痛（2.2%對4.5%，P=0.68）和需要急嘔吐(8%對6.8%，P=0.77)的發生率兩組均相似。

結論：儘管嚴格控制了多種可能導致嘔吐的因素，選擇性剖宮產患者圍術期噁心嘔吐的發生率仍高達18%，且在本研究情況下預防性使用格拉司1mg對產後噁心嘔吐無效。

（李惟一 譯 陳傑 校）

BACKGROUND: Intraoperative nausea and vomiting (IONV) during cesarean delivery (CD) under regional anesthesia has multiple etiologies, and the role of prophylactic antiemetics for prevention of IONV remains controversial. In this trial we sought to determine the efficacy of granisetron for prevention of IONV during elective CD under spinal anesthesia with strict control of the causative factors.

METHODS: The study was conducted as a randomized, double-blind, placebo-controlled trial in 176 parturients. After administration of 10 mL/kg of lactated Ringer’s solution, spinal anesthesia was administered with 0.75% hyperbaric bupivacaine 15 mg, fentanyl 10 µg, and morphine 100 µg. Systolic blood pressure was maintained at 100% of baseline with aliquots of phenylephrine. Oxytocin 0.5 IU was administered IV upon delivery followed by a maintenance infusion. The patients received either granisetron 1 mg or normal saline IV immediately after cord clamping. In case of persistent IONV, rescue dimenhydrinate 50 mg IV was administered. The primary outcome was the presence of postdelivery IONV. Secondary outcomes included the need for rescue antiemetic, hypotension, pain, and adverse effects.

RESULTS: The incidence of postdelivery IONV was 20.4% in the granisetron group and 17.0% in the control group (P = 0.56, NS). The incidence of intraoperative hypotension, pre- (9.6%) and postdelivery (6.2%), was similar in both groups. The incidence of postdelivery pain (2.2% vs 4.5%, P = 0.68) and the requirement for rescue antiemetic (8% vs 6.8%, P = 0.77) were similar in the granisetron and control groups.

CONCLUSIONS: Despite strict control of the causative factors, IONV still affects 18% of patients undergoing elective CD, and prophylactic granisetron 1 mg is ineffective under the studied circumstances.


10. 慢性疼痛醫學中有關健康的生活品質的入門文書

A Primer on Health-Related Quality of Life in Chronic Pain Medicine

Thomas R. Vetter, MD

From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana.

Anesth Analg 2007 104: 703-718.

背景：疼痛是一個複雜又獨特的經歷，病人常常很難用傳統的疼痛強度等級來完全描述。健康的生活品質是一種附的尺度，可以用它來評估病人對慢性疼痛經歷的主觀看法和對生活的不良影響。健康的生活品質包括健康的各個方面和病人認為的幸福的各個方面，特別是他們的身體的，情感的，認知的能，和他們在家庭、工作場所和社區參有意義的活動的能。

方法： 通過系統研究醫學文獻形成測量方法形成文書並用於健康生活品質評估中驗證。將這些方法用於慢性疼痛醫學的臨實踐和研究中。

結果：這一入門文書提供了全面的健康生活品質觀念，可用於各種各樣的對成年人健康生活品質的測量，也可用於遭受慢性疼痛的兒童和青少年。

結論：作者使用的方法能夠用於常規地評估成年人和小兒的慢性疼痛醫學方面的健康生活品質。然而，需進一步研究促進廣泛應用並克服障礙。基於有效檢測健康生活品質的方法對於有價值的分析和正式的決策分析模型是必須的。

（張美榮 譯 陳傑 校）

BACKGROUND: Pain is a complex and individual experience that is often difficult for patients to fully describe using a conventional pain intensity scale. Health-related quality of life is an additional metric by which to assess patients’ subjective perspective on their chronic pain experience and its adverse effect on their lives. Health-related quality of life encompasses those aspects of health and well-being valued by patients, specifically, their physical, emotional, and cognitive function, and their ability to participate in meaningful activities within their family, workplace, and community.

METHODS: A methodical search of the medical literature was undertaken to identify the most commonly applied health-related quality of life measurement instruments. These measurement instruments were then assessed within the context of chronic pain medicine clinical practice and research.

RESULTS: This primer provides an overview of the concept of health-related quality of life as a clinical measurement and the specific means by which to measure health-related quality of life across various cultures in adults, as well as in children and adolescents, suffering from chronic pain conditions.

CONCLUSIONS: We have the ability and impetus to routinely assess adult and pediatric health-related quality of life in chronic pain medicine. However, further attention needs to be focused on overcoming barriers to the more widespread measurement of health-related quality of life. A valid preference-based, utility measure of health-related quality of life is a requirement for performing a cost-utility (cost-effectiveness) analysis and undertaking formal decision analysis modeling.

 

雙側髂腹股溝神經阻滯可以減少非腹腔鏡婦科手術的女性患者的嗎啡用量

Bilateral Ilioinguinal Nerve Block Decreases Morphine Consumption in Female Patients Undergoing Nonlaparoscopic Gynecologic Surgery

Fabienne Oriola, MD*, Yannick Toque, MD*, Anne Mary, MD*, Odile Gagneur, MD{dagger}, Sadek Beloucif, MD, PhD*, and Hervé Dupont, MD, PhD*

From the *Department of Anesthesiology B and Medical and Surgical ICU and {dagger}Department of Gynecologic Surgery, Amiens University Hospital, Amiens, France.

Anesth Analg 2007 104: 731-734.

背景：雙側髂腹股溝神經阻滯對婦科手術尤其是子宮切除術患者術後的疼痛控制可能有利。

方法：作者進行了一項前瞻性、隨機、雙盲研究，將患者分為阻滯組——羅呱卡因＋可樂定和對照組——生理鹽水。比較其術後兩天的嗎啡使用量。所有患者都接受預防性給予止吐藥物和多模式靜脈鎮痛。

結果：隨機選擇70名患者，阻滯組在術後兩天的嗎啡使用量較對照組低51％（21±9mg比41±24mg，P<0.0001）。這種差異不僅在於嗎啡使用量，而且表現為兩天后的差異。兩組患者的視覺類比評分是一致的，嗎啡的副作用無差異。

結論：子宮切除術後雙側髂腹股溝神經阻滯減少術後兩天一的嗎啡用量，而嗎啡副作用方面無差異。

（詹慧 譯 陳傑 校）

BACKGROUND: Bilateral ilioinguinal nerve block may be useful to control postoperative pain in gynecologic surgery, especially hysterectomy.

METHODS: In a prospective, randomized, double-blind study, we compared the combination of ropivacaine and clonidine (block group) versus saline (control group). The main objective of this study was to compare the total dose of morphine required during the first two postoperative days. All patients received antiemetic prophylaxis and multimodal IV analgesia.

RESULTS: Seventy patients were randomized. The total morphine consumption during the first two postoperative days was decreased by 51% in the block group compared with the control group (21 ± 9 mg vs 41 ± 24 mg, P < 0.0001). This difference was not only due to morphine titration, but remained significant over the following 2 days. The course of the visual analog scale was equivalent between the two groups. No difference was observed in the side effects of morphine.

CONCLUSION: The use of bilateral ilioinguinal nerve block for postoperative analgesia after hysterectomy decreased morphine consumption by one-half during the first two postoperative days without differences in side effects from morphine between groups.


嬰兒兒童的麻醉藥物使用

Use of Anesthetic Agents in Neonates and Young Children (Special Article)

R. Daniel Mellon, PhD, Arthur F. Simone, MD, PhD, and Bob A. Rappaport, MD From the Division of Anesthesia, Analgesia, and Rheumatology Products, Office of Drug Evaluation II, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Department of Health and Human Services, Silver Spring, Maryland.

Anesth Analg 2007 104: 509-520.

 

背景：一些鎮靜和麻醉藥物的使用在幼小動物模型產生了病理性中樞神經系統改。這些觀測結果引起了關於這些藥物在兒科患者的使用的關注。我們總結了在發育中的動物身的發現，並記錄了食品藥品管理局（FDA）其他組織對兒科患者潛在風險進行評估的步驟。食品藥品管理局認為這是與麻醉協會就關注這一問題展開的一次意見交換。

方法：我們查閱了測試常用的麻醉藥物對發育中的大腦的神經毒性作用的動物研究文獻。調查策略包括在下列常用和特定術語中交叉神經毒性和神經細胞凋亡這兩個關鍵字：麻醉、N-甲基-D-天門冬氨酸（NMDA）、克他命、咪達唑侖、蘿拉西泮、太尼、美沙醇、嗎啡、meperidine、異氟醚、笑氣、七氟醚、氟烷、恩氟烷、地氟醚、異丙酚、依託醚酯、巴比妥、甲氧氟烷和氯胺酮。我們總結了一些由食品藥品管理局發起的老鼠和猴子的研究，最初是測試克他命作為一典型麻醉藥誘發發育大腦的神經退行性化的潛在風險。

結果：眾多的齧齒類動物研究顯示NMDA受體拮包括克他命會誘發發育大腦的神經退行性化。克他命的效應是量依賴性的。資料提示限制暴露可以限制神經退的潛在風險。還有證據顯示其他常用麻醉藥如異氟醚可以在齧齒類模型誘發神經退，在同時使用咪達唑侖或笑氣時可能這一效應。幾乎沒有關於檢測神經退潛在的能結果的動物模型的記錄。然而，有人報導了齧齒類動物的細微但卻長期的行為改的研究。雖然導致神經退的克他命的用藥量和時間略大於臨實際，但是異氟醚卻不是這樣。還沒有足夠的活體試驗資料支援或反駁這些發現的臨適用性。

結論：動物研究顯示神經退伴隨可能的認知改對於嬰兒和小兒患者麻醉藥物的應用是一項長期的潛在風險。現有的非臨資料提示不僅NMDA受體拮還有其他強γ-氨基酸信號轉換的藥物對發育的大腦有潛在的神經毒性。聯合用藥的潛在風險啟動受體系統或強減輕神經毒性還未知。然而現有的非臨資料顯示一些聯合用藥的毒性大於任何的單獨應用。資料資料的缺乏使我們無法指出哪些麻醉藥物更為安全。持續的幼年動物的研究將提供關於風險問題的進一步的資。FDA期望與麻醉協會和藥品行業合作發展進一步評估麻醉藥物對嬰兒和小兒安全性的策略，以提供資料資料指導臨為兒科患者作出盡可能可靠的麻醉藥物選擇。

（王時來譯 薛張綱校）

BACKGROUND: Some drugs used for sedation and anesthesia produce histopathologic central nervous system changes in juvenile animal models. These observations have raised concerns regarding the use of these drugs in pediatric patients. We summarized the findings in developing animals and describe the steps that the Food and Drug Administration (FDA) and others are taking to assess potential risks in pediatric patients. The FDA views this communication as opening a dialog with the anesthesia community to address this issue.

METHODS: We reviewed the available animal studies literature examining the potential neurotoxic effects of commonly used anesthetic drugs on the developing brain. The search strategy involved crossing the keywords neurotoxic and neuroapoptosis with the following general and specific terms: anesthetic, N-methyl-d-aspartate (NMDA), ketamine, midazolam, lorazepam, fentanyl, methadone, morphine, meperidine, isoflurane, nitrous oxide, sevoflurane, halothane, enflurane, desflurane, propofol, etomidate, barbiturate, methoxyflurane, and chloral hydrate. We summarized several studies sponsored by the FDA in rats and monkeys, initially examining the potential for ketamine, as a prototypical agent, to induce neurodegeneration in the developing brain.

RESULTS: Numerous animal studies in rodents indicate that NMDA receptor antagonists, including ketamine, induce neurodegeneration in the developing brain. The effects of ketamine are dose dependent. The data suggest that limiting exposure limits the potential for neurodegeneration. There is also evidence that other general anesthetics, such as isoflurane, can induce neurodegeneration in rodent models, which may be exacerbated by concurrent administration of midazolam or nitrous oxide. There are very few studies that have examined the potential functional consequences of the neurodegeneration noted in the animal models. However, the studies that have been reported suggest subtle, but prolonged, behavioral changes in rodents. Although the doses and durations of ketamine exposure that resulted in neurodegeneration were slightly larger than those used in the clinical setting, those associated with isoflurane were not. There are insufficient human data to either support or refute the clinical applicability of these findings.

CONCLUSIONS: Animal studies suggest that neurodegeneration, with possible cognitive sequelae, is a potential long-term risk of anesthetics in neonatal and young pediatric patients. The existing nonclinical data implicate not only NMDA-receptor antagonists, but also drugs that potentiate {gamma}-aminobutyric acid signal transduction, as potentially neurotoxic to the developing brain. The potential for the combination of drugs that have activity at both receptor systems or that can induce more or less neurotoxicity is not clear; however, recent nonclinical data suggest that some combinations may be more neurotoxic than the individual components. The lack of information to date precludes the ability to designate any one anesthetic agent or regimen as safer than any other. Ongoing studies in juvenile animals should provide additional information regarding the risks. The FDA anticipates working with the anesthesia community and pharmaceutical industry to develop strategies for further assessing the safety of anesthetics in neonates and young children, and for providing data to guide clinicians in making the most informed decisions possible when choosing anesthetic regimens for their pediatric patients.

 

 

可樂定對兒童術後外周神經阻滯鎮痛的影響

The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children

 

Giovanni Cucchiaro and Arjunan Ganesh

Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.

Anesth Analg 2007 104: 532-537

 

背景：可樂定對外周神經阻滯術後感覺神經阻斷的持續時間的影響是有爭議的。我們評價了可樂定對兒童各類外周神經阻滯術後感覺和運動神經阻斷的持續時間和疼痛時間的影響。

方法：我們回顧了從2002年10月至2005年12月間費城兒童醫院的部分記錄，其中包含為兒童術後鎮痛行鎖骨臂叢、腰叢、骨神經、髂腰筋膜或坐骨神經阻滯的記錄。這些病人在術後即出院。

結果：215例病人(47%)應用布比卡因或羅呱卡因的區域麻醉(LA)，220例病人(53%)應用區域麻醉用可樂定(LAC)。感覺神經阻滯的持續時間在LAC 組(17.2 +/- 5 h)中明顯要比LA 組 (13.2 +/- 5 h) (P = 0.0001)得長.阻滯持續時間的增與外周神經阻滯的方式。運動神經阻滯的持續時間在LAC 組(9.6 +/- 5 vs 4.3 +/- 4 h, P = 0.014)中明顯要長.在LAC組中兩名病人和LA組中一名病人出現長時間的阻滯區域麻木（最長72小時）。未觀察到皮膚感覺異常和不悅異常感。

結論:布比卡因和羅呱卡因中用可樂定可以延長感覺神經阻滯的時間，增強運動神經阻滯的範圍。

（ 陳勇柱譯 薛張綱校）

BACKGROUND: The effect of clonidine on the duration of sensory blockade after peripheral nerve blockade is controversial. We evaluated the effects of clonidine on the duration of sensory and motor block and analgesia time in children who underwent a variety of peripheral nerve blocks.

METHODS: We reviewed the regional anesthesia database that contains data on children

who underwent an infraclavicular, lumbar plexus, femoral, fascia iliaca or sciatic nerve block for postoperative analgesia at The Children's Hospital of Philadelphia between October 2002 and December 2005. Patients were prospectively followed after the nerve block.

RESULTS: Two hundred fifteen patients (47%) received either bupivacaine or ropivacaine local anesthetic (LA) and 220 (53%) a combination of local anesthetic and clonidine (LAC). The duration of sensory block was significantly longer in the LAC (17.2 +/- 5 h) compared with that in the LA group (13.2 +/- 5 h) (P = 0.0001). The increase in duration was independent from the type of peripheral nerve block, local anesthetic used and operation performed. The motor block duration was significantly longer in the LAC group (9.6 +/- 5 vs 4.3 +/- 4 h, P = 0.014). Two patients in the LAC and one in the LA group experience prolonged numbness (max 72 h). No paresthesia or dysesthesia was observed.

CONCLUSION: The addition of clonidine to bupivacaine and ropivacaine can extend

sensory block by a few hours, and increase the incidence of motor blocks.

 

接受經尿道操作的老年病人的鞘內麻醉：一項為了尋找合適量的研究（簡要的報）

Intrathecal Anesthesia for Elderly Patients Undergoing Short Transurethral Procedures: A Dose-Finding Study (Brief Report)

Edna Zohar, Yossi Noga, Uri Rislick, Ilan Leibovitch, and Brian Fredman

Department of Anesthesiology, Intensive Care and Pain Management, Meir Medical Center, Kfar Saba, Israel.

Anesth Analg 2007 104: 552-554

 

100個接受經尿道操作（〈45分鐘）的老年病人（>或者=65歲）鞘內注射7.5mg布比卡因，或者5mg布比卡因+20mug太尼，或者4mg布比卡因+20mug太尼，或者3mg布比卡因+20mug太尼。3mg布比卡因+太尼這一組中，操作過程中需“補救”的太尼量更大（P〈0.03）。用藥後患者能夠很好的行走的時間（分鐘）是以一種量依賴的方式遞減的（分別為：157 +/- 50 vs 147 +/- 37 vs 128 +/- 40 vs 116 +/- 29）。根據研究顯示，鞘內注射4mg布比卡因和20mug太尼能夠提供令人滿意的鎮痛和維持穩定的血流動學，以良好的恢復。

（周時蓓譯 薛張綱校）

One hundred elderly men (> or =65 yr) undergoing transurethral procedures (<45 min) received bupivacaine 7.5 mg, or bupivacaine 5 mg + fentanyl 20 mug, or bupivacaine 4 mg + fentanyl 20 mug, or bupivacaine 3 mg + fentanyl 20 mug, intrathecally. Intraoperative "rescue" fentanyl requirements were higher (P < 0.03) in group bupivacaine 3 mg + fentanyl. Times (min) to ambulation eligibility were decreased in a dose-dependant manner (157 +/- 50 vs 147 +/- 37 vs 128 +/- 40 vs 116 +/- 29, respectively). Of the techniques studied, intrathecal bupivacaine 4 mg + fentanyl 20 mug provided adequate analgesia and was associated with hemodynamic stability and a favorable recovery profile.

 

 

Sugammadex逆轉羅庫溴誘導的神經肌肉阻滯,與使用新斯的明-格隆溴或騰喜龍-阿托品的比較.

Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine.

Sacan O, White PF, Tufanogullari B, Klein K.

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9068, USA.

Anesth Analg. 2007 Mar;104(3):569-74

 

背景:Sugammadex是一種被修飾的γ-環式精複合物,它可快速逆轉殘餘羅庫溴的神經肌肉阻滯.我們用實驗來證明Sugammadex比通常使用的膽鹼酯酶藥物如騰喜龍和新斯的明對於適度殘餘的羅庫溴誘導的阻滯有更迅速的逆轉作用.

方法:60個病人進行任意由標準地氟醚-瑞太尼-羅庫溴誘導的手術,其中20個病人在應用最後一次羅庫溴量15分鐘甚至更長時間後接受Sugammadex,4mg/kg靜脈推注以逆轉神經肌肉阻滯,20個病人用騰喜龍,1mg/kg,聯合阿托品,10μg/kg靜脈推注,另外20個病人用新斯的明,70μg/kg聯合格隆溴,14μg/kg靜脈推注,利用速肌動描記法來記錄他們對於四個成串刺激(TOF)的反應.同時迅速記錄使用逆轉前之後30分鐘病人的平均動脈壓和心率,並在蘇醒室內觀察逆轉使用後的副作用.

結果:這三組病人有相似的統計學特徵,在接受逆轉前使用的羅庫溴總量也相同,儘管他們對四個成串刺激中T1的反應相似,但接受Sugammadex組在TOF比率恢復至0.7和0.9所使用的時間明顯短于騰喜龍組和新斯的明組,分別為Sugammadex(71±25秒和107±61秒),騰喜龍(202±171秒和331±27秒),新斯的明(625±341秒和1044±590秒).Sugammadex組中所有病人的TOF比率都在接受逆轉後5分鐘以內恢復至0.7和0.9,而在騰喜龍組中卻沒有病人出現恢復,新斯的明組中5%的病人得到恢復.新斯的明和格隆溴組的病人在使用逆轉後2分鐘5分鐘的心率明顯高於Sugammadex組.最後,Sugammadex組發生口幹的概率明顯下降,為5%,而新斯的明組和騰喜龍組分別為85%和95%.

結論:Sugammadex,4mg/kg靜脈推注,比新斯的明(70μg/kg靜脈推注)和騰喜龍(1μg/kg靜脈推注)更快更有效地逆轉殘餘的神經肌肉阻滯.同時,使用Sugammadex比當前我們使用的複合逆轉更少發生口幹的情況.

(施 譯 薛張綱校)

BACKGROUND: Sugammadex is a modified [gamma] cyclodextrin compound, which encapsulates rocuronium to provide for a rapid reversal of residual neuromuscular blockade. We tested the hypothesis that sugammadex would provide for a more rapid reversal of a moderately profound residual rocuronium-induced blockade than the commonly used cholinesterase inhibitors, edrophonium and neostigmine. METHODS: Sixty patients undergoing elective surgery procedures with a standardized desflurane-remifentanil-rocuronium anesthetic technique received either sugammadex, 4 mg/kg IV (n = 20), edrophonium, 1 mg/kg IV and atropine, 10 microg/kg IV (n = 20), or neostigmine, 70 microg/kg IV and glycopyrrolate, 14 microg/kg IV (n = 20) for reversal of neuromuscular blockade at 15 min or longer after the last dose of rocuronium using acceleromyography to record the train-of-four (TOF) responses. Mean arterial blood pressure and heart rate values were recorded immediately before and for 30 min after reversal drug administration. Side effects were noted at discharge from the postanesthesia care unit. RESULTS: The three groups were similar with respect to their demographic characteristics and total dosages of rocuronium prior to administering the study medication. Although the initial twitch heights (T1) at the time of reversal were similar in all three groups, the time to achieve TOF ratios of 0.7 and 0.9 were significantly shorter with sugammadex (71 +/- 25 and 107 +/- 61 s) than edrophonium (202 +/- 171 and 331 +/- 27 s) or neostigmine (625 +/- 341 and 1044 +/- 590 s). All patients in the sugammadex group achieved a TOF ratio of 0.9 < or =5 min after reversal administration compared with none and 5% in the edrophonium and neostigmine groups, respectively. Heart rate values at 2 and 5 min after reversal were significantly higher in the neostigmine-glycopyrrolate group compared with that in sugammadex. Finally, the incidence of dry mouth was significantly reduced in the sugammadex group (5% vs 85% and 95% in the neostigmine and edrophonium groups, respectively). CONCLUSION: Sugammadex, 4 mg/kg IV, more rapidly and effectively reversed residual neuromuscular blockade when compared with neostigmine (70 microg/kg IV) and edrophonium (1 mg/kg IV). Use of sugammadex was associated with less frequent dry mouth than that with the currently used reversal drug combinations.

 

 

電子提示儀能增程式文檔記錄依從性以專業費用的報

Electronic Reminders Improve Procedure Documentation Compliance and Professional Fee Reimbursement

Sachin Kheterpal, MD, MBA, Ruchika Gupta, MD, James M. Blum, MD, Kevin K. Tremper, PhD, MD, Michael O’Reilly, MD, MS, and Paul E. Kazanjian, MD

From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.

Anesth Analg 2007 104: 592-597.

 

背景：法醫學，臨醫學和報需要完整和精確的文檔記錄憑證。我們試圖確定和改善圍手術期動脈置管的文檔記錄的依從率 。

方法:我們首先查閱了12 個磁光碟的電子麻醉記錄以建立動脈置管文檔記錄的基線依從率。住院醫生和有執照的護理麻醉師被隨機分配到控制組和試驗組。當手術開始切口到麻醉終止被記錄到電子記錄儀時，記錄儀照例會製作出一張有創動脈血壓動圖表。如果一個病例使用了動脈置管，但是沒有觀察到這個過程的記錄，那麼被分配到這個病例的住院醫生和有執照的護理麻醉師會收到數位傳呼機和電子郵件的提示。控制組的實驗者不會收到數位傳呼機或電子郵件息。在2個磁光碟之後，所有的人員都會收到提示。

結果：我們觀察到基線依從率為80%（2459個置管病例中記錄了1963個）。在2個磁光碟的試驗期內，控制組的實驗者在202個動脈置管中記錄了152個（75%），而試驗組在201個動脈置管中記錄了177個（88%）（p<0.001）。當所有人員都開始收到提示後，在隨後的2個磁光碟期間內，314個動脈置管中有309個被記錄下來（98%）。如果將這樣一個依從率推12個磁光碟的預期的動脈置管，則每年專業費用的報會增40,500美元。

結論：三級護理過程的複雜性使文檔記錄不完善。不昂貴的自動提示儀能夠極大地增依從性，且不需要複雜的正負反饋機制。

（陳佳莉譯 薛張綱校）

BACKGROUND: Medicolegal, clinical, and reimbursement needs warrant complete and accurate documentation. We sought to identify and improve our compliance rate for the documentation of arterial catheterization in the perioperative setting.

METHODS: We first reviewed 12 mo of electronic anesthesia records to establish a baseline compliance rate for arterial catheter documentation. Residents and Certified Registered Nurse Anesthetists were randomly assigned to a control group and experimental group. When surgical incision and anesthesia end were documented in the electronic record keeper, a reminder routine checked for an invasive arterial blood pressure tracing. If a case used an arterial catheter, but no procedure note was observed, the resident or Certified Registered Nurse Anesthetist assigned to the case was sent an automated alphanumeric pager and e-mail reminder. Providers in the control group received no pager or e-mail message. After 2 mo, all staff received the reminders.

RESULTS: A baseline compliance rate of 80% was observed (1963 of 2459 catheters documented). During the 2-mo study period, providers in the control group documented 152 of 202 (75%) arterial catheters, and the experimental group documented 177 of 201 (88%) arterial lines (P < 0.001). After all staff began receiving reminders, 309 of 314 arterial lines were documented in a subsequent 2 mo period (98%). Extrapolating this compliance rate to 12 mo of expected arterial catheter placement would result in an annual incremental $40,500 of professional fee reimbursement.

CONCLUSIONS: The complexity of the tertiary care process results in documentation deficiencies. Inexpensive automated reminders can drastically improve compliance without the need for complicated negative or positive feedback.

 

 

用超聲術評價聲門下管徑的可行性

The Feasibility of Ultrasound to Assess Subglottic Diameter

Karim Lakhal, MD*, Xavier Delplace, MD*, Jean-Philippe Cottier, MD{dagger}, François Tranquart, MD{ddagger}, Xavier Sauvagnac, MD*, Colette Mercier, MD*, Jacques Fusciardi, MD*, and Marc Laffon, MD*

From the *Groupement d’Anesthésie Réanimation, {dagger}Service de Neuroradiologie, and {ddagger}Groupement d’Imagerie Médicale, CHU Tours, Tours, France.

Anesth Analg 2007 104: 611-614.

 

背景：對於健康的病人，聲門下呼吸道的最窄的地方位於環狀軟骨水準。由於導管的管徑過大會損傷氣管粘膜，並導致插管後喘鳴或聲門下狹窄，因此這個狹窄部位決定了氣管插管時選擇氣管導管的尺寸。遺憾的是，依賴於身高、體重或年齡而決定的導管尺寸並不可靠。了解氣道管徑，特別是可以應用旁無創傷的方法瞭解在麻醉和重症監護中是有幫的。

方法;我們對19個志願者（27 ± 3歲，其中9個女性）研究，分別比較超聲和核磁共振測量環狀軟骨處的管徑。

結果：兩種方法測量的結果高度相近(r = 0.99, P < 0.05)，Bland–Altman分析得偏移是0.14 mm, a precision of 精確度0.33 mm,允許限度是 –0.68 mm/0.96 mm.

結論：對年輕成人來說，超聲在評價聲門下呼吸道管徑方面是可行的。

（陳珺珺譯 薛張綱校）

BACKGROUND: In healthy patients, the narrowest diameter of the subglottic upper airway is the width of the air-column at the level of the cricoid cartilage. This diameter governs the selection of the endotracheal tube size, as excessive tube diameter may damage the tracheal mucosa leading to postextubation stridor or subglottic stenosis. Unfortunately, selecting endotracheal tube size based on height, weight, or age does not reliably lead to the proper tube. The knowledge of airway diameter, especially using a bedside noninvasive tool, could therefore be helpful in anesthesia and intensive care

METHODS: We studied 19 healthy volunteers (27 ± 3 yr, nine females) to compare the transverse diameter of the cricoid lumen assessed by ultrasonography and magnetic resonance imaging.

RESULTS: We found a strong correlation between the two techniques (r = 0.99, P < 0.05) confirmed by Bland–Altman analysis with a bias of 0.14 mm, a precision of 0.33 mm, and limits of agreement of –0.68 mm/0.96 mm.

CONCLUSION: In young healthy adults, ultrasonography appeared to be a reliable tool to assess the diameter of the subglottic upper airway.

 

 

D-甲羥基澱粉在大鼠模型中對伴毛細血管滲漏的多菌性膿毒症的炎性作用

Hydroxyethyl Starch, but Not Modified Fluid Gelatin, Affects Inflammatory Response in a Rat Model of Polymicrobial Sepsis with Capillary Leakage

Xiaomei Feng, MD, PhD, Jian Liu, PhD, Min Yu, PhD, Sihai Zhu, MD, and Jianguo Xu, MD, PhD

From the Department of Anesthesiology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, People’s Republic of China.

Anesth Analg 2007 104: 624-630.

 
背景：容量治療對膿毒症的病人有明顯的提高組織灌注和維持血液動學穩定的作用。MFG和HES是最廣泛應用的膠體。在這個研究中，我們通過CLP的感染小鼠，研究HES和MFG在肺毛細血管滲透壓的作用，並研究是否有炎機制。
方法：將動物隨機的分為八組：鹽類控制組，CLP和鹽類，CLP和HES (7.5, 15, and 30 
mL/kg); CLP and MFG (7.5, 15, and 30 mL/kg). 
每組20只小鼠，十個被用來測肺毛細血管滲透壓，十個被用來測其他因素，。CLP後四小時，注射一定量的HES或MFG。外科手術後六小時，測量肺毛細血管滲透壓，腫瘤壞死因數，內皮素，炎性巨噬細胞，白介素-1mRNA表達，肺組織學改，細胞核因數-B也同時被測量。
結果：HES和MFG可以量依賴性的顯著減小肺毛細血管滲透壓。另外，HES還能降低腫瘤壞死因數，內皮素，炎性巨噬細胞，白介素-1mRNA表達，肺組織學改，細胞核因數-B，而MFG沒有這樣的作用。
結論：HES可以通過調節炎性反應來降低毛細血管滲透壓，而對MFG並沒有這樣的炎機制。

（秦 佳譯 薛張綱校）

BACKGROUND: Intravascular volume therapy is crucial in septic patients to improve tissue perfusion and maintain stable hemodynamics. Modified fluid gelatins (MFG) and medium weight hydroxyethyl starches (HES) are the most widely used synthetic colloids. Our aim in this study, performed in septic rats challenged by cecal ligation and puncture (CLP), was to investigate the effects of HES and MFG on pulmonary capillary leakage and to determine whether an antiinflammatory mechanism was involved.

METHODS: Animals were randomly allocated to eight groups: saline control; CLP and saline; CLP and HES (7.5, 15, and 30 mL/kg); CLP and MFG (7.5, 15, and 30 mL/kg). Each group had 20 rats, 10 of which were used for pulmonary capillary leakage and 10 for other measurements. Four hours after CLP, the specified doses of HES or MFG were infused. Six hours after surgery, pulmonary capillary leakage, levels of tumor necrosis factor-{alpha}, interleukin-1ß, and macrophage inflammatory protein-2, intercellular adhesion molecule-1 mRNA expression, myeloperoxidase activity, lung histological changes, and nuclear factor-{kappa}B activation were measured.

RESULTS: HES and MFG significantly attenuated the increase in capillary leakage in a dose-dependent manner. In addition, HES could decrease tumor necrosis factor-{alpha}, interleukin-1ß, and macrophage inflammatory protein-2 expression, intercellular adhesion molecule-1 mRNA expression, myeloperoxidase activity, neutrophil infiltration, and nuclear factor-{kappa}B activation, whereas MFG could not.

CONCLUSIONS: HES may attenuate capillary leakage by modulating an inflammatory response, whereas an antiinflammatory mechanism was not involved in the effects of MFG on capillary leakage.

 

 

針刺足三裏（ST36）能減弱脂多糖誘導的大鼠急性腎損傷但不能減弱肝損傷

Acupuncture stimulation of ST36 (Zusanli) attenuates acute renal but not hepatic injury in lipopolysaccharide-stimulated rats.

Huang CL, Tsai PS, Wang TY, Yan LP, Xu HZ, Huang CJ.

Acupuncture and Moxibustion Institute, Nanjing University of Traditional Chinese Medicine, Nanjing, China.

Anesth Analg 2007 104: 646-654.

 

背景：探究針刺足三裏對膿毒血症致肝腎損傷的影響。方法：將120只大鼠隨機分為10組：1）脂多糖（LPS），2）生理鹽水（NS），3）足三裏後LPS， 4）足三裏後NS， 5）LPS後足三裏， 6）NS後足三裏，7）假手術後LPS，8）假手術後NS， 9）LPS後假手術，10）NS後假手術。對足三裏後LPS、足三裏後NS、假手術後LPS假手術後NS組的大鼠，先針刺足三裏或非穴位點30分鐘，然後注射LPS或NS。對LPS後足三裏、NS後足三裏、LPS後假手術NS後假手術組，注射LPS或NS 3小時後針刺足三裏或非穴位點30分鐘。注射LPS 6小時後處死大鼠。結果：LPS誘導了明顯的肝腎損傷，同時提升了肝腎NO濃度和可誘導NO合酶（iNOS）表達水準。預先針刺足三裏能顯著減弱LPS導致的腎損傷，腎NO濃度和iNOS表達的升高受到制。然而，針刺足三裏不改LPS導致的肝損傷，肝NO濃度和iNOS表達的升高不受影響。另外，LPS誘導之後針刺足三裏對LPS所致器官損傷、NO濃度或iNOS表達化無作用。結論：預先針刺足三裏在大鼠身能顯著減弱膿毒血症誘導的腎損傷，但不能減弱肝損傷，膿毒血症誘導後針刺無保護作用。

（羅 璿譯 薛張綱校）

BACKGROUND: We sought to determine the effects of ST36 acupuncture on sepsis-induced kidney and liver injuries. METHODS: A total of 120 rats were randomized into 10 groups: 1) lipopolysaccharide (LPS), 2) normal saline (N/S), 3) LPS + ST36, 4) ST36, 5) LPS + P-ST36, 6) P-ST36, 7) LPS + Sham, 8) Sham, 9) LPS + P-Sham, and 10) P-Sham groups. Rats in the LPS + ST36, ST36, LPS +Sham, and Sham groups received ST36 (designated as "ST36") or a nonacupoint (designated as "Sham") acupuncture for 30 min followed by LPS or N/S injection. Rats in the LPS + P-ST36, P-ST36, LPS + P-Sham, and P-Sham groups received LPS or N/S injection for 3 h followed by a 30 min of ST36 or a "nonacupoint" acupuncture. Rats were killed at 6 h after LPS injection. RESULTS: LPS caused prominent kidney and liver injuries. The renal and hepatic nitric oxide (NO) concentrations and inducible NO synthase (iNOS) expression were also increased by LPS. ST36 acupuncture pretreatment significantly attenuated the LPS-induced kidney injury and the increases in renal NO concentration and iNOS expression. However, ST36 acupuncture pretreatment did not affect the LPS-induced liver injury and increases in hepatic NO concentration or iNOS expression. Furthermore, ST36 acupuncture performed after LPS did not affect the LPS-induced organ injuries or increases in NO concentration and iNOS expression. CONCLUSIONS: ST36 acupuncture pretreatment significantly attenuated sepsis-induced kidney, but not liver, injury in rats, whereas ST36 acupuncture performed after sepsis induction had no protective effects against sepsis-induced organ injuries.

 

 

使用背景量輸注機控指令單次給藥孕婦自控硬膜外鎮痛的對照試驗

A Comparison of a Basal Infusion with Automated Mandatory Boluses in Parturient-Controlled Epidural Analgesia During Labor

Alex T. Sia, MMED, Yvonne Lim, MMED, and Cecilia Ocampo, MD

From the Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore.

Anesth Analg 2007;104:673-678

 

背景：目前，連續背景量輸注式給藥的產婦自控硬膜外鎮痛（PCEA）術已經在產婦分娩時廣泛使用。我們比較了新的硬膜外背景量輸注同時間斷單次給藥的方法：PCEA機控自動單次給藥（PCEA+AMB），和PCEA背景量持續輸注（PCEA+BCI）。我們猜測使用背景量間斷單次給藥硬的膜外阻滯麻醉的費會比背景持續輸注法少。

方法：我們將42名處於早期產程的健康娠婦女在成接受腰硬聯合鎮痛後，隨機分為兩組，一組接受PCEA+BCI (n = 21,單次給藥5ml，鎖定時間 10分鐘, 背景量 5 mL/h) ，另一組接受PCEA+AMB (n = 21, 患者自控單次給藥 5 mL, 鎖定時間 10 分鐘，背景量自動單次給藥5ml/h[ 略去自控單次給藥在最後一小時內順利給入])，兩組均給予0.1%的羅呱卡因+太尼2 µg/mL。

結果：我們發現使用PECA+AMB方法會減少平均每小時羅呱卡因的費，亦即，基本計算結果（PCEA+AMB組：均值=6.5ml,方差=3.4，PCEA+BCI組:均值=7.5ml,方差2.0, P=0.011）.在PCEA+AMB組患者沒有使用自控單次給藥的比例更高一些（PCEA+BCI：6/21 ； PCEA+AMB：1/21，p=0.03）。第一次使用自控單次給藥距離腰影聯合鎮痛後的時間，在PCEA+AMB組明顯延長（PCEA+AMB組平均時間：15分鐘；PCEA+IMB組平均時間：315分鐘，p=0.04 log檢驗）。在疼痛評分以副作用方面沒有差異。

結論：我們的研究顯示，PCEA+ABM減少了鎮痛費用，以可以作為硬膜外鎮痛維持的有用的模式。

（王光妍譯 薛張綱校）

BACKGROUND: The use of parturient-controlled epidural analgesia (PCEA) with a basal infusion is commonly used in laboring women. We compared a novel approach of providing basal intermittent boluses concurrently with PCEA: PCEA plus automated mandatory boluses (PCEA+AMB) versus PCEA plus basal continuous infusion (PCEA+BCI). We hypothesized that epidural local anesthetic consumption would be lower if basal intermittent boluses were used instead of a basal infusion.

METHODS: We randomized 42 healthy parturients in early labor to receive 0.1% ropivacaine + fentanyl 2 µg/mL either via PCEA+BCI (n = 21,bolus 5 mL, lockout 10 min, basal infusion 5 mL/h) or via PCEA+AMB (n = 21, patient-activated bolus of 5 mL, lockout 10 min, basal automated boluses of 5 mL/h [omitted if a patient-activated bolus was successfully administered in the last 1 h]) after successful induction of combined spinal epidural analgesia.

RESULTS: We found a reduction in the hourly consumption of ropivacaine with PCEA+AMB, i.e., the primary outcome measure (mean = 6.5 mL, sd = 3.4 in the PCEA+AMB group vs 7.5 mL, sd = 2.0 PCEA+BCI group, P = 0.011). A larger proportion of parturients in the PCEA+AMB group did not self-bolus (6/21 vs 1/21 in PCEA+BCI, P = 0.03). The time to the first self-bolus after combined spinal epidural was longer in the PCEA+AMB group (mean survival time 315 min vs 190 min in PCEA+BCI group, P = 0.04 by log rank test). There was no difference in pain scores or side effects.

CONCLUSION: Our study showed that PCEA+AMB reduced analgesic consumption and could be useful as the mode of maintenance for epidural analgesia.

 

 

術後鎮痛對手術後主要併發症的影響：一項系統的最新的證據

Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence.

Spencer S. Liu and Christopher L. Wu

Department of Anesthesiology, Hospital for Special Surgery and the Weill College of Medicine of Cornell University, New York, New York 10021, USA. liusp@hss.edu

Anesth Analg 2007 104: 689-702.

 

背景：很少有獨立的臨試驗有足夠的課題數目能確定術後鎮痛的效果。

方法：我們有系統地在Medline醫學文獻檢索系統以Cochrane資料庫中搜索過去十年中的文獻，並且注意集中到meta分析和大型的隨機對照臨試驗。

結果：18篇meta分析，10篇系統回顧，8篇隨機對照試驗，以2篇觀察報文章被作為回顧或評論。用局麻藥的硬膜外鎮痛具有最大的理論潛，同時也是一項被研究的非常透徹的術。大多數證據證明硬膜外鎮痛只有對行大血管手術或有高危因素的病人具有減少心血管以肺部的併發症的效果。這項發現可能在大型手術向微創介入術的快速發展中顯的不太相關，（比如：腔內腹主動脈修復）那就會只有很小的併發症的危險。還有一致的證據表明局麻藥的硬膜外鎮痛與大型腹部手術後發生腸梗阻有關。沒有最新的證據證明神經阻滯，傷口引流管周圍的局部麻醉，IV級病人用阿片類藥物控制性鎮痛或者是其他全身性多樣的止痛藥對手術後併發症有任何臨意義的處。

結論：總的來說，沒有足夠的證據確定或否認術後鎮痛術對手術後的死亡率或發病率有什麼影響。這主要是因為沒有足夠的課題數量能夠發現當前低發生率的術後併發症之間的差異。

（張 儷譯 薛張鋼校）

BACKGROUND: Few individual clinical trials have had sufficient subject numbers to definitively determine the effects of postoperative analgesia on major outcomes. METHODS: We systematically searched the Medline and the Cochrane Library databases for the past decade and focused on meta-analyses and large, randomized, controlled trials. RESULTS: Eighteen meta-analyses, 10 systematic reviews, 8 additional randomized, controlled trials, and 2 observational database articles were identified for review or comment. Epidural analgesia with local anesthetics has the greatest theoretical potential to affect major outcomes and has been the most thoroughly investigated technique. The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications only after major vascular surgery or in high-risk patients. This finding may become irrelevant because of rapid conversion of major surgery to minimally invasive techniques (e.g., endoluminal abdominal aortic repair) that carry less risk of complications. There is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery. Again, this finding may also become irrelevant with the adoption of laparoscopic techniques and multimodal fast-track programs for abdominal surgery. There is no current evidence that perineural analgesia, continuous wound catheters using local anesthetics, IV patient-controlled analgesia with opioids, or addition of multimodal systemic analgesics have any clinically significant beneficial effect on postoperative complications. CONCLUSIONS: Overall, there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity. This is primarily due to typically insufficient subject numbers to detect differences in currently low incidences of postoperative complications.

 

 

地塞米松對嗎啡耐受大鼠髓穀氨醯胺合成酶谷氨酸脫氫酶表達的影響

The effect of dexamethasone on spinal glutamine synthetase and glutamate dehydrogenase expression in morphine-tolerant rats

Wu GJ, Wen ZH, Chen WF, Chang YC, Cherng CH, Wong CS

Department of Anesthesiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan

Anesth Analg 2007 104:726-730

 

背景：興奮性氨基酸在嗎啡耐受產生過程中起著重要的作用。最近我們證明單次量的嗎啡導致嗎啡耐受大鼠腦液中興奮性氨基酸濃度升高，而地塞米松制嗎啡耐受性的進展。我們進一步檢驗了鞘內注射地塞米松對嗎啡耐受性進展髓細胞內谷氨酸代謝酶（谷氨酸脫氫酶、穀氨醯胺合成酶）表達的影響。方法：將雄性Wistar大鼠植入鞘內導管後分為四組，分別輸注嗎啡（15mg/h）、生理鹽水（1mg/h）、地塞米松（2mg/h）地塞米松（2mg/h）＋嗎啡（15mg/h），持續五天。第五天，取髓作谷氨酸脫氫酶和合成酶的Western印記分析。結果：谷氨酸脫氫酶和合成酶濃度在嗎啡耐受大鼠髓中下調。同期輸注地塞米松減弱嗎啡耐受性和相關的谷氨酸脫氫酶和合成酶下調。結論：鞘注地塞米松減弱長期應用嗎啡導致的谷氨酸脫氫酶和合成酶的下調傷害感受性耐受。

（孫 霞譯 薛張綱校）

BACKGROUND: Excitatory amino acids play an important role in morphine tolerance. Recently, we demonstrated that a single morphine challenge induces an increase in spinal cerebrospinal fluid excitatory amino acid concentrations in morphine-tolerant rats, and that dexamethasone inhibits the development of morphine tolerance. We further examined the effect of intrathecal dexamethasone infusion on the development of morphine tolerance and on expression of the intracellular glutamate metabolizing enzymes, glutamate dehydrogenase and glutamine synthetase, in the spinal cord. METHODS: Male Wistar rats, implanted with an intrathecal catheter, were divided into four groups that were infused for 5 days with intrathecal morphine (15 microg/h), saline (1 microL/h), dexamethasone (2 microg/h), or dexamethasone (2 microg/h) plus morphine (15 microg/h). On Day 5, the spinal cords were removed and prepared for Western blot analysis of glutamate dehydrogenase and glutamate synthetase. RESULTS: Glutamate dehydrogenase and glutamate synthetase concentrations were downregulated in the morphine-tolerant rat spinal cords. Concurrent infusion of dexamethasone attenuated morphine tolerance and the associated glutamate dehydrogenase and glutamate synthetase downregulation. CONCLUSION: Intrathecal dexamethasone attenuates long-term morphine infusion-induced glutamate dehydrogenase and glutamate synthetase downregulation and antinociceptive tolerance.