【精华】Anesthesiology，A&A 摘要翻译

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【第355篇 】高病人量的大学心脏电生理中心发生的气道损伤 Anesth Analg.2013 Jan;116(1):112-7.

Airway trauma in a high patient volume academic cardiac electrophysiology laboratory center.

Yan Z, Tanner JW, Lin D, Chalian AA, Savino JS, Fleisher LA, Liu R.

Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 336 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104. [email protected].

BACKGROUND: Providing anesthesia and managing airways in the electrophysiology suite can be challenging because of its unique setting outside of the conventional operating room. We report our experience of several cases of reported airway trauma including tongue and pharyngeal hematoma and vocal cord paralysis in this setting.

METHODS: We analyzed all of the reported airway trauma cases between December 2009 and January 2011 in our cardiac electrophysiology laboratories and compared these cases with those without airway trauma. Data from 87 cases, including 16 cases with reported airway trauma (trauma group) and 71 cases without reported airway trauma from the same patient population pool at the same period (control group), were collected via review of medical records.

RESULTS: Airway trauma was reported for 16 patients (0.7%) in 14 months among 2434 anesthetic cases. None of these patients had life-threatening airway obstruction. The avoidance of muscle relaxants during induction in patients with a body mass index less than 30 was found to be a significant risk factor for airway trauma (P = 0.04; odds ratio, 10; 95% confidence interval, 1.1-482). Tongue or soft tissue bite occurred in 2 cases where soft bite block was not used during cardioversion. No statistically significant difference was found between the trauma and the control groups for preprocedure anticoagulation, anticoagulation during the procedure, or reversal of heparin at the end of the procedure.

CONCLUSIONS: The overall incidence of reported airway trauma was 0.7% in our study population. Tongue injury was the most common airway trauma. The cause seems to have been multifactorial; however, airway management without muscle relaxant emerged as a potential risk factor. Intubation with muscle relaxant is recommended, as is placing a soft bite block and ensuring no soft tissue is between the teeth before cardioversion.
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高病人量的大学心脏电生理中心发生的气道损伤

背景： 由于电生理室的环境有别于常规手术室，在电生理室进行麻醉和气道管理具有挑战性。本文对我们电生理中心出现气道损伤（舌、咽部血肿及声带麻痹）的一些病例进行总结报道。

方法： 我们分析2009年12月到2011年1月在我们心脏电生理实验室出现气道损伤的病例，并与未出现气道损伤的病例进行比较。共收集87例病例资料，包括16例出现气道损伤病例（气道损伤组），71例同一时期同一人群未出现气道损伤的病例（对照组）。

结果： 在14个月内共进行2434例麻醉，其中16例出现气道损伤（0.7%）。这些病例均未出现威胁生命的气道梗阻。BMI低于30的患者未使用肌肉松弛剂进行诱导被发现是气道损伤的危险因素（P = 0.04；OR：10；95%可信区间，1.1-482）。2例患者在电复律时未使用软牙垫而发生舌或软组织咬伤。气道损伤组和对照组在术前、术中抗凝及术后逆转肝素方面差异无统计学意义。

结论： 在我们研究的人群中，气道损伤的总发生率为0.7%。舌的损伤为最常见的气道损伤。原因可能是多方面的；然而，在管理气道时未使用肌肉松弛剂被认为是潜在危险因素。推荐使用肌肉松弛剂进行气管插管，并放置软牙垫以及确保在电复律时没有软组织位于上下牙齿之间。

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【第354篇】琥珀酰胆碱导致恶性高热的风险评价Anesth Analg. 2013 Jan;116(1):118-22.

Estimate of the relative risk of succinylcholine for triggering malignant hyperthermia.

Dexter F, Epstein RH, Wachtel RE, Rosenberg H.

Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Dr., 6JCP, Iowa City, IA 52242. [email protected].

Abstract

BACKGROUND: Facilities with volatile anesthetic agents stock dantrolene for the treatment of malignant hyperthermia (MH). The availability of dantrolene at these facilities satisfies cost-utility norms even for sites with as few as 1 anesthetic per workday, based on the overall incidence of MH per anesthetic. We considered the stocking of dantrolene at facilities with succinylcholine alone (i.e., where volatile anesthetics are not available), by using registry data and estimates of the frequency of administration of succinylcholine during anesthesia. We determine the magnitude of the relative risk of the administration of succinylcholine for triggering MH.

METHODS: The relative risk of triggering MH by succinylcholine versus volatile agents was calculated using data from 2 sources. The ratio of the number of cases of MH among patients receiving succinylcholine to number among patients not receiving succinylcholine was estimated from the previously published cohort of 284 cases of MH from the North American MH Registry of the MH Association of the United States (MHAUS). The percentage of anesthetics with succinylcholine was estimated using anesthesia information management system data from a typical North American hospital comprising tertiary operating rooms, obstetrics unit, ambulatory surgical center, and endoscopy and radiological suites.

RESULTS: The relative risk of MH with versus without succinylcholine was 19.6 (lower 95% confidence limit > 16.1). Limiting to cases with volatile anesthetics, the relative risk was 9.1 (>7.5). Both relative risks exceed 1.0 (P < 0.0001). Because more than half of the reported cases of MH included the use of succinylcholine, the relative risk exceeded 1.0 provided fewer than half of anesthetics in North America included the use of succinylcholine. The incidences of succinylcholine use at the hospital were 5.8% and 11.6% for all anesthetics and for anesthetics with volatile agents, respectively.

CONCLUSIONS: Our results provide no insight into the triggering mechanism for MH (i.e., succinylcholine could in isolation have an extremely low incidence of inducing MH, yet markedly increase the risk when administered in combination with volatile anesthetics). Until more epidemiologic data are collected and analyzed, having dantrolene available, where succinylcholine may be used, is reasonable, and this practice should be maintained.
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琥珀酰胆碱导致恶性高热的风险评价

背景： 在使用挥发性麻醉药的机构中储备丹曲林可用于治疗恶性高热。基于恶性高热的发生率，在这些机构中储备丹曲林符合成本效益标准，即使该机构每个工作日只实施一例麻醉。我们考虑在仅使用琥珀酰胆碱的机构（例如：没有挥发性麻醉药物的机构）储备丹曲林，评估麻醉时琥珀酰胆碱的使用频率。以确定注射丹曲林诱发恶性高热的风险大小。

方法： 数据来源于2个机构，比较琥珀酰胆碱和挥发性气体诱发恶性高热的相对危险度大小。通过在MHAUS登记并发表的284例恶性高热患者，计算接受琥珀酰胆碱注射的患者发生恶性高热例数与未接受琥珀酰胆碱注射患者发生恶性高热例数的比值。琥珀酰胆碱使用的百分比通过典型南美医院（包含三级手术室、产科中心、门诊手术中心以及内镜和放射中心）的麻醉管理系统数据分析。

结果： 使用琥珀酰胆碱发生恶性高热的相对危险度是未使用琥珀酰胆碱的19.6倍（95%可信区间的下限大于16.1）。 仅限于使用挥发性麻醉药的病例，使用琥珀酰胆碱发生恶性高热的相对危险度为9.1（>7.5）。二者相对危险度都超过1.0（p<0.0001）。由于超过一半报告的恶性高热病例使用琥珀酰胆碱，相对危险度超过1.0说明在南美少于一半的麻醉使用琥珀酰胆碱。在该医院，所有麻醉病例中琥珀酰胆碱的使用率为5.8，在使用吸入性麻醉的病例中占11.6%。

结论： 我们的结果未提供诱发恶性高热的进一步机制（单独使用琥珀酰胆碱导致恶性高热的发生率极低，但与挥发性气体联合应用时刻明显增高恶性高热发生率）。在收集和分析更多的流行病学数据之前，在使用琥珀酰胆碱的机构储备丹曲林是合理的，该临床规范需要保持。
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备注：结果部分有关相对危险度的计算不是特别清楚，请参见全文，多谢告知。
19.6=（[155 withsuccinylcholine/129 without succinylcholi])×([235992 cases/13618 with succinylcholine]-1)
9.1=（[153 withsuccinylcholine/128 without succinylcholi])×([100745 cases/11674 with succinylcholine]-1)

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【第353篇】 有关患者血液管理药物治疗的目前状态 Anesth Analg.2013 Jan;116(1):15-34.

Special article: current status of pharmacologic therapies in patient blood management.

Goodnough LT, Shander A.

Pathology Department, Stanford University, 300 Pasteur Drive Room H-1402, M/C 5626 Stanford, CA 94305. [email protected].

Abstract

Patient blood management(1,2) incorporates patient-centered, evidence-based medical and surgical approaches to improve patient outcomes by relying on the patient's own (autologous) blood rather than allogeneic blood. Particular attention is paid to preemptive measures such as anemia management. The emphasis on the approaches being "patient-centered" is to distinguish them from previous approaches in transfusion medicine, which have been "product-centered" and focused on blood risks, costs, and inventory concerns rather than on patient outcomes. Patient blood management(3) structures its goals by avoiding blood transfusion(4) with effective use of alternatives to allogeneic blood transfusion.(5) These alternatives include autologous blood procurement, preoperative autologous blood donation, acute normovolemic hemodilution, and intra/postoperative red blood cell (RBC) salvage and reinfusion. Reviewed here are the available pharmacologic tools for anemia and blood management: erythropoiesis-stimulating agents (ESAs), iron therapy, hemostatic agents, and potentially, artificial oxygen carriers.

PMID: 23223098
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有关患者血液管理药物治疗的目前状态

【摘要】

患者血液管理（1,2）通过以患者为中心，循证医学和手术方式多个方面使患者依靠自体血而非异体血从而改善预后。需要特别关注一些预防措施，例如治疗贫血。强调以患者为中心是为了区别之前以产品中心的输血医学，其关注的是血液的风险、费用、库存问题而不是患者的预后。患者血液管理（3）将目标定为避免血液输注（4）通过有效使用异体血的替代品。（5）这些替代品包括：自体血采购、术前自体献血、急性等容血液稀释和术中/术后红细胞收集回输。本文回顾有关贫血和血液管理的药物治疗：刺激红细胞生成的药物 (ESAs)、铁剂治疗、止血药和可能的人工氧载体。

GoalYou

【第352篇】阿片类药物滥用者行体外震波碎石术时单次注射低剂量Ketamine可产生阿片类药物“集约效应”：一项临床随机试验

Anesth Analg. 2013 Jan;116(1):75-80.

Opioid-sparing effect of preemptive bolus low-dose ketamine for moderate sedation in opioid abusers undergoing extracorporeal shock wave lithotripsy: a randomized clinical trial.

Gharaei B, Jafari A, Aghamohammadi H, Kamranmanesh M, Poorzamani M, Elyassi H, Rostamian B, Salimi A.

Shahid Beheshti University of Medical Sciences, Anesthesiology Research Center, Labbafinejad Hospital, 9th Boostan, Pasdaran Ave., Tehran 1666694516, Islamic Republic of Iran. [email protected].

Abstract

BACKGROUND: Ketamine has been used as part of a multimodal analgesia regime in opioid abusers undergoing general anesthesia. We studied the opioid-sparing effect of a very low-dose bolus of ketamine as part of moderate sedation for opioid abuse patients undergoing extracorporeal shock wave lithotripsy.

METHODS: In this randomized, placebo-controlled clinical trial, 190 opioid abusers were enrolled. They were stratified into 2 blocks based on their daily opioid consumption. Both blocks were then randomized to receive 0.1 mg/kg IV ketamine (group K) or placebo (group P). Lithotripsy was performed under moderate sedation with intermittent bolus doses of remifentanil (0.2 μg/kg) to alleviate pain. The total remifentanil dose (primary outcome) and respiratory adverse events (secondary outcome) were compared in the 2 groups.

RESULTS: Remifentanil administration in the group with low-opioid consumers was 1.6 ± 0.4 μg/kg (group P) compared with 1.0 ± 0.2 μg/kg in group K (confidence interval [CI](of difference) 95%, 0.4-0.7; P < 0.001). Patients who had high-opioid consumption received 2.0 ± 0.5 μg/kg (group P) vs 1.5 ± 0.3 μg/kg (group K) remifentanil (CI(of difference) 95%, 0.40-0.75; P < 0.001). Ready to discharge time was statistically longer in high-consumption opioid abusers who received placebo compared with group K (55 ± 13 minutes vs 44 ± 8 minutes, CI(of difference) 95%, 6-15; P < 0.001). The incidences of bradypnea, apnea, nausea, vomiting, and hemodynamic changes were not statistically different between the ketamine and placebo groups.

CONCLUSION: Preemptive low-dose ketamine (0.1 mg/kg) as a bolus has opioid-sparing effects in opioid abusers undergoing moderate sedation.
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阿片类药物滥用者行体外震波碎石术时单次注射低剂量Ketamine可产生阿片类药物“集约效应”：一项临床随机试验

【摘要】

背景： Ketamine已经被用于阿片类药物滥用患者全身麻醉的联合镇痛。我们研究阿片类药物滥用患者行体外震波碎石时，单次注射小剂量Ketamine产生的阿片类药物“集约效应”。

方法： 该研究为临床随机对照试验，共包括190个阿片类药物滥用患者。根据患者每天阿片类药物的使用用量分为两大类。每组患者均随机接受0.1 mg/kg Ketamine静脉注射（K组）或者安慰剂（P组）。碎石手术在间断注射瑞芬太尼（0.2 μg/kg）镇痛下进行。对比两组瑞芬太尼的用量（主要结果）和呼吸系统副作用发生情况（次要结果）。

结果： 每天阿片类药物使用剂量较小的患者中，P组瑞芬太尼的用量为1.6 ± 0.4 μg/kg，K组为1.0 ± 0.2 μg/kg（95%可信区间，0.4-0.7；P < 0.001）。每天阿片类药物使用剂量较大的患者中，P组瑞芬太尼的用量为2.0 ± 0.5 μg/kg，K组为1.5 ± 0.3 μg/kg（95%可信区间，0.40-0.75；P < 0.001）。每天阿片类药物使用剂量较大的患者中，P组开始放电的时间（译者注：“放电时间”指的是麻醉开始到开始碎石的时间）长于K组 (55 ± 13 min vs 44 ± 8 min, 95%可信区间, 6-15; P < 0.001)。呼吸过缓、窒息、恶心、呕吐和血流动力学改变的发生率在两组间差别没有统计学意义。

结论： 阿片类药物滥用患者需要中度镇静镇痛时，预先单次注射低剂量Ketamine (0.1 mg/kg)可产生阿片类药物“集约效应”。

良医麻醉

METHODS: This was a prospective, observational clinical study in a university-level intensive care unit. Clinical characteristics, the level of consciousness, and findings in primary head computed tomography were recorded on admission. The study period was divided into three 2-day sections. In each section, a 12-lead ECG, transthoracic echocardiography, the results of standard blood electrolytes and cardiac troponin I, as well as the rate of vasoactive and sedative drug infusions were recorded. Repolarization abnormalities such as prolongation of the QTc interval (millisecond), ischemic-like ECG changes, and morphologic end-repolarization abnormalities (present/absent) were evaluated and analyzed. The 1-year functional outcome was determined using the Glasgow Outcome Score.

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