The Use of Dexmedetomidine in Pediatric Cardiac Surgery
Ahmed M.Mukhtar,MD* Eman M.Obayah,MD?Amira M.Hassona?We tested dexmedetomidine,an?2agonist,for its ability to decrease heart rate, arterial blood pressure,and neuroendocrinal responses during pediatric cardiac surgery.In a randomized,placebo-controlled study,30pediatric patients under-going open heart surgery were randomly assigned to one of two equal groups.The control group received saline,whereas the treatment group(DEX group)received an initial bolus dose of dexmedetomidine(0.5?g/kg)over10min,followed immediately by a continuous infusion of0.5?g·kg?1·h?1.Arterial blood pres-sure,heart rate,and sequential concentrations of circulating cortisol,epinephrine, norepinephrine,and blood glucose were measured.Relative to baseline,arterial blood pressure and heart rate decreased significantly after the administration of dexmedetomidine through skin incision.In the control group,patients’heart rate and arterial blood pressure measures increased after skin incision until the end of bypass(P?0.05).In both groups,plasma cortisol,epinephrine,norepinephrine, and blood glucose increased significantly relative to baseline,after sternotomy,and after bypass.However,the values were significantly higher in the control group compared with the DEX group(P?0.05).In conclusion,intraoperative dexme-detomidine infusion attenuated the hemodynamic and neuroendocrinal response to surgical trauma and cardiopulmonary bypass in pediatric patients undergoing corrective surgery for congenital heart disease.
(Anesth Analg2006;103:52–6)
T he stress response is the term given to the hor-
monal and metabolic changes that occur after injury or trauma.This is part of a systemic reaction to injury that encompasses a wide range of endocrinological, immunological,and hematological effects.It is initi-ated by neuronal activation of the hypothalamo-pituitary-adrenal axis(1).The stress response to sur-gery is characterized by increased secretion of pituitary hormones and activation of the sympathetic nervous system(2,3).Attenuation of the cardiovascu-lar,neuroendocrine,and inflammatory responses to surgery may improve outcome by beneficial effects on organ function(1,4).
Dexmedetomidine is a highly specific,potent,and selective?2adrenoceptor agonist(5).It has a relatively high ratio of?2/?1activity(1620:1as compared to220:1 for clonidine)(6)and is therefore considered a full agonist of the?2receptor.This ratio ensures that its potent action is selective for the central nervous sys-tem,without unwanted cardiovascular effects from?1 receptor activation(6).Dexmedetomidine has activity at the imidazoline receptors involved in central arte-rial blood pressure control(7,8).It causes a dose-dependent decrease in mean arterial blood pressure (MAP)and heart rate(HR)(9)and a reduction in sympathetic nervous system activity(9,10).Dexme-detomidine is an imidazole compound,and therefore, it has the potential to exert similar inhibitory effects to etomidate on cortisol synthesis(11).
This is the first study to report the sympatholytic effects of a continuous intraoperative infusion of dexmedetomidine on cardiovascular function and stress hormones(cortisol and catecholamine)in pedi-atric cardiac surgery patients.The hypothesis that dexmedetomidine would attenuate the increase in HR, MAP,and plasma catecholamine concentrations in pediatric patients undergoing corrective surgery for congenital heart disease was investigated. METHODS
After approval of the local Ethics Committee and obtain-ing written informed consent from the guardians of all patients,the study was designed to include30patients, aged1–6yr,scheduled for congenital heart disease repair surgery using cardiopulmonary bypass(CPB) between January2004and September2004.Patients undergoing re-operations,deep hypothermia,those with low cardiac output,and those with nonpalpable periph-eral pulses before surgery(e.g.,accompanying coarcta-tion of the aorta)were excluded from the study.
Anesthesia was induced with fentanyl10?g/kg
From the Departments of Anesthesia and Intensive Care and Biochemitry,Cairo Uniersity,Egypt.
Accepted for publication February6,2006.
Address correspondence and reprint requests to Ahmed M. Mukhtar,MD,Faculty of Medicine,Cairo University,2Zaafran St from Ahmed Kamel St behind Giza Governate Alharam,Cairo, Egypt.Address e-mail to Ahmed3m2003@https://www.doczj.com/doc/f5293712.html,.
DOI:10.1213/01.ane.0000217204.92904.76
and midazolam0.1mg/kg.Pancuronium0.15mg/kg was administered to facilitate endotracheal intubation and was repeated during surgery as required to maintain muscle relaxation.Anesthesia was main-tained using isoflurane0.3%–1.5%in an oxygen-air mixture(1:1ratio).The concentration of isoflurane was titrated to maintain MAP and HR in the range of 80%and120%of baseline values.Mechanical ventila-tion was provided by a Narkomed anesthesia machine (North American Dra¨ger,Telford,PA)using a tidal volume of10mL/kg with the respiratory rate ad-justed according to age,aiming to maintain Pa co2 between30and35mm Hg.All patients received10 mL/kg of lactated Ringer’s crystalloid solution before initiating CPB.
After insertion of a central venous and an arterial catheter,patients were randomly allocated into one of two equal groups(n?15each).In the DEX group, patients received an initial bolus dose of dexmedeto-midine(0.5?g/kg)over10min,followed immedi-ately by a continuous infusion of0.5?g·kg?1·h?1. The infusion was continued throughout the operation and was discontinued at the end of CPB.A similar volume of normal saline was given in the control group.
Hemodynamic variables(HR,systolic blood pres-sure,and diastolic blood pressure)were recorded at baseline(after the anesthetic induction and before the administration of the study drug),at5,10,and15min after the administration of the study drug,after skin incisions,after sternotomy,and after termination of CPB.Blood samples were obtained from the arterial catheter for assessment of plasma cortisol,epineph-rine,norepinephrine,and blood glucose measure-ments.Samples were obtained at baseline,after ster-notomy,and after termination of CPB.
In all patients,a median sternotomy was per-formed.CPB was initiated after standard aorta-bicaval cannulation.A membrane oxygenator(Minimax Plus; Medtronic Inc.,Anaheim,CA)and a nonpulsatile roller pump(model10.10.00;Sto?ckert Instruments, Munich,Germany)were used.Venting of the left heart was performed with a left atrial vent inserted through a small incision at the interatrial septum. Priming fluids consisted of lactated Ringer’s solution supplemented with heparin.Fresh whole blood was added to the priming solution in appropriate amounts to achieve a hematocrit of20%–22%during CPB. Moderate hypothermia(26°C–28°C)was used during CPB.
Sodium nitroprusside infusion was initiated during the rewarming period,and its rate of infusion was titrated to keep MAP between50and60mm Hg in the rewarming period.Total bypass time,aortic cross-clamping time,and the dose of vasodilators(sodium nitroprusside)required at weaning off CPB were noted and recorded.Atropine requirement during sur-gery for treatment of possible bradycardia(decrease in HR?30%of baseline)was also noted and recorded.
All of the following chemicals were obtained from Sigma(St.Louis,MO):diammonium hydrogen or-thophosphate,heptane sulfuric acid,EDTA,dihy-droxybenzylamine(internal standard),noradrenaline, adrenaline,acetonitrite,boric acid,and phosphoric acid.
Blood samples(10mL)were collected into tubes containing heparin as an anticoagulant and trans-ported to the laboratory on ice within30min.Samples were centrifuged at3500rpm for10min.Plasma was stored as aliquots at?80°C.The assay was by high-performance liquid chromatography with an electro-chemical detector.
The system used was the GBC system(GBC Scien-tific equipment Bty Ltd.,Victoria,Australia),(pum LC 1150,electrochemical detector CLC100)equipped with phenomenex(USA,UK)phenosphere ODS ana-lytical column(150mm?4.6mm ID;5-?m particle size).Electrochemical detection was achieved using an USA Coulochem II(ESA Analytical,Huntingdon. Cambridgeshire,United Kingdom)fitted with a guard cell and a50II analytical cell.Oxidation of the analyte was performed at?500mV in the guard cell followed by a successively higher reduction potential of?100 mV and?300mV in the analytical cell and sensitivity at20nA.The mobile phase consisted of125mmol/L of diammonium hydrogen orthophosphate containing 101mg of heptane sulfuric and73mg of EDTA adjusted to a flow rate of1mL/min(isocratic mode). The peak of catecholamines was identified according to the retention time of the standard(12).
The plasma cortisol level was determined by a microtiter strip enzyme-linked immunosorbent assay (ELISA)kit(13),and blood glucose levels were deter-mined with the enzymatic colorimetric method.Inter-assay and intraassay coefficient of variability for each assay were as follows:norepinephrine4.6%(inter)and 4%(intra),epinephrine4.2%and4%,and cortisol7.1% and4.3%.
Power analysis was performed on norepinephrine because it was the main outcome variable in the present study.Student’s t-test for independent samples was chosen to perform the power analysis, the?-error level was fixed at0.05,and the sample size was30participants divided equally into two groups. We tried multiple combinations of the assumed popu-lation standard deviation and effect size to make the power80%.The final result was that the present study can be80%powerful in detecting an effect size of20U when the assumed population standard deviation value was19.Data were presented as mean(sd). Statistical analysis was performed using Statistica version5.0(StatSoft,Tulsa,OK).Fitting of data to a normal distribution model was tested using the Kolmogorov-Smirnov test.Repeated measures were compared between the groups using two-way analysis of variance with post hoc Scheffe′test.Other variables were compared using two-tailed unpaired Student’s t-test.Gender was compared using?2test.P value was considered statistically significant if?0.05.
RESULTS
Thirty patients were randomized into the study,and they all completed the study.Demographic data were comparable between the two groups (Table 1).
Administration of dexmedetomidine resulted in a significant decrease in HR and MAP relative to base-line,starting after the administration of the drug and continuing to the time of the skin incision.In the control group,HR and MAP increased significantly relative to baseline,starting from skin incision and continuing until the end of the study.Patients in the control group had significantly more rapid HR and MAP levels relative to those in the DEX group after the administration of the drug and lasting for the rest of the study period (P ?0.05;Table 2).
End-tidal isoflurane concentration did not vary between groups throughout the study period (Table 2).
Plasma cortisol,epinephrine,norepinephrine,and blood glucose levels were comparable between groups at baseline.Although all aforementioned variables increased significantly relative to baseline in both groups after sternotomy and after bypass,their levels were significantly higher in the control group com-pared with the DEX group (P ?0.05;Figs.1–4).
The two groups were comparable regarding total bypass time (50?4.9min and 49?5.6min in the DEX and control groups,respectively)and aortic cross-clamping time (30?5.3min and 28?5.2min in the DEX and control groups,respectively).The dose of
nitroprusside required at weaning off CPB was signifi-cantly smaller in the DEX group (0.3?0.36?g ·kg ?1·min ?1)compared with the control group (1.3?0.68?g ·kg ?1·min ?1;P ?0.05).No patient in either group required atropine for treatment of bradycardia.
DISCUSSION
The present study demonstrated that the use of dexmedetomidine in pediatric cardiac surgery results in decreasing HR and MAP,with a concomitant reduction in cortisol,catecholamines,and blood glu-cose levels as markers of stress response.
Few reports investigated the effect of dexmedeto-midine infusion in pediatric patients undergoing non-cardiac surgery (14)and there has been no report concerning using this drug in pediatric patients un-dergoing open heart surgery.
The hemodynamic effects of dexmedetomidine are predictable from the pharmacology of ?adrenoceptor agonists and have been confirmed from previous studies in volunteers (15).These hypotensive and bradycardic effects of dexmedetomidine are presumably mediated by the sympatholytic effect of dexmedetomidine,which is confirmed in our study by significant reductions of both epinephrine and norepinephrine in the DEX group compared with the placebo group.This partly explains
Table 1.Demographic Data
DEX group (n ?15)
Control group (n ?15)
Age (yr) 2.3(1.3) 2.5(1.6)Sex (M/F)8/79/6Weight (kg)12.1(2.5)
12.7(3.0)
Diagnosis
Ventricular septal defect
65Atrial septal defect 67Subaortic membrane 23Co-triatriatum
1
Values are mean (SD )or ratio.DEX ?dexmedetomidine.
Table 2.Hemodynamic Data and End-Tidal Anesthetic Concentration Values
DEX group (n ?15)
Control group (n ?15)
Time of measurement
HR (bpm)
SBP (mm Hg)DBP (mm Hg)End-tidal iso?urane
HR (bpm)
SBP (mm Hg)DBP (mm Hg)End-tidal iso?urane
Baseline
110(11.8)102(7.7)61(4.3)0.7(0.20)113(13.5)108(7.9)65(7.5)0.7(0.16)5min after drug 106(11.5)*100(8.2)58(4.2)*?0.7(0.15)114(12.1)106(6.7)66(6.0)0.8(0.14)10min after drug 100(11.5)*?96(8.0)*?56(4.1)*?0.7(0.12)111(11.6)104(7.1)65(5.0)0.7(0.16)15min after drug 95(10.5)*?90(6.5)*?52(3.1)*?0.7(0.14)110(10.5)103(6.1)63(5.5)0.7(0.17)After skin incision 99(10.0)*?94(5.8)*56(3.2)*0.7(0.15)122(9.3)?116(5.8)?69(5.5)?0.7(0.14)After sternotomy 108(8.9)*102(7.0)*60(2.6)*0.8(0.17)130(9.6)?128(5.8)?81(3.4)?0.7(0.14)After bypass
117(11.0)*
106(5.9)*
61(3.9)*
0.8(0.15)
131(7.2)?
122(6.2)?
74(6.2)?
0.8(0.18)
Values are mean (SD ).DEX ?dexmedetomidine;HR ?heart rate;SBP ?systolic blood pressure;DBP ?diastolic blood pressure.*Signi?cantly different (P ?0.05)relative to the control group;?Signi?cantly different (P ?0.05)relative to
baseline.
Figure 1.Random blood glucose.Columns are mean,and
error bars are standard deviations.*P ?0.05compared with control group;?P ?0.05compared with baseline in the same group.
why patients in the control group required more vaso-dilator than those in the DEX group.Our results are consistent with those of another study (16),which showed that dexmedetomidine infusion decreased the plasma level of catecholamine in healthy volunteers.Activation of the hypothalamo-pituitary-adrenal axis and cortisol secretion associated with surgical trauma are very important perioperative stress re-sponses.Dexmedetomidine was not found to affect the process of steroidogenesis,as proven by the work of Venn et al.(17),who demonstrated that dexmedeto-midine did not affect the response to the adrenocorti-cotropic hormone stimulation test.However,patients receiving dexmedetomidine had significantly lower intraoperative cortisol levels as compared with those who did not receive the drug before surgery (18).This supports our findings that dexmedetomidine admin-istration resulted in lower levels of stress response markers in this pediatric population.
Alpha-2adrenoceptor agonists can cause hypergly-cemia in humans (19,20).The mechanism is thought to involve postsynaptic ?2-adrenoceptor stimulation of pancreatic ?cells,which inhibits insulin release.Inter-estingly,we found that dexmedetomidine infusion did inhibit the hyperglycemic response to surgery and CPB significantly more than placebo,and this may reflect attenuation of sympathoadrenal response.
There are several limitations in the present study
that should be considered.The most important is that it was performed in simple,relatively short proce-dures and in patients with relatively good cardiac function.Indeed patients with more complex cardiac lesions may be at high risk for developing significant bradycardia and hypotension that may need interven-tion when using dexmedetomidine.
We concluded that intraoperative dexmedetomi-dine infusion can be a useful adjuvant in pediatric cardiac anesthesia because it attenuates the hemody-namic and neuroendocrinal response of surgical trauma and CPB.Further studies are required to deter-mine the safety and efficacy of using dexmedetomidine infusion in more complex pediatric cardiac procedures.
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Figure 3.Plasma epinephrine level.Columns are mean,and error bars are standard deviations.*P ?0.05compared with control group;?P ?0.05compared with baseline in the same
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Figure 4.Plasma norepinephrine level.Columns are mean,and error bars are standard deviations.*P ?0.05compared with control group;?P ?0.05compared with baseline in the same
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Figure 2.Plasma cortisol level.Columns are mean,and error bars are standard deviations.*P ?0.05compared with control group;?P ?0.05compared with baseline in the same group.
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metabolic effects of clonidine and adenosine in man.Horm Metab Res1993;25:90–5.
五年级上册成语解释及近义词反义词和造句大全 囫囵吞枣；【解释】：囫囵：整个儿。把枣整个咽下去，不加咀嚼，不辨味道。比喻对事物不加分析考虑。【近义词】：不求甚解【反义词】融会贯穿[造句];学习不能囫囵吞枣而是要精益求精 不求甚解；bùqiúshènjiě【解释】：甚：专门，极。只求明白个大概，不求完全了解。常指学习或研究不认真、不深入【近义词】：囫囵吞枣【反义词】：精益求精 造句；1；在学习上，我们要理解透彻，不能不求甚解 2；学习科学文化知识要刻苦钻研，深入领会，不能粗枝大叶，不求甚解。 千篇一律；【解释】：一千篇文章都一个样。指文章公式化。也比喻办事按一个格式，专门机械。 【近义词】：千人一面、如出一辙【反义词】：千差万别、形形色色 造句；学生旳作文千篇一律，专门少能有篇与众不同旳，这确实是平常旳练习太少了。 倾盆大雨；qīngpéndàyǔ【解释】：雨大得象盆里旳水直往下倒。形容雨大势急。 【近义词】：大雨如柱、大雨滂沱【反义词】：细雨霏霏牛毛细雨 造句；3月旳天说变就变，瞬间下了一场倾盆大雨。今天下了一场倾盆大雨。 坚决果断；áobùyóuyù：意思；做事果断，专门快拿定了主意，一点都不迟疑，形容态度坚决 近义词；不假思索斩钉截铁反义词；犹豫不决 造句；1看到小朋友落水，司马光坚决果断地搬起石头砸缸。2我坚决果断旳承诺了她旳要求。 饥肠辘辘jīchánglùlù【近义词】：饥不择食【反义词】：丰衣足食 造句；1我放学回家已是饥肠辘辘。2那个饥肠辘辘旳小孩差不多两天没吃饭了 滚瓜烂熟gǔnguālànshóu〔shú)【解释】：象从瓜蔓上掉下来旳瓜那样熟。形容读书或背书流利纯熟。【近义词】：倒背如流【反义词】：半生半熟造句；1、这篇课文我们早已背得滚瓜烂熟了 流光溢彩【liúguāngyìcǎi】解释；光影，满溢旳色彩，形容色彩明媚 造句：国庆节，商场里装饰旳流光溢彩。 津津有味；jīnjīnyǒuwèi解释：兴趣浓厚旳模样。指吃得专门有味道或谈得专门有兴趣。 【近义词】：兴致勃勃有滋有味【反义词】：索然无味、枯燥无味 造句；1今天旳晚餐真丰富，小明吃得津津有味。 天长日久；tiānchángrìjiǔ【解释】：时刻长，生活久。【近义词】：天长地久【反义词】：稍纵即逝 造句：小缺点假如不立即改掉, 天长日久就会变成坏适应 如醉如痴rúzuìrúchī【解释】：形容神态失常，失去自制。【近义词】：如梦如醉【反义词】：恍然大悟造句；这么美妙旳音乐，我听得如醉如痴。 浮想联翩【fúxiǎngliánpiān解释】：浮想：飘浮不定旳想象；联翩：鸟飞旳模样，比喻连续不断。指许许多多旳想象不断涌现出来。【近义词】：思绪万千 造句；1他旳话让人浮想联翩。2:这幅画饱含诗情，使人浮想联翩，神游画外，得到美旳享受。 悲欢离合bēihuānlíhé解释；欢乐、离散、聚会。泛指生活中经历旳各种境遇和由此产生旳各种心情【近义词】：酸甜苦辣、喜怒哀乐【反义词】：平淡无奇 造句；1人一辈子即是悲欢离合,总要笑口常开,我们旳生活才阳光明媚. 牵肠挂肚qiānchángguàdù【解释】：牵：拉。形容十分惦念，放心不下 造句；儿行千里母担忧，母亲总是那个为你牵肠挂肚旳人 如饥似渴rújīsìkě：形容要求专门迫切，仿佛饿了急着要吃饭，渴了急着要喝水一样。 造句；我如饥似渴地一口气读完这篇文章。他对知识旳如饥似渴旳态度造就了他今天旳成功。 不言而喻bùyánéryù【解释】：喻：了解，明白。不用说话就能明白。形容道理专门明显。 【近义词】：显而易见【反义词】：扑朔迷离造句；1珍惜时刻，好好学习，那个道理是不言而喻旳 与众不同；yǔzhòngbùtóng【解释】：跟大伙不一样。 〖近义词〗别出心裁〖反义词〗平淡无奇。造句； 1从他与众不同旳解题思路中，看出他专门聪慧。2他是个与众不同旳小孩
The way 的用法 Ⅰ常见用法： 1)the way+ that 2)the way + in which（最为正式的用法） 3)the way + 省略（最为自然的用法） 举例：I like the way in which he talks. I like the way that he talks. I like the way he talks. Ⅱ习惯用法： 在当代美国英语中，the way用作为副词的对格，“the way+ 从句”实际上相当于一个状语从句来修饰整个句子。 1)The way =as I am talking to you just the way I’d talk to my own child. He did not do it the way his friends did. Most fruits are naturally sweet and we can eat them just the way they are—all we have to do is to clean and peel them. 2）The way= according to the way/ judging from the way The way you answer the question, you are an excellent student. The way most people look at you, you’d think trash man is a monster. 3）The way =how/ how much No one can imagine the way he missed her. 4）The way =because
孩子。 Does your throat hurt you? Added the mother to the child. 女孩的表情没有任何变化，而她的目光却一直没有从我的脸上移开。 But the little girl’s expression didn’t change nor did she move her eyes from my face. 你看过她的嗓子了吗？ Have you looked? 我想看，孩子的母亲说，但看不见。 I tried to, said the mother but II couldn’t see. 这个月碰巧她上学的那个学校已经有好几例白喉病。虽然到目前为止没有人说出这件事，但很显然，我们心里都想到了。 As it happens we had been having a number of cases of diphtheria in the school to which this child went during that month and we were all, quite apparently, thinking of that, though no one had as yet spoken of the thing. 好了，我说，我们先看看嗓子吧。 Well, I said, suppose we take a look at the throat first. 我以医生特有的职业方式微笑着，叫着孩子的名字。我说，来吧，玛蒂尔达，张开嘴，让我看一下你的嗓子。 I smiled in my best professional manner and asking for the child’s first name I said, come on, Mathilda, open your mouth and let’s take a look at your throat.没有任何反应。 Nothing doing. 哦，来吧，我劝道，张大你的嘴，让我看看。看，我说着把两只手伸开，我的手里没有东西，张大嘴，让我看看。 Aw, come on, I coaxed, just open your mouth wide and let me take a look. Look, I said opening both hands wide, I haven’t anything in my hands. Just open up and let me see.
悲惨的近义词反义词和造句 导读：悲惨的近义词 悲凉(注释:悲哀凄凉：～激越的琴声。) 悲惨的反义词 幸福(注释:个人由于理想的实现或接近而引起的一种内心满足。追求幸福是人们的普遍愿望，但剥削阶级把个人幸福看得高于一切，并把个人幸福建立在被剥削阶级的痛苦之上。无产阶级则把争取广大人民的幸福和实现全人类的解放看作最大的幸福。认为幸福不仅包括物质生活，也包括精神生活;个人幸福依赖集体幸福，集体幸福高于个人幸福;幸福不仅在于享受，而主要在于劳动和创造。) 悲惨造句 1.一个人要发现卓有成效的真理，需要千百个人在失败的探索和悲惨的错误中毁掉自己的生命。 2.贝多芬的童年尽管如是悲惨，他对这个时代和消磨这时代的地方，永远保持着一种温柔而凄凉的回忆。 3.卖火柴的小女孩在大年夜里冻死了，那情景十分悲惨。 4.他相信，他们每个人背后都有一个悲惨的故事。 5.在那次悲惨的经历之后，我深信自己绝对不是那种可以离家很远的人。 6.在人生的海洋上，最痛快的事是独断独航，但最悲惨的却是回头无岸。 7.人生是艰苦的。对不甘于平庸凡俗的人那是一场无日无夜的斗
争，往往是悲惨的、没有光华的、没有幸福的，在孤独与静寂中展开的斗争。……他们只能依靠自己，可是有时连最强的人都不免于在苦难中蹉跎。罗曼·罗兰 8.伟大的心胸，应该表现出这样的气概用笑脸来迎接悲惨的厄运，用百倍的勇气来应付开始的不幸。鲁迅人在逆境里比在在顺境里更能坚强不屈。遇厄运时比交好运时容易保全身心。 9.要抓紧时间赶快生活，因为一场莫名其妙的疾病，或者一个意外的悲惨事件，都会使生命中断。奥斯特洛夫斯基。 10.在我一生中最悲惨的一个时期，我曾经有过那类的想法：去年夏天在我回到这儿附近的地方时，这想法还缠着我;可是只有她自己的亲自说明才能使我再接受这可怕的想法。 11.他们说一个悲惨的故事是悲剧，但一千个这样的故事就只是一个统计了。 12.不要向诱惑屈服，而浪费时间去阅读别人悲惨的详细新闻。 13.那起悲惨的事件深深地铭刻在我的记忆中。 14.伟大的心胸，应该用笑脸来迎接悲惨的厄运，用百倍的勇气来应付一切的不幸。 15.一个人要发现卓有成效的真理，需要千百万个人在失败的探索和悲惨的错误中毁掉自己的生命。门捷列夫 16.生活需要爱，没有爱，那些受灾的人们生活将永远悲惨;生活需要爱，爱就像调味料，使生活这道菜充满滋味;生活需要爱，爱让生活永远充满光明。
The way的用法及其含义（二） 二、the way在句中的语法作用 the way在句中可以作主语、宾语或表语： 1.作主语 The way you are doing it is completely crazy.你这个干法简直发疯。 The way she puts on that accent really irritates me. 她故意操那种口音的样子实在令我恼火。The way she behaved towards him was utterly ruthless. 她对待他真是无情至极。 Words are important, but the way a person stands, folds his or her arms or moves his or her hands can also give us information about his or her feelings. 言语固然重要,但人的站姿,抱臂的方式和手势也回告诉我们他(她)的情感。 2.作宾语 I hate the way she stared at me.我讨厌她盯我看的样子。 We like the way that her hair hangs down.我们喜欢她的头发笔直地垂下来。 You could tell she was foreign by the way she was dressed. 从她的穿著就可以看出她是外国人。 She could not hide her amusement at the way he was dancing. 她见他跳舞的姿势，忍俊不禁。 3.作表语 This is the way the accident happened.这就是事故如何发生的。 Believe it or not, that's the way it is. 信不信由你, 反正事情就是这样。 That's the way I look at it, too. 我也是这么想。 That was the way minority nationalities were treated in old China. 那就是少数民族在旧中
定冠词the的用法： 定冠词the与指示代词this ,that同源,有“那(这)个”的意思,但较弱,可以和一个名词连用,来表示某个或某些特定的人或东西. (1)特指双方都明白的人或物 Take the medicine.把药吃了. (2)上文提到过的人或事 He bought a house.他买了幢房子. I've been to the house.我去过那幢房子. (3)指世界上独一无二的事物 the sun ,the sky ,the moon, the earth (4)单数名词连用表示一类事物 the dollar 美元 the fox 狐狸 或与形容词或分词连用,表示一类人 the rich 富人 the living 生者 (5)用在序数词和形容词最高级,及形容词等前面 Where do you live?你住在哪? I live on the second floor.我住在二楼. That's the very thing I've been looking for.那正是我要找的东西. (6)与复数名词连用,指整个群体 They are the teachers of this school.(指全体教师) They are teachers of this school.(指部分教师) (7)表示所有,相当于物主代词,用在表示身体部位的名词前 She caught me by the arm.她抓住了我的手臂. (8)用在某些有普通名词构成的国家名称,机关团体,阶级等专有名词前 the People's Republic of China 中华人民共和国 the United States 美国 (9)用在表示乐器的名词前 She plays the piano.她会弹钢琴. (10)用在姓氏的复数名词之前,表示一家人 the Greens 格林一家人(或格林夫妇) (11)用在惯用语中 in the day, in the morning... the day before yesterday, the next morning... in the sky... in the dark... in the end... on the whole, by the way...
The use of force 大意: Mathilda had been ill for three days. Her mother had given her some medicine, but it didn’t do any good. So they had to ask the doctor to come. There had been a number of cases of diphtheria in Mathilda School and two of them had been dead. When the doctor arrived at Olson’s home, he wanted to examine Mathilda throat first. But no matter how he coaxed, She wouldn’t open her mouth. So the doctor had to get the tongue depressor into her mouth. But Mathilda reduced it to splinters. In orde r to protect Mathilda herself and other children, the doctor had to make sure whether she had diphtheria or not, so that he could treat her in time. Letting Mathilda‘s father hold her wrists he tried his best to open her mouth and found she really had diphtheria. This story made us can think such a question that something in life can’t only depend on self-willingness. Under some circumstances, certain force seems necessary. 对医生的评价:After the doctor arrived at the girl’s home, he wanted to see her throat. As there had been a number of cases of diphtheria in the school to which the girl went during that month, the doctor also thought that of the girl. So he smiled to the girl and asked her to open her mouth and let him have a look at her throat. No matter how the doctor coaxed, the girl shut her mouth firmly. Thinking that the girl might have diphtheria and possibly die of it, the doctor decided to use force to open her mouth. He had seen at least two children lying dead in bed of neglect in such cases. He felt that he must get a diagnosis now. So he grasped the girl’s head with his left hand and tried to get the wooden tongue depressor between her teeth. But when the doctor got the wooden spatula behind her last teeth. She gripped the blade between her molars and reduced it to splinters. In the final unreasoning assault the doctor outer powered the girl. He forced the heavy silver spoon back of her teeth and down her throat till she gagged. Her both tonsils were covered with membrane. From that the doctor had done, I thought he was a responsible person. In order to save the lives of the patients, especially those children who did not know how to co-operate with the doctor, he had to take some measure. Otherwise a good or suitable time of treatment would be missed. The doctor appears to be compassionate and keen to human behavior, characteristic of a good doctor, though he is also undeniably blunt and slightly prejudiced. 思想: Though there are reasons often justifiable, what compels the use of force against others isn't simply altruism alone. The overall theme of the story revolves around power and submission and the doctor's unnerved feeling following the forceful encounter. 作者如何写的: The story is narrated in first person by a doctor, who is answering a house visit to see a sick girl. Williams uses interior monologue as a "stream-of-consciousness" tool reflects the narrator's experience of dialogue and gives insight into the character and his appraisal of the situations he encounters. The story is written without the use of quotation marks, and the dialogue is not distinguished from the narrator's comments. The story is rendered from the subjective point of view of the doctor, and explores his subdued enjoyment of forcefully subduing the stubborn child in an attempt to acquire the throat sample.
“tｈｅwａｙ+从句”结构的意义及用法 首先让我们来看下面这个句子: Ｒead the foｌloｗｉnｇpassagｅａnd talkａbout ｉt wi ｔh your classmaｔes．Try tｏｔeｌl whaｔyｏu thiｎk ｏf Tom aｎd ｏｆｔhe ｗay the chiｌｄrenｔrｅated ｈim. 在这个句子中，ｔhe waｙ是先行词,后面是省略了关系副词that或in whｉch的定语从句。 下面我们将叙述“the ｗaｙ+从句”结构的用法。 1.tｈe wａy之后，引导定语从句的关系词是tｈat而不是hoｗ,因此，<<现代英语惯用法词典＞＞中所给出的下面两个句子是错误的：Ｔhｉs is ｔｈeｗayｈowｉtｈａppened. This is the way how he ａlwａｙs treats me. 2．在正式语体中,thaｔ可被in which所代替;在非正式语体中，ｔhat则往往省略。由此我们得到theｗay后接定语从句时的三种模式：1) tｈe ｗaｙ＋ｔhａt-从句２）the way +ｉn whiｃh－从句3) the ｗay +从句 例如：Ｔｈe way(in whiｃh ，thａt) ｔhｅｓｅｃomｒade ｓloｏｋａｔｐrobｌems is wrong．这些同志看问题的方法
不对。 Ｔｈｅｗａy(that ,ｉn ｗhiｃh)yoｕ’ｒe doinｇit is comple ｔeｌy crａzy.你这么个干法,简直发疯。 Wｅａdmiｒｅd him for thｅｗay ｉｎｗhｉch he fａｃeｓdiｆficultieｓ． Waｌlａｃe ａｎd Ｄarwiｎｇreed ｏn the way ｉｎwhi ｃh ｄｉfｆｅrｅnt forms ｏf life had ｂegｕn.华莱士和达尔文对不同类型的生物是如何起源的持相同的观点。 Thｉs is ｔｈe ｗaｙ（tｈａｔ) hｅdｉd it. I lｉkeｄｔhe waｙ(ｔhat) ｓｈeｏｒganized ｔhe ｍeetｉng． 3.theｗay(tｈat)有时可以与hｏw(作“如何”解）通用。例如： That’s tｈe ｗaｙ(tｈaｔ) shｅspoke. = Tｈat’s how shｅspoke.
知己的近义词反义词及知己的造句 本文是关于知己的近义词反义词及知己的造句，感谢您的阅读！ 知己的近义词反义词及知己的造句知己 基本解释：顾名思义是了解、理解、赏识自己的人，如"知己知彼，百战不殆";更常指懂你自己的挚友或密友，它是一生难求的朋友，友情的最高境界。正所谓:"士为知己者死"。 1.谓了解、理解、赏识、懂自己。 2.彼此相知而情谊深切的人。 【知己近义词】 亲信，好友，密友，心腹，挚友，深交，相知，知交，知友，知心，知音，石友，老友，至友 【知己反义词】 仇人敌人陌路 【知己造句】 1、我们想要被人爱、想拥有知己、想历经欢乐、想要安全感。 2、朋友本应是我们的亲密知己和支持者，但对于大多数人来说，有一些朋友比起帮助我们，更多的却是阻碍。 3、那么，为什么你就认为，随着年龄的增长，比起女人来男人们的知己和丰富的人际关系更少，因此一般容易更孤独呢？ 4、他成了我的朋友、我的知己、我的顾问。 5、无论在我当州长还是总统的时候，布鲁斯都是我的密友、顾问和知己。他这样的朋友人人需要，也是所有总统必须拥有的。
6、波兰斯基有着一段声名卓著的电影生涯，也是几乎所有电影界重要人物们的挚友和同事，他们是知己，是亲密的伙伴。 7、搜索引擎变成了可以帮追我们的忏悔室，知己，信得过的朋友。 8、这样看来，奥巴马国家安全团队中最具影响力的当属盖茨了――但他却是共和党人，他不会就五角大楼以外问题发表看法或成为总统知己。 9、我们的关系在二十年前就已经和平的结束了，但在网上，我又一次成为了他精神层面上的评论家，拉拉队，以及红颜知己。 10、这位“知己”，作为拍摄者，站在距离电视屏幕几英尺的地方对比着自己年轻版的形象。 11、父亲与儿子相互被形容为对方的政治扩音筒、知己和后援。 12、这对夫妻几乎没有什么至交或知己依然在世，而他们在后纳粹时期的德国也不可能会说出实话的。 13、她把我当作知己，于是，我便将她和情人之间的争吵了解得一清二楚。 14、有一种友谊不低于爱情；关系不属于暖昧；倾诉一直推心置腹；结局总是难成眷属；这就是知己！ 15、把你的治疗师当做是可以分享一切心事的知己。 16、莉莉安对我敞开心胸，我成了她的知己。 17、据盖洛普民意调查显示，在那些自我认同的保守党人中，尽管布什仍维持72%支持率，但他在共和党领导层中似乎很少有几位知
表示“方式”、“方法”，注意以下用法： 1.表示用某种方法或按某种方式，通常用介词in(此介词有时可省略)。如： Do it (in) your own way. 按你自己的方法做吧。 Please do not talk (in) that way. 请不要那样说。 2.表示做某事的方式或方法，其后可接不定式或of doing sth。 如： It’s the best way of studying [to study] English. 这是学习英语的最好方法。 There are different ways to do [of doing] it. 做这事有不同的办法。 3.其后通常可直接跟一个定语从句(不用任何引导词)，也可跟由that 或in which 引导的定语从句，但是其后的从句不能由how 来引导。如： 我不喜欢他说话的态度。 正：I don’t like the way he spoke. 正：I don’t like the way that he spoke. 正：I don’t like the way in which he spoke. 误：I don’t like the way how he spoke. 4.注意以下各句the way 的用法： That’s the way (=how) he spoke. 那就是他说话的方式。 Nobody else loves you the way(=as) I do. 没有人像我这样爱你。 The way (=According as) you are studying now, you won’tmake much progress. 根据你现在学习情况来看，你不会有多大的进步。 2007年陕西省高考英语中有这样一道单项填空题： ——I think he is taking an active part insocial work. ——I agree with you_____. A、in a way B、on the way C、by the way D、in the way 此题答案选A。要想弄清为什么选A，而不选其他几项，则要弄清选项中含way的四个短语的不同意义和用法，下面我们就对此作一归纳和小结。 一、in a way的用法 表示：在一定程度上，从某方面说。如： In a way he was right.在某种程度上他是对的。注：in a way也可说成in one way。 二、on the way的用法 1、表示：即将来(去)，就要来(去)。如： Spring is on the way.春天快到了。 I'd better be on my way soon.我最好还是快点儿走。 Radio forecasts said a sixth-grade wind was on the way.无线电预报说将有六级大风。 2、表示：在路上，在行进中。如： He stopped for breakfast on the way.他中途停下吃早点。 We had some good laughs on the way.我们在路上好好笑了一阵子。 3、表示：(婴儿)尚未出生。如： She has two children with another one on the way.她有两个孩子，现在还怀着一个。 She's got five children，and another one is on the way.她已经有5个孩子了，另一个又快生了。 三、by the way的用法
‘Unit 1 Text A The Use of Force 他们是我的新病人，我所知道的只有名字，奥尔逊。 They were new patients to me, all I had was the name, Olson. 请您尽快赶来，我女儿病得很重。 “Please come down as soon as you can, my daughter is very sick.” 当我到达时，孩子的母亲迎接了我，这是一位看上去惊恐不安的妇人，衣着整洁却一脸忧伤的神色她只是说，这位就是医生吗？ When I arrived I was met by the mother, a big startled looking woman, very clean and apologetic who merely said, Is this the doctor? 然后带我进了屋。 And let me in. 在后面，她又说到，请你一定要原谅我们，医生，我们让她呆在厨房里，那儿暖和，这里有时很潮湿。 In the back, she added. Y ou must excuse us, doctor, we have her in the kitchen where it is warm. It is very damp here sometimes. 在厨房的桌子旁边，这个孩子穿得严严实实的，坐在她父亲的腿上。 The child was fully dressed and sitting on here father’s lap near the kitchen table. 他父亲试图站起来，但我向他示意不用麻烦，然后我脱下外套开始检查。 He tried to get up, but I motioned for him not to bother, took off my overcoat and started to look things over. 我能够觉察出他们都很紧张，而且用怀疑的眼光上下打量着我。 I could see that they were all very nervous, eyeing me up and down distrustfully. 在这种情形下，他们通常不会提供太多的情况，而是等着我告诉他们病情，这就是为什么他们会在我身上花3美元。 As often, in such cases, they weren’t telling me more than they had to, it was up to me to tell them; that’s why they were spending three dollars on me. 这个孩子用她那冷漠而镇定的目光目不转睛地盯着我，脸上没有任何表情。 The child was fairly eating me up with her cold, steady eyes, and no expression on her face whatever. 她纹丝不动，内心似乎很平静。这是一个非常惹人喜爱的小东西，外表长得象小牛一样结实。 She did not move and seemed, inwardly, quiet; an unusually attractive little thing, and as strong as a heifer in appearance. 但是她的脸发红，而且呼吸急促，我知道她在发着高烧。 But her face was flushed, she was breathing rapidly, and I realized that she had a high fever. 她长着一头漂亮浓密的金发，就像刊登在广告插页上和周日报纸图片版上的那些孩子一样。 She had magnificent blonde hair, in profusion. One of those picture children often reproduced in advertising leaflets and the photogravure sections of the Sunday papers.
仿照的近义词反义词和造句 仿照的近义词 【仿制解释】：仿造：～品 【模仿解释】：个体自觉或不自觉地重复他人的行为的过程。是社会学习的重要形式之一。尤其在儿童方面，儿童的动作、语言、技能以及行为习惯、品质等的形成和发展都离不开模仿。可分为无意识模仿和有意识模仿、外部模仿和内部模仿等多种类型。 仿照的反义词 【独创解释】：独特的创造：～精神ㄧ～一格。 仿照造句 一、老师让我们仿照黑板上的图画一幅画。 二、仿照下面的句式，以“只有”开头，写一结构与之相似的复句。 三、仿照例句的句子，在下面两句的横线上补写相应的内容。 四、仿照例句，以“记忆”或“友情”开头，另写一句话。 五、仿照下面两个例句，用恰当的词语完成句子，要求前后语意关联。 六、仿照开头两句句式，通过联想，在后面两句横线上填上相应的词语。 七、仿照所给例句，用下面的词展开联想，给它一个精彩的解释。 八、仿照例句，以“你”开头，另写一个句子。 九、仿照下列句式，续写两个句子，使之与前文组成意义相关的.句子。 十、我们也仿照八股文章的笔法来一个“八股”,以毒攻毒,就叫做八大罪状吧。
十一、仿照例句，任选一种事物，写一个句子。 十二、仿照下面一句话的句式和修辞，以“时间”开头，接着写一个句子。 十三、仿照例句，以“热爱”开头，另写一句子。 十四、仿照下面的比喻形式，另写一组句子。要求选择新的本体和喻体，意思完整。 十五、根据语镜，仿照划线句子，接写两句，构成语意连贯的一段话。 十六、仿照下面句式，续写两个句式相同的比喻句。 十七、自选话题，仿照下面句子的形式和修辞，写一组排比句。 十八、仿照下面一句话的句式，仍以“人生”开头，接着写一句话。 十九、仿照例句的格式和修辞特点续写两个句子，使之与例句构成一组排比句。 二十、仿照例句，另写一个句子，要求能恰当地表达自己的愿望。 二十一、仿照下面一句话的句式，接着写一句话，使之与前面的内容、句式相对应，修辞方法相同。 二十二、仿照下面一句话的句式和修辞，以“思考”开头，接着写一个句子。 二十三、仿照下面例句，从ABCD四个英文字母中选取一个，以”青春”为话题，展开想象和联想，写一段运用了比喻修辞格、意蕴丰富的话，要求不少于30字。 二十四、仿照下面例句，另写一个句子。 二十五、仿照例句，另写一个句子。 二十六、下面是毕业前夕的班会上，数学老师为同学们写的一句赠言，请你仿照它的特点，以语文老师的身份为同学们也写一句。
The way的用法及其含义（一） 有这样一个句子：In 1770 the room was completed the way she wanted. 1770年，这间琥珀屋按照她的要求完成了。 the way在句中的语法作用是什么？其意义如何？在阅读时，学生经常会碰到一些含有the way 的句子，如：No one knows the way he invented the machine. He did not do the experiment the way his teacher told him.等等。他们对the way 的用法和含义比较模糊。在这几个句子中，the way之后的部分都是定语从句。第一句的意思是，“没人知道他是怎样发明这台机器的。”the way的意思相当于how；第二句的意思是，“他没有按照老师说的那样做实验。”the way 的意思相当于as。在In 1770 the room was completed the way she wanted.这句话中，the way也是as的含义。随着现代英语的发展，the way的用法已越来越普遍了。下面，我们从the way的语法作用和意义等方面做一考查和分析： 一、the way作先行词，后接定语从句 以下3种表达都是正确的。例如：“我喜欢她笑的样子。” 1. the way+ in which +从句 I like the way in which she smiles. 2. the way+ that +从句 I like the way that she smiles. 3. the way + 从句(省略了in which或that) I like the way she smiles. 又如：“火灾如何发生的，有好几种说法。” 1. There were several theories about the way in which the fire started. 2. There were several theories about the way that the fire started.
第一单元 一、英译汉 Aristotle was an ancient Greek philosopher and scientist. 亚里士多德是古希腊的哲学家和科学家。 His writings cover many subjects, including physics, biology, zoology, logic, ethics, poetry, theater, music, linguistics, politics and government, and constitute the first comprehensive system of Western philosophy. 他的作品涵盖了许多学科，包括物理学、生物学、动物学、逻辑学、伦理学、诗歌、戏剧、音乐、语言学、政治和政府，构成了第一个综合的西方哲学体系。 Aristotle was the first to classify areas of human knowledge into distinct disciplines such as mathematics, biology, and ethics. 亚里士多德是第一个将人类的知识领域划分为不同学科的人，如数学，生物学和伦理学。 He believed all people's concepts and all their knowledge were ultimately based on perception. 他相信人所有的观念和所有的知识在根本上都是基于感知能力。 His views on natural sciences laid the groundwork for many of his works. 他对自然科学的看法构成了他许多作品的基础。 He contributed to almost every field of human knowledge in his era. 他几乎对他所处时期的每一个人类知识领域都作出了贡献。 His works contain the earliest known formal study of logic, and even today all aspects of Aristotle's philosophy continue to be the important subject of academic study. His philosophy had a long-lasting influence on the development of all Western philosophical theories.