舒芬太尼用于局麻手术中镇静和镇痛的研究

目的评价舒芬太尼对局麻手术患者的镇静和镇痛效果。方法60例ASAⅠ或Ⅱ级择期整形外科手术患者,男21例,女39例,随机均分为芬太尼恒速输注组(F组),舒芬太尼恒速输注组(S组),舒芬太尼靶控输注(TCI)组(TCI组)。在局部麻醉前5min,F组用负荷剂量芬太尼1μg/kg,随后起始速率1μg.kg-1.h-1持续输注;S组负荷剂量舒芬太尼0.1μg/kg,起始速率0.1μg.kg-1.h-1持续输注;TCI组起始血浆靶浓度0.2ng/ml,随后减为0.1ng/ml维持。各组均静脉复合咪唑安定。结果在局麻时(T1)和手术中(T2),TCI组VAS显著低于其他两组(P<0.01),Ramsay达Ⅳ级的例数显著多于F组(P<0.05)。在T1时点,TCI组咪唑安定用量及术中总用量较其他两组少(P<0.01),阿片药总用量较F组少(P<0.05)。术后24h随访TCI组中对T1、T2完全遗忘例数较F组多(P<0.05)。结论舒芬太尼可以安全有效用于镇静和镇痛,TCI效果更佳。     

The use of ketamine and midazolam for analgesia and sedation in ventilated patients subject to obligatory treatment with catecholamines

This study was undertaken to compare two regimens for analgesic sedation in intensive care patients with exogenous catecholamine therapy, giving special regard to catecholamine demand and hemodynamic parameters. A total of 20 ventilated patients in a surgical intensive care unit were investigated in a prospectively randomized design. Exogenous catecholamine therapy with epinephrine and/or norepinephrine was started at systolic pressure (SAP) less than 85 mmHg or mean arterial pressure (MAP) less than 65 mmHg to maintain cardiovascular function. For analgesic sedation, patients received bolus injections of about 0.2 mg/h fentanyl and 2.5 mg/h midazolam (fentanyl group, n = 10) or an infusion of about 50 mg/h ketamine and 2.5 mg/h midazolam by syringe pump (ketamine group, n = 10). Before the investigation, all patients received fentanyl and midazolam. The study period was 48 h. During the course of the study, mean catecholamine dosage increased significantly in the fentanyl group from 12.1 to 16.3 micrograms/min (+33%, P = 0.003). In the ketamine group, mean catecholamine dosage decreased from 43.9 to 38 micrograms/min (-13%, P = 0.19). No significant differences in group levels or time course were observed with regard to MAP, heart rate, cardiac index, pulmonary capillary wedge pressure, and shunt volume. Levels of pulmonary artery pressure (PAP) were comparable in both groups (ketamine group 29 mmHg, fentanyl group 26 mmHg). In time course, PAP increased by about 5 mmHg in the ketamine group but not in the fentanyl group (P = 0.009). The average central venous pressure (CVP) was 12 mmHg in both groups. At the end of the investigation, CVP decreased in the fentanyl group and increased in the ketamine group (P = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Nasal midazolam and ketamine for paediatric sedation during computerised tomography

We have studied the sedation achieved with a mixture of midazolam (0.56 mg–kg^-1) and ketamine (5 mg kg^-1) administered nasally in 30 children weighing less than 16 kg undergoing computerised tomography. Assessment was two fold using a visual analogue scale; the radiologist/radiographer rated the exam from "failed examination" to "perfect working conditions" while the anesthetist's assessment ranged from "poor sedation" to "perfect sedation with clinical well being". This new method proved to be effective alone in 83% of the cases and there were no complications. The rapid onset obtained after intranasal midazolam and ketamine offers advantages over orally or rectally administered drugs. The absence of respiratory depression and oxygen desaturation suggests that this technique is safe and efficient in the CT room with its particular working conditions.     

雷米芬太尼与咪唑安定辅助局部麻醉镇痛镇静的输注方式探讨

目的探讨雷米芬太尼和咪唑安定辅助局部麻醉手术镇静镇痛的输注方式。方法172例局麻择期手术成年患者随机分为R0.0375、R0.05、R0.0625、R0.075四组,分别输注雷米芬太尼0.0375、0.05、0.0625和0.075μg·kg-1.min-1,并接受咪唑安定0.025mg·kg-1.h-1输注。如果术中患者疼痛的11点数字评分(NRS)>3,单次注射雷米芬太尼10μg;如果术中患者改良的OAA/S镇静评分<2,单次注射咪唑安定0.5mg。结果与R0.0375、R0.05组相比,R0.0625、R0.075组患者因呼吸抑制需减慢或暂停雷米芬太尼输注的发生率显著增加(P<0.05)。无一例患者发生过度镇静。术中知晓的发生率与雷米芬太尼的持续输注剂量成反比,但R0.05、R0.0625、R0.075三组间差异无统计学意义。结论在给予负荷剂量的咪唑安定0.025mg/kg和雷米芬太尼0.5μg/kg后,最好以咪唑安定0.025mg·kg-1.h-1和雷米芬太尼0.05μg·kg-1.min-1的剂量输注,然后根据镇静水平或疼痛程度给予单次剂量的咪唑安定0.5mg或单次剂量的雷米芬太尼10μg。     

Dexmedetomidine and ketamine for sedation during spinal anesthesia in children

Study ObjectiveTo evaluate the combination of dexmedetomidine and ketamine for sedation during lumbar puncture and sedation for spinal anesthesia in children.DesignRetrospective analysis of quality assurance data sheets and anesthetic records.SettingDeveloping countries with the humanitarian group, Kids First.Patients12 infants and children, ranging in age from two to 9 years.InterventionsA bolus dose of ketamine (two mg/kg) and dexmedetomidine (one μg/kg) was given over three minutes followed by a continuous infusion of dexmedetomidine (two μg/kg/hr for the first 30 min, followed by one μg/kg/hr for the duration of the case). Supplemental analgesia/sedation was provided by ketamine (0.5 mg/kg) as needed.MeasurementsThe need for supplemental ketamine, the ability to complete the procedure, and heart rate (HR), blood pressure, end-tidal carbon dioxide (ETCO₂), and oxygen saturation values were recorded.Main ResultsEffective sedation for lumbar puncture and performance of spinal anesthesia were achieved in all patients. One patient required a supplemental dose of ketamine (0.5 mg/kg). Following the bolus dose of ketamine and dexmedetomidine, HR increased by 11 ± 4 bpm. The greatest HR increase was 20 bpm. No patient had a HR increase ≥ 20% from baseline. The HR decrease was ≤ 30 bpm in 10 of the 12 patients, and the greatest HR decrease was 58 bpm. Systolic blood pressure (SBP) increased from baseline by 10 ± 3 mmHg after administration of the bolus dose of ketamine and dexmedetomidine. During the subsequent dexmedetomidine infusion, SBP decreased by 11 ± 9 mmHg. No patient's respiratory rate decreased to less than 10 breaths/min or increased above 24 breaths/min during the procedural sedation. The highest ETCO₂ was 45 ± 2 mmHg (P < 0.0001). Oxygen saturation remained ≥ 95% during the procedure in all patients.ConclusionA combination of ketamine and dexmedetomidine provides effective sedation during spinal anesthesia in infants and children, with limited effects on cardiovascular and ventilatory function.     

A comparison of midazolam and diazepam for sedation during locoregional anesthesia

Midazolam is a recently introduced benzodiazepine with a half life of 1-4 hours. Midazolam (0.15 mg/kg) has been compared with diazepam (0.2 mg/kg) for sedation during locoregional anesthesia in 60 premedicated patients. No difference among the two groups for heart rate, bloodpressure, respiratory rate and incidence, and duration of apnoea was noticed after an i.v. bolus administration. The recovery time was equal in both groups. Midazolam was significantly less painful at injection. The sedation pattern between both groups is only different at 60 minutes, where more better sedated patients are seen in the midazolam group. Except the pain at injection and a better sedation pattern after 60 min. the differences in the other parameters are only borderline.     

瑞芬太尼复合小剂量咪达唑仑用于ERCP监护性麻醉的研究

目的观察瑞芬太尼复合小剂量咪达唑仑用于内镜逆行胰胆管造影术（ERCP）监护性麻醉的效果和安全性。方法选择66例ASAⅠ～Ⅲ级、年龄35～79岁拟在监护性麻醉下行ERCP的患者,随机均分为单纯瑞芬太尼组（R组）和瑞芬太尼复合小剂量咪达唑仑组（RM组）。R组首先持续输注瑞芬太尼0.2μg·kg^-1·min^-15min,随后减为0.15μg·kg^-1·min^-1,RM组在手术开始前静注咪达唑仑0.02mg/kg,其余用药同R组。观察两组患者麻醉前（T₀）、手术开始时（T₁）、手术开始后 min（T₂）、10min（T₃）和术毕（T₄）时MAP、HR、RR、SpO₂、脑电双频指数（BIS）以及术后改良Aldrete镇静评分、操作者对麻醉效果的满意度评分和不良反应发生情况,并记录手术操作时间和麻醉时间。结果与T₀时比较,T₁、T₂时R组MAP均明显升高（P<0.05）;T₂～T₄时两组HR均明显加快,T₁时R组HR明显快于T₀时和RM组。T₁～T₄时两组BIS均明显低于T₀时,且T₁～T₃时RM组BIS明显低于R组（P<0.05）。术后RM组遗忘评分明显高于R组（P<0.05）。R组手术操作者满意度评分明显高于RM组（P<0.05）;术毕时R组的改良Aldrete评分明显高于RM组（P<0.05）。结论瑞芬太尼0.2 μg·kg^-1·min^-1用于ERCP实施监护性麻醉可获得满意的麻醉效果,且安全性佳。     

Midazolam in combination with propofol for sedation during local anesthesia.

STUDY OBJECTIVE: To compare the sedative, anxiolytic, and amnestic effects, as well as the recovery characteristics, when midazolam (vs. a placebo) is administered to patients receiving a propofol infusion for sedation during local anesthesia. DESIGN: Randomized, double-blind, placebo-controlled study to evaluate the perioperative effects of intravenous (IV) midazolam. SETTING: Outpatient surgery center of a university-affiliated medical center. PATIENTS: One hundred thirty-nine consenting, ASA physical status I, II, and III outpatients undergoing elective surgical procedures under local anesthesia. INTERVENTIONS: Patients were randomly assigned to receive either midazolam 2 mg IV or saline 2 ml IV prior to injection of local anesthesia. Intraoperative sedation was maintained using a variable-rate propofol infusion. MEASUREMENTS AND MAIN RESULTS: Preoperative assessment of sedation, anxiety, and amnesia was performed before and after IV midazolam. Intraoperative evaluations included level of sedation, as well as cardiovascular and respiratory measurements, at 1- to 5-minute intervals during the operation. Postoperatively, recovery of psychomotor function and patients' subjective feelings were assessed using the visual analog scale and questionnaires. Amnesia was assessed using picture recall during the perioperative period. In the operating room, midazolam 2 mg IV, compared with the placebo, produced a significantly greater increase in patients' level of sedation (7 +/- 13 mm to 49 +/- 21 mm for midazolam vs. 8 +/- 11 mm to 19 +/- 21 mm for the placebo; p less than 0.01) and a greater decrease in anxiety level (62 +/- 25 mm to 21 +/- 21 mm for midazolam vs. 54 +/- 27 mm to 53 +/- 22 mm for the placebo; p less than 0.01). Although the propofol dosage requirements to maintain comparable levels of sedation were similar in both groups, midazolam decreased patients' recall of intraoperative events (e.g., propofol-induced pain on injection and discomfort with local anesthetic injection) without significantly altering cardiorespiratory parameters or prolonging times to ambulation and discharge from the outpatient facility. CONCLUSIONS: Premedication with midazolam 2 mg IV produced increased sedation, amnesia, and anxiolysis when administered immediately prior to the propofol infusion as part of a sedation technique for outpatient surgery. This combination did not prolong the recovery room stay when compared with propofol alone.     

全身麻醉诱导时咪唑安定与氯胺酮催眠相互作用的研究

目的 以等辐射分析法研究全身麻醉诱导时咪唑安定与氯胺酮之间催眠相互作用.方法 将90例择期上腹部手术患者随机分为:咪唑安定组(M组)、氯胺酮组(K组)、咪唑安定与氯胺酮复合组(C组),每组30例.麻醉诱导前各组以序贯方式给予不同剂量的咪唑安定、氯胺酮及两药复合药物(咪唑安定与氯胺酮剂量的数值比为1:10),给药2 min后开始催眠末点评估,患者对言语指令失去反应即进入催眠末点,对已进入催眠状态的患者进行麻醉末点评估,以序贯法测定三组催眠、麻醉末点半数有效剂量(ED50),以等辐射分析法分析两者之间催眠、麻醉相互作用.结果 在催眠末点:M组ED50为0.18 mg/kg(95%CI 0.09～0.31 mg/kg);K组ED50为0.50 nag/kg(95%CI 0.38～0.61 mg/kg);C组ED50为0.038/0.38 mg/kg(95%CI 0.024/0.24～0.073/0.73mg/kg),在催眠末点,C组ED50偏离相加线无统计学意义.结论 经等辐射分析法证实,咪唑安定与氯胺酮催眠效应上呈现相加作用.     

The necessity and the efficacy of the second administration of midazolam for sedation during spinal anesthesia

We investigated the necessity of the second additional administration of intravenous midazolam for sedation during spinal anesthesia and the adequate dose if necessary. Fifty patients with ages between 35 to 70 years for spinal anesthesia were administered midazolam 0.05 mg.kg-1 intravenously during surgery. Thirty-four patients opened their eyes spontaneously and to these patients midazolam 1 mg was administered every three minutes until patients closed their eyes. All 34 patients closed their eyes with 1 mg of midazolam. Patients opened their eyes again at 47 +/- 16 minutes (mean +/- SD) after the first dose (0.05 mg.kg-1) and at 24 +/- 14 minutes after the second dose (1 mg). The decreases in blood pressure, heart rate and percutaneous arterial oxygen saturation after the administration of midazolam were less after the second administration than those after the first one. The percent of patients with amnesia was larger in the patients with only first administration than those with the second dose. These results suggest that the additional dose of midazolam is not necessary after intravenous midazolam 0.05 mg.kg-1 until patients open their eyes and the additional 1 mg is useful even after patients have opened their eyes.     

不同麻醉深度指标在全麻镇静和镇痛监测中的比较

目的评价脑电双频指数(BIS)和电刺激-循环反应在全麻镇静和镇痛监测中的价值。方法20例择期手术全麻病人,将丙泊酚血浆靶浓度依次设定为1、2、3、4和5μg/ml,记录每一靶浓度下的BIS、SBP、DBP和HR值。维持意识消失时的效应室靶浓度,给予一次60mA强直电刺激,随后将雷米芬太尼效应室靶浓度依次设定为1、2、3、4和5ng/ml,达到每一靶浓度后给予一次同样电刺激,计算每次电刺激前后各指标的变化值(△BIS、△SBP、△DBP和△HR)。结果丙泊酚靶浓度依次增加,BIS值依次减少(P<0.05),两者之间呈负相关(r=-0.789,P<0.01)。不同雷米芬太尼靶浓度时,电刺激均未引起BIS的变化,但引起SBP、DBP和HR增加(P<0.05或P<0.01)。随着雷米芬太尼靶浓度增加,△SBP、△DBP和△HR呈下降趋势。雷米芬太尼靶浓度与△SBP和△HR之间呈负相关(r=-0.386和-0.302,P<0.05)。结论BIS对镇静药浓度变化敏感,对疼痛刺激反应差,电刺激-循环反应能够灵敏地反映镇痛水平,所以麻醉深度监测应该针对不同成分进行多指标、多方法的综合监测。     

Dose-finding study of intravenous midazolam for sedation and amnesia during spinal anesthesia in patients premedicated with intramuscular midazolam

Purpose We investigated the effective and safe dose of intravenous midazolam for sedation and amnesia during spinal anesthesia in patients premedicated with intramuscular midazolam.Methods One hundred and eighty patients aged 20–50 years scheduled for spinal anesthesia received midazolam 0.06mg·kg^–1 and atropine 0.01mg·kg^–1 intramuscularly 15min before entering the operating room. Spinal anesthesia was performed with 0.5% hyperbaric tetracaine. Five minutes after starting surgery, midazolam 0 (control group), 0.01, 0.02, 0.03, 0.04, or 0.05mg·kg^–1 was intravenously administered (30 patients each). Blood pressure, heart rate, respiratory rate, percutaneous oxygen saturation (S_{p O 2}), verbal response, eyelash reflex, and involuntary body movement were measured every 5min for 30min. Memory during surgery was also investigated.Results The number of the patients with loss of verbal response, with loss of eyelash reflex, and with no memory during surgery were significantly larger in the groups receiving midazolam 0.03mg·kg^–1, 0.04mg·kg^–1, and 0.02mg·kg^–1, respectively. The decrease in blood pressure or increase in respiratory rate with decrease in S_{p O 2} was significantly larger in the groups receiving midazolam 0.03mg·kg^–1 or 0.05mg·kg^–1, respectively.Conclusion For sedation and amnesia of the patients aged 20–50 years in spinal anesthesia with about 1h duration receiving intramuscular midazolam 0.06mg·kg^–1 as a premedication, intravenous midazolam 0.02mg·kg^–1 might be effective and safe.     

Respiratory interaction after spinal anesthesia and sedation with midazolam.

The combined use of midazolam and spinal anesthesia is common in clinical practice. Despite the known potential for each to alter ventilation, the effect of their interaction has not been examined. Nineteen healthy volunteers were studied to assess the impact of intravenous midazolam (0.05 or 0.075 mg/kg), spinal anesthesia (T3-T8; mean level, T6), and their combination on resting ventilation and ventilatory responses to progressive hyperoxic hypercapnia. Resting ventilatory pattern was altered significantly by each condition. Midazolam caused a 29% decrease in resting tidal volume and a 24% decrease in mean inspiratory flow rate, while respiratory frequency increased by 14% and minute ventilation remained unchanged. By contrast, spinal anesthesia alone caused a 32% increase in tidal volume, a 24% increase in mean inspiratory flow rate, and a 13% increase in minute ventilation accompanied by a 14% decrease in respiratory frequency. The combination of midazolam and spinal anesthesia caused a significant decrease in minute ventilation (19%), tidal volume (28%), and mean inspiratory flow rate (27%), all of which were significantly more than the predicted sum of the individual interventions. Midazolam and spinal anesthesia each produced a significant decrease in hypercapnic ventilatory response slope, whereas their combination provoked no net change in hypercapnic ventilatory response slope. Interpretation of the hypercapnic ventilatory response data was complicated by shifts in the position of the ventilatory response curve, particularly under the spinal anesthesia condition. It is concluded that intravenous midazolam depresses resting ventilation, spinal anesthesia stimulates resting ventilation, and their combination has a modest synergistic effect of depressing resting ventilation.     

腰椎内固定术后小剂量氯胺酮对舒芬太尼皮下镇痛的影响

目的评价氯胺酮持续皮下输注对舒芬太尼皮下自控镇痛(PCSA)效应的影响,探讨氯胺酮皮下辅助镇痛的最佳剂量。方法拟行腰椎内固定术患者200例,按照随机双盲原则均分为四组:K1、K2、K3组分别以0.5、1、2μg·kg-1·min-1持续输注氯胺酮,C组输注等量生理盐水。术后均行舒芬太尼皮下自控镇痛。比较术后8、24、48h舒芬太尼用量、静息时VAS评分及不良反应情况。结果术后8～48h,C组静息VAS评分均显著高于其它三组(P<0.05或P<0.01),而K3组显著低于K1、K2(P<0.01);K2、K3组舒芬太尼累积用量显著少于C组和K1组,且K3组显著少于K2组(P<0.01)。术后四组PONV发生率差异无统计学意义。K3组嗜睡发生率显著高于其它三组(P<0.05);K3组有8例(16%)复视,2例(4%)幻觉。结论氯胺酮1μg·kg-1·min-1可增强舒芬太尼PCSA效应,降低舒芬太尼需求量,且不良反应未有明显增加。     

Hypothermia during herniorrhaphy using local anesthesia with sedation

Summary General, spinal and epidural anesthesia disrupt the thermoregulatory response. The resultant decrease in core temperature places increased demands on the cardiovascular system. Virtually all of our groin hernia repairs are performed using local anesthesia. The study was designed to ascertain the impact of local anesthesia with intravenous sedation on thermo-regulation and to evaluate the efficacy of perioperative warming in these cases. Tympanic membrane temperatures were monitored in 50 consecutive inguinal herniorrhaphies performed under local anesthesia with intravenous sedation. The first group (n = 45) were not warmed. An upper body warming cover was applied in the last five cases. In the non-warmed group, a decrease in body temperature of –0.81 °C ± 0.38 was recorded. In the five warmed cases, the change in body temperature was –0.12 °C ± 0.18 °C. The results indicate that the hypothermic response during hernia repair under local anesthesia with intravenous sedation is small but significant. The perioperative use of an upper body warming cover is protective.     

Conscious sedation during ophthalmic surgery under local anesthesia

Sedation during ophthalmic local anesthesia helps to ensure comfort and cooperation during eye surgery. Sedation requirements of ophthalmic patients have changed with the popularization of newer surgical and anesthetic techniques. Many sedative agents are available to anesthesiologists including benzodiazepines, intravenous anesthetic induction agents, narcotic analgesics and a-adrenoreceptor agonists. However, there is no single ideal sedative agent, regime or protocol that can completely cater to the wide spectrum of ophthalmic procedures performed in a heterogeneous patient population. Moreover, the clinical practice of sedation during ophthalmic surgery under local anesthesia is varied and not without risk of complications and adverse events. Hence, balanced sedative techniques should only be used after careful consideration of patient profile, the type of eye surgery, and patient and surgeon preferences. Good knowledge of the pharmacology of sedative agents is fundamental to their useful clinical application.