异丙酚静脉复合麻醉在老年人胃肠镜联合检查中的应用

目的 评价异丙酚合并芬太尼静脉麻醉在老年患者胃肠镜联合检查中的效果及安全性.方法 回顾分析326例采用静脉麻醉下胃肠镜联合检查(联合检查组)老年患者的临床资料,与同期接受静脉麻醉下胃镜(胃镜组)或结肠镜检查(结肠镜组)的老年患者进行对照,比较各组血压、心率、血氧饱和度(SpO2)变化情况以及不良反应发生情况.结果 异丙酚平均用量分别为联合检查组(100.4±38.5)mg、胃镜组(130.4±50.5)mg、结肠镜组(170.3±60.3)mg,所有患者均能达到胃肠镜检查的满意镇静程度,无因麻醉并发症终止胃肠镜检查者;心率、血压变化及心血管事件发生率各组间比较,差异无统计学意义(P＞0.05);呼吸事件发生率分别为9例(3.1％)、6例(2.3％)和13例(4.0％),差异亦无统计学意义(P＞0.05).结论 在严格控制适应证、术中严密监测的条件下,应用异丙酚静脉复合麻醉对于老年患者胃肠镜联合检查是安全、有效的.     

心房颤动经导管射频消融的止痛治疗

目的研究小剂量咪唑安定联合芬太尼在心房颤动(简称房颤)经导管射频消融术中的止痛疗效及安全性。方法对50例房颤患者在CARTO指导下行环肺静脉电隔离和/或左房线性消融。消融前静脉给予1μg/kg芬太尼和0.4mg/kg咪唑安定,术中以小剂量(1μg.kg-1.h-1)芬太尼静脉维持,消融剂量1～3μg.kg.-1.h-1,消融剂量以患者无疼痛或仅有轻微疼痛掌握,特别疼痛处加用咪唑安定1mg。结果50例共隔离肺静脉204根,17例患者加做左房线性消融,9例典型心房扑动患者加做右房峡部消融,即刻电隔离成功率98.0%。手术时间262±21min,透视时间38±7min,芬太尼剂量245±32μg,咪唑安定剂量3.1±1.1mg,术中患者仅有轻微疼痛。结论小剂量咪唑安定联合芬太尼在房颤经导管射频消融术中止痛治疗安全有效。     

Chronic fentanyl application induces adrenocortical insufficiency

We report a case of a 64-year-old man with secondary adrenocortical insufficiency who has been on a chronic transdermal fentanyl treatment because of sciatic pain syndrome. Shortly before admission to our hospital, the patient had discontinued his hydrocortisone medication. Adrenal crisis was assumed and during therapy with hydrocortisone infusion, the patient recovered. We suspected an opiate-induced suppression of the hypothalamus-pituitary-adrenal (HPA) axis. Therefore, we gradually reduced the opiate dosage. After 1 week, HPA axis function was markedly improved. We conclude that opiate medication may inhibit - in a life-threatening way - the organism's ability to respond to physical, emotional or metabolic stressors.     

Catecholamine responses to anesthetic induction with fentanyl and sufentanil

In a randomized study, the authors examined the changes in plasma epinephrine and norepinephrine concentrations associated with induction of anesthesia and surgery in 33 patients with good ventricular function undergoing elective coronary artery surgery. After premedication with morphine and scopolamine, patients received either fentanyl, 100 μg/kg (n = 16), or sufentanil, 15 μg/kg, (n = 17), intravenously (IV), over 10 minutes to induce anesthesia. Metocurine, 0.42 mg/kg, IV, produced muscle relaxation. Arterial blood for plasma catecholamine determinations was drawn prior to induction, every two minutes throughout induction, one minute following endotracheal intubation, and one minute after sternotomy. Plasma epinephrine concentration was unchanged with either induction agent. Plasma norepinephrine concentration increased significantly after administration of either narcotic, peaked between six and ten minutes into induction, and returned to the preinduction value after intubation. Induction-related changes in arterial pressure and pulmonary capillary wedge pressure were significantly correlated with changes in the logarithm of plasma norepinephrine concentration. Similar degrees of endogenous norepinephrine release appear to accompany induction with equipotent doses of fentanyl and sufentanil in patients premedicated with morphine and scopolamine. Norepinephrine release may influence the hemodynamic response to induction with narcotics.     

Antifibrillatory action of the narcotic agonist fentanyl

Morphine, an opiate alkaloid with mixed mu- and delta-agonist properties, raises the ventricular fibrillation threshold in anesthetized dogs by altering autonomic tone. To elucidate further underlying structure-activity relationships, the effect of fentanyl, a nonalkaloid, mu-selective agonist in wide clinical use, was studied. Fentanyl (30 micrograms/kg) was given intravenously to 27 chloralose-anesthetized dogs, and ventricular fibrillation threshold was measured by means of the single-stimulus technique. In the baseline state fentanyl raised the ventricular fibrillation threshold by 14%. When the dogs were subjected to hemorrhagic stress, this effect was amplified to 29% (p less than 0.0001). Bilateral cervical vagotomy abolished fentanyl's antifibrillatory effect, but neither atropine sulfate (0.4 mg/kg/hr) nor atropine methylnitrate (0.5 mg/kg/hr) did so. Fentanyl's influence on the fibrillation threshold during hemorrhage was significantly reduced by bilateral stellate ganglionectomy (p less than 0.005). It is concluded that fentanyl raises the ventricular fibrillation threshold by its known sympathoinhibitory action rather than by its vagal efferent activating effect. The facts that an intact vagus is required and that hemorrhage amplifies the effect suggest that the antifibrillatory effect of fentanyl is mediated through the afferent component of the baroreflex arc.     

Conscious sedation with intermittent midazolam and fentanyl in electrophysiology procedures

OBJECTIVES: To determine the safety and efficacy of intermittent midazolam and fentanyl conscious sedation for electrophysiology procedures (EP). BACKGROUND: Intermittent midazolam and fentanyl conscious sedation was administered in 700 consecutive cases (175 radiofrequency ablations, 163 EP studies, 261 pacemakers, and 101 implantable cardioverter-defibrillators) for 471 patients (239 males, 51%) mean age 65 +/- 15 years. The mean dose of midazolam was 0.063 mg/kg/hr and fentanyl was 0.591 microgram/kg/hr. METHODS: Cardiac rate and rhythm were monitored continuously, while blood pressure and arterial oxygen saturation were noninvasively assessed every 5 minutes. Drugs were administered in aliquots of 0.5 to 2.0 mg of midazolam and 6.25 to 25 micrograms of fentanyl as determined by clinical condition every 15 to 30 minutes. RESULTS: There were no deaths. In no case was endotracheal intubation required. Mild hypoxemia (SaO2 > 80%, but < 90%) occurred in 17 cases (2.4%) and was easily reversed with verbal stimulation and oropharyngeal repositioning (12 cases, 1.7%), increased F1O2 (3 cases, 0.4%), or intravenous naloxone (2 cases, 0.3%). Reversible hypotension (systolic blood pressure < 90, but > 60 mmHg) occurred in 14 patients (2.0%) and was corrected with intravenous crystalloid bolus or flumazenil (10 cases, 1.4%) or inotrope infusion (4 cases, 0.6%). No patient stay was prolonged due to sedation. Only five patients (0.7%) had any recollection of the procedure, while two (0.3%) were aware of pain. All hypoxemic episodes occurred during the first hour, whereas 43% (6/14) of hypotensive episodes occurred after the first hour. CONCLUSION: Conscious sedation with intermittent midazolam and fentanyl is safe and efficacious for a broad range of EP procedures.     

Transdermal fentanyl in HSCT patients: an open trial using transdermal fentanyl for the treatment of oral mucositis pain

Fentanyl is a synthetic opioid that can be delivered through a transdermal therapeutic system (TTS). The aim of this study was to assess the efficacy of fentanyl TTS in treating oral mucositis pain in 75 adult hematopoietic stem cell transplant (HSCT) patients. The analysis was based on 62 patients who developed mucositis. Pain control was assessed by the patients using a visual analogue scale (VAS) from day 0 to day +33 after HSCT. Fentanyl TTS was administered at the patient's request. In all, 20 patients did not require fentanyl (group A). The first 22 patients asking for the patch received fentanyl 25 microg/h (group B) and the subsequent 20 patients received 50 microg/h (group C). There were no significant differences in pain relief between groups B and C. The expected effect of a decrease in mean pain score (mean of the VAS scores of all of the patients in the same group each day) following the application of fentanyl TTS was not noted. We can conclude that fentanyl TTS at the doses used in this study may not adequately relieve oral mucositis pain.     

Transdermal fentanyl improves management of postoperative hemorrhoidectomy pain

PURPOSE: Outpatient postoperative hemorrhoidectomy pain remains a difficult problem. The purpose of this study is to evaluate the use of transdermal fentanyl for analgesia following hemorrhoidectomy. METHODS: Patients were prospectively randomized in a double-blind fashion to one of two groups, placebo or transdermal fentanyl. Forty-two patients were eligible for the study (placebo, 21; fentanyl, 17; 4 were excluded). A visual analog scale was used to evaluate postoperative pain (0 = no pain; 10 = worst pain). RESULTS: Fewer patients in the fentanyl group (10/17) required postoperative parental narcotics than the placebo group (21/21) (P <0.05 Fisher's exact test). The amount of narcotics consumed postoperatively was significantly less in the fentanyl group (97.05 mg of meperidine ± 23.27) than in the placebo group (236.19 ± 30.46) (P <.05 Student's t-tesf). Pain scores in the fentanyl group were significantly lower (less pain) than in the placebo group (P <0.05 Kruskal-Wallis). CONCLUSION: Results indicate that use of transdermal fentanyl provides an effective analgesic alternative that improves the transition to noninvasive outpatient pain management in the hemorrhoidectomy patient.     

Tramadol combined with fentanyl in awake endotracheal intubation

Objective

To explore the feasibility and dosage of tramadol combined with fentanyl in awake endotracheal intubation.

Methods

Using Dixon’s up-and-down sequential design, the study enrolled patients from each of the 20-49, 50-60 and 70-and-above age groups scheduled for elective surgery under general anesthesia. The feasibility and dosage of tramadol combined with fentanyl in awake endotracheal intubation, guided by fiberoptic bronchoscopy, were verified.

Results

After intravenous injection with fentanyl 2.2 μg/kg and tramadol 2.0 mg/kg in the 20-49 age group, fentanyl 1.6 μg/kg and tramadol 1.9 mg/kg in the 50-69 age group and fentanyl 1 μg/kg and tramadol 1.8 mg/kg in those at the age of 70 or above, the patients achieved conscious sedation without obvious respiratory depression. Meanwhile, under these dosages, the patients could easily tolerate the thyrocricocentesis airway surface anesthesia and fiberoptic bronchoscope guided tracheal intubation. Postoperative follow-up showed that most patients had memory of the intubation process but without significant discomfort. No awake endotracheal intubation-related side effect was noted.

Conclusions

Fiberoptic bronchoscope guided nasotracheal intubation can be successfully completed with background administration of fentanyl and tramadol. However, the specific dosages need to be tailored in different age of patients.KEY WORDS : Awake endotracheal intubation, fiberoptic bronchoscope, nasotracheal intubation, fentanyl, tramadol     

单纯异丙酚与芬太尼复合异丙酚在无痛胃镜应用中的麻醉效果和安全性比较

目的 探讨单纯异丙酚与芬太尼复合异丙酚应用于无痛胃镜的效果与安全性.方法 选取80例行无痛胃镜检查的患者,随机分为甲(单纯异丙酚组)、乙(芬太尼复合异丙酚组)两组,每组40例.观察麻醉对血流动力学的影响,记录注药至睫毛反射消失时间、术毕苏醒时间、体动次数、药物总量等情况.结果 芬太尼复合异丙酚应用于无痛胃镜优于单纯异丙酚组.结论 芬太尼复合异丙酚应用于无痛胃镜的麻醉效果确切、安全可靠     

Anesthetic induction with fentanyl and intravenous lidocaine for coronary artery surgery

In a randomized, double-blind trial, 59 patients undergoing coronary artery surgery received fentanyl 10, 15, or 25 lag/kg infused over 5 minutes for anesthetic induction. Half of the patients received intravenous lidocaine, 1.5 mg/kg, 1 minute before laryngoscopy. Efficacy of induction as judged by loss of consciousness was evaluated, and hemodynamic values during induction, laryngoscopy, and tracheal intubation were recorded each minute for 10 minutes. Plasma fentanyl concentrations were determined after termination of the fentanyl infusion. Opioid induction with fentanyl was successful in 90% (18 of 20) of patients receiving 25 μg/kg, 89% (17 of 19) of patients receiving 15 μg/kg, but only 55% (11 of 20) of patients receiving 10 μg/kg (P < .01). While plasma fentanyl concentrations were proportional to the dose infused (25 ng/mL, 18 ng/mL, and 14 ng/mL in the 25, 15, and 10 μg/kg fentanyl groups, respectively), there was no relationship between plasma fentanyl concentration and hemodynamic response to laryngoscopy or intubation. Opioid induction caused a gradual decrease in blood pressure that was restored with intubation. Lidocaine partially blocked this restoration (systolic blood pressure 122 ± 5 v 138 ± 5 mmHg, lidocaine v placebo, 1 minute after laryngoscopy, P < .05). Fentanyl, 15 or 25 μg/kg, intravenously, is an effective induction agent for patients with coronary artery disease. Supplementation with intravenous lidocaine, 1.5 mg/kg, will obtund the increase in blood pressure that occurs with laryngoscopy and intubation and help prevent infrequent hypertensive responses seen with this opioid technique.     

无痛苦胃镜检查并发症临床分析

目的探讨联合应用小剂量芬太尼和异丙酚行无痛苦胃镜检查中并发症的预防和治疗。方法对3180例应用异丙酚及芬太尼静脉复合麻醉后进行胃镜检查，并观察和治疗出现的并发症。结果静注芬太尼和异丙酚后受检者血压、心率、呼吸频率均有不同程度的下降，但绝大多数在正常范围内，无须处理；有6例发生心动过缓，经静注阿托品后心率均恢复正常；1例出现呼吸暂停，经面罩加压给氧后恢复正常；血氧饱和度一过性下降3例，加大氧流量后或不需处理，即可自行恢复正常；咳嗽152例，经增加首剂用药量和避免胃镜碰撞会咽软骨和喉头后咳嗽病例明显减少；有1／3的病人诉注射部位疼痛，后我们先注射利多卡因1ml后此症状消失。膈肌痉挛5例，持续2～5min可自行缓解。结论异丙酚及芬太尼静脉复合麻醉用于胃镜检查是一种安全有效的方法。科学的防治措施是检查成功和减少并发症的关键。