右美托咪定—氯胺酮复合麻醉用于膝关节镜手术的可行性
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摘要
目的探讨右美托咪定-氯胺酮静脉复合用于膝关节镜手术麻醉的可行性。方法择期行膝关节镜手术的患者50例,年龄18～60岁,ASA Ⅰ级或Ⅱ级,随机分为右美托咪定-氯胺酮组(D-K组)和丙泊酚-芬太尼组(P-F组),每组25例。D-K组给予右美托咪定(负荷量1μg·kg-1,继以1.5μg·kg-1·h-1,持续泵注)和氯胺酮(负荷量0.5mg·kg-1,继以1mg·kg-1·h-1持续泵注)静脉复合麻醉；P-F组给予靶控输注丙泊酚(起始靶浓度3mg·L-1)和静脉注射芬太尼2μg·kg-1,复合麻醉。观察警觉与镇静(OAA/S)评分、BIS、脉搏血氧饱和度(Sp02)等指标,记录麻醉诱导时间、定向力恢复时间以及不良反应情况,术后调查手术者及患者满意度。结果D-K组患者术中呼吸维持平稳,Sp02均在96%以上,呼气末C02分压维持正常；P-F组共有19例Sp02低于90%,10例出现呼吸暂停,需要放置通气道和(或)辅助通气,2组差异显著(P<0.05)。D-K组术中血流动力学较P-F组更加稳定,但当BIS≤60时心率下降明显。D-K组麻醉诱导时间和定向力恢复时间长于P-F组(p<0.05)。2组患者及手术医师对麻醉效果的满意率相仿。结论右美托咪定-氯胺酮复合可安全用于膝关节镜手术的麻醉,对呼吸无明显抑制作用,可使血流动力学更加稳定,为此类保留自主呼吸的麻醉提供了安全保证。
Objective To investigate the feasibility of dexmedetomidine-ketamine combination in knee arthroscopy.Methods50patients with ASA I or II, aged18-60years, scheduled for knee arthroseopy were randomly divided into two groups (25patients in each), In the D-K group, dexmedetomidine (a bolus of1μg·kg-1was administered for10mins, followed by1.5μg·kg-1·h-1infusion during the operation) and ketamine (a bolus of0.5μg·kg-1was administered, followed by1μg·kg-1·h-1infusion during the operation) were applied. In the P-F group, target-controlled infusion of propofol (the target plasma concentration was set at3mg·L-1)and2μg·kg-1fentanyl were given. The observer's assessment of alertness/sedation (OAA/S) scale, bispectral index (BIS), respiratory rate(RR), end-tidal carbon dioxide tension (PETCO2), mean arterial blood pressure (MAP), pulse oxygen saturation (SpO2) and heart rate(HR) were continuously monitored. Induction time, orientation recovery time and adverse reactions were also recorded. Level of satisfaction with quality of anesthesia was evaluated by patients and surgeons.Results The patients in the group D-K did not have significant respiratory depression (SpO2≥96%and PETCO2remained normal). In the P-F group,19patients (SpO2≤90%) altogether had to insert orophatyngeal airway or give assisted ventilation. Compared with group P-F, the hemodynamic in the D-K group was more stable, but HR decreased significantly when BIS≤60。The induction time and orientation recovery time of D-K group was longer than those of P-F group (P<0.05). There was no significant difference in the level of satisfaction with quality of anesthesia evaluated by patients and surgeons between two groups.Conclusion Dexmedetomidine-ketamine combination has light influence on breathing and more stable hemodynamic and is safe and feasible in knee arthroscopy.
Objective To investigate the feasibility of dexmedetomidine-ketamine combination in knee arthroscopy.Methods50patients with ASA I or II, aged18-60years, scheduled for knee arthroseopy were randomly divided into two groups (25patients in each), In the D-K group, dexmedetomidine (a bolus of1μg·kg-1was administered for10mins, followed by1.5μg·kg-1·h-1infusion during the operation) and ketamine (a bolus of0.5μg·kg-1was administered, followed by1μg·kg-1·h-1infusion during the operation) were applied. In the P-F group, target-controlled infusion of propofol (the target plasma concentration was set at3mg·L-1)and2μg·kg-1fentanyl were given. The observer's assessment of alertness/sedation (OAA/S) scale, bispectral index (BIS), respiratory rate(RR), end-tidal carbon dioxide tension (PETCO2), mean arterial blood pressure (MAP), pulse oxygen saturation (SpO2) and heart rate(HR) were continuously monitored. Induction time, orientation recovery time and adverse reactions were also recorded. Level of satisfaction with quality of anesthesia was evaluated by patients and surgeons.Results The patients in the group D-K did not have significant respiratory depression (SpO2≥96%and PETCO2remained normal). In the P-F group,19patients (SpO2≤90%) altogether had to insert orophatyngeal airway or give assisted ventilation. Compared with group P-F, the hemodynamic in the D-K group was more stable, but HR decreased significantly when BIS≤60。The induction time and orientation recovery time of D-K group was longer than those of P-F group (P<0.05). There was no significant difference in the level of satisfaction with quality of anesthesia evaluated by patients and surgeons between two groups.Conclusion Dexmedetomidine-ketamine combination has light influence on breathing and more stable hemodynamic and is safe and feasible in knee arthroscopy.
引文
1. 庄心良,曾因明,陈伯銮.现代麻醉学[M].第3版.北京：人民卫生出版社,2003.524
2. 邢军,白勇,吴新民.雷米芬太尼抑制扩宫颈体动反应的半数有效浓度[J].临床麻醉学杂志,2008,24(1)：32～34
3. 王世端.麻醉深度监测与全麻管理[R].齐鲁医学杂志,2006,21(3)：280～282
4. Mulroy MF, Larkin KL, Hodgson PS, et al. A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy [J]. Anesth Analg,2000,91(4): 860-864.
5. Forssblad M, Jacobson E, Weidenhielm L. Knee arthroscopy with different anesthesia methods:a comparison of efficacy and cost [J]. Knee Surg Sports Traumatol Arthrosc, 2004,12(5):344-349.
6. Heidvall M, Hein A, Davidson S, et al. Cost comparison between three different gene-ral anaesthetic techniques for elective arthroscopy of the knee [J]. Acta Anaesthesiol Scand,2000,44(2):157-162.
7. Jankowski CJ, Hebl JR, Stuart MJ, et al. A comparison of psoas compartment block and spinal and general anesthesia for outpatient knee arthroscopy [J]. Anesth Analg, 2003,97(4):1003-1009.
8. Carollo DS, Nossaman BD, Ramadhyani U, et al. Dexmedetomidine:a review of clinical application [J]. Curr Opin Anaesthesiol 2008;21:457-461.
9. Venn RM, Bradshaw CJ, Spencer R, et al. Preliminary UK experience of dexmedeto-midine, a novel agent for postoperative sedation in the intensive care unit[J]. Anaesthesia 1999;54:1136-1142.
10. 芦相玉,王宏涛,王世端.比较右美托咪定、丙泊酚、咪达唑仑辅助硬膜外麻醉镇静效果[J].中国新药与临床杂志,2011,30(11)：873-877.
11. Panzer O, Moitra V, Sladen RN Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists[J]. Crit Care Clin 2009;25:451-469.
12. Mester R, Easley RB, Brady KM, et al. Monitored anesthesia care with a combination of ketamine and dexmedetomidine during cardiac catheterization [J]. Am J Ther,2008, 15(1):24-30.
13. Levanen J, Makela ML, Scheinin H. Dexmedetomidine premedication attenuates ketam-ine-induced cardiostimulatory effects and postanesthetic delirium [J]. Anesthesiology,
1995,82(5):1117-1125.
14. Koruk S, Mizrak A, Gul R, et al. Dexmedetomidine-ketamine and midazolam-ketamine combinations for sedation in pediatric patients undergoing extracorporeal shock wave lithotripsy:a randomized prospective study [J]. J Anesth,2010,24(6):858-863.
15. Ramsey MA, Luterman DL. Dexmedetomidine as a total intravenous anesthetic agent [J]. Anesthesiology,2004,101(3):787-790.
16. Hunter JC, Fontana DJ, Hedley LR, et al. Assessment of the role of alpha2-adrenoceptor subtypes in the antinocicep tive, sedative and hypothermic action of dexmedetomidine in transgenic mice [J]. B r J Pharm acol,1997;122:1339-1344.
17. Khan ZP, Ferguson CN, Jones BM. Alpha-2 and imidazoline receptor agonists. Their pharmacology and therapeutic role [J]. Anesthesia,1999,54(2):146-165.
18. Tobias JD. Dexmedetomidine:applications in pediatric critical caro and pediatri anesth-esiology [J]. Pediatric Critical Care Medicine,2007,8(2):115-131.
19. Yusuke K, Raghavendra G, Stefan R, et al. The correlation between bispectral index and observational sedation scale in volunteers sedated with dexmedetomidine and prop-ofol. [J]. Anesth Analg,2009109(6):1811-1815.
20. Guignard B, Chauvin M. Bispectral index increases and decreases are not always signs of inadequate anesthesia[J]. Anesthesiology,2000;92(3):903.
21. Hirota K, Kubota T, Ishihara H, et al. The effects of nitrous oxide and ketamine on the bispectral index and 95% spectral edge frequency during propofol-fentanyl anaesthesia[J]. Eur J Anaesthesiol 1999; 16(11):779-783.
22. Hans P, Dewandre PY, Brichant JF, et al. Comparative effects of ketamine on bispectral index and spectral entropy of the electroencephalogram under sevoflurane anaesthesia. Br J Anaesth, [J].2005;94(3):336-340.
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2. Venn RM, Bradshaw CJ, Spencer R et al. Preliminary UK experience of dexmedetomi-dine, a novel agent for postoperative sedation in the intensive care unit. [J]. Anaesthes-ia 1999:54:1136-1142.
3. Panzer O, Moitra V, Sladen RN. Pharmacology of sedative-analgesic agents:dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists [J]. Crit Care Clin 2009;25:451-469.
4. Gertler R, Brown HC, Mitchell DH et al. Dexmedetomidine:a novel sedative-analgesic agent [J]. Proc (Bayl Univ Med Cent) 2001:14:13-21.
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7. Vilo S, Rautiainen P, Kaisti K et al. Pharmacokinetics of intravenous dexmedetomidine in children under 11 yr of age [J]. Br J Anaesth 2008; 100:697-700.
8. De Wolf AM, Fragen RJ, Avram MJ et al. The pharmacokinetics of dexmedetomidine in volunteers with severe renal impairment [J]. Anesth Analg 2001;93:1205-1209.
9. Haselman MA. Dexmedetomidine:a useful adjunct to consider in some high-risk situation [J]. AANA J 2008;76:335-339.
10. Kamibayashi T, Maze M. Clinical uses of alpha-2 adrenergic agonists [J]. Anesthesiology 2000;93:1345-1349.
11. Penttila J, Helminen A, Anttila M et al. Cardiovascular and parasympathetic effects of dexmedetomidine in healthy subjects [J]. Can J Physio Pharmacol 2004;82:359-362.
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15. A1-Metwalli RR, Mowafi HA, Ismail SA et al. Effect of intra-articular
dexmedetomidine on postoperative analgesia after arthroscopic knee surgery [J]. Br J Anaesth 2008; 101:395-399.
16. Yoshitomi T, Kohjitani A, Maeda S et al. Dexmedetomidine enhances the local anesthetic action of lidocaine via an alpha-2A adrenoceptor [J]. Anesth Analg 2008;107:96-101.
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2. 邢军,白勇,吴新民.雷米芬太尼抑制扩宫颈体动反应的半数有效浓度[J].临床麻醉学杂志,2008,24(1)：32～34
3. 王世端.麻醉深度监测与全麻管理[R].齐鲁医学杂志,2006,21(3)：280～282
4. Mulroy MF, Larkin KL, Hodgson PS, et al. A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy [J]. Anesth Analg,2000,91(4): 860-864.
5. Forssblad M, Jacobson E, Weidenhielm L. Knee arthroscopy with different anesthesia methods:a comparison of efficacy and cost [J]. Knee Surg Sports Traumatol Arthrosc, 2004,12(5):344-349.
6. Heidvall M, Hein A, Davidson S, et al. Cost comparison between three different gene-ral anaesthetic techniques for elective arthroscopy of the knee [J]. Acta Anaesthesiol Scand,2000,44(2):157-162.
7. Jankowski CJ, Hebl JR, Stuart MJ, et al. A comparison of psoas compartment block and spinal and general anesthesia for outpatient knee arthroscopy [J]. Anesth Analg, 2003,97(4):1003-1009.
8. Carollo DS, Nossaman BD, Ramadhyani U, et al. Dexmedetomidine:a review of clinical application [J]. Curr Opin Anaesthesiol 2008;21:457-461.
9. Venn RM, Bradshaw CJ, Spencer R, et al. Preliminary UK experience of dexmedeto-midine, a novel agent for postoperative sedation in the intensive care unit[J]. Anaesthesia 1999;54:1136-1142.
10. 芦相玉,王宏涛,王世端.比较右美托咪定、丙泊酚、咪达唑仑辅助硬膜外麻醉镇静效果[J].中国新药与临床杂志,2011,30(11)：873-877.
11. Panzer O, Moitra V, Sladen RN Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists[J]. Crit Care Clin 2009;25:451-469.
12. Mester R, Easley RB, Brady KM, et al. Monitored anesthesia care with a combination of ketamine and dexmedetomidine during cardiac catheterization [J]. Am J Ther,2008, 15(1):24-30.
13. Levanen J, Makela ML, Scheinin H. Dexmedetomidine premedication attenuates ketam-ine-induced cardiostimulatory effects and postanesthetic delirium [J]. Anesthesiology,
1995,82(5):1117-1125.
14. Koruk S, Mizrak A, Gul R, et al. Dexmedetomidine-ketamine and midazolam-ketamine combinations for sedation in pediatric patients undergoing extracorporeal shock wave lithotripsy:a randomized prospective study [J]. J Anesth,2010,24(6):858-863.
15. Ramsey MA, Luterman DL. Dexmedetomidine as a total intravenous anesthetic agent [J]. Anesthesiology,2004,101(3):787-790.
16. Hunter JC, Fontana DJ, Hedley LR, et al. Assessment of the role of alpha2-adrenoceptor subtypes in the antinocicep tive, sedative and hypothermic action of dexmedetomidine in transgenic mice [J]. B r J Pharm acol,1997;122:1339-1344.
17. Khan ZP, Ferguson CN, Jones BM. Alpha-2 and imidazoline receptor agonists. Their pharmacology and therapeutic role [J]. Anesthesia,1999,54(2):146-165.
18. Tobias JD. Dexmedetomidine:applications in pediatric critical caro and pediatri anesth-esiology [J]. Pediatric Critical Care Medicine,2007,8(2):115-131.
19. Yusuke K, Raghavendra G, Stefan R, et al. The correlation between bispectral index and observational sedation scale in volunteers sedated with dexmedetomidine and prop-ofol. [J]. Anesth Analg,2009109(6):1811-1815.
20. Guignard B, Chauvin M. Bispectral index increases and decreases are not always signs of inadequate anesthesia[J]. Anesthesiology,2000;92(3):903.
21. Hirota K, Kubota T, Ishihara H, et al. The effects of nitrous oxide and ketamine on the bispectral index and 95% spectral edge frequency during propofol-fentanyl anaesthesia[J]. Eur J Anaesthesiol 1999; 16(11):779-783.
22. Hans P, Dewandre PY, Brichant JF, et al. Comparative effects of ketamine on bispectral index and spectral entropy of the electroencephalogram under sevoflurane anaesthesia. Br J Anaesth, [J].2005;94(3):336-340.
1. Carollo DS, Nossaman BD, Ramadhyani U. Dexmedetomidine:a review of clinical app-lications [J]. Curr Opin Anaesthesiol 2008:21:457-461.
2. Venn RM, Bradshaw CJ, Spencer R et al. Preliminary UK experience of dexmedetomi-dine, a novel agent for postoperative sedation in the intensive care unit. [J]. Anaesthes-ia 1999:54:1136-1142.
3. Panzer O, Moitra V, Sladen RN. Pharmacology of sedative-analgesic agents:dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists [J]. Crit Care Clin 2009;25:451-469.
4. Gertler R, Brown HC, Mitchell DH et al. Dexmedetomidine:a novel sedative-analgesic agent [J]. Proc (Bayl Univ Med Cent) 2001:14:13-21.
5. Chrysostomou C, Schmitt CG. Dexmedetomidine:sedation, analgesia and beyond [J]. Expert Opin Drug Metab Toxicol 2008;4:619-627.
6. Dyck JB, Shafer SL. Dexmedetomidine:pharmacokinetics and pharmacodynamics [J]. Anaesth Pharm Rev 1993:1:238-245.
7. Vilo S, Rautiainen P, Kaisti K et al. Pharmacokinetics of intravenous dexmedetomidine in children under 11 yr of age [J]. Br J Anaesth 2008; 100:697-700.
8. De Wolf AM, Fragen RJ, Avram MJ et al. The pharmacokinetics of dexmedetomidine in volunteers with severe renal impairment [J]. Anesth Analg 2001;93:1205-1209.
9. Haselman MA. Dexmedetomidine:a useful adjunct to consider in some high-risk situation [J]. AANA J 2008;76:335-339.
10. Kamibayashi T, Maze M. Clinical uses of alpha-2 adrenergic agonists [J]. Anesthesiology 2000;93:1345-1349.
11. Penttila J, Helminen A, Anttila M et al. Cardiovascular and parasympathetic effects of dexmedetomidine in healthy subjects [J]. Can J Physio Pharmacol 2004;82:359-362.
12. Scholz J, Tonner PH. Alpha2-adrenoceptor agonists in anaesthesia:a new paradigm [J]. Curr Opin Anaesthesiol 2000; 13:437-442.
13. Ebert TJ, Hall JE, Barney JA et al. The effects of increasing plasma concentrations of dexmedetomidine in humans [J]. Anesthesiology 2000:93:382-394.
14. Nelson LE, Lu J, Guo T et al. The alpha2-adrenoceptor agonist dexmedetomidine converges on an endogenous sleep-promoting pathway to exert its sedative effects [J]. Anesthesiology 2003;98:428-436.
15. A1-Metwalli RR, Mowafi HA, Ismail SA et al. Effect of intra-articular
dexmedetomidine on postoperative analgesia after arthroscopic knee surgery [J]. Br J Anaesth 2008; 101:395-399.
16. Yoshitomi T, Kohjitani A, Maeda S et al. Dexmedetomidine enhances the local anesthetic action of lidocaine via an alpha-2A adrenoceptor [J]. Anesth Analg 2008;107:96-101.
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