Kienbaum P, Scherbaum N, Thürauf N, Michel M C, Gastpar M, Peters J
Abteilung für Anästhesiologie und Intensivmedizin, Universität GH Essen, Germany.
Crit Care Med. 2000 Apr;28(4):969-76. doi: 10.1097/00003246-200004000-00010.
Mu-Opioid receptor blockade during general anesthesia is a new treatment for detoxification of opioid addicted patients. We assessed catecholamine plasma concentrations, oxygen consumption, cardiovascular variables, and withdrawal symptoms after naloxone and tested the hypothesis that variables are influenced by the anesthetic administered during detoxification.
Prospective randomized clinical study.
Intensive care unit of a university hospital and psychiatric ward.
Twenty-five mono-opioid addicted patients with mild to moderate systemic disease (ASA II classification) in a methadone substitution program.
General anesthesia with either propofol (129+/-7 microg x kg(-1) x min(-1), mean +/- SEM) or methohexital (74+/-14 microg x kg(-1). min(-1)), mu-opioid receptor blockade by naloxone in a stepwise fashion (increasing doses of 0.4 mg, 0.8 mg, 1.6 mg, 3.2 mg, and 6.4 mg at 15 min intervals followed by 0.8 mg x hr(-1) for 24 hrs) and naltrexone 50 mg x day(-1) orally for > or =4 wks. Clonidine was started 180 mins after the first naloxone dose and its infusion rate was individually adjusted to mitigate withdrawal symptoms during weaning and after extubation.
During propofol and methohexital anesthesia, naloxone induced a 30-fold increase in epinephrine and a significant three-fold increase in norepinephrine plasma concentrations without a significant difference between groups. This increase in catecholamine plasma concentrations was associated with increased oxygen consumption and marked cardiovascular stimulation with both anesthetics, as shown by increased cardiac index, heart rate, and systolic atrial pressure whereas diastolic pressure remained unchanged. Patients receiving propofol could be extubated significantly earlier after discontinuation of the anesthetics. Although the maximum degree of withdrawal symptoms (Short Opioid Withdrawal Scale) on the day after detoxification was similar with both anesthetics, subsequent withdrawal symptoms decreased significantly more rapidly after propofol anesthesia.
Naloxone treatment, in opioid-addicted patients, induced a marked increase in catecholamine plasma concentrations, metabolism, and cardiovascular stimulation during anesthesia with both propofol and methohexital. Although both anesthetics appear suitable for detoxification treatment, the use of propofol is associated with earlier extubation and, surprisingly, a shortened period of long-term withdrawal symptoms during detoxification.
全身麻醉期间使用μ-阿片受体阻滞剂是阿片类药物成瘾患者脱毒治疗的一种新方法。我们评估了纳洛酮给药后儿茶酚胺血浆浓度、氧耗量、心血管变量和戒断症状，并检验了这些变量受脱毒期间所用麻醉剂影响的假设。
前瞻性随机临床研究。
大学医院重症监护病房和精神科病房。
25例在美沙酮替代治疗项目中患有轻至中度全身性疾病（ASA II级分类）的单一阿片类药物成瘾患者。
采用丙泊酚（129±7μg·kg⁻¹·min⁻¹，均值±标准误）或甲己炔巴比妥（74±14μg·kg⁻¹·min⁻¹）进行全身麻醉，以逐步方式使用纳洛酮进行μ-阿片受体阻滞（每隔15分钟递增剂量0.4mg、0.8mg、1.6mg、3.2mg和6.4mg，随后24小时以0.8mg·hr⁻¹持续给药），并口服纳曲酮50mg·day⁻¹，持续≥4周。在首次给予纳洛酮剂量180分钟后开始使用可乐定，其输注速率根据个体情况进行调整，以减轻脱机和拔管后期间的戒断症状。
在丙泊酚和甲己炔巴比妥麻醉期间，纳洛酮使肾上腺素增加30倍，去甲肾上腺素血浆浓度显著增加3倍，两组间无显著差异。儿茶酚胺血浆浓度的这种增加与氧耗量增加以及两种麻醉剂均引起的明显心血管刺激有关，表现为心脏指数、心率和收缩期心房压增加，而舒张压保持不变。停用麻醉剂后，接受丙泊酚的患者拔管时间明显更早。尽管脱毒后第一天的最大戒断症状程度（简短阿片类药物戒断量表）在两种麻醉剂组中相似，但丙泊酚麻醉后随后的戒断症状下降明显更快。
在阿片类药物成瘾患者中，纳洛酮治疗在丙泊酚和甲己炔巴比妥麻醉期间导致儿茶酚胺血浆浓度、代谢和心血管刺激显著增加。尽管两种麻醉剂似乎都适用于脱毒治疗，但丙泊酚的使用与更早拔管相关，而且令人惊讶的是，在脱毒期间长期戒断症状的持续时间缩短。
