纳洛酮对阿片类麻醉的逆转作用再探讨：大剂量芬太尼麻醉后持续输注纳洛酮的临床评估及血浆浓度分析

Naloxone reversal of opioid anesthesia revisited: clinical evaluation and plasma concentration analysis of continuous naloxone infusion after anesthesia with high-dose fentanyl.

作者信息

Takahashi Masahiko, Sugiyama Kimitoshi, Hori Masaki, Chiba Satoko, Kusaka Kiyoshi

机构信息

Division of Pain Control, Department of Anesthesiology and Emergency Medicine, Tohoku University Postgraduate Medical School, 1-1 Seiryo, Aoba-ku, 980-8574, Sendai, Japan.

出版信息

J Anesth. 2004;18(1):1-8. doi: 10.1007/s00540-003-0214-4.

DOI:10.1007/s00540-003-0214-4

PMID:14991468

Abstract

PURPOSE

In spite of several advantages, the need for postoperative ventilatory support limits the use of high-dose opioid anesthesia. We prospectively evaluated the effectiveness of naloxone infusion for the reversal of high-dose fentanyl anesthesia.

METHODS

Anesthesia was maintained with fentanyl in patients undergoing major abdominal surgery. After anesthesia, the trachea was extubated when intravenous naloxone, which was titrated in separate 50- micro g doses, established an acceptable level of consciousness and arterial blood gas (ABG) status under spontaneous respiration; this was followed by continuous infusion started at the rate of the sum of the bolus doses per hour. The naloxone infusion was terminated based on evaluation of the level of consciousness, ABG, and acute abstinence symptoms. Postoperative pain was evaluated using self-reported four-step categorical terms (none, mild, moderate, and severe). Plasma concentrations of fentanyl and naloxone were analyzed in 12 patients, using high-performance liquid chromatography.

RESULTS

Fifty-seven out of 59 eligible patients were successfully extubated at 34 +/- 14 min after termination of fentanyl (total dose, 127 +/- 64 micro g.kg(-1); mean +/- SD) with naloxone (total bolus, 3.4 +/- 2.6 micro g.kg(-1)). All these patients recovered fully without ventilatory support under the naloxone infusion, which was terminated at 11 +/- 7 h. The reduction of the naloxone infusion rate effectively relieved the increased pain, and no supplemental analgesic was used in any patients during the naloxone infusion. Pharmacokinetic analysis did not indicate any correlations between plasma fentanyl and naloxone concentrations.

CONCLUSION

The results suggest that naloxone infusion with individual dose titration facilitates the use of high-dose opioid anesthesia, maintaining the advantager of this anesthesia.

摘要

目的

尽管大剂量阿片类药物麻醉有诸多优点，但术后呼吸支持的需求限制了其应用。我们前瞻性评估了纳洛酮输注用于逆转大剂量芬太尼麻醉的有效性。

方法

在接受腹部大手术的患者中，用芬太尼维持麻醉。麻醉后，当静脉注射纳洛酮（以50微克的剂量递增滴定）在自主呼吸下建立可接受的意识水平和动脉血气（ABG）状态时，进行气管拔管；随后以每小时推注剂量总和的速率开始持续输注。根据意识水平、ABG和急性戒断症状的评估终止纳洛酮输注。使用自我报告的四级分类术语（无、轻度、中度和重度）评估术后疼痛。使用高效液相色谱法分析了12例患者血浆中芬太尼和纳洛酮的浓度。

结果

59例符合条件的患者中有57例在芬太尼（总剂量，127±64微克·千克⁻¹；平均值±标准差）停用后34±14分钟成功拔管，使用了纳洛酮（总推注量，3.4±2.6微克·千克⁻¹）。所有这些患者在纳洛酮输注期间无需呼吸支持即可完全康复，纳洛酮输注在11±7小时终止。降低纳洛酮输注速率有效缓解了疼痛加剧，在纳洛酮输注期间没有患者使用补充镇痛药。药代动力学分析未表明血浆芬太尼和纳洛酮浓度之间存在任何相关性。