氟烷-吗啡与大剂量舒芬太尼用于新生儿心脏手术的麻醉和术后镇痛的比较。

Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery.

作者信息

Anand K J, Hickey P R

机构信息

Department of Medicine, Children's Hospital, Boston, MA.

出版信息

N Engl J Med. 1992 Jan 2;326(1):1-9. doi: 10.1056/NEJM199201023260101.

DOI:10.1056/NEJM199201023260101

PMID:1530752

Abstract

BACKGROUND

Extreme hormonal and metabolic responses to stress are associated with increased morbidity and mortality in sick adults. We hypothesized that administering deep opioid anesthesia to critically ill neonates undergoing cardiac surgery would blunt their responses to stress and might improve clinical outcomes.

METHODS

In a randomized trial, 30 neonates were assigned to receive deep intraoperative anesthesia with high doses of sufentanil and postoperative infusions of opiates for 24 hours; 15 neonates were assigned to receive lighter anesthesia with halothane and morphine followed postoperatively by intermittent morphine and diazepam. Hormonal and metabolic responses to surgery were evaluated by assay of arterial blood samples obtained before, during, and after the operations.

RESULTS

The neonates who received deep anesthesia (with sufentanil) had significantly reduced responses of beta-endorphin, norepinephrine, epinephrine, glucagon, aldosterone, cortisol, and other steroid hormones; their insulin responses and ratios of insulin to glucagon were greater during the operation. The neonates who received lighter anesthesia (with halothane plus morphine) had more severe hyperglycemia and lactic acidemia during surgery and higher lactate and acetoacetate concentrations postoperatively (P less than 0.025). The group that received deep anesthesia had a decreased incidence of sepsis (P = 0.03), metabolic acidosis (P less than 0.01), and disseminated intravascular coagulation (P = 0.03) and fewer postoperative deaths (none of 30 given sufentanil vs. 4 of 15 given halothane plus morphine, (P less than 0.01).

CONCLUSIONS

In neonates undergoing cardiac surgery, the physiologic responses to stress are attenuated by deep anesthesia and postoperative analgesia with high doses of opioids. Deep anesthesia continued postoperatively may reduce the vulnerability of these neonates to complications and may reduce mortality.

摘要

背景

患病成年人对应激的极端激素和代谢反应与发病率和死亡率增加相关。我们推测，对接受心脏手术的危重新生儿实施深度阿片类麻醉会减弱他们对应激的反应，并可能改善临床结局。

方法

在一项随机试验中，30例新生儿被分配接受术中高剂量舒芬太尼深度麻醉及术后24小时阿片类药物输注；15例新生儿被分配接受氟烷和吗啡浅麻醉，术后给予间断吗啡和地西泮。通过检测手术前、手术中和手术后采集的动脉血样本，评估手术的激素和代谢反应。

结果

接受深度麻醉（使用舒芬太尼）的新生儿β-内啡肽、去甲肾上腺素、肾上腺素、胰高血糖素、醛固酮、皮质醇及其他类固醇激素的反应显著降低；术中他们的胰岛素反应及胰岛素与胰高血糖素的比值更高。接受浅麻醉（使用氟烷加吗啡）的新生儿在手术期间有更严重的高血糖和乳酸血症，术后乳酸和乙酰乙酸浓度更高（P<0.025）。接受深度麻醉的组败血症发生率降低（P=0.03）、代谢性酸中毒（P<0.01）和弥散性血管内凝血（P=0.03）发生率降低，术后死亡更少（接受舒芬太尼的30例中无死亡，接受氟烷加吗啡的15例中有4例死亡，P<0.01）。