Tehran University of Medical Sciences, Tehran, Iran.
Perit Dial Int. 2011 May-Jun;31(3):308-14. doi: 10.3747/pdi.2010.00110. Epub 2010 Dec 30.
Laparoscopy is an effective method of implantation for peritoneal dialysis (PD) catheters. Use of the laparoscopic technique is increasing because of its potential advantages over other techniques. In most patients, selection for PD is based on negative criteria, and because of the need for general anesthesia, the laparoscopic technique can be life-threatening in these patients. On the other hand, local anesthesia is insufficient for laparoscopic catheter implantation. To avoid the need for general anesthesia and to achieve patient safety and satisfaction, we designed a type of conscious sedation (dissociative conscious sedation) and compared the efficacy of subcutaneous (SC) and intravenous (IV) ketamine added to narcotics in patients scheduled for laparoscopic implantation of a PD catheter.
Our prospective randomized double-blind study enrolled 60 adult patients with chronic renal failure who were scheduled for laparoscopic implantation of a PD catheter. Patients were randomly assigned to one of two groups: one receiving IV ketamine, and the other receiving SC ketamine. In both groups, patients were premedicated with IV midazolam 0.015 mg/kg, fentanyl 1-2 μg/kg, and lidocaine 1.5 mg/kg. Patients then received 0.6 mg/kg ketamine either intravenously (IV group) or by subcutaneous injection at the anterior aspect of the forearm (SC group). If systolic blood pressure (BP) increased more than 20% from baseline or exceeded 170 mmHg, IV nitroglycerine (TNG) 50 μg was administered incrementally (repeated 50-μg doses). After a desirable level of conscious sedation was achieved, local anesthesia and nitrous oxide pneumoperitoneum were applied, and the PD catheter was implanted under laparoscopic guidance. Heart rate and BP were measured throughout the procedure. Adverse effects and recovery events were recorded.
All patients tolerated the procedure well. Administration of TNG was significantly more frequent in the IV ketamine group. Pain intensity during the surgery was similar in both groups. Both groups were comparable with regard to heart rate, but patients in the SC ketamine group had a significantly lower systolic BP at the 2nd measurement and a lower rate-pressure product at the 2nd, 4th, and 5th measurements. All patients in the SC ketamine group were cooperative during surgery and experienced uneventful recoveries; mild hallucinations were observed in 5 patients in the IV ketamine group. In the IV ketamine group, 3 patients lost the ability to cooperate during surgery. All catheters were successfully placed.
Dissociative conscious sedation is an acceptable alternative to general anesthesia in laparoscopic implantation of the PD catheter. Ketamine by the SC route is as effective as, but safer than, IV ketamine.
腹腔镜是腹膜透析（PD）导管植入的有效方法。由于其相对于其他技术的潜在优势，腹腔镜技术的使用正在增加。在大多数患者中，PD 的选择基于阴性标准，并且由于需要全身麻醉，因此在这些患者中，腹腔镜技术可能危及生命。另一方面，局部麻醉不足以进行腹腔镜导管植入。为了避免全身麻醉的需要，并实现患者的安全和满意度，我们设计了一种清醒镇静（分离性清醒镇静），并比较了在计划进行腹腔镜 PD 导管植入的患者中，皮下（SC）和静脉（IV）氯胺酮加麻醉药的疗效。
我们前瞻性随机双盲研究纳入了 60 例计划进行腹腔镜 PD 导管植入的慢性肾衰竭成年患者。患者随机分为两组：一组接受 IV 氯胺酮，另一组接受 SC 氯胺酮。在两组中，患者均预先给予 IV 咪达唑仑 0.015mg/kg、芬太尼 1-2μg/kg 和利多卡因 1.5mg/kg。然后，患者分别接受 0.6mg/kg 的氯胺酮静脉内（IV 组）或前臂前侧皮下注射（SC 组）。如果收缩压（BP）比基线增加超过 20%或超过 170mmHg，则静脉内给予递增剂量的 50μg 硝酸甘油（TNG）（重复给予 50μg 剂量）。在达到理想的清醒镇静水平后，应用局部麻醉和氧化亚氮气腹，并在腹腔镜引导下植入 PD 导管。整个过程中测量心率和血压。记录不良反应和恢复事件。
所有患者均能很好地耐受手术。IV 氯胺酮组 TNG 的给药频率明显更高。两组手术过程中的疼痛强度相似。两组的心率相当，但 SC 氯胺酮组在第二次测量时收缩压较低，在第二次、第四次和第五次测量时心率-血压乘积较低。SC 氯胺酮组的所有患者在手术过程中均合作，恢复顺利；IV 氯胺酮组的 5 例患者出现轻度幻觉。在 IV 氯胺酮组，3 例患者在手术过程中失去合作能力。所有导管均成功放置。
分离性清醒镇静是腹腔镜 PD 导管植入术全身麻醉的可接受替代方法。SC 氯胺酮与 IV 氯胺酮一样有效，但更安全。
