Zgoła Katarzyna, Kułakowski Piotr, Czepiel Aleksandra, Świątkowski Maciej, Makowska Ewa, Błachnio Elżbieta, Soszyńska Małgorzata, Misiewicz Magdalena
Klinika Kardiologii, Centrum Medycznego Kształcenia Podyplomowego, Szpital Grochowski, Warszawa.
Kardiol Pol. 2014;72(8):707-15. doi: 10.5603/KP.a2014.0086. Epub 2014 May 20.
Anaesthetic drugs and internal electrical shock may alter the haemodynamic status of patients undergoing implantable cardioverter-defibrillator (ICD) testing. Comparative data on the mechanisms of etomidate and propofol-induced changes in haemodynamic parameters are inconsistent. Also the effects of ICD shock on haemodynamics have not been extensively studied.
To compare the haemodynamic effects of etomidate and propofol as well as electrical shock during ICD testing in a prospective, randomised trial.
The study group consisted of 63 consecutive patients (mean age 66 ± 10 years, 51 males) who underwent ICD testing. Haemodynamic parameters were measured using impedance cardiography (Task Force Monitor Systems, CNSystems, Austria) before and after injection of etomidate (n = 30) or propofol (n = 33) as well as immediately after internal defibrillation of ventricular fibrillation (VF). Parameters measured included heart rate, systolic (sBP), diastolic (dBP) and mean (mBP) blood pressure, stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR).
Propofol significantly decreased the values of all measured parameters (sBP: 123.4 ± 17.1 vs. 106.3 ± 18 mm Hg, p < 0.0001; dBP: 83.7 ± 12.2 vs. 74.1 ± 13.8 mm Hg, p < 0.0001; mBP: 93.9 ± 13.1 vs. 81.1 ± 16.1 mm Hg, p < 0.0001; SV: 61.1 ± 19.3 vs. 56.4 ± 15.7 mL, p < 0.003; CO: 4.51 ± 1.07 vs. 4.17 ± 0.73 L/min, p < 0.003; and TPR: 1,735.8 ± 532.6 vs. 1,573.9 ± 390.5 dyn×s/cm⁵), whereas the only significant change following etomidate infusion was a decrease in SV (60.6 ± 11 vs. 56.8 ± 10 mL, p < 0.022). The propofol-induced changes were similar in patients with reduced (< 40%) vs. preserved (≥ 40%) left ventricular ejection fraction (LVEF) and in patients in heart failure NYHA class 0-II vs. class III-IV. Induction of VF and internal electrical shock did not cause major haemodynamic changes apart from significant, albeit very modest, drops in dBP and mBP (77 ± 2 vs. 72.9 ± 18 mm Hg, p < 0.002, and 85.2 ± 17 vs. 81.8 ± 20 mm Hg, p < 0.017, respectively). There were no complications during ICD testing.
Propofol significantly decreased BP probably by both reducing CO and causing vasodilatation, whereas etomidate only slightly decreased dBP and mBP without affecting other parameters. Propofol-induced changes were independent of LVEF or NYHA class. Induction of VF and internal defibrillation did not cause clinically significant changes apart from very modest drops in dBP and mBP values.
麻醉药物和体内电击可能会改变接受植入式心脏复律除颤器（ICD）测试患者的血流动力学状态。依托咪酯和丙泊酚引起血流动力学参数变化机制的比较数据并不一致。此外，ICD电击对血流动力学的影响尚未得到广泛研究。
在一项前瞻性随机试验中比较依托咪酯和丙泊酚以及ICD测试期间电击的血流动力学效应。
研究组由63例连续接受ICD测试的患者（平均年龄66±10岁，51例男性）组成。在注射依托咪酯（n = 30）或丙泊酚（n = 33）之前和之后以及心室颤动（VF）体内除颤后立即使用阻抗心动图（Task Force Monitor Systems，CNSystems，奥地利）测量血流动力学参数。测量的参数包括心率、收缩压（sBP）、舒张压（dBP）和平均血压（mBP）、每搏量（SV）、心输出量（CO）和总外周阻力（TPR）。
丙泊酚显著降低了所有测量参数的值（sBP：123.4±17.1对106.3±18 mmHg，p<0.0001；dBP：83.7±12.2对74.1±13.8 mmHg，p<0.0001；mBP：93.9±13.1对81.1±16.1 mmHg，p<0.0001；SV：61.1±19.3对56.4±15.7 mL，p<0.003；CO：4.51±1.07对4.17±0.73 L/min，p<0.003；TPR：1,735.8±532.6对1,573.9±390.5 dyn×s/cm⁵），而注射依托咪酯后唯一显著的变化是SV降低（60.6±11对56.8±10 mL，p<0.022）。左心室射血分数（LVEF）降低（<40%）与保留（≥40%）的患者以及纽约心脏病协会（NYHA）心功能0-II级与III-IV级的心力衰竭患者中，丙泊酚引起的变化相似。诱发VF和体内电击除了导致dBP和mBP显著但非常轻微的下降外（分别为77±2对72.9±18 mmHg，p<0.002，以及85.2±17对81.8±20 mmHg，p<0.017），并未引起主要的血流动力学变化。ICD测试期间没有并发症。
丙泊酚可能通过降低CO和引起血管扩张显著降低血压，而依托咪酯仅轻微降低dBP和mBP，不影响其他参数。丙泊酚引起的变化与LVEF或NYHA分级无关。诱发VF和体内除颤除了导致dBP和mBP值非常轻微的下降外，并未引起临床上显著的变化。
