Essandoh Michael K, Otey Andrew J, Abdel-Rasoul Mahmoud, Stein Erica J, Turner Katja R, Joseph Nicholas C, Daoud Emile G
Department of *Anesthesiology.
Department of *Anesthesiology.
J Cardiothorac Vasc Anesth. 2016 Oct;30(5):1228-33. doi: 10.1053/j.jvca.2016.06.007. Epub 2016 Jun 8.
To date, general anesthesia has been suggested as the preferred approach for implantation of a subcutaneous implantable cardioverter-defibrillator (S-ICD). The purpose of this study was to assess the use of monitored anesthesia care (MAC) for S-ICD implantation. The goals were to assess adequate sedation and analgesia (efficacy endpoints) and major perioperative airway or hemodynamic compromise (safety endpoints). The authors hypothesized that MAC may provide adequate sedation and analgesia and no major perioperative airway or hemodynamic compromise during S-ICD implantation and multiple defibrillation threshold (DFT) testing.
Prospectively collected data of patients who underwent S-ICD implantation with MAC from 2015 to 2016 were analyzed retrospectively. The efficacy endpoints were the provision of an optimal depth of sedation and analgesia to facilitate S-ICD implantation without intra-procedure patient discomfort or awareness, and the absence of "severe" pain at the lead tunneling and the generator insertion sites post-procedure. The safety endpoints included: (1) periprocedural hypotension, as defined by a mean arterial pressure (MAP)<60 mmHg refractory to conventional pharmacotherapy, (2) heart rate (HR)<45 bpm requiring pharmacologic support, and (3) sedation-induced airway compromise requiring endotracheal intubation.
MAP and HR were recorded during S-ICD implantation and DFT testing. The maximum and minimum infusion rates of propofol, supplemental sedatives, and analgesics, and doses of vasopressor and/or inotropic agents administered intra-procedurally were recorded. Post-procedure pain scores also were noted.
Ten patients underwent S-ICD implantation with MAC (mean age, 56 years; 50% men; mean left ventricular ejection fraction was 39%). Implantation of the S-ICD system using MAC was successful in all patients without any major adverse events. The mean baseline MAP was 92.8 mmHg, and the mean end-procedure MAP was 88 mmHg (p = 0.26). When compared to baseline and end-procedure, the mean lowest intra-procedure MAP was significantly lower (67.4 mmHg; p = 0.0001). The mean baseline HR was 65.7 bpm, and the mean end-procedure HR was 70.1 bpm (p = 0.28). When compared to baseline and end-procedure, the mean lowest intra-procedure HR was significantly lower (55.8 bpm; p<0.001). MAC was not associated with airway compromise in any patient, and post-procedure pain was rated as no greater than "mild".
Among a heterogeneous patient population undergoing S-ICD implantation and DFT testing, the use of MAC is efficacious, feasible, and safe.
迄今为止，全身麻醉已被认为是植入皮下植入式心律转复除颤器（S-ICD）的首选方法。本研究的目的是评估在S-ICD植入过程中使用监护下麻醉管理（MAC）的情况。目标是评估充分的镇静和镇痛效果（疗效终点）以及围手术期主要气道或血流动力学损害情况（安全终点）。作者假设在S-ICD植入和多次除颤阈值（DFT）测试期间，MAC可能提供充分的镇静和镇痛效果，且不会出现围手术期主要气道或血流动力学损害。
回顾性分析2015年至2016年接受MAC下S-ICD植入手术患者的前瞻性收集数据。疗效终点是提供最佳镇静和镇痛深度，以利于S-ICD植入，且术中患者无不适或知晓，术后在导线隧道和发生器植入部位无“严重”疼痛。安全终点包括：（1）围手术期低血压，定义为平均动脉压（MAP）<60 mmHg，对传统药物治疗无效；（2）心率（HR）<45次/分，需要药物支持；（3）镇静引起的气道损害，需要气管插管。
在S-ICD植入和DFT测试期间记录MAP和HR。记录术中丙泊酚、辅助镇静剂和镇痛药的最大和最小输注速率，以及血管升压药和/或正性肌力药物的剂量。还记录术后疼痛评分。
10例患者接受了MAC下的S-ICD植入手术（平均年龄56岁；50%为男性；平均左心室射血分数为39%）。所有患者使用MAC成功植入S-ICD系统，无任何重大不良事件。平均基线MAP为92.8 mmHg，平均手术结束时MAP为88 mmHg（p = 0.26）。与基线和手术结束时相比，术中最低平均MAP显著降低（67.4 mmHg；p = 0.0001）。平均基线HR为65.7次/分，平均手术结束时HR为70.1次/分（p = 0.28）。与基线和手术结束时相比，术中最低平均HR显著降低（55.8次/分；p<0.001）。MAC在任何患者中均未导致气道损害，术后疼痛评分不超过“轻度”。
在接受S-ICD植入和DFT测试的异质性患者群体中，使用MAC是有效、可行且安全的。
