Aliane Jugurtha, Dualé Christian, Guesmi Nader, Baud Charlotte, Rosset Eugenio, Pereira Bruno, Bouvier Damien, Schoeffler Pierre
CHU Clermont-Ferrand, Médecine Péri-Opératoire, Clermont-Ferrand, France.
CHU Clermont-Ferrand, Centre de Pharmacologie Clinique, Clermont-Ferrand, France.
Clin Exp Pharmacol Physiol. 2017 Jul;44(7):739-748. doi: 10.1111/1440-1681.12759.
While both ephedrine and phenylephrine are currently used to treat hypotension occurring during carotid endarterectomy (CEA) under general anaesthesia, phenylephrine may have deleterious effects on the cerebral watershed, due to its exclusively vasoconstrictive action. In this controlled, double-blind randomised trial, we compared the effects of ephedrine and phenylephrine administered in a standardised algorithm to treat the first hypotensive event occurring since induction of anaesthesia until carotid cross-clamping. The algorithm consisted of 1-to-3 boluses of 6 mg of ephedrine or 50 μg of phenylephrine, after a goal-directed fluid therapy. In case of failure, the treatment switched to the other study drug. Cerebral tissue oxygen saturation (SctO ) was monitored by near infrared spectroscopy (NIRS), and the primary outcome was the restoring effect of SctO (ipsilateral to surgery) to baseline values. Secondary postoperative outcomes were: contralateral SctO , neurological outcomes, and plasma S100B protein measured at discharge from post-anaesthesia care unit. Ephedrine treatment provided a higher rate of restoration of ipsilateral SctO than phenylephrine (93.2% vs 85.1%, P=.034); this was also noted for contralateral SctO (93.5% vs 90.7%, P=.026). The gain in SctO on the lowest value during hypotension was also higher under ephedrine than phenylephrine (6.4% vs 4.3% ipsilateral, 5.1% vs 4% contralateral), but not significantly so. Clinical outcomes were unaffected by the treatment, but S100B protein plasma concentration was higher in the phenylephrine group. To conclude, this pilot trial, focusing on intermediate outcomes, suggests that ephedrine should be preferred to phenylephrine to treat hypotension during CEA.
虽然麻黄碱和去氧肾上腺素目前都用于治疗全身麻醉下颈动脉内膜切除术（CEA）期间发生的低血压，但去氧肾上腺素由于其单纯的血管收缩作用，可能对脑分水岭区产生有害影响。在这项对照、双盲随机试验中，我们比较了按照标准化方案给予麻黄碱和去氧肾上腺素，对麻醉诱导后至颈动脉夹闭期间首次发生的低血压事件的治疗效果。该方案包括在目标导向性液体治疗后，给予1至3次6毫克麻黄碱或50微克去氧肾上腺素推注。若治疗失败，则改用另一种研究药物。通过近红外光谱（NIRS）监测脑组织氧饱和度（SctO₂），主要结局是SctO₂（手术同侧）恢复至基线值的效果。术后次要结局包括：对侧SctO₂、神经功能结局以及麻醉后护理单元出院时测得的血浆S100B蛋白。麻黄碱治疗使同侧SctO₂恢复的比例高于去氧肾上腺素（93.2%对85.1%，P = 0.034）；对侧SctO₂情况也是如此（93.5%对90.7%，P = 0.026）。麻黄碱治疗下，低血压期间SctO₂从最低值的升高幅度也高于去氧肾上腺素（同侧为6.4%对4.3%，对侧为5.1%对4%），但差异无统计学意义。治疗对临床结局无影响，但去氧肾上腺素组的血浆S100B蛋白浓度更高。总之，这项聚焦于中间结局的初步试验表明，在CEA期间治疗低血压时，麻黄碱应优于去氧肾上腺素。
