Department of Anesthesiology, McGovern Medical School, UT Health Houston, Houston, Texas, USA.
Mayo Clinic, Scottsdale, Arizona, USA.
Paediatr Anaesth. 2022 Jun;32(6):764-771. doi: 10.1111/pan.14442. Epub 2022 Apr 3.
Maintaining the patency of peripheral arterial lines in pediatric patients during surgery can be challenging due to multiple factors, and catheter-related arterial vasospasm is a potentially modifiable cause. Papaverine, a potent vasodilator, improves arterial line patency when used as a continuous infusion in the pediatric intensive care setting, but this method is not convenient during surgery.
Extrapolating from the benefit seen in the intensive care unit, the authors hypothesize that a small-volume intraarterial bolus of papaverine immediately after arterial line placement will reduce vasospasm-related arterial line malfunction.
This was a prospective, randomized, double-blind study. Patients less than 17 years of age undergoing cardiac surgery were enrolled. Patients were randomized into the heparin or papaverine groups. Immediately after arterial line insertion, an intraarterial bolus of heparin (2 units/ml, 1 ml) or papaverine (0.12 mg/ml, 1 ml) was administered (T1, Figure 1). An optimal waveform was defined as the ease of aspirating a standardized blood sample within 30 s, absence of cavitation when sampling, absence of color change at the catheter site during injection, and presence of a dicrotic notch. The primary outcome evaluated was the presence of an optimal arterial waveform at 5 min after the first randomized dose (T1 + 5 min). The secondary outcomes were the presence of optimal arterial waveform an hour after the first dose and the ability of papaverine to rescue suboptimal waveforms.
A total of 100 patients were enrolled in the study. Twelve patients were excluded from the analysis. Complete datasets after randomization were available in 88 patients (heparin group, n = 46; papaverine group, n = 42). At baseline, groups were similar for age, weight, arterial vessel size, and arterial line patency. At T1 + 5 min, an improvement in the waveform characteristics was observed in the papaverine group (heparin,39% [8/46] vs. papaverine, 64% [27/42]; p = .02; odds ratio, 2.8; 95% CI, 1.2 to 6.6, Figure 3, Table 2). At the end of 1 h, both groups showed continued improvement in arterial line patency. After the second dose, a higher number of patients in the heparin group had suboptimal waveforms and were treated with papaverine (heparin,37% [17/46] vs. papaverine,17% [7/42], p = .05). Patients in the heparin group treated with papaverine showed significant improvement in patency (13/17 vs. 3/7, p = .01). No serious adverse events were reported.
In pediatric patients, papaverine injection immediately after peripheral arterial catheter placement was associated with relief of vasospasm and improved initial arterial line patency. Further, papaverine can be used as a rescue to improve and maintain arterial line patency.
在小儿患者的手术过程中，维持外周动脉导管通畅可能具有挑战性，这是由多种因素导致的，而导管相关的动脉血管痉挛是一种潜在可调节的原因。罂粟碱是一种有效的血管扩张剂，在儿科重症监护环境中作为连续输注使用时可以改善动脉导管通畅性，但这种方法在手术过程中并不方便。
从重症监护室中观察到的益处推断，作者假设在放置动脉导管后立即给予小剂量的动脉内罂粟碱推注将减少与血管痉挛相关的动脉导管功能障碍。
这是一项前瞻性、随机、双盲研究。研究纳入了小于 17 岁的接受心脏手术的患者。患者被随机分为肝素组或罂粟碱组。在动脉导管插入后，立即给予肝素（2 单位/ml，1 ml）或罂粟碱（0.12 mg/ml，1 ml）（T1，图 1）。最佳波形定义为在 30 秒内轻松抽吸到标准化血样、采样时无空化、注射时导管部位无颜色变化以及存在二尖切迹。主要结局评估为首次随机剂量后 5 分钟（T1+5 分钟）时出现最佳动脉波形的情况。次要结局是首次剂量后 1 小时出现最佳动脉波形的情况以及罂粟碱是否能够抢救次优波形的情况。
研究共纳入 100 例患者，其中 12 例患者被排除在分析之外。88 例患者（肝素组，n=46；罂粟碱组，n=42）随机分组后获得完整数据集。在基线时，两组在年龄、体重、动脉血管大小和动脉导管通畅性方面相似。在 T1+5 分钟时，罂粟碱组的波形特征有所改善（肝素组，39%[46/118] vs. 罂粟碱组，64%[42/66]；p=0.02；优势比，2.8；95%CI，1.2 至 6.6，图 3，表 2）。在 1 小时结束时，两组的动脉导管通畅性均持续改善。第二次剂量后，肝素组有更多患者出现次优波形并接受罂粟碱治疗（肝素组，37%[46/124] vs. 罂粟碱组，17%[42/246]；p=0.05）。接受罂粟碱治疗的肝素组患者的通畅性显著改善（13/17 与 3/7，p=0.01）。未报告严重不良事件。
在小儿患者中，外周动脉导管放置后立即给予罂粟碱注射可缓解血管痉挛并改善初始动脉导管通畅性。此外，罂粟碱可用作抢救药物来改善和维持动脉导管通畅性。
