Dupuis J Y, Nathan H J, DeLima L, Wynands J E, Russell G N, Bourke M
Department of Anesthesia, University of Ottawa Heart Institute, Ottawa Civic Hospital, Ontario, Canada.
Anesth Analg. 1994 Sep;79(3):472-81. doi: 10.1213/00000539-199409000-00012.
This randomized double-blind study compared the hemodynamic and metabolic effects of pancuronium and vecuronium during treatment of shivering after cardiac surgery with hypothermic cardiopulmonary bypass. Thirty sedated and pain-free patients who shivered after cardiac surgery were treated with pancuronium (n = 15) or vecuronium (n = 15) 0.08 mg/kg. Baseline values of heart rate (HR), mean arterial pressure, arterial and venous blood gases, total body oxygen consumption indexed to body surface area (VO2-I), and pressure work index (PWI, an estimate of myocardial oxygen consumption) were measured on arrival in the intensive care unit, at onset of shivering, and repeatedly for 2 h after treatment. Continuous ST segment analysis of leads II and V5 were used for detection of myocardial ischemia. Treatment of shivering with pancuronium decreased VO2-I by 32% (P = 0.0001). This was accompanied by a 14% increase in HR (P = 0.001) and a 10% increase in PWI (P = 0.03). Vecuronium decreased VO2-I by 36% (P = 0.003) with a 4% decrease in HR (P = 0.04) and a 6% decrease in PWI (P = 0.06). Myocardial ischemia (n = 3) and ventricular arrhythmias (n = 3) occurred in five patients treated with pancuronium. Only one patient treated with vecuronium had ventricular arrhythmia (P = 0.08). Seven patients treated with pancuronium and eight treated with vecuronium were taking beta-adrenergic blockers preoperatively which was associated with lower HR (96 +/- 16 vs 109 +/- 15 bpm; P = 0.025) and lower PWI (8.8 +/- 1.2 vs 10.7 +/- 1.92 mL.min-1 x 100 g-1; P = 0.003) at onset of shivering. However, beta-adrenergic blockers did not attenuate the relative HR increase induced by pancuronium. No relationship was found between hypercapnia and tachycardia or hypertension. These results suggest that, when compared to pancuronium for treatment of postoperative shivering, vecuronium may be advantageous because it does not increase myocardial work. The disproportionate relationship between VO2-I and PWI after treatment with muscle relaxants indicates that increased VO2-I does not contribute significantly to the hemodynamic disturbances associated with shivering. These disturbances are more likely the results of increased adrenergic activity related to pain and recovery from anesthesia. Shivering and its associated hemodynamic disturbances appear to be concomitant but independent signs of awakening.
这项随机双盲研究比较了泮库溴铵和维库溴铵在低温体外循环心脏手术后治疗寒战期间的血流动力学和代谢效应。30例心脏手术后镇静且无疼痛但发生寒战的患者，接受了0.08mg/kg的泮库溴铵（n = 15）或维库溴铵（n = 15）治疗。在重症监护病房入院时、寒战发作时以及治疗后2小时内反复测量心率（HR）、平均动脉压、动脉和静脉血气、以体表面积指数化的全身氧耗量（VO2-I）以及压力作功指数（PWI，心肌氧耗量的估计值）。使用导联II和V5的连续ST段分析来检测心肌缺血。用泮库溴铵治疗寒战使VO2-I降低了32%（P = 0.0001）。这伴随着HR升高14%（P = 0.001）和PWI升高10%（P = 0.03）。维库溴铵使VO2-I降低了36%（P = 0.003），HR降低了4%（P = 0.04），PWI降低了6%（P = 0.06）。接受泮库溴铵治疗的5例患者发生了心肌缺血（n = 3）和室性心律失常（n = 3）。接受维库溴铵治疗的患者中只有1例发生室性心律失常（P = 0.08）。7例接受泮库溴铵治疗和8例接受维库溴铵治疗的患者术前服用β-肾上腺素能阻滞剂，这与寒战发作时较低的HR（96±16对109±15次/分；P = 0.025）和较低的PWI（8.8±1.2对10.7±1.92 mL·min-1×100 g-1；P = 0.003）相关。然而，β-肾上腺素能阻滞剂并未减弱泮库溴铵引起的相对HR升高。未发现高碳酸血症与心动过速或高血压之间存在关联。这些结果表明，与泮库溴铵治疗术后寒战相比，维库溴铵可能具有优势，因为它不会增加心肌作功。肌肉松弛剂治疗后VO2-I与PWI之间的不成比例关系表明，VO2-I升高对与寒战相关的血流动力学紊乱没有显著贡献。这些紊乱更可能是与疼痛和麻醉恢复相关的肾上腺素能活性增加的结果。寒战及其相关的血流动力学紊乱似乎是伴随出现但独立的苏醒体征。
