Latson T W, Ashmore T H, Reinhart D J, Klein K W, Giesecke A H
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas 75235-9068.
Anesthesiology. 1994 Feb;80(2):326-37. doi: 10.1097/00000542-199402000-00013.
Autonomic reflex dysfunction in patients with diabetes is associated with an increased incidence of hypotension after induction of anesthesia. Whether this finding can be extrapolated to patients with autonomic dysfunction from other causes (e.g., advanced age, hypertension, altered ventricular function) has not been established.
The authors investigated whether autonomic reflex dysfunction in a more generalized patient group (26 consecutively consenting day-surgery patients older than 39 yr) was similarly associated with the occurrence of hypotension after induction. Preoperative tests of autonomic function included: Valsalva maneuver, change in heart rate with forced breathing, change in heart rate and blood pressure with standing, and spectral analysis of heart rate variability. Anesthesia was induced with 3-5 mg/kg thiopental, 2 micrograms/kg fentanyl, and 60% N2O; 0.1 mg/kg vecuronium was used for paralysis; 0-1.5% isoflurane was added for maintenance of anesthesia after intubation. Noninvasive measurements of mean blood pressure were obtained every minute for 10 min after induction and then every 3 min until skin incision.
Twelve patients developed hypotension (mean blood pressure < 70 mmHg), and 14 patients did not. Measurements of autonomic reflex function were significantly more abnormal in the patients who developed hypotension (P < 0.006 for Valsalva measurements, heart rate variability parameters, and change in heart rate with forced breathing). Using critical test values for autonomic tests, the incidence of hypotension was 67-83% in patients with autonomic nervous system dysfunction versus 9-17% in other patients.
The results document that: (1) some degree of autonomic reflex dysfunction is not uncommon in patients older than 39 yr presenting for elective surgery, and (2) such dysfunction is associated with an increased incidence of hypotension when using the described induction technique.
糖尿病患者的自主神经反射功能障碍与麻醉诱导后低血压发生率增加有关。这一发现是否能外推至其他原因导致的自主神经功能障碍患者（如高龄、高血压、心室功能改变）尚未明确。
作者研究了更广泛患者群体（26例年龄大于39岁且连续同意参与的日间手术患者）中的自主神经反射功能障碍是否同样与诱导后低血压的发生有关。自主神经功能的术前测试包括：瓦尔萨尔瓦动作、用力呼吸时心率变化、站立时心率和血压变化以及心率变异性频谱分析。麻醉诱导采用3 - 5mg/kg硫喷妥钠、2μg/kg芬太尼和60%氧化亚氮；0.1mg/kg维库溴铵用于肌松；插管后添加0 - 1.5%异氟醚维持麻醉。诱导后10分钟内每分钟进行无创平均血压测量，然后每3分钟测量一次直至皮肤切开。
12例患者发生低血压（平均血压<70mmHg），14例未发生。发生低血压的患者自主神经反射功能测量明显更异常（瓦尔萨尔瓦动作测量、心率变异性参数以及用力呼吸时心率变化，P<0.006）。使用自主神经测试的临界值，自主神经系统功能障碍患者低血压发生率为67 - 83%，而其他患者为9 - 17%。
结果表明：（1）对于择期手术的39岁以上患者，一定程度的自主神经反射功能障碍并不罕见，（2）使用所述诱导技术时，这种功能障碍与低血压发生率增加有关。
