Adams H A, Beigl B, Schmitz C S, Baltes-Götz B
Abteilung für Anaesthesie und Intensivmedizin, Marienkrankenhaus Trier-Ehrang.
Anaesthesist. 1995 Dec;44 Suppl 3:S540-8.
In this prospective, randomized study, two regimens of total intravenous anaesthesia (TIVA), with propofol and S(+)-ketamine (S-ketamine) and with propofol and alfentanil, were compared with reference to endocrine stress response, circulatory effects and recovery. METHODS. The investigation was conducted in two groups of 20 ASA I-III patients over 60 years of age who were scheduled for endoprothetic orthopaedic surgery. After oral premedication with midazolam, patients received a TIVA with body-weight-adjusted doses of propofol, and S-ketamine or alfentanil as the analgesic component. For CPPV (PEEP 5 mbar), air and oxygen (FiO2 33%) were used. For muscle relaxation, patients of both groups received vecuronium in body-weight-adjusted doses. Blood samples were taken through a central venous line at seven time points before induction of anaesthesia and on the first morning after the operation also for analysis of epinephrine, norepinephrine (by HPLC/ECD), and ADH, ACTH and cortisol (by RIA). In addition, SAP, HR, arterial oxygen saturation, recovery from anaesthesia and side effects were observed. RESULTS. The two groups had comparable group mean values for age (S-ketamine group 71 years, alfentanil-group 70 years), other biometric data, and duration of anaesthesia and operation (Table 1). Plasma levels of epinephrine, norepinephrine (Table 2, Fig. 1), ADH (Table 2, Fig. 2) ACTH and cortisol (Table 2, Fig. 3) were higher in the S-ketamine-group (P < 0.05) owing to the intraoperative course of these endocrine parameters. Before induction, and on the first morning after the operation, levels were comparable between the groups. 5 min after the induction of anaesthesia, SAP and HR (Table 3) were significantly lower in the alfentanilgroup (P = 0.001). Recovery from anaesthesia (orientation with respect to person and location) was faster in the alfentanilgroup (16 vs 39 min, P = 0.001). An arterial oxygen saturation below 90% was observed in 7 patients in the S-ketamine- and 13 patients in the alfentanilgroup (P = 0.03). Four patients with S-ketamine reported dreams, and 1 dream was judged negative. Postoperative emesis was found in 6 patients in the S-ketaminegroup and 12 patients in the alfentanilgroup (P = 0.03). All patients said they would agree to undergo the same anaesthetic technique again. CONCLUSIONS. Considerable differences were found in the endocrine stress response of the two groups. With respect to endocrine response and circulation, TIVA with propofol and S-ketamine had sympathomimetic properties with positive circulatory effects and led to moderate endocrine stimulation. This should be kept in mind in patients with hypotension, hypothyrosis, or adrenocortical insufficiency; because "eustress" might be beneficial in this group of patients. On the other hand, TIVA with propofol and alfentanil showed sympatholytic properties, with negative circulatory effects and a remarkable reduction of endocrine stress response. This might be beneficial in patients with hypertension and states of endocrine hyperfunction. Both regimens were accompanied by such typical side effects as dreams, delayed recovery, reduced ventilation, and emesis, which should also be considered.
在这项前瞻性随机研究中，比较了两种全静脉麻醉（TIVA）方案，即丙泊酚与S（+）-氯胺酮（S-氯胺酮）联合应用以及丙泊酚与阿芬太尼联合应用，观察其对内分泌应激反应、循环效应及恢复情况的影响。方法：选取两组各20例年龄超过60岁、拟行人工关节置换骨科手术的ASA I-III级患者。患者口服咪达唑仑进行术前用药后，接受根据体重调整剂量的丙泊酚全静脉麻醉，并分别以S-氯胺酮或阿芬太尼作为镇痛成分。采用容量控制压力支持通气（PEEP 5 mbar），吸入空气和氧气（FiO2 33%）。两组患者均根据体重调整剂量给予维库溴铵进行肌肉松弛。在麻醉诱导前的7个时间点以及术后第一天早晨，通过中心静脉导管采集血样，用于分析肾上腺素、去甲肾上腺素（采用高效液相色谱/电化学检测法）以及抗利尿激素、促肾上腺皮质激素和皮质醇（采用放射免疫分析法）。此外，观察收缩压、心率、动脉血氧饱和度、麻醉恢复情况及副作用。结果：两组患者在年龄（S-氯胺酮组71岁，阿芬太尼组70岁）、其他生物统计学数据、麻醉及手术持续时间方面的组均值具有可比性（表1）。由于这些内分泌参数的术中变化过程，S-氯胺酮组的血浆肾上腺素、去甲肾上腺素水平（表2，图1）、抗利尿激素水平（表2，图2）、促肾上腺皮质激素和皮质醇水平（表2，图3）均较高（P < 0.05）。在诱导前及术后第一天早晨，两组水平相当。麻醉诱导后5分钟，阿芬太尼组的收缩压和心率（表3）显著较低（P = 0.001）。阿芬太尼组的麻醉恢复（对人物和地点的定向）更快（16分钟对39分钟，P = 0.001）。S-氯胺酮组有7例患者、阿芬太尼组有13例患者出现动脉血氧饱和度低于90%的情况（P = 0.03）。S-氯胺酮组有4例患者报告做梦，其中1例被判定为不良梦境。S-氯胺酮组有6例患者、阿芬太尼组有12例患者出现术后呕吐（P = 0.03）。所有患者均表示愿意再次接受相同的麻醉技术。结论：两组在内分泌应激反应方面存在显著差异。就内分泌反应和循环而言，丙泊酚与S-氯胺酮的全静脉麻醉具有拟交感神经特性，具有积极的循环效应并导致适度的内分泌刺激。对于低血压、甲状腺功能减退或肾上腺皮质功能不全的患者应牢记这一点，因为“良性应激”可能对该组患者有益。另一方面，丙泊酚与阿芬太尼的全静脉麻醉表现出抗交感神经特性，具有消极的循环效应且显著降低内分泌应激反应。这可能对高血压和内分泌功能亢进状态的患者有益。两种方案均伴有如做梦、恢复延迟、通气减少和呕吐等典型副作用，也应予以考虑。
