Jamali S, Ravussin P, Archer D, Goutallier D, Parker F, Ecoffey C
Departement of Anesthesiology and Surgical Intensive Care, Bicêtre Hospital, France.
Anesth Analg. 1996 Mar;82(3):600-6. doi: 10.1097/00000539-199603000-00030.
In many studies reporting an increase in cerebrospinal fluid pressure (CSFP) after opioid administration, concomitant decreases in mean arterial pressure (MAP) have been observed. Autoregulatory cerebral vasodilation may therefore have been a factor in the CSFP increases. We tested the hypothesis that increases in CSFP after bolus injection of opioids could be minimized by modifying concomitant decreases in MAP with phenylephrine. Thirty-three patients with supratentorial mass lesions were studied in a randomized, prospective, double-blind, saline-controlled comparative trial. The principal outcome measures were lumbar CSFP, MAP, and heart rate (HR). Study drugs, sufentanil 0.8 micrograms/kg (n = 12), fentanyl 4.5 micrograms/kg (n = 11), or normal saline (n = 10), were injected intravenously (IV) during stable general anesthesia with 0.3-0.7 minimum alveolar anesthetic concentration (MAC) of isoflurane in oxygen and controlled ventilation (end-tidal carbon dioxide 32-35 mm Hg). Phenylephrine 50-100 micrograms was injected IV when MAP decreased by more than 15% of initial values, and atropine 0.5 mg IV when HR decreased to less than 45 bpm. Opioid administration was associated with significant decreases in MAP, 21 +/- 9 mm Hg (mean +/- SD) in the sufentanil group and 16 +/- 7 mm Hg in the fentanyl group; P < 0.001. These decreases in MAP were of short duration (i.e., corrected with 1-2 min). Patients in the sufentanil group needed more phenylephrine than patients in the fentanyl group (170 +/- 89 micrograms vs 100 +/- 47 micrograms; P < 0.05). No significant change in the CSFP was seen in either the sufentanil (1 +/- 6 mm Hg) or fentanyl-treated patients (O +/- 2 mm Hg). No significant changes in MAP or CSFP were observed in the saline-treated patients. HR decreased after injection of either study drug (P < 0.01) but remained unchanged in the saline group. In summary, during stable anesthesia with isoflurane in oxygen, bolus injections of fentanyl or sufentanil, despite producing rapidly corrected mean decreases in MAP of 18% and 25%, respectively, were not associated with any change in CSFP.
在许多报告中指出，给予阿片类药物后脑脊液压力（CSFP）会升高，同时观察到平均动脉压（MAP）下降。因此，脑自动调节性血管舒张可能是CSFP升高的一个因素。我们测试了这样一个假设：通过用去氧肾上腺素改变伴随的MAP下降，可以将推注阿片类药物后CSFP的升高降至最低。在一项随机、前瞻性、双盲、生理盐水对照的比较试验中，对33例幕上占位性病变患者进行了研究。主要观察指标为腰椎CSFP、MAP和心率（HR）。在异氟烷最低肺泡有效浓度（MAC）为0.3 - 0.7、以氧气进行稳定全身麻醉并控制通气（呼气末二氧化碳分压32 - 35 mmHg）期间，静脉注射（IV）研究药物，舒芬太尼0.8微克/千克（n = 12）、芬太尼4.5微克/千克（n = 11）或生理盐水（n = 10）。当MAP下降超过初始值的15%时，静脉注射去氧肾上腺素50 - 100微克，当HR降至低于45次/分钟时，静脉注射阿托品0.5毫克。给予阿片类药物与MAP显著下降相关，舒芬太尼组下降21±9 mmHg（平均值±标准差），芬太尼组下降16±7 mmHg；P < 0.001。这些MAP的下降持续时间较短（即1 - 2分钟内恢复）。舒芬太尼组患者比芬太尼组患者需要更多的去氧肾上腺素（170±89微克对100±47微克；P < 0.05）。舒芬太尼治疗组（1±6 mmHg）和芬太尼治疗组患者（0±2 mmHg）的CSFP均未出现显著变化。生理盐水治疗组患者的MAP和CSFP均未观察到显著变化。注射任何一种研究药物后HR均下降（P < 0.01），但生理盐水组HR保持不变。总之，在以氧气和异氟烷进行稳定麻醉期间，推注芬太尼或舒芬太尼，尽管分别使MAP迅速校正后的平均下降幅度达到18%和25%，但与CSFP的任何变化均无关。
