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HERALD OF MEDICINE, 2018, 37(6): 712-714
doi: 10.3870/j.issn.1004-0781.2018.06.014
依托咪酯用于老年患者无痛胃镜检查的有效剂量
韦家新

摘要:

目的 探讨老年患者无痛胃镜检查时依托咪酯的半数有效剂量(ED50)和95%患者有效剂量(ED95)。方法 选取2016年2—8月行无痛胃镜检查老年患者共23例。麻醉方式:瑞芬太尼联合依托咪酯方案,待睫毛反射消失后进行胃镜检查。胃镜检查反应阳性标准为出现躁动、皱眉、吞咽及呛咳等反应。依托咪酯剂量的确定采用改良序贯法,起始剂量为0.2 mg·kg-1,相邻间隔剂量设为0.05 mg·kg-1,在出现7个交叉点后终止研究。采用概率回归分析法计算依托咪酯的ED50、ED95结果 胃镜检查反应阴性12例,阳性11例,依托咪酯的ED50为0.18 mg·kg-1,95%CI(0.15,0.22)mg·kg-1;ED95为0.24 mg·kg-1,95%CI(0.21,0.42) mg·kg-1。各有1例患者在胃镜检查过程中发生心动过缓和肌肉震颤,未予特殊处理,麻醉苏醒后均恢复正常。结论 瑞芬太尼联合依托咪酯应用于老年患者无痛胃镜检查时依托咪酯半数有效剂量的确定,提高麻醉的安全性。

关键词: 依托咪酯 ; 瑞芬太尼 ; 胃镜检查 ; 无痛 ; 半数有效剂量

Abstract:

为了降低胃镜检查的痛苦,多数老年患者愿意选择无痛胃镜检查[1]。老年人生理功能减退,对麻醉药品耐受性降低,应选用对生理功能干扰小,术后麻醉苏醒快的药品[2]。依托咪酯是麻醉科常用的静脉全麻药物,其具有诱导快、苏醒快等优点,是目前无痛胃镜检查常用药物[3]。瑞芬太尼起效快、半衰期短、可控性好、无蓄积、术后恢复快,也是无痛胃镜检查的常用药物[4,5]。目前,临床对采用瑞芬太尼联合依托咪酯用于老年无痛胃镜检查,但是对依托咪酯量-效关系的研究尚比较少见[6]。卢盛位等[7]研究依托咪酯联合瑞芬太尼用于老年患者胃镜检查依托咪酯的半数有效剂量(ED50)和 95%患者有效剂量(ED95),发现依托咪酯联合瑞芬太尼用于老年患者无痛胃镜 ED50、ED95分别为0.17和0.23 mg·kg-1。笔者在老年无痛胃镜检查中采用不同浓度依托咪酯联合瑞芬太尼进行麻醉,计算依托咪酯的ED50和ED95,为老年无痛胃镜的安全用药提供参考。

1 资料与方法
1.1 临床资料

选取2016年2—8月在我院行无痛胃镜检查老年患者23例,其中男12例,女11例,年龄62~77岁,体质量44~73 kg,根据美国麻醉医师协会(ASA)分级 Ⅰ~Ⅲ级。纳入标准:①对本研究设计麻醉药物无过敏史者;②自愿加入本研究,签订知情同意书,且能配合观察者。排除标准:①心、肺、肝、肾功能不全者;②精神疾病等不能配合者。本研究获得本院医学伦理委员会批准,所有纳入患者均签订知情同意书。

1.2 方法

1.2.1 麻醉方法 术前常规禁饮4 h,禁食8 h,患者进入手术室后首先建立上肢静脉通道,鼻导管吸氧,心电监护仪监测患者的血压(BP)、血氧饱和度(SpO2)、心率(HR)、呼吸率(RR);先用注射用盐酸瑞芬太尼(宜昌人福药业有限责任公司,批准文号:国药准字H20030197,规格:每支1 mg)0.5 μg·kg-1缓慢静脉注射,再用注射用依托咪酯乳剂(江苏恩华药业股份有限公司,批准文号:国药准字H20020511,规格:10 mL:20 mg),0.2 mg·kg-1静脉注射,在30~60 s注射完毕,在睫毛反射消失之后再进行胃镜检查。

1.2.2 依托咪酯剂量确定方法 采用改良序贯法确定依托咪酯的剂量,第1例患者起始剂量设为0.2 mg·kg-1,下一例患者使用依托咪酯的剂量需根据上一例患者胃镜检查时反应而定,胃镜检查时阳性反应判定标准为发生皱眉、吞咽、呛咳及躁动等反应。相邻间隔剂量设为0.05 mg·kg-1,若上一例出现患者阳性反应,说明依托咪酯剂量不足,则下一例患者依托咪酯使用剂量增加0.05 mg·kg-1,一直等到患者出现阴性反应;若为上一例患者胃镜检查为阴性反应,说明使用依托咪酯的剂量已经足够,则下一例患者的依托咪酯减少0.05 mg·kg-1,直到患者出现阳性反应。在出现阳性与阴性的第7个交叉点后终止研究。胃镜检查过程中如果发生阳性反应表现则增加依托咪酯的剂量直至检查完毕。

在胃镜检查过程中,若患者BP值降低程度超过基础值20%,则给予去氧肾上腺素50~200 ng静脉注射,若患者HR≤55次·min-1,则给予阿托品0.5 mg静脉注射,若SpO2≤95%则增大氧流量或面罩吸氧。

1.3 统计学方法

采用SPSS15.0版统计软件进行处理,采用概率单位回归分析法来计算依托咪酯用于老年胃镜检查的ED50和ED95,以P<0.05表示差异有统计学意义。

2 结果

本研究中胃镜检查反应阴性12例,阳性11例,见图1。老年无痛胃镜检查时麻醉药物采用瑞芬太尼+依托咪酯方案,采用改良序贯法判定依托咪酯的ED50为0.18 mg·kg-1,95%CI (0.15,0.22)mg·kg-1;ED95为0.24 mg·kg-1,95%CI(0.21,0.42)mg·kg-1。研究过程中1例患者发生心动过缓,1例患者发生肌肉震颤,均未给予特殊处理,2例患者不良反应症状均在麻醉苏醒后自行消失。所有受试者均无呼吸抑制及恶心呕吐等不适。

图1 瑞芬太尼联合依托咪酯用于老年无痛胃镜检查的序贯图

3 讨论

无痛胃镜检查目前多采用静脉麻醉的方式。依托咪酯与丙泊酚是最常用的静脉麻醉药物,两者均具有起效快、易苏醒的优点,因此,无痛胃镜多选择用依托咪酯和丙泊酚进行麻醉[8]。然而药理研究发现丙泊酚对机体的循环及呼吸系统具有抑制作用[9]。而老年患者全身生理功能减退,多并存心血管系统疾病,并且呼吸功能随着年龄的增长逐渐减退,尤其是呼吸储备与气体交换功能下降。因此,老年人进行无痛胃镜检查时应尽量避免选用丙泊酚麻醉。依托咪酯是一种快速催眠性静脉全身麻醉药,药理及临床研究发现依托咪酯不会影响压力感受器以及交感神经的功能,因此在保持心血管系统及呼吸系统的稳定性方面具有优势,因此适合老年患者静脉麻醉[9,10]

虽然依托咪酯在保持心血管及呼吸系统稳定性方面具有一定优势,但药物试验发现依托咪酯可抑制肾上腺皮质功能,且与剂量的增加有关[11]。为了减少依托咪酯的不良反应,临床一般趋于选择最小有效剂量进行麻醉。本研究根据前一次胃镜检查时结果决定下一次胃镜检查时依托咪酯的剂量,此方法在较少样本量基础上可以获得可靠的结论,其优点是节省人力及时间,并且可以避免过多的样本接受欠佳的麻醉剂量[12]

文献报道,静脉麻醉时依托咪酯的诱导剂量为0.2~0.6 mg·kg-1,本研究结果发现在老年无痛胃镜检查时依托咪酯的ED50和ED95及其相应95%CI均在以往报道的范围内[13],但处于一个相对较低的水平,分析原因可能与下列因素有关:①患者年龄较大,对药物敏感性增强,依托咪酯的镇静效力在老年患者中会增强。②联合瑞芬太尼麻醉减少依托咪酯的用量。临床研究发现依托咪酯应用于无痛胃镜虽然对循环呼吸的影响较轻,但不能有效抑制胃镜检查时对咽喉部产生的刺激,经常会发生喉痉挛、呛咳以及屏气等不良反应,并且反应程度明显与药物使用剂量有关[14]。瑞芬太尼是一种短效的μ阿片受体类激动药,具有起效时间短、镇痛作用强、半衰期短以及无蓄积等众多优点,能够有效抑制插管过程中刺激咽喉而导致的应激反应,从而提高胃镜检查的安全性[15]。因此,临床进行无痛胃镜检查时一般采用依托咪酯联合瑞芬太尼方案。依托咪酯剂量过大时,偶尔会有呼吸频率减慢、心动过缓、肌肉痉挛及恶心呕吐等不良反应[16]。本研究采用依托咪酯乳剂,其是以中长链脂肪乳作为载体,可以减轻以上不良反应的发生[17]。笔者在本研究中各有1例患者发生心动过缓及肌肉痉挛未经特殊处理自行恢复,说明依托咪酯乳剂的安全性较佳。

The authors have declared that no competing interests exist.

参考文献

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Abstract Background This prospective and randomized study was designed to compare safety, potential complications, and patient and examiner satisfaction of 2 anesthetic combinations - etomidate-remifentanil and propofol-remifentanil - in elderly patients undergoing diagnostic gastroscopy. Material and Methods A group of 720 patients, aged 60-80 years, scheduled for diagnostic gastroscopy under sedation were prospectively randomized. After 0.4-0.6 渭g kg-1 of remifentanil was infused, etomidate or propofol was administered. Patients in the etomidate group received doses of etomidate at 0.1-0.15 mg kg-1 followed by 4-6 mg. Patients in the propofol group received doses of propofol at 1-2 mg kg-1 followed by 20-40 mg. Physiological indexes were evaluated for the 715 of 720 patients that completed the treatment. The onset time, duration time, and discharge time were recorded. Physicians, anesthetists, and patients were surveyed to assess their satisfaction. Results Systolic pressure and diastolic pressure decreased significantly after the procedure in the propofol group (P<0.001). The average heart rate was significantly lower in the propofol group (P<0.05). No periods of desaturation (SpO2 <95%) were observed in either group. The onset time was earlier in the etomidate group (P=0.00). All adverse events, with the exception of myoclonus, were greater in the propofol group, and physician and patient satisfaction in both groups was similar. Conclusions Etomidate-remifentanil administration for sedation and analgesia during gastroscopy resulted in more stable hemodynamic responses and less adverse events in older patients.
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目的 比较靶控输注依托咪酯或异丙酚麻醉在老年患者胃镜检查中的安全性、有效性和优越性.方法 患者静脉注射芬太尼0.05μg/kg,1 min后随机分为两组(n=30):E组静脉靶控输注依托咪酯,设定效应室浓度为0.3μg/mL(Arden模型);P组静脉靶控输注异丙酚,设定效应 室浓度为3μg/mL(Marsh模型).于给药前(T0),插镜时(T1),过食道入口时(T2)、贲门(T3)、十二指肠球部(T4)各时点分别记录 患者术中血流动力学变化以及SPO2变化、镇静及镇痛评分、不良反应及满意度.结果 两组的胃镜检查时间、麻醉恢复时间、镇静镇痛评分、不良反应及满意度差异都无显著性(P>0.05).E组患者术中血流动力学无显著性变化 (P>0.05);P组患者术中MAP持续下降,T1、T2、T3及T4时刻分别较给药前显著下降(P<0.05).结论 在老年患者胃镜检查麻醉中,靶控输注依托咪酯或异丙酚同样安全有效.但靶控输注依托咪酯对血流动力学的影响更轻微,优于异丙酚,在老年患者中有一定优越 性.
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无痛胃镜检查是当前诊断与治疗消化道疾病的一个重要节段。由于胃镜检查是一种侵入性检查,许多患者对此项检查都有一种恐惧感而难以接受,或者在检查过程中患者难以忍受而不能完成检查。本文比较依托咪酯脂肪乳和丙泊酚复合雷米芬太尼用于无痛胃镜的临床效果,现报道如下。资料
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[5] 辛延林. 瑞芬太尼联合丙泊酚或依托咪酯用于电子支气管镜治疗麻醉效果比较[J].医药导报,2016,35(12):1324-1326.
目的:观察比较靶控输注瑞芬太尼复合丙泊酚或依托咪酯用于电子支气管镜介入治疗的呼吸抑制情况和麻醉效果。方法选择ASAⅡ或Ⅲ级行纤维支气管镜介入治疗的患者75例,随机分为依托咪酯组37例和丙泊酚组38例,依托咪酯组采取靶控输注瑞芬太尼复合依托咪酯诱导,丙泊酚组采取靶控输注瑞芬太尼复合丙泊酚,记录和比较两组患者麻醉前和入镜15 min后患者动脉血气分析指标[包括二氧化碳分压( PaCO2)、动脉血氧分压( PaO2)]、手术时间、苏醒时间及手术期间呼吸暂停、供氧不良、低血压、心动过速、肌阵挛、注射痛、恶心呕吐的发生例数。结果丙泊酚组患者入镜后15 min的PaCO2明显高于麻醉前,PaO2水平明显低于麻醉前;依托咪酯组患者的低血压发生率、注射痛发生率明显低于丙泊酚组患者,而苏醒时间、肌阵挛、恶心呕吐发生率明显高于丙泊酚组患者,均差异有统计学意义(P <0.05)。结论靶控输注瑞芬太尼复合丙泊酚用于电子支气管镜介入治疗对患者呼吸抑制作用强于依托咪酯,但可以缩短苏醒时间,减少恶心呕吐、肌阵挛发生率,获得更好的麻醉效果。
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目的 评价胃镜检查术患者乳化依托咪酯.芬太尼-咪达唑仑麻醉的效果.方法 拟行胃镜检查术患者400例,年龄18~60岁,体重40~80 ks,ASA Ⅰ或Ⅱ级,随机分为4组:异丙酚复合芬太尼组(PF组)、乳化依托咪酯复合芬太尼组(EF组)、异丙酚-芬太尼-咪达唑仑组(PFM组)及乳化依托咪酯-芬太尼-咪达唑仑组(EFM组),每组100例.采用双盲法给药.静脉注射芬太尼或芬太尼-咪达唑仑0.1 ml/kg,随后静脉注射异丙酚或乳化依托咪酯1 ml/6 s,待患者睫毛反射消失后停止注射,行胃镜检查术,术中根据患者情况追加少量乳化依托咪酯或异丙酚,保留自主呼吸,面罩吸氧.记录麻醉诱导时间、胃镜检查时间、乳化依托咪酯用量、异丙酚用量、阿托品和麻黄碱使用情况、内镜医师和麻醉科医师对麻醉效果的满意程度及术后苏醒时间;记录术中体动、呼吸暂停、低氧血症、心动过缓、低血压、肌阵挛及术后有关并发症的发生情况.结果 与PF组和PFM组比较,EF组和EFM组苏醒时间延长,术中低氧血症、呼吸暂停、低血压及注射痛的发生率降低,术中最低血压值升高,麻黄碱使用率降低,术中肌阵挛发生率、术后恶心、呕吐及头晕的发生率及麻醉科医师满意程度升高(P<0.05);与EF组比较,EFM组术中肌阵挛及术后恶心、呕吐、头晕的发生率降低,低血压发生率升高(P<0.05).结论 乳化依托咪酯-芬太尼-咪达唑仑对胃镜检查术患者循环和呼吸功能的抑制程度较轻,术中及术后有关并发症发生率低.
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[7] 卢盛位,吴论.依托咪酯联合瑞芬太尼用于老年患者胃镜检查时依托咪酯的半数有效剂量[J].临床麻醉学杂志,2016,32(7):665-667.
目的:测定依托咪酯联合瑞芬太尼用于老年患者胃镜检查依托咪酯的 ED50和 ED95。方法选择行胃镜检查的老年患者23例,男13例,女10例,年龄65~78岁,体重45~76 kg,ASAⅠ~Ⅲ级。预先缓慢静脉注射瑞芬太尼0.3μg/kg,然后注射依托咪酯0.20 mg/kg,待睫毛反射消失后行胃镜检查。依托咪酯的剂量采用改良序贯法确定,起始剂量为0.20 mg/kg,胃镜检查患者反应阳性标准:在整个检查过程中出现躁动、皱眉、吞咽、呛咳等。相邻间隔剂量为0.05 mg/kg,当出现七个交叉点终止研究。应用概率回归分析法计算依托咪酯复合瑞芬太尼老年患者胃镜检查的依托咪酯 ED50和 ED95及95%CI。结果依托咪酯 ED50为0.17 mg/kg,95%CI 为0.14~0.21 mg/kg, ED95为0.23 mg/kg,95%CI 为0.20~0.42 mg/kg。结论依托咪酯联合瑞芬太尼用于老年患者无痛胃镜 ED50、ED95分别为0.17 mg/kg 和0.23 mg/kg。
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[8] 熊云川,郭曲练.麻醉深度指数监测下靶控输注异丙酚复合瑞芬太尼在老年患者胃镜检查中的应用[J].中国内镜杂志,2011,17(6):600-602.
目的探讨麻醉深度指数(CSI)应用于老年患者胃镜检查的优势,观察比较单纯靶控输注TCI异丙酚和TCI瑞芬太尼复合异丙酚两种方法在老年患者胃镜检查中的应用价值及不良反应。方法 90例ASAⅠ、Ⅱ级接受胃镜检查的患者(65岁以上),随机分成3组(n=30):单纯TCI异丙酚组(A组),CSI监测TCI异丙酚组(B组),CSI监测TCI瑞芬太尼复合异丙酚组(C组)。A组根据患者意识和血流动力学调整血浆异丙酚TCI靶浓度,B、C组根据CSI值和血流动力学调整异丙酚和(或)瑞芬太尼TCI血浆靶浓度,检查中维持CSI值40~60。分别记录异丙酚总量,苏醒和应答时间,呼吸抑制、心动过缓、不自主体动、呃逆、恶心和呕吐等不良反应情况。结果 3组患者均顺利完成检查,与A组比较,B、C组的异丙酚总量减少,苏醒和应答时间均缩短,检查中体动减少(P0.05),与B组比较,C组异丙酚总量减少,苏醒时间缩短(P0.05),应答时间和体动反应差异无显著性(P0.05),与A、B组比较,C组发生呼吸抑制、心动过缓的概率明显增高(P0.05),3组呛咳、呃逆、恶心、呕吐的发生率差异无显著性(P0.05)。结论 CSI监测下TCI瑞芬太尼复合异丙酚用于老年患者胃肠镜检查可以达到更合理的麻醉深度而减少检查中不良刺激反应,并减少异丙酚用量,以便麻醉快速苏醒,缺点是需加强呼吸循环管理。
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[9] 曲立哲. 不同药物静脉麻醉用于老年患者胃镜检查的分析[J].中国内镜杂志,2010,16(5):469-471.
目的:评价不药物静脉麻醉用于老年患者胃镜检查的效应及安全性.方法:回顾分析620例采用静脉麻醉下胃 镜检查且年龄≥65岁老年患者的临床资料,按麻醉用药不同分为4组:P组,单纯丙泊酚组;FP组,芬太尼复合丙泊酚组;RP组,瑞芬太尼复合丙泊酚 组;MP组,咪唑安定复合丙泊酚组.分析各组丙泊酚用量、苏醒时间,术中患者MAP、HR、SPO变化及不良反应发生情况.结果:所 有麻醉均达到满意镇静程度;丙泊酚用量P组(90.46±28.28),mg明显高于其他3组[(65.42±20.10)、(61.38±19.84) 和(62.02±21.34)mg](P 均一过性下降,其中SPO<90%的发生率,P组(10.6%)、MP组(11.9%)多于FP组(O%)和RP组(0%) (P<0.05).结论:丙泊酚单独应用或者伍用芬太尼、瑞芬太尼、咪唑安定等均可用于老年患者胃镜检查,其中以伍用芬太尼或瑞芬太尼较为理想.
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[10] 罗小茜,王琇,余晓帆,. 无痛胃镜检查前2小时口服葡萄糖溶液效果观察[J].护理学杂志,2017,32(13):28-31.
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[11] RECH M A,BENNETT S,CHANEY W,et al.Risk factors for mortality in septic patients who received etomidate[J].Am J Emerg Med,2015,33(10):1340-1343.
ABSTRACT To characterize risk factors for mortality in septic patients who received etomidate for rapid sequence intubation. This study was a retrospective cohort conducted at a large, tertiary, urban, academic medical center that included patients with severe sepsis or septic shock who received etomidate between January 1, 2010, and December 31, 2012. A total of 169 patients were included with similar baseline characteristics. There were more men in the nonsurvivor group than in the survivor group (67.1% vs 50.6%, P = .03). Septic shock occurred in 91.5% of nonsurvivors and 69% of survivors (P < .01). Nonsurvivors also had a higher initial lactate of (5.1 ± 4.3 mmol/L vs 3.6 ± 3.4 mmol/L, P = .02) and more vasopressor therapy (91.5% vs 69%, P < .01), required a higher number of vasopressors (2.2 ± 1.1 vs 1.3 ± 1, P < .01), and were administered hydrocortisone (53.7% vs 34.5%, P = .01). Abdominal source of sepsis (P = .048) and number of vasopressors (P = .01) were predictive of 30-day mortality. An alternative sedative induction agent may be considered for use in rapid sequence intubation in patients on multiple vasopressors or with abdominal source of infection. Copyright 08 2015. Published by Elsevier Inc.
DOI:10.1016/j.ajem.2015.07.062      PMID:26321168      URL    
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[12] BANIHASHEM N,ALIJANPOUR E,BASIRAT M,et al.Sedation with etomidate-fentanyl versus propofol-fentanyl in colonoscopies:A prospective randomized study[J].Caspian J Intern Med,2015,6(1):15-19.
The combination of propofol-fentanyl for sedation during colonoscopy is characterized by high prevalence of side effects. Etomidate-fentanyl provides fewer hemodynamic and respiratory complications. The aim of our study was to compare the safety and efficacy of propofol-fentanyl and etomidate-fentanyl for conscious sedation in elective colonoscopy. This double-blind clinical trial was conducted on 90 patients aged between 18- 55 years old who were candidates for elective colonoscopy. Patients were randomized to receive sedation with fentanyl plus propofol or etomidate. Two minutes after injecting 1 micro/kg of fentanyl, the patients received 0.5mg/kg propofol by infusion (25 08/kg/min) or 0.1 mg/kg etmoidate (15 08/kg/min). Pulse rate, mean arterial blood pressure, respiratory rate, and saturation of peripheral oxygen (SPO2) were monitored. In addition, the patient and colonoscopist satisfaction, the recovery time, sedation and pain score in both groups were assessed. Sedation score in propofol group was higher. Pain score as well as the physician and patient satisfaction showed no significant difference between the two study groups. Hemodynamic changes and arterial saturation were the same in both groups. The duration of recovery was 1.27±0.82 minutes in the etomidate group; versus 2.57±2.46 minutes in the propofol group (P=0.001). Recovery time in the etmoid group was 2.68±3.14 minutes and in the propofol group was 5.53±4.67 minutes (p=0.001). The combination of fentanyl and etomidate provides an acceptable alternative to sedation with fentanyl and propofol with the advantage of significantly faster recovery time, in the outpatient setting.
PMID:4478113      URL    
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[13] D'OVIDIO D,SPADAVECCHIA C,ANGELI G,et al.Etomidate anaesthesia by immersion in oriental fire-bellied toads (Bombina orientalis)[J].Lab Anim,2015,49(4):319-326.
DOI:10.1177/0023677215571655      URL    
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[14] UPADHYE S,CYGANIK O .Is single-dose etomidate induction safe in emergency intubation of critically ill patients[J].Ann Emerg Med,2015,11(15):392-398.
The use of etomidate for emergency airway interventions in critically ill patients is very common. In one large registry trial, etomidate was the most commonly used agent for this indication. Etomidate is known to suppress adrenal gland function, but it remains unclear whether or not this adrenal gland dysfunction affects mortality.The primary objective was to assess, in populations of critically ill patients, whether a single induction dose of etomidate for emergency airway intervention affects mortality.The secondary objectives were to address, in populations of critically ill patients, whether a single induction dose of etomidate for emergency airway intervention affects adrenal gland function, organ dysfunction, or health services utilization (as measured by intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation, or vasopressor requirements).We repeated analyses within subgroups defined by the aetiologies of critical illness, timing of adrenal gland function measurement, and the type of comparator drug used.We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; CINAHL; EMBASE; LILACS; International Pharmaceutical Abstracts; Web of Science; the Database of Abstracts of Reviews of Effects (DARE); and ISI BIOSIS Citation index(SM) on 8 February 2013. We reran the searches in August 2014. We will deal with any studies of interest when we update the review.We also searched the Scopus database of dissertations and conference proceedings and the US Food and Drug Administration Database. We handsearched major emergency medicine, critical care, and anaesthesiology journals.We handsearched the conference proceedings of major emergency medicine, anaesthesia, and critical care conferences from 1990 to current, and performed a grey literature search of the following: Current Controlled Trials; National Health Service - The National Research Register; ClinicalTrials.gov; NEAR website.We included randomized controlled trials in patients undergoing emergency endotracheal intubation for critical illness, including but not limited to trauma, stroke, myocardial infarction, arrhythmia, septic shock, hypovolaemic or haemorrhagic shock, and undifferentiated shock states.We included single (bolus) dose etomidate for emergency airway intervention compared to any other rapid-acting intravenous bolus single-dose induction agent.Refinement of our initial search results by title review, and then by abstract review was carried out by three review authors. Full-text review of potential studies was based on their adherence to our inclusion and exclusion criteria. This was decided by three independent review authors. We reported the decisions regarding inclusion and exclusion in accordance with the PRISMA statement.Electronic database searching yielded 1635 potential titles, and our grey literature search yielded an additional 31 potential titles. Duplicate titles were filtered leaving 1395 titles which underwent review of their titles and abstracts by three review authors. Sixty seven titles were judged to be relevant to our review, however only eight met our inclusion criteria and seven were included in our analysis.We included eight studies in the review and seven in the meta-analysis. Of those seven studies, only two were judged to be at low risk of bias. Overall, no strong evidence exists that etomidate increases mortality in critically ill patients when compared to other bolus dose induction agents (odds ratio (OR) 1.17; 95% confidence interval (CI) 0.86 to 1.60, 6 studies, 772 participants, moderate quality evidence). Due to a large number of participants lost to follow-up, we performed a post hoc sensitivity analysis. This gave a similar result (OR 1.15; 95% CI 0.86 to 1.53). There was evidence that the use of etomidate in critically ill patients was associated with a positive adrenocorticotropic hormone (ACTH) stimulation test, and this difference was more pronounced at between 4 to 6 hours (OR 19.98; 95% CI 3.95 to 101.11) than after 12 hours (OR 2.37; 95% CI 1.61 to 3.47) post-dosing. Etomidate's use in critically ill patients was associated with a small increase in SOFA score, indicating a higher risk of multisystem organ failure (mean difference (MD) 0.70; 95% CI 0.01 to 1.39, 2 studies, 591 participants, high quality evidence), but this difference was not clinically meaningful. Etomidate use did not have an effect on ICU LOS (MD 1.70 days; 95% CI -2.00 to 5.40, 4 studies, 621 participants, moderate quality evidence), hospital LOS (MD 2.41 days; 95% CI -7.08 to 11.91, 3 studies, 152 participants, moderate quality evidence), duration of mechanical ventilation (MD 2.14 days; 95% CI -1.67 to 5.95, 3 studies, 621 participants, moderate quality evidence), or duration of vasopressor use (MD 1.00 day; 95% CI -0.53 to 2.53, 1 study, 469 participants).Although we have not found conclusive evidence that etomidate increases mortality or healthcare resource utilization in critically ill patients, it does seem to increase the risk of adrenal gland dysfunction and multi-organ system dysfunction by a small amount. The clinical significance of this finding is unknown. This evidence is judged to be of moderate quality, owing mainly to significant attrition bias in some of the smaller studies, and new research may influence the outcomes of our review. The applicability of these data may be limited by the fact that 42% of the patients in our review were intubated for "being comatose", a population less likely to benefit from the haemodynamic stability inherent in etomidate use, and less at risk from its potential negative downstream effects of adrenal suppression.
DOI:10.1016/j.annemergmed.2015.10.006      PMID:26549558      URL    
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[15] DU Y,CHEN Y J,HE B.The effects of single-dose etomi-date versus propofol on cortisol levels in pediatric patients undergoing urologic surgery:a randomized controlled trial[J].Anesth Analg,2015,121(6):1580-1585.
The effects of general anesthetics on the hypothalamus-pituitary-adrenal axis and cortisol release in children are poorly characterized. Normal, daily fluctuation of cortisol levels complicates assessment of these effects. This study aimed to characterize the effects of etomidate compared with propofol on the normal cortisol secretory pattern in children undergoing urologic surgery by using a salivary cortisol assay.In this prospective, randomized, double-blind, controlled study, we recruited 80 children aged 3 to 12 years assigned ASA physical status I who were scheduled for urologic surgery and 11 healthy child volunteers. Before surgery, cortisol levels of the 11 volunteers and 15 study patients were tested from 7:00 AM to 9:00 PM every hour for 1 day. The study patients were then randomly allocated into an etomidate group and a propofol group, receiving etomidate 0.3 mg/kg (n = 38) or propofol 2 mg/kg (n = 39) and midazolam 0.1 mg/kg, fentanyl 2 渭g/kg, and rocuronium 0.6 mg/kg for induction, respectively. The cortisol levels of the patients were assessed continuously for 2 days postoperatively.The cortisol levels of the etomidate group were continuously and significantly lower than those of the propofol group from the time of discharge from the postanesthesia care unit (approximately 2:00 PM) until 8:00 AM the next morning (all P 0.070).Compared with propofol, a single induction dose of etomidate suppressed postoperative cortisol levels in healthy children undergoing urologic surgery. This suppression lasted approximately 24 hours and was not associated with any changes in clinical outcomes.
DOI:10.1213/ANE.0000000000000981      PMID:26496368      URL    
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[16] SINGH P M,ARORA S,BORLE A,et al.Evaluation of etomidate for seizure duration in electroconvulsive therapy:a systematic review and Meta-analysis[J].J ECT,2015,31(4):213-225.
DOI:10.1097/YCT.0000000000000212      URL    
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[17] MENG X L,WANG L W,ZHAO W,et al.Effects of different etomidate doses on intraoperative somatosensory-evoked potential monitoring[J].Ir J Med Sci,2015,184(4):799-803.
Somatosensory-evoked potentials (SSEPs) are widely used for intraoperative spinal cord monitoring. Although many general anesthetics inhibit SSEPs, etomidate has been reported to boost SSEPs. This clinical study aimed to test whether etomidate doses less than 0.302mg/kg amplify SSEP monitoring.Patients were divided into four groups: A, B, C, and D. Etomidate doses of 0.1, 0.2, and 0.302mg/kg were infused into patients in groups A, B, and C, respectively, after baseline SSEPs were obtained. Group D patients were infused with saline. In the subsequent 1502min, the amplitudes and latencies of SSEPs were recorded and compared.Etomidate exhibited amplification effects on SSEPs, and this effect increased with dose escalation. The amplitude changes in groups A, B, and C were significantly different (P02=020.002, P02=020.000, and P02=020.000, respectively) from that of group D. The amplitude change was largest in group C and significantly greater than those in groups A and B (P02=020.006, P02=020.000). Latency was not significantly affected (P02<020.05) by etomidate.Small doses of etomidate that were less than 0.302mg/kg had dose-related amplification effects on SSEP monitoring.
DOI:10.1007/s11845-014-1174-4      PMID:25060967      URL    
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关键词(key words)
依托咪酯
瑞芬太尼
胃镜检查
无痛
半数有效剂量


作者
韦家新