【罂粟摘要】依托咪酯与丙泊酚在冠心病患者行非心脏手术中的比较：一项随机临床试验
依托咪酯与丙泊酚在冠心病患者行非心脏手术中的比较：一项随机临床试验
贵州医科大学 高鸿教授课题组
翻译：吴学艳 编辑：佟睿 审校：曹莹
理想的全身麻醉深度应达到手术所需的镇静、镇痛和肌肉松弛水平，同时最大程度降低对意识的生理反应。随着人口老龄化，冠心病(CHD)患者接受重大非心脏手术时麻醉策略的选择成为一个越来越重要的问题；是由于全身麻醉与围手术期心脏并发症和死亡风险相关，而这种风险在冠心病患者中更高。
比较依托咪酯和丙泊酚麻醉在冠心病患者中的血流动力学功能和心血管事件发生率。
此项前瞻性研究纳入了连续接受行重大非心脏手术的稳定性冠心病患者，(NYHA分级I/II级)、(ASA分级II/III级)；将患者随机分为依托咪酯/瑞芬太尼或丙泊酚/瑞芬太尼两组，使用计算机生成随机数表和顺序编号、不透明、密封的信封中进行随机化，直到病人进入手术室，麻醉医师才打开信封。所有患者、数据收集者和数据分析员都不知道所使用麻醉类型。主要观察指标是麻醉期间发生的心血管事件(心动过缓、心动过速、低血压、ST-T段改变和室性早搏)和24小时的肌钙蛋白I水平，次要指标是血流动力学参数、脑电双频指数和麻醉期间血管活性药物的使用情况。
最终分析包括丙泊酚组和依托咪酯组各40例患者。丙泊酚组麻醉期间心动过缓、低血压、ST-T段改变和室性早搏的发生率明显高于依托咪酯组(P<0.05)。两组心动过速的发生率相似；两组患者麻醉诱导前和术后24小时的肌钙蛋白I水平无明显差异。与依托咪酯组比较，丙泊酚组麻醉诱导后3min(T1)、气管插管即刻(T2)心率明显减慢，T1时收缩压降低；T1、T2、插管后3min、5min舒张压和平均动脉压降低(均P<0.05)；异丙酚组在诱导期和维持期的升压药使用量明显多于依托咪酯组(P<0.001)。
在接受非心脏手术的冠心病患者中，依托咪酯麻醉组比丙泊酚麻醉组心血管事件发生率低，血流动力学变化小。
Etomidate vs propofol in coronary heart disease patients undergoing major noncardiac surgery: A randomized clinical trial
Abstract
Background：The ideal depth of general anesthesia should achieve the required levels of hypnosis, analgesia, and muscle relaxation while minimizing physiologic responses to awareness. The choice of anesthetic strategy in patients with coronary heart disease (CHD) undergoing major noncardiac surgery is becoming an increasingly important issue as the population ages. This is because general anesthesia is associated with a risk of perioperative cardiac complications and death, and this risk is much higher in people with CHD.
Aim：To compare hemodynamic function and cardiovascular event rate between etomidate- and propofol-based anesthesia in patients with CHD.
Methods:This prospective study enrolled consecutive patients (American Society of Anesthesiologists grade II/III) with stable CHD (New York Heart Association class I/II) undergoing major noncardiac surgery. The patients were randomly allocated to receive either etomidate/remifentanil-based or propofol/ remifentanil-based general anesthesia. Randomization was performed using a computer-generated random number table and sequentially numbered, opaque, sealed envelopes. Concealment was maintained until the patient had arrived in the operating theater, at which point the consulting anesthetist opened the envelope. All patients, data collectors, and data analyzers were blinded to the type of anesthesia used. The primary endpoints were the occurrence of cardiovascular events (bradycardia, tachycardia, hypotension, ST-T segment changes, and ventricular premature beats) during anesthesia and cardiac troponin I level at 24 h. The secondary endpoints were hemodynamic parameters, bispectral index, and use of vasopressors during anesthesia.
Results:The final analysis included 40 patients in each of the propofol and etomidate groups. The incidences of bradycardia, hypotension, ST-T segment changes, and ventricular premature beats during anesthesia were significantly higher in the propofol group than in the etomidate group (P < 0.05 for all). The incidence of tachycardia was similar between the two groups. Cardiac troponin I levels were comparable between the two groups both before the induction of anesthesia and at 24 h after surgery. When compared with the etomidate group, the propofol group had significantly lower heart rates at 3 min after the anesthetic was injected (T1) and immediately after tracheal intubation (T2), lower systolic blood pressure at T1, and lower diastolic blood pressure and mean arterial pressure at T1, T2, 3 min after tracheal intubation, and 5 min after tracheal intubation (P < 0.05 for all). Vasopressor use was significantly more in the propofol group than in the etomidate group during the induction and maintenance periods (P < 0.001).
Conclusion ：In patients with CHD undergoing noncardiac major surgery, etomidate-based anesthesia is associated with fewer cardiovascular events and smaller hemodynamic changes than propofol-based anesthesia.