瑞芬太尼在老年患者快速序贯诱导中的有效性和安全性研究:一项三臂平行双盲随机对照试验

背景与目的

快速序贯诱导(RSI)被推荐用于误吸风险的患者，但会引起一系列血流动力学并发症：如心动过速等。本试验旨在评估老年患者RSI期间瑞芬太尼对下列情况发生风险的影响:心动过速、高血压和低血压。

方  法

在这项三臂平行双盲多中心对照研究中，三个医疗中心可进行RSI的老年患者(65 - 90岁)被随机分配到三组，使用依托咪酯（0.3 mg/kg）诱导麻醉，然后在15秒内使用安慰剂，或使用低剂量（0.5μg/kg）或高剂量（1.0μg/kg）瑞芬太尼，然后使用琥珀胆碱1.0 mg/kg。在插管前和插管后分别记录心率(HR)和平均动脉压(MAP)。

结  果

本试验最终共纳入80例患者，两组之间的基线水平HR和MAP无统计学差异。对于主要疗效指标心率和平均动脉压，对照组在诱导和插管之间的心率绝对值变化大于瑞芬太尼0.5μg/kg组和瑞芬太尼1.0μg/kg组。而对照组MAP的增加大于瑞芬太尼组(P< 0.0001)。对照组高血压发生次数是瑞芬太尼低剂量（0.5μg/kg）组和高剂量（1.0μg/kg）组的两倍（分别为60%、30%、28%；P=0.032），但对照组无低血压发作，瑞芬太尼低剂量（0.5μg/kg）组和高剂量（1.0μg/kg）组分别为11%和24%（P=0.016）。

结  论

老年患者快速序贯诱导(RSI)，使用瑞芬太尼（0.5-1.0μg/kg）可预防心动过速和高血压的发生。

原始文献摘要

Ashokkumar Jayaraj, Hemavathi Balachander, Suresh K. Kuppusamy;Efficacy and Safety of Remifentanil in a Rapid Sequence Induction in elderly patients: a three-arm parallel double blind randomised controlled trial [J].Anaesth Crit Care Pain Med;

Background:

Rapid sequence induction (RSI) is recommended in patients at risk of aspiration, but induced hemodynamic adverse events, including tachycardia. In elderly patients, this trial aimed to assess the impact of the addition of remifentanil during RSI on the occurrence of: tachycardia(primary outcome), hypertension (due to intubation) nor hypotension (remifentanil). 

Methods:

In this three-arm parallel, double blind, multicentre controlled study, elderly patients (65 to 90 yearsold) hospitalised in three centres and requiring RSI were randomly allocated to three groups, where anaesthesia was induced with etomidate (0.3 mg/kg) followed within 15 seconds by either placebo, or low (0.5 μg/kg), or high (1.0 μg/kg) doses of Remifentanil, followed by succinylcholine 1.0 mg/kg.Heart rate (HR) and mean arterial pressure (MAP) were recorded before induction and after intubation. 

Results:

In total, eighty patients were randomised and analysed. Baseline HR and MAP were similar between groups. For primary endpoint, the absolute change in HR between induction and intubation was greater in the control group (15 bpm; 95% CI [8-21]) than that in the remifentanil 0.5 μg/kg group (4 bpm; 95% CI [-1-+8]; p = 0.005) and the remifentanil 1.0μg/kg group (-3 bpm; 95% CI [-9-+3]; p < 0.0001). The increase in MAP was greater in the placebo group than in both remifentanil groups (p < 0.0001). Twice as many hypertension episodes were recorded in the placebo group compared to the remifentanil 0.5 μg/kg and 1.0μg/kg groups (60%, 30%, and 28% patients respectively; p = 0.032), but no placebo patients experienced hypotension episodes versus 11% and 24% in the remifentanil 0.5 μg/kg and 1.0μg/kg groups respectively (p = 0.016). 

Conclusions:

Remifentanil (0.5-1.0 μg/kg) prevents the occurrence of tachycardia and hypertension in elderly patients requiring RSI.