利多卡因声门麻醉与呼吸道反射.pdf
利多卡因声门麻醉与呼吸道反射.pdf
第四军医大学口腔医学院麻醉科 邱宝军 Background laryngeal and respiratory reflexes apnoea coughing laryngospasm laryngeal and respiratory reflexes expiration reflex spasmodic panting痉挛性气喘 麻醉医师义务 An increased incidence of laryngospasm and apnoea hypoxaemia are more common and more severe in children Lidocaine has been demonstrated to reduce the incidence of laryngospasm，however, its effectiveness has been questioned 研究目的 The purpose of this study was to characterise the changes in laryngeal and respiratory reflex responses following intravenous lidocaine when the larynx was stimulated during sevoflurane anaesthesia and to determine whether these effects were transient. Methods ethics committeet informed consent laryngeal mask airway ASA：I-II 25–84 months 12–35 kg cardiopulmonary disease 心肺疾病 cerebral dysfunction 脑功能障碍 neuromuscular disease 神经肌肉疾病 excluded respiratory infection 呼吸道感染 medical treatment for asthma 近期哮喘治疗 malignant hyperthermia 恶性高热 麻醉前处理 0.3mg/kg（口服或直 肠）10-20min前 麻醉诱导 50% O2 sevoflurane 50 % N2 O 6L/mim intravenous access Stop N2O O2 spontaneously breathing system semi-closed breathing No response to a jaw trust manoeuvre sevoflurane concentration of 2.5%. lidocaine 2mg/kg 60s pre-filled infusion pump 3 consecutive occasions: (i) baseline under sevoflurane anaesthesia; (ii) 2 min (iii) 10 min 0.25 ml 蒸馏水 Laryngeal and respiratory reflex responses and endoscopic images were recorded continuously before, during and after each stimulation. An experienced paediatric anaesthetist performed all the studies . In addition, a paediatric anaesthetist independent of the study team was responsible for the overall care of the patient. Safety laryngospasm>10 s： jaw thrust + positive airways pressure of 10 cmH2O laryngospasm or SpO2< 90% 1 mg/kg 0.01 mg/kg explain 1.잠재 고객 laryngospasm complete closure of the glottis on video images lasting more than 10 s;(声门完全关闭>10s ) apnoea without complete closure of the glottis lasting more central apnoea than 10 s(声门没有完全关闭 ，呼吸暂停>10s) a forceful expiration following inspiration（吸气后强力呼气） cough reflex, a forceful expiration without a preceding inspiration expiration reflex （没有吸气的强力呼气） rapid shallow breathing (respiratory frequencygreater than 60 spasmodic panting 痉挛性气喘 breaths. min)1) lasting more than 10 s（浅快呼吸>10s） Blood samples lidocaine concentrations patient’s arm opposite to that in which the lidocaine bolus was administered 2 times 2 and 10 min after administration of lidocaine Serum lidocaine concentrations centrifuged（离心）and analysed simultaneously using an enzyme immunoassay（免疫检测） 88 children 3rd stimulation 中位数（内距又称为四分位差/范围） 平均值（标准差) After administration of a lidocaine bolus, the mean minute ventilation decreased, resulting in a mean increase in end-tidal carbon dioxide levels, which was significant at 10 min following the lidocaine bolus. The mean arterial blood pressure was lower than baseline at both 2 min and 10 min following the lidocaine bolus.。 The mean (SD) serum concentration of lidocaine 2 min after administration of lidocaine 3.2 (0.8)ug/ml 10 min after administration of lidocaine 2.0(0.4)ug/ml Compared with baseline, the incidence of laryngospasm lasting greater than 10 s was reduced by 60%, from 15 patients to 6 patients (p = 0.011) during the second stimulation, 2 min after the intravenous administration of lidocaine. Compared with baseline, the incidence of laryngospasm was not significantly reduced following the third stimulation 10 min after lidocaine administration. Compared with baseline, the incidence of central apnoea lasting more than 10 s was significantly reduced ，2 min after the intravenous administration of lidocaine. There were no differences in the incidence of cough reflex, expiration reflex or spasmodic panting. The mean (SD) Duration of Apnoea 10min after 2 min after administration of lidocaine 21.7 (34.7) s baseline shorter 30.8 (28.5) s administration of lidocaine similar 30.8 (34.9) s Apnoea: 10min later ≈baseline , the effect was short-lived re-establishment:10min later ≈baseline , the effect was short-lived The mean (SD) duration re-establishment of normal breathing laryngeal and respiratory reflex responses 2 min after administration of lidocaine 28.8 (37.4)s 10 min after administration of lidocaine baseline significantly reduced 45.8(41.5) s no differences ？s Conclusion The intravenous administration of lidocaine significantly reduced the incidence of laryngospasm evoked by laryngeal stimulation in children anaesthetised with sevoflurane; however, the effect was short-lived and incomplete. 学到一种临床模型 Clinical model using laryngeal stimulation Model of laryngospasm I：小儿喉部喷利多（类似蒸馏水） 是否亦有可能诱发喉痉挛？ II：气管导管内喷利多是否会引发 气管痉挛呢？ 临床试验需更重安全 临床经验丰富的麻醉医师 临床试验 Safety 独立的安全保障团队 切实的危机处理预案 临床试验的真实性（40/128） 能否对试验方案进行改进？ 是否有比利多卡因更好的药？ 思考和创新 是否有更安全的给药方案？ 静脉全身用药安全？还是局部用药安全？(Bis) 局部雾化给药如何？ 能否设计局部雾化给药方案与静脉给药对比？ 感谢科室，梦想在这里绽放！ 谢谢聆听并指正!