Rocuronium－－鎮靜劑的給藥順序在施行快速麻醉誘導時的效果與安全性

Effectiveness and Safety of Rocuronium-hypnotic Sequence for Rapid-sequence Induction

背景：施行快速誘導時給予鎮靜劑之前注射rocuronium可能同時提供可接受的插管情況與較短的窒息時間。我們設計一前瞻性、隨機取樣的試驗，在模仿快速誘導的狀況下，評估這種給藥順序的效果與安全性。方法：九十名成年病人分成三組，每組有三十名病人。Ro-Th組病人接受rocuronium 0.6 mg/kg，接著thiopental 5 mg/kg；Th-Ro組病人接受 thiopental 5 mg/kg，接著rocuronium 0.6 mg/kg；Th-Sx組病人接受thiopental 5 mg/kg，接著succinylcholine 1 mg/kg。肌肉鬆弛劑注射後六十秒鐘施行喉頭鏡檢查和氣管內管插管。評估和比較各組插管情況、喉頭鏡檢查前窒息時間、插管使用時間、與全部窒息時間。同時記錄注射疼痛、肌肉麻痺的感覺、Sp02低於95％、與其他的不良作用。結果：三組病人插管情況都是可接受的，優良插管情況部分三組沒有差別。Ro-Th組的喉頭鏡檢查前窒息時間與全部窒息時間均最短；三組的插管使用時間沒有差別。在Ro-Th組五名病人有注射疼痛、三名在誘導期間感覺到呼吸無力的事件、與一名的Sp02掉至94％。結論：與傳統給藥順序比較，在施行快速誘導時rocuronium──鎮靜劑的順序可以提供類似的插管情況與更短的窒息時間。這種順序給藥時，維持點滴管路的暢通是最基本的，如此才可以避免病人清醒地意識到肌肉麻痺的感覺。

Background: Either succinylcholine or rocuronium administered after a hypnotic is the current technique for rapid-sequence induction. It is assumed that rocuronium administered before a hypnotic (Rocuronium-hypnotic sequence) may equally provide an acceptable intubation condition as well as a shorter period of apnea in rapid-sequence induction. We designed a prospective, randomized study to evaluate the effectiveness and safety of the technique in a similar rapid-sequence induction. Methods: Ninety adult patients receiving elective surgeries were enrolled in this study. In all patients the procedure in the study began with i.v. injection of fentanyl 2 μg/kg, followed by preoxygenation with 100% O2 for 2 min. Afterward, the patients were randomly allocated to 3 groups with each group consisting of 30 patients. In Rocuronium-thiopental (Ro-Th) group the patients received rocuronium 0.6 mg/kg and then thiopental 5 mg/kg; in Th-Ro group the patients received thiopental 5 mg/kg and then rocuronium 0.6 mg/kg; and in Thiopental-Succinylcholine (Th-Sx) group, the control group, the patients received thiopental 5 mg/kg and then succinylcholine 1 mg/kg. Laryngoscopy and endotracheal intubation were performed 60 s after the injection of the muscle relaxant. The intubation condition, the apneal time before laryngoscopy, the intubation time, and total apneal time were investigated and compared. Presence of injection pain, sense of paralysis, SpO2 less than 95% during induction, and any unexpected adverse event were also recorded. Results: Six patients (1 in Ro-Th group, 2 in Th-Ro group, and 3 in Th-Sx group, respectively) were excluded from the study. The intubation conditions were acceptable in all patients of three groups who completed the study, and as to excellent intubation condition there was no difference between the three groups. In Ro-Th group both the apneal time before laryngoscopy (32.4 ± 5.4 s) and total apneal time (48.5 ± 11.0 s) were the shortest. Th-Ro group (53.2 ± 5.8 and 67.5 ± 8.3 s, respectively) and Th-Sx group (54.4 ± 5.8 and 68.4 ± 7.7 s, respectively) were similar in both aspects. With respect to intubation time there was no significant difference among the three groups. Five patients in Ro-Th group and one patient in Th-Sx group felt mild injection pain. Three patients in Ro-Th group were noted to have diminished breathing during induction, which was not recalled during enquiry in the postoperative visit. One patient in Ro-Th group saw a fall of SpO2 down below 95% (94% the minimal) during the apnea period. Conclusions: Compared with traditional hypnotic-rocuronium or hypnotic-succinylcholine sequence, rocuronium (0.6 mg) - thiopental sequence can provide a similar intubation condition but cause a much shorter apneal period in rapid-sequence induction. In carrying out recuronium-thiopental sequence induction, maintaining a patent infusion line is essential to avoid drug precipitation and awareness of muscular weakness as a result of illtimed action of thiopental.