心房颤动射频消融术中应用丙泊酚深度镇静的临床观察

Unconscious sedation with propofol during catheter ablation of atrial fibrillation

目的研究心房颤动(房颤)导管射频消融术中采用丙泊酚深度镇静的有效性、安全性及对操作过程的影响。方法入选160例房颤患者采用持续静脉注射丙泊酚行深度镇静,同期60例未采用丙泊酚的房颤患者作为对照组。深度镇静先给予负荷量丙泊酚1 mg／kg,然后经左锁骨下静脉持续给予维持剂量,起始维持剂量为药典推荐剂量的中位数8 mg·kg-1·h-1术中根据患者的生理指标每10 min调整剂量一次,直至实现理想深度镇静。理想深度镇静的标准:患者意识及疼痛反应消失,但生命体征稳定,无需呼吸及循环支持。分析丙泊酚剂量的影响因素及深度镇静对操作过程的影响。结果160例患者中,除14例(8．8％)外均实现理想深度镇静,未能实现的主要原因是出现不能耐受的不良反应包括低血压、呼吸抑制、剧烈呛咳。实现理想深度镇静的患者,从开始给药至实现理想深度镇静的平均时间为(30±10)min,平均药物维持剂量为(8±3)mg·kg-1·h-1。单变量分析发现年龄>65岁、体重<50 kg及女性患者为给药剂量的影响因素;多变量分析发现仅年龄及体重影响给药剂量。实现理想深度镇静的患者平均手术时间((180±30)min vs(190±37)min,P=0．04]和平均累计放电时间[(59±16)min vs (66±19)min,P=0．007]显著减少且低于对照组,而肺静脉隔离成功率及并发症发生率两组相似。结论房颤导管射频消融术中采用丙泊酚深度镇静安全有效,可提高手术效率,保证手术的顺利进行。

Objective To investigate the efficacy and safety of unconscious sedation with propofol during catheter ablation of atrial fibrillation （AF）. Methods Unconscious sedation with propofol was carried out in 160 patients,and other 60 patients served as control group. Propofol was initiated with load dosage of 1 mg/ kg, and maintained with a median of pharmacopeia- recommended dosage （8 mg.kg^ -1 . h^- 1）. The maintenance dosage was titrated according to physiological parameters. Stable unconscious sedation was defined as loss of consciousness without interrupting physiological parameters. ANOVA and multiple stepwise regression analysis were employed to test the significant factors predicting propofol dosage. Results Of the 160 patients received propofol, stable unconscious sedation was achieved in 146 patients, intolerable side effects hampered reaching stable unconscious sedation in the remaining 14 patients. The intolerable side effects included hypotension, respiratory suppression, and coughing. Univariate analysis revealed a potential relationship between dosage and age, body weight, and gender. This significance only limited to age and body weight after multivariate regression analysis. The total procedure time[（ 180±30） min vs（ 190 ±37） min,P =0. 04] and ablation appli- cation time[ （59 ±16） min vs （66± 19） min, P =0. 007]were significantly reduced with unconscious sedation. While pulmonary vein isolation rate and complication rate were comparable between 2 groups. Conclusion Unconscious sedation with propofol can be safely and effectively carried out in majority of patients undergoing transcatheter ablation of atrial fibrillation. Stable unconscious sedation allows operator to perform ablation smoothly.