臺灣博碩士論文加值系統

背景：研究顯示，口咽置入局部麻醉劑lidocaine，可降低光纖內視鏡清醒插管時的循環反應。本研究嘗試將此一局部麻醉效果，延伸用於麻醉誘導插管時。

目的：本研究在探討全身麻醉誘導期，插管前給予口咽置入局部麻醉劑2% lidocaine 5 ml，能否改善血壓和心率對氣管插管的反應。

材料和方法： 56位接受常規預定手術之成年病患被隨機分成二組，實驗組病患在全身麻醉誘導後45秒，於口咽置入局部麻醉劑2% lidocaine 5 mL，造成口咽及氣管表皮麻醉；對照組病患在全身麻醉誘導後45秒，於口咽置入生理鹽水5 mL。三分鐘後，給予受試者氣管插管，期間每分鐘監測受試者之血壓 (收縮壓、舒張壓、平均血壓) 和心率。口咽置入局部麻醉劑後，連續監測受試者每分鐘之血壓和心率達六分鐘。將兩組氣管插管後一分鐘之血壓和心率，以及其與基礎值之變動，以非配對 t-試驗比較，以確定口咽置入局部麻醉劑lidocaine，對降低氣管插管時循環反應的效果。

結果：在氣管插管後一分鐘之血壓和心率，lidocaine 組均比對照組為低(P < 0.05)。氣管插管後一分鐘之收縮壓、舒張壓、平均血壓與基礎值之變動差在對照組均較高 (P < 0.001)，然而心率變動差兩組並無差異。

結論：氣管插管前口咽置入局部麻醉劑lidocaine，可以降低因插管時刺激造成之心率及血壓的上升的循環反應。此為一簡單又有效，可以局部麻醉上呼吸道的方法，能使麻醉誘導及氣管插管時的循環反應較為平穩。

Purpose: This study attempts to determine whether oropharyngeal instillation of 5mL of 2% lidocaine for 3 min before intubation modifies changes in heart rate (HR) and blood pressure (BP) responses to the stimulation.

Materials and methods: Fifty-six surgical patients were randomized to receive oropharyngeal instillation with either 5 mL of 2% lidocaine (lidocaine group) or 5 mL of normal saline (control group) 45 s after induction bolus. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), and HR were recorded every min thereafter for 6 min. Laryngoscopy and intubation was attempted at 3 min after intervention. The 1-min postintubation values of HR, SBP, DBP, and MBP between the groups, and their changes from baseline were compared as a priori using the unpaired t-test.

Results: The 1-min postintubation values of SBP, DBP, MBP, and HR were significantly lower in the lidocaine group as compared to the control group (P < 0.05). The differences in mean values of SBP, DBP, and MBP changes from baseline were significantly greater in the control group (P ≤ 0.001), while that of HR was not significant. More patients (P < 0.001) become hypertensive at 1-min postintubation in the control group than in the lidocaine group. No differences in tachycardia incidence were found.

Conclusion: We conclude that oropharyngeal administration of lidocaine before intubation attenuates the cardiovascular responses to the stimulation. It is a simple and effective method for achieving anesthesia of the upper airway and rendering induction smoother with respect to cardiovascular changes.

Contents

Abstract p.5

中文摘要 p.7

Chapter 1. Introduction p.8

Chapter 2. Rationale and hypotheses p.11
1.Rationale of this study p.11
2.Hypothesis and specific objectives p.12

Chapter 3. Literature review p.13
1. Intravenous lidocaine and cardiovascular response to intubation p.14
2. Laryngotracheal lidocaine and cardiovascular response to intubation p.18
3.Summary p.23

Chapter 4. Materials and methods p.30
1.General study design p.30
2.Study population p.30
3.Randomization p.30
4.Methods p.31
5.Data recording p.32
6.Sample size calculation p.32
7.Statistical analysis p.33

Chapter 5. Results p.35

Chapter 6. Discussion p.40
1.Major findings
2.Comparison with previous studies p.40
3.Possible mechanism p.42
4.Methodological consideration p.42
5.Strengths p.45
6.Limitations p.45
7.Further perspectives p.46
8.Conclusion p.47

References p.48

Appendix
Approval of the Institutional Review Board of Cathay General Hospital p.53

Tables and Figures List

Table 3-1. Prospective studies on intravenous lidocaine and response to intubation p.25
Table 3-2. Prospective studies on laryngotracheal lidocaine and response to intubation p.27
Table 5-1. Characteristics of the patients and baseline variables p.36
Table 5-2. Hemodynamic variables at 1-min postintubation between the groups p.37
Table 5-3. Postintubation circulatory changes from baseline in each group p.38

Figure 4-1. Study design flow chart p.34
Figure 5-1. Heart rate and blood pressure changes from baseline p.39

References
1.Takeshima K, Noda K, Higaki M. Cardiovascular response to rapid anesthesia induction and endotracheal intubation. Anesth Analg Curr Res 1964;43:201-8.
2.Forbes AM, Dally FG. Acute hypertension during induction of anesthesia and endotracheal intubation in normotensive man. Br J Anaesth 1970;42:618-24.
3.Widdicombe JG: Pulmonary and respiratory tract receptors. J Exp Biol 1982;100:41-57.
4.Sant’Ambrogio G: Nervous receptors of the tracheobronchial tree. Annu Rev Physiol 1987;49:611-27.
5.Tomori Z, Widdicombe JG. Muscular bronchomotor and cardiovascular reflexes elicited by mechanical stimulation of the respiratory tract. J Physio 1969;200:25-49.
6.Fox EJ, Sklar GS, Hill CH, et al. Complications related to the pressor response to endotracheal intubation. Anesthesiology 1977;47:524-5.
7.Roy WL, Edelist G, Gilbert B. Myocardial ischemia during non-cardiac surgical procedures in patients with coronary artery disease. Anesthesiology 1979;51:393-7.
8.Chung DC, Mainland PA, Kong AS. Anesthesia of the airway by aspiration of lidocaine. Can J Anesth 1999;46:215-9.
9.Mainland PA, Kong AS, Chung DC, et al. Absorption of lidocaine during aspiration anesthesia of the airway. J Clin Anesth 2001;13:440-6.
10.Denlinger JK, Ellison N, Ominsky AJ. Effects of intratracheal lidocaine on circulatory responses to tracheal intubation. Anesthesiology 1974;41:409-12.
11.Takita K, Morimoto Y, Kemmotsu O. Tracheal lidocaine attenuates the cardiovascular response to endotracheal intubation. Can J Anesth 2001;48:732-6.
12.Sitzman BT, Rich G F, Rockwell JJ, et al. Local anesthetic administration for awake direct laryngoscopy: Are glossopharyngeal nerve blocks superior? Anesthesiology 1997;86:34-40.
13.Prys-Roberts C, Greene LT, Meloche R, et al. Studies of anaesthesia in relation to hypertension. II. Haemodynamic consequences of induction and endotracheal intubation. Br J Anaesth 1971;43:53-8.
14.Kindler CH, Schumacher PG, Schneider MC, et al. Effects of intravenous lidocaine and/or esmolol on hemodynamic responses to laryngoscopy and intubation: a double-blind, controlled clinical trial. J Clin Anesth 1996;8:491-6.
15.Stoelting RK. Circulatory changes during direct laryngoscopy and tracheal intubation: influence of duration of laryngoscopy with or without prior lidocaine. Anesthesiology 1977;47:381-3.
16.Tam S, Chung F, Campbell M. Intravenous lidocaine: Optimal time of injection before tracheal intubation. Anesth Analg 1987;66:1036-8.
17.Wilson IG, Meiklejohn BH, Smith G. Intravenous lignocaine and sympathoadrenal responses to laryngoscopy and intubation. The effect of varying time of injection. Anaesthesia. 1991;46(3):177-80.
18.Aouad MT, Sayyid SS, Zalaket MI, et al. Intravenous lidocaine as adjuvant to sevoflurane anesthesia for endotracheal intubation in children. Anesth Analg 2003;96:1325-7.
19.Kim WY, Lee YS, Ok SJ, et al. Lidocaine does not prevent bispectral index increases in response to endotracheal intubation. Anesth Analg 2006;102:156-9.
20.Hamill JF, Bedford RF, Weaver DC, et al. Lidocaine before endotracheal intubation: intravenous or laryngotracheal? Anesthesiology 1981;55:578-81.
21.Chraemmer-Jorgenson B, Hoilund-Carlsen PF, Marving J, et al. Lack of effect of intravenous lidocaine on haemodynamic responses to rapid sequence induction of general anesthesia. Anesth Analg 1986;65:1037-41.
22.Laurito CE, Bangham VL, Becker GL, et al. Effects of aerosolized and/or intravenous lidocaine on haemodynamic responses to laryngoscopy and intubation in out-patients. Anesth Analg 1988;67:389-92.
23.Miller CD, Warren SJ. I.V. lignocaine fails to attenuate the cardiovascular response to laryngoscopy and tracheal intubation. Br J Anaesth 1990;65:216-9.
24.Singh H, Vichitvejpaisal P, Gaines GY, et al. Comparative effects of lidocaine, esmolol, and nitroglycerine in modifying the hemodynamic response to laryngoscopy and intubation. J Clin Anesth 1995;7:5-8.
25.Hamaya Y, Dohi S. Differences in cardiovascular response to airway stimulation at different sites and blockade of the responses by lidocaine. Anesthesiology 2000;93:95-103.
26.Weigand H. Circulatory response to endolaryngeal microsurgery under light general anesthesia and the influence of surface anesthesia. Anesth Analg Cur Res 1969;48:953-7.
27.Mostafa SM, Murthy BVS, Barrett PJ, et al. Comparison of the effects of topical lignocaine spray applied before or after induction of anaesthesia on the pressor response to direct laryngoscopy and intubation. Europ J Anaesth 1999;16:7-10.
28.Oxorn D, Chung DC. A simple technique for topical anaesthesia of the airway (Letter). Can J Anaesth 1990;37:823.
29.Kong As, Mainland P, Lai C, et al. A solution for topical anaesthesia in awake intubation (Letter). Anaesth Intensive Care 1993;21:246.
30.Schnider TW, Minto CF, Shafer SL, et al. The influence of age on propofol pharmacodynamics. Anesthesiology 1999; 90:1502-16.
31.Venus B, Polassani V, Pham CG. Effects of aerosolized lidocaine on circulatory responses to laryngoscopy and tracheal intubation. Crit Care Med 1984;12:391-4.
32.Thompson JP, Hall AP, Russell J et al. Effect of remifentanil on the haemodynamic response to orotracheal intubation. Br J Anaesth 1998;80:467-9.
33.Leslie JB, Kalayjian RW, McLoughlin TM, et al. Attenuation of the hemodynamic responses to endotracheal intubation with preinduction intravenous labetalol. J Clin Anesth 1989;1:194-200.
34.Fujii Y, Saitoh Y, Takahashi S, et al. Diltiazem-lidocaine combination for the attenuation of cardiovascular responses to tracheal intubation in hypertensive patients. Can J Anesth 1998;45:933-7.
35.Viegas O, Stoelting RK. Lidocaine in arterial blood after laryngotracheal administration. Anesthesiology 1975;43:491-3.
36.Gaumann DM, Tassonyi E, Fathi F, et al. Effects of topical laryngeal lidocaine on sympathetic response to rigid panendoscopy under general anesthesia. ORL 1992;54:49-53.
37.Shribman AJ, Smith G, Achola KJ. Cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation. Br J Anaesth 1987;59:295-9.
38.Ko SH, Kim DC, Han YJ, et al. Small-dose fentanyl: optimal time of injection for blunting the circulatory responses to tracheal intubation. Anesth Analg 1998;86:658-61.