Qualitätsvergleich von modifizierter Neurolept-, balancierter und intravenöser Anästhesie Teil 2. Ergebnisse der Krefelder Studie 1992*

Zusammenfassung

Bei 1318 Patienten wurden Narkosesicherheit, Verträglichkeit und Vigilanz nach Neurolept – (NLA), balancierter – (BAL) – und intravenöser Propofolanästhesie (IVA) anhand von DGAI-ZEKListe und -Fragebogen sowie spezieller Vigilanztests analysiert. Prämedikation und Narkoseführung waren standardisiert. Als Ausdruck unterschiedlicher Narkosesicherheit wurden nach NLA bei 45%, nach BAL und IVA bei 35% bzw. 36% der Patienten therapiebedürftige Ereignisse registriert (p=0,004). Im einzelnen zeigten NLA-Patienten gehäuft Tachykardien, Arrhythmien und Hypertonien (p=0,05), während bei IVA Hypotensionen vermehrt beobachtet wurden (p<0,001). Schwere kardiohämodynamische Ereignisse waren bei lediglich 6,6% aller Patienten zu verzeichnen, wobei 5% der IVA-Patienten im Vergleich zu 6,3% bzw. 8,3% nach BAL und NLA intensivtherapiepflichtige Interventionen am seltensten nötig hatten. Hinsichtlich ihrer Ansprechbarkeit, Konzentrations- und Sprachfähigkeit wurden IVA- und NLA-Patienten ungleich besser bewertet als die verzögert erwachenden BAL-Patienten (p<0,05). Da zudem Übelkeit und Erbrechen nach IVA signifikant geringer ausgeprägt waren (p<0,05), wurde diese Narkose aus Patientensicht hoch favorisiert (p<0,01). Insgesamt ging daher die IVA aufgrund der geringen Zahl gravierender kardiohämodynamischer Komplikationen (ZEK), einer kurzen Aufwachphase und fehlender Nebenwirkungen als das beste Verfahren aus diesem Vergleich hervor.

Abstract

The safety and tolerance of neuroleptanaesthesia (NLA), balanced anaesthesia (BAL), and intravenous anaesthesia with propofol (IVA) were analysed for the first time in a prospective, randomised clinical trial.

Methods. In all, 1318 surgical patients received either NLA, BAL, or IVA. Patients who had regional anaesthesia, were aged under 18 years, or were nonco-operative or vitally threatened (ASA class IV to V) did not participate in the study. Premedication and anaesthetic course were set up at a standard of 30% oxygen and 70% nitrous oxide. Incidents, events, and complications due to anaesthesia were obtained (IEC key of the German Society of Anaesthesia and Critical Care Medicine, DGAI). Furthermore, postanaesthetic alertness based on specific recovery tests and the quality of anaesthesia from the patient's viewpoint, rated by patient questionnaires from the DGAI were evaluated. All parameters were calculated and checked for statistical significance using the chi-square test.

Results and discussion. The groups were broadly comparable with respect to age (P=0.91), ASA class (P=0.42), preoperative blood pressure (P=0.36), and length of anaesthesia (P=0.82). The anaesthesia, which averaged 103 min, comprised the following regimens: (1) NLA: 7.1 mg droperidol and 0.008 mg/kg body weight fentanyl, (2) IVA: 493.4 mg propofol and 0.004 mg/kg body weight fentanyl, and (3) BAL: 2.6 mg droperidol and 0.004 mg/kg body weight fentanyl with 0.4 vol.% isoflurane.

With respect to anaesthetic risk, the following reactions were observed: the use of NLA led to a high incidence of tachycardia (P=0.001), arrhythmias (P=0.05), and hypertensive reactions (P= 0.001), whereas in the IVA group only hypotension (P=0.0001) occurred. However, after the use of BAL none of the aforementioned complications were detectable to any considerable degree. Similarly, patients who had cardiac disease showed greater IEC changes after the use of NLA than after BAL or IVA (P=0.02) (Tables 1 and 2).

The heart rates and blood pressures during BAL and IVA were extremely stable, and therefore, vasoactive therapy was required considerably less in comparison to NLA (P=0.001) (Table 4). Recovery after the use of IVA was strikingly rapid: the patient's responsiveness, orientation, and ability to concentrate was significantly better than after the other anaesthetic regimen (P=0.01) (Table 5). With regard to the typical discomforts after anaesthesia, IVA was highly superior to BAL and NLA: nausea (P=0.0003) and retching (P=0.03) hardly ever occurred (Table 6). Due to the tolerable manner of waking up and rapid return of orientation and the ability to concentrate, IVA was highly favoured by the patients (P=<0.01) (Table 7).

Conclusion. The present results show clear clinical advantages of BAL and IVA in contrast to neuroleptanaesthesia. Due to the very low incidence of side effects such as nausea and vomiting IVA was highly recommended by the patients, at least in part because of the rapid recovery time.