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(Bispectral Index™) Und Hämodynamischer (Herzfrequenz, Blutdruck) Parameter in Abhängigkeit Vom Verfahren Und Der Qualität Der Narkoseinduktion Im Kindesalter

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(Bispectral Index™) Und Hämodynamischer (Herzfrequenz, Blutdruck) Parameter in Abhängigkeit Vom Verfahren Und Der Qualität Der Narkoseinduktion Im Kindesalter Verhalten elektroenzephalographischer (Bispectral Index™) und hämodynamischer (Herzfrequenz, Blutdruck) Parameter in Abhängigkeit vom Verfahren und der Qualität der Narkoseinduktion im Kindesalter Dissertation zur Erlangung des akademischen Grades Dr. med. an der Medizinischen Fakultät der Universität Leipzig eingereicht von: Daniel Paffrath geboren am 20.10.1977 in Nordhausen angefertigt an der: Universität Leipzig Medizinische Fakultät Klinik und Poliklinik für Anästhesiologie und Intensivtherapie Betreuer: Prof. em. Dr. med. habil. Derk Olthoff Dr. med. Jan Wallenborn Beschluss über die Verleihung des Doktorgrades vom: 13.12.2010 Bibliographische Beschreibung: Paffrath, Daniel Verhalten elektroenzephalographischer (Bispectral Index™) und hämo- dynamischer (Herzfrequenz, Blutdruck) Parameter in Abhängigkeit vom Verfahren und der Qualität der Narkoseinduktion im Kindesalter. Universität Leipzig, Dissertation 89 S., 140 Lit., 25 Abb., 7 Tab. Referat: In der vorliegenden Arbeit wurden elektroenzephalographische und hämodynami- sche Parameter zur Überwachung der Narkoseinduktion bei Kindern, sowie das Auftreten von Exzitationen, Hustenereignissen und Intubationsreaktionen untersucht. In die Studie wurden insgesamt 54 Kinder (4 - 14 Jahre) eingeschlossen, die randomisiert drei Induktionsverfahren (schrittweise Einleitung mit Sevofluran, „single breath-Technik“, total intravenöse Anästhesie mit Propofol) zugewiesen wurden. In allen drei Gruppen reflektierte das Verhalten des Bispectral Index die dynamischen Veränderungen des hypnotischen Niveaus. Das Zustandsbild „Wach“ ließ sich in allen drei Gruppen zuverlässig von den Zuständen „Verlust des Lidreflexes“, „Tonusverlust“ und „Intubation“ trennen (Pk ≥ 0,9). Unabhängig von der Narkoseinduktion zeigte der Bispectral Index in allen drei Gruppen eine ausreichende Hypnosetiefe zum Zeitpunkt der Intubation ([SEV-S] = 30±14; [SEV-V] = 24±10; [PROP] = 32±11). Dennoch wurden nach Sevofluran vermehrt Exzitationen (21 vs. 4; p ≤ 0,008) und nach Propofol verstärkt Hustenereignisse (11 vs. 3; p ≤ 0,011) und Intubationsreaktionen (3 vs. 0) registriert. Es war nicht möglich mit Hilfe des Bispectral Index diese Ereignisse vorherzusagen. Dies liegt wahrscheinlich an der fehlenden Erfassung spinal vermittelter Reaktionen. Problematisch ist weiterhin die Heterogenität der Einzelmesswerte aufgrund der breiten Altersverteilung. Somit unterstreicht diese Arbeit die Notwendigkeit einer Weiterentwicklung der EEG-gestützten Monitorsysteme insbesondere hinsichtlich alterspezifischer Besonderheiten. Die Qualität der Narkoseinduktion unterscheidet sich rein klinisch, nicht aber hinsichtlich des Erreichens spezieller prozessierter EEG- Werte. Inhaltsverzeichnis: 1 Einleitung ...................................................................................... 7 2 Methodik ...................................................................................... 12 2.1 Elektroenzephalographie ......................................................................... 12 2.1.1 Grundlagen der Elektroenzephalographie ....................................................................... 12 2.1.2 Wirkungen von Anästhetika auf das Elektroenzephalogramm ........................................ 14 2.1.3 Bispectral Index ............................................................................................................... 15 2.1.4 Interindividuelle Unterschiede und Einfluss des Lebensalters ........................................ 17 2.1.5 Verwendete Geräte und Elektroden ................................................................................ 18 2.2 Klinische Pharmakologie ......................................................................... 20 2.2.1 Propofol (Disoprivan®) ..................................................................................................... 20 2.2.2 Sevofluran (Sevorane®) ................................................................................................... 20 2.2.3 Alfentanil (Rapifen®) ........................................................................................................ 21 2.3 Versuchsablauf ......................................................................................... 22 2.3.1 Studiendesign, Fallzahl, Studiendauer, Studienabbruch................................................. 22 2.3.2 Probanden, Aufklärung und Einwilligung, Randomisation............................................... 23 2.3.3 Einschluss- und Ausschlusskriterien ............................................................................... 23 2.3.4 Standardisierung der drei Einleitungsverfahren .............................................................. 24 2.3.5 Datenerfassung ............................................................................................................... 26 2.3.6 Flussdiagramm ................................................................................................................ 27 2.3.7 Definition der klinischen Korrelate ................................................................................... 28 2.4 Zielvariablen .............................................................................................. 29 2.4.1 Bispektral Index ............................................................................................................... 29 2.4.2 Hämodynamik .................................................................................................................. 29 2.4.3 Einleitungszeiten .............................................................................................................. 29 2.4.4 Anästhesiequalität ........................................................................................................... 30 2.5 Statistische Auswertung .......................................................................... 31 3 Ergebnisse .................................................................................. 32 3.1 Biometrische Daten .................................................................................. 32 3.2 BIS .............................................................................................................. 33 3.2.1 Verlauf des BIS zu den klinischen Korrelaten ................................................................. 33 3.2.2 Trennschärfe des BIS für ausgewählte klinische Korrelate ............................................. 38 3.3 Hämodynamik ........................................................................................... 39 3.3.1 Herzfrequenz ................................................................................................................... 39 3.3.2 Blutdruck .......................................................................................................................... 40 3.4 Zeitanalysen .............................................................................................. 43 3.5 Qualität der Narkoseinduktion ................................................................. 43 3.5.1 Intubationsreaktion .......................................................................................................... 43 3.5.2 Exzitation ......................................................................................................................... 44 3.5.3 Hustenereignis ................................................................................................................. 45 4 Diskussion ................................................................................... 47 4.1 Ziel der Arbeit, Methodenkritik, biometrische Daten und Zeitanalysen .......................................................................................................... 47 4.2 Die Veränderungen von BIS und Kreislaufparametern zu den klinischen Korrelaten ........................................................................................... 51 5 Zusammenfassung der Arbeit .................................................... 67 6 Anhang ........................................................................................ 72 6.1 Versuchsprotokolle ................................................................................... 72 7 Literaturverzeichnis .................................................................... 75 Verzeichnis der verwendeten Abkürzungen: Abb. ... Abbildung ANOVA ... Varianzanalyse (engl. analysis of variance) ASA … American Society of Anesthesiologists BIS … Bispectral Index™ BMI … Body Mass Index bpm ... beats per minute (1/min) DAD … Diastoischer arterieller Blutdruck EEG … Elektroenzephalogramm EKG … Elektrokardiogramm EEG … Elektroenzephalogramm EMG … Elektromyographie engl. … englisch etCO2 … Endtidale Kohlendioxidkonzentration exp. … expiratorisch Fa. … Firma FiO2 … Inspiratorischer Sauerstoffgehalt GABA … Gamma - Amino - Buttersäure Gr. … Gruppe h … Stunde HF … Herzfrequenz HS … Hautschnitt Hz … Hertz IN … Intubation insp. … inspiratorisch Kap. … Kapitel KG … Körpergewicht kg … Kilogramm kΩ … Kiloohm Lit. … Literatur LOC ... Lidreflexverlust (engl. loss of consciousness) m … männlich MAC ... Minimale alveoläre Konzentration MAC-h … Produkt aus MAC-Wert und der Zeit in Stunden MAD … Mittlerer arterieller Blutdruck mg … Milligramm min … Minute mmHg … Millimeter Quecksilbersäule MW … Mittelwert n … Anzahl NG … Narkosegas pEEG … prozessiertes Elektroenzephalogramm PRÄ … Präoperativer Wert RR … Blutdruck SD … Standardabweichung SAD … Systolischer arterieller Blutdruck SEF … Spektrale Eckfrequenz SEF90 … Spektrale Eckfrequenz 90 SpO2 … Sauerstoffsättigung
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