不同濃度cocaine介入對口腔顎面手術經鼻插管鼻出血之效果

研究背景: 經鼻插管(NTI)是口腔顎面外科病患接受全身麻醉時，常需要的插管方式，因可提供較清楚的手術視野；但鼻腔粘膜血管豐富，以血管收縮劑合併局部麻醉劑，作為鼻粘膜的表面麻醉(Topical anesthesia )是插管前必要的步驟，主要是減少插管時出血的機會。臨床上使用的cocaine濃度建議為4-10%。研究目的: 比較4%Cocaine與6％Cocaine，對經鼻插管(NTI)時鼻出血的預防效果，瞭解口腔疾病病患人口學特性與經鼻插管鼻出血的相關性，瞭解Cocaine是否對心跳、平均動脈壓造成明顯的作用。研究方法: 採雙盲隨機分組，於2010年10月至2011年2月間，某醫學中心口腔顎面外科接受常規口腔顎面手術，需經鼻插管全身麻醉病患，計選取病患ASA為Ι、Ⅱ級的患者共79位，年齡16-65歲。在經鼻插管前隨機分配接受4%(n=39)或6%(n=40)cocaine的鼻粘膜表面麻醉(topical anesthesia)，並使用電子影像喉頭鏡(Glidescope)進行經鼻插管及光學纖維內視鏡影像系統，記錄分析出血發生率及出血程度，人口學相關性、插管阻力、心跳和平均動脈壓之變化。結果: 4%與6%cocaine鼻出血發生率分別為43.59%(17/39)、50%(20/40)，（p=0.57），其中大部分研究對象都是小量出血，4%Cocaine 有1例發生嚴重程度出血，但兩組鼻出血嚴重程度並無顯著性差異（p=0.46）；出血部位主要為鼻咽部(nasopharynx)。插管時遇到的阻力越明顯出血機率越高。心跳、平均動脈壓方面:濃度較高的6%Cocaine在鼻粘膜的表面麻醉(topical anesthesia)5分鐘後心跳、平均動脈壓引起較明顯的作用（p值分別為0.01和0.04），但是在插管時所引起心跳、平均動脈壓並無顯著性差異。結論: 經由兩種不同濃度cocaine的比較之後，得知它們預防鼻出血發生率及出血嚴重程度之效果無顯著性差異；本研究發現出血部位主要為鼻咽部(nasopharynx)，建議日後在經鼻插管時應更謹慎評估，此部分的損傷及預防措施的介入及改善。關鍵詞:cocaine、經鼻插管、鼻出血

關鍵字

cocaine ；經鼻插管；鼻出血

並列摘要

Background: Nasal intubation (NTI) is usually mandatory for patients undergoing oral and maxillofacial surgery. NTI provides secure airway to maintain general anesthesia and a clearer surgical field. However, hypervascular nasal mucosa may be prone to epistaxis during NTI. Topical anesthesia with vasoconstrictor is a necessary preparation to reduce epistaxis. Clinical recommendation of topical cocaine is between 4 to10%. Study objective: The aim of this study was to compare the effect between 4% cocaine and 6% cocaine on prevention of epistaxis during NTI. Furthermore, adverse hemodynamic effects of cocaine and the relationship between patient characteristics and epistaxis were also investigated. Methods: A total of 79 patients aged 16-65 years old undergoing oral or maxillofacial surgery were enrolled from October 2010 to February 2011. Patients were randomized to receive 4% cocaine (n=39) or 6% cocaine (n=40) as topical anesthesia for nasal mucosa before NTI. NTI was performed by Glidescope. The incidence and severity of epistaxis was assessed by fiberoptic bronchoscope recording. Patient characteristics ， intubation resistance and hemodynamic changes during NTI were all recorded. Results: The incidence of epistaxis was 43.59% (17/39) in patients received 4% cocaine and 50% (20/40) in 6% cocaine (p=0.57). Most of them suffered from mild bleeding. The severity of epistaxis did not differ between two groups (p=0.46). Higher resistance during NTI was associated with epistaxis. Most nasal bleeding sites were located at nasopharynx. Topical anesthesia with 6% cocaine resulted in higher heart rate and mean arterial pressure than 4% cocaine (p=0.01,0.04 respectively). Changes of heart rate and mean arterial pressure caused by intubation did not differ significantly between groups. Conclusion: Pretreatment with two concentrations of cocaine had comparable effects on incidence and severity of epistaxis. Nasopharynx is the most common site of epistaxis. A detailed evaluation and pretreatment are highly recommended to prevent epistaxis during NTI. Key words: cocaine, nasotracheal intubation (NTI),epistaxis