日本臨床麻酔学会 vol.33
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1 730 Vol.33 No.5/Sep 日本臨床麻酔学会第 32 回大会シンポジウム日臨麻会誌 Vol.33 No.5, , 2013 吸入麻酔薬 亜酸化窒素の生き残る道 * 萬家俊博 [ 要旨 ] 亜酸化窒素はこれまで長年にわたって臨床で用いられてきたガス性吸入麻酔薬であるが, その環境に及ぼす影響や種々の有害作用のために臨床で用いられることが少なくなってきた. 日本におけるレミフェンタニルの臨床導入がさらに拍車をかけている. 亜酸化窒素の地球温暖化への悪影響がことさら強調されてきたが, 実は揮発性吸入麻酔薬も個々に温暖化係数を有する. デスフルラン単独よりもデスフルランと亜酸化窒素併用の方が地球温暖化への影響を低減できるとの試算もある. 患者の背景因子と手術上の禁忌要件の有無を考慮して, 亜酸化窒素を低流量で併用することは, これからも手術室における全身麻酔の一つの方法として生き残るものと考える. キーワード : 亜酸化窒素, 副作用, 鎮痛作用, 温室効果ガス, 地球環境 はじめに 160 Ⅰ 亜酸化窒素の有害作用と有用性 亜酸化窒素の有害作用 表
2 731 表 1 亜酸化窒素の有害作用と有益作用有害な作用 ( 欠点 ) 有益と考えられる作用巨赤芽球性貧血鎮痛作用高ホモシステイン血症と心筋虚血短時間作用性神経 脊髄の障害術中覚醒の予防効果中枢神経への影響長期間安全に使用されてきた実績術後悪心 嘔吐 (PONV) 体内閉鎖腔の拡大作用低酸素誘発無気肺催奇形性と職業暴露免疫抑制 1 4 B 12 B Badner 6 Myles 7 ENIGMA Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia trial 2. 亜酸化窒素の有用性 表 1 8
3 732 Vol.33 No.5/Sep minimum alveolar concentration MAC 104 MAC MAC sparing effect 1 9, 10 9, N-methyl-D-aspartate NMDA 11 NMDA NMDA 12 NMDA 13, 14 NMDA 15, 16 Hopkins 3 表 2 吸入麻酔薬の大気中での残存期間 (Lifetime) と地球温暖化係数 (GWP) Compound Lifetime( 年 ) GWP 20 Carbon dioxide(co 2) 1 Sevoflurane Isoflurane 3.6 1,401 Desflurane 10 3,714 Nitrous oxide GWP year global warming potential 20 CO ,050 7 Ⅱ 亜酸化窒素の地球環境に及ぼす影響 18, 19 20, 表 ,
4 733 表 3 頻用されている吸入麻酔薬の地球温暖化への影響の比較 吸入麻酔薬 ( 濃度 ) Sevoflurane 0.8% 2.0% Isoflurane 0.5% 1.2% Desflurane 2.4% 6.0% Carrier gases 60% N 2O/40% O 2 Air/O 2 60% N 2O/40% O 2 Air/O 2 60% N 2O/40% O 2 Air/O 2 CDE 20(g/h) 40,940 6,980 44,610 15, , ,186 Ratio N 2O/O 2: air/o 2 5.9:1 2.9:1 0.6:1 CDE year carbon dioxide equivalent of inhaled drug with air/oxygen O 2 or inhaled drug N 2O 2L/min 1 MAC-Hour 22 Ryan 22 2L/min 表 3 MAC sparing effect Ⅲ 亜酸化窒素併用麻酔と予後 Myles 7 ENIGMA trial 24 Sanders 25 GALA General Anaesthesia compared with Local Anaesthesia for carotid surgery trial
5 734 Vol.33 No.5/Sep まとめ B 12 参考文献 1) Myles PS, Leslie K, Silbert B, et al.:a review of the risks and benefits of nitrous oxide in current anaesthetic practice. Anaesth Intensive Care 32: , ) Jahn UR, Berendes E:Nitrous oxide--an outdated anaesthetic. Best Pract Res Clin Anaesthesiol 19: , ) Hopkins PM:Nitrous oxide:a unique drug of continuing importance for anaesthesia. Best Pract Res Clin Anaesthesiol 19: , ) Yang YF, Herbert L, Rüschen H, et al.:nitrous oxide anaesthesia in the presence of intraocular gas can cause irreversible blindness. BMJ 325: , ) Badner NH, Drader K, Freeman D, et al.:the use of intraoperative nitrous oxide leads to postoperative increases in plasma homocysteine. Anesth Analg 87: , ) Badner NH, Beattie WS, Freeman D, et al.:nitrous oxide-induced increased homocysteine concentrations are associated with increased postoperative myocardial ischemia in patients undergoing carotid endarterectomy. Anesth Analg 91: , ) Myles PS, Leslie K, Chan MT, et al.:avoidance of nitrous oxide for patients undergoing major surgery:a randomized controlled trial. Anesthesiology 107: , ) 萬家俊博 : 亜酸化窒素の長所 ( 亜酸化窒素は全く不要なのか?). 臨麻 31: ,2007 9) 福田和彦 : 亜酸化窒素の鎮痛機構. 臨麻 31: , ) 福田和彦 : 全身麻酔機序と鎮痛. 麻酔 60: , )Jevtović-Todorović V, Todorović SM, Mennerick S, et al.:nitrous oxide(laughing gas)is an NMDA antagonist, neuroprotectant and neurotoxin. Nat Med 4: , )Guignard B, Bossard AE, Coste C, et al.:acute opioid tolerance:intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology 93: , )Guignard B, Coste C, Costes H, et al.:supplementing desflurane-remifentanil anesthesia with small-dose ketamine reduces perioperative opioid analgesic requirements. Anesth Analg 95: , )Koppert W, Sittl R, Scheuber K, et al.:differential modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by S-ketamine and clonidine in humans. Anesthesiology 99: , )Richebé P, Rivat C, Creton C, et al.:nitrous oxide revisited:evidence for potent antihyperalgesic properties. Anesthesiology 103: , )Echevarría G, Elgueta, F, Fierro C, et al.:nitrous oxide(n 2O)reduces postoperative opioid-induced hyperalgesia after remifentanil-propofol anaesthesia in humans. Br J Anaesth 107: , )Alkire MT, Gorski LA:Relative amnesic potency of five inhalational anesthetics follows the Meyer-Overton rule. Anesthesiology 101: , ) 大島健幸 : 亜酸化窒素地球環境への課題と将来. 臨麻 31: , ) 萬家俊博 : 全身麻酔における亜酸化窒素 ( 笑気 ) の有用性. 日臨麻会誌 26: , )Sulbaek Andersen MP, Nielsen OJ, Wallington TJ, et al.:assessing the impact on global climate from general anesthetic gases. Anesth Analg 114: , )Sulbaek Andersen MP, Nielsen OJ, Karpichev B, et al.:atmospheric chemistry of isoflurane, desflurane, and sevoflurane:kinetics and mechanisms of reactions with chlorine atoms and OH radicals and global
6 735 warming potentials. J Phys Chem A 116: , )Ryan SM, Nielsen CJ:Global warming potential of inhaled anesthetics:application to clinical use. Anesth Analg 111:92-98, )Sulbaek Andersen MP, Sander SP, Nielsen OJ, et al.:inhalation anaesthetics and climate change. Br J Anaesth 105: , )Leslie K, Myles PS, Chan MT, et al.:nitrous oxide and long-term morbidity and mortality in the ENIGMA trial. Anesth Analg 112: , )Sanders RD, Graham C, Lewis SC, et al.:nitrous oxide exposure does not seem to be associated with increased mortality, stroke, and myocardial infarction:a non-randomized subgroup analysis of the General Anaesthesia compared with Local Anaesthesia for carotid surgery(gala)trial. Br J Anaesth 109: , )Turan A, Mascha EJ, You J, et al.:the association between nitrous oxide and postoperative mortality and morbidity after noncardiac surgery. Anesth Analg 116: , 2013 Nitrous Oxide is Still Useful in Current Anesthesia Practice Toshihiro YOROZUYA Surgical Division, Ehime University Hospital Nitrous oxide has been used for many decades as a basic gas component of general anesthesia. Due to increased concerns about environmental pollution and possible adverse effects of nitrous oxide, however, the role of this important carrier gas has been limited in current anesthesia practice. The role of nitrous oxide was also re-evaluated after remifentanil became available in Janan. Nitrous oxide is destructive to the ozone layer as well as possessing global warming potential. However, volatile inhaled anesthetics are also recognized greenhouse gases. Desflurane has a greater potential impact on global warming than other inhaled anesthetics. Additional 60% of nitrous oxide combined with desflurane to deliver 1 MAC may decrease the 20-year environmental impact. There are specific contraindications to the use of nitrous oxide, but in the absence of these, its use with low fresh gas flow rates may still be useful in current anesthesia practice. Key Words : Nitrous oxide, Side effect, Analgesic effect, Greenhouse gas, Global environment The Journal of Japan Society for Clinical Anesthesia Vol.33 No.5, 2013
日本臨床麻酔学会 vol.36
441 日本臨床麻酔学会第 35 回大会教育講演日臨麻会誌 Vol.36 No.4, 441 447, 2016 プロポフォール麻酔の基本 * 小板橋俊哉 [ 要旨 ] プロポフォールが本邦で使用されるようになってから 20 年近くが経過している. 本稿で は, プロポフォール麻酔の基本について概説する. プロポフォールの効果部位濃度と血中濃度の違いや薬物動態学, 薬力学についての基本的知識は必要である.
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