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Riassunto.

E’ da tempo dibattuta la capacità, da parte di molti farmaci usati in

anestesia, di scatenare reazioni immunitarie di tipo allergico. Numerose

ricerche sono state compiute negli anni al fine di evidenziare i farmaci

responsabili di questo tipo di reazioni, con risultati controversi. Nell’ul-

timo decennio alcuni studi hanno puntato il dito sui bloccanti neuro-

muscolari non depolarizzanti come principali responsabili di anafilassi

intraoperatoria; d’altra parte in letteratura lo shock anafilattico in sala

è riportato come un fenomeno raro. La necessità di dati precisi ha

dato vita a questo studio sui curari. Abbiamo analizzato i livelli pla-

smatici di istamina e triptasi di 22 pazienti sottoposti ad interventi in

anestesia generale, tramite quattro prelievi effettuati prima della som-

ministrazione di farmaci, ovvero basali, dopo l’induzione con propofol

e fentanest, dopo il curaro e dopo la somministrazione del richiamo

del curaro, in particolare rocuronio e cisatracurio. Nei soggetti analiz-

zati non c’è stato alcun rilascio di istamina, nè variazioni nei livelli di

triptasi. Non c’è quindi nessuna risposta immune, ed anzi l’istaminemia

risulta più in relazione con il livello di veglia che non con la sommini-

strazione dei farmaci usati per l’induzione.

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Appendice I Protocollo Studio Curari

• 1° prelievo basale in corsia

• somministrazione antibiotico

• INDUZIONE: Fentanest 2g/Kg + Propofol 2mg/Kg

• 2° prelievo a 2’ dalla somministrazione del Propofol

• CURARO: Nimbex 0,2 mg/Kg Esmeron 0,6 mg/Kg

• 3° prelievo a 3’ dalla somministrazione di curaro

• MANTENIMENTO con Sevoflurano

• Fentanest 2,5 g/Kg all’incisione

• RICHIAMO DEL CURARO: Nimbex 0,03 mg/Kg dopo 40 minuti Esmeron 0,1 mg/Kg dopo 30 minuti

• 4° prelievo 3’ dopo il richiamo del curaro

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Appendice II

Le classi di rischio anestesiologico.

CLASSE ASA DESCRIZIONE

I Nessuna alterazione organica, biochimica o psichiatrica.

Esempio: ernia inguinale in paziente in abs.

II

Malattia sistemica lieve, correlata o meno alla ragione dell'intervento chirurgico.

Esempi: bronchite cronica, obesità moderata, diabete control- lato, infarto del miocardio di vecchia data, ipertensione arte- riosa moderata.

III

Malattia sistemica severa, ma non invalidante, correlata o meno alla ragione dell'intervento chirurgico.

Esempi: cardiopatia ischemica con angor, diabete insulino-di- pendente, obesità patologica, insufficienza respiratoria moderata.

IV

Malattia sistemica grave con prognosi severa che pregiudica la sopravvivenza indipendentemente dall'intervento chirurgico.

Esempi: insufficienza cardiaca severa, angina instabile, aritmie refrattarie al trattamento, insufficienza multiorgano -respiratoria, renale, epatica, endocrina- avanzata.

V

Paziente a rischio di vita che si presuppone non possa so- pravvivere nelle 24 ore successive, e che viene sottoposto all'intervento chirurgico come ultima possibilità.

Esempio: rottura aneurisma aorta con grave stato di shock.

E

Ogni intervento chirurgico non dilazionabile e che non con- sente una completa valutazione del paziente.

La lettera E viene aggiunta alla presunta classe ASA

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Appendice III

Tabella dei dati ottenuti.

Pz. Istamina (umoli/l) Triptasi (μg/l)

cisatracurio

prelievi I° II° III° IV° I° II° III° IV°

1 1,93 1,24 1,33 4,12 6 5,10 5,10 4,90

2 0,01 0,01 0,01 0,42 11,00 6,80 6,90 8,60

3 4,80 0,01 0,50 1,55 5,30 4,90 4,10 4,10

4 1,81 0,26 0,01 0,96 11,00 9,20 9,90 9,20

5 2,27 1,52 1,24 4,83 3,20 3,10 2,70 2,80

6 2,34 2,05 3,52 3,44 4,30 3,80 3,70 3,60

7 1,78 5,08 1,46 3,88 2,50 1,00 1,10 1,20

9 2,08 4,32 0,72 1,37 3,40 3,10 2,70 2,70

10 1,95 2,01 1,83 1,38 6,40 5,90 6,30 5,70

11 2,95 5,49 3,14 2,46 2,90 2,20 2,30 2,30

22 4,13 3,08 4,43 4,56 2,90 2,50 2,50 2,68

medie 2,37 2,28 1,66 2,63 5,35 4,33 4,99 4,34

rocuronio

8 1,35 2,12 3,96 3,04 6,30 5,60 5,20 4,90

12 16,69 1,16 0,02 0,96 5,30 4,90 4,90 5,10

13 3,63 1,66 1,10 3,45 1,00 2,70 2,40 3,10

14 11,26 5,39 8,61 10.19 8,80 8,50 8,10 7,90

15 3,17 2,10 2,06 2,43 1,00 1,00 1,00 1,00

16 3,79 2,98 4,15 3,23 3,10 2,20 2,80 2,70

17 3,56 1,77 3,81 3,43 9,70 7,40 7,80 6,60

18 2,16 0,75 2,00 2,43 6,90 5,50 5,80 5,10

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Pz. Istamina (umoli/l) Triptasi (μg/l)

19 1,98 2,67 0,49 0,81 5,00 4,00 4,30 4,00

20 0,42 0,16 2,39 3,80 4,30 3,60 4,10 4,00

21 2,93 2,43 3,20 2,90 3,50 3,40 3,59 2,54

medie 4,63 2,11 2,89 3,33 4,99 4,44 4,54 4,27

Elaborazione statistica.

trattamento 0 = cisatracurio

trattamento = 0 One-sample t test

---

Variable | Obs Mean Std. Err. Std. Dev. [95% Conf. Interval]

---+---

diff_i2 | 11 -.0890909 .6731695 2.232651 -1.589006 1.410824 ---

mean = mean(diff_i2) t = -0.1323 Ho: mean = 0 degrees of freedom = 10 Ha: mean < 0 Ha: mean != 0 Ha: mean > 0 Pr(T < t) = 0.4487 Pr(|T| > |t|) = 0.8973 Pr(T > t) = 0.5513

---

---+---

diff_i3 | 11 -.7145455 .437134 1.449809 -1.688541 .2594498 ---

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---

---+---

diff_i3 | 11 -1.740909 1.573675 5.219288 -5.247275 1.765456 ---

---

---+---

diff_i4 | 11 -1.297273 1.497572 4.966885 -4.634071 2.039526 ---

---

---+---

diff_t4 | 11 -.7236364 .3870806 1.283801 -1.586106 .1388329 ---

mean = mean(diff_t4) t = -1.8695 Ho: mean = 0 degrees of freedom = 10 Ha: mean < 0 Ha: mean != 0 Ha: mean > 0 Pr(T < t) = 0.0455 Pr(|T| > |t|) = 0.0911 Pr(T > t) = 0.9545