問：

請問如果做三、四種手術，時間可能會長一點，可以在睡眠中進行嗎？因為我很害怕醒著動手術，無法放鬆，雖然不至於痛，但是卻感到很不舒服，如果做多種手術，也是必須局部麻醉下進行嗎？不能夠打安眠藥睡覺進行嗎？安全性如何？

答：

所謂睡覺針、無意識手術、睡眠麻醉，通常指的是一種乳白色的鎮定劑，叫做propofol, (同樣成份的藥劑，也有不同的商標名)

使用這種藥劑，有極大的方便性，注射後兩、三分鐘之內，患者就會睡著，昏迷時間短，國內許多醫師都偏好以這種注射方式，來進行美容手術。但是國外有關各種藥劑的安全性，討論甚多，在此摘錄並且翻譯重點部份，供讀者參考：

In the
News - December 5, 2005

Wake-up call needed on nurse-administered
anesthesia
Advocates warn of medical malpractice liability risks in
administration of popular sedative

SAN ANTONIO, TX - A popular
sedative with no known antidote
poses a huge medical malpractice liability risk for hospitals
and health care providers because it often is administered under conditions that
contradict the manufacturer's warning, say an attorney and a nurse manager.
Compounding the problem is an effort by some physicians to persuade federal
regulators to remove the warning label from the general anesthetic, according to
the two advocates for keeping and following the warning label. The pair warned
hospital risk managers of the risks created by ignoring the label during a
session at the American Society for Healthcare Risk Management's annual
conference, held Oct. 23-26 in San Antonio. The patient sedation procedure that
the pair opposes is known as NAPS, short for nurse-administered propofol
sedation. The general anesthetic propofol, which was introduced in 1986, is
manufactured by London-based AstraZeneca P.L.C. under the brand name Diprivan.

一種被大家普遍使用，卻無解藥的鎮定劑，有可能產生極大的風險，因為大家使用這種藥劑的時候，經常都沒有依照製造商所貼的警語進行，一位律師與護理行政主管說。

引發這兩位提出討論的原因，是因為有些醫師試圖說服美國政府改變規定，把這種全身麻醉劑上所貼的警告標籤去除。這項討論在10月23～26於德州聖安東尼舉辦的,全美健康維護與風險管理2005年會中提出，

The
anesthetic is popular among health care providers for several reasons, according
to attorney and endoscopy nurse Deborah A. Krohn. Ms. Krohn practices law at
Siegel & Krohn P.C. in Towson, Md., and is a nurse at The Johns Hopkins
Hospital in Baltimore. Ms. Krohn noted that propofol works within two or three
minutes, which is a fraction of the time required by other anesthetics; it is
easy to administer; and patients recover quickly from the sedativee. The
anesthetic is used in hospitals, ambulatory centers and physician and dentist
offices during a variety of procedures, including minor surgeries, minor bone
fracture repairs, burn debridement, plastic and reconstructive surgery and
dental surgery. The risks to patients who are sedated by the drug are collapsed
airways, reduced blood pressure, reduced heart rates and low oxygen saturation,
according to Ms. Krohn.

這種藥劑之所以風行，是因為注射後兩、三分鐘內開始作用，患者甦醒也很迅速。各醫療機構中的一些小手術，包括骨折治療、燒傷擴創、整形與牙科手術等，都極為普遍。

使用這種藥劑的風險是，呼吸衰竭、血壓降低、心博降低、血氧濃度降低，律師Krohn女士說。

To
date, the drug has a good safety record, noted Laura A. Kress,
a nurse manager and the assistant director of nursing at Johns Hopkins. But Ms.
Krohn suggested that safety studies are somewhat misleading. She said the
studies compare the risks of propofol, which has been used on relatively healthy
patients, to the risks of other anesthetics used to sedate patients who are
sicker. An important medical issue with the drug is that there is a
19-fold difference among patients in how the drug metabolizes, Ms. Krohn
noted. That unpredictability in a patient's reaction to the
drug is not correlated to any factor such as age, weight or illness,
she said. ``Perhaps the scariest thing of all'' is that there is no known agent
that can reverse the effects of the drug, Ms. Krohn said. Unlike with other
anesthetics, a patient sedated with propofol ``cannot be rescued
pharmacologically. There is no antidote,'' she explained. Therefore, patients
who are sedated with the drug need ``airway management'' by a specialist in this
area. ``Airway protection is everything.'' Ms. Krohn said.

護理行政主管Laura
說，雖然目前這種藥劑的安全紀錄並不差，但是在作此調查者可能犯了一項錯誤就是，這種藥劑通常被用於比較健康的人身上，卻被拿來與其他全身麻醉劑，使用於疾病較為嚴重患者的結果相比較，所以說這是錯誤的研究。

她說，使用這種藥劑最可怕的問題是，這種藥劑沒有解藥。此外，患者對這種藥劑的反應，無法預估，患者與患者之間，將這種藥物代謝速度的差距，高達19倍，這種差距與年齡、體重、疾病或其他任何因素皆無關，所以無法精確預期患者的反應。

Krohn女士說，總結來說，這種藥劑沒有解藥，不能夠靠施打解藥來解決問題，而是應該由麻醉專門人員插管來維持暢通無阻，是最重要的保命之道。

Indeed,
the drugmaker's warning label states that the drug should be delivered by a
person trained in administering general anesthesia. The anesthetist should not
be otherwise involved in the patient's procedure, the label also warns. But
propofol often is administered by nurses who have no special training in either
anesthesia or airway protection, Ms. Kress and Ms. Krohn said. Indeed, risk
managers should be aware there is no consensus in the medical community about
the level of educational and clinical competency that nurses should have before
administering propofol. Only in Oregon and Indiana are there institutional
programs designed to educate nurses who administer the sedative, Ms. Krohn said.
The lack of training for nurses compromises their ability to rescue patients who
have bad reactions to the drug, Ms. Kress said. ``I'm worried about that,'' she
said. One in 10,000 patients under sedation will have a problem, she said. ``The
question is, `Do you have the right people in the room if that happens?''' ``In
my experience, this is below the radar of nurse managers,'' Ms. Krohn said.
``I've seen it go bad.'' But earlier this year, the American College of
Gastroenterology petitioned the U.S. Food and Drug Administration to remove the
manufacturer's warning label. Anesthesiologists recently filed their objections.
The debate over how the drug is administered is driven by economics, Ms. Krohn
asserted. ``As a nurse, I'm repulsed by that,'' she said. Ms. Krohn explained
that because propofol sedates patients much more quickly than other anesthetics,
physicians and dentists can perform more procedures each day. And by using
nurses to sedate patients, physicians do not have to share their fees with
anesthesiologists, she said. As the FDA considers whether to remove propofol's
warning label, NAPS is being opposed by a growing number of state nursing
boards, according to Ms. Krohn. Nonetheless, around half the states either
permit it or have unclear positions, she said. Meanwhile, Ms. Krohn noted, the
Joint Commission on Accreditation of Healthcare Organizations, a nonprofit
organization that accredits more than 15,000 U.S. health care organizations,
requires health care organizations to be prepared to rescue patients.

事實上，製藥廠的警告標籤上聲明，這種藥劑必須受過全身麻醉訓練者，才能夠施打。警語標籤同時聲明，施打藥劑者，不可以參與手術或治療措施，但是propofol
經常被沒有受過全身麻醉訓練的護士注射，更沒有呼吸道保護措施在旁。---------

Kress女士說，"我所擔心的是"，"接受注射者當中，每一萬個人就會有一個發生問題，患者身旁是否有適當的急救人員？"

本診所手術患者的做法是：

1.從1997年以來，本診所全部手術，包括隆乳、抽脂或是腹部拉皮等手術，都只採用局部麻醉或是脹麻法麻醉，進行手術。除了比較安全外，許多整形手術，須要患者於手術之中配合，例如雙眼皮釘針後的檢查，抽脂手術中患者姿勢的配合，與手術中的討論，或是隆乳手術後，須要患者對於乳房大小與形狀表示意見，都須要患者處於神智清楚狀態，全身麻醉劑反而帶來不便。

2.如果多項手術同時進行，本診所通常採區域麻醉法，也就是手術之前，我們先以最細的針頭，在神經根附近，注射微量麻醉劑。這樣一來，手術進行中，再追加麻醉劑的時候，患者的疼痛極少，絕大多數患者，甚至難以察覺。

張醫師