纳布啡复合丙泊酚在无痛胃镜检查麻醉中神经功能及安全性评价
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摘要
目的评价纳布啡复合丙泊酚在无痛胃镜检查麻醉中的安全性和对神经功能的影响。方法选择拟行无痛胃镜检查的患者1000例,其中男553例,女447例,年龄18～64岁,体质量40～75kg,美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级。按随机数字表法分为芬太尼组(F组)、瑞芬太尼组(R组)、舒芬太尼组(S组)、纳布啡组(N组)及对照组(C组),每组200例。所有药物配制成10mL并编号:(1)号芬太尼8μg/m L,(2)号舒芬术尼0. 8μg/m L,(3)号瑞芬太尼5μg/m L,(4)号纳布啡1mg/m L,(5)号生理盐水10mL。监测并记录左侧卧位后(T0)、镇痛药推注完毕(T1)、丙泊酚推注完毕(T2)、胃镜置入即刻(T3)、胃镜置入十二指肠(T4)、胃镜检查结束(T5)、苏醒后(T6)患者的收缩压(SBP)、舒张压(DBP)、心率(HR)、呼吸频率(RR)及脉搏血氧饱和度(SPO_2);记录麻醉起效时间、胃镜检查时间、苏醒时间、离院时间;评价手术医师满意度;记录患者术中SPO_2<90%、呼吸暂停、心动过缓或过速以及术后便秘、疼痛、恶心呕吐、尿潴留、术中知晓等并发症的发生情况;采用简易智能精神状态检查量表(MMSE)评价患者离院时(T7)、术后24h(T8)、术后72h(T9)神经功能。结果5组不同时间点SBP、DBP、HR存在差别(P<0. 05),与T0比较,5组SBP、DBP在T2～T5均降低,F组、S组、R组及C组HR、RR在T2～T5均降低(P<0. 05)。5组患者在苏醒时间、离院时间及丙泊酚用量上差异有统计学意义(P<0. 01),与C组比较,F组、S组R组及N组麻醉苏醒时间、离院时间及丙泊酚用量显著降低(P<0. 01)。与N组比较,F组、S组、R组及C组医师满意度降低(P<0. 01);与C组比较,F组、S组、R组满意度增加(P<0. 05或<0. 01);与F组比较,R组满意度降低(P<0. 01)。与N组比较,R组SPO_2<90%、呼吸暂停、心动过缓或过速等并发症发生率增加,C组SPO_2<90%、呼吸暂停等发生率增加(P<0. 01);与C组比较,F组、S组、R组、N组患者术后疼痛发生率下降(P<0. 01),S组、N组患者术后恶心呕吐发生率下降(P<0. 05)。5组患者在T7、T8时间点MMSE评分上差异有统计学意义(P<0. 01)。与C组比较,F组在T8时升高(P<0. 05),S组在T7时升高(P<0. 05),N组在T7、T8时升高(P<0. 01)。结论纳布啡复合丙泊酚在无痛胃镜检查的麻醉中,能减少丙泊酚的用量,稳定循环和呼吸功能,降低早期认识功能障碍的发生,进一步保护了神经功能。
Objective To evaluate the safety and neurological function of nalbuphine combined with propofol in painless gastroscopy anesthesia.Methods A total of one thousand patients with 553 males and 447 females,aged 18-64 years old,weighing40-75 kg,ASA physical status I or II,scheduled for painless gastroscopy,were randomly allocated into 5 groups according random number table method: fentanyl group( group F),remifentanil group( group R),sufentanil group( group S),nalbuphine group( group N) and control group( group C),each group of 200 cases.The drug was prepared into 10 mL and numbered: No.1 fentanyl8μg/m L,No.2 sufentanil 0. 8μg/m L,No.3 remifentanil 5μg/m L,No.4 nalbuphine 1mg/m L and No.5 saline 10 mL. Systolic blood pressure( SBP),diastolic blood pressure( DBP),heart rate( HR),respiratory rate( R) and pulse oxygen saturation( SPO_2)were recorded after left supine position( T0),analgesic injection( T1),propofol injection( T2),gastroscopy immediately( T3),gastroscopy into duodenum( T4),gastroscopy examination( T5) and recovery( T6).The onset time of anesthesia,the time of gastroscopy,the time of recovery and the time of leaving hospital were recorded.The satisfaction of surgeons was evaluated. The incidence of SPO_2<90%,apnea,bradycardia or tachycardia,postoperative pain,nausea and vomiting,urinary retention and intraoperative awareness were recorded.Neurological function was assessed by Mini Mental State Examination( MMSE) at the time of discharge( T7),24 hours( T8) and 72 hours( T9) after operation.Results There were differences in SBP,DBP and HR at different time points between the 5 groups( P<0. 05).Compared with T0,SBP and DBP in five groups were decreased in T2 ～ T5,HR and RR in group F,group S,group R and group C were all decreased in T2 ～ T5( P<0. 05).There were significant differences in recovery time,discharge time and propofol dosage among the five groups( P<0. 01).Compared with group C,the recovery time,discharge time and propofol dosage in group F,group S,group R and group N were significantly decreased( P<0. 01).Compared with group N,the satisfaction degree of doctors in group F,group S,group R and group C was decreased( P<0. 01).Compared with group C,the satisfaction degree in group F,group S and group R was increased( P<0. 05 or<0. 01).Compared with group F,the satisfaction degree in group R was decreased( P<0. 01).Compared with group N,the incidences of complications such as SPO_2<90%,apnea,bradycardia and tachycardia in group R were increased,and the incidences of complications such as SPO_2< 90%,and apnea in group C were increased( P<0. 01).Compared with group C,the incidences of postoperative pain in group F,group S,group R and group N were decreased( P< 0. 01),while the incidence of postoperative nausea and vomiting in group S and group N were decreased( P<0. 05).There were significant difference in the MMSE scores among the 5 groups at the time points of T7 and T8( P<0. 01).Compared with group C,the MMSE scores in group F was increased at the time point of T8( P<0. 05),the MMSE scores in group S was increased at the time point of T7( P<0. 05),and the MMSE scores in group N were increased at the time point of T7 and T8( P<0. 01).Conclusion Nalbuphine combined with propofol can reduce the dosage of propofol,stabilize circulatory and respiratory function,reduce the occurrence of early cognitive dysfunction,and further protect the nervous function in painless gastroscopy anesthesia.
Objective To evaluate the safety and neurological function of nalbuphine combined with propofol in painless gastroscopy anesthesia.Methods A total of one thousand patients with 553 males and 447 females,aged 18-64 years old,weighing40-75 kg,ASA physical status I or II,scheduled for painless gastroscopy,were randomly allocated into 5 groups according random number table method: fentanyl group( group F),remifentanil group( group R),sufentanil group( group S),nalbuphine group( group N) and control group( group C),each group of 200 cases.The drug was prepared into 10 mL and numbered: No.1 fentanyl8μg/m L,No.2 sufentanil 0. 8μg/m L,No.3 remifentanil 5μg/m L,No.4 nalbuphine 1mg/m L and No.5 saline 10 mL. Systolic blood pressure( SBP),diastolic blood pressure( DBP),heart rate( HR),respiratory rate( R) and pulse oxygen saturation( SPO_2)were recorded after left supine position( T0),analgesic injection( T1),propofol injection( T2),gastroscopy immediately( T3),gastroscopy into duodenum( T4),gastroscopy examination( T5) and recovery( T6).The onset time of anesthesia,the time of gastroscopy,the time of recovery and the time of leaving hospital were recorded.The satisfaction of surgeons was evaluated. The incidence of SPO_2<90%,apnea,bradycardia or tachycardia,postoperative pain,nausea and vomiting,urinary retention and intraoperative awareness were recorded.Neurological function was assessed by Mini Mental State Examination( MMSE) at the time of discharge( T7),24 hours( T8) and 72 hours( T9) after operation.Results There were differences in SBP,DBP and HR at different time points between the 5 groups( P<0. 05).Compared with T0,SBP and DBP in five groups were decreased in T2 ～ T5,HR and RR in group F,group S,group R and group C were all decreased in T2 ～ T5( P<0. 05).There were significant differences in recovery time,discharge time and propofol dosage among the five groups( P<0. 01).Compared with group C,the recovery time,discharge time and propofol dosage in group F,group S,group R and group N were significantly decreased( P<0. 01).Compared with group N,the satisfaction degree of doctors in group F,group S,group R and group C was decreased( P<0. 01).Compared with group C,the satisfaction degree in group F,group S and group R was increased( P<0. 05 or<0. 01).Compared with group F,the satisfaction degree in group R was decreased( P<0. 01).Compared with group N,the incidences of complications such as SPO_2<90%,apnea,bradycardia and tachycardia in group R were increased,and the incidences of complications such as SPO_2< 90%,and apnea in group C were increased( P<0. 01).Compared with group C,the incidences of postoperative pain in group F,group S,group R and group N were decreased( P< 0. 01),while the incidence of postoperative nausea and vomiting in group S and group N were decreased( P<0. 05).There were significant difference in the MMSE scores among the 5 groups at the time points of T7 and T8( P<0. 01).Compared with group C,the MMSE scores in group F was increased at the time point of T8( P<0. 05),the MMSE scores in group S was increased at the time point of T7( P<0. 05),and the MMSE scores in group N were increased at the time point of T7 and T8( P<0. 01).Conclusion Nalbuphine combined with propofol can reduce the dosage of propofol,stabilize circulatory and respiratory function,reduce the occurrence of early cognitive dysfunction,and further protect the nervous function in painless gastroscopy anesthesia.
引文
[1] Zhou X,Li BX,Chen LM,et al.Etomidate plus propofol versus propofol alone for sedation during gastroscopy:a randomized prospective clinical trial[J].Surg Endosc,2016,30(11):5105-5116.
[2]冉茂荣,侯景利,巩固,等.不同剂量丙泊酚对老年无痛胃镜检查认知功能的影响[J].四川医学,2012,33(2):323-324.
[3] Liu J,Liu R,Meng C,et al.Propofol decreases etomidaterelated myoclonus in gastroscopy[J].Medicine(Baltimore),2017,96(26):e7212.
[4]李彦君,张建新.右美托咪定复合丙泊酚对高血压患者无痛胃镜检查应激反应及早期认知功能的影响[J].海南医学院学报,2017,23(17):2445-2448.
[5]张振,罗辉宇,徐阳,等.丙泊酚分别复合盐酸纳布啡、地佐辛、舒芬太尼、用于无痛胃镜的效果比较[J].中国药房,2017,28(3):315-317.
[6]战海燕,朴美花,王艳姝,等.依托咪酯全凭静脉麻醉对老年骨科患者术中应激反应和早期术后认知功能障碍发生率的影响[J].2013,39(5):986-990.
[7]曾治宇,林娜,张明东,等.单样本率比较(单组目标值法)的样本量计算及其简便实现[J].中国卫生统计,2018,35(2):313-314.
[8] Ye L,Xiao X,Zhu L.The comparison of etomidate and propofol anesthesia in patients undergoing gastrointestinal endoscopy:a systematic review and meta-analysis[J]. Surg Laparosc Endosc Percutan Tech,2017,27(1):1-7.
[9]丁玲玲,王晓琳,邓志杰,等.丙泊酚复合芬太尼、舒芬太尼、瑞芬太尼在胃镜检查术中麻醉效果的比较[J].北京医学,2009,31(10):602-604.
[10]赵银洁,王伍超,陈杨,等.阿片类镇痛药复合异丙酚在无痛胃镜检查麻醉中的应用比较[J].国际麻醉学与复苏杂志,2012,33(8):513-516.
[11]徐志勇,王晓,黄景峰,等.胃镜检查术患者不同剂量瑞芬太尼复合异丙酚麻醉效果的比较随机、双盲、多中心研究[J].中华麻醉学杂志,2008,28(1):86-87.
[12] Lisa F Potts,Eun S,Park,et al.Dualκ-agonist/μ-antagonist opioid receptor modulation reduces levodopa-induced dyskinesia and corrects dysregulated striatal changes in the nonhuman primate model of Parkinson disease[J].Annals of neurology,2015,77(6):930-941.
[13]夏江燕,陆新健,袁静,等.丙泊酚复合阿片类药物在胃镜检查中的应用[J].临床麻醉学杂志,2016,32(5):464-467.
[14]陈佳林,周丽芳,韦,等.右美托咪定对丙泊酚诱导新生大鼠大脑发育的远期影响[J].临床麻醉学杂志,2018,34(2):163-166.
[15]吴江燕.右美托咪定联合丙泊酚用于老年患者无痛胃镜麻醉的效果[J].临床合理用药杂志,2018,11(20):47-48.
[16] Gear RW,Bogen O,Ferrari LF,et al.NOP receptor mediates anti-analgesia induced by agonist-antagonist opioids[J]. Neuroscience,2014,257(2):139-148.
[2]冉茂荣,侯景利,巩固,等.不同剂量丙泊酚对老年无痛胃镜检查认知功能的影响[J].四川医学,2012,33(2):323-324.
[3] Liu J,Liu R,Meng C,et al.Propofol decreases etomidaterelated myoclonus in gastroscopy[J].Medicine(Baltimore),2017,96(26):e7212.
[4]李彦君,张建新.右美托咪定复合丙泊酚对高血压患者无痛胃镜检查应激反应及早期认知功能的影响[J].海南医学院学报,2017,23(17):2445-2448.
[5]张振,罗辉宇,徐阳,等.丙泊酚分别复合盐酸纳布啡、地佐辛、舒芬太尼、用于无痛胃镜的效果比较[J].中国药房,2017,28(3):315-317.
[6]战海燕,朴美花,王艳姝,等.依托咪酯全凭静脉麻醉对老年骨科患者术中应激反应和早期术后认知功能障碍发生率的影响[J].2013,39(5):986-990.
[7]曾治宇,林娜,张明东,等.单样本率比较(单组目标值法)的样本量计算及其简便实现[J].中国卫生统计,2018,35(2):313-314.
[8] Ye L,Xiao X,Zhu L.The comparison of etomidate and propofol anesthesia in patients undergoing gastrointestinal endoscopy:a systematic review and meta-analysis[J]. Surg Laparosc Endosc Percutan Tech,2017,27(1):1-7.
[9]丁玲玲,王晓琳,邓志杰,等.丙泊酚复合芬太尼、舒芬太尼、瑞芬太尼在胃镜检查术中麻醉效果的比较[J].北京医学,2009,31(10):602-604.
[10]赵银洁,王伍超,陈杨,等.阿片类镇痛药复合异丙酚在无痛胃镜检查麻醉中的应用比较[J].国际麻醉学与复苏杂志,2012,33(8):513-516.
[11]徐志勇,王晓,黄景峰,等.胃镜检查术患者不同剂量瑞芬太尼复合异丙酚麻醉效果的比较随机、双盲、多中心研究[J].中华麻醉学杂志,2008,28(1):86-87.
[12] Lisa F Potts,Eun S,Park,et al.Dualκ-agonist/μ-antagonist opioid receptor modulation reduces levodopa-induced dyskinesia and corrects dysregulated striatal changes in the nonhuman primate model of Parkinson disease[J].Annals of neurology,2015,77(6):930-941.
[13]夏江燕,陆新健,袁静,等.丙泊酚复合阿片类药物在胃镜检查中的应用[J].临床麻醉学杂志,2016,32(5):464-467.
[14]陈佳林,周丽芳,韦,等.右美托咪定对丙泊酚诱导新生大鼠大脑发育的远期影响[J].临床麻醉学杂志,2018,34(2):163-166.
[15]吴江燕.右美托咪定联合丙泊酚用于老年患者无痛胃镜麻醉的效果[J].临床合理用药杂志,2018,11(20):47-48.
[16] Gear RW,Bogen O,Ferrari LF,et al.NOP receptor mediates anti-analgesia induced by agonist-antagonist opioids[J]. Neuroscience,2014,257(2):139-148.