不同剂量右美托咪定复合瑞芬太尼-丙泊酚控制性降压在难治性鼻窦炎患者鼻内窥镜手术中的临床研究
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摘要
目的观察不同剂量右美托咪定复合瑞芬太尼-丙泊酚控制性降压对难治性鼻窦炎患者鼻内窥镜手术的临床疗效。方法选取80例拟行鼻内窥镜手术的难治性鼻窦炎患者为研究对象,按随机数字表法分为,A组、B组、C组、D组,每组20例。所有患者在全身麻醉下行手术,静脉注射丙泊酚2 mg/kg、阿曲库铵0.6~1.0 mg/kg、瑞芬太尼2μg/kg诱导麻醉,气管插管后行机械通气,继以丙泊酚4~8 mg·kg~(-1)·h~(-1)和瑞芬太尼0.25μg·kg~(-1)·min~(-1)持续泵注并间断注射阿曲库铵维持麻醉。B组、C组、D组分别于麻醉诱导前10 min静脉泵注0.5μg/kg、0.8μg/kg、1.0μg/kg右美托咪定,并以0.5μg·kg~(-1)·h~(-1)维持至手术结束;A组输注等量0.9%氯化钠溶液。比较4组麻醉诱导前(T0)、手术结束时(T1)、拔管时(T2)、拔管后30 min(T3)血流动力学指标[心率(HR)、平均动脉压(MAP)]及血浆激素[肾上腺素(E)、去甲肾上腺素(NE)和皮质醇(Cor)]水平。比较4组麻醉达标时间、术中出血量、拔管时间、唤醒时间、拔管质量评分。分别采用SSFQ评分表、Ramsay镇静评分表评价术野质量、复苏质量。分别采用VAS评分、BCS评分评价患者疼痛程度及镇痛满意度。结果与T0时比较,A组T1、T2时HR、MAP明显升高,B、C、D组T1、T2时HR、MAP较A组明显降低(P<0.05);C、D组T3时HR、MAP明显降低(P<0.05)。与T0时比较,A组T1~T3时E、NE、Cor水平明显升高,B、C、D组T1~T3时E、NE、Cor水平较A组明显降低(P<0.05)。与A组比较,其余3组麻醉达标时间明显缩短,术中出血量明显减少,SSFQ术野质量评分及术后2 h、术后7d VAS评分明显降低,Ramsay镇静评分、BCS评分明显升高(P<0.05)。与A、B组比较,C、D组拔管时间、唤醒时间明显延长,拔管质量评分明显降低(P<0.05)。结论右美托咪定复合瑞芬太尼-丙泊酚控制性降压用于难治性鼻窦炎鼻内窥镜手术能够有效维持血流动力学稳定,抑制机体应激反应,其中0.5μg/kg右美托咪定效果最为显著。
Objective To investigate the therapeutic effects of endoscopic surgery with different doses of dexmedetomidine combined with remifentanil anesthesia and propofol controlled hypotension on refractory sinusitis. Methods Eighty patients with refractory sinusitis who were ready to receive nasal endoscopic surgery in our hospital were enrolled in the study. Accoring to random digital table,these patients were divided into group A,B,C,D,with 20 patients in each group. All the patients were intravenously injected with propofol 2 mg/kg,atracurium 0. 6 ~ 1. 0 mg/kg and remifentanil 2μg/kg for induction of anaesthesia,and general anesthesia was maintained with propofol 4 ~ 8 mg · kg~(-1)· h~(-1) and remifentanil0. 25μg·kg~(-1)·min~(-1). The patients in groups B,C,D received dexmedetomidine 0. 5μg/kg,0. 8μg/kg,1. 0μg/kg,respectively,and then maintained with 0. 5μg·kg~(-1)·h~(-1) until the end of surgery,however,the patients in group A received the same volume of 0. 9% sodium chloride solution via a pump in 15 min before induction. Then HR,MAP and plasma levels of E,NE and Cor were detected and compared among the four groups before operation(T0),after surgery(T1),at extubation time(T2) and 30 min after extubation(T3). The time to reach anesthetic effect,the intraoperative bleeding volume during surgery,extubation time after operation,wake-up time and extubation quality score were observed and compared among the four groups. Moreover the scores of surgical field quality(SSFQ) were used to evaluate the quality of surgical field,and Ramsay sedation scale was used to evaluate the quality of recovery. In addition VAS and BCS scores were used to evaluate pain degree and satisfaction degree of analgesia. Results As compared with those at T0,the levels of HR and MAP in group A were significantly increased at T1 and T2,however,whih in groups B,C,D were significantly lower than those in group A(P <0. 05). The levelsof HR and MAP at T3 in groups C and D were significantly lower than those in group A(P < 0. 05). As compared with those at T0,the lasma levels of E,NE and Cor during T1 ~ T3 were significantly increased in group A,however,which in groups B,C,D were significantly lower than those in group A(P < 0. 05). The the time of reaching anesthetic effects in group B,C,D was significantly shorter than that in group A,and the intraoperative bleeding volume during surgery was significantly less than that in group A,moreover the extubation time after operation and wake-up time were significantly longer than those in group A. In addition extubation quality score,SSFQ and VAS scores at 2 h and 7 d after surgery in group B,C,D were significantly lower than those in group A,and Ramsay scores and BCS scores in group B,C,D were significantly higher than those in group A(P < 0. 05). Besides the extubation time after operation and wake-up time in group C and group D were significantly longer than those in group A and group B,moreover,the extubation quality scores in group C and group D were significantly lower than those in group A and group B(P < 0. 05). Conclusion The endoscopic surgery with different doses of dexmedetomidine combined with remifentanil anesthesia and propofol controlled hypotension in treatment of refractory sinusitis can effectively maintain hemodynamics stabilization and inhibit the stress response of body,in which, the effects of dexmedetomidine 0. 5μg/kg are the more significant.
Objective To investigate the therapeutic effects of endoscopic surgery with different doses of dexmedetomidine combined with remifentanil anesthesia and propofol controlled hypotension on refractory sinusitis. Methods Eighty patients with refractory sinusitis who were ready to receive nasal endoscopic surgery in our hospital were enrolled in the study. Accoring to random digital table,these patients were divided into group A,B,C,D,with 20 patients in each group. All the patients were intravenously injected with propofol 2 mg/kg,atracurium 0. 6 ~ 1. 0 mg/kg and remifentanil 2μg/kg for induction of anaesthesia,and general anesthesia was maintained with propofol 4 ~ 8 mg · kg~(-1)· h~(-1) and remifentanil0. 25μg·kg~(-1)·min~(-1). The patients in groups B,C,D received dexmedetomidine 0. 5μg/kg,0. 8μg/kg,1. 0μg/kg,respectively,and then maintained with 0. 5μg·kg~(-1)·h~(-1) until the end of surgery,however,the patients in group A received the same volume of 0. 9% sodium chloride solution via a pump in 15 min before induction. Then HR,MAP and plasma levels of E,NE and Cor were detected and compared among the four groups before operation(T0),after surgery(T1),at extubation time(T2) and 30 min after extubation(T3). The time to reach anesthetic effect,the intraoperative bleeding volume during surgery,extubation time after operation,wake-up time and extubation quality score were observed and compared among the four groups. Moreover the scores of surgical field quality(SSFQ) were used to evaluate the quality of surgical field,and Ramsay sedation scale was used to evaluate the quality of recovery. In addition VAS and BCS scores were used to evaluate pain degree and satisfaction degree of analgesia. Results As compared with those at T0,the levels of HR and MAP in group A were significantly increased at T1 and T2,however,whih in groups B,C,D were significantly lower than those in group A(P <0. 05). The levelsof HR and MAP at T3 in groups C and D were significantly lower than those in group A(P < 0. 05). As compared with those at T0,the lasma levels of E,NE and Cor during T1 ~ T3 were significantly increased in group A,however,which in groups B,C,D were significantly lower than those in group A(P < 0. 05). The the time of reaching anesthetic effects in group B,C,D was significantly shorter than that in group A,and the intraoperative bleeding volume during surgery was significantly less than that in group A,moreover the extubation time after operation and wake-up time were significantly longer than those in group A. In addition extubation quality score,SSFQ and VAS scores at 2 h and 7 d after surgery in group B,C,D were significantly lower than those in group A,and Ramsay scores and BCS scores in group B,C,D were significantly higher than those in group A(P < 0. 05). Besides the extubation time after operation and wake-up time in group C and group D were significantly longer than those in group A and group B,moreover,the extubation quality scores in group C and group D were significantly lower than those in group A and group B(P < 0. 05). Conclusion The endoscopic surgery with different doses of dexmedetomidine combined with remifentanil anesthesia and propofol controlled hypotension in treatment of refractory sinusitis can effectively maintain hemodynamics stabilization and inhibit the stress response of body,in which, the effects of dexmedetomidine 0. 5μg/kg are the more significant.
引文
1 Akdis CA,Bachert C,Cingi C,et al.Endotypes and phenotypes of chronic rhinosinusitis:a PRACTALL document of the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy,Asthma&Immunology.J Allergy Clin Immunol,2013,131:1479-1490.
2 中华耳鼻咽喉头颈外科杂志编辑委员会鼻科组,中华医学会耳鼻咽喉头颈外科学分会鼻科学组.慢性鼻-鼻窦炎诊断和治疗指南(2012).中国医刊,2013,48:103-105.
3 韩德民.难治性鼻及鼻窦炎.中国医学文摘耳鼻咽喉科学,2010,25:59-62.
4 杨驱云,赵侃,沈毅,等.难治性鼻-鼻窦炎综合治疗的疗效观察.临床耳鼻咽喉头颈外科杂志,2016,30:111-114.
5 Chu KS,Wang FY,Hsu HT,et al.The effectiveness of dexmedetomidine infusion for sedating oral cancer patients undergoing awake fibreoptic nasal intubation.Eur J Anaesthesiol,2010,27:36-40.
6 Cooper RM,O’Sullivan E,Popat M,et al.Difficult Airway Society guidelines for the management of tracheal extubation.Anaesthesia,2012,67:318-340.
7 Shams T,Bahnasawe NSE,Abusamra M,et al.Induced hypotension for functional endoscopic sinus surgery:A comparative study of dexmedetomidine versus esmolol.Saudi Janaesth,2013,7:175-180.
8 孙梅杰,边雯,李刚,等.不同血浆靶浓度瑞芬太尼对鼻内镜手术患者鼻黏膜微循环的影响.临床麻醉学杂志,2011,27:119-122.
9 吴秀秀,陈永权,薛玉荣,等.右美托咪定不同给药方式对妇科腹腔镜患者血流动力学及术后镇痛的影响.中国临床药理学与治疗学,2016,21:821-825.
10 Volkov PA,Churadze BT,Sevalkin SA,et al.Dexmedetomidine as a part of analgesic component of general anes thesia for laparoscopic operations.Anesteziologiia I Reanimatologiia,2015,60:4-8.
11 朱俊峰,赵秋华,张瀚.不同右美托咪定剂量对慢性鼻窦炎鼻息肉手术围拔管期应激反应的影响.热带医学杂志,2015,15:1246-1247.
2 中华耳鼻咽喉头颈外科杂志编辑委员会鼻科组,中华医学会耳鼻咽喉头颈外科学分会鼻科学组.慢性鼻-鼻窦炎诊断和治疗指南(2012).中国医刊,2013,48:103-105.
3 韩德民.难治性鼻及鼻窦炎.中国医学文摘耳鼻咽喉科学,2010,25:59-62.
4 杨驱云,赵侃,沈毅,等.难治性鼻-鼻窦炎综合治疗的疗效观察.临床耳鼻咽喉头颈外科杂志,2016,30:111-114.
5 Chu KS,Wang FY,Hsu HT,et al.The effectiveness of dexmedetomidine infusion for sedating oral cancer patients undergoing awake fibreoptic nasal intubation.Eur J Anaesthesiol,2010,27:36-40.
6 Cooper RM,O’Sullivan E,Popat M,et al.Difficult Airway Society guidelines for the management of tracheal extubation.Anaesthesia,2012,67:318-340.
7 Shams T,Bahnasawe NSE,Abusamra M,et al.Induced hypotension for functional endoscopic sinus surgery:A comparative study of dexmedetomidine versus esmolol.Saudi Janaesth,2013,7:175-180.
8 孙梅杰,边雯,李刚,等.不同血浆靶浓度瑞芬太尼对鼻内镜手术患者鼻黏膜微循环的影响.临床麻醉学杂志,2011,27:119-122.
9 吴秀秀,陈永权,薛玉荣,等.右美托咪定不同给药方式对妇科腹腔镜患者血流动力学及术后镇痛的影响.中国临床药理学与治疗学,2016,21:821-825.
10 Volkov PA,Churadze BT,Sevalkin SA,et al.Dexmedetomidine as a part of analgesic component of general anes thesia for laparoscopic operations.Anesteziologiia I Reanimatologiia,2015,60:4-8.
11 朱俊峰,赵秋华,张瀚.不同右美托咪定剂量对慢性鼻窦炎鼻息肉手术围拔管期应激反应的影响.热带医学杂志,2015,15:1246-1247.