舒芬太尼和芬太尼用于神经外科手术麻醉的比较研究
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摘要
目的
在大脑开颅肿瘤切除手术的麻醉中,比较舒芬太尼与芬太尼对于血流动力学和麻醉苏醒期不良反应及机体应激反应的影响。
方法
选择ASAⅠ-Ⅱ级择期行大脑开颅颅内肿瘤切除术的患者50例,随机分为舒芬太尼组(S组)和芬太尼组(F组),每组25例。常规诱导,静注咪达唑仑0.04mg/kg,丙泊酚2mg/kg,S组舒芬太尼0.4μg/kg,F组芬太尼4μg/kg,待意识消失后,静注维库溴铵0.1mg/kg。3分钟后行气管插管,连接呼吸机,氧流量2L/min,调节呼吸参数使呼气末二氧化碳分压维持在30～35mmHg。插管后开始吸入七氟烷1～2MAC、静脉持续泵注丙泊酚3～4mg/kg/h静吸复合麻醉。术中启动微量泵分别持续静脉输注舒芬太尼0.2μg/kg/h(s组),芬太尼2μg/kg/h(F组)。维库溴铵在麻醉诱导后每间隔45～60min追加2mg。术中依据MAP和HR变化作出相应处理。舒芬太尼或芬太尼在手术结束前约30min时停药,关硬脑膜后停止吸入七氟烷,丙泊酚持续泵注至缝皮结束。记录:两组入室安静10min(T_0)、诱导后(T_1)、插管后1min(T_2)、头架固定时(T_3)、切皮时(T_4)、切开硬脑膜(T_5)、关闭硬脑膜(T_6)、呼吸恢复后即刻(T_7)、拔管后即刻(T_8)各时点的MAP、HR、SpO_2;分别在入室安静10min后、切皮后30min、拔除气管导管后即刻,采桡动脉血化验血糖、血肾上腺素浓度;手术结束后观察并记录自主呼吸恢复时间、拔管时间、拔管后和术后2h疼痛程度及不良反应发生率。术后48小时随访疼痛程度,镇痛药应用情况及恶心、呕吐等不良反应发生率。
结果
F组HR在插管后1min、开颅、关颅、呼吸恢复后即刻及拔管后即刻均大于基础值(P＜0.05),S组HR在开颅、呼吸恢复后即刻及拔管后即刻均大于基础值(P＜0.05);两组MAP在诱导后、开颅、关颅都较基础值降低,F组切皮时、拔管后即刻MAP较基础值增高(P＜0.05);S组在其余时间点与基础值比较无显著差异(P＞0.05);颅内手术各期F组的MAP、HR值均高于S组(P＜0.05);自主呼吸恢复时间、拔管时间S组短于F组(P＜0.05)。S组术后寒战、躁动发生率低于F组(P＜0.05),术后恶心、呕吐两组间无显著差异。拔管后即刻、术后2h S组VAS疼痛评分低于F组(P＜0.05),术后48h随访VAS疼痛评分两组间无显著差异。两组在基础值、切皮后30min、拔管后即刻的血糖、血肾上腺素浓度差值无显著差异。
结论
与芬太尼比较,舒芬太尼应用于神经外科手术患者全麻过程中血流动力学更稳定,能够有效抑制插管时的心血管反应,麻醉苏醒期更平稳,术后寒战、躁动发生率少,术后恶心、呕吐的发生率无显著差异。对围术期血糖、血肾上腺素水平的影响无显著差异。
Objective
To compare the effects of sufentanil and fentanyl on hemodynamics,recovery profiles from general anesthesia and the stress reaction in patients undergoing intracranial tumor resection.
Methods
A total of fifty ASA physical statusⅠorⅡpatients scheduled for intracranial tumor resection were randomized to S(sufentanil) or F(fentanyl) group(25 for each). Sufentanil was performed on the patients in S group by combination of intravenous propofol and sevoflurane anesthesia while conducted on the patients in F group using fentanyl plus propofol continuous intravenous infusion followed by sevoflurane anaesthesia.Induction of anesthesia was begun with midazolam 0.04mg/kg,group S sufentanil 0.4μg/kg,group F fentanyl 4μg/kg,propofol 2mg/kg.Vecuronium 0.1 mg/kg was given on Loss of Consciousness(LOS).Tracheal intubation was performed after three minutes of induction,with mechanical ventilation,according to maintaining end-tidal carbon dioxide partial pressure(P_(ET)-CO_2) at 30～35mmHg regulating appropriately respiratory parameters.After intubation,sevoflurane was inhaled at the concentration of 1～2MAC,the flux of oxygen was 2L/min,followed by continuous intravenous pumping of propofol(3～4mg/kg/h) and sufentanil(0.2μg//kg/h)(group S) or fentanyl(2μg//kg/h)(group F).Vecuronium 2mg was injected at intervals of 45～60 min. For sufentanil was stopped about 30min before the end of operation.Sevoflurane was stopped after dural closure and propofol was stopped when the operation was finished. The patient's blood pressure,heart rate were continuously monitored and recorded at different time points including baseline values(T_0),post-anesthesia induction(T_1),1min after tracheal intubation(T_2),head holder application(T_3),skin and dural incisions(T_4、T_5),dural closure(T_6),spontaneous breath recovery(T_7) and after tracheal extubation(T_8).At time points including T_0,30 minutes after skin incision,1 minute after tracheal extubation(T_8),radial arterial blood sampling were underwent to detect the concentration of blood glucose(BG) and epinephrine(EPI).Time to recovery of spontaneous breath and extubation from the end of operation,postoperative pain intensity at after extubation and 2h after operation and adverse effects were recorded. Patient's follow-up visit was done in 48 hours after operation.The pain intensity,the use of supplemental analgesics and the incidence of adverse reactions were recorded.
Results
In group F,the Heart Rates(HR) during 1min after endotracheal intubation,dural incision and closure,spontaneous breath recovery and after tracheal extubation were higher than baseline value(P＜0.05),while they were higher than baseline value during dural incision,spontaneous breath recovery and after tracheal extubation in group S(P＜0.05).Group F and S on MAP after anesthesia induction,dural incision and closure were lower than baseline values(P＜0.05).Group F on MAP at skin incision and after tracheal extubation were higher than baseline value(P＜0.05),but during skin incision and after tracheal extubation,group S was not different from baseline value(P＞0.05).Group F on MAP,HR in every intracranial episodes were higher than group S.The extubation time and the consciousness time were shorter in group S than in group F(P＜0.05),The incidence of postoperative shivering and restlessness in group S was lower than group F.The incidence of nausea and vomiting in group S was not different from that in group F(P＞0.05).VAS scores at after extubation,2h after operation,group S were lower than group F(P＜0.05).There were no differences between group F and group S about VAS scores at 48h after operations.The changes of the concentration of blood glucose(BG) and epinephrine(EPI) at each time points were similar in two groups.
Conclusions
Sufentanil combining with propofol and sevoflurane is superior to fentanyl in general anesthesia in intracranial surgery.Compared to fentanyl,the anesthesia induction and maintenance are more stable,and the quality of consciousness is better by the use of sufentanil.The incidence of nausea and vomiting are similar for both groups.The inhibition of fentanyl and sufentanil on the concentration of blood glucose(BG) and epinephrine(EPI) at each time points are similar.
在大脑开颅肿瘤切除手术的麻醉中,比较舒芬太尼与芬太尼对于血流动力学和麻醉苏醒期不良反应及机体应激反应的影响。
方法
选择ASAⅠ-Ⅱ级择期行大脑开颅颅内肿瘤切除术的患者50例,随机分为舒芬太尼组(S组)和芬太尼组(F组),每组25例。常规诱导,静注咪达唑仑0.04mg/kg,丙泊酚2mg/kg,S组舒芬太尼0.4μg/kg,F组芬太尼4μg/kg,待意识消失后,静注维库溴铵0.1mg/kg。3分钟后行气管插管,连接呼吸机,氧流量2L/min,调节呼吸参数使呼气末二氧化碳分压维持在30～35mmHg。插管后开始吸入七氟烷1～2MAC、静脉持续泵注丙泊酚3～4mg/kg/h静吸复合麻醉。术中启动微量泵分别持续静脉输注舒芬太尼0.2μg/kg/h(s组),芬太尼2μg/kg/h(F组)。维库溴铵在麻醉诱导后每间隔45～60min追加2mg。术中依据MAP和HR变化作出相应处理。舒芬太尼或芬太尼在手术结束前约30min时停药,关硬脑膜后停止吸入七氟烷,丙泊酚持续泵注至缝皮结束。记录:两组入室安静10min(T_0)、诱导后(T_1)、插管后1min(T_2)、头架固定时(T_3)、切皮时(T_4)、切开硬脑膜(T_5)、关闭硬脑膜(T_6)、呼吸恢复后即刻(T_7)、拔管后即刻(T_8)各时点的MAP、HR、SpO_2;分别在入室安静10min后、切皮后30min、拔除气管导管后即刻,采桡动脉血化验血糖、血肾上腺素浓度;手术结束后观察并记录自主呼吸恢复时间、拔管时间、拔管后和术后2h疼痛程度及不良反应发生率。术后48小时随访疼痛程度,镇痛药应用情况及恶心、呕吐等不良反应发生率。
结果
F组HR在插管后1min、开颅、关颅、呼吸恢复后即刻及拔管后即刻均大于基础值(P＜0.05),S组HR在开颅、呼吸恢复后即刻及拔管后即刻均大于基础值(P＜0.05);两组MAP在诱导后、开颅、关颅都较基础值降低,F组切皮时、拔管后即刻MAP较基础值增高(P＜0.05);S组在其余时间点与基础值比较无显著差异(P＞0.05);颅内手术各期F组的MAP、HR值均高于S组(P＜0.05);自主呼吸恢复时间、拔管时间S组短于F组(P＜0.05)。S组术后寒战、躁动发生率低于F组(P＜0.05),术后恶心、呕吐两组间无显著差异。拔管后即刻、术后2h S组VAS疼痛评分低于F组(P＜0.05),术后48h随访VAS疼痛评分两组间无显著差异。两组在基础值、切皮后30min、拔管后即刻的血糖、血肾上腺素浓度差值无显著差异。
结论
与芬太尼比较,舒芬太尼应用于神经外科手术患者全麻过程中血流动力学更稳定,能够有效抑制插管时的心血管反应,麻醉苏醒期更平稳,术后寒战、躁动发生率少,术后恶心、呕吐的发生率无显著差异。对围术期血糖、血肾上腺素水平的影响无显著差异。
Objective
To compare the effects of sufentanil and fentanyl on hemodynamics,recovery profiles from general anesthesia and the stress reaction in patients undergoing intracranial tumor resection.
Methods
A total of fifty ASA physical statusⅠorⅡpatients scheduled for intracranial tumor resection were randomized to S(sufentanil) or F(fentanyl) group(25 for each). Sufentanil was performed on the patients in S group by combination of intravenous propofol and sevoflurane anesthesia while conducted on the patients in F group using fentanyl plus propofol continuous intravenous infusion followed by sevoflurane anaesthesia.Induction of anesthesia was begun with midazolam 0.04mg/kg,group S sufentanil 0.4μg/kg,group F fentanyl 4μg/kg,propofol 2mg/kg.Vecuronium 0.1 mg/kg was given on Loss of Consciousness(LOS).Tracheal intubation was performed after three minutes of induction,with mechanical ventilation,according to maintaining end-tidal carbon dioxide partial pressure(P_(ET)-CO_2) at 30～35mmHg regulating appropriately respiratory parameters.After intubation,sevoflurane was inhaled at the concentration of 1～2MAC,the flux of oxygen was 2L/min,followed by continuous intravenous pumping of propofol(3～4mg/kg/h) and sufentanil(0.2μg//kg/h)(group S) or fentanyl(2μg//kg/h)(group F).Vecuronium 2mg was injected at intervals of 45～60 min. For sufentanil was stopped about 30min before the end of operation.Sevoflurane was stopped after dural closure and propofol was stopped when the operation was finished. The patient's blood pressure,heart rate were continuously monitored and recorded at different time points including baseline values(T_0),post-anesthesia induction(T_1),1min after tracheal intubation(T_2),head holder application(T_3),skin and dural incisions(T_4、T_5),dural closure(T_6),spontaneous breath recovery(T_7) and after tracheal extubation(T_8).At time points including T_0,30 minutes after skin incision,1 minute after tracheal extubation(T_8),radial arterial blood sampling were underwent to detect the concentration of blood glucose(BG) and epinephrine(EPI).Time to recovery of spontaneous breath and extubation from the end of operation,postoperative pain intensity at after extubation and 2h after operation and adverse effects were recorded. Patient's follow-up visit was done in 48 hours after operation.The pain intensity,the use of supplemental analgesics and the incidence of adverse reactions were recorded.
Results
In group F,the Heart Rates(HR) during 1min after endotracheal intubation,dural incision and closure,spontaneous breath recovery and after tracheal extubation were higher than baseline value(P＜0.05),while they were higher than baseline value during dural incision,spontaneous breath recovery and after tracheal extubation in group S(P＜0.05).Group F and S on MAP after anesthesia induction,dural incision and closure were lower than baseline values(P＜0.05).Group F on MAP at skin incision and after tracheal extubation were higher than baseline value(P＜0.05),but during skin incision and after tracheal extubation,group S was not different from baseline value(P＞0.05).Group F on MAP,HR in every intracranial episodes were higher than group S.The extubation time and the consciousness time were shorter in group S than in group F(P＜0.05),The incidence of postoperative shivering and restlessness in group S was lower than group F.The incidence of nausea and vomiting in group S was not different from that in group F(P＞0.05).VAS scores at after extubation,2h after operation,group S were lower than group F(P＜0.05).There were no differences between group F and group S about VAS scores at 48h after operations.The changes of the concentration of blood glucose(BG) and epinephrine(EPI) at each time points were similar in two groups.
Conclusions
Sufentanil combining with propofol and sevoflurane is superior to fentanyl in general anesthesia in intracranial surgery.Compared to fentanyl,the anesthesia induction and maintenance are more stable,and the quality of consciousness is better by the use of sufentanil.The incidence of nausea and vomiting are similar for both groups.The inhibition of fentanyl and sufentanil on the concentration of blood glucose(BG) and epinephrine(EPI) at each time points are similar.
引文
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14 Albanese J,Viviand X,et al.Sufentanil,fentanyl,and alfentanil in head trauma patients:a study on cerebral hemodynamics.Crit Care Med,1999 2;27(2):407-11.
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16 Lysakowski C,Dumont L,et al.Effects of fentanyl,alfentanil,remifentanil and sufentanii on loss of consciousness and bispectral index during propofol induction of anaesthesia.British Journal of Anaesthesia,2001;86(4):523-7.
17 Martorano P,Facco E,Falzetti G,et al.Spectral entropy assessment with auditory evoked potential in neuroanesthesia.Clin Neurophysiol,2007,118:505-512.
18 Samir Jamali,David Archer,et al.The Effect of Skull-Pin Insertion on Cerebrospinal Fluid Pressure and Cerebral Perfusion Pressure:Influence of Sufentanil and Fentanyl.Anesth Analg,1997;84:1292-6.
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12 Abonen J,Olkkola KT,Hynynen M,et at,Comparison of alfentanil,fentanyl and sufentanil for total intravenous anesthesia with propofol in patients undergoing coronary artery bypass surgery.Br J Anaesth,2000,85;533-540.
13 Mendes GM,Selmi AL.Use of a combination of propofol and fentanyl,alfentanil or sufentanil for total intravenous anesthesia in cats.J Amvet M ed Assoc,2003,223(11);1608-1613.
14 Albanese J,Viviand X,et al.Sufentanil,fentanyl,and alfentanil in head trauma patients:a study on cerebral hemodynamics.Crit Care Med,1999 2;27(2):407-11.
15 Scott JC,Cooke JE,Stanski DR.Electroencephaloographic quantitation of opioid effect:comparative pharmacodynamics of fentanyl and sufentanil.Anesthesiology,1991,74:34.
16 Lysakowski C,Dumont L,et al.Effects of fentanyl,alfentanil,remifentanil and sufentanii on loss of consciousness and bispectral index during propofol induction of anaesthesia.British Journal of Anaesthesia,2001;86(4):523-7.
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18 Samir Jamali,David Archer,et al.The Effect of Skull-Pin Insertion on Cerebrospinal Fluid Pressure and Cerebral Perfusion Pressure:Influence of Sufentanil and Fentanyl.Anesth Analg,1997;84:1292-6.
19 Schraag S,M chl U,Bothner U,et al.Interaction modeling of propofol and sufentanil on loss of consciousness.JCL Anesth,1999,119:391.
20 田玉科,Erhard Hartung.舒芬太尼与芬太尼复合异丙酚静脉麻醉的比较.中华麻醉学杂志,1998,18:608.
21 Aurelie Bourgoin,Jacques Albanese,et al.Effects of suffentanil or ketamine administered in target-controlled infusion on the cerebral hemodynamics of severely brain-injured patients.Crit Care Med,2005;33(5):1109-1113.
22 耿志宇,宋琳琳,许幸等,异丙酚复合芬太尼或瑞芬太尼靶控麻醉与静吸复合麻醉的比较,中华麻醉学杂志,2004,24:14-17.
23 吴奇伟,岳云等.腹部手术患者舒芬太尼联合异丙酚靶控输注的麻醉效果.中华麻醉学杂志,2005,11(25):867.
24 Samir Jamali,Patrick Ravussin,et al.The Effects of Bolus Administration of Opioids on Cerebrospinal Fluid Pressure in Patients with Supratentorial Lesions.Anesth Analg,1996;82:600-6.
25 Stephan H,Groger P,Weyland A,et al.The effect of sufentanil on cerebral blood flow,cerebral metabolism and the CO2 reactivity of the cerebral vessels in man[J].Anaesthesist,1991;40:153-60.
26 Hanel F,Wemer C,yon Knobelsdorff G,et al.The effects of fentanyl and sufentanil on cerebral hemodynamics[J].Neurosurg Anesthesiol 1997,9:223-7.
27 Vuyk J.Clinical interpretation of pharmacokinetic and pharmacodynamic propofol-opioid interactions.Acta Anaesthesiol Belg,2001;52(4):445-51.
28 Gesztesi Z,Mootz B L,White P F.The use of remifentanil infusion for hemodynamic control during intracranial surgery[J].Anesthe Analg,1996,83(2):348-353.