瑞芬太尼用于鼻内镜手术控制性降压的临床观察
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摘要
目的观察异氟醚麻醉下瑞芬太尼控制性降压的效果、术野质量及对应激反应的影响。
方法40例ASAⅠ～Ⅱ级、年龄20～60岁的择期鼻内镜手术病人,排除严重心、肺、肝、肾、脑疾患、血糖异常或使用糖皮质激素以及术前有滥用阿片类药物的患者。随机分为R组和F组,均选上午手术患者。
常规麻醉诱导。麻醉维持:两组均于诱导后异氟醚持续吸入,调整呼气末异氟醚浓度在0.4%～1%之间,维库溴胺0.5～1μg·kg~(-1)·min~(-1)静脉持续泵入。R组瑞芬太尼1μg/kg静脉注射后,以0.3～0.8μg·kg~(-1)·min~(-1)持续泵入达到并维持预期血压MAP:60～80mmHg(1mmHg=0.133kpa),术中随时调整。F组芬太尼0.03～0.08μg·kg~(-1)·min~(-1)持续泵入,硝普钠1μg·kg~(-1)·min~(-1)开始泵入,适当调整泵入量0.5～3μg·kg~(-1)·min~(-1),血压达到并维持预期血压MAP60～80mmHg,术中保持控制性低血压。手术开始。术毕两组均于手术结束前10min停维库溴胺,手术结束时停异氟醚。R组停瑞芬太尼,F组术毕停芬太尼,渐停硝普钠泵入。两组均待血压回升至接近术前水平,进入拔管程序。
麻醉前常规22号动脉针桡动脉穿刺置管,使用H.P系列监护仪及Edwarde PX260压力传感器连续监测记录桡动脉收缩压(SBP)、舒张压(DBP)平均动脉压(MAP)及心率(HR)值。术中于开窦前及开窦术中每5min共8个时点分别记录心率、收缩压、平均动脉压,描述其趋势。两组开始降压到达到目标血压时间。持续监测术中血氧饱和度(SpO_2)、尿量、呼气末异氟醚浓度。
术野质量:于手术开始后每10分钟评估一次术野质量。评估标准:Fromme术野质量评估表:Ⅰ-Ⅴ级。
于麻醉前(T1)、控制性降压后手术前(T2)、手术开始后45分钟至1小时(T3)分别采周围静脉血。用强生CAT/TYP 2138999型快速血糖仪测血糖。样血凝血后取血清送-70摄氏度冰箱冷冻,集中采用HJ-19皮质醇(Cor)放射免疫分析试剂盒(批号060225)检测血皮质醇水平。
记录手术持续时间和麻醉结束后不良反应。
统计学分析:采用SPSS 11.2软件包进行统计学处理。计数资料用卡方检验。计量资料以(?)±s表示,变量呈正态性及方差齐,组内比较用t检验,组间比较采用t检验、单因数方差分析及协方差及重复测量方差分析,否则用秩和检验,α=0.05,P＜0.05表示差异有统计学意义。
结果一般情况:性别、年龄、体重、ASA分级、手术种类、异氟醚呼气末浓度、SpO_2比较差异无统计学意义(P＞0.05),手术持续时间R组比F组短(P＜0.05)。
控制性降压期间:两组SBP、MAP均低于麻醉前(P＜0.01),心率慢于麻醉前,R组(P＜0.01),F组(P＜0.05)。两组血压及心率值比较,R组低于F组(P＜0.05)。趋势表及趋势图显示开窦前及开窦术中各时点SBP、MAP、HR随时间变化趋势差别有统计学意义,该时段F组SBP、MAP、HR值均高于R组,F组SBP及MAP明显增高,HR增快,而R组血压无明显上升趋势,HR稳定中有轻微下降趋势(P＜0.05)。
术野评分R组平均秩明显低于F组(P＜0.01),说明R组术野质量明显好于F组。
两组各自血糖值T3与T1、T2比较无统计学意义(P＞0.05)。各组皮质醇值T3明显低于T1、T2值(P＜0.01)。血糖、皮质醇值各对应时点R组与F组比较无统计学意义。
术中各组尿量均保持在1.5ml·kg~(-1)·h~(-1)以上。R组开始给药到血压下降到预期水平时间短于F组(P＜0.01)。
结论与传统方法相比,鼻内镜手术中异氟醚麻醉下瑞芬太尼控制性降压可达理想的降压效果,提高了术野质量,有效抑制了术中应激反应。
Objective To investigate the effects,Quality of the surgical field and influence to the stress response of Controlled hypotension with remifentanil under anesthesia of isoflurane during endoscopic sinus surgery.
Methods 40 patients aged 20～60 undergoing selective endoscopic sinus surgery,ASA gradeⅠ～Ⅱ,were randomly assigned into R and F group.They had not serious disease on heart,lung,liver,kidney and brain.Their blood glucose were normal.They were not received medication for glucocorticoid and apium before.A 22-gauge catheter was inserted into a radial artery for direct determination of arterial blood pressure(SBP,DBP and MAP)and heart rate(HR)which were continuously recorded.They were received anesthesia with isoflurane(0.4 vol%～1vol%)constant inhalation and vecuronium(0.5～1μg·kg~(-1)·min~(-1))constant infusion immediately after conventional induction of anesthesia. Remifentanil(0.3～0.8μg·kg~(-1)min~(-1))constant infusion was used in group R to keep mean arterial pressure between 60 and 80 mmHg.So was sodium nitroprusside(0.5～3μg·kg~(-1) min~(-1))in group F.The blood pressure,MAP and HR of the two group were recorded at the time before and after induction and stage during Controlled hypotension. Quality of the surgical field were rated every 10 minutes during Controlled hypotension(Rating standard:FrommeⅠ～Ⅴdegree).Blood pressure and heart rate trend of the time points before and every 5 minutes during nasal sinus operation were recorded. Blood glucose and cortisol at the time before induction(T1),before surgery(T2)and 45 minutes to 60minutes from the beginning of the operation during controlled hypotension(T3)were recorded.All data were analyzed with the statistical software of SPSS 11.2.Chi square test were used for numeration data.The measurement data met homoscedasticity presented as (?)±s were tested by t-test and variance analysis,otherwise by rank sum test.α=0.05.The threshold for statistical significance was taken as P＜0.05.
Results The SBP,MAP of the two group during Controlled hypotension were lower(P＜0.01),and the HR were lower(R group P＜0.01 but F P＜0.05)compared with those before anesthesia.The SBP,MAP,HR during controlled hypotension of R group were lower than those of F(P＜0.05).Quality of the surgical field rated of R group were significantly better(P＜0.01)during Controlled hypotension compared with F.Blood glucose and cortisol level at each T1,T2 and T3 are not significantly different between the two group with convariance analysis.Blood glucose level at T3 is not significantly different compared with T1 and T2,but cortisol is lower of each group(P＜0.01).The SBP,MAP,HR of group F fluctuated obviously during the sinus operation and have a rising tendency.But it was not the same as those of group R,the HR of group R even have a declining tendency slightly(P＜0.05).It is revealed that the blood pressure and heart rate appear relatively stable of R group than those of F from the trend graph.
Conclusions Compared with sodium nitroprusside,controlled hypotension was achieved satisfactorily with remifentanil under anesthesia of isoflurane accompanying with better quality of the surgical field and inhibition to stress response.
方法40例ASAⅠ～Ⅱ级、年龄20～60岁的择期鼻内镜手术病人,排除严重心、肺、肝、肾、脑疾患、血糖异常或使用糖皮质激素以及术前有滥用阿片类药物的患者。随机分为R组和F组,均选上午手术患者。
常规麻醉诱导。麻醉维持:两组均于诱导后异氟醚持续吸入,调整呼气末异氟醚浓度在0.4%～1%之间,维库溴胺0.5～1μg·kg~(-1)·min~(-1)静脉持续泵入。R组瑞芬太尼1μg/kg静脉注射后,以0.3～0.8μg·kg~(-1)·min~(-1)持续泵入达到并维持预期血压MAP:60～80mmHg(1mmHg=0.133kpa),术中随时调整。F组芬太尼0.03～0.08μg·kg~(-1)·min~(-1)持续泵入,硝普钠1μg·kg~(-1)·min~(-1)开始泵入,适当调整泵入量0.5～3μg·kg~(-1)·min~(-1),血压达到并维持预期血压MAP60～80mmHg,术中保持控制性低血压。手术开始。术毕两组均于手术结束前10min停维库溴胺,手术结束时停异氟醚。R组停瑞芬太尼,F组术毕停芬太尼,渐停硝普钠泵入。两组均待血压回升至接近术前水平,进入拔管程序。
麻醉前常规22号动脉针桡动脉穿刺置管,使用H.P系列监护仪及Edwarde PX260压力传感器连续监测记录桡动脉收缩压(SBP)、舒张压(DBP)平均动脉压(MAP)及心率(HR)值。术中于开窦前及开窦术中每5min共8个时点分别记录心率、收缩压、平均动脉压,描述其趋势。两组开始降压到达到目标血压时间。持续监测术中血氧饱和度(SpO_2)、尿量、呼气末异氟醚浓度。
术野质量:于手术开始后每10分钟评估一次术野质量。评估标准:Fromme术野质量评估表:Ⅰ-Ⅴ级。
于麻醉前(T1)、控制性降压后手术前(T2)、手术开始后45分钟至1小时(T3)分别采周围静脉血。用强生CAT/TYP 2138999型快速血糖仪测血糖。样血凝血后取血清送-70摄氏度冰箱冷冻,集中采用HJ-19皮质醇(Cor)放射免疫分析试剂盒(批号060225)检测血皮质醇水平。
记录手术持续时间和麻醉结束后不良反应。
统计学分析:采用SPSS 11.2软件包进行统计学处理。计数资料用卡方检验。计量资料以(?)±s表示,变量呈正态性及方差齐,组内比较用t检验,组间比较采用t检验、单因数方差分析及协方差及重复测量方差分析,否则用秩和检验,α=0.05,P＜0.05表示差异有统计学意义。
结果一般情况:性别、年龄、体重、ASA分级、手术种类、异氟醚呼气末浓度、SpO_2比较差异无统计学意义(P＞0.05),手术持续时间R组比F组短(P＜0.05)。
控制性降压期间:两组SBP、MAP均低于麻醉前(P＜0.01),心率慢于麻醉前,R组(P＜0.01),F组(P＜0.05)。两组血压及心率值比较,R组低于F组(P＜0.05)。趋势表及趋势图显示开窦前及开窦术中各时点SBP、MAP、HR随时间变化趋势差别有统计学意义,该时段F组SBP、MAP、HR值均高于R组,F组SBP及MAP明显增高,HR增快,而R组血压无明显上升趋势,HR稳定中有轻微下降趋势(P＜0.05)。
术野评分R组平均秩明显低于F组(P＜0.01),说明R组术野质量明显好于F组。
两组各自血糖值T3与T1、T2比较无统计学意义(P＞0.05)。各组皮质醇值T3明显低于T1、T2值(P＜0.01)。血糖、皮质醇值各对应时点R组与F组比较无统计学意义。
术中各组尿量均保持在1.5ml·kg~(-1)·h~(-1)以上。R组开始给药到血压下降到预期水平时间短于F组(P＜0.01)。
结论与传统方法相比,鼻内镜手术中异氟醚麻醉下瑞芬太尼控制性降压可达理想的降压效果,提高了术野质量,有效抑制了术中应激反应。
Objective To investigate the effects,Quality of the surgical field and influence to the stress response of Controlled hypotension with remifentanil under anesthesia of isoflurane during endoscopic sinus surgery.
Methods 40 patients aged 20～60 undergoing selective endoscopic sinus surgery,ASA gradeⅠ～Ⅱ,were randomly assigned into R and F group.They had not serious disease on heart,lung,liver,kidney and brain.Their blood glucose were normal.They were not received medication for glucocorticoid and apium before.A 22-gauge catheter was inserted into a radial artery for direct determination of arterial blood pressure(SBP,DBP and MAP)and heart rate(HR)which were continuously recorded.They were received anesthesia with isoflurane(0.4 vol%～1vol%)constant inhalation and vecuronium(0.5～1μg·kg~(-1)·min~(-1))constant infusion immediately after conventional induction of anesthesia. Remifentanil(0.3～0.8μg·kg~(-1)min~(-1))constant infusion was used in group R to keep mean arterial pressure between 60 and 80 mmHg.So was sodium nitroprusside(0.5～3μg·kg~(-1) min~(-1))in group F.The blood pressure,MAP and HR of the two group were recorded at the time before and after induction and stage during Controlled hypotension. Quality of the surgical field were rated every 10 minutes during Controlled hypotension(Rating standard:FrommeⅠ～Ⅴdegree).Blood pressure and heart rate trend of the time points before and every 5 minutes during nasal sinus operation were recorded. Blood glucose and cortisol at the time before induction(T1),before surgery(T2)and 45 minutes to 60minutes from the beginning of the operation during controlled hypotension(T3)were recorded.All data were analyzed with the statistical software of SPSS 11.2.Chi square test were used for numeration data.The measurement data met homoscedasticity presented as (?)±s were tested by t-test and variance analysis,otherwise by rank sum test.α=0.05.The threshold for statistical significance was taken as P＜0.05.
Results The SBP,MAP of the two group during Controlled hypotension were lower(P＜0.01),and the HR were lower(R group P＜0.01 but F P＜0.05)compared with those before anesthesia.The SBP,MAP,HR during controlled hypotension of R group were lower than those of F(P＜0.05).Quality of the surgical field rated of R group were significantly better(P＜0.01)during Controlled hypotension compared with F.Blood glucose and cortisol level at each T1,T2 and T3 are not significantly different between the two group with convariance analysis.Blood glucose level at T3 is not significantly different compared with T1 and T2,but cortisol is lower of each group(P＜0.01).The SBP,MAP,HR of group F fluctuated obviously during the sinus operation and have a rising tendency.But it was not the same as those of group R,the HR of group R even have a declining tendency slightly(P＜0.05).It is revealed that the blood pressure and heart rate appear relatively stable of R group than those of F from the trend graph.
Conclusions Compared with sodium nitroprusside,controlled hypotension was achieved satisfactorily with remifentanil under anesthesia of isoflurane accompanying with better quality of the surgical field and inhibition to stress response.
引文
[1]Fromme GA,Gould AB,Lund BA,et al.Controled hypotension for orthognatic surgery.Anesth Analg,1986,65:683-686.
[2]Beers R,Camporesi E.Remifentanil update:clinical science and utility[J].CNS Drugs,2004,18(15):1085.
[3]Haigh CG..Drug development in anaesthesia:the remifentanil.Minerva Anestesiol,2000,66(5):414.
[4]Christian S,Marie J,Pierre.Y,et al.Remifentanil induces consistent and sustained controlled hypotension in children during middle ear surgery.CAN J ANESTH,2003,50(3):270-276.
[5]Degoute CS,Ray MJ,Manchon M,et al.Remifentanil and controlled hypotension;comparison with nitropmsside or esmolol during tympanoplasty.Can J Anaesth,2001,48(1):20.
[6]Cavemi V,Rosa G,Pinto P,et al.Hypotensive anesthesia and recovery of cognitive function in long-term craniofacial surgery[Clinical Notes].Journal of Craniofacial Surgery,2005,16(4):531-536.
[7]Dal D,Celiker V,Ozer E,et al.Induced hypotension for tympanoplasty:a comparison of desflurane,isoflurane and sevoflurane.Eur J Anaesthesiol,2004,21(11):902-6.
[8]毛瑞芬,高秀江,周长浩等.不同剂量的瑞芬太尼对全身麻醉患者血流动力学的影响.[J]中国心血管病研究杂志,2004,12(2):967-969.
[9]Myre K,Raeder J,Rostrup M,et al.Catecholamine release during laparoscopic fundoplication with high and low doses of remifentanil.[J].Acta Anaesthesiologica Scandinavia,2003,47(3):267-273.
[10]Unlugenc H,Itegin M,Ocal L,et al.Remifentanil Produces vasorelaxation in isolated rat thoracic aorta strips.[J].Acta Anaesthesiologica Scandinavia,2003,47(1):65-69.
[11]Servin,Frederique S.Remifentanil:an update[Drugs in anaesthesia].Current Opinion in Anaesthesiology,2003,16:367-372.
[12]Gemma,M,Tommasino C,Cozzi S,et al.Remifentanil provides hemodynamic stability and faster awakening time in Transsphenoidal Surgery.[Neurosurgical Anesthesia].Anesthesia & Analgesia,2002,94:163-168.
[13]庄心良,曾因明,陈伯銮,主编.现代麻醉学.第3版.北京:人民卫生出版社,2003,1702-1703.
[14]Weale,NK,Rogers CA,Cooper R.Effect of remifentanil infusion rate on stress response to the pre-bypass phase of paediatric cardiac surgery.BJA:British Journal of Anaesthesia,2004,92:187-194
[1]Beers R,Camporesi E.Remifentanil update:clinical science and utility.CNS Drugs,2004,18(15):1085.
[2]Cohen J,Royston D.Remifentanil.Curr Opin Crit Care,2001 Aug,7(4):227-31.
[3]Haigh CG.Drug development in anaesthesia:the remifentanil.Minerva Anestesiol,2000May,66(5):414.
[4]Egan,Talmage D.Pharmacokinetics and pharmacodynamics of remifentanil:an update in the year.2000[Review Article].eurrent Opinion in Anaesthesiology,2000,13(4):449-455.
[5]Tuncali B,Karci A,Bacakoglu A K,et al.Controlled Hypotension and Minimal Inflation Pressure:A New Approach for Pneumatic Tourniquet Application in Upper Limb Surgery.Anesthesia and Analgesia,2003,97(5):1529-1532.
[6]Adams,John MF,Charlton R Anaesthesia for microvascular free tissue transfer.BJA CEPD Reviews,2003,3(2):33-37.
[7]Christian S.Degoute MD,Marie J,et al.Remifentanil induces consistent and sustained controlled hypotension in children during middle ear surgery.CAN[J]ANESTH,2003,50(3):270-276.
[8]Degoute CS,Ray MJ,Manchon M,et al.Remifentanil and controlled hypotension;comparison with nitroprusside or esmolol during tympanoplasty.Can J Anaesth,2001,48(1):20.
[9]毛瑞芬,高秀江,周长浩等.不同剂量的瑞芬太尼对全身麻醉患者血流动力学的影响.[J]中国心血管病研究杂志,2004,12(2):967-969.
[10]Myre K,Raeder J,Rostrup M,et al.Catecholamine re-lease during laparoscopic fundoplication with high and low doses of remifentanil.[J].Acta Anaesthesiologica Scandinavia,2003,47(3):267-273.
[11]Unlugenc H,Itegin M,Ocal 1,et al.Remifentanil Pro-duces vasorelaxation in isolated rat thoracic aorta strips.[J].Acta Anaesthesiologica Scandinavia,2003,47(1):65-69.
[12]Servin,Frederique S.Remifentanil:an update[Drugs in anaesthesia].Current Opinion in Anaesthesiology,2003,16:367-372.
[13]Caverni V,Rosa G,Pinto,et al.Hypotensive Anesthesia and Recovery of Cognitive Function in Long-term Craniofacial Surgery[Clinical Notes].Journal of Craniofacial Surgery,2005,16(4):531-536.
[14]Dal D,Celiker V,Ozer E,et al.Induced hypotension for tympanoplasty:a comparison of desflurane,isoflurane and sevoflurane.Eur J Anaesthesiol,2004,21(11):902-6.
[15] Manola M, Deluca E, Moscillo L, et al. Using remifentanil and sufentanil in functional endoscopic sinus surgery to improve surgical conditions. ORL J Otorhinolaryngol Relat Spec, 2005, 67(2):83.
[16] Chillemi S, Sinardi D, Marino A, et al. The use of remifentanil for bloodless surgical field during vertebral disc resection. Minerva Anestesiol, 2002, 68 (9): 645.
[17] Gemma M, Tommasino C, Cozzi S ,et al. Remifentanil Provides Hemodynamic Stability and Faster Awakening Time in Transsphenoidal Surgery. [Neurosurgical Anesthesia]. Anesthesia & Analgesia, 2002, 94: 163-168.
[18] Weale NK, Rogers CA, Cooper R. Effect of remifentanil infusion rate on stress response to the pre-bypass phase of paediatric cardiac surgery. BJA: British Journal of Anaesthesia, 2004, 92: 187-194.
[2]Beers R,Camporesi E.Remifentanil update:clinical science and utility[J].CNS Drugs,2004,18(15):1085.
[3]Haigh CG..Drug development in anaesthesia:the remifentanil.Minerva Anestesiol,2000,66(5):414.
[4]Christian S,Marie J,Pierre.Y,et al.Remifentanil induces consistent and sustained controlled hypotension in children during middle ear surgery.CAN J ANESTH,2003,50(3):270-276.
[5]Degoute CS,Ray MJ,Manchon M,et al.Remifentanil and controlled hypotension;comparison with nitropmsside or esmolol during tympanoplasty.Can J Anaesth,2001,48(1):20.
[6]Cavemi V,Rosa G,Pinto P,et al.Hypotensive anesthesia and recovery of cognitive function in long-term craniofacial surgery[Clinical Notes].Journal of Craniofacial Surgery,2005,16(4):531-536.
[7]Dal D,Celiker V,Ozer E,et al.Induced hypotension for tympanoplasty:a comparison of desflurane,isoflurane and sevoflurane.Eur J Anaesthesiol,2004,21(11):902-6.
[8]毛瑞芬,高秀江,周长浩等.不同剂量的瑞芬太尼对全身麻醉患者血流动力学的影响.[J]中国心血管病研究杂志,2004,12(2):967-969.
[9]Myre K,Raeder J,Rostrup M,et al.Catecholamine release during laparoscopic fundoplication with high and low doses of remifentanil.[J].Acta Anaesthesiologica Scandinavia,2003,47(3):267-273.
[10]Unlugenc H,Itegin M,Ocal L,et al.Remifentanil Produces vasorelaxation in isolated rat thoracic aorta strips.[J].Acta Anaesthesiologica Scandinavia,2003,47(1):65-69.
[11]Servin,Frederique S.Remifentanil:an update[Drugs in anaesthesia].Current Opinion in Anaesthesiology,2003,16:367-372.
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