咪唑安定靶控输注与单次静注临床效果的比较
摘要
目的本研究旨在探讨静吸复合全麻中TCI靶控输注咪唑安定的使用效果,为临床合理应用咪唑安定提供科学依据。方法选择40例择期腹部手术全麻病人,随机分为两组,每组20例。T组(TCI组)诱导和维持采用TCI靶控输注咪唑安定;C组(对照组)诱导采用单次静注咪唑安定。T,C组均给予芬太尼,维库溴铵,C组再给予异丙酚依次诱导,术中用安氟醚和其他静脉药维持。常规监测心电图(ECG),心率(HR),收缩压(SBP),舒张压(DBP),脉搏血氧饱和度(SpO2),两组病人诱导前(T0),插管时(T1),手术开始时(T2),手术刺激最强时(T3),拔管时(T4)的SBP,DBP,HR,BIS,HRV,MAC,及两组病人术中麻醉的用药情况及总量,拔管时间,苏醒状态。所有测定数据均为均数±标准差( )表示,应用SPSS软件分析数据,结果采用t检验,p<0.05为有统计学意义。结果T组诱导开始后血压,心率略降,较基础值无明显差异,C组血压下降明显,其他各时间段内的变化无统计学差异。T,C组术中各个时间段内的BIS,HRV无统计学差异,但T组的MAC明显低于C组。T组术中用药少于C组。两组病人拔管时间无统计学差异,但C组有1/3患者出现躁动。结论使用TCI靶控输注咪唑安定,术中麻醉深度适宜,血流动力学平稳,麻醉药用量减少,且术毕苏醒过程平稳,无躁动。
Objective Midazolam is a kind of new BZ ramification withquicker effect,shorter T1/2 ,less bad reaction,wider safe range andless inhibition of circulation than other BZs.Single infusion ofmidazolam is commonly used for induction of general anesthesia.But we should increase the dosage of other anesthesic drugs tostablize the course of the operation and get the best effect ofanesthsia,which usually leads to recovery delay .In thisobservation,we try to discuss the clinical effect of midazolamadministered by target-controlled infusion in general anesthesia andexpect to get a more reasonable way in clinical use.
Method Forty ASA Ⅰ～Ⅱ patients ,scheduled for electiveabdominal surgery under general anesthesia were enrolled in thestudy ,and their ages were between 29～63 years,their weightswere limit to 20% fluctuation of their normal weights.They hadnormal function of heart,lung, liver and kidney. And the patientswere randomly allocated into two groups ( 20 in each group),groupT (midazolam was infused by TCI) and group C (midazolam wasinfused once). We monitored ECG,HR,BP,SPO2,BIS ( maintained40 ～ 60 ,observed by multi-monitor produced by Huaxiangscientific corp. Heilongjiang),HRV (total range 0.03Hz ～0.35Hz).We stick five ECG anodes on the patients'forehead and
cansus after degreasing by colors.HRV could be monitoredaccording to ECG.The patients were premedicated withintramuscular scopolamine 0.3 mg.Anesthesia of group T wasinduced with midazolam by TCI-I (produced by Silugaocorp.Beijing ) with the effect target concentration 300ng/ml andthe recovery concentration 100ng/ml until suture of abdominalwall,and anesthesia of group C was infused with midazolam withthe concentration of 0.1～0.15mg/kg .Group T and group Ccontinued to be induced with Fentanly 4 ug/kg,vecuronium 0.08～0.1mg/kg , propofol 1～2 mg/kg of group C ,then intubationcompleted . Datex -Ohmeda anesthesic device was connected formechanical respiration ,tidal volumn 10～15ml/kg , respiration rate12～15/min.Anesthesia was maintained with Enflurane and theother medicine according to BIS and HRV alteration. Observingitems: 1.In all the patients, ECG,HR,BP,SpO2 were monitored.2. SBP,DBP,HR,BIS,HRV,MAC were recorded at entering-room(T0), intubation (T1), beginning operation (T2),the strongest stressin the operation (T3),extubation (T4). 3.We monitored theconsumption of medicine. 4.We recorded the recovery time ofbreath and the tracheal extubation time and the state of thesepatients.The results were expressed with “ ”by SPSSware,statistic analysis was performed with T test to examineintergroup deviation. When p<0.05 it was considered statisticallysignificant. Results:All the patients in these groups had no
difference in basic information.BP and HR of group T had minordecrease and there was no significant deviation after induction.BPof group C decreased significantly but HR did not.There was nosignificant deviation for other times .BIS,HRV of these two groupshad no significant difference,but MAC had differences.Theconsumption of midazolam in group T was more than that in groupC but the intermittent time for additional Fentanyl was longer andthe dosage was less and the consumption of Enflurane was also lessthan that in group C .There was no significantly differencestatistically in the recovery time of breath and the trachealextubation time and state.The patients of group T were more stableduring recovery than group C.1/3 patients of group C came torestless.Conclusion Target-controlled infusion is one of intravenousinjection way which is automatically adjusted according toobjective or target concentration by computer connected toinjective pump so as to control or maintain anesthesiadepth .TCI,as a way for anesthesic drug iv. is not always controlledby computer.Anesthesian can adjust the target concentrationaccording to the clinic need to stablize the anesthesia.TCImidazolam is used to control target concentration to get the stableanesthesia depth by computer in general anesthesia and it candecrease the fluctuation of the respiration and circulation withchange of the concentration in blood. It is quick and stable to
induce by TCI midazolam according to effective concentration andit is convenience to be used by computer.The consumption of othermedicine can be decreased and the intermittent time of additionalFentanyl is extended by TCI midazolam.It can obviously decreaseMAC and there is no statistic difference in the recovery time andthe tracheal extubation time and state.
Objective Midazolam is a kind of new BZ ramification withquicker effect,shorter T1/2 ,less bad reaction,wider safe range andless inhibition of circulation than other BZs.Single infusion ofmidazolam is commonly used for induction of general anesthesia.But we should increase the dosage of other anesthesic drugs tostablize the course of the operation and get the best effect ofanesthsia,which usually leads to recovery delay .In thisobservation,we try to discuss the clinical effect of midazolamadministered by target-controlled infusion in general anesthesia andexpect to get a more reasonable way in clinical use.
Method Forty ASA Ⅰ～Ⅱ patients ,scheduled for electiveabdominal surgery under general anesthesia were enrolled in thestudy ,and their ages were between 29～63 years,their weightswere limit to 20% fluctuation of their normal weights.They hadnormal function of heart,lung, liver and kidney. And the patientswere randomly allocated into two groups ( 20 in each group),groupT (midazolam was infused by TCI) and group C (midazolam wasinfused once). We monitored ECG,HR,BP,SPO2,BIS ( maintained40 ～ 60 ,observed by multi-monitor produced by Huaxiangscientific corp. Heilongjiang),HRV (total range 0.03Hz ～0.35Hz).We stick five ECG anodes on the patients'forehead and
cansus after degreasing by colors.HRV could be monitoredaccording to ECG.The patients were premedicated withintramuscular scopolamine 0.3 mg.Anesthesia of group T wasinduced with midazolam by TCI-I (produced by Silugaocorp.Beijing ) with the effect target concentration 300ng/ml andthe recovery concentration 100ng/ml until suture of abdominalwall,and anesthesia of group C was infused with midazolam withthe concentration of 0.1～0.15mg/kg .Group T and group Ccontinued to be induced with Fentanly 4 ug/kg,vecuronium 0.08～0.1mg/kg , propofol 1～2 mg/kg of group C ,then intubationcompleted . Datex -Ohmeda anesthesic device was connected formechanical respiration ,tidal volumn 10～15ml/kg , respiration rate12～15/min.Anesthesia was maintained with Enflurane and theother medicine according to BIS and HRV alteration. Observingitems: 1.In all the patients, ECG,HR,BP,SpO2 were monitored.2. SBP,DBP,HR,BIS,HRV,MAC were recorded at entering-room(T0), intubation (T1), beginning operation (T2),the strongest stressin the operation (T3),extubation (T4). 3.We monitored theconsumption of medicine. 4.We recorded the recovery time ofbreath and the tracheal extubation time and the state of thesepatients.The results were expressed with “ ”by SPSSware,statistic analysis was performed with T test to examineintergroup deviation. When p<0.05 it was considered statisticallysignificant. Results:All the patients in these groups had no
difference in basic information.BP and HR of group T had minordecrease and there was no significant deviation after induction.BPof group C decreased significantly but HR did not.There was nosignificant deviation for other times .BIS,HRV of these two groupshad no significant difference,but MAC had differences.Theconsumption of midazolam in group T was more than that in groupC but the intermittent time for additional Fentanyl was longer andthe dosage was less and the consumption of Enflurane was also lessthan that in group C .There was no significantly differencestatistically in the recovery time of breath and the trachealextubation time and state.The patients of group T were more stableduring recovery than group C.1/3 patients of group C came torestless.Conclusion Target-controlled infusion is one of intravenousinjection way which is automatically adjusted according toobjective or target concentration by computer connected toinjective pump so as to control or maintain anesthesiadepth .TCI,as a way for anesthesic drug iv. is not always controlledby computer.Anesthesian can adjust the target concentrationaccording to the clinic need to stablize the anesthesia.TCImidazolam is used to control target concentration to get the stableanesthesia depth by computer in general anesthesia and it candecrease the fluctuation of the respiration and circulation withchange of the concentration in blood. It is quick and stable to
induce by TCI midazolam according to effective concentration andit is convenience to be used by computer.The consumption of othermedicine can be decreased and the intermittent time of additionalFentanyl is extended by TCI midazolam.It can obviously decreaseMAC and there is no statistic difference in the recovery time andthe tracheal extubation time and state.
引文
(1)Reves JG, Fragen RJ , Ronald Vinik H , et al . Midazolam: pharmacology and uses. Anesthesilogy , 1985 ,62 (3) ∶310
(2)吴新民.咪唑安定的临床应用.中华麻醉学志,1998 ,18(7) ∶387
(3)Samuelson PN , Reves JG, Kouchoukos NT , et al . Hemodynamic responses to anesthetic induction with midazolam or diazepam in patients with ischemic heart disease. Anesth Analg , 1981 ,60 (9) ∶802
(4)朱斌,叶铁虎.靶控输注的临床应用研究进展《.国外医学》,2003,24(1):6～9
(5)刘芳,魏建西,李俊峡等. 正常人群的心率变异性 .中华心血管病杂志,1995 ,23 (1) :425.
(6)Leslie K, Sessier D , Smith WD ,et al. Prediction of movement during propofol/ nitrous oxide anesthesia. Anesthesiology , 1996 ,84∶52～63.
(7)类维富,吴奇.靶控输注静脉麻醉及闭环反馈吸入麻醉《.黑龙江医学》,2003,27(10):726～729
(8)郑斯聚.咪唑安定临床研究进展.国外医学麻醉与复苏分册,1989 ,10 (2) ∶104
(9)Alexander CM, Gross JB. Sedative doses of midazolam depress hypoxic ventilatory responses in human. Anesth Analg , 1988 ,67(4) ∶377
(10)Kearse LA ,Manberg P ,Chamoun N ,et al. Bispectral analysis of the electroencephalogram correlates with patients movement to skin incision during propofol/ nitrous oxide anesthesia. Anesthesiology ,1994 ,81∶1365～1370.
(11)Chernik DA, GillingsD,Laine H, et al. Validity and reliability of the Observer's Assessment of Alertness/ Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol, 1990, 10 (4) : 244
(12)程华春. 心率、心率变异性与麻醉.国外医学·麻醉学与复苏分册, 2001, 22 (2) : 70
(13)Kato M, Komatsu T, Kimura T, et al. Spectral analysis of heart rate variability during isoflurane anesthesia. Anesthesiology, 1992, 77 (4) : 669
(14)江学成.靶控输注麻醉的限制.《临床麻醉学杂志》,2004,20(3):190～191
(15)Buylaert WA. Pharmacology in critical illness. Verh K Acad Geneeskd Belg ,2001 ,63 :475～480.
(2)吴新民.咪唑安定的临床应用.中华麻醉学志,1998 ,18(7) ∶387
(3)Samuelson PN , Reves JG, Kouchoukos NT , et al . Hemodynamic responses to anesthetic induction with midazolam or diazepam in patients with ischemic heart disease. Anesth Analg , 1981 ,60 (9) ∶802
(4)朱斌,叶铁虎.靶控输注的临床应用研究进展《.国外医学》,2003,24(1):6～9
(5)刘芳,魏建西,李俊峡等. 正常人群的心率变异性 .中华心血管病杂志,1995 ,23 (1) :425.
(6)Leslie K, Sessier D , Smith WD ,et al. Prediction of movement during propofol/ nitrous oxide anesthesia. Anesthesiology , 1996 ,84∶52～63.
(7)类维富,吴奇.靶控输注静脉麻醉及闭环反馈吸入麻醉《.黑龙江医学》,2003,27(10):726～729
(8)郑斯聚.咪唑安定临床研究进展.国外医学麻醉与复苏分册,1989 ,10 (2) ∶104
(9)Alexander CM, Gross JB. Sedative doses of midazolam depress hypoxic ventilatory responses in human. Anesth Analg , 1988 ,67(4) ∶377
(10)Kearse LA ,Manberg P ,Chamoun N ,et al. Bispectral analysis of the electroencephalogram correlates with patients movement to skin incision during propofol/ nitrous oxide anesthesia. Anesthesiology ,1994 ,81∶1365～1370.
(11)Chernik DA, GillingsD,Laine H, et al. Validity and reliability of the Observer's Assessment of Alertness/ Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol, 1990, 10 (4) : 244
(12)程华春. 心率、心率变异性与麻醉.国外医学·麻醉学与复苏分册, 2001, 22 (2) : 70
(13)Kato M, Komatsu T, Kimura T, et al. Spectral analysis of heart rate variability during isoflurane anesthesia. Anesthesiology, 1992, 77 (4) : 669
(14)江学成.靶控输注麻醉的限制.《临床麻醉学杂志》,2004,20(3):190～191
(15)Buylaert WA. Pharmacology in critical illness. Verh K Acad Geneeskd Belg ,2001 ,63 :475～480.