丙泊酚雷米芬太尼靶控输注麻醉对腹腔镜胆囊切除术的影响
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摘要
目的
观察在腹腔镜胆囊切除术(Laparoscopic cholecystectomy，LC)中应用靶控输注(Target-controlled influsion，TCI)丙泊酚和雷米芬太尼对呼吸、循环、血清皮质醇(cortisol,COR)、白细胞介素-6(Interleukin-6，IL-6)、恶心呕吐发生率的影响，并评价脑电双频指数(Bispectral index BIS)在麻醉监测中的意义。
方法
一、一般资料
择期行腹腔镜胆囊切除术的患者60例，ASAⅠ-Ⅱ，年龄20-60岁，体重指数(BMI)<25kg/m~2。排除患有心肺疾病史和其他重要系统疾病史的患者。
二、分组
所有病例随机分为两组：(P组)靶控输注丙泊酚和雷米芬太尼全凭静脉麻醉组30例，行靶控诱导和维持；(Ⅰ组)常规麻醉诱导术中复合吸入维持组30例。术中通过调节异氟烷吸入浓度或丙泊酚和雷米芬太尼靶控浓度，使麻醉期间BIS值维持在45±5之间，MAP和HR波动在基础值的±20％范围内。两组均以维库溴铵术中间断静注维持肌松。
三、观察指标
(1)MAP、HR：观察并记录入室静卧10 min(T_0基础值)、气腹开始(T_1)、气腹后5min(T_2)、气腹后10men(T_3)、15min(T_4)、20 min(T_5)、气腹停止时(T_6)各时点的监测值：
(2)P_(ET)CO_2、MV、PIP：观察并记录T_1、T_2、T_3、T_4、T_5、T_6各时点的监测值
(3)脑电双频指数(BIS)：观察并记录T_1、T_2、T_3、T_4、T_5、T_6各时点的监测值
(4)术中知晓调查：手术结束后及术后8-12小时询问麻醉后有无不良感受和记忆。
(5)术后24小时恶心呕吐发生率评定。
(6)测定入室后10min(t_1)及气腹20min(t_2)时点血清皮质醇(COR)、白细胞介素-6(IL-6)水平。
四、统计分析
计量资料以均数±标准差((?)±S)表示，使用SPSS11.0软件系统进行统计学处理。组内行配对t检验，组问行单因素方差分析，率的检验采用Ridit分析。P<0.05认为差别具有显著性意义。
结果
1、对呼吸循环功能影响的比较
与T_i比较气腹后P组及Ⅰ组T_2-T_5时点PIP均明显升高，T_3-T_6时点P_(ET)CO_2明显升高而MV在T_2-T_5时点则明显降低(P<0.05)；组间比较未见明显差异(P>0.05)。T_1-T_6时点的MAP HR与T_0比较，P组无显著性差异(P>0.05)，Ⅰ组MAPT_2-T_5时点与T_0比较，则有显著性差异(P<0.05)；T_2-T_5时点P组较Ⅰ组有显著性差异(P<0.05)。
2、血清COR IL-6水平
P组t_2时点COR和IL-6较t_1时点无明显差异(P>0.05)，Ⅰ组t_2时点COR和IL-6较t_1时点明显升高(P<0.05)；组间比较，t_2时点P组明显低于Ⅰ组，有明显统计学差异(P<0.05)，t_1点两组无明显差异(P>0.05)。
3、BIS
T_1-T_6时点两组内、组间无显著性差异(P>0.05)。
4、术中知晓调查
手术结束后及术后8-12小时询问患者，麻醉后和术中均无不良感受和知晓。
5、术后24小时恶心呕吐发生率评定
P组PONV发生率明显少于Ⅰ组(P<0.05)。
结论
1、丙泊酚和雷米芬太尼靶控输注全凭静脉麻醉下，可以有效地抑制腹腔镜胆囊切除术引起的应激反应，维持血流动力学的相对稳定。
2、在监测血流动力学的同时联合应用BIS可以更好地反映麻醉过程中麻醉深度的动态变化，预防术中知晓和麻醉过深。
3、腹腔镜胆囊切除术采用丙泊酚和雷米芬太尼靶控输注全凭静脉麻醉较吸入麻醉比较明显减少术后恶心呕吐的发生。
To observe the effect of two anesthesitic methods of propofol and remifentanyltarget-controlled influsion ( TCI ) or isoflurane and nitrous oxide inhalation onthe function of respiratory, circulation systems, airway pressure, nausea, vomitting, thelevel of cortisol (COR) & Interleukin-6 (IL-6) during laparoscopic cholecystectomy( LC ) , meanwhlie to evaluate the Bispectral index (BIS) under the monitoring ofgeneral anesthesia.Methods
1、General materialsSixity ASAⅠ-Ⅱpatients for elective LC were randomly divided into twogroups.Their age range is 40-60, body weight index〈25kg/m~2,all excluded respiratory、circulation and other system diseases.
2、Grouping
The patients were randomly allocated to two groups.Group P ( n=30 ) : thepatients were intubated after induced and maintained through Total intravenousanesthesia (TIVA) with propofol and remifentany TCI.Group I ( n=30 ) : the patientswere intubated after induced and maintained with inhalation intubation of isofluraneand nitrous oxide, adjust the concentration of isoflurane inhalation or propofol andremifentany TCI to control the MAP、HR within the range of±20% the basiclevels.Intravenous injecting vecuronium interruptedly so as to maintain musclerelaxation. Anesthetics of all patients of two group after operation would be stopped.
3、Targets observed
Blood samples were taken and recorded targets and BIS at six time points :10minafter patients entered the operation room(baseline) (T0) , starting aeroperitoneum (T1)、 5(T2)、10(T3)、15(T4)、20min(T5) during the pneumoperitoneum and immediately afterthe pneumoperitoneum (T6) . Targets observed were as followings.(1) record MAP andHR.at patients entering romm(T0) , starting aeroperitoneum (T1) , afteraeroperitoneum5min (T2) ,10(T3) , 15(T4) , 20min(T5) and release gas (T6) (2) PETCO2,Mv and PIP at starting aeroperitoneum (T1) , after aeroperitoneum5min(T2) ,10(T3) , 15(T4) , 20min(T5) and release gas (T6) respectively. (3) Bispectral index(BIS). (4) awareness. (5) Incidence of the postoperative nausea, vomiting(PONV)at 24 hafter the operation. (6) level of cortisol (COR) & Interleukin-6 (IL-6) at 10min patientsentered and after 20min of aeroperitoneum.
4、Statistical analysis
SPSS 11．0 software was used to analysize all quantitative data. Mean±standarddeviation indicated quantitative data,and use t-test to analyse. P<0．05 were consideredsignificant difference.Results
1 Comparision of the effect to the function of of respiratory &circulatory system.
PIP significantly enhanced at T2-T5 and PETCO2 significantly enhanced atT3-T6 both Group P and group I (P<0．05) .but MV significantly decreased afteraeroperitoneum at T2-T5 both Group P and group I (P<0．05) . PETCO2、PIP and MVwere not significant diffenence at any time between the two groups (P>0．05) , but MVwas not different obviously(P>0．05) .MAP and/or HR at T1-T6 afterpneumoperitoneum was no diffenent in group P (P>0．05) but significant different ingroup I(P<0．05) at T2-T5 in comparison with T0．
2 The level of COR and IL-6
There was no significant diffence between at t2 and t1 in group P (P>0．05) butsignificant diffence in group I(P<0．05) .
3 Bispectral index BIS
There are no significant diffence at T_1-T_6 between the two group and nosignificant differece within each group(P>0．05) .
4 awareness
No awareness occurred 8-12hr after operation.
5 The incidence of the postoperative nausea and vomitiing(PONV)
The incidence and the severity of the PONV was significantly less in Group P thanin Group I (P<0．05) .Conclusions
1 The anaesthesia through TIVA with propofol and remifentany TCI caneffectively suppress the effect of of stress leaded by operation and pneumoperitoneumin laparoscopic cholecystectomy and maintained the stabilization of hemodynamicsand respiratory,which is better than inhalational anesthesia
2 Hemodynamics monitoring associated BIS can provide us a morecomprehensive the depth of anesthesia,thus we can regulate the dosage of anesthetics inthe aim of avoiding awareness or extremely deep anesthesia.
3 The anaesthesia through TIVA with propofol and remifentany TCI can reducethe incidence and the severity of the postoperative nausea and vomiting moreeffectively than inhalational anesthesia.
观察在腹腔镜胆囊切除术(Laparoscopic cholecystectomy，LC)中应用靶控输注(Target-controlled influsion，TCI)丙泊酚和雷米芬太尼对呼吸、循环、血清皮质醇(cortisol,COR)、白细胞介素-6(Interleukin-6，IL-6)、恶心呕吐发生率的影响，并评价脑电双频指数(Bispectral index BIS)在麻醉监测中的意义。
方法
一、一般资料
择期行腹腔镜胆囊切除术的患者60例，ASAⅠ-Ⅱ，年龄20-60岁，体重指数(BMI)<25kg/m~2。排除患有心肺疾病史和其他重要系统疾病史的患者。
二、分组
所有病例随机分为两组：(P组)靶控输注丙泊酚和雷米芬太尼全凭静脉麻醉组30例，行靶控诱导和维持；(Ⅰ组)常规麻醉诱导术中复合吸入维持组30例。术中通过调节异氟烷吸入浓度或丙泊酚和雷米芬太尼靶控浓度，使麻醉期间BIS值维持在45±5之间，MAP和HR波动在基础值的±20％范围内。两组均以维库溴铵术中间断静注维持肌松。
三、观察指标
(1)MAP、HR：观察并记录入室静卧10 min(T_0基础值)、气腹开始(T_1)、气腹后5min(T_2)、气腹后10men(T_3)、15min(T_4)、20 min(T_5)、气腹停止时(T_6)各时点的监测值：
(2)P_(ET)CO_2、MV、PIP：观察并记录T_1、T_2、T_3、T_4、T_5、T_6各时点的监测值
(3)脑电双频指数(BIS)：观察并记录T_1、T_2、T_3、T_4、T_5、T_6各时点的监测值
(4)术中知晓调查：手术结束后及术后8-12小时询问麻醉后有无不良感受和记忆。
(5)术后24小时恶心呕吐发生率评定。
(6)测定入室后10min(t_1)及气腹20min(t_2)时点血清皮质醇(COR)、白细胞介素-6(IL-6)水平。
四、统计分析
计量资料以均数±标准差((?)±S)表示，使用SPSS11.0软件系统进行统计学处理。组内行配对t检验，组问行单因素方差分析，率的检验采用Ridit分析。P<0.05认为差别具有显著性意义。
结果
1、对呼吸循环功能影响的比较
与T_i比较气腹后P组及Ⅰ组T_2-T_5时点PIP均明显升高，T_3-T_6时点P_(ET)CO_2明显升高而MV在T_2-T_5时点则明显降低(P<0.05)；组间比较未见明显差异(P>0.05)。T_1-T_6时点的MAP HR与T_0比较，P组无显著性差异(P>0.05)，Ⅰ组MAPT_2-T_5时点与T_0比较，则有显著性差异(P<0.05)；T_2-T_5时点P组较Ⅰ组有显著性差异(P<0.05)。
2、血清COR IL-6水平
P组t_2时点COR和IL-6较t_1时点无明显差异(P>0.05)，Ⅰ组t_2时点COR和IL-6较t_1时点明显升高(P<0.05)；组间比较，t_2时点P组明显低于Ⅰ组，有明显统计学差异(P<0.05)，t_1点两组无明显差异(P>0.05)。
3、BIS
T_1-T_6时点两组内、组间无显著性差异(P>0.05)。
4、术中知晓调查
手术结束后及术后8-12小时询问患者，麻醉后和术中均无不良感受和知晓。
5、术后24小时恶心呕吐发生率评定
P组PONV发生率明显少于Ⅰ组(P<0.05)。
结论
1、丙泊酚和雷米芬太尼靶控输注全凭静脉麻醉下，可以有效地抑制腹腔镜胆囊切除术引起的应激反应，维持血流动力学的相对稳定。
2、在监测血流动力学的同时联合应用BIS可以更好地反映麻醉过程中麻醉深度的动态变化，预防术中知晓和麻醉过深。
3、腹腔镜胆囊切除术采用丙泊酚和雷米芬太尼靶控输注全凭静脉麻醉较吸入麻醉比较明显减少术后恶心呕吐的发生。
To observe the effect of two anesthesitic methods of propofol and remifentanyltarget-controlled influsion ( TCI ) or isoflurane and nitrous oxide inhalation onthe function of respiratory, circulation systems, airway pressure, nausea, vomitting, thelevel of cortisol (COR) & Interleukin-6 (IL-6) during laparoscopic cholecystectomy( LC ) , meanwhlie to evaluate the Bispectral index (BIS) under the monitoring ofgeneral anesthesia.Methods
1、General materialsSixity ASAⅠ-Ⅱpatients for elective LC were randomly divided into twogroups.Their age range is 40-60, body weight index〈25kg/m~2,all excluded respiratory、circulation and other system diseases.
2、Grouping
The patients were randomly allocated to two groups.Group P ( n=30 ) : thepatients were intubated after induced and maintained through Total intravenousanesthesia (TIVA) with propofol and remifentany TCI.Group I ( n=30 ) : the patientswere intubated after induced and maintained with inhalation intubation of isofluraneand nitrous oxide, adjust the concentration of isoflurane inhalation or propofol andremifentany TCI to control the MAP、HR within the range of±20% the basiclevels.Intravenous injecting vecuronium interruptedly so as to maintain musclerelaxation. Anesthetics of all patients of two group after operation would be stopped.
3、Targets observed
Blood samples were taken and recorded targets and BIS at six time points :10minafter patients entered the operation room(baseline) (T0) , starting aeroperitoneum (T1)、 5(T2)、10(T3)、15(T4)、20min(T5) during the pneumoperitoneum and immediately afterthe pneumoperitoneum (T6) . Targets observed were as followings.(1) record MAP andHR.at patients entering romm(T0) , starting aeroperitoneum (T1) , afteraeroperitoneum5min (T2) ,10(T3) , 15(T4) , 20min(T5) and release gas (T6) (2) PETCO2,Mv and PIP at starting aeroperitoneum (T1) , after aeroperitoneum5min(T2) ,10(T3) , 15(T4) , 20min(T5) and release gas (T6) respectively. (3) Bispectral index(BIS). (4) awareness. (5) Incidence of the postoperative nausea, vomiting(PONV)at 24 hafter the operation. (6) level of cortisol (COR) & Interleukin-6 (IL-6) at 10min patientsentered and after 20min of aeroperitoneum.
4、Statistical analysis
SPSS 11．0 software was used to analysize all quantitative data. Mean±standarddeviation indicated quantitative data,and use t-test to analyse. P<0．05 were consideredsignificant difference.Results
1 Comparision of the effect to the function of of respiratory &circulatory system.
PIP significantly enhanced at T2-T5 and PETCO2 significantly enhanced atT3-T6 both Group P and group I (P<0．05) .but MV significantly decreased afteraeroperitoneum at T2-T5 both Group P and group I (P<0．05) . PETCO2、PIP and MVwere not significant diffenence at any time between the two groups (P>0．05) , but MVwas not different obviously(P>0．05) .MAP and/or HR at T1-T6 afterpneumoperitoneum was no diffenent in group P (P>0．05) but significant different ingroup I(P<0．05) at T2-T5 in comparison with T0．
2 The level of COR and IL-6
There was no significant diffence between at t2 and t1 in group P (P>0．05) butsignificant diffence in group I(P<0．05) .
3 Bispectral index BIS
There are no significant diffence at T_1-T_6 between the two group and nosignificant differece within each group(P>0．05) .
4 awareness
No awareness occurred 8-12hr after operation.
5 The incidence of the postoperative nausea and vomitiing(PONV)
The incidence and the severity of the PONV was significantly less in Group P thanin Group I (P<0．05) .Conclusions
1 The anaesthesia through TIVA with propofol and remifentany TCI caneffectively suppress the effect of of stress leaded by operation and pneumoperitoneumin laparoscopic cholecystectomy and maintained the stabilization of hemodynamicsand respiratory,which is better than inhalational anesthesia
2 Hemodynamics monitoring associated BIS can provide us a morecomprehensive the depth of anesthesia,thus we can regulate the dosage of anesthetics inthe aim of avoiding awareness or extremely deep anesthesia.
3 The anaesthesia through TIVA with propofol and remifentany TCI can reducethe incidence and the severity of the postoperative nausea and vomiting moreeffectively than inhalational anesthesia.
引文
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31 Gehring H,Kuhamann K,Klotz KF, et al.Effects of propofol VS isoflurane on respiratory gas exchange during laparoscopic cholecystectomy.Acta Anesthesol Scand, 1998,42:189-194.
32 Fombeur PO,Tilleul PR,Beaussier MI,et al.Cost-effectiveness of propofol anesthesia using TCI with a standard regimen using desflurane.Am J Health Syst Pham,2002,59:1344-1350.
33 Borgeat A,Wilder S,Saiah M,et al.Subhypnotic doses of propofol possess direct antiemetic properties.Anesth Analg, 1992,74:539-543.
34 Gan TJ, El-Molem H, Ray J,et al. Patient-controlled antiemesis: a randomized, double-blind comparison of two doses of propofol versus placebo. Anesthesiology, 1999,90:1564-1570.
35 Apfel CC,Roewer N.postoperative nausea and vomiting.Anaes-thesist,2004,53: 377-389.
36 Borgeat A,Wilder S,Saiah M,et al.Subhypnotic doses of propofol possess direct antiemetic properties.Anesth Analg, 1992,74:539-543.
37 Barann M,Gothert M,Fink K,et al.Inhibition by anesthetics of Guanidinium flure through the voltage gated sodium channel and the cation channel of the 5-HT3 receptor of NIE 115 neuroblastoma cells.Naunyn Schmiedebergs Arch pharmacol, 1993,347:125-129.
38 Lerman J,Eustis S,Smith DR.. Effect of droperidol pretreatment on postanesthetic vomiting in children undergoing strabismus surgery. Anesthesiology,1986,65:322-325.
39 Hirose T,Inoue M,Uchida M, et al. Enflurane-induced release of an excitatory amino acid, glutamate, from mouse brain synaptosomes.Anesthesiology, 1992,77:109-113.
40 Collins GGEffects of the anaesthetic2,6-diisopropylphenol on synaptic transmission in the rat olfactory cortex slice.Br J Pharmacol, 1988,95:939-949.
1 万里，张传汉，张旭，等．泌尿外科腹腔镜手术对全麻患者呼吸和循环的影响．中华实验外科杂志，2002，19：479-480．
2 Halachmi S,E12Ghoneimi A,Bissonnette B,et al.Hemodynamic and respiratory effect of pediatric urological laparoscopic surgery:a retrospective study Urol,2003,170:1651-1652.
3 Schauer PR,Luna J,Ghiatas A,et al.Pulmonary function after laparoscopic cholecystectomy Surgery, 1993,114:389-389.
4 Sharma KC, Brandstetter RD, Brensilver JM,et al.Cardiopulmonary physiology and pathophysiogy as a consequence of laparoscopic surgery. Chest, 1996,110:810-810.
5 时吉庆，刘长安，龚建平．腹腔镜手术对机体应激和代谢反应的影响．临床外科杂志，2003，1：49-50．
6 姚常柏，张丽红，王小宁．异丙酚对腹腔镜气腹应激反应的影响．中国综合临床，2005，7：627-629．
7 Legakis IN,Golematis BC,Dourakis N,et al.Low T_3 syndrome with asynchronous changes of TT_3 and rT_3 values in laparo2scopic.Chececyslectamy Endocr Res, 1998, 24:205-213.
8 李金龙，陈勇，李荣祥，等．腹腔镜及大小胆囊切除术创伤反应对比研究．肝胆胰外科杂志，2001，13：18-20．
9 Servin F.TCI compared with manually controlled of propofol:a multicentye study.Anesthesia, 1998,53:82-86.
10 Hugcc Jr, McLeskey CH, Nahrwold ML,et al.Hemodynamic effects of propofol: data from over 25,000 patients, 1993,77:21-29.
11 吴安石．异丙酚在心脏手术中的应用．国外医学麻醉学与复苏分册，1996，17：224-227．
12 Bernard JM, Wouters PF, Doursout MF,et al. Effects of sevoflurane and isoflurane on cardiac and coronary dynamics in chronically instramented dogs. Anesthesiology, 1990,72:659-662.
13 彭德民，王彩霞，姚立农．异丙酚TCI在妇科腹腔镜手术中应用．第四军医大学学报，2005，26：1193．
14 Glass PS,Gan TJ, Howell S. A review of the pharmacokinetics and pharmaco-dynamics of remifentanil.Anesth Analg, 1999, 89:272-274.
15 曹慎健．艾司洛尔的临床应用．新药与临床，1989，8：152-54．
16 Johannsen EK,Munro AJ.Remifentanil in emergency caesarean section in pre2eclampsia complicated by thrombocytopenia and abnormalliverfunction. Anesth Intensive Care, 1999,27:527-529.
17 Glass PSA,Gan TJ,Howell S. A review of the pharmacokinetics and pharmacodynamics of remifentanil. Anesth Analg, 1999,89:97-114.
18 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．中国心血管病杂志，2004，12：967-969．
19 耿志宇，许幸，吴新民．瑞芬太尼复合异丙酚靶控输注诱导时的量效关系．中华麻醉学杂志，2004，4：260-263．
20 Mertens MJ,Olofsen E,Engbers FH,et al.Propofol reduces periopera2tive remifentanil requirements in a synergistic manner:response surfacemodeling of pe propofol interactions. Anesthesiol2ogy,2003,99:347.
21 黄安宁，陈娜．瑞芬太尼复合异丙酚全静脉麻醉用于腹腔镜胆囊切除术的临床研究．武警医学，2005，2：105-108．
22 曹小平，陈兵，张玉龙，等．瑞芬太尼—异丙酚全凭静脉麻醉用于腹腔镜胆囊切除术的临床研究．四川医学，2005，2：175-176．
2 李临海，陈训如．CO_2气腹对神经系统的影响．国外医学外科学分册，2002，29：288-289．
3 晋云，陈训如．二氧化碳气腹对呼吸循环影响研究的新近展．解放军医学杂志，2002，27：647-648．
4 Path G, Scherbaum WA,Bomstein SR.The role of interleukin-6 in the human adrenal gland.Eur J Clin Invest,2000,30:91-95.
5 Leshek, Sessler DI,Schroeder M,Walters K.Propofol blood concentration and the bispectral index predict suppression of learning during propofol/epidural anesthesia in volunteers.Anesth Analg,1995,81:1269-1274.
6 Iselin-chaves IA,Flaishon R,Sebel PS,et al.The effect of the interaction ofpropofol and alfentanil on recall,loos of consciousness,and the bispec-tral index.Anasth Analg, 1998,87:949-955.
7 Hail JD,Lochwood GG.Bispectral index comparison of two montages.Br Anaesth, 1998, 80:342.
8 GEPTSE.PharmacokineticsconceptsforTCIanaesthesia.Anaesthesia, 1998,53:4-12.
9 庄心良，曾因明，陈伯銮．现代麻醉学．第3版．北京：人民卫生出版社．2003，1362-1363．
10 王晓宁，张丽红．丙泊酚与异氟醚对腹腔镜胆囊切除术患者的镇吐作用．中华麻醉学杂志，2005，25：76-77．
11 Okota S.Interleukin 6 as a therapeutic targetin systemic-set juvenile idiopathic arthritis.Curr opin Rheumato,2003,15:581-586.
12 Dcee VA.Propofol nitrous oxide versus thiopental isofiurance nitrous oxide for general anesthasia.Anesthasiology, 1998,69:63-68.
13 Roman Y, Alfonso A,Louzao MC,et al.Confocal microscopy study of the different patterns of 2-NBDG uptake in rabbit enterocytes in the apical and basal zone.Pflugers Arch,2001,443:234-239.
14 Milne SE,Kenny GNC,Schraag S.propofol sparing effect of remifentanil using closed-loop anaesthesia.Br J Anaesth,2003,90:623-629.
15 耿志宇，许幸，等．雷米芬太尼复合丙泊酚靶控输注诱导时的量效关系．中华麻醉学杂志，2004，24：260-263．
16 吴群，韩宇．靶控输注丙泊酚与吸入异氟烷麻醉在腹腔镜胆囊切除术中的效果．肝胆胰外科杂志，2004，16：103-105．
17 张光金，潘雷达，陆青，等．手术前后检测L-6的临床意义．上海免疫杂志，1997，17：177-178．
18 Path G, Scherbaum WA,Bomstein in SR.The role of interleukin-6 in the huma adremal gland.Eur J Clin Invest,2000,30:91-95.
19 Plunkett JJ,Reeves JD,Ngo L,et al. Urine and plasma catecholamine and concentration after myocardial revascularization modulation by continuous sedation.Anesthesiology, 1997,86:785-796.
20 李晶，吴忠，张梅，等．类风湿关节炎患者白细胞介素-6与皮质醇节律的研究．中华风湿病学杂志，2002，6：252-254．
21 Kristansson M,Saraste L,Soop M,et al. Dininished interleukin-6 and C-reactive protein response to laparoscopic versus open cholecystectomy.Acta Anesthesiol Stand, 1999,43:146-152.
22 Bone RC.Toward a theory regarding the pathogenesis of the systemic inflammatory response syndrome;whatwe do and do not know about cytokine regulation.Crit Care Med, 1996,24:163-172.
23 夏江燕，景亮．麻醉深度监测技术及其临床应用．东南大学学报(医学版)，2003，10：421-424．
24 Andra E,Julie K,et al. Bispectral index monitoring during Sedation with sevoflurane,Mifazolam,and propofol. Anesthesiology,2001,95:1151-1159.
25 GlassS,Bloom Marc,Lee Kearse,et al.Bispectral analysismeasures sedation and memory effects of propofol, midazofane.Anaesthesia, 1997,86:836-847.
26 HansP.Effect epidural hupivacaine on the relationship between the bispectral index and end-expiratory concentrations of deflurane.Anaesthesia, 1999,54:899-902.
27 Nard B, Meniguax C, Dupont X,et al. The effect of remifentanil on the bispectral index change and hemodynamic responses after orotracheal intubation. Anesth Analg,2000,90:161-167.
28 Chan AN, Edwards ND. Randomized placebo-controlled trial to assess the effect of remifentanil and propofol on bispectral index and sedation. BrJ Anaesth, 2000,84: 489-490.
29 Thune A,Appelgren,Haglind E.Prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy. A prospective randomised study of metoclopramidc and transdermal hyoscine.Eur J Surgery, 1995,161:265-268.
30 Kim SI,Ham TH, Kil HY, et al.Prevention of postoperative nausea and vomiting by continuous in female receiving intravenous patientcontrolled analgesia.Br J Anesth,2000,85:898-900.
31 Gehring H,Kuhamann K,Klotz KF, et al.Effects of propofol VS isoflurane on respiratory gas exchange during laparoscopic cholecystectomy.Acta Anesthesol Scand, 1998,42:189-194.
32 Fombeur PO,Tilleul PR,Beaussier MI,et al.Cost-effectiveness of propofol anesthesia using TCI with a standard regimen using desflurane.Am J Health Syst Pham,2002,59:1344-1350.
33 Borgeat A,Wilder S,Saiah M,et al.Subhypnotic doses of propofol possess direct antiemetic properties.Anesth Analg, 1992,74:539-543.
34 Gan TJ, El-Molem H, Ray J,et al. Patient-controlled antiemesis: a randomized, double-blind comparison of two doses of propofol versus placebo. Anesthesiology, 1999,90:1564-1570.
35 Apfel CC,Roewer N.postoperative nausea and vomiting.Anaes-thesist,2004,53: 377-389.
36 Borgeat A,Wilder S,Saiah M,et al.Subhypnotic doses of propofol possess direct antiemetic properties.Anesth Analg, 1992,74:539-543.
37 Barann M,Gothert M,Fink K,et al.Inhibition by anesthetics of Guanidinium flure through the voltage gated sodium channel and the cation channel of the 5-HT3 receptor of NIE 115 neuroblastoma cells.Naunyn Schmiedebergs Arch pharmacol, 1993,347:125-129.
38 Lerman J,Eustis S,Smith DR.. Effect of droperidol pretreatment on postanesthetic vomiting in children undergoing strabismus surgery. Anesthesiology,1986,65:322-325.
39 Hirose T,Inoue M,Uchida M, et al. Enflurane-induced release of an excitatory amino acid, glutamate, from mouse brain synaptosomes.Anesthesiology, 1992,77:109-113.
40 Collins GGEffects of the anaesthetic2,6-diisopropylphenol on synaptic transmission in the rat olfactory cortex slice.Br J Pharmacol, 1988,95:939-949.
1 万里，张传汉，张旭，等．泌尿外科腹腔镜手术对全麻患者呼吸和循环的影响．中华实验外科杂志，2002，19：479-480．
2 Halachmi S,E12Ghoneimi A,Bissonnette B,et al.Hemodynamic and respiratory effect of pediatric urological laparoscopic surgery:a retrospective study Urol,2003,170:1651-1652.
3 Schauer PR,Luna J,Ghiatas A,et al.Pulmonary function after laparoscopic cholecystectomy Surgery, 1993,114:389-389.
4 Sharma KC, Brandstetter RD, Brensilver JM,et al.Cardiopulmonary physiology and pathophysiogy as a consequence of laparoscopic surgery. Chest, 1996,110:810-810.
5 时吉庆，刘长安，龚建平．腹腔镜手术对机体应激和代谢反应的影响．临床外科杂志，2003，1：49-50．
6 姚常柏，张丽红，王小宁．异丙酚对腹腔镜气腹应激反应的影响．中国综合临床，2005，7：627-629．
7 Legakis IN,Golematis BC,Dourakis N,et al.Low T_3 syndrome with asynchronous changes of TT_3 and rT_3 values in laparo2scopic.Chececyslectamy Endocr Res, 1998, 24:205-213.
8 李金龙，陈勇，李荣祥，等．腹腔镜及大小胆囊切除术创伤反应对比研究．肝胆胰外科杂志，2001，13：18-20．
9 Servin F.TCI compared with manually controlled of propofol:a multicentye study.Anesthesia, 1998,53:82-86.
10 Hugcc Jr, McLeskey CH, Nahrwold ML,et al.Hemodynamic effects of propofol: data from over 25,000 patients, 1993,77:21-29.
11 吴安石．异丙酚在心脏手术中的应用．国外医学麻醉学与复苏分册，1996，17：224-227．
12 Bernard JM, Wouters PF, Doursout MF,et al. Effects of sevoflurane and isoflurane on cardiac and coronary dynamics in chronically instramented dogs. Anesthesiology, 1990,72:659-662.
13 彭德民，王彩霞，姚立农．异丙酚TCI在妇科腹腔镜手术中应用．第四军医大学学报，2005，26：1193．
14 Glass PS,Gan TJ, Howell S. A review of the pharmacokinetics and pharmaco-dynamics of remifentanil.Anesth Analg, 1999, 89:272-274.
15 曹慎健．艾司洛尔的临床应用．新药与临床，1989，8：152-54．
16 Johannsen EK,Munro AJ.Remifentanil in emergency caesarean section in pre2eclampsia complicated by thrombocytopenia and abnormalliverfunction. Anesth Intensive Care, 1999,27:527-529.
17 Glass PSA,Gan TJ,Howell S. A review of the pharmacokinetics and pharmacodynamics of remifentanil. Anesth Analg, 1999,89:97-114.
18 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．中国心血管病杂志，2004，12：967-969．
19 耿志宇，许幸，吴新民．瑞芬太尼复合异丙酚靶控输注诱导时的量效关系．中华麻醉学杂志，2004，4：260-263．
20 Mertens MJ,Olofsen E,Engbers FH,et al.Propofol reduces periopera2tive remifentanil requirements in a synergistic manner:response surfacemodeling of pe propofol interactions. Anesthesiol2ogy,2003,99:347.
21 黄安宁，陈娜．瑞芬太尼复合异丙酚全静脉麻醉用于腹腔镜胆囊切除术的临床研究．武警医学，2005，2：105-108．
22 曹小平，陈兵，张玉龙，等．瑞芬太尼—异丙酚全凭静脉麻醉用于腹腔镜胆囊切除术的临床研究．四川医学，2005，2：175-176．