氟比洛芬酯复合芬太尼预防胃、结肠手术全麻苏醒期躁动
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摘要
全麻苏醒期躁动是全麻苏醒期常见的并发症,表现为烦躁不安、手脚乱动、哭闹不止、无法安抚,同时心率增快、血压增高,可诱发心肌缺血、导致脑血管意外。如不及时采取措施,对患者术后恢复期的安全及身心健康将产生严重的不利影响。其发生的机制尚不明确,苏醒期躁动的相关因素很多,包括患者自身因素如年龄、性别、种族、文化、个体人格差异及健康状况有关,手术原因如手术部位不同、术中失血、呼吸循环功能障碍及代谢紊乱等等,麻醉原因如麻醉方法、麻醉用药(术前用药、麻醉诱导及麻醉维持用药、肌松药的残留作用、拮抗药物的应用)等。近年来认为各种有害刺激是诱发和加重躁动的最常见原因,在各种有害刺激中有报道指出疼痛引起苏醒期患者躁动的比例较高,目前通过镇痛减少躁动的研究比较多,本实验研究的目的是：通过比较氟比洛芬酯、芬太尼、氟比洛芬酯和芬太尼联合应用于胃、结肠手术全麻患者,观察氟比洛芬酯复合芬太尼抑制全麻苏醒期躁动的效果,同时观察病人苏醒过程中血压、心率的变化,苏醒时间,拔管时间及其他不良反应。
方法：择期结肠癌、直肠癌手术患者60例,美国麻醉学会(American Society of Anesthesiologists, ASA)分级Ⅱ～Ⅲ级：年龄范围35～79岁,体量45～90kg。无长期应用阿片类药物史;无神经系统及癫痫病史的患者。根据用药不同随机分为3组,每组20例,于手术结束前20min分别静脉注射：①A组给予芬太尼1.5ug/kg;②B组给予氟比洛芬酯1.0mg/kg;③C组给予芬太尼1.5ug/kg和氟比洛芬酯1.0mg/kg。患者术前禁饮禁食8h,入手术室后开放手背静脉,输入0.9%氯化钠注射液10ml/(kg·h)。常规多功能监护仪监测心电图(ECG)、无创血压(BP)、呼吸频率(RR)、脉搏氧饱和度(SpO2)。术前以长托宁0.5mg静注。麻醉诱导：依次静脉注射咪达唑仑0.05～0.06 mg/kg、芬太尼2～4 ug/kg、顺阿曲库铵0.15mg/kg、依托咪酯0.3mg/kg,充分供氧去氮后,气管插管,接呼吸机行控制性机械通气,频率为12次/min,潮气量8～10ml/kg, I:E=1:2,根据呼气末CO2分压(维持于35～40mmHg)调整每分通气量。麻醉维持：持续泵入异丙酚(4～8mg/kg/h)、瑞芬太尼(8～12ug/kg/h)注射液,根据血压、心率调整,维持麻醉。每隔20～40min根据手术需要间断给予顺阿曲库铵2～5mg,术中根据禁食缺少量,基础需要量,麻醉引起的体液改变,手术过程中的失血失液量给予输液,并观察术中尿量情况等。手术结束前静脉注射托烷司琼2mg,手术结束前20min分别静脉注射芬太尼1.5ug/kg(A组);氟比洛芬酯1.0mg/kg(B组);芬太尼1.5ug/kg和氟比洛芬酯1.0mg/kg (C组)。观察病人的躁动情况、苏醒时间、拔管时间及术后不良反应等。
结果：三组患者在麻醉前、手术开始后1h的HR、MAP比较差异无统计学意义(p>0.05)；在拔管前5 min, C组与B组的HR比较明显较低,差异有统计学意义(p<0.05)；在拔管时,A组、C组的心率比B组均明显较低,差异有统计学意义(P<0.05),C组与B组的血压比较明显较低,差异有统计学意义(P<0.05)；在拔管后5 min,C组与B组的心率比较明显较低,差异有统计学意义(P<0.05)；A、B、C三组患者的心率在拔管后5 min与拔管前5 min比较均明显增高,B组患者的血压在拔管后5 min与拔管前5 min比较明显增高。三组患者镇静躁动评分,A、B组与C组比较差异有显著性(p<0.05),三组患者苏醒时间、拔管时间差异无统计学意义(p>0.05),术后不良反应三组间比较无差异(P值>0.05)。
结论：芬太尼1.5ug/kg和氟比洛芬酯1.0mg/kg于手术结束前20min联合比各自单独应用静脉注射,对预防胃、结肠手术术后躁动效果更好,使病人苏醒过程更平稳,且不延长患者的呼吸恢复和苏醒时间。
Purpose:To observe the effect of flurbiprofen axetil combined with fentanyl for preventing anesthesia agitation after gastric and colonic operations.
Method:60 patients at ASAⅡ～Ⅲlevel have undergone gastric or colonic operations with general anesthesia and at an opted time. Age of patients ranged at 35～79 years old; weight of patients ranged at 45～90kg. There was no long-term opioid medication history, or neurological system disease history, or epileptic disease history among patients. Patients with any one of the following conditions were excluded from the study:those with peptic ulcer, serious hematologic diseases, serious abnormal functioning of heart, liver or kidney, serous high blood pressure, and those having historical allergy to any component of the pharmaceutical under study, having aspirin asthma history, having intubation difficulty and those having used blood transfusion as the operation required. Patients were randomly divided into three groups with 20 people in each group. Group A were treated with fentanyl, Group B flurbiprofen axetil, and Group C fentanyl and flurbiprofen axetil. After settling the patients in the operation room, open the veins on the back of hand, then infuse 0.9% sodium chloride parenteral solution. Use a standard multifunctional monitor instrument to monitor the following indicators: electrocardiogram (ECG), non-invasive blood pressure (BP), respiration rate (RR), and pulse oximetric saturation (SpO2). All patients were treated with the same anesthesia method; they all received rapid induced general anesthesia, and the anesthesia were purely and entirely maintained through veins. Twenty minutes prior to the operation, Group A received fentanyl 1.5ug/kg, Group B received flurbiprofen axetil 1.0mg/kg, and Group C received fentanyl 1.5ug/kg and flurbiprofen axetil 1.0mg/kg. Heart rate and blood pressure were recorded at these time points:before the anesthesia,1 h after the operation,5 minutes before the extubation, during extubation, and 5 minutes after the extubation. Meanwhile observe the agitation of patients, recovery/wake-up time, extubation time and untoward reactions after the operation, etc..
Result:When comparing the three groups:as to the HR and MAP prior to the anesthesia and 1 h after the operation, there were no statistically significant difference among all three groups(p>0.05); as to HR at 5 minutes prior to the extubation, Group C was lower than Group B, with statistical significance (p<0.05); as to the heart rate during extubation, both Group A and Group C were lower than Group B, with statistical significance (P<0.05); as to the blood pressure, Group C is lower than Group B, with statistical significance (P<0.05); as to the heart rate 5 minutes after extubation, Group C is lower than Group B with statistical significance (P<0.05). The heart rate of all three groups increased considerably 5 minutes after the extubation compared with 5 minutes prior to the extubation. The blood pressure in Group B increased considerably 5 minutes after the extubation compared with 5 minutes prior to the extubation, suggesting that, after receiving fentanyl, the patients experienced smaller cyclic variation/fluctuation during recovery/wake-up, or we can say the recovery was smoother. Administer RASS for all three groups. The scores of Group A and Group B were different than that of Group C, with statistical significance (p<0.05), indicating that the prescription of fentanyl 1.5ug/kg and flurbiprofen axetil 1.0mg/kg is effective in preventing post-operation agitation in the cases of gastric and colonic operations. As to the recovery time and extubation time, there were no statistically significant differences among the three groups (p>0.05). This is mainly the result of balanced analgesia. A balanced analgesia is one that combines analgesic medicines of different pharmacological types, with the aim of enhancing analgesic effect and reducing untoward reactions. As for the post-operational untoward reactions, there were no statistically significant differences among the three groups (p>0.05).
Conclusion:Injecting Fentanyl 1.5ug/kg and flurbiprofen axetil 1.0mg/kg via veins 20 minutes before the end of the operation is very effective for preventing post-operational agitation in the cases of gastric and colonic operations. It serves to smooth the recovery process without elongating the recovery time and extubation time, producing satisfactory anesthesia result, hence holding encouraging promises for wider clinical application.
方法：择期结肠癌、直肠癌手术患者60例,美国麻醉学会(American Society of Anesthesiologists, ASA)分级Ⅱ～Ⅲ级：年龄范围35～79岁,体量45～90kg。无长期应用阿片类药物史;无神经系统及癫痫病史的患者。根据用药不同随机分为3组,每组20例,于手术结束前20min分别静脉注射：①A组给予芬太尼1.5ug/kg;②B组给予氟比洛芬酯1.0mg/kg;③C组给予芬太尼1.5ug/kg和氟比洛芬酯1.0mg/kg。患者术前禁饮禁食8h,入手术室后开放手背静脉,输入0.9%氯化钠注射液10ml/(kg·h)。常规多功能监护仪监测心电图(ECG)、无创血压(BP)、呼吸频率(RR)、脉搏氧饱和度(SpO2)。术前以长托宁0.5mg静注。麻醉诱导：依次静脉注射咪达唑仑0.05～0.06 mg/kg、芬太尼2～4 ug/kg、顺阿曲库铵0.15mg/kg、依托咪酯0.3mg/kg,充分供氧去氮后,气管插管,接呼吸机行控制性机械通气,频率为12次/min,潮气量8～10ml/kg, I:E=1:2,根据呼气末CO2分压(维持于35～40mmHg)调整每分通气量。麻醉维持：持续泵入异丙酚(4～8mg/kg/h)、瑞芬太尼(8～12ug/kg/h)注射液,根据血压、心率调整,维持麻醉。每隔20～40min根据手术需要间断给予顺阿曲库铵2～5mg,术中根据禁食缺少量,基础需要量,麻醉引起的体液改变,手术过程中的失血失液量给予输液,并观察术中尿量情况等。手术结束前静脉注射托烷司琼2mg,手术结束前20min分别静脉注射芬太尼1.5ug/kg(A组);氟比洛芬酯1.0mg/kg(B组);芬太尼1.5ug/kg和氟比洛芬酯1.0mg/kg (C组)。观察病人的躁动情况、苏醒时间、拔管时间及术后不良反应等。
结果：三组患者在麻醉前、手术开始后1h的HR、MAP比较差异无统计学意义(p>0.05)；在拔管前5 min, C组与B组的HR比较明显较低,差异有统计学意义(p<0.05)；在拔管时,A组、C组的心率比B组均明显较低,差异有统计学意义(P<0.05),C组与B组的血压比较明显较低,差异有统计学意义(P<0.05)；在拔管后5 min,C组与B组的心率比较明显较低,差异有统计学意义(P<0.05)；A、B、C三组患者的心率在拔管后5 min与拔管前5 min比较均明显增高,B组患者的血压在拔管后5 min与拔管前5 min比较明显增高。三组患者镇静躁动评分,A、B组与C组比较差异有显著性(p<0.05),三组患者苏醒时间、拔管时间差异无统计学意义(p>0.05),术后不良反应三组间比较无差异(P值>0.05)。
结论：芬太尼1.5ug/kg和氟比洛芬酯1.0mg/kg于手术结束前20min联合比各自单独应用静脉注射,对预防胃、结肠手术术后躁动效果更好,使病人苏醒过程更平稳,且不延长患者的呼吸恢复和苏醒时间。
Purpose:To observe the effect of flurbiprofen axetil combined with fentanyl for preventing anesthesia agitation after gastric and colonic operations.
Method:60 patients at ASAⅡ～Ⅲlevel have undergone gastric or colonic operations with general anesthesia and at an opted time. Age of patients ranged at 35～79 years old; weight of patients ranged at 45～90kg. There was no long-term opioid medication history, or neurological system disease history, or epileptic disease history among patients. Patients with any one of the following conditions were excluded from the study:those with peptic ulcer, serious hematologic diseases, serious abnormal functioning of heart, liver or kidney, serous high blood pressure, and those having historical allergy to any component of the pharmaceutical under study, having aspirin asthma history, having intubation difficulty and those having used blood transfusion as the operation required. Patients were randomly divided into three groups with 20 people in each group. Group A were treated with fentanyl, Group B flurbiprofen axetil, and Group C fentanyl and flurbiprofen axetil. After settling the patients in the operation room, open the veins on the back of hand, then infuse 0.9% sodium chloride parenteral solution. Use a standard multifunctional monitor instrument to monitor the following indicators: electrocardiogram (ECG), non-invasive blood pressure (BP), respiration rate (RR), and pulse oximetric saturation (SpO2). All patients were treated with the same anesthesia method; they all received rapid induced general anesthesia, and the anesthesia were purely and entirely maintained through veins. Twenty minutes prior to the operation, Group A received fentanyl 1.5ug/kg, Group B received flurbiprofen axetil 1.0mg/kg, and Group C received fentanyl 1.5ug/kg and flurbiprofen axetil 1.0mg/kg. Heart rate and blood pressure were recorded at these time points:before the anesthesia,1 h after the operation,5 minutes before the extubation, during extubation, and 5 minutes after the extubation. Meanwhile observe the agitation of patients, recovery/wake-up time, extubation time and untoward reactions after the operation, etc..
Result:When comparing the three groups:as to the HR and MAP prior to the anesthesia and 1 h after the operation, there were no statistically significant difference among all three groups(p>0.05); as to HR at 5 minutes prior to the extubation, Group C was lower than Group B, with statistical significance (p<0.05); as to the heart rate during extubation, both Group A and Group C were lower than Group B, with statistical significance (P<0.05); as to the blood pressure, Group C is lower than Group B, with statistical significance (P<0.05); as to the heart rate 5 minutes after extubation, Group C is lower than Group B with statistical significance (P<0.05). The heart rate of all three groups increased considerably 5 minutes after the extubation compared with 5 minutes prior to the extubation. The blood pressure in Group B increased considerably 5 minutes after the extubation compared with 5 minutes prior to the extubation, suggesting that, after receiving fentanyl, the patients experienced smaller cyclic variation/fluctuation during recovery/wake-up, or we can say the recovery was smoother. Administer RASS for all three groups. The scores of Group A and Group B were different than that of Group C, with statistical significance (p<0.05), indicating that the prescription of fentanyl 1.5ug/kg and flurbiprofen axetil 1.0mg/kg is effective in preventing post-operation agitation in the cases of gastric and colonic operations. As to the recovery time and extubation time, there were no statistically significant differences among the three groups (p>0.05). This is mainly the result of balanced analgesia. A balanced analgesia is one that combines analgesic medicines of different pharmacological types, with the aim of enhancing analgesic effect and reducing untoward reactions. As for the post-operational untoward reactions, there were no statistically significant differences among the three groups (p>0.05).
Conclusion:Injecting Fentanyl 1.5ug/kg and flurbiprofen axetil 1.0mg/kg via veins 20 minutes before the end of the operation is very effective for preventing post-operational agitation in the cases of gastric and colonic operations. It serves to smooth the recovery process without elongating the recovery time and extubation time, producing satisfactory anesthesia result, hence holding encouraging promises for wider clinical application.
引文
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[2]黄瑞云,宣庆,陈海明.全麻术后躁动原因分析与处理方法探讨[J].广西医学,2010,32(7)：825-826.
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[1]靳三庆,庞婷,梁青春.全麻病人苏醒期躁动的研究进展[A].2006年中华医学会全国麻醉学术年会知识更新讲座.
[2]黄瑞云,宣庆,陈海明.全麻术后躁动原因分析与处理方法探讨[J].广西医学,2010,32(7)：825-826.
[3]刘仁玉,吴安玉.术后躁动[J].国外医学麻醉学与复苏分册,1995,16(1)：35-37.
[4]李宁,薛建军.全麻苏醒期病人躁动情况观察[J].现代医院,2007,7(12)：32-33.
[5]徐伟囡,潘学文.全麻恢复期病人躁动原因的分析及处理[J].浙江创伤外科,2005,10(1)：52.
[6]李红燕,张爱丽.全麻苏醒期病人躁动的临床观察[J].河南职工医学院学报,2001,13(3)：封3.
[7]artley M, Vaughan RS. Problems associated with tracheal extubation. Br J Anaesth,1993.71,561. Eggers KA. Tramado 1. Br J Anesthesia, 1995,74:247-249.
[8]Mikawa K,Nishina K,Mackawa N,et al.Attention of cardiovascular respo nses to tracheal extubation:Verapamil versus diltiazem. Anesth Analg,1996,82(11):1205.
[9]赵建明,刘建芳,梁军成.瑞芬太尼临床的应用[J].中国临床药理学杂志,2008,7(4)：368-369.
[10]Dershwitz M, Randel GI,Rosow CE,et al. Initial clinical experience with remifentanil, a new opioid metabolized by esterase. Anesth Analg,1995, 81:619-623.
[11]Thompson JP, Rowbotham DJ.Remifentanil:an opioid for the 21st century. BrJ Anaesth,1996,76:341-343.
[12]Joly V,Richebe P,Guignard B,et al.Remifentanil-in-duced post-operative hyperalgesia and its preventionwith small-dose ketamine[J]. Anesth esiology,2005,103(1):147-155.
[13]毕娜.术后疼痛及止痛的进展[J].国外医学·护理分册,1999,18(5)：211-214.
[14]刘俊杰,赵俊.现代麻醉学[M].第2版.北京：人民卫生出版社,1996.68.
[15]Cravero JP, Beaeh M,Thyr B, et al. The effect of small dose fentanyl on the emergence characteristics of Pediatric Patients after sevoflurane anesthesia without surgery. Anesth Analg,2003,97:364-367.
[16]刘红星.氟比洛芬酯注射液及其应用[J].临床药物治疗杂志,2005,3：60-61.
[17]傅得兴,封宇飞.非甾体抗炎药的安全性研究.中国全科医学,2008,11：136-138.
[18]Yoshitani K,Kawaguchi M,Tatsumi K,et al.Intravenous administration of flurbiprofen does not affect cerebral blood flow velocity and cerebral oxygenation under isoflurane and propofol anesthesia.Anesth Analg,2004, 98:471-476.
[19]徐国柱,李晓玲,段砺瑕,等。氟比洛芬酯脂微球载体注射液治疗中度术后疼痛的Ⅱ期临床试验[J].中国新药杂志,2004,13：846-848.
[20]Hirota K, Fukushi S, Baba S,et al.Flurbiprofen does not change the bispectral index and 95% spectral edge frequency during total intravenous anesthesia with propofol and fentanyl.Eur J Anaes thesiol,2002,19:483-486.
[21]崔明珠,孟凡民.氟比洛芬酯减轻小儿全麻术后躁动临床观察[J].中日友好医院学报,2009,23(6)：362-364
[22]柴小青,方才.氟比洛芬酯预防/减少全麻术后躁动与咽喉疼痛的 临床观察[J].临床麻醉学杂志,2006,22(11)：845-846.