不同辅助药物用于硬膜外麻醉下妇科手术的临床观察
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摘要
目的评价不同辅助药物在硬膜外麻醉下妇科手术中的镇静、遗忘、肌松和抗牵拉反应的效果。
方法择期硬膜外麻醉下行“经腹全子宫切除术”的患者60例,ASA I～II级,随机分为三组(每组20例):I组,芬太尼组;II组,哌替啶组;Ⅲ组,舒芬太尼组。于L2～3椎间隙行硬膜外腔穿刺置管,注入2%利多卡因试验量3ml后,采用0.75%罗哌卡因将麻醉平面控制在T6-8～S4左右。于切皮前5min缓慢静注各组辅助药物。记录入室、切皮、牵拉腹膜、手术探查、牵拉子宫、关腹及术毕各时点的血压和心率。评估术中牵拉反应、腹肌松弛和镇静(Ramsay镇静评分)的程度,观察不良反应的发生情况。术后随访,评价患者对手术操作过程的遗忘情况。
结果三组患者给予辅助药物后,MAP较基础值均有明显下降(P<0.05),I组和II组术毕恢复至基础水平,术毕时Ⅲ组的MAP低于I组和II组(P<0.05);I组牵拉子宫时,MAP降至最低,且明显低于其它两组(P<0.05)。辅助用药后,II组和Ⅲ组HR无明显变化,I组牵拉腹膜时HR开始下降,至牵拉子宫时降至最低,且低于II组(P<0.05)。II组和Ⅲ组牵拉反应程度低于I组(P<0.05)。II组和Ⅲ组的肌松效果及遗忘效果均优于I组(P<0.05)。Ⅲ组Ramsay镇静评分高于I组(P<0.05)。三组的SpO2及恶心发生率无明显差异(P>0.05),患者均未出现瘙痒和呕吐等其它不良反应。
结论哌替啶及舒芬太尼分别复合咪唑安定应用于连续硬膜外麻醉下妇科手术,可以良好的抑制牵拉反应,术中患者血压心率稳定,肌松效果、镇静情况和遗忘效果满意,是安全有效的辅助用药。
Objective To observe the sedative and amnestic effects, the degree of muscle relaxation and prevention of visceral traction reaction of various adjunctive drugs in patients undergoing gynecological surgery under epidural anesthesia.
Methods Sixty patients (ASA I～II ) scheduled for elective abdominal hysterectomy were randomly divided into three groups:Group I:fentanyl and midazolam;Group II:pethidine and midazolam;GroupⅢ:sulfentanil and midazolam. We selected L2～3 intervertebral space as the puncture site of epidural anesthesia and used 0.75% ropivacaine after test dose, adjusting the anesthesia level to T6-8～S4. All the adjunctive drugs were intravenously administered slowly 5 minutes before incision. The blood pressure and heart rate were recorded at the time of preanesthesia, incision, surgical exploration, uterus traction, suturing abdominal cavity and the end of operation. The degree of sedation, muscle-relaxing, visceral traction reaction and the incidence of side-effects were evaluated and observed during the operation. The patients were postoperatively surveyed to evaluate the degree of amnesia.
Results The MAP of three groups decreased significantly after the adjunctive drugs were administered,compared with the preanesthesia period (P<0.05); the MAP recoveried at the end of operation in I group andⅡgroup; theⅢgroup’s MAP was lower than the other two groups’at the end of operation(P<0.05). The lowest MAP in I group happened at the time of uterus traction and it was lower significantly than the other two groups’. The HR was not different inⅡgroup andⅢgroup, compared with the preanesthesia period. The I group’s HR was decreased when entering abdomen cavity, and it was lowest at the time of uterus traction (P<0.05). And it was lower significantly than theⅡgroup’s. As to the degree of visceral traction reaction, the I group’s was stronger than the other two groups’(P<0.05). The effects of abdominal muscle relaxation ofⅡgroup andⅢgroup were better than that of I group (P<0.05). The Ramsay Sedation Scale ofⅢgroup was higher than that of I group(P<0.05).Ⅱgroup andⅢgroup had better amnesia effect than I group (P<0.05). The SpO2 in three groups were not different. The incidences of nausea were not different and there were no incidences of pruritus and vomiting in three groups.
Conclusion Pethidine and sulfentanil respectively combined with midazolam can prevent the visceral traction reaction in patients undergoing gynecological surgery under epidural anesthesia. The patients have stable circulation, good muscle relaxation, satisfactory sedation and amnesia effect. They are effective and safe adjunctive drugs in patients undergoing gynecological surgery under epidural anesthesia.
方法择期硬膜外麻醉下行“经腹全子宫切除术”的患者60例,ASA I～II级,随机分为三组(每组20例):I组,芬太尼组;II组,哌替啶组;Ⅲ组,舒芬太尼组。于L2～3椎间隙行硬膜外腔穿刺置管,注入2%利多卡因试验量3ml后,采用0.75%罗哌卡因将麻醉平面控制在T6-8～S4左右。于切皮前5min缓慢静注各组辅助药物。记录入室、切皮、牵拉腹膜、手术探查、牵拉子宫、关腹及术毕各时点的血压和心率。评估术中牵拉反应、腹肌松弛和镇静(Ramsay镇静评分)的程度,观察不良反应的发生情况。术后随访,评价患者对手术操作过程的遗忘情况。
结果三组患者给予辅助药物后,MAP较基础值均有明显下降(P<0.05),I组和II组术毕恢复至基础水平,术毕时Ⅲ组的MAP低于I组和II组(P<0.05);I组牵拉子宫时,MAP降至最低,且明显低于其它两组(P<0.05)。辅助用药后,II组和Ⅲ组HR无明显变化,I组牵拉腹膜时HR开始下降,至牵拉子宫时降至最低,且低于II组(P<0.05)。II组和Ⅲ组牵拉反应程度低于I组(P<0.05)。II组和Ⅲ组的肌松效果及遗忘效果均优于I组(P<0.05)。Ⅲ组Ramsay镇静评分高于I组(P<0.05)。三组的SpO2及恶心发生率无明显差异(P>0.05),患者均未出现瘙痒和呕吐等其它不良反应。
结论哌替啶及舒芬太尼分别复合咪唑安定应用于连续硬膜外麻醉下妇科手术,可以良好的抑制牵拉反应,术中患者血压心率稳定,肌松效果、镇静情况和遗忘效果满意,是安全有效的辅助用药。
Objective To observe the sedative and amnestic effects, the degree of muscle relaxation and prevention of visceral traction reaction of various adjunctive drugs in patients undergoing gynecological surgery under epidural anesthesia.
Methods Sixty patients (ASA I～II ) scheduled for elective abdominal hysterectomy were randomly divided into three groups:Group I:fentanyl and midazolam;Group II:pethidine and midazolam;GroupⅢ:sulfentanil and midazolam. We selected L2～3 intervertebral space as the puncture site of epidural anesthesia and used 0.75% ropivacaine after test dose, adjusting the anesthesia level to T6-8～S4. All the adjunctive drugs were intravenously administered slowly 5 minutes before incision. The blood pressure and heart rate were recorded at the time of preanesthesia, incision, surgical exploration, uterus traction, suturing abdominal cavity and the end of operation. The degree of sedation, muscle-relaxing, visceral traction reaction and the incidence of side-effects were evaluated and observed during the operation. The patients were postoperatively surveyed to evaluate the degree of amnesia.
Results The MAP of three groups decreased significantly after the adjunctive drugs were administered,compared with the preanesthesia period (P<0.05); the MAP recoveried at the end of operation in I group andⅡgroup; theⅢgroup’s MAP was lower than the other two groups’at the end of operation(P<0.05). The lowest MAP in I group happened at the time of uterus traction and it was lower significantly than the other two groups’. The HR was not different inⅡgroup andⅢgroup, compared with the preanesthesia period. The I group’s HR was decreased when entering abdomen cavity, and it was lowest at the time of uterus traction (P<0.05). And it was lower significantly than theⅡgroup’s. As to the degree of visceral traction reaction, the I group’s was stronger than the other two groups’(P<0.05). The effects of abdominal muscle relaxation ofⅡgroup andⅢgroup were better than that of I group (P<0.05). The Ramsay Sedation Scale ofⅢgroup was higher than that of I group(P<0.05).Ⅱgroup andⅢgroup had better amnesia effect than I group (P<0.05). The SpO2 in three groups were not different. The incidences of nausea were not different and there were no incidences of pruritus and vomiting in three groups.
Conclusion Pethidine and sulfentanil respectively combined with midazolam can prevent the visceral traction reaction in patients undergoing gynecological surgery under epidural anesthesia. The patients have stable circulation, good muscle relaxation, satisfactory sedation and amnesia effect. They are effective and safe adjunctive drugs in patients undergoing gynecological surgery under epidural anesthesia.
引文
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5曾斌其.非全麻病人应用咪唑安定的顺行性遗忘作用[J].临床麻醉学杂志, 2006, 22(9): 677- 678.
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2 HU CX, LU ZH, GAO CR. Effects of Midazolam-Tramadol in epidural anesthesia on sedation and drag response during operation[J]. J Clin Anesthesiol, 2002, 18: 603.
3 Naguib M, Samarkandi AH. The comparative dose-response effects of melatonin and midazolam for premedication of adult patients:A double-blinded, placebo-controlled study[J]. Anesth Analg, 2000, 91(2): 473-479.
4 Young C, Knudsen N, Hilton A , et al. Sedation in the intensive care unit [J]. Crit Care Med , 2000, 28(3): 854-866.
5曾斌其.非全麻病人应用咪唑安定的顺行性遗忘作用[J].临床麻醉学杂志, 2006, 22(9): 677- 678.
6张汝金,鲍莉莉,李秋霞,等.咪唑安定与丙泊酚联合应用于术中镇静的临床观察[J].临床麻醉学杂志, 2001, 17(7): 389-390.
7刘存明,张国楼,王忠云,等.咪唑安定辅助区域麻醉合适镇静深度及用量探讨[J].临床麻醉学杂志, 2005, 21(1): 20-22.
8刘鲲鹏,廖旭,薛富善.舒芬太尼的药理学和临床应用[J].中国医药导刊, 2005, 7(6): 454-457.
9 Ramsay MA, Savege TM, Simpson BR, et al. Controlled sedation with alphaxalone- alphadolone[J]. Br Med J, 1974, 22(2): 656-659.
10 Sung-Mee Jung, Po-Soon Kang, Hee-UK Kwon. Comparison of Epidural Anesthesia with Levobupivacaine and Ropivacaine for Caesarean Section[J]. Anesthesiology 2006, 105: A1663.
11吴新民.咪唑安定的临床应用[J].中华麻醉学杂志, 1998, 18(7): 387.
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