硬膜外腔舒芬太尼辅助硬膜外麻醉的临床观察
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摘要
目的对比静脉和硬膜外腔舒芬太尼辅助用于胆道手术硬膜外麻醉的效果;探讨硬膜外腔应用舒芬太尼的临床意义。
方法选择在硬膜外麻醉下行“胆道探查,T管引流”手术的患者90例,ASAⅠ-Ⅱ级,将其分为三组(C组、I组和E组),每组30例。选择T8-9椎间隙为穿刺点进行硬膜外腔穿刺置管,采用1%利多卡因与0.25%地卡因的混合液,将无痛平面调为T4-T12左右。待麻醉平面固定后,E组硬膜外腔推注舒芬太尼30ug;I组静脉输注舒芬太尼15ug/hr,同时硬膜外腔推注生理盐3ml;C组为空白对照组,仅硬膜外腔推注生理盐3ml。分别记录麻醉前、麻醉后、进腹时及之后10、20、30、60分钟和术毕时的平均动脉压(MAP)、心率(HR);评估术中牵拉反应、腹肌松弛和镇静的程度;观察术中的SPO2及瘙痒和恶心呕吐等副作用的发生情况;分别于麻醉前和术毕时抽静脉血测血清皮质醇浓度。应用SPSS10.0统计学软件,计量资料采用方差分析,以均数±标准差((?)±s)表示;计数资料采用x~2检验进行统计。P＜0.05为差异有显著意义。
结果
1.患者的一般资料:三组患者的年龄、身高、体重、手术时间、局麻药用量和输液总量等无显著差异(P＞0.05);E组和I组的舒芬太尼用量无显著差异(P＞0.05)。
2.血流动力学指标的比较:
平均动脉压(MAP):三组患者麻醉之后各时间点的MAP均低于麻醉前,差异有显著意义(P＜0.05);C组和I组分别于进腹后20min和10min时最低,与手术开始前(麻醉前和麻醉后)相比差异有显著意义(P＜0.05);E组麻醉后各时间点的MAP无显著差异(P＞0.05)。在进腹后20min时,C组的MAP显著低于E组和I组(P＜0.05)。
心率(HR):进腹后10min和20min时,C组和I组的HR均显著低于手术开始前(P＜0.05)和同时间点的E组的HR(P＜0.05);I组在术毕时的HR亦显著低于手术开始前(舒芬太尼注射前)(P＜0.05)。
麻黄素的使用情况:E组、I组和C组的麻黄素和/或阿托品使用率分别为30%、40%和36.67%,差异无显著意义(p＞0.05)。
3.麻醉效果的比较:C组牵拉反应的程度强于其他两组,差异有显著意义(P＜0.01);I组的牵拉反应的程度强于E组,差异有显著意义(P＜0.05);其中C组、I组和E组中麻醉效果较满意(0-1级)的病例分别为23.33%、63.33%和86.67%。E组患者的肌松效果优于其他两组,差异有显著意义(P＜0.05);其中C组、I组和E组中肌松效果较差的病例分别为26.67%、20%和6.67%。术中Ramsay镇静评分E组和I组之间无显著性差异(p＞0.05),镇静程度都强于C组,差异有显著意义(p＜0.01);其中C组、I组和E组中镇静评分为3-4级的病例分别占0,76.67%和70%。
4.血清皮质醇浓度(ng/ml)的比较:C组、I组和E组术毕时的血清皮质醇浓度(361.38±31.25、306.25±33.35和207.54±28.62)显著高于麻醉前(124.32±25.13、115.18±24.54和117.64±22.04)(P＜0.05);三组术毕时的皮质醇浓度两两相比差异有显著意义(P＜0.05),E组的最低。
5.副作用发生情况的比较:三组患者的SPO2无显著差异(P＞0.05)。E组患者的瘙痒发生率为36.67%,高于I组(6.67%)和C组(0),差异有显著意义(P＜0.01)。E组的恶心呕吐发生率(13.33%)低于C组(43.33%),差异有显著意义(P＜0.05)。
结论本研究的结果说明:(1)硬膜外腔辅助应用舒芬太尼30ug可以增强硬膜外麻醉效果和减轻应激反应,有利于血流动力学稳定,减少了术中恶心呕吐的发生率,是一种安全有效的硬膜外麻醉辅助用药方法,优于静脉应用。(2)硬膜外腔应用舒芬太尼的作用机制与静脉应用不尽相同,从临床研究方面证实了脂溶性阿片类药物椎管内作用机制的存在。
Objective:To observe the effect of epidural Sufentanil for the supplementation of epidural anesthesia for the biliary tract surgery, compared with Sufentanil administered intravenously.
Methods:90 patients,ASAⅠ-Ⅱ,undergoing biliary tact surgery,were divided into C group(n=30)、I group(n=30)and E group(n=30).we selected T8-9 interspace as the puncture site of epidural anesthesia and used 1%lidocaine comibined with 0.25%tetracaine,adjusting the anesthesia level to T4-T12.Then,the patients in E group was injected 30 ug Sufentanil into epidural space;the patients in I group was infused Sufentanil 15ug/hr intravenously and injected 3ml normal saline into epidural space;the patients in C group was only injected 3ml normal saline into epidural space. Record the MAP、HR at the time ofpreanesthesia、postanesthesia、entering abdominal cavity and 10min、20min、30min、60min after that;Evaluate the degree of sedation、muscle-relaxing and visceral traction reaction during the operation;Observe SPO2 and the incidence of side-effects;Blood sample was taken for serum cortisol level before anesthesia and at the end of the operation.
Results:
1、There was no difference in the distribution of age,weight and height, the duration of operation,the initial and total dose of local anesthetics,and the total volume of fluid infused among the three groups(P＞0.05);There was no difference in the total dose of sufentanil between the E group and I group.
2、The MAP of the three groups decreased significantly after the epidural anesthesia,compared with the preanesthesia period(P＜0.05);The lowest MAP in C group and I group happened separatively at the time of 20min or 10min after entering abdomen cavity(EAC),which was different significantly to the the preoperative period(P＜0.05);At the time of 20min after EAC,the C group's MAP was lower significantly than the other two groups'(P＜0.05).At the time of 10min and 20min after EAC,the HR of C group and I group was decreased significantly,compared with the preoperative period(P＜0.05),which is lower significantly than the E group (P＜0.05).
3、As to the degree of visceral traction reaction,the C group's was stronger significantly than the other two group's(P＜0.01);and I group's was stronger significantly than E group's(P＜0.05).The effect of abdominal muscle relaxation of E group was better than the other two group's(P＜0.05). The Ramsay Sedation Scale of I group and E group was higher significantly than C group(P＜0.01).
4、There was significant difference in the serum cortisol level among the three groups at the end of operation(P＜0.05),and the E group's was the lowest.
5、The incidence of pruritus of E group was higher significantly than I group and C group(P＜0.01).The incidence of nausea and vomitting of E group was lower significantly than C group(P＜0.05).
Conclusions:Our findings suggest that:
1、Epidural sufentanil 3oug is an effective and safe adjuvant method for the thoracic epidural block,which is superior to the intravenous adjuvant method.
2、There is much difference in the action mechanism between the epidural and intravenous sufentanil,and the intravertebal mechanism of epidural liposoluble opioids is proved existing by this clinical study.
方法选择在硬膜外麻醉下行“胆道探查,T管引流”手术的患者90例,ASAⅠ-Ⅱ级,将其分为三组(C组、I组和E组),每组30例。选择T8-9椎间隙为穿刺点进行硬膜外腔穿刺置管,采用1%利多卡因与0.25%地卡因的混合液,将无痛平面调为T4-T12左右。待麻醉平面固定后,E组硬膜外腔推注舒芬太尼30ug;I组静脉输注舒芬太尼15ug/hr,同时硬膜外腔推注生理盐3ml;C组为空白对照组,仅硬膜外腔推注生理盐3ml。分别记录麻醉前、麻醉后、进腹时及之后10、20、30、60分钟和术毕时的平均动脉压(MAP)、心率(HR);评估术中牵拉反应、腹肌松弛和镇静的程度;观察术中的SPO2及瘙痒和恶心呕吐等副作用的发生情况;分别于麻醉前和术毕时抽静脉血测血清皮质醇浓度。应用SPSS10.0统计学软件,计量资料采用方差分析,以均数±标准差((?)±s)表示;计数资料采用x~2检验进行统计。P＜0.05为差异有显著意义。
结果
1.患者的一般资料:三组患者的年龄、身高、体重、手术时间、局麻药用量和输液总量等无显著差异(P＞0.05);E组和I组的舒芬太尼用量无显著差异(P＞0.05)。
2.血流动力学指标的比较:
平均动脉压(MAP):三组患者麻醉之后各时间点的MAP均低于麻醉前,差异有显著意义(P＜0.05);C组和I组分别于进腹后20min和10min时最低,与手术开始前(麻醉前和麻醉后)相比差异有显著意义(P＜0.05);E组麻醉后各时间点的MAP无显著差异(P＞0.05)。在进腹后20min时,C组的MAP显著低于E组和I组(P＜0.05)。
心率(HR):进腹后10min和20min时,C组和I组的HR均显著低于手术开始前(P＜0.05)和同时间点的E组的HR(P＜0.05);I组在术毕时的HR亦显著低于手术开始前(舒芬太尼注射前)(P＜0.05)。
麻黄素的使用情况:E组、I组和C组的麻黄素和/或阿托品使用率分别为30%、40%和36.67%,差异无显著意义(p＞0.05)。
3.麻醉效果的比较:C组牵拉反应的程度强于其他两组,差异有显著意义(P＜0.01);I组的牵拉反应的程度强于E组,差异有显著意义(P＜0.05);其中C组、I组和E组中麻醉效果较满意(0-1级)的病例分别为23.33%、63.33%和86.67%。E组患者的肌松效果优于其他两组,差异有显著意义(P＜0.05);其中C组、I组和E组中肌松效果较差的病例分别为26.67%、20%和6.67%。术中Ramsay镇静评分E组和I组之间无显著性差异(p＞0.05),镇静程度都强于C组,差异有显著意义(p＜0.01);其中C组、I组和E组中镇静评分为3-4级的病例分别占0,76.67%和70%。
4.血清皮质醇浓度(ng/ml)的比较:C组、I组和E组术毕时的血清皮质醇浓度(361.38±31.25、306.25±33.35和207.54±28.62)显著高于麻醉前(124.32±25.13、115.18±24.54和117.64±22.04)(P＜0.05);三组术毕时的皮质醇浓度两两相比差异有显著意义(P＜0.05),E组的最低。
5.副作用发生情况的比较:三组患者的SPO2无显著差异(P＞0.05)。E组患者的瘙痒发生率为36.67%,高于I组(6.67%)和C组(0),差异有显著意义(P＜0.01)。E组的恶心呕吐发生率(13.33%)低于C组(43.33%),差异有显著意义(P＜0.05)。
结论本研究的结果说明:(1)硬膜外腔辅助应用舒芬太尼30ug可以增强硬膜外麻醉效果和减轻应激反应,有利于血流动力学稳定,减少了术中恶心呕吐的发生率,是一种安全有效的硬膜外麻醉辅助用药方法,优于静脉应用。(2)硬膜外腔应用舒芬太尼的作用机制与静脉应用不尽相同,从临床研究方面证实了脂溶性阿片类药物椎管内作用机制的存在。
Objective:To observe the effect of epidural Sufentanil for the supplementation of epidural anesthesia for the biliary tract surgery, compared with Sufentanil administered intravenously.
Methods:90 patients,ASAⅠ-Ⅱ,undergoing biliary tact surgery,were divided into C group(n=30)、I group(n=30)and E group(n=30).we selected T8-9 interspace as the puncture site of epidural anesthesia and used 1%lidocaine comibined with 0.25%tetracaine,adjusting the anesthesia level to T4-T12.Then,the patients in E group was injected 30 ug Sufentanil into epidural space;the patients in I group was infused Sufentanil 15ug/hr intravenously and injected 3ml normal saline into epidural space;the patients in C group was only injected 3ml normal saline into epidural space. Record the MAP、HR at the time ofpreanesthesia、postanesthesia、entering abdominal cavity and 10min、20min、30min、60min after that;Evaluate the degree of sedation、muscle-relaxing and visceral traction reaction during the operation;Observe SPO2 and the incidence of side-effects;Blood sample was taken for serum cortisol level before anesthesia and at the end of the operation.
Results:
1、There was no difference in the distribution of age,weight and height, the duration of operation,the initial and total dose of local anesthetics,and the total volume of fluid infused among the three groups(P＞0.05);There was no difference in the total dose of sufentanil between the E group and I group.
2、The MAP of the three groups decreased significantly after the epidural anesthesia,compared with the preanesthesia period(P＜0.05);The lowest MAP in C group and I group happened separatively at the time of 20min or 10min after entering abdomen cavity(EAC),which was different significantly to the the preoperative period(P＜0.05);At the time of 20min after EAC,the C group's MAP was lower significantly than the other two groups'(P＜0.05).At the time of 10min and 20min after EAC,the HR of C group and I group was decreased significantly,compared with the preoperative period(P＜0.05),which is lower significantly than the E group (P＜0.05).
3、As to the degree of visceral traction reaction,the C group's was stronger significantly than the other two group's(P＜0.01);and I group's was stronger significantly than E group's(P＜0.05).The effect of abdominal muscle relaxation of E group was better than the other two group's(P＜0.05). The Ramsay Sedation Scale of I group and E group was higher significantly than C group(P＜0.01).
4、There was significant difference in the serum cortisol level among the three groups at the end of operation(P＜0.05),and the E group's was the lowest.
5、The incidence of pruritus of E group was higher significantly than I group and C group(P＜0.01).The incidence of nausea and vomitting of E group was lower significantly than C group(P＜0.05).
Conclusions:Our findings suggest that:
1、Epidural sufentanil 3oug is an effective and safe adjuvant method for the thoracic epidural block,which is superior to the intravenous adjuvant method.
2、There is much difference in the action mechanism between the epidural and intravenous sufentanil,and the intravertebal mechanism of epidural liposoluble opioids is proved existing by this clinical study.
引文
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[1] Jean L. Joris, Eric A. Jacob, Daniel I. Sessler, Spinal Mechanisms Contribute to Analgesia Produced by Epidural Sufentanil Combined with Bupivacaine for Postoperative Analgesia Anesth Analg 2003 ;97:1446-1451.
[2] Menigaux C, Guignard B, Fletcher D, et al. More epidural than intravenous sufentanil is required to provide comparable postoperative pain relief. Anesth Analg 2001; 93: 472-6.
[3] Minami M, Markawa K,Yabuchi K,et al . Double in situ hybridization study on coexistence of mu - , delta - and kappa - opioid receptor mRNAs with preprotachykinin A mRNA in the rat drsal root ganglia .Brain Res Mol Brain Res. 1995 Jun,30(2):230-210.
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[1] Jean L. Joris, Eric A. Jacob, Daniel I. Sessler, Spinal Mechanisms Contribute to Analgesia Produced by Epidural Sufentanil Combined with Bupivacaine for Postoperative Analgesia Anesth Analg 2003 ;97:1446-1451.
[2] Menigaux C, Guignard B, Fletcher D, et al. More epidural than intravenous sufentanil is required to provide comparable postoperative pain relief. Anesth Analg 2001; 93: 472-6.
[3] Minami M, Markawa K,Yabuchi K,et al . Double in situ hybridization study on coexistence of mu - , delta - and kappa - opioid receptor mRNAs with preprotachykinin A mRNA in the rat drsal root ganglia .Brain Res Mol Brain Res. 1995 Jun,30(2):230-210.
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[5] Kohno T ,Kumamoto E ,Higashi H ,Shimoji K,Yoshimura MActions ofopioids on excitatory and inhibitory transmission in substantia gelatinosa of adult rat spinal cord. J Physiol. 1999,518(Pt 3):803.
[6] Grudt TJ ,Henderson G. Glycine and GABAA receptor - mediated synaptic transmission in rat substantia gelatinosa : inhibition by mu - opioid and GABAB agonists . J Physiol. 1998 ,507(Pt 2) :473-483.
[7] Maves TJ, Gebhart GF. Antinociceptive synergy between intrathecal morphine and lidocaine during visceral and somatic nociception in the rat. Anesthesiology 1992; 76: 91-9.
[8] Penning JP, Yaksh TL. Interaction of intrathecal morphine with bupivacaine and lidocaine in the rat. Anesthesiology 1992; 77: 1186-2000.
[9] Vercauteren M, Meert TF. Isobolographic analysis of the interaction between epidural sufentanil and bupivacaine in rats. Pharmacol Biochem Behav 1997; 58: 237-42.
[10] Fraser, H M : Chapman, V : Dickenson, A H. Spinal local anaesthetic actions on afferent evoked responses and wind-up of nociceptive neurones in the rat spinal cord: combination with morphine produces marked potentiation of antinociception. Pain. 1992 Apr; 49(1): 33-41.
[11] Dickenson AH. Spinal cord pharmacology of pain. Br J Anaesth. 1995 Aug;75(2): 193-200.
[12] Chen-Hwan Cherng, Chih-Ping Yang, and Chih-Shung Wong. Epidural Fentanyl Speeds the Onset of Sensory and Motor Blocks During Epidural Ropivacaine Anesthesia. Anesth Analg 2005; 101:1834-1837.
[13] Bachmann-Mennenga, B; Veit, G.; Steinicke, B;Biscoping, J; Heesen, M. Efficacy of sufentanil addition to ropivacaine epidural anaesthesia for Caesarean section. Acta Anaesthesiologica Scandinavica, 2005,49(4): 532-537(6).
[14] Ummenhofer WC, Arends RH, Shen DD, Bernards CM. Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil. Anesthesiology 2000; 92: 739-53.
[15] U. Eichenberger, C. Giani, S. Petersen-Felix, T. Graven-Nielsen, Lumbar epidural fentanyl: segmental spread and effect on temporal summation and muscle pain, British Journal of Anaesthesia, 2003, Vol. 90, No. 4 467-473.
[16] Stevens RA, Petty RH, Hill HF, et al. Redistribution of sufentanil to cerebrospinal fluid and systemic circulation after epidural administration in dogs. Anesth Analg 1993; 76: 323-7.
[17] Grass JA Schmidt R Schmidt R .A randomized, double blind,dose response comparison of epidural fentanyl versus sufentanil analgesia after Cesarean seetion. Anesthesia and Analgesia 1997 , 85 (02): 365-371.
[18] Whiting WG, Sandier AN, LauLC, ChovazPM Analgesic and respiratory effects of epidural sufentanil in post-thoracotomy patients. Anesthesiology 1988; 69:36-42.
[19] Yaksh TL. Spinal opiate analgesia: characteristics and principles of action. Pain 1981; 11:293-346.
[20] Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiology 1984; 61: 276-310.
[21] Scott JC, Cooke JE, Stanski DR. Electroencephalographic quantification of opioid effect: comparative pharmacodynamic of fentanyl and sufentanil. Anesthesiology 1991; 74: 34-42.
[22] Lehmann KA, Gerhard A, Horrichs-Haermayer G, Grond S, Zech D. Postoperative patient-controlled analgesia with sufentanil: analgesic efficacy and minimum effective concentrations. Acta Anaesthesiol Scand 1991; 35: 221-6.
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