不同剂量右美托咪定复合瑞芬太尼-丙泊酚控制性降压在鼻内窥镜手术中的应用效果

摘要

目的 观察不同剂量右美托咪定复合瑞芬太尼-丙泊酚控制性降压在鼻内窥镜手术中的应用效果.方法 选取120例拟行鼻内窥镜手术患者为研究对象,按随机数字表法分为4组,即A组、B组、C组、D组,每组30例.所有患者均在全身麻醉下行手术,静脉注射丙泊酚2 mg/kg、阿曲库铵0.6~1.0 mg/kg、瑞芬太尼2 μg/kg诱导麻醉,气管插管后行机械通气,继以丙泊酚4~8 mg·kg-1·h-1和瑞芬太尼0.25 μg·kg-1·min-1持续泵注并间断注射阿曲库铵维持麻醉.B组、C组、D组分别于麻醉诱导前10 min静脉泵注0.5 μg/kg、0.8 μg/kg、1.0 μg/kg右美托咪定,并以0.5 μg·kg-1·h-1维持至手术结束;A组输注等量0.9%氯化钠溶液.分别记录控制性降压开始前(T0)、血压降至靶目标后5 min(T1)、30 min(T2)、拔气管导管后10 min(T3)、30 min(T4)、60 min(T5)的心率(HR)、平均动脉压(MAP);采用Fromme术野质量评分量表评价4组T1、T2时术野质量;采用Ramsay镇静分级和VAS疼痛评分量表评价各组T3、T4、T5时镇静和疼痛情况;记录4组控制性降压时间、呼吸恢复时间、睁眼时间及拔管时间;比较4组术后鼻部胀痛、谵妄躁动、寒战等不良反应发生率.结果 与T0比较,A组T1、T2时HR、MAP明显升高,B、C、D组T1、T2时HR、MAP较A组明显降低(P<0.05);C、D组T3~T5时HR、MAP明显降低(P<0.05).与A组比较,B、C、D组术野质量评分、VAS疼痛评分明显降低,Ramsay评分明显升高(P<0.05).与A组比较,C、D组睁眼时间及拔管时间明显延长(P<0.05).4组控制性降压时间、呼吸恢复时间比较差异无统计学意义(P>0.05).与A组比较,B、C、D组鼻部胀痛、谵妄躁动、寒战发生率明显降低(P<0.05).结论 右美托咪定复合瑞芬太尼-丙泊酚控制性降压用于鼻内窥镜手术患者能够改善术野,提高麻醉苏醒质量,其中0.5 μg/kg右美托咪定是合适的临床应用剂量.%Objective To observe the effects of different dose dexmedetomidine combined with remifentanil and propofol in controlled hypotension of nasal endoscopic surgery. Methods A total of 120 patients who would receive nasal endoscopic surgery in our hospital were randomly divided into group A,group B,group C and group D,with 30 patients in each group.All the patients were given propofol 2mg/kg by intravenous injection, atracurium 0.6 ~1.0mg/kg and remifentanil 2μg/kg for induction of anaesthesia, and general anesthesia was maintained with propofol 4 ~ 8mg·kg-1·h-1and remifentanil 0.25μg·kg-1·min-1. Before induction of anaesthesia the patients in group B,group C and group D were given dexmedetomidine of 0.5μg/kg,0.8μg/kg,1.0μg/kg,respectively, then keeping anaesthesia effects with dexmedetomidine 0.5μg·kg-1·h-1until the end of surgery,however,the patients in group A were given the same volume of 0.9% sodium chloride solution. The mean arterial pressure(MAP) and heart rate(HR) of patients were detected before injection(T0),at 5 min (T1) and 30 min (T2) after blood pressure dropping to target,at 10 min(T3), 30 min(T4)and 60 min(T5)after intubation. The quality of surgical field at T1 and T2 was evaluated by Fromme surgical field quality scoring.The sedation state and and pain status at T3,T4,T5 were evaluated by Ramsay and VAS pain score.Moreover the time of controlled hypotension, postoperative spontaneous breathing recovery time, awakening and extubation time were recorded. In addition the incidence rates of postoperative distending pain of nose,delirium,restlessness and shivering were observed and compared among the four groups.Results As compared with those at T0, the HR and MAP in group A were significantly increased at T1 and T2, however,which in groups B,C,D were significantly lower than those in group A(P<0.05).Moreover the HR and MAP in groups C and group D were significantly lower than those in group A at T3,T4,T5 (P<0.05). As compared with those in group A,the Fromme scores and VAS scores in group B,C and D were significantly decreased(P<0.05),however,Ramsay scores were significantly increased (P<0.05). The time of awakening and extubation time in group C and group D were significantly longer than those in group A (P < 0. 05). In addition there were no significant differences in controlled hypotension time and postoperative spontaneous breathing recovery time among groups (P>0.05). Moreover the incidence rates of distending pain of nose,delirium,restlessness and shivering in group B,C and D were significantly decreased,as compared with those in group A (P<0.05). Conclusion The dexmedetomidine combined with remifentanil and propofol controlled hypotension for patients receiving nose endoscopic surgery can effectively improve the operation field and enhance the palinesthesia quality after anesthesia,in which dexmedetomidine 0.5g/kg is an appropriate clinical dose.