右美托咪定复合小剂量氯胺酮在困难气道纤维支气管镜插管中镇静遗忘的效果

摘要

目的：观察右美托咪定复合小剂量氯胺酮在择期手术困难气道患者纤维支气管镜经鼻气管插管中的镇静遗忘的效果。方法择期困难气道纤维支气管镜经鼻插管患者90例,ASA Ⅰ或Ⅱ级,按照随机数字表法均分为三组：右美托咪定1.0μg/kg+氯胺酮0.5 mg·kg-1·h-1(DK组)、右美托咪定1.0μg/kg+丙泊酚2.0 mg·kg-1·h-1(DP 组)和右美托咪定1.0μg/kg+瑞芬太尼5.0μg·kg-1·h-1(DR 组)。比较三组患者入室后安静10 min(T0)、纤维支气管镜置入前(T1)、气管导管进入声门即刻(T2)及插管后5 min(T3)时 HR、MAP 、SpO 2及 Ramsay 镇静评分和不良反应,及术后24 h 随访患者对气管插管过程的知晓情况。结果与 T0时比较,T1时 DP 和 DR 组 HR明显减慢,MAP 明显下降,T1时 DP 组 SpO 2明显降低(P <0.05)；T3时 DP 和 DR 组 HR 明显加快,DR 组 MAP 明显增高(P <0.05)；T2时 DR 组 MAP 明显高于 DP 组。T2时 DP 组和 DR 组Ramsay 镇静评分明显低于 DK 组,T3时 DR 组 Ramsay 镇静评分明显低于 DK 和 DP 组(P <0.05)；DP 组心动过缓、呼吸抑制发生率明显高于 DK 组,DR 组呛咳、躁动、心动过速、插管知晓发生率明显高于 DK 组(P <0.05)。结论右美托咪定复合小剂量氯胺酮用于困难气道患者经鼻纤支镜插管可保证良好的镇静遗忘效果,维持稳定的血流动力学,并且不良反应发生率低。%Objective To investigate the influence of low-dose ketamine and dexmedetomidine on cardiovascular response during. sedative amnesia fiberoptic nasotracheal intubation. Methods Ninety ASA Ⅰ or Ⅱ patients scheduled to recerve general anesthesia were evenly random-ized to dexmedetomidine and ketamine (group DK),dexmedetomidine and propofol (group DP)and dexmedetomidine and remifentanil (group DR).Ten minutes before intubation,the patients in group DK received intravenously dexmedetomidine 1.0 μg/kg plus ketamine 0.5 mg·kg-1 ·h-1 ;those in group DP received intravenously dexmedetomidine 1.0 μg/kg plus propofol 2.0 mg · kg-1 · h-1 ;those in group DR received intravenously dexmedetomidine 1.0 μg/kg plus remifentanil 5.0μg·kg-1 ·h-1 .Nasotracheal intubation was performed with fiberoptic bronchoscopy after dexemeto-midine injection and complete topical anesthesia.HR,MAP,SpO 2 and Ramsay sedation score were re-corded before anesthesia (T0 ,baseline),before intubation (T1 ),immediately intubated (T2 )and five minutes after intubation (T3 ).Side effects such as restlessness,bucking,respiratory depression and cardiovascular event during intubation and awareness of intubation were also recorded.Results All pa-tients in three groups were performed successfully.HR and MAP were significantly decreased in groups DP and DR at T1 (P <0.05),SpO 2 was significantly decreased in group DP at T1 (P <0.05);MAP in group DR were higher than those in group DP,HR in groups DP and DR were significantly increased than those in group DK at T3 (P < 0.05 );Ramsay score were significantly decreased in groups DP and DR at T2 ,significantly lower in group DR at T3 than those in groups DK and DP (P<0.05).The incidences of bradycardia and respriatory depression were significantly higher in group DP than those in group DK,and bucking,restlessness,tachycardia incidence rate in group DR were significantly higher than those in groups DK and DP (P <0.05).Conclusion Dexmedetomidine com-bined with low dose ketamine together with topical anesthesia is an ideal method for sedative amnesia fiberoptic nasotracheal intubation with slighter cardiovascular response and less side effects.