右美托咪陡预防全麻气管插管和拔管心血管反应的临床观察.pdf

岭南现代临床外科2012年2月第12卷第1期LINGNANMODERNCLINICSINSURGERY,FEB2012,VOL12NO1临床研究基金项目广东省自然科学基金S2011010004558作者单位510120广东广州中山大学孙逸仙纪念医院麻醉科张蓉,李玉娟,重症医学科陈亮通讯作者李玉娟,EMAILYUJUAN_04YAHOOCOMCN右美托咪陡预防全麻气管插管和拔管心血管反应的临床观察张蓉1李玉娟陈亮2摘要目的观察右美托咪陡预防全身麻醉气管插管和拔管过程中心血管反应的临床效果D方法选择30例拟在全身麻醉下行择期腹部手术的患者ASAIL级,随机分G802G81G82G83G81CG81和右美托咪陡G81DG81,G84G8115例DDG81全麻G85G86G87G88G89G8AG8B右美托咪陡1UG/KG,15MING8CG8BG8DCG81G8EG88G89G8CG8BG8FG90的G91G92G93G94DG95G81G85G86G96G97G98G80G99G9AG9B15MG/KG,G9CG9DG9E3LG/KGG9FGA0GA1GA2GA3GA4GA502MG/KGDGA6GA7GA8GA9GAA下GABGACGADGAEGAFG95G81患者的GB0G98GB1G89GB2MAP心GB3HR心GB3GB4GB5GB2GB6GB7RPP的GB8GB9①G8BG97G87基GBAGBB,DEXGBCG91G92G93G94GBDG8BGBE51015MIN②插管G871MIN,插管GBFGC0,插管GBE135MIN③GC1管G875MIN,拔管GBFGC0,拔管GBE3510MINDGA6GA7G95G81插管和拔管期GAERPP12000的GC2G91GC3GC4D结果DG81G8BG97GBE1015插管G871MIN的HRGAA基GBAGBB下GC5P005DDG81插管GBFGC0插管GBE1MIN拔管GAD的MAP和HRG98GC6GC7GC8GC9CG81P005DG8BG97GBE15MINGCA拔管GBEGACGADGAEGAFDG81患者的RPPG98GC8GC9CG81P005DDG81在插管和拔管期GAERPP12000的GC2G91GB3GC6GC7GCBGC9CG81P005DG95G81患者的GCCGCDGADGAE拔管GADGAE和RAMSAYGCE分GA9GAAGCFGD0GD1GD2GD3学GD4GD5D结论右美托咪陡GD6GC7GD7GD8GD9气管插管和拔管GAD的心血管反应,GDAGDB血GDCGB1GDD学的GDEGDF,GE0GADG82麻醉GE1GE2期GE3GE4GE5GE6D关键词右美托咪陡气管插管气管GC1管心血管反应中日分类号R6142文献标识码A文童编号1009976X201201005605DOI103969/JISSN1009976X201201022CLINICALOBSERVATIONOFDEXMEDETOMIDINEINPREVENTIONFROMCARDIOVASCULARRESPONSETOTRACHEALINTUBATIONANDEXTUBATIONDURINGGENERALANESTHESIAZHCNGRONG1,LIYUJUCN,CHENLICNG21DEPCRTMENTOFANESTHESIOLOGY,2DEPCRTMENTOFCRITICCLCCREMECICINE,THESUNYCTSENMEMORICLHOSPITCL,SUNYCTSENUNIZERSITY,GUCNGZHOU,510120CORRESPONCINGCUTHORLIYUJUCN,EMCILYUJUCN_04YCHOOCOMCNABSTRACTIOBJECTIVETOEVALUATETHEEFFECTOFDEXMEDETOMIDINEINPREVENTINGCARDIOVASCULARRESPONSEINDUCEDBYTRACHEALINTUBATIONANDEXTUBATIONDURINGGENERALANESTHESIAMETHODSATOTALOF30PATIENTSASAILUNDERWENTSELECTIVEABDOMINALOPERATIONUNDERGENERALANESTHESIAWERERANDOMLYDIVIDEDINTOTWOGROUPSCONTROLGROUPGROUPC,N15ANDDEXMEDETOMIDINEGROUPGROUPD,N15THEPATIENTSINGROUPDRECEIVEDDEXMEDETOMIDINE1UG/KGINTRAVENOUSINJECTIONOVER15MINWHILETHOSEINGROUPCRECEIVEDEGUALVOLUMEOFNORMALSALINEBEFOREANESTHESIAINDUCTIONANESTHESIAWASINDUCEDWITHPROPOFOL15MG/KG,FENTANYL3LG/KGANDCISATRACURIUM02MG/KGINBOTHGROUPSMEANARTERIALBLOODPRESSUREMAP,HEARTRATEHRANDTHERATEPRESSUREPRODUCTRPPWERERECORDEDATTHESEMOMENT①BEFOREINFUSIONBASELINEVALUE,5MIN,10MINAND15MINAFTERINFUSION②1MINBEFOREINTUBATION,THEMOMENTOFINTUBATION,1MIN,3MINAND5MINAFTERINTUBATION③5MINBEFOREEXTUBATION,THEMOMENTOFEXTUBATION,AND3MIN,5MINAND10MINAFTEREXTUBATIONTHEINCIDENCESOFRPPMORETHAN12000WERECACULATEDDURINGINTUBATIONANDEXTUBATIONRESULTSAT10,15MINAFTERINFUSIONAND1MINBEFOREINTUBATION,HRSIGNIFICANTLYDECREASEDINGROUPD,COMPAREDWITHTHEBASELINEVALUEP005ATTHEMOMENTOFINTUBATION,1MINAFTERINTUBATION,ANDTHEMOMENTOFEXTUBATION,MAPANDHRSIGNIFICANTLYDECREASEDINGROUPD,COMPAREDWITHGROUPCP005ATEACHTIMEPOINTFROM15MINAFTERINFUSIONTOAFTEREXTUBATION,RPPSIGNIFICANTLYDECREASEDINGROUPD,COMPAREDWITHGROUPCP005THEINCIDENCESOFRPPMORE56CMYK万方数据岭南现代临床外科2012年2月第12卷第1期LINGNANMODERNCLINICSINSURGERYFEB2012VOL12NO1表1患者一般资料比较I15JIS性别男/女年龄岁体重KG手术时间MINC组7/8380105560131820251D组8/73737455392830222右美托咪陡DEXMEDETOMIDINEDEX是特异性高选择性的。2受体激动剂具有催眠抗焦虑镇静抗交感镇痛效应更因其无呼吸抑制稳定的血流动力学及独特的可唤醒效应最早被国外广泛用于重症监护病房患者的镇静镇痛DB前临床K将其推广于术前用G80G81G82G83G84G85G86用G80G87G88G83G84G85G86用G80术G89镇痛G8AG8BG8CG8DG8812DG8E于右美托咪陡G8F国G90G91用的时间G92G93G94G95G96G97G98G99DEXG9AG9BG81G82G83G84患者G9CG9DG9EG9DG9FGA0G9DGA1血G9DGA2应的效GA3GA4及GA5G83G84GA6GA7期的GA8GA9D1资料与方法11一般资料2010年7月2010年9月G94GAA30GABG8FG81G82G83G84G9CG9DG9EG9DGAC择期GADGAEGAF手术患者男15GAB女15GAB年龄1860岁体重4580KGASAILGB0DGB1有患者无GA1血G9DGB2病GB3无异GB4手术G83G84GB3无GB5GB6GB7GB5GB2病GB5GB6GB8GB9GBAGBBGB2病及G80GBCGBDGBCGBEGBFGB3GA1GC0GC1GC2GC3GC4GC5及GC0GC6GC7GC8GC9GCAGCBGB4DGCCGCDGCEGCF2组GA5GD0组C组G9F右美托咪陡组D组GD1组15GABD12麻醉方法患者GD2GD3前30GCEGD4GB8GD5GD6GD7GD8GD9GDA01GGDB托GDC05MGGD2GD3G89GDDGDE监GDFGE0GE1国GE2GE3GE4MP50GDF定血GE5BPGA1GE6HRGE7GE8血GE9GEAG9FGEBSPO2GEC稳定5MING89的GEDGEEGEFGCFGD5G80前GF0GF1GEEDGF2时GF3GF4外GF5静GE7GA410ML/KGH的GF6GEBGF7GD5GF8GF9GFADD组G8FG83G84GFBGFC前静GE7GFDGD5GFEGFF右美托咪陡江苏恒瑞医G80股份有限公司1LG/KG用生理GFE水配制成4LG/ML15MINGFDGD5完北京恩路高医疗科技有限公司CP1000型GD5射GFDC组静GE7GFDGD5G8A量生理GFE水D两组G83G84GFBGFCGCA静GE7GD5射丙泊酚15MG/KG芬太尼3LG/KG待患者意识消失G89静GD5顺式GDB曲库铰02MG/KG2MING89GADG9CG9DG90G9EG9DGCD械通G9C潮G9C量VT810ML/KG呼吸频GE6RR1012次/MIN吸呼GD8IIE1I2维持呼G9C末二GE9化碳GCEGE5PETCO23540MMHGGE9G9C流量1L/MINDG83G84维持吸GD223的七氟醚维持G83G84深GEB08MAC10MACD术中GA4瑞芬太尼0102UG/KGMIN维持控制血GE5G8FGF0GF1GEE30定时追加GB8松G80D手术GF3始缝皮时将七氟醚调至1维持缝皮结柬G89停吸七氟醚并将GE9流量调至6L/MIND静GD5新斯的明1MGG9FGDB托GDC05MG混合GFA括抗残余GB8松GEF用D当患者出现意识吞咽咳嗽GA2射GA6GA7自主呼吸规则GC5睁眼G9F完成指令性的动GEF潮G9C量达到7ML/KG吸G80G9C时SPO2维持G8F95GA4KPETCO2G92G81GBE45MMHGG82合KG83G84G85G89吸G86G87GA0G88G9CG9DGFCG9DD13观察指标G89G8A两组患者GACG8BG8C时间G8D的G8EG8FGE5SBPG90G91GE5DBPGF8GCA动GE7GE5MAPGA1GE6HR①GD5G80前GF0GF1GEEDEXG92生理GFE水GF7GD5G8951015MIN②G9EG9D前1MING9EG9DG93G94G9EG9DG89135MIN③GA0G9D前5MINGA0G9DG93G94及GA0G9DG893510MING95G96GA4KG8CG97G98时G8D的GA1GE6G8EG8FGE5G99G9ARPPDG89G8A停G9B吸GD2七氟醚至患者呼G9C睁眼的时间G93苏醒时间停G9BGF7GD5G83G84G80至GA0G88G9CG9DGFCG9D的时间G93GA0G9D时间DGA0G9DG89镇静G9DGCEG9E用RAMSAYG9F1GCEGCF患者焦虑2GCEGCF患者GF8静合GEF具有定GA0力3GCEGCF患者GA1GA2GC5GA3GA4指令4GCEGCF患者GD2GA2GA5GA6呼唤GA2应GBFGA75GCEGCF患者GD2GA2GA5GA6呼唤GA2应GA8GA96GCEGCF患者GD2GA2GA5GAA激无GA2应D14统计学方法G9E用SPSS130GBBG95GABGACGADGADGBBG95GCEGAEDG95量GAFGB0GA4GCAGEDG84G85GB1XISGB2GB3组G90GD8GB4G9E用配GA5GB5G94IGC8GB6组间GD8GB4G9E用独GB7GB5G94IGC8GB6G95GEDGAFGB0GD8GB4G9E用X2GC8GB6P005GCFGB1异有GBBG95学意GB8D2结果21一般情况比较两组患者性别年龄体重G9F手术时间GB1异无GBBG95学意GB8GB21D22两组患者各时间点血流动力学变化的比较两组患者G8C时间G8DG8CGB9指G84的GBA化GBBGB22GB23GB24D至G9EG9D前两组患者的MAPGB1异无GBBG95学意GB8D组GD5G80G891015G9EG9D前1MIN的HRGB4GF0GF1GEEGACGBCP005GBD无GBE重GA1动GBEGBFDC组患者G9EG9DG93G94MAPHRRPPGCE别GD8GF0GF1GEEGF8GCAGC0加163185G9F327PS005G9EG9DG891MINGCE别GC0加89125G9F213PS005D组患者G9EG9DG93G94G9EG9DG891MIN的MAPHRRPPGC1GF0GF1GEEGD8GB4无GBBG95学意GB8DD组患者G9EG9D前1MING9EG9DG93THAN12000INGROUPDWERESIGNIFICANTLYLESSTHANTHATINGROUPCDURINGINTUBATIONANDEXTUBATIONP005THEREWERENOSIGNIFICANTDIFFERENCESINTHERECOVERYTIMEEXTUBATIONTIMEANDRAMSAYCONSCIOUSSEDATIONSCOREBETWEENTHETWOGROUPSP005CONCLUSIONDEXMEDETOMIDINECANEFFECTIVELYREDUCECARDIOVASCULARRESPONSESTOTRACHEALINTUBATIONANDEXTUBATIONDURINGGENERALANESTHESIAANDHAVEHEMODYNAMICSTABILIZINGEFFECTSWHILENOTPROLONGINGTHERECOVERYTIMEFROMANESTHESIAKEYWORDSDEXMEDETOMIDINETRACHEALINTUBATIONTRACHEALEXTUBATIONCARDIOVASCULARRESPONSES57CMYK万方数据岭南现代临床外科2012年2月第12卷第1期LINGNANMODERNCLINICSINSURGERY,FEB2012,VOL12NO1表2两组患者注药期间MAPHR及RPP变化的比较I15JISJ指标MAPMMGR次/MINRPP组别C组D组C组D组C组D组基础值841488025779313878014893323173998857022310注药后5MIN845598126379714875211194853187868715918598注药后10MIN8417884267A809158728125A95810181988729318574注药后15MIN83410981167794153674105A92845174627788116006A与C组比较,P005与基础值比较,AP005表3两组患者插营期间MAPHR及RPP变化的比较I15JISJ指标MAPMMGR次/MINRPP组别C组D组C组D组C组D组插管前1MIN71896A71184A75816761688A7374018829A6060411690A插管即刻978144A82492928140A7709112249430916A87994170711MIN917150A77682879111A7379111134120566A80194141123MIN79011774288A8051167029091044191027139114453A5MIN739106A69498A77512866778A7883417708A6514913323A插管后与C组比较,P005与基础值比较,AP005表5两组患者苏醒时间拔营时间和拔营后RAMSAY评分的比较I15JISJ观察指标苏醒时间MIN拔管时间MINRAMSAY评分C组14342155402306D组14728160282706表4两组患者拔营期间MAPHR及RPP变化的比较I15JISJ指标MAPMMGR次/MINRPP组别C组D组C组D组C组D组拔管前5MIN84610572368A8371087539897006216367844513784A拔管即刻97680A8256992179A8488812227516065A98328138883MIN861908016582272779105988351180388091140335MIN84779791547916274591921558188823571129210MIN81476A76848A763687239185338102957806312086拔管后与C组比较,P005与基础值比较,AP005刻插管后1MIN3MIN5MIN的RRPP均较C组低P005DC组患者拔管即刻MAPRRPP分别比基础值平均增加163,190和353PS005D组患者MAPRRPP与基础值比较无统计学意义P005,三者均比C组低P005拔管期间各时间点D组RPP均比C组低P005D从插管到插管后5MIN的观察期间,C组RPP12000的发生率为200,D组为17P005从拔管到拔管后10MIN的观察期间,C组RPP12000的发生率为183,D组为17P005D23麻醉恢复情况比较表5示,两组患者的苏醒时间拔管时间和拔管后RAMSAY评分比较差异无统计学意义D3讨论患者在气管插管和气管拔管期间,气道受到刺激导致交感肾K腺系统活性增强,儿茶酚G80G81平KG82,表现为G83G84G82G85G86率加G87,G88G89的G8A激G8BG8AG8CG8DG8E患者G8FG90,G91增加G86G92G83管G93发G94的发生率DG95G96G88G89的G8A激G8BG8A,G97G98G86G83管G99G9A的G9BG9C,G8CG9DG8E期患者G9E分G9FGA0D临床KGA1GA2GA3GA4G8A激G8BG8A的GA5GA6GA7GA8GA2GA9G84药GAA者增加GABGACGABGAD药GAE的GAFGB0,前者GB1GB2G9AGA3GA4G83G84G86率的G88G89GB3GB4,GB5G8FG9AGB6G96GB7GADGB8GB9G8BG8A,后者GBAGBBGBC导致GBDGBEGB6G96和苏醒GBFGC0DGC1GC2GC3GC4GC5GC6GC7GC8GC9的G95G96G88G89G8A激G8BG8A的GCAGCBGCCGC8G9FGA0意义DGCDGCEGCFGD0C组在气管插管即刻和拔管即刻MAPR与基础值比较GD1GD2KG82,GD3D组MAP和R与基础值比较差异无统计学意义,G91GD4GD5GD6GD7GD8GD9GC8GC9GB6G96GDA插管和拔管时的G8A激G8BG8A,GDBG98GDAGDCG8CG9BG9C的G83GDDGB9GDE学DRPPGA7G8BG8AG86GDFGE0GE1的GE2GE3指标,RPP12000GE4示G86GDFGE1GE0GB0增加,RPP22000与G86GDFGE5G83G85G89GDCGE63D注药后15MINGE7拔管后各时间点D组患者的RPP均低GE8C组,D组在插管和拔管期间RPP12000的发生率GD2GE9低GE8C组,GE4示GD5GD6GD7GD8GD9G9AGD1GD258CMYK万方数据岭南现代临床外科2012年2月第12卷第1期LINGNANMODERNCLINICSINSURGERYYFEB2012YVOL12NO1降低心肌耗氧量Y此可能与其同时降低血压和心率有关D同时Y右美托咪陡对患者苏醒时间和拔管时间没有显著的延长Y没明显增加RAMSAY镇静评分Y对麻醉恢复期无明显影响D右美托咪陡是一种新型高选择性2肾K腺素受体激动剂Y2009年6月该药在我国K市D右美托咪陡通过激动中枢神G80G81G822受体G83G84G85的G86G87G88G89G8AG8BYG8CG8DG8EG8FG90G91G92G93动G94G95G96G97G98YG99G9A镇静G9BG96G9CG9DDG9E种镇静G97G98是可G9FGA0GA1激GA2GA3GA4GA5醒的YGA6在G99G9A镇静的过GA7中Y无GA8GA9GAAGABYG9E可能GACGADGAEGAFGB0GB1中右美GB2对麻醉恢复期无明显影响的GB3GB4DGB5GAE镇静G9CG9D外Y右美托咪陡可通过G9CG9DGB6GB7GB8GB9GBAGBBGBCGBD和中间神G80GBEGBBGBCGB9GBF2受体YGC0GC1GC2GC3GC4GC5YGAAGABGC6GC7GC8GC9GCAG88的GCBGCCGA2GAAGABGCDGCE延GB8GB7GB8GCFGD0肾K腺素能通GD1GBBGBCGBDGBFPGD2GD3和其GD4GD5GD6性GD7GD8的GADGD9YG99G9A镇GC7G9CG9D48D右美托咪陡对心血管G81G82的G9CG9D是降低GDAGDB神G80G81G82的GDCGDD性Y降低GAE血GDEGDFGD3GE0和GE1GE2GE3GE4GE5GE6YGE7GACGAEGE8激GE9GE8YGEAGEB降低血压和心率Y有GECGED降低GEE管和拔管时血GEF动GF0GF1GE9GE8YG8FG90患者心血管GF2能的GF3GF4911DSCHEININ12GF5GB0GB1Y麻醉GF6GCCGBDGF7GF806UG/KG右美托咪陡Y能GF9降低血GDEGCFGD0肾K腺素GE5GE6YGFAGFBGFCGFDGFEGFF和气管GEE管G8C起的心血管GE9GE8DTALKE13GF5对GCE血管手术的患者YG91麻醉GF6GCCGBD20MIN开始YGF7GF8右美托咪陡至手术结柬GB948HYG8D现右美托咪陡可有GECGAAGAB麻醉苏醒期间心率增快及血GDEGCFGD0肾K腺素分泌的增多DGAFGB0GB1表明GEE管即刻拔管即刻DGB2的MAPHR和RPP与CGB2比较差异有G82计GF1意义YG9E也证实GAEG9FKGB0GB1DGF7GF81UG/KG右美托咪陡初期Y会出现短暂的血压升高Y随着时间延长Y才逐渐出现降压和降心率的G9CG9DDGAFGB0GB1显示YDGB2在注药GB910MIN的MAP比基础值升高Y但注药GB915MIN的MAP与基础值比较差异无G82计GF1意义DDGB2在注药GB910MIN15MIN的HR比基础值GCD降Y但无G8DG9A严重的心动过GE7D出现暂时性的血压升高主要是GA1激血管平滑肌G99G9A直接外周血管收缩GECGE8的结果D暂时性高血压通常不需要治疗Y可通过GE7慢输注速GE610MINGE7GACY故禁忌快速静脉注射GF7药D如果有心率明显GCD降YGE8GC0G9D阿托品GF5药GD2保G90心率D综K所述Y通过GAFGB0GB1的临床观察Y麻醉GF6GCCGBDGF7GF8右美托咪陡能显著GFA轻全身麻醉气管GEE管和拔管G8C起的心血管GE9GE8Y降低心