依托咪酯复合咪哒唑仑及芬太尼麻醉在无痛胃肠镜联合检查中的应用.doc

依托咪酯复合咪哒唑仑及芬太尼麻醉在无痛胃肠镜联合检查中的应用裘剑波，林家燕，齐 超，孙 璐，陈明生（解放军第113医院 麻醉科，浙江 宁波 315040）摘要： 目的 探讨依托咪酯复合咪哒唑仑及芬太尼麻醉在无痛胃镜和肠镜联合检查中应用的麻醉效果和安全性。方法 120例无痛胃镜和结肠镜联合检查的患者，按抽签法随机分为依托咪酯复合组（E组，n=60）和丙泊酚复合组（P组，n=60）。依次静脉注射咪哒唑仑11.5mg，芬太尼0.05-0.07mg，丙泊酚11.5mg/kg或依托咪酯0.10.3mg/kg，待患者入睡，睫毛反射消失后开始胃镜检查，最后行结肠镜检查，检查中酌情追加小剂量依托咪酯或丙泊酚。记录两组患者镜检前、镜检即刻，置入镜后3、5、8、10和15min的SBP、DBP、HR、SpO2变化、苏醒时间和不良反应。结果 全部病例麻醉均满意，均顺利完成检查或治疗；苏醒时间E组（6.93.4）min，P组（6.12.9）min，E组苏醒时间比P组稍长，但两组差异无统计学意义（P0.05）。所有患者麻醉后血压和心率均有不同程度下降，其中血压下降超过基础血压的20%或90mmHg，P组14例（23.3%），E组5例（8.3%），两组比较有明显统计学差异（P0.01） ；患者心率低于55bpm以下，P组有8例（13.3%）E组2例（3.3%），两组比较有统计学差异（P0.05）。SpO2一过性低于90%，P组11例（18.3%），E组2例（3.3%），两组比较有明显统计学差异（P0.01）。E组2例轻微肌颤， P组无肌颤；恶心、呕吐P组有2例，E组有4例；两组比较差异无统计学意义（P0.05）。结论 依托咪酯复合咪哒唑仑及芬太尼麻醉在无痛胃肠镜联合检查中的麻醉效果是满意，临床上也是安全的。和丙泊酚比较而言，依托咪酯复合咪哒唑仑及芬太尼麻醉对呼吸和循环的影响更小，更适合无痛胃肠和肠镜联合检查术。关键词：依托咪酯；丙泊酚；胃镜；结肠镜；联合检查Comparison of etomidate and propofol combined with midazolam and fentanyl anesthesia in the treatment of elderly patients with painless colonoscopyQIU Jian-bo ,QI Chao ,LIN Jia-yan, LI Peng,CHEN Ming-sheng.(Department of Anesthesiology ,the 113th Hospital of PLA,Ningbo ,Zhejiang 315040, P.R,China)Abstract: 【Objective】Comparison the anesthetic effect and security of etomidate and propofol combined with midazolam and fentanyl anesthesia in the treatment of elderly patients with painless colonoscopy. 【Methods】120 cases of patients undergoing colonoscopy and treatment were randomly divided into two groups: Etomidate composite group (E group, n=60) and Propofol composite group (P group, n=60). In both groups, patients were given midazolam 1mg and fentanyl 0.03-0.05mg intravenously. Subsequently, P group patients were given propofol 11.5mg/kg intravenously while E group patients were given Etomidate 0.10.3mg/kg intravenously. After the patient to sleep and the lash reflex was abolished, we started the colonoscopy and treatment. Recording the awakening time, adverse reactions and changes in patients SBP, DBP, HR and SpO2 at the following time points: before colonoscopy, colonoscopy instantly, 3min, 5min, 8min, and 10min after inserting the colonoscope. 【Results】 Both two groups of patients were satisfied with the anesthetic effect and successfully completed colonoscopy and treatment. The patients awakening time in E group was 6.93.4min, has no statistically significant difference than 6.12.9min in the P group (P0.05). Blood pressure and heart rate were decreased in all patients after anesthesia. In P group, there were 14 patients (23.3%) whose blood pressure were decreased by more than 20% of the basal blood pressure or lower than 90mmHg after anesthesia; while in E group only 5 patients (8.3%) had this happens. The two groups have statistically significant differences (P0.01). There were 8 patients (13.3%) in P group with heart rate less than 55bpm after anesthesia, whereas in E group there were only 2 (3.3%) cases, which has a statistically significant difference compared with the P group (P0.05). 11 patients (18.3%) in P group after anesthesia, whose SpO2 had a transient lower than 90%, however in E group only 2(3.3%) cases occurred. The two groups have statistically significant differences (P0.01). Two patients in E group developed mild amyostasia, yet P group did not occur; 2 cases of patients in P group with symptoms of nausea and vomiting, while 4 cases occur in E group. There was no statistically significant difference between the two groups (P0.05). 【Conclusion】 Both etomidate and propofol combined with midazolam and fentanyl anesthesia in the treatment of elderly patients with painless colonoscopy can obtain a satisfactory anesthetic effect and be safe in clinical. However, in comparison, etomidate combined with midazolam and fentanyl anesthesia has smaller impact on the respiratory and circulatory, and more suitable for elderly patients with painless colonoscopy.Keywords: Colonoscopy；Etomidate；Propofol；Elderly patients消化内镜是目前检查和治疗消化道疾病的最重要手段1。无痛胃镜、结肠镜检查治疗是在检查和治疗过程中使用静脉麻醉药，使患者处于麻醉状态，消除病人的恐惧、疼痛和不适反应，能让内镜医生有充足的时间进行诊治操作，防止漏诊，提高了患者内窥镜检查和治疗的耐受性。近几年，行胃肠镜联合检查（一次进行）的患者越来越多。但是，胃肠镜联合检查较单纯胃镜或肠镜检查延长了检查时间，增加了麻醉药的用量，其安全性如何少有报道。本文旨在探讨依托咪酯复合咪哒唑仑及芬太尼麻醉在无痛胃肠镜联合检查中应用的麻醉效果和安全性，现报告如下。1 资料与方法11 一般资料 需行胃镜和结肠镜联合检查或治疗的患者120例，男54例，女66例，ASA级，年龄2183岁，体重4289kg。伴随疾病：高血压病48例，冠心病23例，脑梗塞后遗症12例，糖尿病15例，COPD疾病9例。120例患者按抽签法随机分为依托咪酯复合组（E组，n=60）和丙泊酚复合组（P组，n=60）。12 麻醉方法 术前准备好胃镜、结肠镜、麻醉机、多功能监护仪、气管插管器械、吸引器及必要的抢救设备和药品等。被检查和治疗者禁饮食8h以上，并行肠道准备，对患者进行系统评估，签定麻醉知情同意书。开放前臂静脉，左侧卧位，持续低流量面罩吸氧（3L/min）5min后，依次静脉注射咪哒唑仑11.5mg，芬太尼0.05-0.07mg，丙泊酚中/长链脂肪乳注射液（北京费森尤斯卡比医药有限公司）11.5mg/kg或依托咪酯脂肪乳注射液（江苏恩华药业股份有限公司生产，缓慢注射）0.10.3mg/kg，待患者入睡，睫毛反射消失后开始胃镜检查，然后肠镜检查或治疗。SpO295%时给予头后仰托下颌处理，使呼吸道通畅；SpO290%时给予人工面罩加压给氧辅助呼吸；HR55bpm则静脉注射阿托品0.250.5mg，SBP低于基础值的20%或90mmHg时静脉注射麻黄碱5mg，检查和治疗过程中视时间长短及患者反应酌情追加依托咪酯或丙泊酚。13 观察指标 记录两组患者镜检前、镜检即刻，置入镜后3、5、8、10和15min的SBP、DBP、HR、SpO2变化、苏醒时间和恶心、呕吐、肌颤等不良反应。 14 统计学分析 采用SPSS10.0统计软件进行分析，计量资料xs表示，比较采用t检验，计数资料比较用卡方检验，以P0.05为差异有统计学意义。2 结 果2.1 麻醉效果 两组患者的镜检时间、年龄、体重、ASA分级、伴随疾病差异无统计学意义；120例患者用药23min后，OAA/S评分34级镇静状态，均顺利完成检查或治疗；苏醒时间E组（6.93.4）min，P组（6.12.9）min，E组苏醒时间比P组稍长，但两组差异无统计学意义（P0.05）22 生命体征变化及麻醉不良反应 所有患者麻醉后血压和心率均有不同程度下降，血压下降超过基础血压的20%或90mmHg，P组14例（23.3%），E组5例（8.3%），静脉注射麻黄碱5mg后，血压均恢复正常，两组比较有明显统计学意义（P0.01） ；患者心率低于55bpm以下，P组有8例（13.3%）E组2例（3.3%），静脉注射阿托品0.250.5mg后心率均恢复正常，两组比较有统计学意义（P0.05）。SpO2一过性低于90%，P组11例（18.3%），E组2例（3.3%），给予人工面罩加压给氧辅助呼吸后恢复正常，两组比较有明显统计学意义（P0.01）。E组2例轻微肌颤， P组无肌颤；恶心、呕吐P组有2例，E组有4例；两组比较差异无统计学意义（P0.05）。3 讨论 传统的胃镜或结肠镜检查容易引起恶心、呕吐、疼痛等不适反应，再加之焦虑恐惧和肠镜检查治疗的牵拉不适可引起交感神经兴奋，儿茶酚胺等物质释放增加，易引起患者心血管疾病的发生。结肠镜检查和治疗患者，术前由于口服导泻剂（如甘露醇或硫酸镁等）或清洁灌肠行肠道准备，使体内大量水分及电解质排出体外，在禁食和导泻的双重作用下，机体的血容量可能相对不足，对老年或心脏储备功能较差的患者，影响其心血管功能的稳定性。目前用于无痛胃肠镜检查中最常用的药物之一是丙泊酚，丙泊酚是一种新型的快速、短效静脉麻醉药，静脉注入后病人迅速入睡，停药后可在短期内苏醒，而且苏醒完全。但对呼吸和循环具有明显的抑制作用4，5，使动脉血压下降6，检查治疗中可出现血压下降、心率减慢、低氧血症和呼吸抑制等并发症；特别对老年和高龄患者尤甚。而依托咪酯和丙泊酚一样均属于非巴比妥类的静脉短效催眠性静脉麻醉药，作为一种脂溶性新型镇静剂，依托咪酯对交感神经系统和对压力感受器的功能没有影响而保持心血管系统的稳定，可使冠状动脉阻力下降7，静脉注射后对心血管系统几乎无影响，对高血压老年患者更有利8；同时对呼吸系统也无明显抑制作用3。依托咪酯还具有起效快，安全范围广，效价比高等优点。小剂量咪达唑仑对呼吸、循环几乎没有影响5。提前给予小剂量咪达唑仑；阿片类药物：如芬太尼；减慢依托咪酯的推注速度均可大大减少肌颤的发生率。本研究结果表明，所有患者麻醉后血压和心率均有不同程度下降，其发生率P组均高于E组，P组患者SpO2一过性低于90%的发生率也显著高于E组，但E组苏醒时间和P组相比无统计学意义。芬太尼及丙泊酚对循环、呼吸均有抑制作用，两者合用时更加明显，尤其对心血管合并症较多，心肺储备功能较差的高龄患者。本组采用的丙泊酚为中/长链脂肪乳注射液，依托咪酯也是脂肪乳注射液，均未见明显的静脉注射痛。因此认真的术前系统评估、适量的药物剂量和严密的术中监测和及时的处理是维持血流动力学稳定的关键。总之，依托咪酯与丙泊酚复合咪哒唑仑及芬太尼麻醉在无痛胃肠镜联合检查和治疗中的麻醉效果是满意，依托咪酯复