异丙酚和瑞芬太尼靶控静脉麻醉用于颅内动脉瘤介入治疗....doc

异丙酚和瑞芬太尼靶控静脉麻醉用于颅内动脉瘤介入治疗的可行性吉林大学第一医院麻醉科130021徐海洋 王艳姝 周春燕 麻海春1摘要 目的：研究异丙酚和瑞芬太尼全静脉麻醉应用于颅内动脉瘤介入治疗的可行性。 方法：ASA级择期行颅内动脉瘤介入治疗的患者30例，随机分为A、B两组，每组15例，A组吸入异氟醚，间断给予芬太尼；B组靶控输注异丙酚和瑞芬太尼，观察两组患者拔管时间、麻醉医师暴露在放射线下的总时间，患者拔管后即刻和拔管后30min的意识状态(OAAS)及伤口疼痛程度(VRS)。结果：B组患者的拔管时间及手术中麻醉医师暴露在放射线下的总时间明显短于A组（P0.01）；B组患者拔管后即刻及拔管后30min，意识状态评分明显高于A组（P0.01及P0.05）；两组患者伤口疼痛程度评分无显著性差异（P0.05）。结论：异丙酚和瑞芬太尼靶控静脉麻醉特别适合颅内动脉瘤的介入治疗。关键词 异丙酚 瑞芬太尼 靶控输注 颅内动脉瘤Feasibility of TCI anesthesia using propofol and remifentanil to intervenient therapy of cerebral aneurysmXU Hai-yang, WANG Yan-shu, ZHOU Chun-yan, MA Hai-chunDepartment of Anesthesiology, First Hospital, Jilin University, Changchun 130021, China Abstract: Objective To explore the rationality of intravenous anesthesia with propofol and remifentanil to intervenient therapy of cerebral aneurysm. Methods 30 ASA patients with cerebral aneurysm undergoing intervenient therapy were randomly divided into two groups. The group were received isoflurane and fentanyl, the group B were received propofol and remifentanil in TCI method. To observe the time of tracheal extubation and exposure to radiation for anesthesiologist, and assess OAAS and VRS at tracheal extubation, 30min after extubation. Results Times of of tracheal extubation and exposure to radiation for anesthesiologist were significantly less in the group B than in the group A. The observers assessment of alertness/sedation (OASS) scores at tracheal extubation, 30min after extubation were higher in the group B than in the group A. The verbal rating scores(VRS) at tracheal extubation, 30min after extubation were similar for two groups. Conclution Propofol/remifentanil TCIbased anesthesia is very perfect for intervenient therapy of cerebral aneurysm.Key words：propofol; remifentanil; target-controlled infusion; cerebral anurysm 基于药代动力学的靶控输注（Target controlled infusion TCI）在临床中已经得到广泛应用，与传统给药方式比较，可控型高，更为简便精确。新合成的“超短效”阿片类药瑞芬太尼因结构中含有酯键，容易被血浆和组织中的非特异性酯酶代谢降解，药代动力学模式与其他阿片类药不同。颅内动脉瘤的介入治疗具有创伤小的优点。目前没有关于异丙酚和瑞芬太尼应用于颅内动脉瘤患者的介入治疗的相关报道，本文作者研究了颅内动脉瘤异丙酚和瑞芬太尼全静脉麻醉过程，为临床的合理应用提供可行性依据。1资料与方法1.1 病例选择 选择2005年在本院择期行颅内动脉瘤介入治疗的患者30例，ASA级，男17例，女13例，年龄3864岁，平均54.4岁，体重4978kg，平均62.0kg, 术前无精神病史，无意识及肢体活动障碍，未长期服用阿片或安定类药物。利用数字分组法随机分为A组及B组，每组15例。1.2 麻醉方法 两组患者麻醉前30min肌肉注射阿托品0.5mg 。诱导用药为芬太尼3-4g/kg，维库溴铵0.1mg/kg，依托咪酯0.3mg/kg，气管插管。术中维持：A组为吸入异氟醚，间断给予芬太尼，必要时给予维库溴铵；B组异丙酚血浆靶控3g/ml，瑞芬太尼血浆靶控4ng/ml，必要时给予维库溴铵。根据术中情况调整异氟醚及异丙酚剂量。1.3 观察与评价 术毕停药，记录患者的拔管时间、麻醉医师暴露在放射线下的总时间，观察患者拔管后即刻和拔管后30min的意识状态及伤口疼痛程度。意识状态采用OAAS评分：1对轻推或轻拍无反应，昏睡；2仅对轻推或轻拍有反应；3仅在大声或反复呼唤后有反应，言语模糊，语速较慢；4对正常声音呼名反应迟钝，语速较慢；5对正常声音呼名反应迅速，完全清醒。伤口疼痛程度采用VRS评分：0级不痛；1级轻微疼痛；2级中度疼痛；3级非常疼痛；4级剧痛。1.4 统计处理 所有数据以均值标准差表示，组间比较采用t检验，P0.05为差异有显著性，P0.01为差异非常显著。2 结果2.1 一般情况 A组患者男8例，女7例，平均年龄为(54.27.1)岁，平均体重为(61.67.1)kg，平均麻醉时间为(100.714.4)min；B组患者男9例，女6例，平均年龄为(54.74.9)岁，平均体重为(62.37.4) kg，平均麻醉时间为(107.320.5)min。两组患者的年龄、性别、体重及麻醉时间无显著差异（P0.05）。2.2 术后苏醒及恢复的拔管时间及手术中麻醉医师暴露在放射线下的总时间明显短于A组（P0.01）；观察患者拔管后即刻及拔管后30min，B组意识状态评分明显高于A组（P0.01及P0.05）；两组伤口疼痛程度评分无显著性差异（P0.05）。见表1。Tab.1 The comparisons of duration and after operation between group A and group BGrouptime of tracheal extubation (min)time of exposure to radiation for anesthesiologist t(min)the scores of OASS extubation 30min after extubationthe verbal rating scoresextubation 30min after extubationA15.12.48.31.92.70.6 4.50.50 0.10.4B11.62.3*2.50.8*3.80.4* 4.90.3*0.10.3 0.40.5* P0.05, * P0.01 compared with group A3 讨论TCI是静脉麻醉给药方法的重要改进1。其以药代动力学和药效动力学为基础，通过调节目标药物血浆或效应室浓度来控制麻醉深度。TCI方式以血浆或效应室的目标浓度为调节指标，而不是以给药速率为调控指标，使麻醉更平稳，减少了麻醉医师术中单次给药的操作，使麻醉医师暴露在放射线下的总时间从（8.31.9）min减少至（2.50.8）min，显著减少了放射线对麻醉医师不良作用。阿片类药常用于减轻或消除术中的应激反应。新合成的阿片类药盐酸瑞芬太尼是一个“超短效”阿片类药，因结构中含有酯键而容易被血浆和组织中的非特异酯酶代谢降解，药代动力学模式与其他阿片类药不同，分布容积小，起效快，清除快，消除半衰期和持续输注半衰期短，输注停止后瑞芬太尼血浆浓度减少一半的时间仅需3-5分钟，即使以最大有效速率输注，长时间输注也不影响停药后患者的苏醒2。本研究结果显示B组患者术后拔管时间、意识状态恢复程度均优于A组患者，与文献报道相一致3,4。由于瑞芬太尼持续输注半衰期短，术毕停药后血浆浓度很快下降，病人很快就会感到疼痛，限制了其临床应用。但对于颅内动脉瘤介入治疗的患者，一方面因颅内动脉瘤的介入治疗具有创伤小，刺激小等优点，而无术后患者疼痛之虞；另一方面异丙酚和瑞芬太尼复合用药能产生剂量依赖性的脑血流减少，保护脑血管的自动调节功能5，手术结束后患者能从麻醉状态迅速苏醒，以便外科医师及早对神经系统功能进行术后评估6。异丙酚和瑞芬太尼都是超短效的静脉麻醉药，两药复合的靶控输注麻醉在国外已经得到广泛研究和应用78。通过本研究，我们认为异丙酚和瑞芬太尼全凭静脉麻醉特别适合颅内动脉瘤的介入治疗。参考文献1.Glass PSA, Shafer SL, Reves JG. 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