丁依紅,顧陳懌,沈利榮,吳涼森,施征,陳躍來(lái)

(1.上海中醫(yī)藥大學(xué)附屬岳陽(yáng)中西醫(yī)結(jié)合醫(yī)院麻醉科,上海 200437;2.上海中醫(yī)藥大學(xué)針灸推拿碩士生,上海201203;3.上海市針灸經(jīng)絡(luò)研究所,上海 200030;4.上海中醫(yī)藥大學(xué),上海 201203)

針刺復(fù)合全麻對(duì)圍術(shù)期維庫(kù)溴銨肌松效應(yīng)的影響

丁依紅1,顧陳懌1,沈利榮2,吳涼森2,施征3,陳躍來(lái)4

(1.上海中醫(yī)藥大學(xué)附屬岳陽(yáng)中西醫(yī)結(jié)合醫(yī)院麻醉科,上海 200437;2.上海中醫(yī)藥大學(xué)針灸推拿碩士生,上海201203;3.上海市針灸經(jīng)絡(luò)研究所,上海 200030;4.上海中醫(yī)藥大學(xué),上海 201203)

【摘要】目的 觀察不同麻醉方法對(duì)腹腔鏡膽囊切除術(shù)患者維庫(kù)溴銨肌松效應(yīng)的影響。方法 選擇80例腹腔鏡膽囊切除術(shù)患者,ASAⅠ～Ⅱ級(jí)。隨機(jī)分為經(jīng)穴組(針刺經(jīng)穴復(fù)合全麻組)、非經(jīng)非穴組(針刺非經(jīng)非穴復(fù)合全麻組)、全麻組。三組患者均采用芬太尼3μg·kg-1、異丙酚2 mg·kg-1、維庫(kù)溴銨0.1 mg·kg－1進(jìn)行全麻誘導(dǎo),術(shù)中以靜脈血漿靶控輸注異丙酚,間斷靜脈注射芬太尼、維庫(kù)溴銨維持麻醉。經(jīng)穴組選取雙側(cè)合谷、內(nèi)關(guān)、足三里、陽(yáng)陵泉、曲池,非經(jīng)非穴組選用經(jīng)穴組每個(gè)經(jīng)穴所在經(jīng)脈與外側(cè)相鄰經(jīng)脈連線的中點(diǎn),與經(jīng)穴相平處取穴,進(jìn)針得氣后持續(xù)電針刺激,直至術(shù)畢。應(yīng)用肌松監(jiān)測(cè)儀持續(xù)監(jiān)測(cè)維庫(kù)溴銨的顯效時(shí)間、起效時(shí)間、維持時(shí)間和恢復(fù)指數(shù)。并記錄術(shù)中麻醉藥用量及術(shù)后清醒時(shí)間、拔管時(shí)間和定向時(shí)間。結(jié)果 三組的肌松效應(yīng)中顯效時(shí)間、起效時(shí)間、恢復(fù)指數(shù)無(wú)顯著差異(P＞0.05),而經(jīng)穴組的維持時(shí)間與全麻組比較差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。經(jīng)穴組與全麻組比較術(shù)中麻醉藥用量明顯減少(P＜0.05)。經(jīng)穴組術(shù)后清醒時(shí)間、拔管時(shí)間和定向時(shí)間顯著縮短(P＜0.01)。結(jié)論 針刺經(jīng)穴復(fù)合全麻可延長(zhǎng)肌松藥的維持時(shí)間,減少術(shù)中麻醉藥的用量,患者術(shù)后恢復(fù)快,有利于患者盡早康復(fù)。

【關(guān)鍵詞】針刺麻醉;針刺復(fù)合全麻;維庫(kù)溴銨;肌松效應(yīng)

針刺麻醉(AA)[1](簡(jiǎn)稱針麻)在圍手術(shù)期有鎮(zhèn)靜、鎮(zhèn)痛[2,3]、調(diào)節(jié)機(jī)體內(nèi)環(huán)境、器官保護(hù)[4,5]和防止術(shù)后惡心嘔吐[6,7]、提高機(jī)體免疫力[8]、促進(jìn)機(jī)體康復(fù)等作用,但未曾有報(bào)道針麻對(duì)肌松效應(yīng)也有影響。本研究應(yīng)用HXD-Ⅰ型C028手掌式肌松監(jiān)測(cè)儀對(duì)80例腹腔鏡膽囊切除術(shù)患者進(jìn)行肌松效應(yīng)的研究。

1 臨床資料

選擇腹腔鏡膽囊切除術(shù)患者80例,美國(guó)麻醉醫(yī)師協(xié)會(huì)病情分級(jí)標(biāo)準(zhǔn)(ASA)Ⅰ～Ⅱ級(jí),年齡29～80歲;體重50～80 kg,心功能分級(jí)Ⅰ～Ⅱ級(jí),既往無(wú)嚴(yán)重心血管疾病、糖尿病、內(nèi)分泌及免疫性疾病,且無(wú)激素應(yīng)用史和術(shù)前輸血史。以盲法原則隨機(jī)抽樣法分為經(jīng)穴組(針刺經(jīng)穴復(fù)合全麻組)、非經(jīng)非穴組(針刺非經(jīng)非穴復(fù)合全麻組)、全麻組。三組一般資料比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05),具有可比性,詳見(jiàn)表1。

表1 三組腹腔鏡膽囊切除術(shù)患者一般資料比較 (±s)

表1 三組腹腔鏡膽囊切除術(shù)患者一般資料比較 (±s)

組別 n 男 女 年齡(y) 體重(kg) 身高(cm) 手術(shù)時(shí)間(min)性別(n)經(jīng)穴組 27 5 22 55±11 67.96±10.62 163.86±7.69 60.64±16.97非經(jīng)非穴組 28 6 22 57±15 66.32±8.21 164.71±4.98 54.43±19.57全麻組 25 8 17 61±10 63.57±12.03 161.93±8.23 51.14±16.95

2 麻醉方法

三組患者均常規(guī)禁食,麻醉前30 min肌肉注射苯巴比妥鈉0.1 g、阿托品0.5 mg?；颊呷胧蚁刃猩现庵莒o脈開(kāi)放,以8～10 mL·kg－1·h－1的速度輸注乳酸林格氏液,連接BSM-4111K型多功能監(jiān)測(cè)儀監(jiān)測(cè)脈搏血氧飽和度(SpO2)、心率(HR)、平均動(dòng)脈壓(MAP)、呼氣末二氧化碳分壓(PETCO2)、心電圖(EKG)、腦電雙頻譜指數(shù)(BIS)。平靜休息10 min后,記錄SpO2、HR、MAP、PETCO2、BIS作為麻醉前基礎(chǔ)值。

2.1 全麻組

面罩吸純氧,人工輔助呼吸,全麻誘導(dǎo)依次靜脈注射芬太尼3 μg·kg－1、異丙酚2 mg·kg－1,待患者入睡后,應(yīng)用肌松監(jiān)測(cè)儀(HXD-Ⅰ型C028)四個(gè)成串(TOF)刺激,定標(biāo)測(cè)定對(duì)照值,待第一個(gè)顫搐反應(yīng)值/對(duì)照值(T1/Tc)穩(wěn)定100%后開(kāi)始快速靜脈注射維庫(kù)溴銨0.1 mg·kg－1,于T1/Tc降至1%時(shí)行喉鏡明視下氣管插管,機(jī)械通氣(Detaxohmed S/5 Aespire),潮氣量8～10 mL·kg－1,呼吸頻率10～12次/min,吸呼比為1:2。BIS處于全麻狀態(tài)下(40～65),按需追加芬太尼1.5 μg·kg－1,術(shù)中持續(xù)靜脈異丙酚靶控輸注血漿靶濃度2.5 μg·mL－1,術(shù)中T1/Tc恢復(fù)至25%時(shí)追加維庫(kù)溴銨0.05 mg·kg－1,直到手術(shù)結(jié)束。

2.2 經(jīng)穴組

針麻取雙側(cè)合谷、內(nèi)關(guān)、足三里、陽(yáng)陵泉、曲池,以上所有穴位進(jìn)針得氣后接G6805-2型電針儀,通電刺激至術(shù)畢。波型為疏密波,疏波4 Hz,密波20 Hz,刺激強(qiáng)度以患者耐受為度,峰電流5 mA。誘導(dǎo)15～30 min后開(kāi)始全麻誘導(dǎo),氣管插管后電刺激強(qiáng)度逐步加大至峰電流7～7.5 mA。全麻誘導(dǎo)、術(shù)中維持同全麻組。

2.3 非經(jīng)非穴組

針麻取穴選擇非經(jīng)非穴處(經(jīng)穴組每個(gè)經(jīng)穴所在經(jīng)脈與外側(cè)相鄰經(jīng)脈連線的中點(diǎn),與經(jīng)穴相平處)電針刺激。以上所有部位進(jìn)針得氣后接G6805-2型電針儀,通電刺激至術(shù)畢。刺激強(qiáng)度和過(guò)程與經(jīng)穴組相同。誘導(dǎo)15～30 min后開(kāi)始全麻誘導(dǎo),全麻誘導(dǎo)、術(shù)中維持同全麻組。

3 治療效果

3.1 觀察指標(biāo)

①記錄術(shù)中維庫(kù)溴銨的顯效時(shí)間、起效時(shí)間、維持時(shí)間和恢復(fù)指數(shù);②記錄術(shù)中麻醉藥用量(芬太尼、異丙酚、維庫(kù)溴銨);③記錄術(shù)后清醒時(shí)間、拔管時(shí)間和定向時(shí)間。

3.2 統(tǒng)計(jì)學(xué)方法

計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差表示,采用SPSS13.0統(tǒng)計(jì)軟件,組間比較采用One-Way ANOVA模塊進(jìn)行單因素方差分析,重復(fù)測(cè)量數(shù)據(jù)組內(nèi)比較采用Repeated Measures模塊進(jìn)行兩兩比較,組間比較采用Multivariate模塊進(jìn)行兩兩比較,計(jì)數(shù)以n表示,采用卡方檢驗(yàn),P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

3.3 結(jié)果

3.3.1 三組維庫(kù)溴銨肌松效應(yīng)的比較

經(jīng)穴組與全麻組比較,維持時(shí)間顯著延長(zhǎng)(P＜0.05),而三組的顯效時(shí)間、起效時(shí)間、恢復(fù)指數(shù)均無(wú)顯著差異(P＞0.05)。詳見(jiàn)表2。

3.3.2 三組術(shù)中麻醉藥用量的比較

經(jīng)穴組與全麻組比較,芬太尼、維庫(kù)溴銨和異丙酚的用量均減少(P＜0.01,P＜0.05),經(jīng)穴組芬太尼和異丙酚用量顯著少于全麻組(P＜0.01)。經(jīng)穴組的異丙酚用量亦少于非經(jīng)非穴組(P＜0.05)。詳見(jiàn)表3。

3.3.3 三組術(shù)后清醒時(shí)間、拔管時(shí)間和定向時(shí)間比較

經(jīng)穴組與全麻組、非經(jīng)非穴組比,術(shù)后清醒時(shí)間、拔管時(shí)間和定向時(shí)間均縮短(P＜0.01)。詳見(jiàn)表4。

表2 三組維庫(kù)溴銨肌松效應(yīng)的比較 (±s,s)

表2 三組維庫(kù)溴銨肌松效應(yīng)的比較 (±s,s)

注:與全麻組比較1)P＜0.05

組別 n 顯效時(shí)間 起效時(shí)間 維持時(shí)間 恢復(fù)指數(shù)經(jīng)穴組 27 80.44±31.79 180.19±57.46 2785.11±650.021)1097.04±517.46非經(jīng)非穴組 28 79.36±31.45 179.43±61.86 2639.04±487.55 1183.44±683.87全麻組 25 91.32±34.31 184.72±54.37 2416.92±546.86 1047.56±426.97

表3 三組術(shù)中麻醉藥用量比較 (±s)

表3 三組術(shù)中麻醉藥用量比較 (±s)

注:與經(jīng)穴組比較1)P＜0.05,2)P＜0.01

組別 n 芬太尼(mg) 維庫(kù)溴銨(μg/kg·min) 異丙酚(mg)經(jīng)穴組 27 0.23±0.05 2.15±0.43 446.18±115.31非經(jīng)非穴組 28 0.25±0.05 2.44±0.42 514.18±166.931)全麻組 25 0.26±0.062)2.76±0.411)570.98±149.502)

表4 三組術(shù)后清醒時(shí)間、拔管時(shí)間和定向時(shí)間比較(±s,min)

表4 三組術(shù)后清醒時(shí)間、拔管時(shí)間和定向時(shí)間比較(±s,min)

注:與經(jīng)穴組比較1)P＜0.01

組別 n 清醒時(shí)間 拔管時(shí)間 定向時(shí)間經(jīng)穴組 27 3.00±2.39 6.80±5.58 9.93±7.54非經(jīng)非穴組 28 8.02±7.311)17.00±13.411)20.70±13.581)全麻組 25 10.20±8.471)16.02±10.651)18.76±11.151)

4 討論

經(jīng)過(guò)半個(gè)多世紀(jì)的臨床實(shí)踐和實(shí)驗(yàn)研究,針麻的研究取得了重大成果,并在推動(dòng)臨床麻醉的發(fā)展中發(fā)揮了積極的作用[9]。近年來(lái),研究經(jīng)穴特異性已被列入了中國(guó)針灸學(xué)科的重大課題[10]。我院以往的研究[11]表明,針刺經(jīng)穴復(fù)合全麻具有循環(huán)系統(tǒng)平穩(wěn),術(shù)中麻醉藥用量減少的特點(diǎn)。本次研究主要應(yīng)用HXD-Ⅰ型C028手掌式肌松監(jiān)測(cè)儀對(duì)80例腹腔鏡膽囊切除術(shù)患者進(jìn)行肌松效應(yīng)的研究,以闡明經(jīng)穴特異性的科學(xué)內(nèi)涵。

肌松效應(yīng)包括顯效時(shí)間(從注藥至T1/Tc抑制5%所用時(shí)間)、起效時(shí)間(從注藥至T1/Tc最大抑制所用時(shí)間)、肌松維持時(shí)間(T1/Tc恢復(fù)至25%所用時(shí)間)、恢復(fù)指數(shù)(T1/Tc由恢復(fù)25%至恢復(fù)75%所用時(shí)間)、單位時(shí)間用藥量(手術(shù)過(guò)程中的總用藥量/體重×肌松維持時(shí)間)。結(jié)果發(fā)現(xiàn)三組的顯效時(shí)間、起效時(shí)間、恢復(fù)指數(shù)均無(wú)顯著差異(P＞0.05),但經(jīng)穴組的維持時(shí)間較全麻組顯著延長(zhǎng)(P＜0.05),而且從術(shù)中麻醉藥的用量上也可看出經(jīng)穴組中維庫(kù)溴銨的用藥量明顯少于全麻組(P＜0.05)。從這兩方面可以說(shuō)明針刺經(jīng)穴復(fù)合全麻對(duì)維庫(kù)溴銨肌松效應(yīng)有一定的影響,即延長(zhǎng)了維庫(kù)溴銨的維持時(shí)間,從而減少了維庫(kù)溴銨的用藥量。

從術(shù)中麻醉藥(芬太尼、異丙酚、維庫(kù)溴銨)的用藥量來(lái)看,經(jīng)穴組均少于非經(jīng)非穴組和全麻組,尤其芬太尼和異丙酚的用量(P＜0.01),且從維庫(kù)溴銨的肌松效應(yīng)中可見(jiàn),三組的恢復(fù)指數(shù)沒(méi)有顯著差異(P＞0.05),因此,術(shù)后清醒時(shí)間、拔管時(shí)間和定向時(shí)間的比較中,經(jīng)穴組所需時(shí)間明顯比非經(jīng)非穴組和全麻組縮短(P＜0.01),術(shù)后恢復(fù)也較快,蘇醒室的逗留時(shí)間縮短,有利于患者早日康復(fù)。

針刺經(jīng)穴復(fù)合全麻能夠明顯延長(zhǎng)肌松藥的維持時(shí)間,減少術(shù)中麻醉性鎮(zhèn)痛藥、鎮(zhèn)靜藥和肌松藥的用量,顯著減輕藥物麻醉對(duì)生命指標(biāo)的不利影響(血壓降低、心指數(shù)降低、外周阻力增高等),術(shù)后清醒時(shí)間、拔管時(shí)間及定向時(shí)間明顯縮短,術(shù)后住院時(shí)間縮短,因此,繼續(xù)探索針刺經(jīng)穴復(fù)合全麻方式,實(shí)施針麻輔助麻醉是針刺經(jīng)穴復(fù)合全麻在手術(shù)中應(yīng)用的必然趨勢(shì)。

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【中圖分類號(hào)】R246.2

【文獻(xiàn)標(biāo)志碼】A

DOI:10.3969/j.issn.1005-0957.2011.04.227

文章編號(hào):1005-0957(2011)04-0227-03

收稿日期2010-12-20

基金項(xiàng)目:上海市衛(wèi)生局中醫(yī)藥科研基金資助(2008L054A)

作者簡(jiǎn)介:丁依紅(1965 - ),女,副主任醫(yī)師

Acupuncture Combined General Anesthesia on Muscle Relaxation of Vecuronium under Operation

DING Yi-hong1, GU

Chen-yi1, SHEN Li-rong2, WU Liang-sen2, SHI Zheng3, CHEN Yue-lai4. 1.Anesthesiology Department of Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine,Shanghai 200437,China; 2.Master Student of Acupuncture-moxibustion and Tuina, Shanghai University of Traditional Chinese Medicine,Shanghai 201203, China; 3.Shanghai Research Institute of Acupuncture and Meridian,Shanghai 200030,China; 4.Shanghai University of Traditional Chinese Medicine,Shanghai 201203,China

[Abstract]ObjectiveTo observe the effects of different anesthesia approaches on the muscle relaxation of vecuronium in patients undergoing laparoscopic cholecystectomy (LC). Methods Eighty patients were randomized into three groups: acupoint group (acupuncture combined general anesthesia by using acupoints), non-acupoint group (acupuncture combined general anesthesia by using non-acupoints) and general anesthesia group. Anesthesia was induced by using Fentanyl 3 μg·kg-1, propofol 2 mg·kg-1and vecuronium 0.1 mg·kg－1in all the groups. Target controlled infusion of propofol and intravenous injection of fentanyl and vecuronium were used to maintain the anesthesia condition. In the acupoint group, bilateral Hegu (LI 4), Neiguan (PC 6), Zusanli (ST 36), Yanglingquan (GB 34) and Quchi (LI 11) were selected to receive acupuncture and subsequent electro-stimulation after qi arrival, till the end of the operation; for the non-acupoint group, same procedure was applied but with non-acupoints, which were located at the midpoints between the selected acupoint and the point of the adjacent meridian. Muscle relaxation detector was used in measuring the effect time, onset time, and maintenance time as well as the recovery index. The dose of anesthetics, the time to recovery, extubation time, and orientation time were all noted. Result Regarding to the muscle relaxation effect of the three groups, the comparison of effect time, onset time and recovery index did not show significant differences (P＞0.05), while the comparison of maintenance time between the acupoint group and general anesthesia group showed significant difference (P＜0.05). Compared with the general anesthesia group, the acupoint group used notably smaller dose of anesthetics (P＜0.05), and it took significantly shorter time in comparison of the time to recovery, extubation time and orientation time (P＜0.05). Conclusion Acupuncture combined general anesthesia prolongs the maintenance time of the muscle relaxant, reduces the anesthetics dose, and contributes to the earlier recovery of the patients.

[Key words]Acupuncture anesthesia; Acupuncture combined anesthesia; Vecuronim bromide; Muscle relaxation