陳金仙+顧曉霞+蔡樹云+彭雪+楊光平
作者簡介:陳金仙,女,副主任醫(yī)師,醫(yī)學學士。Email:gu7450210@163.com.
陳金仙,顧曉霞,蔡樹云,彭雪,楊光平
(廣東醫(yī)學院附屬醫(yī)院麻醉科,湛江524001)
【摘要】目的探討麻醉手術前使用右美托咪定對患者麻醉術前身心應激的抑制程度。
方法選擇100例20~60歲、ASAⅠ~Ⅱ級的擇期手術患者,隨機分為兩組:實驗組(A組)于麻醉前45 min鼻內(nèi)滴注右美托咪定1 μg/kg,對照組(B組)麻醉前45 min鼻內(nèi)滴注等容量的生理鹽水;分別于用藥前后測定患者SBP、DBP、HR、SpO2、焦慮視覺模擬評分(AVAT)、腎上腺素(E)和去甲腎上腺素(NE)的水平。
結果對照組患者SBP、DBP、HR、SpO2在用藥前后比較差異無統(tǒng)計學意義(P>005),實驗組在用藥前后各時間點的SBP、SpO2的變化無統(tǒng)計學意義(P>0.05),但在用藥后T4、T5時DBP與對照組比較有統(tǒng)計學意義(P<001);實驗組用藥后各時點HR開始下降,與用藥前及對照組同一時間點比較差異有統(tǒng)計學意義(P<001)。對照組患者在用藥45 min后AVAT、E、NE的水平明顯升高,差異有統(tǒng)計學意義(P<001);實驗組在用藥后AVAT明顯下降,E、NE的水平明顯上升高,差異有統(tǒng)計學意義(P<001);且兩組用藥后AVAT、E、NE的水平比較差異有統(tǒng)計學意義(P<001)。
結論 右美托咪定滴鼻預處理可以減輕麻醉手術前患者的生理和心理應激,是一種安全有效的術前用藥。
【關鍵詞】右美托咪定;滴鼻;身心應激
中圖分類號:R614文獻標識碼:A文章編號:10031383(2014)03031304
DOI:10.3969/j.issn.10031383.2014.03.015
Effect of dexmedetomidine nasal drop as premedication on the psychophysical stress of patients before anesthesia for surgery
CHEN Jinxian,GU Xiaoxia,CAI Shuyun,PENG Xue,YANG Guangping
(Department of Anesthesiology,Affiliated Hospital of Guangdong Medical College,Zhanjiang 524001,Guangdong,China)
【Abstract】ObjectiveTo investigate the inhibition degree of dexmedetomidine(DEX) on patients psychophysical stress before anesthesia for surgery.
Methods100 patients aged from 20 to 60 with ASA of gradeⅠtoⅡ,who had been scheduled for surgery,were randomly divided into the experimental group (Group A) and the control group(Group B).The experimental group were given 1 μg/kg of DEX by intranasal instillation 45 mins before anesthesia,while the control group were given the same volume of saline (also by intranasal instillation)45mins before anesthesia.Then,the SBP,DBP,HR,SpO2,anxiety visual analogue scale (AVAT),level of epinephrine (E) and norepinephrine (NE) before and after operation were tested,respectively.
Results Difference of the SBP,DBP,HR and SpO2 were not statistically significant before and after operation in the control group(P>0.05).Difference of SBP and SpO2 of the experimental group at different points in time before and after operation was not statistically significant either (P>0.05),but comparison of DBP at T4 and T5 after operation between two groups showed statistically significant difference (P<0.01).HR at different points in time of the experimental group decreased after DEX was given.They were significantly different from those beforetreatment and those of the control group in the same points in time(P<0.01).45 mins after treatment,the AVAT,E and NE of the control group significantly increased,significantly different from those before treatment(P<0.01).The AVAT of the experimental group significantly decreased after treatment,while their E and NE significantly increased, so the difference was statistically significant(P<0.01). Moreover, difference in AVAT,E and NE of two groups after treatment were statistically significant(P<0.01).
ConclusionIntranasal dexmedetomidine can reduce the patients psychophysical stress in anesthesia before surgery.It is a kind of safe and effective premedication.
【Key words】dexmedetomidine;nasal drop;psychophysical stress
研究表明,患者在手術前存在不同程度的焦慮,發(fā)生率一般在60%左右,最高可達80%[1],當術前患者對手術產(chǎn)生過度緊張和焦慮的情緒反應時,就會直接影響手術的順利進行以及術后的身體恢復[2],因此術前用藥的主要目的是鎮(zhèn)靜和緩解患者焦慮情緒。右美托咪定是一種高效、高選擇性腎上腺素α2受體激動劑,它在術前用藥方面是一個新的嘗試,與咪唑安定相比,有它獨特的優(yōu)越性:因具有獨特的“可喚醒”的鎮(zhèn)靜狀態(tài)和抑制交感活動的效應,是一種新型的鎮(zhèn)靜鎮(zhèn)痛藥物[3,4]。隨著舒適化醫(yī)療和人性化麻醉的興起,術前無創(chuàng)性給藥方式逐漸取代肌注給藥方式,鼻腔給藥不通過肝臟的首過效應,用藥量小,無創(chuàng),病人感覺舒適,越來越受到國內(nèi)外學者的關注和喜愛。本研究觀察術前鼻內(nèi)滴注右美托咪定對手術患者身心應激的影響,為臨床術前用藥提供參考。
1資料與方法
1.1一般資料 選取擇期手術患者100例,年齡18~60歲,ASA分級Ⅰ~Ⅱ級。術前均經(jīng)醫(yī)院倫理委員會批準,患者簽署知情同意書。排除標準:①體重超過80 kg,或體重指數(shù)(BMI)>30 kg/m2;②有嚴重的心血管和呼吸系統(tǒng)疾病;③肝、腎功能嚴重受損;④患有嚴重精神疾病或存在語言交流障礙的患者;⑤經(jīng)常服用鎮(zhèn)痛藥或鎮(zhèn)靜藥;⑥患有心動過緩和房室傳導阻滯;⑦有嚴重的鼻內(nèi)疾患,不利于藥物吸收的患者。隨機分為實驗組(A組)和對照組(B組),每組50例。實驗組男26例,女24例,平均年齡(36.5±3.3)歲,平均體重(55.0±7.9)kg,ASAⅠ級36例,Ⅱ級14例,對照組男28例,女22例,平均年齡(37.4±4.8)歲,平均體重(57.0±8.8)kg,ASAⅠ級39例,Ⅱ級11例。兩組患者性別、年齡及體重差異無統(tǒng)計學意義(P>005),具有可比性。
1.2研究方法
兩組病人分別于麻醉前45 min雙盲給予鼻腔滴入1 μg/kg的右美托咪定和生理鹽水(均按0.1 ml/kg量給予),患者入室后開放外周靜脈,給予面罩吸氧,流量3 L/min,常規(guī)行左橈動脈穿刺,采用多功能監(jiān)護儀動態(tài)監(jiān)測病人心電圖(ECG)、心率(HR)、收縮壓(SBP)、舒張壓(DBP)、脈搏氧飽和度(SpO2)。
1.3觀察指標
兩組患者分別于用藥前5 min(T1)及用藥后10 min(T2)、20 min(T3)、30 min(T4)、40 min(T5)觀察記錄患者的SBP、DBP、HR、SpO2,于用藥前一天和用藥后45 min對患者進行焦慮視覺模擬評分(AVAT)。并抽取患者靜脈血放入-80℃冰箱保存,最后統(tǒng)一用ELISA試劑盒檢測不同時間點腎上腺素(E)和去甲腎上腺素(NE)的水平。
1.4統(tǒng)計學方法
采用SPSS 15.0統(tǒng)計軟件分析數(shù)據(jù);計量資料以均數(shù)±標準差(-±s)進行統(tǒng)計描述,組間比較采用獨立樣本t檢驗,組內(nèi)比較用重復測量資料的方差分析;計數(shù)資料采用構成比進行統(tǒng)計描述,獨立樣本構成比的比較采用卡方檢驗;對于非正態(tài)計數(shù)資料采用秩和檢驗;以P<005為差異統(tǒng)計學意義。
2結果
2.1兩組患者圍術期SBP、DBP、HR、SpO2變化的比較
對照組在用藥前后各時間點的SBP、DBP、SpO2的變化差異無統(tǒng)計學意義(P>005);實驗組在用藥前后各時間點的SBP、SpO2的變化差異無統(tǒng)計學意義(P>005),但在用藥后T4、T5時DBP與對照組比較有統(tǒng)計學意義(P<001);但均未出現(xiàn)明顯低血壓。對照組患者在用藥前后各時間點HR明顯增快,實驗組患者用藥前HR較快,與對照組比較差異無統(tǒng)計學意義(P>005),但實驗組用藥后各時點HR均明顯下降,與用藥前及對照組同一時間點比較差異有統(tǒng)計學意義(P<001)。見表1。
2.2兩組患者用藥前后AVAT、E、NE的比較
兩組用藥前1天AVAT、E、NE的水平比較差異無統(tǒng)計學意義(P>005);對照組患者在用藥45 min后AVAT、E、NE的水平明顯上升,差異有統(tǒng)計學意義(P<001);實驗組在用藥后AVAT明顯下降,E、NE的水平明顯上升,差異有統(tǒng)計學意義(P<001);且兩組用藥后AVAT、E、NE的水平比較差異有統(tǒng)計學意義(P<001)。見表2。
表1兩組患者SBP、DBP、HR、SpO2變化(n=50,-±s)
指標組別T1T2T3T4T5
SBP(mmHg)A組123.7±14.1121.8±11.4119.9±11.1116.5±12.2119.6±10.9
B組126.6±15.0126.2±13.3120.1±12.1119.7±10.2122.4±12.3
DBP(mmHg)A組73.7±10.169.8±9.465.9±9.1 64.5±10.2▲66.5±6.9▲
B組77.6±11.169.2±10.369.1±9.171.7±10.279.4±12.3
HR(次/min)A組96.4±9.981.9±11.4★▲74.1±8.3★▲70.5±10.5★▲66.9±9.7★▲
B組97.6±11.191.2±10.390.1±9.190.9±10.291.4±12.3
SPO2(%)A組99.2±0.398.5±0.897.3±1.197.5±0.598.6±0.6
B組99.1±0.497.3±1.396.6±0.397.7±1.298.2±0.4
注:與T1比較,★P<001;與B組比較,▲P<001。
表2兩組用藥前后AVAT、E和NE值變化(n=50,-±s)
組別時間AVAT(mm)E(pg/ml)NE(pg/ml)
A組用藥前1天 67.26±14.1247.61±6.2256.31±25.3
用藥后45 min30.08±9.11▲#72.36±2.3▲#277.4±16.4▲#
B組用藥前1天65.88±10.6746.34±5.8257.16±30.9
用藥后45 min80.92±12.7#102.4±9.1#369.9±27.3#
注:與B組比較,▲P<001;與用藥前1天比較,#P<001。
3討論
手術和麻醉均是一種有創(chuàng)性操作,大多數(shù)患者都會擔心手術可能導致痛苦與不適,故而在術前存在不同程度的恐懼、不安及焦慮情緒,甚至有些患者因焦慮過度懼怕而拒絕手術,導致不能及時有效地治療疾病而發(fā)生更嚴重的后果。本研究在術前通過鼻腔內(nèi)給予右美托咪定,取得了很好的鎮(zhèn)靜抗焦慮效果,緩解了患者麻醉手術前的焦慮和緊張狀態(tài)。
右美托咪定是一種新型高選擇性α2腎上腺素能受體激動藥[5],由于其以受體的選擇性(α2/α1為1300∶1)遠高于可樂定(α2/α1為39∶1) [6],半衰期約為23 h(可樂定為6~10 h)[7],效價比可樂定高3倍,有獨特的鎮(zhèn)靜、抗應激、抗寒戰(zhàn)等作用[8],備受臨床關注。本研究顯示,實驗組和對照組在用藥前1天AVAT比較差異無統(tǒng)計學意義,在用藥45 min后實驗組不僅低于用藥前1天,而且明顯低于對照組;E和NE水平在用藥前1天無差異,但在用藥后實驗組的E和NE水平顯著低于對照組,差異有統(tǒng)計學意義(P<001)。右美托咪定對麻醉手術前患者生理和心理應激的抑制作用可能是因為其激動中樞α2A腎上腺素能受體所致,抑制交感神經(jīng)過度興奮,減少血漿兒茶酚胺的釋放[9]。從而產(chǎn)生明顯的中樞鎮(zhèn)靜作用和交感抑制作用,減輕了患者麻醉手術前身心的應激反應。
雖然Dex對α2/αl受體的選擇性高,但是高濃度的右美托咪定也會表現(xiàn)出明顯的直接血管收縮效應,導致血壓升高。為了減輕這種反應,本研究采用了鼻內(nèi)提前45 min預先噴入的方法,結果右美托咪定組未對患者造成明顯心動過緩和嚴重的高血壓等不良反應,并且右美托咪定組收縮壓、舒張壓的變化與同時點的對照組比較差異無統(tǒng)計學意義(P>005);兩組用藥前心率比較差異無統(tǒng)計學意義,用藥后右美托咪定組心率有所下降,與同時點的對照組比較差異有統(tǒng)計學意義(P<001)。所以有合并基礎疾病易發(fā)生心動過緩的患者應慎用右美托咪定,重度心臟傳導阻滯和重度心室功能不全患者不推薦使用。
綜上所述,麻醉手術前鼻內(nèi)預噴右旋美托咪定,能安全有效抑制患者術前身心應激誘發(fā)的心血管反應,產(chǎn)生近似自然睡眠的鎮(zhèn)靜作用且對呼吸無抑制作用[10],值得臨床參考應用。
參考文獻
[1] Lemon J,Edelman S.Psychological adaptation to ICDs and the influence of anxiety sensitivity[J].Psychol Health Med,2007,12(2):163171.
[2] Walburn J,Vedhara K,Hankins M,et al.Psychological stress and wound healing in humans: a systematic review and metaanalysis[J].J Psychosom Res,2009,67(3):253271.
[3] Dominic S,Carollo Bobby D,Nossaman,et al.Dexmedetomidine: a review of clinical applications[J].Current Opinion in Anesthesiology,2008,21(4):457461.
[4] Afonso J,Reis F.Dexmedetomide: current role in anesthesia and intensive care[J].Rev Bras Anestesiol,2012,62(1):118133.
[5] 劉玲,紀風濤,劉付寧,等.右美托咪定對老年患者腰-硬聯(lián)合麻醉的鎮(zhèn)靜效應[J].臨床麻醉學雜志,2011,27(1):5154.
[6] Murrell JC,Hellebrekers LG.Medetomidine and dexmedetomidine:a review of cardiovascular efects and antinociceptive properties in the dog[J].Vet Anaesth Analg,2005,32(3):117127.
[7] Ebertt J,Hall J E,Barney JA,et a1.The effects of in creasing plasma concentrations ofdexmedetomidinein humans[J].Anesthesiology,2000,93(2):382394.
[8] Katarzyna R,Piotr K,Hanna M.The effect of dexmedetomidine sedation on brachialplexus block in patientswith endstage renal disease[J].European Journal of Anaesthesiology,2009,26(10):851855.
[9] Willigers HM,Prinzen FW,Roekaerts PM.The Effects of esmolol and dexmedetomidine on myocardial oxygen consumption during sympathetic stimulation in dogs[J].J Cardiothorac Vasc Anesth,2006,20(3):364370
[10]Bergese SD,Patrick Bender S,Mc Sweeney TD,et al.A Comparative study of dexmedetomidine with midazolam and midazolam alone for sedationduring elective awake fiberoptic intubation[J].J Clin Anesth,2010,22(1):3540.
(收稿日期:2014-01-14修回日期:2014-05-25)
(編輯:潘明志)
雖然Dex對α2/αl受體的選擇性高,但是高濃度的右美托咪定也會表現(xiàn)出明顯的直接血管收縮效應,導致血壓升高。為了減輕這種反應,本研究采用了鼻內(nèi)提前45 min預先噴入的方法,結果右美托咪定組未對患者造成明顯心動過緩和嚴重的高血壓等不良反應,并且右美托咪定組收縮壓、舒張壓的變化與同時點的對照組比較差異無統(tǒng)計學意義(P>005);兩組用藥前心率比較差異無統(tǒng)計學意義,用藥后右美托咪定組心率有所下降,與同時點的對照組比較差異有統(tǒng)計學意義(P<001)。所以有合并基礎疾病易發(fā)生心動過緩的患者應慎用右美托咪定,重度心臟傳導阻滯和重度心室功能不全患者不推薦使用。
綜上所述,麻醉手術前鼻內(nèi)預噴右旋美托咪定,能安全有效抑制患者術前身心應激誘發(fā)的心血管反應,產(chǎn)生近似自然睡眠的鎮(zhèn)靜作用且對呼吸無抑制作用[10],值得臨床參考應用。
參考文獻
[1] Lemon J,Edelman S.Psychological adaptation to ICDs and the influence of anxiety sensitivity[J].Psychol Health Med,2007,12(2):163171.
[2] Walburn J,Vedhara K,Hankins M,et al.Psychological stress and wound healing in humans: a systematic review and metaanalysis[J].J Psychosom Res,2009,67(3):253271.
[3] Dominic S,Carollo Bobby D,Nossaman,et al.Dexmedetomidine: a review of clinical applications[J].Current Opinion in Anesthesiology,2008,21(4):457461.
[4] Afonso J,Reis F.Dexmedetomide: current role in anesthesia and intensive care[J].Rev Bras Anestesiol,2012,62(1):118133.
[5] 劉玲,紀風濤,劉付寧,等.右美托咪定對老年患者腰-硬聯(lián)合麻醉的鎮(zhèn)靜效應[J].臨床麻醉學雜志,2011,27(1):5154.
[6] Murrell JC,Hellebrekers LG.Medetomidine and dexmedetomidine:a review of cardiovascular efects and antinociceptive properties in the dog[J].Vet Anaesth Analg,2005,32(3):117127.
[7] Ebertt J,Hall J E,Barney JA,et a1.The effects of in creasing plasma concentrations ofdexmedetomidinein humans[J].Anesthesiology,2000,93(2):382394.
[8] Katarzyna R,Piotr K,Hanna M.The effect of dexmedetomidine sedation on brachialplexus block in patientswith endstage renal disease[J].European Journal of Anaesthesiology,2009,26(10):851855.
[9] Willigers HM,Prinzen FW,Roekaerts PM.The Effects of esmolol and dexmedetomidine on myocardial oxygen consumption during sympathetic stimulation in dogs[J].J Cardiothorac Vasc Anesth,2006,20(3):364370
[10]Bergese SD,Patrick Bender S,Mc Sweeney TD,et al.A Comparative study of dexmedetomidine with midazolam and midazolam alone for sedationduring elective awake fiberoptic intubation[J].J Clin Anesth,2010,22(1):3540.
(收稿日期:2014-01-14修回日期:2014-05-25)
(編輯:潘明志)
雖然Dex對α2/αl受體的選擇性高,但是高濃度的右美托咪定也會表現(xiàn)出明顯的直接血管收縮效應,導致血壓升高。為了減輕這種反應,本研究采用了鼻內(nèi)提前45 min預先噴入的方法,結果右美托咪定組未對患者造成明顯心動過緩和嚴重的高血壓等不良反應,并且右美托咪定組收縮壓、舒張壓的變化與同時點的對照組比較差異無統(tǒng)計學意義(P>005);兩組用藥前心率比較差異無統(tǒng)計學意義,用藥后右美托咪定組心率有所下降,與同時點的對照組比較差異有統(tǒng)計學意義(P<001)。所以有合并基礎疾病易發(fā)生心動過緩的患者應慎用右美托咪定,重度心臟傳導阻滯和重度心室功能不全患者不推薦使用。
綜上所述,麻醉手術前鼻內(nèi)預噴右旋美托咪定,能安全有效抑制患者術前身心應激誘發(fā)的心血管反應,產(chǎn)生近似自然睡眠的鎮(zhèn)靜作用且對呼吸無抑制作用[10],值得臨床參考應用。
參考文獻
[1] Lemon J,Edelman S.Psychological adaptation to ICDs and the influence of anxiety sensitivity[J].Psychol Health Med,2007,12(2):163171.
[2] Walburn J,Vedhara K,Hankins M,et al.Psychological stress and wound healing in humans: a systematic review and metaanalysis[J].J Psychosom Res,2009,67(3):253271.
[3] Dominic S,Carollo Bobby D,Nossaman,et al.Dexmedetomidine: a review of clinical applications[J].Current Opinion in Anesthesiology,2008,21(4):457461.
[4] Afonso J,Reis F.Dexmedetomide: current role in anesthesia and intensive care[J].Rev Bras Anestesiol,2012,62(1):118133.
[5] 劉玲,紀風濤,劉付寧,等.右美托咪定對老年患者腰-硬聯(lián)合麻醉的鎮(zhèn)靜效應[J].臨床麻醉學雜志,2011,27(1):5154.
[6] Murrell JC,Hellebrekers LG.Medetomidine and dexmedetomidine:a review of cardiovascular efects and antinociceptive properties in the dog[J].Vet Anaesth Analg,2005,32(3):117127.
[7] Ebertt J,Hall J E,Barney JA,et a1.The effects of in creasing plasma concentrations ofdexmedetomidinein humans[J].Anesthesiology,2000,93(2):382394.
[8] Katarzyna R,Piotr K,Hanna M.The effect of dexmedetomidine sedation on brachialplexus block in patientswith endstage renal disease[J].European Journal of Anaesthesiology,2009,26(10):851855.
[9] Willigers HM,Prinzen FW,Roekaerts PM.The Effects of esmolol and dexmedetomidine on myocardial oxygen consumption during sympathetic stimulation in dogs[J].J Cardiothorac Vasc Anesth,2006,20(3):364370
[10]Bergese SD,Patrick Bender S,Mc Sweeney TD,et al.A Comparative study of dexmedetomidine with midazolam and midazolam alone for sedationduring elective awake fiberoptic intubation[J].J Clin Anesth,2010,22(1):3540.
(收稿日期:2014-01-14修回日期:2014-05-25)
(編輯:潘明志)