黃貴林，趙玉陽(yáng)，勾寶晶,2*

右美托咪定與咪達(dá)唑侖在經(jīng)內(nèi)鏡逆行胰膽管造影術(shù)中的應(yīng)用比較

黃貴林1，趙玉陽(yáng)1，勾寶晶1,2*

目的 觀察比較右美托咪定與咪達(dá)唑侖在經(jīng)內(nèi)鏡逆行胰膽管造影術(shù)(ERCP)中對(duì)患者血流動(dòng)力學(xué)及術(shù)后并發(fā)癥的影響。方法 選取擇期行ERCP的患者60例，隨機(jī)分為2組，即右美托咪定組(D組)和咪達(dá)唑侖組(M組)，每組30例。D組于10 min內(nèi)給予1 μg/kg負(fù)荷劑量的右美托咪定，隨后以0.5 μg/(kg·h)速度泵注，使拉姆齊鎮(zhèn)靜評(píng)分(Ramsay Sedation Scale，RSS)維持于3～4分。M組靜脈注射0.04 mg/kg咪達(dá)唑侖，然后逐次追加0.5 mg，使RSS評(píng)分維持于3～4分。觀察并比較兩組患者注藥前(T1)、注藥后(T2)、手術(shù)開(kāi)始5 min(T3)、10 min(T4)、15 min(T5)及入恢復(fù)室后(T6)等各時(shí)點(diǎn)的生命體征(HR、MAP)及不良反應(yīng)發(fā)生情況。結(jié)果 D組T3、T4、T5、T6各時(shí)點(diǎn)的HR明顯低于T1，且明顯低于M組(P<0.05)；M組T3、T4、T5各時(shí)點(diǎn)的MAP明顯低于T1，且明顯低于D組(P<0.05)；在手術(shù)過(guò)程中，M組患者嗆咳發(fā)生率為83.3%，躁動(dòng)發(fā)生率為50%，而D組分別為20%和3%，兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；D組需要丙泊酚輔助的例數(shù)略少于M組，但差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 相對(duì)于咪達(dá)唑侖，右美托咪定是ERCP清醒鎮(zhèn)靜時(shí)的更好選擇。

清醒鎮(zhèn)靜；右美托咪定；經(jīng)內(nèi)鏡逆行胰膽管造影術(shù)；咪達(dá)唑侖

0 引言

右美托咪定是一種高選擇性的α2腎上腺素能受體激動(dòng)劑，其主要作用為抗交感、鎮(zhèn)靜、遺忘和鎮(zhèn)痛[12]，能夠?yàn)榛颊咛峁┆?dú)特的“清醒鎮(zhèn)靜”和鎮(zhèn)痛狀態(tài)，且無(wú)呼吸抑制。中樞神經(jīng)系統(tǒng)的α2激動(dòng)劑可使突觸后受體激活，降低交感神經(jīng)興奮性，從而降低心率和血壓。

1 資料與方法

1.1 臨床資料 經(jīng)倫理委員會(huì)批準(zhǔn)并與患者及家屬簽署知情同意書(shū)。選擇擇期行ERCP的患者60例，性別不限，年齡18～60歲，ASA Ⅰ～Ⅱ級(jí)，按照隨機(jī)數(shù)字表法分為2組，每組30例。排除標(biāo)準(zhǔn)：ASA Ⅲ級(jí)及以上；術(shù)前SpO2<90%；機(jī)械通氣；伴其他合并癥，如糖尿病、高血壓、肝腎功能不全等；語(yǔ)言功能障礙或耳聾；對(duì)該類(lèi)藥物過(guò)敏；懷孕的患者。

1.2 研究方法 患者入手術(shù)室后連接心電監(jiān)護(hù)，建立靜脈通路。于手術(shù)開(kāi)始前靜脈注射芬太尼1 μg/kg。D組于10 min內(nèi)靜脈注射1 μg/kg負(fù)荷劑量的右美托咪定，隨后以0.5 μg/(kg·h)速度泵注，使拉姆齊鎮(zhèn)靜評(píng)分(Ramsay Sedation Scale，RSS)維持于3～4分。M組靜脈注射0.04 mg/kg咪達(dá)唑侖，然后逐次追加0.5 mg，以使RSS評(píng)分維持于3～4分。當(dāng)患者術(shù)中不能配合，手術(shù)無(wú)法正常進(jìn)行時(shí)，使用丙泊酚輔助鎮(zhèn)靜。

1.3 觀察指標(biāo) 觀察并比較兩組患者在注藥前(T1)、注藥后(T2)、手術(shù)開(kāi)始5 min(T3)、10 min(T4)、15 min(T5)及入恢復(fù)室后(T6)等各時(shí)點(diǎn)的生命體征(包括HR及MAP)，記錄術(shù)中不良反應(yīng)的發(fā)生情況，并計(jì)算其發(fā)生率。記錄各組中需要丙泊酚輔助鎮(zhèn)靜的例數(shù)。

2 結(jié)果

2.1 兩組患者各時(shí)點(diǎn)生命體征比較 D組T3、T4、T5、T6各時(shí)點(diǎn)的HR明顯低于T1，且明顯低于M組(P<0.05)；M組T3、T4、T5各時(shí)點(diǎn)的MAP明顯低于T1，且明顯低于D組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見(jiàn)表1、表2。

表1 兩組患者心率的比較(次/min)

注：與T1時(shí)比較，*P<0.05；與M組比較，#P<0.05

表2 兩組患者平均動(dòng)脈壓的比較(mmHg)

注：與T1比較，*P<0.05；與D組比較，△P<0.05

2.2 兩組患者并發(fā)癥發(fā)生情況比較 在手術(shù)過(guò)程中，M組嗆咳發(fā)生率為83.3%，躁動(dòng)發(fā)生率為50%，而D組分別為20%和3%，明顯低于M組，兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.01)，見(jiàn)表3。

表3 兩組患者并發(fā)癥發(fā)生情況比較(例，%)

注：與M組比較，##P<0.01

2.3 兩組患者輔助鎮(zhèn)靜例數(shù)比較 D組2例患者需要丙泊酚輔助，M組為4例，兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。

3 討論

在ERCP手術(shù)中，適度的鎮(zhèn)痛和鎮(zhèn)靜可以減輕患者的焦慮、不適和疼痛，使手術(shù)過(guò)程中患者更加舒適并加快手術(shù)進(jìn)程，避免由于患者不合作而引起的十二指腸穿孔、胰腺炎等并發(fā)癥的發(fā)生[13]。

右美托咪定是一種高選擇性的α2腎上腺素能受體激動(dòng)劑，主要作用為抗交感、鎮(zhèn)靜、遺忘和鎮(zhèn)痛[12]，是目前需要術(shù)中喚醒的手術(shù)的首選鎮(zhèn)靜藥，該藥物可以單獨(dú)使用，也可以與其他靜脈麻醉藥同時(shí)使用，從而減少其他鎮(zhèn)靜藥及鎮(zhèn)痛藥的用量。Shin等[14]研究發(fā)現(xiàn)，右美托咪定可以使血流動(dòng)力學(xué)更加穩(wěn)定，但是可能會(huì)通過(guò)抗交感作用使心率下降。本實(shí)驗(yàn)結(jié)果表明，D組患者在靜注右美托咪定后各時(shí)點(diǎn)的MAP與T1時(shí)比較差異無(wú)統(tǒng)計(jì)學(xué)意義，即血流動(dòng)力學(xué)穩(wěn)定；而M組T3～T5各時(shí)點(diǎn)的MAP明顯低于T1時(shí)點(diǎn)，可能是咪達(dá)唑侖合并阿片類(lèi)藥物后所致的血壓降低。D組中T3～T6各時(shí)點(diǎn)的HR明顯低于T1，且明顯低于M組，而M組的HR并未發(fā)生明顯變化，該結(jié)果與郝靜等[15]的研究結(jié)果基本一致。由此可見(jiàn)，右美托咪定可以使血流動(dòng)力學(xué)更加穩(wěn)定，且在一定程度上降低心率。

與右美托咪定相比，咪達(dá)唑侖為強(qiáng)鎮(zhèn)靜藥，并無(wú)鎮(zhèn)痛作用[16]。Nair等[17]研究證實(shí)，術(shù)中應(yīng)用咪達(dá)唑侖作為鎮(zhèn)靜藥物，其副作用明顯多于右美托咪定，與本實(shí)驗(yàn)中M組患者并發(fā)癥明顯高于D組的結(jié)果一致。此外，D組患者需要丙泊酚輔助鎮(zhèn)靜的例數(shù)比M組少，提示右美托咪定較咪達(dá)唑侖的鎮(zhèn)靜作用強(qiáng)，且兼具鎮(zhèn)痛作用。

總之，在短時(shí)間內(nèi)的有創(chuàng)性手術(shù)如ERCP中，使用右美托咪實(shí)施清醒鎮(zhèn)靜較咪達(dá)唑侖能達(dá)到更好的效果。右美托咪定是一種安全的藥物，且術(shù)中不良反應(yīng)較少，但是關(guān)于在ERCP中的使用報(bào)道較少。因此，需要進(jìn)一步多中心隨機(jī)對(duì)照試驗(yàn)加之驗(yàn)證。

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Comparison of dexmedetomidine and midazolam for conscious sedation in ERCP

HUANG Gui-lin1,ZHAO Yu-yang1,GOU Bao-jing1,2*

(1.Kuandian Central Hospital,Dandong 118200,China;2.Children′s Hospital of Fudan University,Shanghai 201102,China)

Objective To compare the differences between dexmedetomidine and midazolam in ERCP by observing the changes of hemodynamics and the incidences of complications.Methods 60 patients who required ERCP were randomly divided into two equal groups: dexmedetomidine group(group D,n=30) and midazolam group(group M,n=30).All patients received fentanyl 1 μg/kg at the beginning of ERCP.Group D received dexmedetomidine at a loading dose of 1 μg/kg for 10 min,then they were injected continuously by 0.5 μg/(kg·h) until Ramsay Sedation Scale (RSS) score reached 3～4.Group M received midazolam 0.04 mg/kg and additional 0.5 mg until RSS reached 3～4.HR and MAP at pre-loading(T1),post-loading(T2),5 min of ERCP(T3),10 min of ERCP(T4),15 min of ERCP(T5),and the time when reached the recovery room(T6) and complications in procedures were recorded.Results HR of group D was lower at T3,T4,T5,T6(P<0.05),there were significant differences between the two groups(P<0.05).MAP of group M was lower at T3,T4,T5(P<0.05),there were significant differences between the two groups(P<0.05).During the procedure,the incidences of gagging(83.3%) and restlessness(50%) of group M was higher than those of group D(20%and 3%respectively)(P<0.05).The number of cases required propofol in group D was slightly less than that of group M,but there was no significant difference between the two groups(P>0.05).Conclusion Dexmedetomidine is a better choice for conscious sedation in ERCP than midazolam.

Conscious sedation;Dexmedetomidine;ERCP;Midazolam

2014-07-13

1.寬甸中心醫(yī)院，遼寧 丹東 118200；2.復(fù)旦大學(xué)附屬兒科醫(yī)院，上海 201102

*通信作者

10.14053/j.cnki.ppcr.201503029