曹為民,范俊峰,陶 陽(yáng),宋 華,周江雨

(湖北省襄陽(yáng)市婦幼保健院麻醉科，湖北 襄陽(yáng) 441000)

無(wú)痛宮腔鏡手術(shù)中不同劑量右美托咪定聯(lián)合丙泊酚靶控輸注的應(yīng)用分析

曹為民,范俊峰,陶 陽(yáng),宋 華,周江雨

(湖北省襄陽(yáng)市婦幼保健院麻醉科，湖北 襄陽(yáng) 441000)

目的 分析右美托咪定聯(lián)合丙泊酚靶控輸注在無(wú)痛宮腔鏡手術(shù)中的劑量選擇及圍術(shù)期不良反應(yīng)。方法 選取襄陽(yáng)市婦幼保健院2014至2016年150例行無(wú)痛宮腔鏡手術(shù)患者75例于術(shù)前泵注1μg/kg右美托咪定為對(duì)照組，75例于術(shù)前泵注0.5μg/kg右美托咪定為實(shí)驗(yàn)組。兩組患者均在12min內(nèi)結(jié)束泵注并全部采用丙泊酚靶控輸注保留麻醉，同時(shí)按照患者病情適當(dāng)控制丙泊酚靶控濃度。觀察兩組患者不同時(shí)間點(diǎn)的血流動(dòng)力學(xué)指標(biāo)，并對(duì)比分析兩組患者術(shù)中、術(shù)后疼痛和惡心反胃等不良反應(yīng)。結(jié)果 對(duì)比兩組患者治療前、消除腫物時(shí)和術(shù)畢時(shí)的平均動(dòng)脈壓(MAP)均無(wú)統(tǒng)計(jì)學(xué)意義(t值分別 -0.98、-0.46、-0.31，均P>0.05)，心率(HR)對(duì)比亦無(wú)統(tǒng)計(jì)學(xué)意義(t值分別 -0.83、-0.53、-1.03，均P>0.05)；兩組患者在麻醉后、擴(kuò)宮時(shí)的MAP比較，均無(wú)統(tǒng)計(jì)學(xué)意義(t值分別1.21、-0.98，均P>0.05)，但實(shí)驗(yàn)組患者的HR明顯高于對(duì)照組(t值分別為6.87、5.63，均P<0.05)；實(shí)驗(yàn)組術(shù)后警覺(jué)/鎮(zhèn)靜評(píng)分(OAA/S)明顯高于對(duì)照組(t=8.96，P=0.00)，患者蘇醒時(shí)間明顯較對(duì)照組短(t= -7.93，P=0.00)而對(duì)比兩組的丙泊酚用量，差異并無(wú)統(tǒng)計(jì)學(xué)意義(t=1.07，P=0.11)；實(shí)驗(yàn)組治療后嗜睡的發(fā)生率遠(yuǎn)低于對(duì)照組(χ2= 16.98，P=0.01)；兩組患者治療中呼吸受限、術(shù)后煩悶、惡心反胃、疼痛不良反應(yīng)的發(fā)生率分別進(jìn)行對(duì)比，均無(wú)明顯差異(χ2值分別為 2.75、1.86、3.04、3.15，均P>0.05)。結(jié)論 右美托咪定聯(lián)合丙泊酚靶控輸注在無(wú)痛宮腔鏡手術(shù)中應(yīng)采取小劑量原則，能夠減輕丙泊酚用量和副作用，有效減少術(shù)后不良反應(yīng)的出現(xiàn)，安全性、可靠性較高。

右美托咪定；丙泊酚；宮腔鏡手術(shù)；麻醉

宮腔鏡手術(shù)作為臨床上普遍認(rèn)可的一種有效診治女性患者宮腔疾病的手段，因其具有創(chuàng)傷較少、手術(shù)時(shí)間迅速等特點(diǎn)，所以，患者的麻醉奏效時(shí)間、清醒時(shí)間的長(zhǎng)短及麻醉療效的好壞極大地影響著手術(shù)質(zhì)量[1-3]。右美托咪定作為選擇性較好的α2腎上腺素受體激動(dòng)劑之一[4]，能夠有效減輕患者痛苦、迅速鎮(zhèn)靜以及阻礙交感活性，同時(shí)對(duì)患者的呼吸不會(huì)造成困擾[5-6]。近年來(lái)，右美托咪定逐漸在對(duì)麻醉手術(shù)患者和危重急癥患者中發(fā)揮著極大的作用，然而關(guān)于其是否能夠應(yīng)用于宮腔鏡患者的手術(shù)中，且不同劑量是否會(huì)對(duì)患者帶來(lái)不同治療效果的報(bào)道相對(duì)較少。因此，本文對(duì)150例行無(wú)痛宮腔鏡手術(shù)患者進(jìn)行觀察，分析右美托咪定聯(lián)合丙泊酚靶控輸注在無(wú)痛宮腔鏡手術(shù)中的劑量選擇及圍術(shù)期不良反應(yīng)的情況。

1資料與方法

1.1一般資料

隨機(jī)選取襄陽(yáng)市婦幼保健院2014至2016年150例行無(wú)痛宮腔鏡手術(shù)的患者，年齡在28～50歲，平均為(38.17±4.53)歲，美國(guó)麻醉醫(yī)師協(xié)會(huì)(American Society of Anesthesiologists，ASA)Ⅰ～Ⅲ級(jí)。150例患者其中75例于術(shù)前泵注1μg/kg右美托咪定為對(duì)照組，75例于術(shù)前泵注0.5μg/kg右美托咪，定為實(shí)驗(yàn)組，兩組患者均聯(lián)合丙泊酚麻醉。伴有嚴(yán)重肝腎功能不全、嚴(yán)重心血管疾病以及精神狀態(tài)不佳者予以排除。

1.2治療方法

所有受試者治療之前均進(jìn)行常規(guī)禁飲禁食，保持清醒狀態(tài)進(jìn)入手術(shù)室。對(duì)照組通過(guò)術(shù)前泵注1μg/kg右美托咪定，實(shí)驗(yàn)組通過(guò)術(shù)前泵注0.5μg/kg右美托咪定；所有患者均在12min內(nèi)結(jié)束泵注并全部采用丙泊酚靶控輸注保留麻醉，起初輸注1μg/mL的劑量；等到受試者失去意識(shí)時(shí)實(shí)施手術(shù)，期間按照患者病情適當(dāng)控制丙泊酚靶控濃度；術(shù)畢終止用藥。手術(shù)期間為促進(jìn)患者血流動(dòng)力學(xué)平衡可適當(dāng)通過(guò)各種血管活性藥物；術(shù)中常規(guī)鼻導(dǎo)管吸氧，若患者脈搏氧飽度<90%，應(yīng)及時(shí)對(duì)患者進(jìn)行面罩加壓供氧以防止呼吸受阻。

1.3判斷指標(biāo)

對(duì)比兩組患者圍術(shù)期不同時(shí)間點(diǎn)的血流動(dòng)力學(xué)指標(biāo)情況，分析兩組患者麻醉前、術(shù)畢警覺(jué)/鎮(zhèn)靜評(píng)分(observer assessment of alertness/sedation scale，OAA/SS)鎮(zhèn)靜得分情況，對(duì)比兩組受試者麻醉時(shí)間、手術(shù)時(shí)間、術(shù)畢清醒時(shí)間及丙泊酚用量的情況，同時(shí)比較兩組患者術(shù)中呼吸受阻、術(shù)畢嗜睡、疼痛、惡心反胃等并發(fā)癥的出現(xiàn)情況。OAA/SS鎮(zhèn)靜得分原則，0分：對(duì)擠捏斜方肌失去感覺(jué)；1分：對(duì)一般推拉失去感覺(jué)；2分：對(duì)一般拍打肩膀或臉部存在感覺(jué)；3分：對(duì)喧嘩或多次喊叫存在感覺(jué)；4分：對(duì)一般喊叫感覺(jué)不明顯；5分：對(duì)一般喊叫感覺(jué)強(qiáng)烈。

1.4統(tǒng)計(jì)學(xué)方法

2結(jié)果

2.1兩組患者圍術(shù)期血流動(dòng)力學(xué)指標(biāo)對(duì)比

對(duì)照組和實(shí)驗(yàn)組患者術(shù)前、消除腫物時(shí)和術(shù)畢的血流動(dòng)力學(xué)指標(biāo)分別進(jìn)行對(duì)比，差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)；對(duì)照組和實(shí)驗(yàn)組患者在麻醉后、擴(kuò)宮時(shí)的平均動(dòng)脈壓(mean arterial pressure，MAP)比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(t=1.21，P=0.09；t=0.98，P=0.65)，但實(shí)驗(yàn)組患者的心率(heart rate，HR)明顯高于對(duì)照組(t=6.87，P=0.01；t=5.63，P=0.02)，見(jiàn)表1。

組別例數(shù)(n)指標(biāo)術(shù)前麻醉后擴(kuò)宮時(shí)消除腫物時(shí)術(shù)畢對(duì)照組75MAP(mmHg)99.04±12.7480.91±9.4384.83±9.8987.82±9.0292.83±9.72HR(次/分)87.89±8.9352.91±9.7355.97±8.6172.83±6.7378.92±6.37實(shí)驗(yàn)組75MAP(mmHg)97.54±10.9482.69±5.0381.03±6.6286.78±6.2791.62±7.37HR(次/分)85.66±9.4163.89±8.0364.83±10.4270.29±5.8375.82±4.98ta-0.98 1.21-0.98 -0.46 -0.31 tb-0.83 6.875.63-0.53 -1.03 Pa0.190.090.650.310.56Pb0.240.010.020.290.15

注：兩組同期MAP對(duì)比：ta、Pa；兩組同期HR對(duì)比：tb、Pb。

2.2兩組患者麻醉前、術(shù)后OAA/SS鎮(zhèn)靜得分以及丙泊酚用量情況對(duì)比

實(shí)驗(yàn)組患者麻醉前的OAA/SS鎮(zhèn)靜得分稍高于對(duì)照組患者，但差異并不明顯(t=1.32，P=0.08)；實(shí)驗(yàn)組患者術(shù)后OAA/SS鎮(zhèn)靜得分明顯高于對(duì)照組(t=8.96，P=0.00)，患者蘇醒時(shí)間明顯較對(duì)照組短(t=-7.93，P=0.00)，而兩組丙泊酚用量進(jìn)行對(duì)比，差異無(wú)統(tǒng)計(jì)學(xué)意義(t=1.07，P=0.11)，見(jiàn)表2。

組別例數(shù)(n)麻醉前OAA/SS得分術(shù)后OAA/SS得分蘇醒時(shí)間(min)丙泊酚用量(mg)對(duì)照組753.29±0.413.31±0.6919.73±5.73283.67±50.93實(shí)驗(yàn)組753.79±0.514.76±0.7212.59±4.93296.73±66.93t1.328.96-7.93 1.07P0.080.000.000.11

2.3兩組患者圍術(shù)期不良反應(yīng)情況對(duì)比

實(shí)驗(yàn)組治療后嗜睡的發(fā)生率遠(yuǎn)遠(yuǎn)低于對(duì)照組(χ2= 16.98，P=0.01)；兩組患者治療期間呼吸受阻以及術(shù)后煩悶、惡心反胃、疼痛的發(fā)生率分別進(jìn)行對(duì)比，差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)，見(jiàn)表3。

表3 兩組患者圍術(shù)期不良反應(yīng)情況對(duì)比[n(%)]

3討論

3.1宮腔鏡手術(shù)優(yōu)勢(shì)與劣勢(shì)

宮腔鏡手術(shù)具有創(chuàng)傷較少、手術(shù)時(shí)間迅速等特點(diǎn)，所以，術(shù)中術(shù)者務(wù)必創(chuàng)造安全舒適的手術(shù)環(huán)境，讓患者足夠止痛鎮(zhèn)靜，術(shù)后短時(shí)間促使患者清醒，降低術(shù)后各種并發(fā)癥的出現(xiàn)。盡管宮腔鏡手術(shù)是臨床上普遍認(rèn)可的以診治女性宮腔疾病方法，但在宮頸管擴(kuò)張時(shí)可能導(dǎo)致其嚴(yán)重神經(jīng)反射，發(fā)生惡心反胃、血壓明顯降低及心率降低的情況，情況劇烈時(shí)會(huì)導(dǎo)致患者發(fā)生昏厥甚至心搏驟?，F(xiàn)象；同時(shí)在患者宮腔內(nèi)實(shí)施宮腔鏡手術(shù)治療時(shí)會(huì)帶來(lái)嚴(yán)重疼痛感，出現(xiàn)極大應(yīng)激反應(yīng)，引起血流動(dòng)力學(xué)的不穩(wěn)定性[7-9]。所以，如何有效減輕患者的迷走神經(jīng)發(fā)射和疼痛感以降低術(shù)后不良反應(yīng)的發(fā)生率，提高患者的生命質(zhì)量變得尤為重要。

3.2丙泊酚藥物特點(diǎn)

丙泊酚作為常見(jiàn)的靜脈麻醉藥物之一，具有起效時(shí)間迅速、恢復(fù)時(shí)間快、可控性良好及麻醉效果顯著等優(yōu)勢(shì)，已經(jīng)逐漸在不同內(nèi)鏡檢查及小手術(shù)中發(fā)揮著極大的作用[10-11]。因丙泊酚缺乏止痛的療效，故大多患者出現(xiàn)術(shù)后伴有嚴(yán)重的疼痛感[12-13]；同時(shí)，一旦丙泊酚過(guò)度用藥，會(huì)導(dǎo)致患者出現(xiàn)呼吸和循環(huán)功能受阻，故臨床上如何選擇更為合適且有效的鎮(zhèn)痛藥物也是術(shù)者不得不面臨的問(wèn)題之一。

3.3右美托咪定藥物特點(diǎn)

右美托咪定即為α2腎上腺素受體激動(dòng)劑之一，其選擇性較好且止痛鎮(zhèn)靜的效果較為明顯。因其不同劑量的選擇上會(huì)對(duì)患者心率帶來(lái)一定影響，并且其能夠阻礙交感活性，會(huì)輕度降低患者血壓和心率[14]。本次實(shí)驗(yàn)中兩組患者泵注右美托咪定后血壓、心率均低于用藥前，同時(shí)對(duì)照組患者用藥劑量相對(duì)較大，造成患者在麻醉后、擴(kuò)宮時(shí)的心率明顯低于實(shí)驗(yàn)組，這一結(jié)果與上述臨床研究報(bào)道達(dá)成一致。其次，采用右美托咪定使其作用于藍(lán)斑核以發(fā)揮鎮(zhèn)靜催眠的療效，同時(shí)不同劑量的選擇會(huì)對(duì)其鎮(zhèn)靜催眠產(chǎn)生不同的作用[15]。本次研究中，兩組患者均在泵注右美托咪定后取得較好的鎮(zhèn)靜作用，然而因?qū)φ战M患者通過(guò)1μg/kg的劑量使其術(shù)后清醒時(shí)間長(zhǎng)于實(shí)驗(yàn)組。作為輔助性的麻醉藥物之一，右美托咪定本身有著良好的止痛鎮(zhèn)靜的療效，能夠減輕其他配伍藥物的劑量和副作用。因其劑量的不同，本次實(shí)驗(yàn)中對(duì)照組患者的丙泊酚劑量較實(shí)驗(yàn)組低，但差異并不明顯；同時(shí)，因?qū)嶒?yàn)組患者鎮(zhèn)靜程度較輕，患者治療后嗜睡的發(fā)生率遠(yuǎn)低于對(duì)照組。兩組患者治療期間呼吸受阻以及術(shù)后煩悶、惡心反胃、疼痛的發(fā)生率分別進(jìn)行對(duì)比，均無(wú)明顯差異。可見(jiàn)，右美托咪定聯(lián)合丙泊酚能夠有效減少術(shù)后并發(fā)癥的出現(xiàn)，安全性、可靠性較高。

綜上所述，右美托咪定聯(lián)合丙泊酚靶控輸注在無(wú)痛宮腔鏡手術(shù)中應(yīng)采取小劑量原則，能夠減輕丙泊酚用量和副作用，有效減少術(shù)后不良反應(yīng)的出現(xiàn)，安全性、可靠性較高，臨床上值得應(yīng)用和推廣。

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[專(zhuān)業(yè)責(zé)任編輯：陳 寧]

Analysis of different doses of dexmedetomidine combined with propofol for target controlled infusion in painless hysteroscopy surgery

CAO Wei-min, FAN Jun-feng, TAO Yang, SONG Hua, ZHOU Jiang-yu

(DepartmentofAnesthesiology,MaternalandChildHealthHospitalofXiangyangCity,HubeiXiangyang441000,China)

Objective To analyze the different doses selection of dexmedetomidine combined with propofol for target controlled infusion in painless hysteroscopic surgery and perioperative adverse reactions. Methods Totally 150 cases undergoing painless hysteroscopic surgery were selected in Maternal and Child Health Hospital of Xiangyang City during 2014 to 2016 and were divided into control group including 75 cases with preoperative infusion of 1μg/kg dexmedetomidine and experiment group including 75 cases with preoperative infusion of 0.5μg/kg dexmedetomidine. The pumping was ended in 12 minutes. Target controlled infusion of propofol anesthesia was used and the concentration was controlled according to patients’ disease. The hemodynamics indexes at different time of two groups were observed and pain, nausea and other adverse reactions were compared between two groups during and after surgery. Results The mean arterial pressure (MAR) in two groups before treatment, eliminating mass and after surgery showed no significant difference (tvalue was -0.98, -0.46 and -0.31, respectively, allP>0.05), and the heart rate (HR) also showed no significant difference (tvalue was -0.83, -0.53 and -1.03, respectively, allP>0.05). The MAP of two groups after anesthesia and at uterus dilatation was not significantly different (tvalue was 1.21 and -0.98, respectively, bothP>0.05), but HR in the experiment group was significantly higher than that of the control group (tvalue was 6.87 and 5.63, respectively, bothP<0.05). Observer Assessment of Alertness/Sedation Scale (OAA/S) score in the experimental group after treatment was significantly higher than that of the control group (t=8.96,P=0.00) and the awake time was lower than that of the control group (t=-7.93,P=0.00). But propofol dosage showed no significant difference between two groups (t=1.07,P=0.11). The incidence of sleepiness in the experimental group after treatment was far lower than in the control group (χ2=16.98,P=0.01). The incidence of respiratory depression during operation, boredom, nausea and pain after treatment between two groups showed no significant difference (χ2value was 2.75, 1.86, 3.04 and 3.15, respectively, allP>0.05). Conclusion The principle of small dose of dexmedetomidine combined with target controlled infusion of propofol should be adopted in painless hysteroscopic surgery, which can reduce the dosage and side-effects of propofol, effectively reduce the adverse reactions after operation with high safety and reliability.

dexmedetomidine; propofol; hysteroscopic surgery; anesthesia

2016-12-16

曹為民(1962-)，男，副主任醫(yī)師，主要從事婦產(chǎn)科臨床麻醉工作。

10.3969/j.issn.1673-5293.2017.03.044

R713

A

1673-5293(2017)03-0354-03