王 平,李元海,徐 暉

BIS指導(dǎo)下丙泊酚靶控輸注復(fù)合硬膜外阻滯在腎移植患者中的應(yīng)用

王 平1,李元海2,徐 暉3*

目的探討腎移植患者在腦電雙頻指數(shù)(BIS)指導(dǎo)下行靶控輸注(TCI)丙泊酚復(fù)合硬膜外阻滯對(duì)麻醉誘導(dǎo)時(shí)血流動(dòng)力學(xué)變化、術(shù)后恢復(fù)及腎功能的影響。方法選擇擇期行腎移植術(shù)的患者60例，隨機(jī)分為2組，每組30例。試驗(yàn)組采用丙泊酚靶控輸注復(fù)合硬膜外阻滯，對(duì)照組采用單純丙泊酚靶控輸注靜脈麻醉，兩組均行BIS監(jiān)測(cè)。分別監(jiān)測(cè)入手術(shù)室時(shí)(T0)、誘導(dǎo)前(T1)、插管前(T2)、插管即刻(T3)、插管后3 min(T4)患者的MAP、HR,同時(shí)記錄患者意識(shí)消失時(shí)間及此刻的丙泊酚靶控輸注效應(yīng)室濃度，并記錄患者術(shù)后蘇醒時(shí)間、丙泊酚用量。結(jié)果試驗(yàn)組T1時(shí)MAP較T0時(shí)明顯下降(P<0.05)，T2時(shí)兩組MAP、HR較T0時(shí)顯著下降(P<0.05)，試驗(yàn)組T3時(shí)MAP、HR較穩(wěn)定，對(duì)照組MAP、HR則明顯升高，兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。與對(duì)照組比較，試驗(yàn)組意識(shí)消失時(shí)間較短，丙泊酚效應(yīng)室濃度低、用量少，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；試驗(yàn)組蘇醒時(shí)間明顯短于對(duì)照組，蘇醒質(zhì)量高，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。兩組患者術(shù)后腎功能比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論BIS監(jiān)測(cè)下丙泊酚靶控輸注復(fù)合硬膜外阻滯用于腎移植患者可以穩(wěn)定血流動(dòng)力學(xué)，取得滿意的麻醉效果，減少麻醉用量，蘇醒迅速，對(duì)于術(shù)后腎功能無不利影響。

腦電雙頻指數(shù)；靶控輸注；丙泊酚；硬膜外阻滯;血流動(dòng)力學(xué)；腎移植

0 引言

腎功能衰竭患者晚期合并多種并發(fā)癥，患者對(duì)麻醉和藥物耐受性較差，麻醉的風(fēng)險(xiǎn)較高。因此，腎移植手術(shù)要求麻醉誘導(dǎo)平穩(wěn)，保持血流動(dòng)力學(xué)穩(wěn)定，術(shù)后麻醉藥物無蓄積，麻醉恢復(fù)完全、迅速。其中，對(duì)于麻醉深度的控制尤為重要，目前臨床上常采用腦電雙頻指數(shù)(Bispectral index，BIS)作為監(jiān)測(cè)手段。丙泊酚是麻醉誘導(dǎo)和維持常用的短效靜脈麻醉藥物，靶控輸注(Target-controlled infusion，TCI)丙泊酚可以使麻醉誘導(dǎo)平穩(wěn)，在臨床中已經(jīng)得到廣泛應(yīng)用。但是大劑量長(zhǎng)時(shí)間輸注丙泊酚會(huì)產(chǎn)生蓄積作用，引發(fā)丙泊酚輸注綜合征，影響腎移植患者術(shù)后的恢復(fù)[1]。而且，麻醉誘導(dǎo)時(shí)，大劑量丙泊酚會(huì)引起循環(huán)的劇烈波動(dòng)，易導(dǎo)致麻醉意外和并發(fā)癥[2-3]。因此,本研究旨在觀察BIS監(jiān)測(cè)下丙泊酚靶控輸注復(fù)合硬膜外阻滯在腎移植患者術(shù)中血流動(dòng)力學(xué)的變化、麻醉的蘇醒質(zhì)量及術(shù)后對(duì)于腎功能的影響。

1 資料與方法

1.1 一般資料 本研究通過醫(yī)院倫理委員會(huì)的批準(zhǔn)，所有患者簽署知情同意書。選取我院2014-2016年行腎移植手術(shù)患者60例，ASA Ⅲ～Ⅳ級(jí)，男45例，女15例，年齡(35.6±7.4)歲，所有患者均無硬膜外阻滯禁忌證。60例腎移植患者根據(jù)隨機(jī)數(shù)字表法分為2組：試驗(yàn)組采用丙泊酚靶控輸注復(fù)合硬膜外阻滯麻醉方法，對(duì)照組采用單純丙泊酚靶控輸注，每組30例。所有患者術(shù)前均常規(guī)接受血液透析3個(gè)月～5年，術(shù)前24 h均進(jìn)行1次血液透析治療，術(shù)前有高血壓者口服降壓藥，維持血壓穩(wěn)定在基礎(chǔ)水平。兩組患者年齡、性別、體重、ASA分級(jí)、并發(fā)癥等一般情況比較差異無統(tǒng)計(jì)學(xué)意義。

1.2 麻醉方法 患者入室后，行橈動(dòng)脈穿刺置管，開放外周靜脈。所有患者常規(guī)監(jiān)測(cè)心電圖、有創(chuàng)血壓、脈搏血氧飽和度。連接BIS監(jiān)護(hù)儀(Aspect公司，美國(guó))。試驗(yàn)組先行硬膜外阻滯，取T12～L1間隙穿刺，向頭部置管4 cm，給予1%利多卡因4 mL作為試驗(yàn)劑量。若無異常，給予0.75%羅哌卡因5 mL，控制麻醉平面在T5～T6以下。之后進(jìn)行誘導(dǎo)，麻醉誘導(dǎo)方法：試驗(yàn)組在麻醉平面調(diào)好后，采用靶控輸注丙泊酚，血漿靶濃度為2.5 μg/mL，同時(shí)靜脈注射舒芬太尼0.5 μg/kg、咪達(dá)唑侖0.05 mg/kg。待患者意識(shí)消失后，給予肌松藥，肌松起效后行氣管插管；對(duì)照組麻醉誘導(dǎo)方法與試驗(yàn)組相同。麻醉維持：兩組患者均靜脈輸注瑞芬太尼0.2 μg/(kg·min)，術(shù)中根據(jù)肌松要求間斷靜脈注射順苯磺酸阿曲庫(kù)銨，肌松藥最后給藥時(shí)間為手術(shù)結(jié)束前1 h。試驗(yàn)組間斷1 h給予0.75%羅哌卡因4 mL，直至手術(shù)結(jié)束。以BIS值(40～60)為標(biāo)準(zhǔn)來調(diào)節(jié)丙泊酚的血漿靶濃度，至手術(shù)前5 min。對(duì)照組調(diào)控血漿靶濃度標(biāo)準(zhǔn)同試驗(yàn)組。

1.3 觀察指標(biāo) 分別觀察兩組入手術(shù)室時(shí)(T0)、誘導(dǎo)前(T1)、氣管插管前(T2)、氣管插管即刻(T3)、氣管插管后3 min(T4)患者的平均動(dòng)脈壓(MAP)、心率(HR)值，并記錄患者意識(shí)消失時(shí)間和意識(shí)消失時(shí)的丙泊酚靶控輸注效應(yīng)室濃度。記錄患者蘇醒時(shí)間、術(shù)后疼痛滿意度、丙泊酚用量及術(shù)后1周內(nèi)腎功能的變化。

2 結(jié)果

2.1 兩組患者血流動(dòng)力學(xué)變化比較 試驗(yàn)組T1時(shí)MAP與T0時(shí)和對(duì)照組T1時(shí)比較下降明顯(P<0.05)；與T0時(shí)比較，T2時(shí)兩組MAP和HR均明顯降低(P<0.05)；與T2時(shí)比較，T3時(shí)對(duì)照組MAP和HR明顯升高(P<0.05)，而試驗(yàn)組則較平穩(wěn)，T3時(shí)兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；與T0時(shí)比較，T4時(shí)兩組的MAP明顯下降(P<0.05)。見表1、表2。

2.2 兩組患者意識(shí)消失時(shí)間、意識(shí)消失時(shí)丙泊酚靶控輸注效應(yīng)室濃度及術(shù)中丙泊酚用量比較 與試驗(yàn)組比較，對(duì)照組意識(shí)消失時(shí)間明顯延長(zhǎng)(P<0.05)，意識(shí)消失時(shí)丙泊酚的靶控輸注效應(yīng)室濃度和術(shù)中丙泊酚用量明顯升高(P<0.05)，見表3。

2.3 兩組患者麻醉恢復(fù)及術(shù)后疼痛比較 兩組患者麻醉時(shí)間相近，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)；對(duì)照組蘇醒拔管時(shí)間比試驗(yàn)組明顯延長(zhǎng)(P<0.05)，術(shù)后疼痛比例比試驗(yàn)組明顯增多(P<0.05)。見表4。

表1 兩組患者不同時(shí)間點(diǎn)MAP比較(mmHg)

表2 兩組患者不同時(shí)間點(diǎn)HR比較(次/min)

表3 兩組患者意識(shí)消失時(shí)間、意識(shí)消失時(shí)丙泊酚靶控輸注效應(yīng)室濃度及丙泊酚用量比較

表4 兩組患者麻醉時(shí)間、蘇醒拔管時(shí)間及術(shù)后疼痛比較

2.4 兩組患者術(shù)后腎功能比較 與移植前比較，腎移植后兩組患者各時(shí)間點(diǎn)Cr、BUN濃度明顯降低(P<0.01)，尿量明顯增加(P<0.01)。組間比較，兩組患者Cr、BUN、尿量值在各時(shí)間點(diǎn)組間比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，見表5。

3 討論

對(duì)于麻醉深度的監(jiān)測(cè)，使用腦電雙頻指數(shù)BIS作為監(jiān)護(hù)手段，可以使麻醉用藥更加精準(zhǔn)[4-6]。對(duì)于麻醉方式，單純的椎管內(nèi)阻滯麻醉用藥少、對(duì)循環(huán)影響小，又有硬膜外導(dǎo)管可以術(shù)后鎮(zhèn)痛，是早期用于腎移植的主要麻醉方式[7]。但椎管內(nèi)麻醉個(gè)體差異較大，會(huì)出現(xiàn)麻醉不完善，肌松效果不確切，患者不能耐受牽拉反應(yīng)，因此，單純的椎管內(nèi)阻滯已經(jīng)被全身麻醉取代。全身麻醉能提供更好、更安全的手術(shù)條件，維持穩(wěn)定的血流動(dòng)力學(xué)和充分的氧供，完善的肌松，解除患者的焦慮恐懼心理，降低交感神經(jīng)興奮，對(duì)增加腎血流有益[8-10]。

但全身麻醉主要采用靜脈麻醉藥物，其代謝產(chǎn)物主要經(jīng)過肝腎代謝，腎移植患者處于腎功能衰竭晚期，原有的腎臟功能喪失，對(duì)于藥物代謝能力很差，新移植的腎臟功能尚未完全恢復(fù)，大量的麻醉藥物易產(chǎn)生蓄積作用，術(shù)后會(huì)產(chǎn)生呼吸和循環(huán)抑制。因此，既要完善麻醉又要減少用藥，復(fù)合麻醉即硬膜外阻滯復(fù)合全身麻醉成為首選。

丙泊酚作為常用的麻醉誘導(dǎo)和維持藥物，具有短效、迅速入睡和蘇醒獨(dú)特等優(yōu)點(diǎn)。但是其對(duì)循環(huán)功能有明顯的抑制作用，可以顯著降低血壓，對(duì)于老年、心功能不全的重癥患者的降壓作用更明顯[11]。與靜脈推注丙泊酚相比，靶控輸注丙泊酚可以根據(jù)患者的生命體征來改變血漿效應(yīng)室濃度，以調(diào)節(jié)患者的麻醉適合度，從而獲得更加穩(wěn)定的血流動(dòng)力學(xué)[12]。研究表明，硬膜外阻滯可以擴(kuò)張血管，使血壓下降，而人工靜脈推注丙泊酚復(fù)合硬膜外阻滯會(huì)在麻醉誘導(dǎo)期發(fā)生劇烈的血流動(dòng)力學(xué)變化[13]。靶控輸注丙泊酚復(fù)合硬膜外阻滯在老年人、體弱患者的麻醉誘導(dǎo)過程中可以減輕氣管插管的不良反應(yīng)，維持循環(huán)的穩(wěn)定，減輕患者圍術(shù)期心肌損害[14-15]。

本研究中，試驗(yàn)組T1時(shí)MAP、HR明顯下降，但均在血壓波動(dòng)的允許范圍內(nèi)；T2時(shí)兩組患者的MAP、HR較T0時(shí)均明顯下降；而T3時(shí)，對(duì)照組MAP、HR明顯升高，試驗(yàn)組則變化不大，這可能是由于硬膜外阻滯平面較高，抑制了交感神經(jīng)的興奮傳導(dǎo)，同時(shí)激活了垂體系統(tǒng)，降低了氣管插管時(shí)循環(huán)的劇烈波動(dòng)。試驗(yàn)組患者意識(shí)消失時(shí)間及此時(shí)的丙泊酚血漿效應(yīng)室濃度均小于對(duì)照組，提示腎移植患者在丙泊酚TCI復(fù)合硬膜外時(shí)，在較低的血漿效應(yīng)室濃度下可以進(jìn)行刺激性操作氣管插管。雖然試驗(yàn)組氣管插管時(shí)丙泊酚的用量減少，但其穩(wěn)定性更好。麻醉恢復(fù)期，試驗(yàn)組丙泊酚用量少，蓄積少，蘇醒快，復(fù)合硬膜外麻醉術(shù)后止疼效果明顯優(yōu)于對(duì)照組。兩組患者術(shù)后腎功能比較差異無統(tǒng)計(jì)學(xué)意義。麻醉過程中要注意硬膜外藥物的用量，注意擴(kuò)容，保持血壓平穩(wěn)。

表5 兩組患者圍術(shù)期Cr、BUN、尿量比較

注：與移植前比較,*P<0.01

綜上所述，BIS監(jiān)測(cè)下丙泊酚TCI復(fù)合硬膜外阻滯可以很好地抑制麻醉氣管插管時(shí)血流動(dòng)力學(xué)的劇烈波動(dòng)，合適的硬膜外阻滯效果并不會(huì)增加麻醉誘導(dǎo)期間MAP、HR劇烈下降的風(fēng)險(xiǎn)性。丙泊酚靶控輸注復(fù)合硬膜外在BIS的監(jiān)護(hù)下，可以更加精準(zhǔn)地調(diào)節(jié)用量，減少丙泊酚用量，減輕腎移植患者腎臟負(fù)擔(dān)。其硬膜外用量的調(diào)節(jié)和丙泊酚靶控輸注的配合，需要更多的實(shí)驗(yàn)來論證探討。

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Target-controlledinfusionofpropofolincombinationwithepiduralblockinpatientsreceivingrenaltransplantationundertheguidanceofbispectralindex

WANG Ping1,LI Yuan-hai2,XU Hui3*

(1.Department of Anesthesiology,Jiangyin Hospital of Traditional Chinese Medicine,Jiangyin 214400,China;2.Department of Anesthesiology,the First Affiliated Hospital of Anhui Medical University,Hefei 230000,China;3.Department of Anesthesiology,the Third Affiliated Hospitial of Bengbu Medical College,Bengbu 233000,China)

ObjectiveTo investigate the effects of target-controlled infusion (TCI) of propofol combined with epidural anesthesia on hemodynamic changes,postoperative recovery and renal function in patients undergoing renal transplantation under the guidance of bispectral index (BIS).MethodsTotally 60 renal transplantation patients were randomly divided into 2 groups:experimental group (n=30) and control group (n=30).Experimental group was treated with target-controlled infusion of propofol combined with epidural block for anesthesia,while control group

target-controlled infusion of propofol for anesthesia,all of them being monitored by BIS.MAP and HR were recorded at operation room (T0),before induction (T1),before intubation (T2),immediately after intubation (T3),and 3 min after intubation (T4).The time of consciousness-lost,the effect-site concentration when losing consciousness,the recovery time and the dosage of propofol were recorded.ResultsThe MAP was declined more at T1than T0in experimental group (P<0.05),and the MAP and HR were more obviously declined at T2than T0in both groups (P<0.05).The MAP and HR in experimental group at T3were stable,while in control group they were significantly increased,and the difference between the two groups was significant (P<0.05).Compared with control group,the consciousness-lost time of experimental group was shorter than that of control group,and the effect-site concentration and the dosage of propofol were low,the difference being statistically significant (P<0.05).The recovery time of experimental group was significantly shorter than that of control group,and the quality of recovery was high,the difference being statistically significant (P<0.05).There was no significant difference in postoperative renal function between the two groups (P>0.05).ConclusionBIS-monitoring TCI of propofol combined with epidural anesthesia for renal transplantation patients can stabilize the hemodynamics,achieve a satisfactory anesthetic effect,and reduce the consumption of propofol,and the recovery from anesthesia is fast.There is no adverse effect on postoperative renal function.

Bispectral index;Target-controlled infusion;Propofol;Epidural block;Hemodynamic;Renal transplantation

2017-02-24

1.江陰市中醫(yī)院麻醉科，江蘇 江陰 214400；2.安徽醫(yī)科大學(xué)第一附屬醫(yī)院麻醉科，合肥 230000；3.蚌埠醫(yī)學(xué)院附屬蚌埠市第三人民醫(yī)院麻醉科，安徽 蚌埠 233000

*通信作者

10.14053/j.cnki.ppcr.201710010