不同处理方法对全麻手术病人气管拔管应激反应的影响

Effects of preanesthetic oral clonidine and epidural block on extubation response after general anesthesia

目的探讨不同处理方法对全麻病人术后气管拔管应激反应的影响。方法44例气管插管全麻下手术病人,随机分为四组(n=11):对照组(N组)、可乐定组(K组)、硬膜外组(EP组)、可乐定复合硬膜外组(KEP组)。除K组和KEP组病人分别于麻醉前60min口服可乐定5 uuuuuuuuuuuuuuuuuuug/kg外,四组病人其它麻醉前用药相同;分别在麻醉前、拔管前、拔管后1、2、5、10 min经桡动脉采集动脉血7 ml, 测定血浆肾上腺素、去甲肾上腺素(NE)、皮质醇、血糖、血乳酸浓度,并做血气分析,同时记录以上各时点的血液动力学参数。结果与拔管前比较,N组、EP组拔管后1min HR、SBP、DBP升高,拔管后2 min SBP、DBP仍较高;与N组比较,K、EP、KEP组病人拔管后1 min肾上腺素、NE、皮质醇水平均较低, 拔管后2、5min K组、KEP组血浆激素水平较低,K组、KEP组拔管前、拔管后1、2min血乳酸水平较低, 拔管后1、2min血糖水平较低,K组、KEP组拔管后1、2 min HR、SBP、DBP较低(P<0.05或0.01)。与N组比较,K、EP、KEP组病人拔管后1 min血肾上腺素、NE、皮质醇水平均较低,拔管后2、5 min K组、KEP组血浆激素水平较低(P<0.05或0.01)。与N组比较,K组、KEP组拔管前、拔管后1、2min血乳酸升高程度较低;拔管后1、2min血糖升高程度较低(P<0.05或0.01)。N组、EP组拔管后1 min HR、SBP、DBP比拔管前升高,拔管后2 min SBP、DBP仍较高;K组、KEP组拔管后1、2min HR、SBP、DBP较N 组低(P<0.05或0.01)。结论全麻病人麻醉前服用可乐定或拔管时复合硬膜外给药能明显减轻气管拔管引起的应激反应。

Objective To evaluate the effects of premedication with oral clonidine and/or epidural block on the stress response to tracheal extubation after operation performed under general anesthesia. Methods Forty four ASA Ⅰ -Ⅲ patients undergoing elective operation under general anesthesia were randomly divided into 4 groups with 11 patients in each group： Ⅰ control group （N）; Ⅱ clonidine group （K）; Ⅲ epidural group （EP） and Ⅳ clonidine ＋ epidural group （K ＋ EP） . The patients were premedicated with intramuscular atropine 0.5 mg and phenobarbital 0.1 g. In group K and group K-EP oral clonidine 5μg· kg^-1 was included in prenledication. In group EP and K-EP epidural catheter was placed and 2% lidocaine 3 ml was injected as test dose before induction of general anesthesia. Anesthesia was induced with fentanyl 2 μg· kg^-1 , propofol 2 mg· kg^-1 and vecuronium 0.2 mg · kg^-1 and maintained with isoflurane inhalation and intermittent i.v. boluses of fentanyl and vecuronium. Radial artery, was cannulated for direct continuous BP monitoring. BP, HR, CVP, ECG and SpO2 were continuously monitored during operation. The blood samples were taken before induction of anesthesia, before extubation and at , 2, 5, 10 min after extubation tor determination of plasma epinephrine （E） norepinephrine （NE） angiotensin Ⅱ （AⅡ）, cotisol （C） and blood sugar and lactate, hldication tot tracheal extubation included spontaneous breathing （VT 〉 0.4 L, PETCO2 〈 45 mm Hg） and recovery of coughing and swallow reflex. Results The four groups were comparable with respect to age, sex, types of operation, operation and extubation. There were significant increases duration of operation and the duration between end of in plasma E, NE, C, blood sugar and lactate at 1 and 2 min after tracheal extubation as compared to the baseline values before induction of anesthesia and before extubation （P 〈 0.05, 0.01）. The increase in plasma E, NE and C and blood sugar and lactate was significantly larger in control group （N） than in the other 3 groups. Blood pressure and heart rate significantly increased after extubation compared to those before extubation in all 4 groups. The increase was significantly smaller in group K and K-EP than in group N and EP. Conclusion Oral clonidine before anesthesia and/or epidural block can attenuate the stress response to tracheal extubation at the end of surgery.