瑞芬太尼在神经外科手术麻醉中靶浓度的研究

Study on Target-controlled Infusion of Remifentanil during Neurosurgical Anesthesia

目的探讨瑞芬太尼与丙泊酚联合靶控输注(TCI)全凭静脉麻醉在神经外科手术中的适宜TCI靶浓度。方法选择100例ASAⅠ~Ⅲ级择期行开颅手术的患者。丙泊酚麻醉诱导,初始血浆靶质量浓度(简称靶浓度)设为5 mg.L-1,瑞芬太尼血浆靶浓度为3μg.L-1,待患者意识消失后,将丙泊酚血浆靶浓度降低并维持在3 mg.L-1,静脉注射维库溴铵0.1 mg.kg-1,3 min后行气管插管。术中持续监测血流动力学变化,调节瑞芬太尼靶浓度,将无创血压(MAP)维持在基础值的+10%^-20%范围内。间断静脉注射维库溴铵维持肌松。缝合硬膜时静注氯诺昔康8 mg。记录不同麻醉期瑞芬太尼血浆靶浓度和效应室靶浓度,观察麻醉恢复期情况。结果开颅前期(麻醉诱导至切皮)、开颅期(切皮至剪开硬膜)、颅内操作期和关颅期(缝合硬膜至术毕)瑞芬太尼血浆靶浓度分别为(2.98±0.39)μg.L-1、(3.44±0.86)μg.L-1(、3.55±1.00)μg.L-1和(3.33±1.08)μg.L-1,95%置信区间上限分别为3.01μg.L-1、3.52μg.L-1、3.63μg.L-1和3.43μg.L-1;效应室靶浓度分别为(2.83±0.53)μg.L-1、(3.43±0.85)μg.L-1、(3.54±0.99)μg.L-1和(3.31±1.09)μg.L-1,95%置信区间上限分别为2.87μg.L-1、3.50μg.L-1、3.62μg.L-1和3.41μg.L-1。麻醉后呼吸恢复时间为(10±6)min,呼之睁眼时间为(13±8)min,拔管时间为(16±7)min,定向力恢复时间为(21±8)min。结论瑞芬太尼与丙泊酚联合靶控输注静脉麻醉用于神经外科手术诱导迅速,术中血流动力学平稳,术后麻醉恢复快。血浆靶浓度和效应室靶浓度达到平衡的时间短,数值接近,用血浆靶控能够满足临床需要;当丙泊酚血浆靶浓度为3 mg.L-1时,根据95%置信区间上限,建议在开颅前期、开颅期、颅内操作期和关颅期,将瑞芬太尼血浆靶浓度分别设为3.0μg.L-1、3.5μg.L-1、3.6μg.L-1和3.4μg.L-1。

Objective To investigate the optimal TCI target concentrations of remifentanil with propofol at different anesthetic and neurosurgical stages. Methods 100 ASA Ⅰ-Ⅲ patients scheduled for elective craniotomy were anesthetized with target controlled infusion of propofol and remifentanil. The initial plasma target-concentrations Of propofol and remifentanil for induction of anesthesia were 5 mg·L^-1 and 3 μg·L^-1, respectively. When patients lost consciousness, the plasma targetconcentration of propofol was decreased and maintained to 3 mg·L^-1 and vecuronium with the dose of 0. 1 mg·kg^-1 was administrated. 3 rain later intubation was performed. The plasma target-concentration of remifentanil was adjusted to maintain the mean arterial pressure within ＋10%--20% of baseline. The calculated plasma target-concentration and effect-site concentration were recorded at different stages of operation. Before the dura was sutured, lornoxicam 8 mg was administrated intravenously. The hemodynamics and anesthetic recovery profiles were observed. Results The plasma target-concentrations of remifentanil were （2.98±0.39）μg·L^-1 , （3.44±0.86）μg·L^-1 , （3.55±1.00）μg·L^-1 and （3.33±1.08）μg·L^-1 before skin incision, during skull opening, intracranial procedure and skull closing, respectively, and the upper limit of 95 % confidences were 3.01 μg·L^-1 , 3. 52 μg·L^-1 , 3. 63 μg·L^-1 , 3. 43 μg·L^-1 , respectively. The calculated effect-- site concentrations of remifentanil were （2.83±0.53）μg·L^-1 , （3.43±0.85）μg·L^-1 , （3.54±0.99）μg·L^-1 and （3.31±1.09）μg·L^-1 , and the upper limit of 95% confidences were 2. 87 μg·L^-1, 3. 50 μg·L^-1, 3. 62 μg·L^-1, 3. 41 μg·L^-1, respectively. The postoperative recovery times of spontaneous breathing, opening eyes, extubation and orientation were （10±6）min, （13±8）min, （16±7）min and （21±8）min, respectively. Conclusion The target-controlled infusion of propofol with remifentanil used for neurosurgery has advantages of rapid induction of anesthesia, stable hemodynamics and better recovery profile. With 3 mg·L^-1 of propofol TCI, the optimal plasma target-concentrations of remifentanil are 3.0 μg·L^-1 , 3.5 μg·L^-1, 3.6 μg·L^-1 and 3.4 μg·L^-1 before skin incision, during skull opening, intracranial procedure and skull closing, respectively.