减轻妇科手术创伤反应的临床麻醉方法比较(前瞻性随机对照研究)

Different anesthetic methods for decreasing gynecological surgical trauma responses:A prospective randomized controlled trial

目的在保障患者安全的前提下减轻妇科盆腔手术麻醉造成的不良反应,比较减轻伤害性刺激的临床麻醉方法。方法采用前瞻性随机对照研究,将48例妇科ASAⅠ～Ⅱ级拟行盆腔手术随机分为4组,每组12例。A组,椎管内麻醉复合靶控输注咪达唑仑镇静;B组,椎管内麻醉复合静脉推注咪达唑仑镇静;C组,椎管内麻醉;D组,椎管内麻醉复合全身麻醉。比较4组围术期循环、SpO2、BIS值、麻醉前及术毕血皮质醇、IL-6水平,及临床麻醉情况。结果A组患者镇静程度适宜(OAA/S3～4级,BIS值75～85),无一过性呼吸抑制。术前各组皮质醇水平无统计学差异,(术毕-术前)/术前A组为0.43±0.18,显著低于C组0.65±0.14(q=4.061,P<0.05),A组1例术中发生牵拉不适显著低于C组7例(P=0.027)。B组患者镇静较深,可达OAA/S2级,9例发生一过性呼吸抑制,皮质醇(术毕-术前)/术前为0.62±0.23,显著高于A组0.43±0.18(q=3.508,P<0.05)。C组中患者发生牵拉不适7例显著多于A、D组(P值分别是0.027,0.005),且皮质醇(术毕-术前)/术前为0.65±0.14,变化最明显。D组患者术毕皮质醇(术毕-术前)/术前与A、C组差异无统计学意义(q=1.056,P>0.05;q=2.816,P>0.05)。结论椎管内麻醉复合靶控咪达唑仑镇静组手术、麻醉创伤造成的皮质醇变化较小、不良反应较轻,适合妇科手术使用。

Objective To investigate anesthetic methodology for decreasing surgical trauma responses in gynecological operations. Methods A prospective randomized controlled trial was carried out. The study was approved by the Ethics Committee of Peking University Health Science Center （Warrant No： 0536）. A written informed consent was obtained from each patient and his/her relatives. A total of 48 ASAⅠ-Ⅱ patients scheduled for selective gynecological surgery was enrolled in this study. They were randomly divided into four groups with 12 patients in each group： the Group A undergoing combined spinal and epidural anesthesia （CSEA） with target controlled infusion of midazolam for sedation; the Group B undergoing CSEA with intravenous bolus of midazolam for sedation; the Group C receiving CSEA; and the Group D, CSEA combined with general anesthesia. Blood pressure, heart rate, oxygen saturation （SpO2 ） , bispectral index （BIS） , and serum levels of cortisol and IL-6, as well as anesthetic responses, were monitored and compared among the four groups. Results The Group A had a moderate sedation degree （ OAA/S： degree 3 - 4 ; BIS value： 75 -85）. No respiratory inhibition was noted in this group. Before operation, levels of serum cortisol had no statistical differences between every two groups. The ratio of cortisol changes （ end-operation value minus preoperative value） to preoperative value in the Group A was 0.43 ±0. 18, significantly lower than that in the Group C （0. 65 ±014; q =4. 061, P 〈0. 05）. Intraoperative tension discomfort happened in 1 patient in the Group A, significantly fewer than in the Group C （7 patients, P = 0. 027）. Patients in the Group B were relatively deeply sedated, and many of them reached OAA/S degree 2. Transient respiratory inhibition happened in 9 patients in this group. The ratio of cortisol changes to preoperative cortisol value in the Group B was 0.62 ±0.23, significantly higher than that in the Group A （0.43 ± 0.18 ; q = 3. 508, P 〈 0.05 ）. Significantly more patients were bothered with tension discomfort in the Group C than in the Group A （P = 0. 027） and the Group D （P = 0. 005）. Among the four groups, the most significant change was observed in the Group C on the ratio of cortisol changes to preoperative cortisol value （0.65± 0. 14）. There was no statistically significant difference on the ratio between the Group D and the Group A （q = 1. 056, P 〉 0.05） or Group C （q = 2. 816, P 〉 0. 05）. Conclusions Combined spinal and epidural anesthesia combined with target controlled infusion of midazolam has slight side effects and serum cortisol changes, suitable for gynecological operations.