不同剂量瑞芬太尼对胸科手术血流动力学和皮质醇浓度影响的比较

Camparison of the effect of anesthesia with different doses of remifentanil for thoracic surgery on haemodynamics and cortisol concentration

目的观察不同剂量的瑞芬太尼在胸科手术中对血液动力学和皮质醇浓度的影响，为瑞芬太尼在胸科手术中的合理应用提供理论依据。方法择期胸科手术患者60例，ASAⅠ～Ⅱ级，随机分为三组（n=20）。麻醉诱导：咪唑安定0．1mg／kg、异丙酚2．0mg／kg、瑞芬太尼（Ⅰ、Ⅱ、Ⅲ组分别为1．0、1．5、2．0ug/kg）、维库溴铵0．1mg／kg静注。麻醉维持：异丙酚4～6mg／（kg·h）和瑞芬太尼[Ⅰ、Ⅱ、Ⅲ组分别以0．10、0．15、0．20ug／（kg·min）]微量泵持续输注，间断静脉维库溴铵0．33～0．05mg／kg。分别记录麻醉前基础值（T0）、气管插管（T1）、切皮（T2）、探查肺门（T3）、手术结束（T4）、拔管（T5）时的平均动脉压（MAP）、心率（HR），同时采血测皮质醇浓度。记录停药至自主呼吸恢复时间、呼之睁眼时间、拔管时间、定向力恢复时间。结果三组病人的一般情况，停药至自主呼吸恢复时间、呼之睁眼时间、拔管时间、定向力恢复时间组间比较无统计学差异（P〉0．05）。Ⅰ组MAP、HR术中显著高于麻醉前基础值（P〈0．05）；Ⅱ组MAP、HR术中与麻醉前基础值比较差异无统计学意义（P〉0．05），切皮时显著低于Ⅰ组（P〈0．05）；Ⅲ组术中MAP、HR下降，探查肺门、手术结束时显著低于麻醉前基础值（P〈0．05），术中显著或异常显著低于Ⅰ组相应时点；Ⅰ、Ⅱ、Ⅲ组拔管后均显著高于麻醉前基础值。1组探查肺门、手术结束时皮质醇浓度显著高于麻醉前基础值（P〈0．05）；Ⅱ组探查肺门、手术结束时显著低于Ⅰ组（P〈0，05）；Ⅲ组在切皮、探查肺门、手术结束、拔管时点显著低于Ⅰ组（P〈0．05）。结论瑞芬太尼1．5ug／kg静注诱导后0．15ug／（kg·min）微量泵持续输注麻醉过程平稳，能有效抑制应激反应，可安全有效地应用于胸科手术。

Objective To observe the effect of anesthesia with different doses of remifentanil in thoracic surgery on haemodynamics and cortisol concentration, and provide the theory base for the reasonable use of remifentanil in thoracic surgery. Methods Sixty ASA Ⅰ - Ⅱ patients under elective thoracic surgery were randomly divided into three groups （ n = 20 ）. Induction of anesthesia ： injection of midazolam 0. 1 mg/kg, propofol 2.0 mg/kg, remifentanil （ in group Ⅰ , Ⅱ, Ⅲ 1.0,1.5,2.0 ug/kg respectively）, vecuronium 0. 1 mg/kg. Maintenance of anesthesia ： micro pump infusion of propofol 4 - 6 mg/kg and remifentanil [ in group Ⅰ, Ⅱ, Ⅲ,0. 10,0. 15,0. 20 ug/（ kg · min） respectively], interrupted injection of vecuronium 0. 03 -0. 05 mg/kg. At the time before anesthesia（ T0 ）, tracheal intubation （ T1 ）, skin incision （ T2 ）, explore hilum of lung （W3 ） ,termination of surgery（ T4 ） , after tracheal extubation （ T5 ） recorded the mean arterial pressure（MAP） and heart rate （ HR）, meanwhile collected the blood samples for the analysis of cortisol. The time for stopping administration of anesthesia until full spontaneous respiration, eye opening, tracheal extubation, orientation were recorded. Results There were no statistic differences among three groups in general station or the time for stopping administration of anesthesia until full spontaneous respiration, eye opening , tracheal extubation, orientation. In Group Ⅰ MAP,HR during surgery were higher than that before anesthesia（ P 〈0. 05） ;In group Ⅱ there were no statistic differences between MAP, HR before anesthesia and that during surgery;In group Ⅲ MAP, HR descended during surgery, and MAP, HR at explore hilum of lung, termination of surgery were lower than that before anesthesia（ P 〈0. 05） ,and MAP,HR during surgery were lower or extremely lower than those in group Ⅰ （ P 〈 0. 01 ） ;Both three groups MAP, HR after tracheal extubation were higher than that before anesthesia（ P 〈0. 05）. In group Ⅰ cortisol concentration at explore hilum of lung,termination of surgery was higher than that before anesthesia（ P 〈 0. 05） ;In group Ⅱ cortisol concentration at explore hilum of lung,termination of surgery was lower that in group Ⅰ （ P 〈0. 05） ;In group Ⅲ skin incision,explore hilum of lung, termination of surgery, after tracheal extubation were lower than that in group Ⅰ. Conclusion Remifentanil, micro pump infusion of 0. 15 ug/（ kg ·min） during surgery after injection of 1.5 ug/（ kg · min） induction, can be used safely and effectively in thoracic surgery.