异丙酚复合麻醉下髋关节置换术患者瑞芬太尼控制性降压的效果

Efficacy of controlled hypotension with remifentanil and propofol in patients undergoing hip replacement

目的探讨异丙酚复合麻醉下髋关节置换术患者瑞芬太尼控制性降压的效果。方法择期行髋关节置换术患者30例,ASA分级Ⅱ级或Ⅲ级,随机分为2组（n=15）：瑞芬太尼组（R组）和硝普钠组（N组）。2组麻醉诱导气管插管后在30min内静脉输注6%羟乙基淀粉200/0．5 15ml/kg行急性高容量血液稀释,桡动脉穿刺置管监测平均动脉压（MAP）和心率（HR）,颈内静脉穿刺置管监测中心静脉压,术中维持脑电双频谱指数45～55。2组于切皮前开始降压,R组和N组分别持续静脉输注瑞芬太尼0．3～0．7μg·kg^-1·min^-1、硝普钠0．5～6．0μg·kg^-1·min^-1,使MAP降低到术前基础值的70%左右（60～70mm Hg）并维持至术毕。分别于急性高容量血液稀释后控制性降压前即刻（T0）、控制性降压20min（T1）、40min（T2）、术毕（T3）时抽取静脉血,测定血红蛋白（Hb）、红细胞压积（Hct）、乳酸（Lac）浓度,同时抽取动脉血,行动脉血气分析,记录开始降压至目标血压所需的时间（降压诱导时间）、停降压药后MAP恢复至基础值的时间（MAP恢复时间）及术中出血量、输血量。结果与N组比较,R组降压诱导时间、MAP恢复时间、血气分析指标及Lae水平差异无统计学意义（P＞0．05）,T（1,2）时HR降低,出血量减少（P＜0．05或0．01）；N组有5例患者发生反射性心动过速,需使用艾司洛尔,T3时有2例患者发生反跳性高血压,2组术后均未见并发症。结论异丙酚复合麻醉下髋关节置换术患者持续静脉输注瑞芬太尼0．3～0．7μg·kg^-1·min^-1控制性降压可控性好,降压及恢复平稳,且血液保护作用优于硝普钠。

Objective To evaluate the efficacy of controlled hypotension with remifentanil and propofol in patients undergoing hip replacement. Methods Thirty ASA Ⅱ or Ⅲ patients （16 male, 14 female） undergoing elective hip replacement were randomly divided into 2 groups （ n = 15 each） ： Ⅰ remifentanil group （R） and Ⅱ nitroprusside group （N）. The patients were premedicated with intramuscular scopolamine 0.3 mg and midazolam 0.05 mg/kg. Anesthesia was induced with propofol 2 mg/kg, fentanyl 3 μg/kg and vecuronium 0.1 mg/kg and maintained with propofol 4-8 mg·kg^-1·h ^-1 and intermittent intravenous boluses of vecuronium. 6 % hydroxyethyl starch 200/0.5 15 ml/kg was infused over 30 min after tracheal intubation in both groups. Continuous intravenous infusion of remifentanil （ at 0.3-0.7 μg·kg^-1·min^-1） or nitroprusside （ at 0.5-6.0 μg·kg^-1·min^-1） was started before skin incision to decrease MAP to 70% of preoperative level （baseline） （60-70 mm Hg） which was maintained during operation. Radial artery and right internal jugular were cannulated for BP and CVP monitoring. BIS was continuously monitored and maintained at 45-55 during operation. Blood samples were taken from artery and vein for blood gas analysis and blood lactate determination before and at 20 and 40 min of controUed hypotension （T0, T1 , T2 ） and at the end of operation （T3）. Results MAP was reduced to 60-70 mm Hg in （6.5 ± 2.3）min （group R） and （6.3 ± 2.5） min （group N） respectively. HR was significantly lower at T1 and T2 in group R than in group N （P 〈 0.01 ） . Five patients in group N developed reflex tachycardia and esmolol was administered. Rebound hypertension occurred in 2 patients in group N. Blood loss was significantly less in group R than in group N. There were no significant differences in pH, PaCO2, PaO2 and lactate between the 2 groups. There was no postoperative complication in both groups. Conclusion Remifentanil combined with propofol can induce and maintain controlled hypotension in patients undergoing hip replacement.