纤维支气管镜清醒插管时不同剂量瑞芬太尼复合咪达唑仑的效果

Efficacy of different doses of remifentanil combined with midazolam for awake fiberoptic bronchoscopy

目的观察纤维支气管镜（FOB）清醒插管时不同剂量瑞芬太尼复合咪达唑仑的效果。方法择期气管插管全麻下行手术病人48例,年龄35～45岁,ASA均为Ⅰ级,Mallampati分级为Ⅰ或Ⅱ级,随机分为单纯表面麻醉组（L组）、表面麻醉＋瑞芬太尼0．6μg/kg＋咪达唑仑60μg/kg组（R1组）和表面麻醉＋瑞芬太尼1．0μg/kg＋咪达唑仑60μg/kg组（R2组）,每组16例。3组病人均用1%地卡因行鼻腔、咽喉表面麻醉,R1组和R2组均静脉注射咪达唑仑60μg/kg,3min后两组分别缓慢静脉注射瑞芬太尼0．6μg/kg、1．0μg/kg,1min后采用F1-10P型FOB行气管插管,记录麻醉前（T0）、FOB进入鼻腔或咽腔即刻（T1）、挑起会咽进入声门即刻（T2）、插入气管导管即刻（T3）时的平均动脉压（MAP）、心率（HR）、脉搏血氧饱和度（SpO2）及插管过程中有无躁动、呛咳、恶心等插管反应,术后随访插管过程中病人的知晓情况。结果与T0比较,L组T1、T2时MAP及HR明显升高,R2组T1和T2时SpO2下降,T1时HR明显降低,3组T3时MAP明显降低（P＜0．05）；与L组比较,R1组和R2组T1、T2时MAP降低,T1时HR降低（P＜0．01）；与R1组比较,R2组T1时HR降低,T1、T2时SpO2下降（P＜0．05）。与L组比较,R1组呛咳、躁动及插管知晓发生率明显减少（P＜0．05）,R2组各插管反应及插管知晓发生率明显减少（P＜0．01）；与R1组比较,R2组躁动发生率明显减少（P＜0．05）。结论在表面麻醉的基础上,静脉注射瑞芬太尼1．0μg/kg复合咪达唑仑60μg/kg可为病人FOB清醒插管提供良好的条件。

Objective To investigate the efficacy of different doses of remifentanil combined with midazolam for awake fiberoptic bronchoscopy. Methods Forty-eight ASAⅠ patients aged 35-45 yr undergoing general anesthesia for elective surgery were randomly divided into 3 groups according to the type of anesthesia for tracheal intubation （ n = 16 each） ： group Ⅰ received topical anesthesia only; group Ⅱ and Ⅲ received midazolam 60μg/kg and remifentanil 0.6 or 1.0 μg/kg on top of topical anesthesia. The patients were premedicated with intramuscular atropine 0.5 mg and sodium phenobarbital 0.1 g. Tracheal intubation was performed with the assistance of fiberoptic bronchoscope （FOB） （Pentax F1-10P）. All patients received topical anesthesia of oral or nasal cavity, pharynx, epiglottis and vocal cords with 1% tetracaine. In group Ⅱ and Ⅲ midazolam 60μg/kg was given Ⅳ first and 3 min later remifentanil 0.6 or 1.0μg/kg was injected Ⅳ over 30 seconds. Endotracheal tube was threaded onto the labricated stem of FOB and FOB was inserted into nasal or oral cavity and advanced until the tip of FOB was positioned in the oropharynx above the glottis as observed by the operator through the scope. The patients were asked to take a few deep breaths. Propofol 2.0-2.5 mg/kg was then given followed by atracurium 0.5-0.6 mg/kg. The tip of the scope was advanced through the cords and into trachea. MAP, HR and SpO： were continuously monitored and recorded before anesthesia （T0, baseline）, when FOB was inserted into nasal or oral cavity （T1） and advanced through vocal cords （T2） and when endotracheal tube was threaded onto trachea （T3 ）. Responses like restlessness, nausea and coughing were also recorded. The patient＇s awareness of the intubation was noted after operation. Results MAP and HR were significantly increased at T1 and T2 as compared with the baseline values before anesthesia at T0 in group Ⅰ. SpO2 was significantly decreased at T1 and T2 and HR was significantly decreased at T1 as compared with the baseline values in group Ⅲ . MAP was significantly decreased at T3 as compared with the baseline value at To in all 3 groups. The ineidenees of restlessness, nausea and coughing were significantly higher in group Ⅰ than in other 2 groups. The incidence of awareness of tracheal intubation was significantly lower in group Ⅱ and Ⅲ than in group Ⅰ . Conclusion Remifentanil 1.0 μg/kg combined with midazolam 60 μg/kg given Ⅳ on top of topical anesthesia with 1% tetraeaine can provide a good intubation condition with less intubation response.