瑞芬太尼控制性降压在鼻内镜手术中的应用

Remifentanil inducing controlled hypotension in functional endoscopic sinus surgery

目的：探讨瑞芬太尼持续输注在静吸复合全麻下鼻内镜手术中控制性降压的效果,并对术野质量和患者苏醒期清醒镇静程度进行评定。方法：对60例择期全麻下行鼻内镜手术患者采用硝普钠（N组）、瑞芬太尼（R组）或瑞芬太尼复合小剂量硝普钠（RN组）控制性降压,维持平均动脉压（MAP）在60-70mmHg。记录降压前即刻（T0）、降压30 min（T1）和停降压待血压自然恢复稳定后（T2）时的MAP、心率（HR）及手术时间、降压持续时间、拔管时间和各组硝普钠或瑞芬太尼用量,对术野质量和苏醒期清醒镇静程度进行评定。结果：R组28例（70%）单纯用瑞芬太尼可达到降压目的,RN组12例（30%）出现瑞芬太尼降压封顶现象,辅用小剂量硝普钠后降压理想且能减小瑞芬太尼的用量。降压期间,N组HR明显增快（P〈0.05）,停降压后出现反跳性高血压;R和RN组HR减慢（P〈0.05）,停降压后MAP回复至降压前水平。R、RN组的术野质量优于N组（P〈0.05）,拔管时间和苏醒期清醒镇静程度组间比较,差异无统计学意义（P〉0.05）。结论：瑞芬太尼用于静吸复合全麻下鼻内镜手术中行控制性降压安全可行,能提供良好的术野质量,患者苏醒期清醒迅速、完全;部分患者出现降压封顶现象,复合小剂量硝普钠后降压理想且能减少瑞芬太尼的用量。

Objective： To investigate the efficacy of remifentanil inducing controlled hypotension in functional endoscopic sinus surgery. Methods： Sixty patients with ASA class I or H subjected to general anesthesia were divided into three groups： the sodium nitroprusside group（N）, the remifentanil group（R） and the remifentanil-sodium nitroprusside group（RN）. A deliberate hypotension was induced to retain the MAP at 60-70 mmHg by SNP, remifentanil or remifentanil combined with SNP. MAP and HR were determined before hypotension （T0）, during hypotension （Tl） and after stopping hypotension（T2 ）. The duration of operation and hypotension, the time from the end of the operation to extubation of the tracheas, and the dose of SNP and remifentanil were also determinded. Quality of the surgical field and of patients were assessed. Results： MAP could be retained at 60-70 mmHg by remifentanil in 28 patients of group R （70%）. The hypotensive ceiling-effect of remifentanil was produced in 12 patients of group PuN （30%）. After the addition of a small dosage of sodium nitroprosside, target MAP was easily achieved and the dosage of remifentanil was decreased. During induced hypotension, HR was significantly increased in group N （ P 〈 0.05）. However, HR was significantly decreased in groups R and RN （ P 〈 0.05）. Rebound hypertension only occurred in group N.Quality of the surgical field was better in groups R and RN than in group N. There were no significant differences of the time from the end of the operation to extubation of the tracheas and the patients＇ consciousness from anesthesia among the three groups. Conclusion： Induced hypotension by remifentanil combined with a balanced anesthesia is feasible and safe for functional endoscopic sinus surgery. In the operation, the quality of the surgical field and the consciousness from anesthesia are good.