瑞芬太尼用于鼻内镜手术控制性降压对应激反应的影响

Effect of controlled hypotension by remifentanil on stress response during functional endoscopic sinus surgery

目的观察瑞芬太尼用于鼻内镜手术控制性降压对应激反应的影响。方法择期全麻下鼻内镜手术患者60例,ASAⅠ～Ⅱ级,根据降压所用药物不同分为硝普钠组(N组,n=20)、瑞芬太尼组(R组,n=28)及瑞芬太尼复合硝普钠组(RN组,n=12)。常规麻醉诱导后,术者进行消毒时开始行控制性降压,维持MAP在60 mm Hg～70mm Hg之间。分别记录控制性降压前即刻(T_0),维持降压30 min时(T_1)及停止降压待血压自然恢复稳定后(T_2)的HR、MAP。于T_0、T_1、T_2时分别抽取动脉血测定血管紧张素Ⅱ(AT-Ⅱ)、醛固酮(ALD)、血栓烷B_2(TXB_2)、6-酮-前列腺素F_1α(6-keto-PGF1α)、内皮素(ET)和一氧化氮(NO)的浓度。结果三组患者相比T_1时点,N组HR比R组和RN组明显增快(P<0.05).N组降压停止后出现反跳性高血压,R组和RN组停止降压后MAP回复至降压前水平。T_1、T_2时点N组AT-Ⅱ、ALD的浓度比R和RN组明显升高(P<0.05)。T_1、T_2时点RN组NO/ET比值明显高于同时点N组(P<0.05),T_2时点R组NO/ET比值明显高于同时点N组(P<0.05)。T_1、T_2时点R、RN组TXB_2/PGF_(1α)比值明显高于同时点R和RN组(P<0.05)。结论瑞芬太尼持续输注用于异氟醚吸入麻醉下鼻内镜手术中控制性降压能够降低AT一Ⅱ和ALD的分泌,改善NO/ET平衡,降低TXB_2/PGF_(1α)比值,有效抑制机体应激反应。

Objective To observe the effect of controlled hypotension by remifentanil on stress response during functional endoscopic sinus surgery. Methods Sixty patients with ASA I-Ⅱ undergoing functional endoscopic sinus surgery under general anesthesia were included in this study. According to the hypotensive medication, patients were divided into 3 groups： sodium nitroprusside group （group N, n =20） , remifentanil group （group R, n =28） and remifentanil- sodium nitroprusside group （group RN, n = 12）. After routine induction patients were intubated. When surgeons sterilized the operating field, controlled hypotension was taken to maintain MAP between 60 mm Hg to 70 mm Hg. MAP, HR were recorded before hypotension （ T0） , during hypotension （ T1） and after stopping hypotension （T2）. The concentration of plasma AT- Ⅱ, ALD, TXB2, 6 -keto- PGF1α, endothelin （ET）, and nitric oxide （NO） were determined at above time points. Results Compared with group R and RN, HR increased significantly in group N （ P 〈 0. 05 ） at T1. Rebound hypertension only occurred in group N. MAP returned to baseline in group R and group RN after stopping hypotention. At T1 and T2 , the concentration of plasma AT -Ⅱ, ALD and TXB2 were significantly higher in group N than those in group R or RN, respectively （P 〈0.05）. At T1 and T2 , NO/ET ratio in group RN were significantly higher than those of group N （P 〈0.05） ; At T1 NO/ET ratio in group R were significantly higher than those of group N （ P 〈 0.05 ）. At T1 TXB2/PGF1 α ratio in group N were higher than those of group R or RN （ P 〈 0.05 ）. Conclusion Controlled hypotension by continuous infusion of remifentanil during anesthesia with isoflurane can effectively suppress the stress response during functional endoscopic sinus surgery and maintain the balance of TXB2/ PGF1 α and NO/ET.