择期全麻手术患者舒芬太尼靶控输注系统的评价

Evaluation of target-controlled infusion system for sufentanil administration in patients undergoing elective operation under general anesthesia

目的评价择期全麻手术患者应用Bovill药代动力学参数行舒芬太尼靶控输注（TCI）的准确性。方法择期静吸复合全麻下行腰椎管狭窄症矫正手术患者60例,ASAⅠ或Ⅱ级,按年龄分为老年组（≥65岁,0组）、中年组（45～64岁,M组）和青年组（18～44岁,Y组）,每组20例。麻醉诱导开始舒芬太尼效应室靶浓度为0.4ng/ml,此后每15分钟递增0.2ng/ml,直至0.8ng/ml,15min后降为0.6ng/ml,维持20min后,以0.4ng/ml维持25min,然后停止输注舒芬太尼。术中根据脑电双频谱指数（BIS）、MAP和肌松程度等调整吸入异氟烷浓度和肌松药用量。每组随机选取10例患者,在每一设定的效应室靶浓度维持末[0.4ng/ml（T1）、0.6ng/ml（T2）、0.8ng/ml（T3）、0.6ng/ml（T4）、0.4ng/ml（T5）]采血,以液相色谱.质谱联用法测定舒芬太尼血药浓度。于麻醉诱导前（基础值）、T1、T2、T3、T4、T5和拔管即刻（T6）记录MAP、HR和BIS,并记录睁眼时间和拔管时间,拔管即刻和在麻醉恢复室中伤口疼痛和副作用情况。记录TCI系统的偏离性、精确度和摆动度。结果与基础值比较,3组T1～5时MAP降低,T2～5时HR减慢,T6时HR增快,T1～6时BIS降低（P〈0.05或0.01）。3组舒芬太尼实测血药浓度均随设定的效应室靶浓度的依次升高或降低而升高或降低（P〈0.05）,但3组间各时点比较差异无统计学意义（P〉0.05）。O组、M组和Y组偏离性分别为-9.9%、-9.3%和-8.5%,精确度分别为17.2%、14.5%和20.4%,摆动度分别为12.0%、10.3%和14.5%。结论舒芬太尼TCI系统可安全、有效地用于成人全麻手术患者。采用Bovill药代动力学参数TCI舒芬太尼时,国人的实测血药浓度较血浆靶浓度低10%。

Objective To evaluate the accuracy of the target-controlled inffusion （TCI） of sufentanil using the population pharmacokinetic paraineters of sufentanil described by Bovill in clinical anesthesia,Methods Sixty ASA Ⅰ or Ⅱ patients undergoing elective orthopedic surgery for lumbar spinal canal stenosis under combined intravenous-inhalational anesthesia were divided into 3 age groups （ n = 20 each） ： A the elderly group （ ≥ 65 yr） ; B the middle-aged group （45-64 yr） and the young group （18-44 yr）. Radial artery was cannulated for BP monitoring and blood sampling. ECG, HR, BP, BIS （Aspect USA） and neuro-museular transmission （TOF-Wateh SX, Organon, Hoolland） were monitored. Sufeutanil was administered with a specific TCI system incorporating the population phannacokinetic parameters of sufentanil described by Bovill （Silugao Science ＆ Technology Co, Beijing, China）. The initial effect-site concentration was set at 0.4 ng/ml followed by increments of 0.2 ng/ml every 15 min Uiltil 0.8 ng/ml. The target elliot-site concentration was then decreased to 0.6 ng/ml （maintained tot 20 inin） and 0.4 ng/ml （maintained for 25 min）. At the end of each target effect-site concentration （5-10 rain after steady state concentration was reached）, arterial blood sainples were taken in 10 patients randomly from each group for determination of plasma sufentanil concentration by liquid ellromatography-mass spectrometry/mass spectrometry, Time to eye-opening and extubation from the end of operation, postoperative pain and adverse effects were recorded. Results The bias （median perfonnance error, MDPE） of the TCI system fur sufentanil was - 9.9% in the elderly group, - 9.3% in the middle-aged group and - 8.5% in the young group respectively. The precision （median absolute performance error, MDAPE） was 17.2% , 14.5% and 20.4% respectively the three groups. Conclusion The TCI system for sufentanil can be used safely and efficiently in adult patients from the young to the aged. Using the population pharmacokinetic parameters described by Bovill the measured plasma concentration of sufentanil is about 10% lower than the target plasma concentration in Chinese.