不同速率输注瑞芬太尼对老年手术患者麻醉维持的影响

Effects of infusion remifentanil at different rates on maintenance of anesthesia in old patients undergoing operation

目的:比较不同速率输注瑞芬太尼对腹部手术老年患者术中血流动力学和应激反应水平的影响。方法:30例择期行腹部手术老年患者随机分为A、B、C3组(即瑞芬太尼0.05、0.10和0.15μg/(kg·min)组),每组10例。3组麻醉诱导气管插管后分别以上述速率静脉输注瑞芬太尼复合异丙酚4.5mg/(kg·h)以及间断静脉注射阿曲库铵0.2mg/kg维持麻醉。术中出现高血压、低血压和心动过缓时相应采取单次或多次追加瑞芬太尼0.85μg/kg、麻黄素6mg和阿托品0.5mg维持生命体征平稳。观测术前(基础值)、术中和术后血压、心率,检测基础值、气管插管后10min、手术开始10min和拔管后10min静脉血浆中去甲肾上腺素(NE)和肾上腺素(E)水平。记录术中追加瑞芬太尼、硝酸甘油、麻黄素、阿托品的次数。并记录手术时间、术中失血量和补液量以及拔管、出手术室时间和拔管后10minVAS评分。结果:A组血压手术开始30min、60min和拔管后10min升高(P均<0.05);B组血压气管插管后10min降低,拔管后10min升高(P均<0.05);C组血压气管插管后10min、手术开始20min、30min、60min降低,拔管后10min升高,心率气管插管后10min、手术开始60min减慢(P<0.05或0.01);3组心率拔管后10min均增快(P均<0.05)。A、B组NE和E、C组NE手术开始10min、拔管后10min均升高;A组气管插管后10minNE和E亦升高,C组E拔管后10min升高(P<0.05或0.01)。A组追加瑞芬太尼次数多于其他2组,C组追加麻黄素次数和补液量多于其他2组(P均<0.05)。3组拔管时间、出手术室时间和拔管后10minVAS评分差异均无统计学意义(P均>0.05),且VAS评分均>6分。结论:腹部手术老年患者持续输注瑞芬太尼维持麻醉的合适速率为0.10μg/(kg.min)。术毕停用瑞芬太尼后,及时、充分地补充镇痛是必须的。

Aim ： To evaluate the effects of infusion remifentanil at different rates on maintenance of anesthesia in old patients undergoing operation on abdominal region. Methods ：A total of 30 old patients undergoing operation on abdominal region were randomly divided into 3 groups;group A, B, and C（0.05,0.10, and 0.15 μg/（kg·min） ）. After induction, anesthesia was maintained with remifentanil infusion at above-mentioned rates and propofol infusion rate at 4.5 mg/（ kg·h） and intermittent intravenous injection bolus atraeurium 0.2 mg/kg. Bolus remifentanil （0.85 μg/kg） , ephedrine （6 mg） , and atropine （0.5 mg） were intravenously injected corresponding to hypertension, hypotension, and bradycardia during the surgery. Arterial blood pressure（BP）, heart rate （HR） were recorded before induction and 10 min after tracheal intubation and 10 min, 20 min, 30 min, and 60 min of the surgery, and 10 min after extubation. Venous plasma norepinephrine（NE） and epinephrine （E）concentration were analyzed before induction and 10 min after intubation, 10 min of the surgery,and 10 min after extubation. The intraoperative boost frequency of remifentanil, ephedrine and atropine were recorded. The operation time, blood loss and fluid replacement volume, visual analogue scale（VAS） score at 10 min after extubation and patients leaving time were also recorded. Results： Compared with baseline before induction, BP were significantly higher at 30 min, 60 min of the surgery, and 10 min after extubation in group A and were significantly lower at 10 min after tracheal intubation and higher at 10 min after extubation in group B （P 〈 0.05 ）. BP were lower at 10 min after tracheal intubation and 20 min, 30 min, and 60 min of the surgery and higher at 10 min after extubation and HR were decreased at 10 min after tracheal intubation and 60 min of the surgery in group C （P 〈 0.05 or 0.01 ）. HR were all increased at 10 min after extubation in three groups（P 〈0.05）. There were significantly increased in plasma NE and E in group A and group B and in plasma NE in group C at 10 min of the surgery and 10 min after extubation（P 〈0.05 or0.01）. Plasma NE and E concentration significantly increased at 10 min after tracheal intubation in group A and plasma E concentration significantly increased at 10 min after extubation in group C（P 〈 0.05 or 0.01 ）. Boost remifentanil in group A and ephedrine in group C were appeared more frequently than in other two groups （P 〈 0.05 ）. More fluid replacement volume had been given in group C than in group A and B （ P 〈 0.05 ）. There were no significant difference in extubation and patients leaving time and VAS score among three groups （P 〉 0.05） and the VAS scores were all above 6 in three groups. Conclusion：The appropriate rate of remifentanil infusion is 0.10 μg/（ kg ·min） in older patients on maintenance of anesthesia. Promptly and sufficiently supply analgesia is necessary at the end of the surgery after remifentanil take out of service to smooth the postoperative pain.