老年患者长时间输注不同剂量瑞芬太尼诱发术后急性阿片耐受的研究

Development of acute opioid tolerance following continuous remifentanil infusion in elder patients

目的探讨行胰十二指肠切除术老年患者术中，长时间持续输注不同剂量瑞芬太尼，能否诱发术后急性阿片耐受。方法选择老年患者AsAI～Ⅲ级胰十二指肠切除术患者30例，随机分为高剂量组（H组，n=15）和低剂量组（L组，n=15）。H组和L组，术中分别持续输注瑞芬太尼0．3μg·kg～·min^-1和0．1μg·kg～·min^-1。术中均持续输注维库溴铵2μg·kg～·min^-1和吸入七氟醚维持麻醉。心率或平均动脉压超过或低于其基础值的20％，则将七氟醚上调或下调1％。记录术后麻醉恢复室芬太尼用量、术后24h的芬太尼累积用量、术后芬太尼总用量（麻醉恢复室用量和术后24h的芬太尼累积用量），用视觉模拟评分法（VAS）和PCA有效按压次数与总按压次数之比（I／A）评价疼痛强度。对以上指标术后最初4h，之后每4h采集数据一次，共采集24h。结果与L组比较，H组术后麻醉恢复室芬太尼用量、术后24h的芬太尼累积用量、术后芬太尼总量的需求显著升高（P〈O．01）；H组PcA有效按压次数与总按压次数之比明显低于L组（P〈0．01）；H组与L组术后芬太尼总量相差大于30％（H组较L组高出约1．6倍）；两组患者VAS差异无统计学意义（P〉0．05）。结论老年患者行胰十二指肠切除术时持续输注高剂量瑞芬太尼可诱发术后急性阿片耐受。

Objective To observe the development of acute opioid tolerance after intraoperative continuous remifentanil infusion in elder patients. Methods Thirty elder patients aged 60y-80y （ ASA I - Ⅲ ） undergoing operation of duodenopancreatectomy were randomly assigned to two groups （n = 15 ）. Patients received continuous infusion of 0.3 μg·kg～·min^-1（ high-dose group） or 0.1 μg·kg～·min^-1（ low-dose group） remifentanil during surgery. Anesthesia was maintained with sevoflurane inhalation and vecuronium injection. The inspired sevoflurane concentration was increased or decreased by 1% in the case of HR and/or SBP over or below baseline values by 20%. Fentanyl consumption was recorded and PCA effect was observed in the first postoperative 24 h. Results The fentanyl consumption in postanesthetic care unit, within the first postoperative 24 h and the postoperative total consumption in high-dose group were significantly more than those in low-dose group （ 1.6 times, P 〈 0.01 ）. The ratio of PCA I/A in high-dose group was less than that in low-dose group at each time point （ P 〈 0.01 ）, without difference in VAS between two groups. Conclusion Acute opioid tolerance develops following intraoperative continuous high-dose remifentanil infusion in elder patients.