老年患者瑞芬太尼分步靶控输注复合异丙酚麻醉效果

Total intravenous anesthesia with a step-by-step target-controlled infusion of remifentanil and propofol in elderly patients

目的观察瑞芬太尼分步靶控输注全麻对老年患者腹腔镜下胆囊切除术时应激反应抑制、循环和苏醒的影响。方法60例ASAⅠ-Ⅲ患者随机分成4组，每组15例。麻醉诱导时A组、B组、c组和D组分别给予0．06mg／kg芬太尼、血浆靶浓度4．0μg/L输入芬太尼、血浆靶浓度4．0μg/L输入瑞芬太尼及血浆靶浓度从2．0μg/L分阶段增至4．0μg/L输入瑞芬太尼，同时给予血浆靶浓度3．0μg/L异丙酚及维库溴胺完成麻醉诱导。除B组在胆囊取出后停止芬太尼输入外，各组所有药物均在术毕时停止输入。予T0、T1、T2、T3和T4点记录血流动力学参数及测定血清皮质醇、醛固酮和血糖浓度。记录苏醒拔管时间、术毕至出恢复室时间、拔管时OAA／S评分和从术毕至OAA／S评分达5分时间。记录麻醉手术过程中血管活性药物应用情况。结果4组患者在麻醉诱导时MAP及HR均有不同程度下降，C组最为明显，MAP及HR分别下降至（59±12）mmHg和（54±6）次／min（P〈0．05）；4组患者苏醒拔管时MAP及HR均增加，A、B两组增加显著，分别增高至（113±13）mmHg、（81±8）次／min和（110±12）mmHg、（80±7）次／min（P〈0．05）；A、B两组T4点皮质醇、醛固酮浓度比11D点明显增高（P〈0．05）；C组阿托品、麻黄碱、艾司洛尔和乌拉地尔使用总次数为20次，比其余3组明显增加（P〈0．05）。C、D两组拔管时间、出恢复室时间和OAA／S评分至5分时间比A、B两组明显缩短（P〈0．05）；C、D两组拔管时OAA／S评分明显高于A、B两组（P〈0．05）。结论瑞芬太尼TCI可有效抑制老年患者气管插管和上腹部手术等刺激引起的应激反应，苏醒迅速且质量高，分步TCI时循环更加平稳。

Objective To observe the restrain of stress reaction, circulation stability and the palinesthesia from anaesthesia during a step-by-step target-controlled infusion （TCI） of remifentanil in elderly patients under laparoscopic cholecystectomy. Methods Sixty ASA class Ⅰ -Ⅲ patients were randomly divided into 5 groups：IS case each group. A dose of 0.06 mg/kg fentanyl was given in group A,4.0 μg/L blood plasma target level of fentanyl was given in group B ,4.0 μg/L blood plasma target level of remifentanil was given in group C, and blood plasma target level of remifentanil was given from 2.0 μg/L to 4.0 μg/L step by step in group D during anesthesia. Midazolam, propofol and vecuronium bromide were also given during anesthesia induction. Hemodynamic parameters at T0, T1, T2, T3 and T4 were recorded, and the concentrations of serum corticosteroid, aldosterone and blood sugar determined. The time of extubation, return to ward, OAA/S score after extubation, and OAA/S score to 5 was recorded. The use of vasoactive agent during operations was also recorded. Results MAP and HR were decreased during anesthesia induction in 4 groups, and more significant in group C （ P 〈 0.05 ）. MAP and HR were increased during trachea extubation in 4 groups, and more significant in groups A, B （ P 〈 0.05 ）. The concentrations of corticosteroid and aldosterone were increased significantly at T4 compared to T0 （ P 〈 0.05 ）. The frequency of using vasoactive agents was increased significantly in group C （ P 〈 0.05 ）. The time of extubataion, leaving PACU,and OAA/S score to 5 was significantly shortened in groups C,D （P 〈0.05）. The OAA/S scores were significantly higher in groups C, and D than in groups A, and B （P 〈 0.05 ）. Conclusion TCI of remifentanil can restrain stress reaction caused by tracheal intubation and operation stimulation effectively, and provide quickly paiinesthesia with high quality in elderly patients, but a step-by-step TCI of remifentanil can provide more stable circulation.