两种麻醉方法用于气管切开及插管的效果比较

Comparison of two types of anesthesia used for tracheal incision and intubation

目的观察瑞芬太尼复合咪达唑仑能否减轻喉肿瘤患者气管切开及插管时的心血管反应并同时降低知晓发生率。方法择期喉肿瘤手术患者30例,年龄35～55岁,ASA为Ⅰ～Ⅱ级,喉阻塞为Ⅰ～Ⅱ度,随机分为氟芬合剂组(I组)、瑞芬太尼+咪达唑仑组(R组),每组15例。所有患者在1%利多卡因局部浸润麻醉下行气管切开,气管切开之前,I组患者静脉注射氟芬合剂2mL,R组患者缓慢静脉注射咪达唑仑50μg.kg-1,继之瑞芬太尼0.05μg.kg-1.min-1持续输注。气管切开完成即将插管时,I组患者静脉注射氟芬合剂2mL,R组患者缓慢静脉注射瑞芬太尼1μg.kg-1(大于1min),记录局部浸润麻醉前(T0)、插管前即刻(T1)、插管成功即刻(T2)、麻醉诱导后2min(T3)的HR、MAP、SpO2;记录麻醉诱导时得普利麻的用量;记录气管切开过程中患者有无躁动、呛咳等反应。术后随访患者对气管切开及插管过程的知晓情况。患者SpO2<90%定义为呼吸抑制。结果与T0比较,I组T1时的MAP及HR无明显变化,T2时MAP及HR明显升高(P<0.05),T3时MAP及HR明显降低(P<0.05);R组T1及T2时MAP及HR无明显变化,T3时MAP与T0比较有所下降,但无统计学意义,而HR明显降低(P<0.05)。与I组比较,T2时R组MAP及HR明显降低(P<0.05),而T3时MAP明显升高(P<0.05)。所有患者均无明显呼吸抑制。两组患者气管插管完成后麻醉诱导所需得普利麻量有显著差异(P<0.01);与I组比较,R组呛咳、躁动等插管反应及插管知晓发生率明显降低(P<0.01)。结论在局部麻醉的基础上,瑞芬太尼复合咪达唑仑能明显减轻气管切开及插管引起的心血管反应及知晓发生率。

Objective To investigate if midazolam combined with remifentanil could provide a good condition for tracheal incision and intubation with less intubation responses and awareness. Methods 30 ASA Ⅰ or Ⅱ laryngocarci- noma patients aged 35-55 yrs were randomly divided into 2 groups （ n = 30 each） according to the types of anesthesia for tracheal incision and intubation： patients of group I received innovar 2 mL before tracheal incision, while those of group R received midazolam 50 μg·kg^-1 followed by a constant infusion of remifentanil（0.05 μg·kg^-1· min-1 ）. Tracheal incision was achieved under local infiltration anesthesia. Just before tracheal intubation, all patients assigned to group Ⅰ received innovar 2 mL, while patients assigned to group R received remifentanil 1μg·kg^-1, MAP, HR and SpO2 were monitored and recorded before local infiltration anesthesia （ TO ）, before tracheal intubation （ T1 ）, at the moment of tracheal intubation success （ T2 ）, and two minutes after anesthesia induction （ T3 ）. Propofol used for anesthesia induction was recorded as well. Responses such as restlessness and coughing were also recorded＇. The patients＇ awareness of tracheal incision and intubation was recorded after operation. Results As compared with the baseline values at To, MAP and HR were significantly increased at T2 （ P 〈 0.05 ）, while MAP and HR at T3 were significantly decreased in group Ⅰ（P 〈0.05 ） ; In group R, HR at T3 were significantly decreased（ P 〈 0.05 ）. As compared with group Ⅰ, HR and MAP at T2 in group R were significantly decreased（ P 〈 0.05 ）, while MAP at T3 were significantly increased （ P 〈 0.05 ）. Propofol used for anesthesia induction was much higher in group I than that in group R （ P 〈 0.01 ）. The incidences of tracheal intubation responses such as coughing and restless were significantly higher in group Ⅰ than that in group R（ P 〈 0.01 ）. The incidence of awareness was significantly lower in group R than that in groupⅠ （ P 〈 0.01 ） . Conclusion Midazolam combined with remifentanil can provide a good condition for tracheal incision and intubation with less intubation responses and awareness.