地氟烷与七氟烷在门诊手术全身麻醉维持中的对比研究：对苏醒早晚期及围手术期咳嗽的影响

背景目前地氧垸已经用于门诊全身麻醉手术的维持阶段，其相对于七氖烷在围手术期的优略性尚存争议。尽管各研究一致指出，地氟烷比七氟烷苏醒更快，但这种差异对苏醒晚期的影响却未有明确报道。并且，地氟烷与七氟烷相比，对咳嗽发生率的影响也存在争议。方法本研究中纳入了130例在全身麻醉下行浅表门诊手术的患者，随机分为2组。所有患者都静脉注射丙泊酚2mg/kg诱导，置入喉罩，采用1％-3％的七氟烷或3％-8％的地氟炕维持麻醉，吸入混合空气或氧气。调节吸入麻醉药的浓度，维持血流动力学稳定，并维持脑电双频谱指数（BIS）于50—60。并用局部浸润和静脉注射酮洛酸30mg镇痛。在手术结束时给予预防性止吐药物，包括昂丹司琼4mg、地塞米松4mg及甲氧氨普胺10mg。评估标准包括睁眼恢复时间，对指令做出反应的时间，定向力恢复的时间，14分快通道评分，首次进食时间，能坐立，可站立，独立行走及出院时间。手术后早期及离院后24小时内，记录患者对于麻醉的满意度，手术后第1天恢复正常活动的能力，不良反应的发生（如咳嗽、意向性运动、氧饱和度〈90％、咽痛及手术后恶心、呕吐），手术后镇痛药及止吐药的使用情况。结果2组患者的流行病学资料相近。尽管围手术期地氯烷组咳嗽的总体发生率高于七氟烷组（分别为60％和32％，P〈0．05），然而在真正应用吸入麻醉药期间（即麻醉维持中），咳嗽发生率的组间差异无显著性。地氧烷组患者苏醒较快，但两组所有患者在离开手术室之前都达到了快通道恢复标准（快通道评分≥12）。此外，离院时间（七氟炕组90±31分钟，地氟炕组98±5分钟）及手术后第1天能恢复正常活动的患者比率（七氟烷48％，地氟炕60％），在两组间的差异无显著性。结论用地氧烷进行维持全身麻醉具有苏醒迅速、咳嗽发生率高的特点。尽管与七氟烷相比，地氟炕在麻醉早期恢复较快，但两组晚期恢复的差异无显著性。两种吸入麻醉药都适用于门诊手术的麻醉。

BACKGROUND： There is controversy regarding the relative perioperative benefits of desflurane versus sevoflurane when used for maintenance of anesthesia in the ambulatory setting. Although studies have consistently demonstrated a faster emergence with desflurane （versus sevoflurane）, the impact of this difference on the later recovery end points has not been definitively established. Furthermore, the effect of desflurane （versus sevoflurane） on the incidence of coughing is also controversial. METHODS： We randomized 130 outpatients undergoing superficial surgical procedures requiring general anesthesia to one of two maintenance anesthetic treatment groups. All patients were induced with propofoI, 2 mg/kg IV, and after placement of a laryngeal mask airway, anesthesia was maintained with either sevoflurane 1% -3% or desflurane 3% - 8% in an air/oxygen mixture. The inspired concentration of the volatile anesthetic was varied to maintain hemodynamic stability and a Bispectral Index value of 50-60. Analgesia was provided with local anesthetic infiltration and ketorolac （30 mg IV）. Antiemetic prophylaxis consisted of a combination of ondansetron （4 mg）, dexamethasone （4 rag）, and metodopramide （10 mg） at the end of surgery. Assessments included recovery times to eye opening, response to commands, orientation, fast o track score of 14, first oral intake, sitting, standing, ambulating unassisted, and actual discharge. Patient satisfaction with an- esthesia, the ability to resume normal activities on the first postoperative day, adverse side effects （e.g., coughing, purposeful movement, oxygen desaturation 〈90%, sore throat, postoperative nausea, and vomiting）, and the requirement for postoperative analgesic and antiemetic drugs were recorded in the early postoperative period and during the initial 24-h period after discharge. RESULTS： The two study groups had comparable demographic characteristics. Although the overall incidence of coughing during the perioperative period was higher in the desflurane group （60% versus 32% in the sevoflurane group, P 〈 0. 05）, the incidences of coughing during the actual administration of the volatile anesthetics （i.e., the maintenance period） did not differ between the two groups. Emergence from anesthesia was more rapid after desflurane; however, all patients achieved fast-track recovery criteria （fast-track score≥ 12） before leaving the operating room. Finally, the time to discharge home （90 ± 31 rain in sevoflurane and 98 - 35 min in desflurane, respectively） and the percentage of patients able to resume normal activities on the first postoperative day （sevoflurane 48% and desflurane 60%） did not differ significantly between the two anesthetic groups. CONCLUSIONS： Use of desflurane for maintenance of anesthesia was associated with a faster emergence and a higher incidence of coughing. Despite the faster initial recovery with desflurane, no significant differences were found between the two volatile anesthetics in the later recovery period. Both volatile anesthetics should be available for ambulatory anesthesia.