妇科腹腔镜手术患者气腹不同阶段伤害性刺激强度的变化

Changes in noxious stimulation intensity at different periods of pneumoperitoneum in gynecological laparoscopic surgery

目的 评价妇科腹腔镜手术患者气腹不同阶段伤害性刺激强度的变化.方法 拟行妇科腹腔镜手术患者45例,年龄25～36岁,ASA分级Ⅰ或Ⅱ级,体重指数18～23 kg/m2,采用随机数字表法,将患者随机分为3组（n=15）：Ⅰ组采用全凭静脉麻醉,靶控输注瑞芬太尼（血浆靶浓度4～6ng/ml）和异丙酚（血浆靶浓度2 μg/ml）维持麻醉,根据BP和HR变化调整药物浓度,维持血液动力学平稳.Ⅱ组和Ⅲ组均吸入异氟醚（呼气末浓度1%～2%）,靶控输注瑞芬太尼（血浆靶浓度2～4 ng/ml）,两组分别于气腹前5 min、腹腔快速充气结束后5 min时停用瑞芬太尼,吸入异氟醚（呼气末浓度1%～2%）维持麻醉至手术结束.分别于麻醉前（T0）、气腹前5 min（T1）、气腹5 min（T2）和气腹15 min（T3）时监测HR和MAP,抽取肘静脉血,测定血浆皮质醇（Cor）、去甲肾上腺素（NE）和肾上腺素（E）的浓度.结果 与T0时比较,Ⅱ组T2,3时HR和MAP、血浆NE和E浓度、T3时cor浓度升高（P〈0.05）;与Ⅰ组比较,Ⅱ组T2,3时HR和MAP、血浆NE和E浓度、T3时Cor浓度升高（P〈0.05）;与Ⅱ组比较,Ⅲ组T2,3时HR和MAP、血浆NE和E浓度、T3时Cor浓度降低（P〈0.05）.结论 妇科腹腔镜术患者气腹不同阶段中,腹腔快速充气阶段的伤害性刺激最强,应注意调控麻醉深度.

Objective To evaluate the changes in noxious stimulation intensity at different periods of pneumoperitoneum in gynecological laparoscopic surgery.Methods Forty-five ASA Ⅰ or Ⅱ patients, aged 25-36 yr, with body mass index 18-23 kg/m2 , undergoing elective gynecological laparoscopic surgery, were randomly divided into 3 groups （ n = 15 each）. In group Ⅰ , anesthesia was maintained with TCI of remifentanil （target plasma concentration 4-6 ng/ml） and propofol （target plasma concentration 2 μg/ml）, and the concentrations were adjusted according to the changes in BP and HR to maintain hemodynamics stable, Ⅱ and Ⅲ groups received inhalation of isoflurane （end-tidal concentration 1%-2% ） and TCI of remifentanil （target plasma concentration 2-4 ng/ml）. TCI of remifentanil was then stopped at 5 min before pneumoperitoneum （group l] ） or at 5 rain after the end of rapid inflation （group Ⅲ ）, and isoflurane was inhaled （end-tidal concentration 1%-2% ） to maintain anesthesia until the end of operation in Ⅱ and Ⅲ group. Before anesthesia （ To ）, 5 min before pneumoperitonemn （T1）, 5 and 15 min of pneumoperitoneum （T2.3）, HR and MAP were monitored and venous blood samples were taken for determination of plasma eortisol （Cor）, norepinephrine （NE） and epinephrine （E） concentrations. Resuits HR, MAP and NE and E concentrations at T2.3 , and Cor concentrations at T3 were significantly higher than those at To in group Ⅱ , and in group Ⅱ than in group Ⅰ （P 〈 0.05） . HR, MAP and NE and E concentrations at T2.3 ,and Cot concentrations at T3 were significantly lower in group Ⅲ than in group Ⅱ （P 〈 0.05） . Conclusion The intensity of noxious stimulation is strongest during rapid inflation among the different periods of pneumoperitoneum in gynecological laparoscopic surgery and the depth of anesthesia should be regulated.