监测麻醉管理在经皮扩张气管切开术中的临床应用

The clinical application of monitored anesthesia care in percutaneous dilatational tracheostomy

目的研究监测麻醉管理(MAC)下经皮扩张气管切开术(PDT)患者血流动力学和麻醉深度变化。方法将46例口腔癌患者随机均分为局部麻醉组(L组)和MAC组(M组),每组23例。L组给予2%利多卡因气管黏膜表面麻醉和局部浸润麻醉,M组在表面麻醉和局部麻醉后静脉注射咪达唑仑、丙泊酚和芬太尼,然后进行PDT。按镇静/警觉(OAA/S)评分标准对镇静深度进行评价,并记录入室后(基础值,T1)、局部麻醉后(T2)、静脉给药后/切皮前(T3)、切皮时(T4)、扩张钳扩张时(T5)和气管切开导管进入气管时(T6)的平均动脉压(MAP)、心率(HR)、状态熵(SE)和反应熵(RE)。术后随访M组患者是否术中知晓。结果与基础值相比,L组的MAP和HR值在T4～T6时均显著升高(P<0.05);M组的MAP和HR值在T3时显著下降(P<0.05),T4～T6时与基础值差异无统计学意义。M组的MAP和HR值在T3～T6时均显著低于L组(P<0.05)。不论是与基础值相比,还是与L组相比,M组的SE和RE值在T3～T6时均显著降低(P<0.01)。随着OAA/S评分的降低,RE和SE值也显著降低(P<0.05)。术后随访,M组患者无1例术中知晓。结论 MAC技术使患者具有更高舒适度,对PDT过程无记忆,血流动力学更加平稳,是实施PDT的一种较好麻醉方法。

Objective To investigate the changes in hemodynamics and depth of anesthesia under monitored anesthesia care （MAC） in patients undergoing percutaneous dilatational tracheostomy （PDT）. Methods Forty-six patients with oral cancer were divided into two groups with 23 cases each： Local anesthesia group （group L） and MAC group （group M）. Local and intratracheal surface anesthesia were performed with 2% lidocaine in group L. Midazolam, propofol and fentanyl were added to group M after local and intratracheal surface anesthesia, then PDT was carried out. During the induction, observer＇s assessment of alertness/sedation （OAMS） scale was used to assess the depth of sedation. Mean ar- terial blood pressure （MAP）, heart rate CHPO, state entropy（SE） and response entropy（RE） were recorded before anesthe- sia （basal value, T1）, after local anesthesia （T2）, after intravenous ＇administration/before incision （T3）, during incision （T4）, during dilating with stretching pliers （T5） and endotracheal intubation（T6）. A postoperative follow-up was taken in group M. Results MAP and HR increased significantly at T4-T6 in group L and decreased at T3 60〈0.05） with no change at T4-T6 in group M compared with those in TI. MAP and HR at T3-T6 in group M were obviously lower than those in group L. SE and RE at T3-T6 in group M were obviously lower than those at T1 or in group L（P〈0.01） and de- creased significantly with the reduction of OAA/S scale（P〈0.05） during the induction. Intraoperative awareness in group M was not found through postoperative follow-up. Conclusion Patients undergoing PDT under MAC has more comfortability, more stable hemodynamics and no memory, so MAC is a better anesthesia for PDT than local anesthesia.