靶控输注瑞芬太尼联合七氟烷用于腰椎手术控制性降压的前瞻性随机对照研究

Efficacy of TCI Remifentanil Combined with Inhalational Sevoflurane Controlled Hypotension in Lumbar Surgery

目的观察靶控输注(target controlled infusion,TCI)瑞芬太尼联合七氟烷控制性降压应用于腰椎手术的安全性和有效性。方法 2009年12月～2011年8月,ASAⅠ～Ⅱ级择期行腰椎减压内固定手术60例,随机分为硝酸甘油组和瑞芬太尼组,每组30例。手术切皮前15 min开始实施控制性降压,硝酸甘油组从0.5μg.kg-1.min-1开始泵注硝酸甘油,瑞芬太尼组从血浆浓度4 ng/ml起TCI瑞芬太尼,调整硝酸甘油输注速度或瑞芬太尼TCI的血药浓度维持平均动脉圧(meanarterial pressure,MAP)在目标血压,关闭手术切口时停止控制性降压。记录控制性降压期间各时点的MAP、心率(heart rate,HR)、脉搏氧饱和度(pulse oximety,SpO2)、脑电双频指数(bispectral index,BIS)值,同时记录2组患者术中麻醉时间、手术时间和控制性降压时间、出血量、自体血回输量、术毕拔管时间等指标。在手术开始后30、60 min由外科医生进行术野质量评分(the score of surgical field quality,SSFQ)。结果 2组患者控制性降压时间、术毕拔管时间、术中出血量、自体血回输量差异无统计学意义(P>0.05),所有患者均未输血。2组均能提供较好的手术视野,术野评分无显著性差异(Z=-1.093,P=0.274)。控制性降压后5 min瑞芬太尼组MAP显著低于硝酸甘油组(t=2.819,P=0.007)。2组患者在控制性降压期间均能维持理想的目标血压,但硝酸甘油组HR显著高于基础值(P<0.05),而瑞芬太尼组HR显著低于基础值(P<0.05)。停止降压后5、15 min,硝酸甘油组MAP和HR仍显著高于瑞芬太尼组(P<0.05),但停止降压后30 min,2组间无统计学差异(P>0.05)。结论 TCI瑞芬太尼复合七氟烷可安全、有效地应用于脊柱外科手术的控制性降压。

Objective To investigate the efficacy and safety of controlled hypotension by using target controlled infusion （TCI） of remifentanil combined with inhalation of sevoflurane in lumbar surgery. Methods Scxty ASA I - II patients undergoing lumbar surgery were randomly assigned to nitroglycerin and remifentanil groups. Controlled hypotension started 15 minutes before incision. In nitroglycerin group, controlled hypotension was induced with nitroglycerin. In remifentanil group, TCI remifentanil was titrated from an initial plasma concentration of 4 ng/ml. A target mean arterial pressure was 55 - 65 mm Hg or reduction 30% of the baseline. Invasive mean arterial blood pressure, heart rate, pulse oximety, bispectral index, blood loss, the amount of autologous blood salvaged, the time of controlled hypotension and extubation were recorded. The score of surgical field quality was assessed by surgeons at 30, 60 minute after incision. Results The amount of bleeding and blood salvaged, the length of controlled hypotension and the time of extubation were not clinically significant different between the two groups （ P 〉 0.05）. No patient in either of the groups received allogeneic blood transfusion. The dryness of the surgical site was similar in the two groups （ Z = - 1. 093, P = 0. 274）. Controlled hypotension was achieved at the target mean arterial pressure in the both. Compared to the nitroglycerin group, the MAP and heart rate were lower in the remifentanil group at 5 minutes after controlled hypotension （t = 2.819, P = 0. 007）. The heart rate in the nitroglycerin group was higher than the baseline, but lower than the baseline of the remifentanil group （P 〈 0.05 ）. Five and fifteen minutes after discontinuing controlled hypotension, the MAP and HR differed significantly between the two groups （P 〈 0.05）, but not clinically significant at 30 minute （P 〉 0. 05 ）. Conclusion With appropriate surgical conditions in the surgical site, TCI remifentanil is effective and safe in controlled hypotension in lumbar surgery.