右美托咪啶联合硝酸甘油在鼻内镜手术控制性降压中的应用

The effects of dexmedetomidine combined with nitroglycerin in controlling hypotension during endoscopic sinus surgery

目的比较右美托咪啶(DEX)联合硝酸甘油(NTG)与单用NTG在鼻内镜术中控制性降压效果。方法 40例ASAⅠ～Ⅱ择期行鼻内镜手术患者随机分为DEX复合NTG组(ND)和NTG组(N组),每组20例。所有患者均采用全凭静脉麻醉。以咪唑安定、瑞芬太尼、丙泊酚和顺式阿曲库铵快速诱导插管,术中静脉泵注瑞芬太尼、丙泊酚和间断注射顺式阿曲库铵维持麻醉。气管插管完成后ND组给予负荷剂量DEX1.0μg/kg,10min泵完,继以0.5μg.kg-1.h-1泵至控制性降压结束。N组泵入等量的0.9%氯化钠注射溶液。两组患者均在鼻腔消毒时开始泵注NTG 1.0μg.kg-1.min-1,调节泵速维持MAP 55～65 mmHg。止血完成停用DEX和NTG。观察并记录麻醉诱导前(T0)和控制性降压15 min(T1)、30 min(T2)、45 min(T3),以及拔管后15 min(T4)的HR、MAP。由对所选降压药物不知情的手术医生于T1～T3时点按Fromme评分法进行术野质量评分。统计用药开始至达到降压目标时间、NTG用量、停药后血压恢复至术前水平时间、拔管时间。结果与T0比较,T1～T3时点两组MAP显著降低(P<0.05),N组心率明显增快(P<0.05),组间比较,N组HR明显增快(P<0.05),ND组达到目标血压时间较短且NTG用量明显减少(P<0.05)。T1～T3时点ND组Fromme评分低于N组(P<0.05)。两组停药后血压恢复及拔管时间差异无统计学意义。结论 DEX复合NTG用于鼻内镜手术控制性降压安全有效,NTG用量明显减少,术野干燥及镜下清晰度好。

Objective To compare the effects of using dexmedetomidine combined with nitroglycerin and nitroglycerin alone in controlling hypotension during endoscopic sinus surgery. Methods Forty ASA Ⅰ or Ⅱ patients, aged 20-60yr, weighting 50-76 kg who undergoing endoscopic sinus surgery, were randomly divided into 2 groups （ n = 20 each） ：dexmedetomidine combined with nitroglycerin group （group ND） and nitroglycerin group （group N）. Midazolam, refentanl, propofol and cis-atracurium were used for rapid intravenous induction. Refentanl, propofol and eisatracurium were administrated for anesthesia maintenance. Group ND received dexmedetomidine 1 μg/kg over 10 min after intubation followed by 0.5 μg · kg^-1 · h^-1 infusion during maintenance,while group D received the same amounts of saline. When the surgeons began to sterilize the nasal cavity, nitroglycerin was administrated from 1.0 μg · kg^-1 · h^-1and titrated according to target MAP. The target MAP during controlled hypotension was maintained between 55 and 65 mmHg. MAP and HR were recorded at the time points of pre-induction （To） ,15 min （T1 ） ,30 min （ T2 ） and 45 min （ T3 ） after controlling hypotension and 15 min after extubation （ T4 ）. The Fromme scores of surgical field were assessed by the same surgeon, blinded to the study drugs. The time of MAP reaching to target MAP and returning to preoperative level, the operating time, extubation time and the total dosage of nitroglycerin were recorded. Results Compared with To, MAP in both group decreased and HR in group N increased significantly at T, - T3 during operation （ P 〈 0. 05 ）. Compared with group N, HR remained stable, the time of MAP reaching to target lever wasshorter and the total dosage of nitroglycerin was less in group ND （ P 〈 0.05 ）. Meanwhile, group ND had lower Fromme scores （P 〈 0.05）. Time of MAP returned to preoperative level and extubation time had no significant difference between two groups. Conclusion Dexmedetomidine combined with nitroglycerin can be used to control blood pressure safely and effectively during endoscopic sinus surgery, which can provide less dosage of nitroglycerin and more clear surgery field.