听觉诱发电位监测调控麻醉深度对应激反应及血流动力学的影响

Effects of auditory evoked potential monitoring directed anesthetic depth control on the stress response and hemodynamic

目的比较用传统方法与用听觉诱发电位指数（A-lineARXindex，AAI）调控麻醉深度对应激反应及血流动力学的影响。方法择期行腹腔镜手术女性患者40例，美国麻醉医师协会（ASA）分级I～Ⅱ级，心功能1～2级，掷币法随机分为两组：AAI调控组（A组），对照组（B组），每组20例。全麻诱导后，A组根据AAI值调整麻醉深度，维持AAI在（20±5）范围内；B组根据血压、心率（HR）来调节麻醉深度，调节平均动脉压（MAP）和HR维持在基础值±20％以内。于入室后（T0），插管后即刻（T1），CO2气腹后5min（T2），手术开始后30min（T3），气管拔管后即刻（T4），各时间点采静脉血测定血糖、皮质醇水平。同时记录围术期12个时间点P1-12的AAI、MAP、HR及任何麻醉深度不足的临床表现，如呛咳、流泪。结果术后睁眼时间A组（6±5）min明显比B组（8±6）min缩短（P〈0．05），B组术中呛咳有2例，术中做梦有1例，而A组均无。两组血浆皮质醇值组内比较A组T3（146±31）0,g／L、T4（147±33）μg／L比T0（171±31）μg/L有明显降低（P=0．022，P=0．017），两组间比较A组L、T4时点比B组有明显降低（P=0．003，P=0．049）。血糖值A组组内比较T1（4．8±0．7）mmol／L、T2（4．8±0．7）mmol／L比T0（5．5±0．8）mmol／L有明显降低（P=0．014，P=0．020）。观察两组12个时点MAP和HR发现A组P3、P4、P7时点的MAP值比B组降低；A组P2、P3、P4、PI0、P11、P12时点的HR值比B降低，差异有统计学意义（R0．05）。结论与传统用血压和HR等指标比较，AAI监测用于调控麻醉深度可以有效地抑制CO：气腹及腹腔镜手术引起的应激反应，使血流动力学保持平稳，避免术中麻醉深度不足，术毕苏醒迅速，预防术中知晓。

Objective To compare the effect of stress response and intraoperative hemodynamic changes by using auditory evoked potential Index （A-line ARX Index, AAI） for judge the depth of anesthesia, versus using the traditional methods such as heart rate and blood pressure. Methods 40 ASA I -Ⅱ female patients undergoing laparoscopic surgery were randomly assigned to group A （using AAI method）and group B （control group, using heart rate and blood pressure） by coin flip method. The AAI values of Group A was controlled to maintain the depth of anesthesia in （20±5） AAI. In Group B which using heart rate and blood pressure to adjust the depth of anesthesia and the mean arterial pressure, the heart rate was maintained in the basic value-＋20%. Five fixed time points were selected to determine the cortisol levels and blood glucose： before induction of anesthesia （To, baseline）, laryngoscopy and endotracheal intubation（T1）, 5 min after CO2 gasless laparoscopic（T2）, 30 min after began operating（T3） and extubation （T4）. AAI, hear rate, blood pressure and any clinical signs of inadequate depth of anesthesia such as coughing and lacrimation were recorded at 12 fixed time points during surgery and anesthesia. Results There were no significant differences between the two groups in the general information and general drugs. Open eyes time of the patient in group A （6-＋5） min were shorter than that in group B （84-6） min （P〈0.05）. There were two patients in group B coughing during operation while none in group A. One patient reported intraoperative awareness in group B while none in group A. The serum cortisol of two groups had a certain degree of reduction after the start of the anesthesia. Significant difference was found in cortisol level in the patients of group A at time points T3 （146±31） μg/L and T4 （147±33） μg/L compared with that at time point To （171±31） μg/L （P=0.022, P=0.017）. There were also significant differences at time points T3 and T4 between the two groups （P=0.003, P=0.049）. There was downward trend of the blood glucose from induction of anesthesia in group A. There were significant differences in the blood glucose level among the time pointsT1（4.8±0.7） retool/L, T2 （4.8±0.7） mmol/L and T0 （5.5±0.8） mmol/L in group A （P=0.014, P=0.020）, while in group B there were no significant differences. The AAI value of the patients in group A began to decrease significantly after induction, dramatically increased when the COz was stopped and seaming the skin. There were signifieant differences of MAP in the time points P3, P4, P7 between two groups（P〈0.05）, and there were also significant differences of HR in the time points P2, P3, P4, Pl0, P11, P12between two groups （P〈0.05）. Conclusions Using AAI monitoring in general anesthetie depth control ean restrain the stress response caused by CO2 gasless laparoseopie surgery, maintain blood dynamics to stable, and avoid intraoperative awareness.