靶控输注麻醉方式对腹腔镜胆囊切除术患者应激反应的影响

Effects of target controlled infusion on the stress reaction of patients underwent laparoscopic cholecystectomy

目的探讨靶控输注丙泊酚联合瑞芬太尼麻醉方式对腹腔镜患者应激反应的影响。方法行腹腔镜手术患者90例分为:A组(40例)靶控输注丙泊酚(血浆靶浓度3μg/mL)联合瑞芬太尼(血浆靶浓度3 ng/mL);B组(26例)单纯靶控输注丙泊酚(血浆靶浓度3μg/mL);C组(24例)静脉泵入丙泊酚0.2～0.6 mg.kg-1.h-1。比较各组患者麻醉前(T0)、诱导成功后(T1)、气腹后30 min(T2)、术毕时(T3)、术后24 h(T4)生命体征,包括心率(HR)、平均动脉压(MAP)、动脉血氧饱和度(SpO2)、呼气末二氧化碳分压(PETCO2);反应机体应激反应指标包括血清皮质醇(COR)、白细胞介素-6(IL-6)、C反应蛋白(CRP)、血糖(GLU)。结果 A组、B组患者HR、MAP、SpO2、PETCO2在麻醉过程中无显著改变(P>0.05)。C组HR在麻醉后呈升高趋势,MAP呈下降趋势,SpO2在T1、T2时相均显著低于T0(P<0.05);PETCO2在麻醉后各时相较T0显著增高(P<0.05)。A组HR、MAP在T1～T4各时相与C组相比有显著差异(P<0.05);SpO2在T1、T2均显著高于C组(P<0.05);PETCO2在T1～T3均显著低于C组(P<0.05)。COR、IL-6、CRP、GLU在A组各时相均无显著差异,B组在T2、T3、T4各时相较T0显著增高(P<0.05);C组在T1～T4各时相较T0均显著增高(P<0.05);A组IL-6、CRP、GLU在T2、T3均分别低于B组和C组(P<0.05)。A组术后苏醒时间显著低于B组和C组(P<0.05)。A组术后出现恶心、呕吐比例(12.50%)显著低于B组(23.08%)和C组(33.33%),P<0.01。结论丙泊酚联合瑞芬太尼靶控输注麻醉能够维持腹腔镜胆囊切除术患者的血流动力学稳定,减少CO2气腹造成的损伤,减少机体的应激反应,术后苏醒快,并发症少,是腹腔镜胆囊切除术的安全可靠的麻醉方式。

Objective To explore the effects of target controlled infusion （TCI） of propofol combined with remifentanil on the stress reaction of patients underwent laparoscopic cholecystectomy. Methods Totally 90 patients underwent laparoscopic cholecystectomy were divided into group A, B, C. TCI of 3 μg/mL propofol and 3 ng/mL remifentanil was applied in group A, TCI of 3 μg/mL propofol in group B and 0.2 - 0.6 mg·kg^-1·h^-1 propofol through the venous pump in group C. The heart rate （HR） , mean arterial pressure （MAP） , arterial oxygen saturation （ SpO2 ） , end-tidal pressure of carbon dioxide （ PETCO2 ） , and the levels of corticosteroid （COR） , interleukin-6 （ IL- 6）, C-reaction protein （CRP）, blood glucose （GLU） were analyzed and compared at different time points of before the anesthesia （T0）, after the induction （T1） , 30 minutes after the pneumoperitoneum （T2） , operation finished （T3） and 24 hours after the operation （T4）. Results There was no significant difference in HR, MAP, SpO2 , PETCO2 during the anesthesia between group A and B （P 〉 0.05 ）. The HR in group C was increased but MAP was decreased after the anesthesia. SpO2 was obviously lowered at T1 and T2 compared with that at TO in group C and the PETCOzwas increased at TI -T4 compared with that at TO （P 〈 0.05）. There were obvious differences in HR and MAP at T1-T4 between group A and group C （P 〈0.05）. SpOzwas obviously higher at T1 and T2 and PETCO2was lower at T1 - T3 between group A and group C （ P 〈 0.05 ）. The levels of COR, IL-6, CRP, and GLU were not changed in group A, but increased in group B at T2 T4 compared with that at TO （ P 〈 0.05 ）, and obviously up-regulated in group C at T1 - T4 （ P 〈 0.05 ）. There were obvious differences between group A and group B and C at T2 and T3 in the levels of IL-6, CRP, and GLU （ P 〈 0.05 ）. The palinesthesia time of group A was obviously less than that in group B and C （P 〈0.05）. The ratio of nausea and vomiting postoperation of group A（ 12.50% ）was lower than that of group B （23.08%） and C （33.33%） , P 〈 0.01. Conclusion TCI of propofol combined with remifentanil can maintain the stable hemodynamics, decrease the injury of CO2 pneumoperitoneum and the stress reaction. It is a safe and anesthesia method for laparoscopic eholecystectomy with fast palinesthesia and fewer complications.