瑞芬太尼靶控输注用于肝脏部分切除术的准确性评价

Predictive performance of target-controlled infusion of remifentenil in patients receiving partial hepatectomy

目的应用Base Primea静脉麻醉输注工作站,将瑞芬太尼/丙泊酚靶控输注(TCI)静脉全身麻醉复合硬脊膜外腔阻滞用于肝脏部分切除术,观察瑞芬太尼TCI系统的执行情况。方法选择36例美国麻醉医师学会(ASA)分级Ⅰ或Ⅱ级,年龄18～65岁,择期行肝脏部分切除术的患者,根据瑞芬太尼血浆靶浓度分入瑞芬太尼2ng/mL组、瑞芬太尼4ng/mL组和瑞芬太尼6ng/mL组,每组12例。3组患者均在瑞芬太尼/丙泊酚TCI复合硬脊膜外腔阻滞下完成手术,丙泊酚的血浆靶浓度为均3μg/mL,按照不同的分组给予相应剂量瑞芬太尼TCI至手术结束。分别于TCI开始(T0)及TCI后5min(T1)、10min(T2)、20min(T3)、30min(T4)、60min(T5)、90min(T6)、120min(T7)记录患者的心率(HR)、平均动脉压(MAP)、脑电双频指数(BIS)、听觉诱发电位指数(AAI)。抽取桡动脉血,采用液质联用分析法(LC-MS/MS)测定瑞芬太尼血药浓度,以执行误差(PE)、偏离度(MDPE)、精确度(MDAPE)及摆动度(wobble)的第10、90百分位数(P10、P90)和中位值(M)评价瑞芬太尼TCI系统执行的效果。结果 3组在T1至T5时间点的MAP均显著低于同组T0时间点(P值均<0.05),但仍在临床正常范围内;在T1至T5时间点的HR与同组T0时间点的差异无统计学意义(P值均>0.05);在T1至T5时间点的BIS、AAI均显著低于同组T0时间点(P值均<0.05)。3组间同时间点的HR、MAP、BIS、AAI的差异均无统计学意义(P值均>0.05)。瑞芬太尼2ng/mL组在T1、T2和T3时间点,瑞芬太尼4ng/mL组在T3、T5和T7时间点,以及瑞芬太尼6ng/mL组在T2、T5时间点的瑞芬太尼实测血药浓度均显著低于同组设定的靶浓度(P值分别<0.05、0.01)。瑞芬太尼TCI系统的PE、MDPE、MDAPE、wobble分别为-4.87%、-5.15%、21.29%、14.34%。结论 TCI时瑞芬太尼的实测浓度与设定的靶浓度存在PE,但PE在临床可接受范围,故瑞芬太尼TCI系统能安全有效地应用于静脉全身麻醉复合硬脊膜外腔阻滞的肝脏部分切除术。

Objective To evaluate the effect of target-controlled infusion （TCI） of remifentenil in patients receiving partial hepatectomy under general intravenous anesthesia combined with epidural block. Methods A total of 36 patients with American Society of Anesthesiologists （ASA） grade I orⅡ, aged 18 - 65 years old, undergoing elective partial hepatectomy, were enrolled in this study. They were randomly divided into 3 groups （n= 12） according to the target level of remifentanil of 2, 4 and 6 ng/mL. General intravenous anesthesia combined with epidural block was induced and maintained with propofol at a target level of 3 pg/mL and remifentanil at different target levels throughout the operation by TCI. Heart rate （HR）, mean arterial pressure （MAP）, bispectral index （BIS） and A-line ARX Index （AAI） were monitored during anesthesia. Blood samples were taken at radial artery for determination of remifentanil concentration by liquid chromatography-mass spectrometry detection （LC-MS/MS）. The performance error （PE）, median performance error （MDPE）, median absolute performance error （MDAPE） and wobble were calculated to evaluate TCI devices. Results Although the MAP during anaesthesia was significantly lower than the baseline （P〈0.05）, it was the within normal range in all the patients. There were no significant differences in HR between each time point and baseline （P〈0.05）. The BIS and AAI during anaesthesia were significantly lower than the baseline （P〈0.05）. There were no significantdifferences in terms of HR, MAP, BIS and AAI among three groups during anesthesia （P〈0.05）. The measured plasma concentrations of remifentanil were lower than target concentrations in group 2 ng/mL at T1, T2 and T3 （ P〈 0.05, 0.01 ）, so were those in group 4 ng/mL at T3, T4 and T7 and those in group 6 ng/mL at 1-2 and Ts （ P〈0.05, 0.01 ）. The PE, MDPE, MDAPE and wobble of remifentanil TCI system were - 4.87 %, - 5.15 %, 21.29 %, and 14.34%, respectively. Conclusion Remifentanil can be administered by TCI with an acceptable performance error between estimated and measured plasma concentrations. The predictive performance of remifentanil TCI system is acceptable for the patients with partial hepatectomy under general intravenous anesthesia combined with epidural block.