七氟烷或丙泊酚复合瑞芬太尼麻醉在重症肌无力患者胸腺切除术中的应用

A clinical evaluation of the effect of sevoflurane or propofol in combination with remifentanil in myasthenia gravis patients undergoing thymectomy

目的探讨七氟烷或丙泊酚复合瑞芬太尼麻醉在重症肌无力患者经胸骨正中切口胸腺扩大切除术中的应用,并比较其效果。方法搜集2008年7月-2011年6月于解放军309医院麻醉科行胸骨正中切口胸腺扩大切除术的重症肌无力患者156例,分为2组,其中应用靶控静脉输注丙泊酚和瑞芬太尼麻醉(P组)80例,应用吸入七氟烷复合静脉输注瑞芬太尼麻醉患者(S组)76例,均不加用肌松药。采用4个成串刺激(TOF)检测神经肌肉传递功能。以手术开始(切皮)前作为0时点,每30min记录1次各规定时间点的血流动力学变化,以及基础状态下与拔管后的血气分析及呼吸频率等指标,直至麻醉结束,同时记录麻醉时间、手术时间、清醒时间、麻醉恢复室(PACU)停留时间、拔管时间、输入液体及瑞芬太尼总量。结果两组患者在不使用肌松药的情况下均顺利完成手术,S组手术开始后各时间点TOF值均明显低于P组(P<0.05)。手术后,P组pH值和PaCO2较S组显著升高(P<0.05),PaO2则显著降低(P<0.05)。在患者清醒时间、拔管时间、PACU停留时间及瑞芬太尼用量的比较上,S组明显低于P组(P<0.05)。两组患者在血流动力学及脑电双频指数(BIS)、手术时间、麻醉时间、输入液体总量上差异无统计学意义(P>0.05)。结论重症肌无力患者接受胸骨正中切口胸腺扩大切除术时,在不使用肌松药的情况下,应用七氟烷或丙泊酚复合瑞芬太尼麻醉安全有效。七氟烷复合瑞芬太尼对神经肌肉传递功能的抑制更具有优势,对术后呼吸功能的影响更小。

Objective To explore the application and clinical effect of either sevoflurane or propofol combined with remifentanil in anesthesia of patients with myasthenia gravis（MG） undergoing a transsternal thymectomy.Methods One hundred and y-six MG patients who underwent transsternal thymectomy in 309 Hospital of PLA from July 2008 to June 2011 were enrolled.Eighty patients were anesthetized with remifentanil and propofol infused with a target-controlled infusion plasma model（P group）,and 76 patients were anesthetized with sevo urane plus remifentanil（S group）.No muscle relaxant was used.Neuromuscular transmission was monitored by a train-of-four（TOF） ratio.e hemodynamics in each time point was recorded,the arterial blood gas analysis of basal and the time-to-extubation and respiratory rate were evaluated.Simultaneously,anesthetic time,operating time,the time-to-awakening,the time-stay-in-PACU,liquid amount and dosage of remifentanil were recorded.Results All surgical procedures were completed successfully.Neuromuscular transmission signi cantly decreased in the S group,of which the each-time-point value of the TOF ratio decreased significantly compared with that in P group（P＆lt;0.05） during the operation.The post-operative pH,PaCO2 and PaO2 were signi cantly di erent between the two groups,with an increasing pH ＆ PaCO2and a decreasing PaO2in P group（P＆lt;0.05）.e wakeup and extubation time,the stay-in-PACU and dosage of remifentanil signi cantly decreased in S group（P＆lt;0.05）.No di erences were observed in hemodynamics,BIS,operative and anesthetic time,and liquid amount between the two groups（P＆gt;0.05）.Conclusion It is found that anesthesia in MG patients undergoing transstrenal thymectomy can be performed safely with sevo urane or propofol in combination with remifentanil without the use of muscle relaxant.e anesthesia with sevo urane plus remifentanil may have a reversible muscular relaxant e ect and a faster recovery of neuromuscular transmission,and less in uence on post-operative respiratory function.