右美托咪定替代丙泊酚对妇科腹腔镜手术全身麻醉维持和术后恢复的影响

The effect of dexmedetomidine alternative to propofol administered in general anesthesia on maintalnance and recovery in patients undergoing gynecologic laparoscopy

目的观察右美托咪定替代丙泊酚对妇科腹腔镜手术全身麻醉维持和术后恢复的影响。方法将120例妇科腹腔镜手术患者按随机数字表法分为C组、D1组和D2组，每组40例，C组麻醉维持为丙泊酚100μg／（kg·min）、雷米芬太尼0．10～0．25μg／（kg·min），D-组麻醉维持为丙泊酚100μg／（kg·min）、雷米芬太尼0．10～0．25μg／（kg·min）、右美托咪定0．2μg／（kg。h），Dz组麻醉维持为右美托咪定2．0－3．0μg／（kg·h）、雷米芬太尼0．10～0．25恤g／（kg·min），间断静脉注射顺阿曲库铵维持麻醉。记录患者入手术室时（T0）、诱导后（T1）、插管后（T2）、切皮后（T]）、气腹后即刻（T4）、气腹后10min（B）、气腹后20min（T6）、手术结束时（B）、离开麻醉后恢复室时（B）和术后第1天（T9）的心率、平均动脉压（MAP）；苏醒时间、拔管时间、离开麻醉后恢复室时间；苏醒、拔管及离开麻醉后恢复室时Ramsay镇静评分、Riker躁动评分，术后第1天恢复质量评分。结果D：组T2-T3-T7MAP明显高于C组和D。组[（93±10）、（99±11）、（94±13）、（95±10）、（91±10JmmHg（1mmHg=0．133kPa）比（88±11）、（90±10）、（87±9）、（86±9）、（83±8）mmHg和（87±9）、（90±10）、（86±8）、（85±7）、（83±7）mmHg]，差异有统计学意义（P〈0．05）；三组在各时间点心率比较差异无统计学意义（P〉0．05）。三组苏醒时间、拔管时间、离开麻醉后恢复室时间比较差异均无统计学意义（P〉0．05）。苏醒时C组Ramsay镇静评分明显低于D1组和D1组[（3．7±1．3）分比（4．0±0．9）、（4．2±0．9）分]、Riker躁动评分明显高于D1组和D2组[（3．1±1．0）分比（2．8±0．6）、（2．7±0．9）分]，拔管时C组Riker躁动评分明显高于D1组和D1组[（3．S±0．7）分比（3．2±0．4）、（3．0±0．5）分]、且D1组Riker躁动评分明显高于D2组，C组和D1组术后第1天恢复质量评分明显低于D2组[（93±13）、（93±15）分比（108±10）分]，差异均有统计学意义（P〈0．05）。术后随访无一例术中知晓。结论妇科腹腔镜手术全程使用2．0-3．0μg／（kg·h）右美托咪定维持可以提高拔管质量和术后恢复质量，对拔管时间无影响，但在气腹早期存在血流动力学变化。

Objective To evaluate the effect of dexmedetomidine alternative to propofol administered in general anesthesia on maintainance and recovery in patients undergoing gynecologic laparoscopy. Methods One hundred and twenty patients undergoing gynecologic laparoscopy, were divided into group C, D1 and D2 with 40 cases each by random digits table method. Group C received propofol 100 μg / （kg. min） and remifentanil 0.10 - 0.25μg / （kg. min） intravenous infusion, group D1 received propofol 100 μg/（kg. min）, remifentanil 0.10 - 0.25 μ g/（kg.min） and dexmedetomidine 0.2 μ g/（kg. h）intravenous infusion, while group Dz received dexmedetomidine 2.0 -3.0 μg / （kg .h） and remifentanil 0.10 -0.25 μg/ （kg＇min）. Cis-atracurium was given on time to maintainanee of anesthesia. The heart rate （ HR ）, mean arterial pressure （MAP） were recorded at the following time points： arriving at operating room （To） ,anesthesia induction （T1）,intuhation （T2）,skin incision （T3）,pneumoperitoneum （T4）, 10 min after p neumoperitoneum （T5）, 20 min after pneumoperitoneum （T6）, the end of operation （T T）, discharge from post anesthesia care unit（T5） and the first postoperative day （T9）. The time of emergence, extubation and duration in post anesthesia care unit were recorded too. Ramsay scale and Riker Sedation-Agitation Scale on emergence, extubation and discharge from post anesthesia care unit and post anesthesia recovery score at T9 were also recorded. Results The MAP in group Dz was higher at T3 to T7 time-points than that in group C and group D1 [ （93 ± 10）, （99 ± 11 ）, （94 ± 13）, （95 ± 10）, （91 ± 10） mm Hg （ 1 mm Hg = 0.133 kPa） vs. （88±11）,（90±10）,（87±9）,（86±9）,（83±8）mmngand （87±9）,（90±10）,（86±8）,（85±7）, （83± 7 ） mm Hg], there were significant difference （P 〈 0.05 ）. There were no significant difference among groups on the HR at each time point and the time of emergence, extubation and duration in post anesthesia care unit （P 〉 0.05）. Ramsay scale was lower on emergence and Riker Sedation-Agitation Scale was higher on emergence and extubation ira group C than that in group D1 and group D2 [（3.7 ±1.3） scores vs. （4.0 ±0.9）, （4.2 ±0.9） scores, （3.1 ± 1.0） scores vs. （2.8 ±0.6）, （2.7 ±0.9） scores, （3.3 ±0.7） scores vs. （3.2 ± 0.4）, （3.0 ±0.5） scores], there were significant differences （P 〈 0.05）. Riker Sedation-Agitation Scale was higher on extubation in group D1 than that in group D1（P 〈 0.05）. Post anesthesia recovery score at T9 in group D2 was apparently increased compared with that in group C and group D1 [ （ 108 ± 10） scores vs. （93 ± 13）,（93 ± 15） scores]（P〈0.05）. Conclusions Dexmedetomidine 2.0- 3.0 μ g/ （kg.h） administered in general anesthesia on maintainance in gynecologic laparoscopy can improve the quality of extubation and promote postoperative recovery without prolonging extubation time, but have a influence on hemodynamic changes at early stage of pneumoperitoneum.