右美托咪定联合地佐辛对老年患者上腹部手术全麻恢复期的临床效果

Clinical effect of dexmedetomidine combined with dezocine in elderly patients with upper abdominal operation during recovery from general anesthesia

目的探讨临床小剂量右美托咪定（dexmedetomidine，Dex）联合地佐辛用于老年患者上腹部手术全麻恢复期的临床效果。方法择期上腹部手术患者80例，性别不限，年龄≥65岁，体重52kg～71kg，美国麻醉医师协会（ASA）分级Ⅱ～Ⅲ级，按随机数字表法分为4组（每组20例）：Dex组（A组）、Dex＋地佐辛组（B组）、地佐辛组（C组）、对照组（D组），均采用气管内全凭静脉麻醉，于手术结束前约30min时，A组静脉输注Dex 0．25μg／kg、B组静脉输注Dex0．25μg／kg，继静脉注射地佐辛0．1mg／kg、C组静脉注射地佐辛0．1mg／kg、D组静脉输注等容量生理盐水，容量为15ml，输注时间15min，术毕拔除气管导管送人麻醉恢复室（postanesthesia care unit，PACU）。观察给药前（T0）、拔管即刻（T1）、拔管后5min（T2）时的血流动力学变化，记录患者自主呼吸恢复时间、苏醒时间、拔除气管导管时间，以及患者在PACU的等级量表评分（VRS），Ramsay镇静评分及术后副作用。结果T1、T2时，B组的平均动脉压（mean arterial pressure，MAP）[（82±11）、（76±9）mmHg（1mmHg=0．133kPa）]较A、C、D3组的MAP[（86±11）、（85±11）、（95±12）mmHg]降低（P〈0．05）；D组T1、T2时点的心率（heatrt rate，HR）[（114±11）、（101±9）次／min]比B时明显增快，MAP[（113±15）、（95±12）mmHg]比L时明显升高（P〈0．05）；与D组比较，A、B、C3组躁动、寒战、心血管事件发生率明显降低（P〈0．05），B组副作用发生率低于A、C两组（P〈0．05）；与A组苏醒时间及拔出气管导管时间[（11．2±2．7）、（8．7±2．5）min]比较，B组苏醒时间及拔出气管导管时间略延长[（16．4±2．4）、（11．6±2．6）min]（P〈0．05）；与A、C两组比较，B组在T。时脉搏血氧饱和度（surplus pulse O2，Sp02）降低（P〈0．05）；与B组拔管后5、30minVRS评分及Ramsay镇静评分比较，A、C两组拔管后5、30min的VRS评分明显下降，Ramsay镇静评分升高（P〈0．05）。结论手术结束前30min缓慢静脉输注小剂量Dex或静脉注射地佐辛对老年患者上腹部手术麻醉恢复期都是安全有效的。Dex复合地佐辛可提供更稳定的血流动力学和较好的镇痛和镇静，降低术后副作用的发生率，但麻醉苏醒时间和拔除气管导管时间略延长，拔除气管导管即刻可发生一过性呼吸抑制。

Objective To investigate the clinical effects of a Clinical small dose of dexmedetomidine （Dex） combined with dezocine in elderly patients with upper abdominal operation during recovery from general anesthesia. Methods Eighty ASA Ⅱ or Ⅲ patients of both sexes, aged ≥65 y, weighing 52 kg-71 kg,undergoing elective upper abdominal operationwere randomly divided into four groups with 20 patients each： Dex group（group A）, Dex±dezocine group（group B ）, dezocine group（group C ） and contorl group （group D ）. Anesthesia was induced with iv injection of midazolam, fentanyl, proppfol and rocuronium, Dex 0.25 μg/kg was injected intravenously over 15 rain starting from 30 min before the end of operation in group A, dezocine 0.1 mg/kg was injected intravenously in group B, dexmedetomidine 0.25 μg/kg was injected and then dezoeine 0.1 mg/kg was injected intravenously in group C. While the equal volume of normal saline was administered instead in group D. The patients were sent to postanesthesia care unit （PACU） after extubation. Hemodynamie changes before treatment （T0）, extubation time （T1）,and 5 min after extubation （T2） were observed, spontaneous breathing recovery time, wake-up time and extubation time were recorded, Ramsay scores and VRS scores and adverse reactions after surgery during PACU were also recorded. Results Mean artery pressure （MAP） [ （90± 3 ）, （ 99± 12 ）, （113±15） mmHg（ 1 mmHg=0.133 kPa）]of patients in group B were decreased significantly than that of other three group at T1 and T2 （P〈0.05）. Heart rate （HR） and MAP of patients in group D at T1 and T2 was increased significantly than that of patients in group D at To （P〈0.05）. Compared with group D, incidents of restlessness, chills and cardiovascular events was significantly decreased （P〈0.05） among the other 3 groups. The adverse reaction rate in group B was lower than that of group A and group C （P〈0.05）. Wake-up time and extubation time [ （16.4±2.4）, （11.6±2.6）min） ] in group B were slightly longer than that of time [ （11.2±2.7）, （8.7±2.5） min） ] in group A（P〈0.05）. Compare with groupA and group C, surplus pulse O2（SPO2） of group B was decreased at T1（P〈0.05 ）. Compare with VRS and Ramsay scores after extubation times of 5 min and 30 min in group B, VRS scores in group A and group C were decreased significantly,while Ramsay scores were increased （P〈0.05）. Conclusions Thirty mins before the end of surgery, slow intravenous infusion of small doses of Dex or intravenous dezocine in elderly patients undergoing upper abdominal operation anesthesia is safe and effective, Dex combined with dezocine can provide more stable hemodynamics and good analgesia and sedation, decrease the adverse reactions from its usual ccurrence rate, but the anesthesia recovery time and extubation time were slightly longer, immediate tracheal extubation caused respiratory inhibition.