瑞芬太尼靶控浓度对支撑喉镜手术患者皮质醇和白介素-6的影响

Influence of remifentanil TCI on cortisol and interleukin-6 of patients undergoing laryngoscope operation

目的观察靶控输注(TCI)不同靶浓度瑞芬太尼对支撑喉镜手术患者术中应激性指标皮质醇和炎性因子白介素-6(IL-6)的影响。方法择期成人声带息肉摘除手术患者60例,ASAⅠ或Ⅱ级,入室后监测心电图(ECG)、心率(HR)、脉搏氧饱和度(SpO2)、无创动脉压(NIBP)。瑞芬太尼和异丙酚均进行TCI,异丙酚TCI血浆靶控浓度为4μg/ml。瑞芬太尼根据TCI浓度分为五组(1组5 ng/ml,2组4.2 ng/ml,3组3.5 ng/ml,4组2.9 ng/ml,5组2.4 ng/ml)。患者意识消失后(OAA/S≤2)给予维库溴铵0.1 mg/kg,纯氧通气3 min后气管插管。气管插管完成后连接麻醉机。3 min后进行支撑喉镜置入,继而完成手术。记录患者HR、平均动脉压(MAP),数据采集的时间点为:基础值,诱导后,支撑喉镜置入前,支撑喉镜置入后3 min内最高值。每个数值记录3次,取其平均值。于支撑喉镜置入前、支撑喉镜置入后3 min抽取血样,采用放射免疫法测量应激性指标皮质醇和IL-6。比较各靶控浓度组内患者支撑喉镜置入前、后的皮质醇、IL-6的变化。并记录各个时点的镇静警醒评分。结果患者一般资料无统计学差异。通过对诱导后与基础值HR、MAP的比较,可以观察到,瑞芬太尼靶控浓度在5 ng/ml和4.2 ng/ml时可以引起较明显的心血管系统抑制,表现为HR、MAP测量值下降(P<0.05);通过对支撑喉镜置入前后HR、MAP的比较和对支撑喉镜置入前后血样本中皮质醇、IL-6数值的比较,可以观察到,瑞芬太尼靶控浓度在2.9 ng/ml和2.4 ng/ml时,很难有效抑制支撑喉镜引起的应激反应,表现为HR、MAP、皮质醇和IL-6数值上升(P<0.05)。全部患者诱导后、支撑喉镜置入前、后的OAA/S评分均为1。结论伍用异丙酚TCI浓度4μg/ml时,瑞芬太尼TCI浓度3.5 ng/ml能够有效抑制支撑喉镜应激反应而又不会引起严重的诱导抑制。

Objective To determine the influence of Remifentanil TCI on irritable index：cortisol and inflammatory index： interleukin-6 of patients undergoing laryngoscope operation. Methods Sixty physical status Ⅰ or Ⅱ patients undergoing vocal cord polypectomy were selected. Electrocardiogram （ECG）, heart rate （HR） and pulse oxygen saturation （SpO2） were monitored. Arterial blood pressure （ABP） was monitored after an arteria radialis puncturation made with local anesthesia. Both remifentanil and propofol were target controlled infused. All patients were divided into 5 groups according to the plasma target controlled concentration of remifentanil （1 group 5 ng/ml, 2 group 4.2 ng/ml, 3 group 3.5 ng/ml, 4 group 2.9 ng/ml, 5 group 2.4 ng/ml）. Propofol was initiated with TCI at 4μg/ml. Vecuronium Bromide was given at 0.1 mg/kg after patients losing consciousness （OAA/S≤2） and intubation was given after pure oxygen given 3 min. Then anaesthetic machine was connected. 3 minute later laryngeal endoscope was inserted, and then operation was carried on. Heart rate （HR） and mean blood press （MBP） after induction and before laryngoscope used and the highest data in 3 minute were recorded. Regard data of lying calmly as base data. Every data was observed thrice and the average data was recorded. Blood samples were taken before and after laryngoscope used 3 min. Irritable index： cortisol and inflammatory index： interleukin-6 were measured with radio-immunity method, Variations of cortisol and interleukin-6 and blood glucose before laryngoscope used were compared. Observer＇s Assessment of Alert/Sedation Scale （OAA/S） was recorded at all times. Results General data of patients had no statistical difference. HR and MBP of basic data and after induction were observed, with the same target controlled concentration of propofol, remifentanil may induce inhibition of cardiovascular system at 5 ng/ml and 4.2 ng/ml, with HR and MBP decreasing obviously （P〈0.05）; HR, MBP before and after laryngoscope used, and the value of plasma cortisol and interleukin-6 and blood glucose before and after laryngoscope used were observed. Remifentanil can hardly effectively inhibit laryngoscope irritable response at 2.9 ng/ml and 2.4 ng/ml, with HR, MBP, cortisol and interleukin-6 increasing dramatically （P〈0.05）. OAA/S of all patients after induction, before and after laryngoscope used was 1. Conclusions Propofol target controlled infusion at 4μg/ml can sustain enough sedation. Remifentanil target controlled infusion at 3.5 ng/ml could inhibit laryngoscope irritable response and avoid severe induction response.