瑞芬太尼预防颈丛麻醉下甲状腺手术牵拉反应的临床观察

Clinical observation of the effects of remifentanil on draw reaction at cervical plexus anesthesia for thyroid operation

目的观察辅助使用瑞芬太尼、度氟合剂防治颈丛阻滞麻醉下甲状腺手术牵拉反应的效果。方法选择ASAⅠ~Ⅱ级择期行甲状腺手术患者60例,随机分为A、B、C 3组,每组20例,A组(瑞芬太尼组):切皮后先给瑞芬太尼0.05~0.08μg/kg做为负荷量(注射时间不小于1分钟),然后持续泵注瑞芬太尼0.05μg·kg-1·min-1。术中根据情况调整注射剂量。B组(瑞芬太尼和度氟合剂联合组):消毒皮肤时静注度氟合剂1/2量(杜冷丁50 mg、氟哌利多2.5 mg),分离颈白线时持续泵注瑞芬太尼0.05μg·kg-1·min-1,术中根据情况调整瑞芬太尼输注速度。C组(度氟合剂组):消毒皮肤时静注度冷丁1 mg/kg,氟哌利多0.05 mg/kg。术中出现牵拉反应明显时,追加度冷丁或芬太尼。A、B两组在皮肤缝合前停注瑞芬太尼。结果 C组患者手术后血压、心率明显升高,尤其分离甲状腺时,升高更为明显,与麻醉前比较,差异有统计学意义(P<0.05)。A、B两组患者与C组比较,手术后及牵拉甲状腺时,血压、心率升高幅度较小,差异有统计学意义(P<0.05);C组患者在牵拉甲状腺或其上极时疼痛较为明显,虽然增加了镇痛剂,也不能完全抑制疼痛,与A、B两组比较,差异有统计学意义(P<0.05)。A组患者手术结束时,Ramsay评分较低,而VPS评分较高,与B、C两组比较,差异有统计学意义(P<0.05)。结论持续输注小剂量的瑞芬太尼,能有效抑制颈丛阻滞下甲状腺手术的牵拉反应,若与小剂量的度氟合剂联合使用,瑞芬太尼剂量明显减少,安全性更高,效果更佳。

Objective To observe the effects of remifentanil on draw reaction at cervical plexus anesthesia for thyroid operation. Methods 60 cases of elective thyroid operation,ASAⅠ-Ⅱ,were randomly divided into three groups (group A,b and C,20 cases each).In group A,remifentanil 0.05 ~0.08 μg/kg was injected over 1 min and infused at a rate of 0.05 μg·kg-1 ·min-1 after skin incision.In group B,dolantin 50 mg and droperidol 2.5 mg were administered when disinfecting skin,and then 0.05 μg·kg-1 ·min-1 remifentanil was used by continual pump infusion since separated the cervical white line.While patients in group C received dolantin 1 mg/kg and droperidol 0.05 mg/kg when disinfecting skin,and superaddition of dolantin or fentanil in the event of a serious draw reaction.Adjusted injection rate of remifentanil according to the situations during operation,and stopped injecting before skin suture.Results In group C,the blood pressure and the heart rate increased significantly after surgery,especially when separating the thyroid gland(P<0.05).Patients in group A and B have a significantly lower increasing amplitude of BP and HR than that in group C after surgery or when pulling the thyroid gland(P<0.05 ).Pa-tients in group C had obvious pain aggravated when pulling the thyroid gland or its upper pole,which could not be suppressed by increasing the analgesic.while the pain was dramatically sighter and repressible in group A and B(P<0.05).At the end of the surgery,patients in group A had a lower Ramsay score and a higher VPS score is higher than those in groups B and C(P<0.05 ).Conclusion Continuous infusion with small dose of remifentanil can inhibit draw reaction in thyroid surgery under cervical plexus block anesthesia.If combined with a small dose of dolantin and droperidol,the dose of remifentanil should be reduced considerably,which would be safer and more effective.