重型颅脑损伤患者胃管不同置入方式下应激反应的研究

A study of stress response to different ways of indwelling gastric tube in patients with severe craniocerebral injury

目的：观察纤维支气管镜（纤支镜）辅助下留置胃管和传统置管方式对重症监护病房（ICU）重型颅脑损伤患者应激反应的影响。方法将兰州大学第二医院外科ICU收住的126例重型颅脑损伤患者按随机数字表法分为纤支镜辅助留置胃管组（试验组）和传统方式留置胃管组（对照组），每组63例。试验组采用镜杆涂有利多卡因凝胶的奥林巴斯BF-P60纤支镜经鼻进入，到达会厌后调整镜头进入食管10 cm，沿活检口置入导引钢丝，边退镜边缓慢继续推送导丝；纤支镜退出后将准备置入的胃管内外管壁用石蜡油充分润滑后，沿导丝缓慢推入到合适位置后退出导丝，注射空气，有气过水声后固定。对照组用传统方式置管。于置管前及置管后1、3、5 min时监测患者收缩压（SBP）、舒张压（DBP）、心率（HR）、呼气末二氧化碳分压（PETCO2）及血浆去甲肾上腺素（NE）、肾上腺素、血管紧张素Ⅱ（AngⅡ）、血糖的变化。结果两组置管前SBP、DBP、HR、PETCO2、肾上腺素、NE、AngⅡ、血糖比较差异均无统计学意义（均P＞0.05）。试验组置管后各时间点SBP、DBP、HR、PETCO2、NE、肾上腺素、AngⅡ、血糖水平与置管前比较差异均无统计学意义（均P＞0.05），对照组置管后各时间点SBP、DBP、HR、NE、肾上腺素、AngⅡ、血糖水平均较置管前明显升高，PETCO2较置管前明显降低，试验组和对照组上述指标于置管后1 min比较差异即有统计学意义〔SBP（mmHg，1 mmHg＝0.133 kPa）：125.1±15.4比135.5±13.6，DBP（mmHg）：85.6±16.1比91.1±17.2，HR（次/min）：99.4±13.8比107.9±16.5，PETCO2（mmHg）：32.5±2.8比29.8±4.1，NE（ng/L）：365.4±29.7比475.7±49.9，肾上腺素（ng/L）：75.4±7.2比83.6±7.4， AngⅡ（ng/L）：65.3±6.9比73.3±9.1，血糖（mmol/L）：10.1±1.9比13.4±3.0，均P＜0.05〕，至置管后5 min试验组和对照组间各指标差异仍有统计学意义〔SBP（mmHg）：123.7±14.8比129.7±15.1，DBP（mmHg）：84.3±14.6比88.4±14.2，HR（次/min）：97.7±13.6比31.6±3.9，PETCO2（mmHg）：33.5±3.1比31.6±3.9， NE（ng/L）：363.9±31.3比457.7±48.4，肾上腺素（ng/L）：74.6±7.8比83.5±8.5，AngⅡ（ng/L）：64.3±8.4比71.9±5.9，血糖（mmol/L）：9.6±2.3比12.7±3.1，均P＜0.05〕。结论与传统方式比较，纤支镜辅助下留置胃管引起的应激反应轻。

ObjectiveTo observe the effect on stress response to indwelling gastric tube assisted by bronchofiberoscope and traditional way in patients with severe craniocerebral injury in intensive care unit（ICU）. Methods 126 patients admitted in Department of Surgery ICU in Lanzhou University Second Hospital were randomly divided into bronchofiberoscope assisted indwelling gastric tube group（experimental group） and the traditional way of indwelling gastric tube group（control group）, 63 cases in each group. In the experimental group, the rod of mirror, Olypus BF-P60, was coated with lidocaine gel, through the nasal cavity it was sent into interior, when arrived at epiglottis, the operator adjusted the mirror head and let it go into the esophagus（about 10 cm）, then put a steel wire as a guide into a hole for biopsy, and simultaneously, as the operator pulled out the rod, the wire was continuously pushed slowly further inside; after the bronchofiberoscope was completely withdrawn, valelinum liquidum was used to ensure sufficient lubrication to the external and internal walls of the indwelling gastric tube ready to be sent into the stomach, afterwards the tube was slowly pushed along the guide wire to an appropriate location and then the wire was pulled out, the operator injected air, when he or she heard the gurgling sound as the gas passing water, fixed the tube. In the control group, the traditional way of indwelling gastric tube was applied. Before and after indwelling gastric tube for 1, 3, 5 minutes, the changes of systolic pressure（SBP）,diastolic pressure（DBP）,heart rate（HR）, end-expiratory carbon dioxide partial pressure（PETCO2） and plasma concentrations of norepinephrine（NE）, adrenaline, angiotensinⅡ（AngⅡ）, glucose（GLU） were examined.Results The plasma levels of SBP, DBP, HR, PETCO2, adrenaline, NE, AngⅡ and blood GLU had no statistical significant differences before operation in comparisons between both groups（allP〉0.05）. Compared to those before indwelling the tube, the levels of SBP, DBP, HR, PETCO2, NE, adrenaline, AngⅡ and GLU at various time points after the indwelling in experimental group were of no statisticalsignificant differences（allP〉0.05）, while the levels of SBP, DBP,HR, adrenaline, NE, AngⅡand GLU in control group at various time points after indwelling were higher obviously than those before operation, and the level of PETCO2 was decreased significantly compared with that before operation. The differences in the above indexes were significant between the treatment and control groups at 1 minute after indwelling〔SBP（mmHg, 1 mmHg=0.133 kPa）： 125.1±15.4 vs. 135.5±13.6, DBP（mmHg）： 85.6±16.1 vs. 91.1±17.2, HR（bpm）： 99.4±13.8 vs. 107.9±16.5, PETCO2（mmHg）： 32.5±2.8 vs. 29.8±4.1, NE（ng/L）： 365.4±29.7 vs. 475.7±49.9, adrenaline（ng/L）： 75.4±7.2 vs. 83.6±7.4, AngⅡ（ng/L）： 65.3±6.9 vs. 73.3±9.1, GLU（mmol/L）： 10.1±1.9 vs. 13.4±3.0, allP〈0.05〕; the differences in the above indexes remained significant between the treatment and control groups till 5 minutes after indwelling〔SBP（mmHg）： 123.7±14.8 vs. 129.7±15.1, DBP（mmHg）： 84.3±14.6 vs. 88.4±14.2, HR（bpm）： 97.7±13.6 vs. 31.6±3.9, PETCO2（mmHg）： 33.5±3.1 vs. 31.6±3.9, NE（ng/L）： 363.9±31.3 vs. 457.7±48.4, adrenaline（ng/L）： 74.6±7.8 vs. 83.5±8.5, AngⅡ（ng/L）： 64.3±8.4 vs. 71.9±5.9, GLU（mmol/L）： 9.6±2.3 vs. 12.7±3.1, allP〈0.05〕.ConclusionCompared with traditional way, the indwelling of gastric tube assisted by branchofiberoscopy can induce milder stress response.