颈丛神经阻滞复合不同剂量瑞芬太尼对甲状腺手术患者的影响

The different doses of remifentanil composite cervical plexus nerve block influence in patients with thyroid surgery

目的：探讨颈丛神经阻滞复合不同剂量的瑞芬太尼在甲状腺手术中的应用效果及最适宜的用药浓度。方法：甲状腺手术患者100例,年龄18~60岁,体重45~75kg。随机分为A组（瑞芬太尼0.05μg/kg·min）、B组（瑞芬太尼0.08μg/kg·min）、C组（瑞芬太尼0.10μg/kg·min）和D组（空白对照,单纯颈丛神经阻滞）,每组25例。记录四组患者入手术室后安静平卧10min（T1）、颈丛神经阻滞后1min（T2）、切皮时（T3）、分离甲状腺上下极时（T4）、缝皮时（T5）和术毕（T6）的平均动脉压（MAP）、心率（HR）、脉搏血氧饱和度（Sp O2）。测定T1~T6时间点的血糖值（Glu）、皮质醇值（Cor）、脑电双频指数（BIS值）及Ramsay镇静评分。记录患者的不良反应发生情况和术后满意度。结果：A组、B组、C组与D组疼痛、恶心、呕吐等发生情况和术后满意度比较（P〈0.05）,差异有统计学意义,效果优于D组。与D组比较,C组的Sp O2下降明显,差异有统计学意义（P〈0.05）,C组对呼吸抑制明显。四组在T3~T6时间点MAP和HR较T1~T2时间点均升高,D组升高显著,差异有统计学意义（P〈0.05）;反映机体应激情况的指标Glu和Cor,A组、B组、C组与D组比较,差异有统计学意义（P〈0.05）,A组、B组、C组在T3~T6时间点均能抑制机体应激反应,D组在T3~T6时间点比T1~T2时间点Cor升高明显（P〈0.01）。A组、B组、C组与D组比较,BIS值在T2~T6时间点明显下降,差异有统计学意义（P〈0.05）。四组镇静指数比较,D组明显低于A组、B组和C组,差异有统计学意义（P〈0.05）。结论：颈丛神经阻滞复合不同剂量瑞芬太尼均能满足甲状腺手术术中镇静镇痛,对血流动力学影响较单纯颈丛神经阻滞小,并能有效抑制机体在手术过程中的应激反应,提高患者满意度,但其对呼吸的抑制作用随剂量的增加而明显,所以临床应用应选择适合的剂量,本研究瑞芬太尼0.05μg/kg·min和瑞芬太尼0.08μg/kg·min无明显差异,瑞芬太尼0.1μg/kg·min对呼吸抑制较明显。

Objective：Study of cervical plexus nerve block composite with different doses of remifentanil in the application effect of thyroid surgery and the most appropriate drug concentration.Methods： 100 patients with thyroid surgery, ages 18 to 60 years old, weight 45kg to 75kg. Were randomly divided into group A （remifentanil 0.05μg/kg min）, group B （remifentanil 0.08μg/kg min）, group C （remifentanil 0.1μg/kg min）and group D（blank control, simple cervical plexus nerve block）, 25 cases in each group. Record the mean arterial pressure（MAP）, heart rate（HR）and pulse oxygen saturation（SpO2）of four groups of patients when the patients into the operating room quiet lie after 10 min （T,）, 1 rain after cervical plexus nerve block （T2）, cut the skin （T3）, separation of the thyroid gland on or off the pole（T4）, sewing leather（T5） and end of the surgery （T6）. Monitoring T1 to T6 point of the value of glucose （Glu）, cortisol value （Cor）, bispectral index （BIS） and Ramsay sedation scores. Records the adverse reactions occurred in patients and the satisfaction evaluation with postoperative.Results：In group A, group B and group C compared with group D occurrence such as pain, nausea, vomiting and postoperative satisfaction is（P〈0.05 ）,the difference was statistically significant, the effect is better than group D.Compared with group D, group C SpO2 falling significantly, the difference was statistically significant（P〈0.05）, group C has an obvious respiratory depression. Four groups of MAP and HR in T3-T6 were rising than T1, T2 points,group D increased significantly,the difference was statistically significant（P〈0.05）;reaction of the body＇s stress situation index Glu and Cor, group A, group B and group C compared with group D,the difference was statistically significant （P〈0.05）,group A, group B and group C at T3-T6 points can suppress the stress reaction,Cor rise significantly at group D in T3NT6 points than T1, T2 points, （P〈0.01）.Group A,group B and group C compared with group D, the BIS value in T2-T6 time decreased obviously, the difference was statistically significant （P〈0.05）. Four groups of sedation index comparison, group D was lower than group A, group B and group C, the difference was statistically significant （P〈0.05）. Conclusion： Different doses of remifentanil composite cervical plexus nerve block in patients can meet thyroid surgery intraoperatie sedation analgesia, influence on hemodynamic relatively is small than simple cervical plexus nerve block, and can effectively suppress the stress reaction in the operation process, improve the patients＂ satisfaction, but the inhibitory effect of breathing with the increase of the dose,so clinical application should choose suitable dose, this study show remifentanil （including 0.05μg/kg min） and remifentanil （including 0.08μg/kg min） has no obvious difference, remifentanil （including 0.1 μg/kg min） inhibition of respiratory is more obviously.