右美托咪定对原位肝移植患者麻醉诱导插管期间血流动力学的影响

Effect of dexmedetomidine on the hemodynamic response to the induction of general anesthesia and tracheal intubation

目的采用脉搏指示持续心排血量（pulse indicated continue cardiac output，PiCCO）监测观察原位肝移植（orthotopic liver transplantation，OLT）患者以0．5μg／kg右美托咪定（dexmedetomidine，Dex）预给药10min对全身麻醉诱导插管期血流动力学的影响。方法根据随机数字表法将24例拟行OLT患者分为对照组（Ns组）和Dex组（DP组），每组12例。DP组，麻醉诱导前Dex以0．5μg／kg静脉泵注10rain，随后以丙泊酚血浆靶浓度3．0mgCL、瑞芬太尼效应室靶浓度3．0Ixg／L进行靶控输注（targetcontrolledinfusion，TCI），静脉注射顺式阿曲库铵0．15mg／kg；NS组，诱导前以相同剂量的0．9％氯化钠注射液静脉泵注10rain作为对照，麻醉诱导方法同DP组，待丙泊酚与瑞芬太尼到达效应室浓度后气管插管。分别记录Dex预先给药前（T0），负荷剂量量即刻（T1），丙泊酚和瑞芬太尼达到效应室浓度时（T2），气管插管时（T3），气管插管后1（T4）、3（T5）、5min（T6）各个时间点的平均动脉压meanarterialpressure，MAP）、心率（heartrate，HR）、连续心脏指数（pulse indicator continuous cardiacindex，PCCI）、外周血管阻力指数（systemic vascular resistance index，svm）、全心射血分数（global ejectionfraction，GEF）、血管外肺水容量（extravascular lung water，EvLw）、中心静脉压（central venous pressure，CVP）和麻醉深度（Narcotrend number，NT）。结果与T0和NS组比较，DP组T。时SVRI[2012±627）dyne·s·cm-5·m2升高，EVLW、HR和NT显著降低（P〈0．05）；与T0、T。比较，两组T：时PCCI均明显下降（P〈0．05）；与Ns组比较，DP组B时PCCI显著升高[（2．64±0．55）L·min-1·m-2比（3．24±0．47）L·min-1．m2]（P〈O．01）；DP组内PCCI在T3～T6时呈上升趋势，T5、T6时明显高于NS组（P〈0．05）DP组GEF于T2[（28．5±2．8）％比（20．1±3．8）％]～R[（28．2±3．2）％比（19．0±3．5）％]时点均明显高于NS组（P〈0．05）。Ns组内T2时MAP、GEF、PCCI和SVRI均明显低于T0和T1（P〈0．05）；T3时明显升高（P〈0．05）；T4、T5时各指标逐渐回落，到T6时恢复至T2水平；但EVLW逐渐升高，T1[（424±80）ml比（345±68）ml]-T6[（445±85）ml比（340±66）ml]时均明显高于DP组（P〈0．05）。结论OLT患者全身麻醉诱导前给予Dex0．5μg／kg（10min泵完），不仅可以提高SVRI，维持GEF和PCCI，还能降低EVLW。

Objective To investigate the effect of dexmedetomidine （Dex） on the hemodynamic response to the induction of general anesthesia and tracheal intubation with pulse indicated continue cardiac output （PiCCO）. Methods A total of twenty four patients scheduled for orthotopic liver transplantation were enrolled in this study. According to random number table, they were assigned to Dex group （group DP, an initial dose of 0.5 μg/kg for 10 rain, followed by a continuous infusion of 0.5 μg·kg-1·h-1, n= 12） and control group （group NS, an initial dose of the same amount of 0.9% sodium chloride, n=12）. Anesthesia was induced with propofol and remifentanil using a target-controlled infusion （TCI） system. The initial target propofol and remifentanil effective concentration were 3.0 mg/L and 3.0μg/L respectively, followed by intravenous injection with 0.15 mg/kg cisatracurium. Intubation was carried out until the TCI system reached the effective concentration. Mean arterial pressure （MAP）, heart rate （HR）, pulse indicator continuous cardiac index （PCCI）, systemic vascular resistance index （SVRI）, global ejection fraction （GEF）, central venous pressure （CVP）, extravascular lung water （EVLW） , Narcotrend number （NT） were recorded at time points of pre-Dex （T0）, post-Dex（T1）, TCI system reached the effective concentration（T2）, intubation（T3）, 1 min after intubation（T4）, 3 min after intubation（T5）, 5 min after intubation（T6）. Results Compared with To and group NS, SVRI was increased significantly at T, [2 012±627） dynescm-m-2] （P〈0.05）. EVLW, HR and NT were significantly decreased at T1 （P〈0.05） in group DP. Compared with To and %, PCCI was sharply decreased at T2 in group NS and group DP, and compared with group NS, PCCI was significantly higher at T2 in group DP [（2.64±0.55） L·min-1·m-1 vs （3.24±0.47） L·min-1·m-2]（P〈0.01）. In group DP, PCCI with an upward tendency from T3 to T6 was significantly higher than group NS at T5 and T5 respectively（P〈0.05）. GEF at from T2[ （28.5±2.8）% vs （20.1±3.8）%] to T6 [（28.2±3.2） % vs （19.0±3.5）%] in group DP was obviously higher than NS（P〈0.05）. Compared with To and Tl, MAP, GEF, PCCI and SVRI in group NS at T2 were decreased significantly（P〈0.05）, then increased obviously at T3, and fell at T4-T5, till T6 reached to the level of T2. The number of EVLW was progressively ascending in group NS, and were significantly higher than group DP at %[（424±80） ml vs （345±68） ml]-T6[（445±85） ml vs （340±66） ml]（P〈0.05）. Conclusions For the patients undergoing liver transplantation, Dex administration during anesthetic induction is useful, because it not only increased the MAP, maintained the GEF and PCCI, but also decreased the EVLW.