不同剂量的舒芬太尼在合并心血管疾病患者内镜逆行胰胆管造影术麻醉效果的临床研究

The Clinical Study on the Anesthetic Effect of Different Doses of Sufentanil in Patients with Cardiovascular ERCP

目的：研究不同剂量的舒芬太尼在合并心血管疾病患者ERCP术中麻醉效果及安全性。方法111例ASAⅡ~Ⅲ级合并心血管疾病行ERCP术患者,随机分为3组（n=37例）：S1组、S2组、S3组。每组经静脉10min输注右美托咪定0.5μg/kg后分别复合硫酸镁10mg/kg＋舒芬太尼0．1μg/kg、0．12μg/kg、0．15μg/kg静脉缓慢注射。随即血浆靶控输注依托咪酯,设定血浆浓度0.5 ug/mL。每组术中采用持续泵注硫酸镁6mg/（ kg·h）＋依托咪酯靶控血浆浓度0.3~0.5μg/mL维持麻醉。根据BIS 值调整依托咪酯的血浆浓度,维持BIS值于55左右。观察并记录入室麻醉前、诱导后、插镜时、内镜置入十二指肠乳头、苏醒等不同时点平均动脉压（ MAP）心率（ HR）、心率收缩压乘积（ RPP）、血氧饱和度（ SpO 2）、及各时点的BIS值。统计手术操作时间、麻醉苏醒及定向力恢复时间和不良反应的发生率。结果所有患者均较顺利完成手术操作。 MAP及HR在插镜时、镜入十二指肠镜乳头开口时S2、S3明显低于S1组,差异有统计学意义（ P〈0．05）。手术全程S3组心动过缓发生率高于S2组,差异有统计学意义（P〈0．05）。 RPP：镜入十二指肠镜乳头开口时S2、S3明显低于S1组,差异有统计学意义（P〈0．01）。 BIS：诱导后至镜入十二指肠S3各时点均明显低于S1,差异有统计学意义（P〈0．01）；插管时S3〈S2〈S1,差异有统计学意义（P〈0．05）,置入十二指肠镜时S3、S2〈S1,差异有统计学意义（P〈0．05）；SPO2：插镜时S3〈S1,差异有统计学意义（P〈0．05）,镜入十二指肠乳头时 S3〈S2、S1,差异有统计学意义（P〈0．05）。术中躁动、呛咳发生率S1组明显高于S2、S3组,差异有统计学意义（P〈0．05）,呼吸抑制发生率S1、S2显著低于S3组（P〈0．05）,三组患者无术中知晓的发生。结论舒芬太尼复合右美托咪定、硫酸镁在合并心血管疾病患者ERCP手术中,舒芬太尼0．12μg/kg能维持较满意的麻醉深度,术中血流动力学平稳,不良反应发生率少,有良好的安全性。

Objective To study the comparison of intraoperative anesthetic effect and safety of different doses of sufen-tanil in patients with cardiovascular ERCP. Method 90 cases of ASA grade Ⅱ~Ⅲ patients with cardiovascular ERCP, who were randomly divided into 3 groups（n=37 cases）：group S1,group S2,group S3. Each group was infused dexmedetomidine 10min by intravenous after 0. 5ug/kg, respectively composited magnesium sulfate 10mg/kg and sufentanil 0. 1ug/kg, 0. 12ug/kg, 0. 15ug/kg with intravenous injection slowly. Then the target plasma concentration of etomidate set the plasma concentration as 0. 5ug/ml. Each group was treated by magnesium sulfate continuous infusion of 6mg/（kg·h） ＋ of the target plasma concentration of etomidate of 0. 3 ~0. 5ug/ml to maintain anesthesia. According to BIS,the plasma concentration of etomidate was adjusted to maintain the BIS at about 55 or so. Observed and recorded MAP、HR、RPP、SpO 2 and BIS at different time such as before anesthe-sia, after induction, when a mirror was inserted, endoscopic placement of duodenal papilla, recovery etc. . Add up the time of the surgery, anesthesia recovery,orientation recovery and the incidence rate of untoward reaction. Results All patients were success-fully completed the surgery. MAP and HR of group S2 and group S3 were significantly lower than those of group S1 （ P〈0. 05 ） when the mirror was inserted and the mirror was in duodenal papilla. The heartbeat bradycardia of group S3 was significantly high-er than that in S2 group（P〈0. 05）during the whole surgery. RPP：The RPP of group S2 and S3 were significantly lower than those＆nbsp;of group S1（P〈0. 01）when the mirror was in the duodenal papilla. BIS：After anesthesia induction to the mirror inserted the duo-denum,the BIS of group S3 was significantly lower than that of S1 at each time point（P〈0. 01）; when intubated：S3〈S2〈S1 （P〈0. 05）, when placed duodenoscope：S3、S2〈 S1（P〈0. 05）;SPO2：when intubated：S3〈S1（P〈0. 05）,when the mirror in-serted the duodenal papilla：S3〈S2、S1（P〈0. 05）. The intraoperative restlessness and the incidence of choking cough of group S1 were significantly higher than those of group S2 and group S3（P〈0. 05）, the incidence of respiratory depression of group S1 and group S2 was significantly lower than that of group S3（P〈0. 05）, three groups of patients knew nothing happened during the sur-gery. Conclusion Sufentanil composited dexmedetomidine and magnesium sulfate were during the ERCP in patients with cardio-vascular disease surgery, sufentanil of 0. 12ug/ kg could maintain satisfactory depth of anesthesia. Intraoperative hemodynamic is stable, less incidence of adverse reactions, there is good security.