肝功能不同患者靶控输注丙泊酚的药效反应

Pharmacodynamic effect of propofol by target controlled infusion in patients with different liver functions

目的 观察外科手术中肝功能不同患者靶控输注丙泊酚的药效反应.方法 本前瞻性研究对象为2013 年6 月至2014 年6 月在中山大学附属第三医院接受气管插管全身麻醉下开腹手术的60 例患者.其中男51 例,女9 例;年龄18～70 岁,中位年龄48 岁.所有患者均签署知情同意书,符合医学伦理学规定.根据肝功能Child-Pugh 分级将患者分为4 组肝功能正常组（N 组）7 例,肝功能分级A 级组（A 组）21 例,B 级组（B 组）20 例,C 级组（C 组）12 例.术中所有患者采用靶控输注丙泊酚,目标血药浓度3 μg/ml.记录4 组患者在麻醉诱导期（靶控输注30 min 内）脑电双频指数（BIS）值及血流动力学指标,比较各组BIS 下降至40 以下患者的百分率及血流动力学事件发生率.率的比较采用χ2 检验或Fisher 确切概率法.结果 麻醉诱导期,4 组患者的BIS 随时间逐渐下降,20 min 时基本稳定.N、A、B、C 组BIS 下降至40 以下的百分率分别为9.2%、11.2%、20.4%、26.8%,C 组明显高于N 组和A 组（χ^2=12.28,18.81;P〈0.05）.麻醉诱导期,N、A、B、C 组低血压发生频率分别为0、5%、8%、16%,C 组明显高于N、A、B 组（P〈0.0001,P〈0.0001,P=0.0195）.N、A、B、C 组心动过缓发生频率分别为15%、5%、3%、0,C 组明显低于N、A、B 组（P〈0.0001,P=0.0003,P=0.0085）.结论 采用丙泊酚靶控输注麻醉诱导时,肝功能不同患者麻醉深度呈现相似的变化趋势,但重度肝功能不全患者更易出现脑电波暴发性抑制和低血压.

Objective To observe the pharmacodynamic effect of propofol by target controlled infusion(TCI) in patients with different liver functions during surgery.Methods Sixty patients undergoing laparotomy under general anesthesia with endotracheal intubation in the Third Affiliated Hospital of Sun Yat-sen University between June 2013 and June 2014 were enrolled in this prospective study.Among the 60 patients,51 were males and 9 were females with the age ranging from 18 to 70 years old and the median of 48 years old.The informed consents of all patients were obtained and the local ethical committee approval had been received.The patients were divided into 4 groups according to the Child-Pugh liver function grading,the normal liver function group(N group,n=7),grade A group(A group,n=21),grade B group(B group,n=20) and grade C group(C group,n=12).TCI propofol were given to allpatients during the operation with the target plasma concentration of 3 μg/ml.Bispectral index(BIS) and hemodynamic parameters of the 4 groups during the anesthesia induction period(within 30 min of TCI) were recorded.The percentage of patients with BIS dropped below 40 and the incidence of hemodynamic events in each group were compared.The comparison was conducted using Chi-square test or Fisher's exact test.Results During the anesthesia induction period,BIS of the 4 groups dropped with time and was stable at 20 min.The percentage of patients with BIS below 40 in N,A,B and C group was respectively 9.2%,11.2%,20.4% and 26.8%,C group was significantly higher than N and A group(χ2=12.28,18.81;P<0.05).During the anesthesia induction period,the incidence of hypotension in N,A,B and C group was respectively 0,5%,8% and 16%,C group was significantly higher than N,A and B group(P<0.0001,P<0.0001,P=0.0195).The incidence of bradycardia in N,A,B and C group was respectively 15%,5%,3% and 0,C group was significantly lower than N,A and B group(P<0.0001,P=0.0003,P=0.0085).Conclusions Similar trends of change in anesthesia depth are observed in patients with different liver function when using propofol TCI,but patients with severe hepatic dysfunction may more likely to develop fulminant suppression of brain wave and hypotension.