个体化靶控输注丙泊酚在重度烧伤患者麻醉中的临床应用

The Clinical Application of Individualized Target- controlled Infusion of Propofol in the Anaesthesia of Seriously Burn Patients

目的评估和比较脑电双频指数（BIS）监测下,对重度烧伤患者采用个体化效应室浓度下靶控输注丙泊酚麻醉的效果及可行性.方法选择重度烧伤择期行焦痂切除术患者160例,年龄18--60岁,ASAⅡ--Ⅲ级,烧伤总体表面积（TBSA）31%--50%或三度烧伤面积11%-20%.随机分为A、B、C、D 4组,观察各组患者于入室时（T_1）,气管插管时（T_2）,手术开始10 min（T3）,术毕（T4）,拔管时（T5）的MAP、SV、HR,并同期抽取桡动脉血以ELISA方法测定各组患者血皮质醇值.记录呼之睁眼、Aldrete评分达9分的时间及不良反应发生率.结果 （1）4组患者均顺利完成手术,4组患者在停药后至呼之睁眼、Aldrete为9分的时间之间存在统计学差异（P〈0.05）,但B、C 2组在苏醒时间之间无统计学差异（P〉0.05）;（2）4组患者于T_1-T_5点的MAP、HR及皮质醇水平之间均有统计学差异（P〈0.05）,A、D 2组患者的SV水平于各时间点也有统计学差异,但B、C 2组SV水平于T_1-T_5时间点均无统计学差异（P〉0.05）,4组患者的MAP、HR、SV及皮质醇于T_1点无统计学差异（P〉0.05）,但在T_2-T_5各时间点MAP、HR及皮质醇水平之间均有统计学差异（P〈0.05）,组内两两比较显示,在B、C 2组间患者的MAP、HR、SV及皮质醇水平并无统计学差异（P〉0.05）,A组的皮质醇水平明显高于其他3组,而D组则明显低于其他3组,差异均具有统计学意义（P〈0.05）;（3）4组患者均未见术中知晓发生,A组患者的体动、呛咳及醒后躁动的发生率均高于其他3组,差异具有统计学意义（P〈0.05）;D组低血压的发生率要高于其他3组（P〈0.05）,且D级苏醒延迟的发生率明显高于其他3组,差异具有显著的统计学意义（P〈0.01）.结论在BIS监测下,维持麻醉时丙泊酚的效应室浓度（Ce）在患者意识消失的效应室浓度基础上再上调0.8-1.0μg/m L,实施麻醉个体化.患者的血流动力学更平稳,恢复清醒时间更短,不良反应发生率更低.

Objective T_o assess and compare the effect and feasibility of individualized T_CI propofol anaesthesia under the monitoring of bispectral index（BIS）, which is applied to patients with serious burn under different effectsite concentrations.Methods 150 seriouslyburn patients for selective surgery were chosen for escharectomies.T_heir ages ranged from 18 to 60 with ASA II ∽III level and total burn surface area（T_BSA） of31%∽50% or threedegree burns over 11% to 12% of their bodies,and were randomly divided into A, B, C and D group.MAP, SV and Heart Rate（HR） of these patients were observed when they were sent into the operating room（T_1）,intubated（T_2）, operatd for ten minutes（T_3） and when the operation was finished and extubated（T_5）,and at the same time drew their radial artery bloods and mensurated their blood cortisol values by the method of ELISA.T_ime of eyes open while calling out and Aldrete score of nine points and the adverse reaction incidence rate were recorded..Results（1） All operations on patients of the four groups had been finished smoothly,and there were statistical differences（P〈0.05） of time eyes open while calling out and ninepoint Aldrete.However,there was no statistical difference of palinesthesia time between B and C group;（2） T_here were statistical differences（P〈0.05） of MAP,HR and cortisol level from T_1 to T_5point among patients of the four groups.T_here were statistical differences of SV level at each time point of patients of A and D group, but there was no statistical difference（P〈0.05） of SV level from T_1 to T_5time points of patients of B and C group.T_here was no statistical difference（P〈0.05） of MAP, HR, SV and cortisol at T_1 point of patients of the four groups, but there were statistical differences（P〈0.05） of MAP,HR and cortisol level at each time point from T_2 to T_5.T_he results of the indices of two patients of each team were compared to show that：there was no statistical difference（P〈0.05） of MAP,HR,SV and cortisol level between patients of B and C group.T_he cortisol level of patients of A group was obviously higher than that of patients of the other three groups while the index of patients in D group was obviously lower than that of patients of the other three groups.So there was statistical meaning（P〈0.05） of cortisol level difference of patients of A and D group;（3） T_he situation of intraoperative awareness was not seen among patients of the four groups.T_he incidence rates of bucking with body movement and dysphoria after awakening of patients of A group were obviously higher than indices of patients of the other three groups,and there was a statistical meaningof difference（P〈0.05）;T_he incidence rate of hypotension of patients of D group was higher than that of patients of the other three groups（P〈0.05）, and the incidence rate of delayed palinesthesia of patients in D group was obviously higher than that index of of patients of the other three groups, so there was distinct statistical meaning（P〈0.01） of differences.Conclusion Under the monitoring of BIS,if the effectsite concentration（Ce） being set to maintain propofol during anaesthesia, is enhanced by 0.8 ∽1.0 μg/m L, on the basis of the effectsite concentration in which patients lose their consciousness, patients＇ hemodynamics will be more stable, and it will take them shorter time to regain their consciousness with a lower incidence rate of untoward effect.T_he scheme is safe,effecitive and worth promoting in the clinical application.