右美托咪定用于老年危重患者清醒喉罩置入全身麻醉的效果观察

Effects of dexmedetomide in the application of LMA in the airway management in critically ill elderly patients awake

目的：探讨预注小剂量右美托咪定用于老年危重症患者清醒状态下置入喉罩行全身麻醉的临床价值。方法选择60例择期接受全身麻醉下手术的老年危重患者，按随机数字表法分为两组（n ＝30）；观察组：于麻醉诱导前10 min 静脉泵注右美托咪定0．4μg／kg，静注咪达唑仑0．03 mg／kg，苏芬太尼0．2μg／kg，1％的丁卡因。对照组：于麻醉诱导前10 min 给予等容积的0．9％氯化钠注射液，其余同观察组。分别观察两组泵注右美托咪定后的 BIS 值（T1），给予诱导药物后准备置入喉罩时的 BIS 值（T2），置入喉罩时患者发生躁动、呛咳、恶心反射等不良反应的例数（T3），喉罩置入后的血流动力学变化，丙泊酚、瑞芬太尼的用量，手术结束后 Steward 苏醒评分等。结果两组 BIS 值：T1时比较：（77．6±6．2）比（96．5±3．1），t ＝14．929，P ＜0．01；T2比较：（71．2±5．7）比（90．8±3．3），t ＝16．066，P ＜0．01；T3比较：2例比9例，t ＝2．335，P ＜0．05；麻醉药物用量比较：丙泊酚（146．6±36．7）mg 比（182．7±25．3）mg，t ＝4．436，P ＜0．01；瑞芬太尼（293．5±74．3）μg 比（365．4±51．7）μg，t ＝4．351，P ＜0．01；两组术中生命体征、血气检测、Steward 评分等比较：HR（87．2±9．3）次／min 比（94．6±10．2）次／min，t ＝2．937，P ＜0．05；MAP（93．7±10．1）mmHg 比（103．5±14．3）mmHg， t ＝3．066，P ＜0．01；pH（7．37±0．04）比（7．34±0．05），t ＝2．566，P ＜0．05；PaO2（155．7±34．6）mmHg 比（108．5±37．7）mmHg，t ＝5．052，P ＜0．01；PaCO2（37．7±5．8）mmHg 比（41．5±7．3）mmHg，t ＝2．233，P ＜0．05；BE（－3．1±0．8）mmol／L 比（－5．8±1．5）mmol／L，t ＝8．699，P ＜0．01；Steward 评分（5．5±0．5）分比（5．0±0．6）分，t ＝3．571，P ＜0．01；VAS（1．9±0．5）分比（3．9±0．8）分，t ＝18．779，P ＜0．01。结论小剂量右美托咪定0．4μg／kg 诱导前静脉泵注，复合丁卡因表面麻醉，有利于患者清醒状态下的喉罩置入，对于老年危重症患者，其对血流动力学影响较小，术中血气指标平稳，提高了麻醉和苏醒质量及镇痛效果，减少了麻醉药物的用量，对保证临床麻醉医疗质量安全有重要的临床意义。

Objective To investigate pre -injection of low -dose demedetomidine in the curative of apply-ing laryngeal masks in the airway management in critically ill elderly patients awake.Methods 60 case of critically ill elderly patients who underwent general anesthesia were collected,and they were randomly into two groups.The observation group：before induction of anesthesia,injected dexmedetomide 0.4μg/kg,midazolam 0.03mg/kg,sufen-tanil 0.2μg/kg,throat topical anesthesia by 1% tetracaine.The control group：injected the same volume of sodium chloride solution 10 min before induction of anesthesia.Observed the BIS after the infusion of dexmedetomidine（T1）;the BIS before laryngeal mask airway insertion and after topical anesthesia（T2）;the restlessness,cough,nausea reflex and so on,when laryngeal mask airway insertion（T3）;the hemodynamic changes after laryngeal mask insertion;the dosage of propofol and remifentanil;postoperative Steward score,complications,analgesic effect,etc.SPSS statistical program 13.0 was used for statistical analysis.Results There was no significant difference between the two groups before operation（P 〉0.05）.The T1,T2,T3,and anesthetic dosage had significant differences.The comparison results were as follows：T1：（77.6 ±6.2）vs （96.5 ±3.1）,t =14.929,P 〈0.01;T2：（71.2 ±5.7）vs （90.8 ±3.3）,t =16.066,P 〈0.01;T3：（2 -9）cases,t =2.335,P 〈0.05.The comparison of anesthetic dosage：propofol （146.6 ± 36.7）mg vs （182.7 ±25.3）mg,t =4.436,P 〈0.01;Remifentanil （293.5 ±74.3）μg vs （365.4 ±51.7）μg,t =4.351,P 〈0.01.During the operation,the vital signs,blood gas,complications,analgesia score and so on,were signif-icantly different（P 〈0.05）.HR （87.2 ±9.3）times/min vs （94.6 ±10.2）times/min,t =2.937,P 〈0.05;MAP （93.7 ±10.1）mmHg vs （103.5 ±14.3）mmHg,t =3.066,P 〈0.01;pH （7.37 ±0.04）vs （7.34 ±0.05）,t =2.566,P 〈0.05;PaO2 （155.7 ±34.6）mmHg vs （108.5 ±37.7）mmHg,t =5.052,P 〈0.01;PaCO2 （37.7 ± 5.8）mmHg vs （41.5 ±7.3）mmHg,t =2.233,P 〈0.05;BE （-3.1 ±0.8）mmol/L vs （-5.8 ±1.5）mmol/L,t =8.699,P 〈0.01;Steward score （5.5 ±0.5 ）points vs （5.0 ±0.6）points,t =3.571,P 〈0.01;VAS （1.9 ± 0.5）points vs （3.9 ±0.8）points,t =18.779,P 〈0.01.Conclusion For elderly critically ill patients,a small dose of dexmedetomidine before induction,with midazolam,sufentanil intravenous injection and tetracaine anesthesia,can maintain stable vital signs and blood gas analysis,shorten the anesthesia time,improve the quality of anesthesia and recovery and the effect of analgesia,reduce the dosage of anesthetics and the complication of anesthesia.There was important clinical significance to ensure the medical safety.