有哮喘史患者采用无阿片类镇痛药全身麻醉联合硬膜外麻醉的可行性

Feasibility of no opioid analgesic general anesthesia combined epidural anesthesia for patients with asthma history

目的探讨对有哮喘病史患者,术中不使用阿片类镇痛药全身麻醉联合硬膜外麻醉能否达到理想的麻醉效果,以及能否有效预防术中哮喘的发作。方法选取2013年3月至2016年9月准备在腹腔镜下择期行子宫肌瘤或卵巢囊肿切除术并有支气管哮喘史的患者50例,年龄30~60岁,ASAⅡ~Ⅲ级。随机分为两组,每组25例:Ⅰ组采用追加阿片类镇痛药诱导气管插管全身麻醉,Ⅱ组无阿片类镇痛药全身麻醉联合硬膜外麻醉。两组均先静脉注射甲基泼尼松龙、氨茶碱,然后以氨茶碱术中静脉滴注维持。采集两组患者麻醉前(T_0)、诱导后插管前(T_1)、气管插管即刻(T_2)、插管后5 min(T_3)、清醒准备拔管时(T4)、拔管后5 min(T5)等各时点的脑电双频指数(BIS)、平均动脉压(MAP)、心率(HR)、指脉氧饱和度(SpO_2)、气道峰压(Ppeak)、呼气末二氧化碳分压(PETCO2)等指标变化情况以及术中哮喘发作情况,清醒后能否耐受气管导管、清醒后切口疼痛、术后挣扎躁动、患者术后告知术中知晓、术后咽喉部疼痛不适等。结果两组患者各时点BIS值、MAP、HR、SpO_2、PETCO2等指标组间比较差异均无统计学意义(P均>0.05);Ⅰ组患者Ppeak在T_3时点时明显比Ⅱ组患者升高[(19.3±3.6)cm H2O vs(16.8±2.5)cm H2O,P<0.05]。Ⅱ组患者术中哮喘发作发生率较Ⅰ组有所下降,但差异无统计学意义(4.0%vs 24.0%,P>0.05),清醒后切口疼痛发生率明显低于Ⅰ组,差异有统计学意义(0 vs 32.0%,P<0.05);两组患者在清醒后耐受气管导管、术后挣扎躁动、术后告知术中知晓、术后咽喉部疼痛不适等发生率相比差异无统计学意义(P均>0.05)。结论无阿片类镇痛药全身麻醉联合硬膜外麻醉能达到较好的麻醉效果,并可降低插管后气道压力,有降低有哮喘史患者术中哮喘发生率的趋势,但尚需扩大样本量进一步研究。

Objective To investigate whether the no opioid analgesic general anesthesia combined epidural anesthesia could reach an ideal anesthesia effect and effectively prevent the attack of intraoperative asthma in patients with asthma history. Methods Fifty patients with hysteromyoma or ovarian cyst and with asthma history（ aged 30-60 years,ASA classⅡ-Ⅲ） who planed to perform laparoscopic gynecologic surgery between March 2013 and September 2016 were selected.The patients were randomly divided into two groups（ n = 25 each） ： group I and group Ⅱ. The conventional tracheal intubation general anesthesia was used in group I,and no opioid analgesic general anesthesia using dynastat-induced induction trachea intubation combined epidural anesthesia was used in group Ⅱ. Intravenous injection of methylprednisolone and aminophylline was used firstly,and then intraoperative intravenous infusion of aminophylline was maintained to the completion of surgery in both two groups. After anesthesia,bispectral index（ BIS）,mean arterial pr essure（ MAP）,heart rate（ HR）,pulse oxygen saturation（ SpO2）,peak airway pressure（ Ppeak） and end tidal carbon dioxide partial pressure（ PETCO2）,the condition of intraoperative asthma attacks,the status of withstanding endotracheal catheter after awake,incision pain after waking,postoperative struggle and restlessness,intraoperative awareness informed by patients after operation,postoperative pharynx and throat sore or discomfort,etc,before anesthesia（ T0）,after induction and before intubation（ T1）,in a moment of trachea intubation（ T2）,5 min after intubation（ T3）,after awake when ready for extubation（ T4） and 5 min after extubation（ T5） in two groups were collected. Results There were no significant differences in BIS value,MAP,HR,SpO2 and PETCO2at each point between two groups（ all P〈0. 05）. Ppeak at T3 in groupⅠ was significantly higher than that in group Ⅱ[（ 19. 3 ± 3. 6） cm H2 O vs（ 16. 8 ± 2. 5） cm H2 O,P〈0. 05]. The incidence of intraoperative asthma attacks in group Ⅱ decreased somewhat compared with group Ⅰ,but there was no significant difference between two groups（ 4. 0% vs 24. 0%,P〈0. 05）. The incidence of incision pain after waking in group Ⅱ was significantly lower than that in group Ⅰ（ 0 vs 32. 0%,P〈0. 05）. There were no significant differences in tolerated status to endotracheal catheter after awake,postoperative struggle and restlessness,intraoperative awareness informed by patients after operation,postoperative pharynx and throat sore or discomfort between two groups（ all P〈0. 05）. Conclusion No opioid analgesic general anesthesia combined epidural anesthesia can achieve better anesthesia effect,reduce the airway pressure after intubation and have a tendency to reduce the incidence of intraoperative asthma in patients with asthma history,however,further research of enlarging the sample size is still needed.