连续气管内-咽喉表面麻醉对全身麻醉药物用量的影响

Effects of continuous endotracheal-laryngopharynx topical anesthesia on the general anesthetic requirements during surgery

目的使用注药型气管导管,施行连续气管内-咽喉表面麻醉对全身麻醉药物用量的影响。方法择期下肢骨科手术患者40例,ASA分级Ⅰ或Ⅱ级,年龄20~46岁,BMI 22~28 kg/m^2,随机分为注药组(试验组,n=20)和非注药组(对照组,n=20)。静注咪达唑仑0.04 mg/kg、舒芬太尼0.2μg/kg、依托咪酯0.25 mg/kg和维库溴铵0.1 mg/kg麻醉诱导,气管内插入注药型气管导管,试验组立即对气管内(声门下)注射1%丁卡因1 m L和咽喉(声门上)1%丁卡因0.5 m L,随后每隔1 h再注射表面麻醉药于整个术中,对照组则不注药。以丙泊酚4~6 mg/(kg·h)静脉泵入,舒芬太尼0.1μg/kg和维库溴铵0.08 mg/kg按需间断静注,七氟醚(挥发罐刻度0.5~0.8)Vol%吸入,来维持术中脑电双频谱指数(BIS)40~50、血压(BP)和心率(HR)变化幅度小于30%基础值。分别于患者入室安静后(基础值,T_0),切皮前(T_6),手术开始15 min(T_7)、60 min(T_8)、90 min(T_9)和手术结束时(T_(10))记录收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)、HR数值和取桡动脉血测定血糖(Glu)、血浆肾上腺素(E)、去甲肾上腺素(NE)和皮质醇(Cor)水平;手术结束时统计全麻用药量。结果在术前、术中,2组患者SBP、DBP、MAP、HR、BIS和血浆E、NE、Cor浓度及血糖Glu水平,在各时点比较组间均相似,差异无统计学意义(P>0.05);在T10试验组BIS值较对照组明显升高(68.70 vs 58.45,P<0.05);全身麻醉用药量,七氟醚、丙泊酚、芬太尼和维库溴铵,试验组比对照组分别减少3.4%、8.3%、4.1%和4.6%,差异无统计学意义。结论本研究在较小样本量下,连续气管内-咽喉表面麻醉能轻度减轻机体应急反应,并促进苏醒。尽管气管内插管患者全身麻醉药用量有减少的趋势,但本研究可能因为样本量小而未能显示统计学差异。

Objective To survey general anesthetic requirements in patients with continuous endotracheal and laryngopharynx topical anesthesia injecting medicine intraoperatively via an injecting port of endotracheal tube. Methods Forty ASA grade Ⅰ-Ⅱ patients aged20-46 years old with BMI 22-28 kg/m^2,undergoing elective orthopedic surgery,were randomly divided into the test group（ injecting medicine,n = 20） and the control group（ no medicine,n = 20）. Anesthesia was induced with midazolam 0. 04 mg/kg,sufentanil0. 2 μg/kg,etomidate 0. 25 mg/kg and vecuronium 0. 1 mg/kg. Patients were orally intubated with an endotracheal tube and injected a1. 5 m L（ 1 m L for endotracheal and 0. 5 m L for laryngopharynx） of 1% tetracaine for topical anesthesia,and then injected similarly at hourly intervals during the surgery in the test group,but not-injected in the control group. Propofol 4-6 mg/（ kg·h） was administered intravenously,and sufentanil 0. 1 μg/kg and vecuronium 0. 08 mg/kg were also intravenously injected intermittently. Sevoflurane（ 0. 5-0. 8） Vol% inhalation anesthesia to maintain BIS at 40-50 level,stable BP and HR within 30% baseline values. Artery blood samples for measuring epinephrine（ E）,norepinephrine（ NE）,Cortisol（ Cor） and glucose（ Glu） were taken at T0（ baseline）,T6（ pre-incision）,T7（ post-incision 15 min）,T8（ post-incision 60 min）,T9（ post-incision 90 min） and T（10）（ operation end）. Anesthetic dosage was calculated at the end of each surgery. Results Values of SBP,DBP,MAP,HR,BIS and plasma concentrations of E,NE,Cor,and blood Glu levels were all similar（ P〉0. 05） at each time point between the two groups during operation. But values of BIS at T（10） in the test group was significantly higher than those in the control group（ 68. 70 vs 58. 45,P〈0. 05）. The total dosage of sevoflurane,propofol,sufentanil and vecuronium in the test group was decreased 3. 4%,8. 3%,4. 1% and 4. 6% compared with the control group,respectively,but did not yield statistical significance between the two groups. Conclusion In this small sample study,continuous endotracheallaryngopharynx topical anesthesia using 1% tetracaine via injecting port of endotracheal tube was shown to decrease the stress responses and hasten emergence. The requirements of general anesthetic in the surgery seemed to be reduced,but the difference did not yield statistical significance likely due to small sample size.