不同剂量右美托咪定复合舒芬太尼在老年患者肝癌射频消融术中的应用

Discussions about the proper dose of dexmedetomidine combined with small dose of sufentanil in anesthesia for radio frequency ablation in liver cancer geriatrics

目的探讨右美托咪定复合舒芬太尼0.3μg/kg在老年患者肝癌射频消融术(radio frequency ablation,RFA)中的适宜应用剂量。方法选择择期行RFA患者60例,男53例,女7例,年龄65～84岁,BMI 18.1～35.4kg/m2,ASAⅡ或Ⅲ级,Child-Pugh A或B级,随机分为三组,每组20例。射频治疗前20min开始泵注右美托咪定,D1组:0.3μg·kg^(-1)·h^(-1);D2组:0.5μg·kg^(-1)·h^(-1);D3组:0.7μg·kg^(-1)·h^(-1),同时给予舒芬太尼0.3μg/kg缓慢静滴。于入室时(T_0)、给药20min时(T_1)、消融开始时(T_2)、消融开始后10min时(T_3)和术毕时(T_4)测定Ramsay评分。记录术毕、术后2、4、8、16h的VAS评分;记录依托咪酯、硝酸甘油、乌拉地尔和纳洛酮用量;记录术中知晓、呼吸道梗阻、穿刺针移位和肝被膜下血肿、一过性高血压、低血压、心动过缓和口干等不良反应情况。结果与T_0时比较,T_2和T_3时D2和D3组Ramsay评分明显升高(P<0.05);与D1组比较,D2、D3组术后2、4和8hVAS评分明显降低(P<0.05),D2和D3组依托咪酯、硝酸甘油、乌拉地尔用量明显减少(P<0.05);与D2组比较,D1组术中知晓明显增多(P<0.05),D3组纳洛酮用量明显增多(P<0.05),D3组呼吸道梗阻、一过性高血压、心动过缓发生率明显增多(P<0.05)。结论右美托咪定0.5μg·kg^(-1)·h^(-1)复合舒芬太尼0.3μg/kg在老年RFA中可提供良好的清醒镇痛效果,减少呼吸道梗阻等不良反应的发生,是较为合理的临床用药剂量。

Objective To investigate the optimal dose of dexmedetomidine （DEX） combined with sufentanil 0.3μg·kg^（-1） for anesthesia of radio frequency ablation（RFA）for liver cancer geriatrics.Methods Our study was a random,single blind one.Sixty patients of both sexes,males 53 and females 7,aged 65-84 years,BMI 18.1-35.4 kg/m2,falling into ASA physical statusⅡ orⅢ and Child-Pugh class A or B,scheduled for elective RFA for liver cancer,were randomly assigned into 3 groups（n =20 each）.All groups received different dose of DEX and 0.3μg/kg sufentanil infused 20 minutes before RFA surgery：group D1 （DEX 0.3μg·kg^（-1）·h^（-1））,group D2（DEX 0.5μg·kg^（-1）·h^（-1））,and group D3（DEX 0.7μg·kg^（-1）·h^（-1））.Ramsay sedation score were recorded at the following time points：patients entered into the operating room （T0）,20 minutes after DEX infused （T1）,ablation beginning（T2）,10 minutes after ablation beginning （T3） and the end of operation （T4）.Visual analogue scale（VAS）was recorded at T4,and 2,4,8,12 hours after the ablation respectively.The dosages of etomidate,nitroglycerin,urapidil,and naloxone were noted.The complications and side effects were also noted.The complications of intraoperative awareness,respiratory obstruction,puncture needle displacement,and submembrane hematoma of the liver,and the adverse reaction of hypertention,hypotension and tachycardia were recorded.Results Compare to T0,Ramsay sedation score of groups D2 and D3 at T2-T3 was increased significantly （P〈0.05）.Compare to group D1,VAS of groups D2 and D3 at 2,4,8 hours after the ablation were decreased significantly （P〈0.05）.The dosage of etomidate,nitroglycerin,and urapidil in groups D2 and D3 were decreased significantly compare to group D1 （P〈0.05）.Compare to group D2,the incidence of intraoperative awareness of group D1 were increased significantly（P〈0.05）,the dose of naloxone of group D3 （70.48±21.38μg）was increased significantly （P〈0.05）,the incidence of transient hypertension,bradycardia and respiratory depression of group D3 were increased significantly （P〈0.05）.Conclusion The combination dexmedetomidine 0.5μg·kg^（-1）·h^（-1） with sufentanil 0.3μg/kg can provide good conscious analgesia,reduce respiratory depression and adverse reactions is a reasonable clinical use for elderly patients under going RFA.