活体肾移植术中靶控输注丙泊酚效应室浓度与实测血浆药物浓度的对比分析

Comparison of effect-site concentration and measured plasma drug concentration during target-controlled infusion ofpropofol inliving kidney transplantation

目的探讨终末期肾功能衰竭(ESRD)患者行亲属供肾肾移植术,丙泊酚靶控输注(TCI)效应室浓度与实测血浆药物浓度相关性。方法选取2016年3~10月安徽省立医院择期活体供肾肾移植受体27例,选择血浆靶控,采用丙泊酚和瑞芬太尼诱导麻醉,维持脑电双频指数(BIS)为45~55。依次记录麻醉诱导后10、20、30及40 min及肾移植术中开放髂血管后10、20、30及40 min各时间点丙泊酚TCI效应室浓度,并采集动脉血3 mL,经高效液相色谱串联质谱法(HPLC/MS/MS)测定人血浆实测丙泊酚浓度。监测计算肾移植手术中丙泊酚TCI的偏象度及精密度。结果与麻醉前(基础值)比较,麻醉后术中HR减慢、平均动脉压(MAP)及BIS值下降,差异有统计学意义(P<0.05),Sp O_2差异无统计学意义(P>0.05)。与麻醉前(基础值)比较,术中髂血管开放前中心静脉压(CVP)差异均无统计学意义(P>0.05),术中髂血管开放后CVP较开放前均增高,差异有统计学意义(P<0.05)。髂血管开放前丙泊酚TCI偏离度及精密度分别为9.58%、10.42%,髂血管开放后丙泊酚TCI偏离度及精密度分别为14.17%、14.19%,二者均在临床使用范围(-15%<偏离度<15%,精密度<30%)。髂血管开放前丙泊酚效应室浓度、髂血管开放后丙泊酚效应室浓度与实测血浆药物浓度间均存在显著的相关性(F=2.35,R2=0.58,F=2.95,R2=0.71,P<0.05)。髂血管开放前后丙泊酚效应室浓度与实测血浆药物浓度间浓度差值比较,差异无统计学意义(P>0.05)。结论 TCI丙泊酚用于ESRD患者术中维持,效应室浓度与实测血药浓度存在显著相关关系。肾移植患者术中丙泊酚TCI,其偏离度及精密度均在临床使用范围。髂血管开放后大量补液对麻醉深度影响较小,无需增加丙泊酚效应室浓度。

ObjectiveTo investigate the correlation between effect-site concentration and measured plasma drug concentration duringtarget-controlled infusion(TCI)of propofol in those patients with end-stage renal disease(ESRD)receivingkidney transplantation from relative donors.MethodsTwenty-seven patients underwent elective kidney transplantation fromliving donors in our hospital between Mar2016and Oct2016,withthe target-controlled infusion mode of plasma target-controlled infusion,were collected.The target initial plasmaconcentration of propofol set at anesthesia inductionwas4.0mg/L,and the TCI concentration of remifentanil was limited to5~6ng/mL,the bispectral index(BIS)maintainedat45~55during the operation.If the BIS value dropped below45or raised above55,the TCI concentration ofpropofol should bedecreased or increased by0.2mg/L.At the time of10min,20min,30min,and40min after anesthesia induction and after opening of iliac blood vessels in renal transplantation,the TCI effect-site concentrationsof propofol were recordedin turn.The measuredhuman plasma concentrationsof propofol from3mL arterial blood collectedwere determinedby high performance liquid chromatography-tandem mass spectrometry(HPLC-MS/MS).ResultsCompared with the pre-anesthesia values(baseline values),there were significant differences in the decrease ofheart rate(HR),mean arterial pressure(MAP)and BIS value during theanesthesiaperiod(all P<0.05),but no significant difference was foundin SpO2between them(P>0.05).In comparison with the pre-anesthesia values(baseline values),there was no significant difference in the central vein pressure(CVP)before opening of iliac vesselsduringthe operation(P>0.05),but significantCVP increasewas foundafter opening ofiliac vessels(P<0.05).The deviation and precision degreesof propofolTCI before opening ofiliac vessels were9.58%and10.42%,respectively,and afteropening ofiliac vessels theywere14.17%and14.19%,respectively,both in clinical userange(-15%<deviation degree<15%,precision degree<30%).There were significant correlation between the measured plasma drugconcentration of propofol and the effect-site concentrationof propofol before or after opening of iliac vessels(F=2.35,R2=0.58,all P<0.05).But the concentration differences of propofol betweenmeasured plasma drugconcentration and effect-site concentration before or after opening of iliac vessels wereofno statistical significance(P<0.05).ConclusionThe correlation between measured plasma drug concentration and effect-site concentrationof propofol inthe intraoperative steadypropofol TCIfor ESRD patients was significant.In renal transplantation,the deviation and precision degreesof propofol TCI were bothin clinical use range.And considerablefluid infusionafter opening of iliac vessels has less effect on the anesthesia depth,so to increase the effect-site concentration of propofolwould be unnecessary.