氢吗啡酮麻醉诱导和超前镇痛对老年病人术后躁动影响及其机制的单盲、随机、对照研究

Effects of the hydromorphone anesthesia induction and preemptive analgesia on postoperative agitation in elderly patients and its mechanism:a single-blind,randomized,controlled study

目的观察氢吗啡酮在麻醉诱导和超前镇痛对老年全麻病人术后躁动和应激反应的影响。方法选择2017年1月至2018年12月在复旦大学附属华东医院就诊择期在全麻下行胆囊切除术病人122例,采用电脑随机数字表法将病人分为观察组和对照组,每组各61例。观察组使用氢吗啡酮麻醉诱导和超前镇痛,对照组使用芬太尼麻醉诱导。观察两组在麻醉前(T0)、气管插管后(T1)、手术开始时(T2)、手术完成时(T3)和拔管时(T4)的平均动脉压(MAP),心率(HR)和血氧饱和度(Sp O2)的动态变化。观察两组麻醉后自主呼吸时间、苏醒时间、拔管时间、躁动评分、镇静评分、视觉模拟评分(VAS)和舒适度评分(BCS)的比较。观察两组麻醉后不同时点前列腺素E2(PGE2),5-羟色胺(5-HT),β-内啡肽(β-EP),P物质(SP),肿瘤坏死因子(TNF)-α,白介素(IL)-6,高迁移率族蛋白B-1(HMGB-1),单核细胞趋化蛋白-1(MCP-1),肾素,血管紧张素Ⅱ,醛固酮和皮质醇水平的变化。结果重复测量方差分析结果发现,MAP和HR在时间、组间以及交互因素均差异有统计学意义(P=0.000),且T检验分析结果发现,观察组MAP和HR在T1-T4时间点均显著小于对照组(P<0.01)。两组的SpO2在各个时间点均差异无统计学意义(P>0.05)。两组麻醉后的自主呼吸时间,苏醒时间,拔管时间和镇静评分差异无统计学意义(P>0.05),而观察组的躁动评分(1.68±0.35)分和VAS(2.37±0.57)分较对照组(2.76±0.24)、(3.85±0.81)分明显降低(P<0.01),BCS评分(3.15±0.53)分较对照组(2.24±0.42)分明显升高(P<0.01)。两组在麻醉前和术后即刻PGE2,5-HT,β-EP,SP,TNF-α,IL-6,HMGB-1,MCP-1,肾素,血管紧张素Ⅱ,醛固酮和皮质醇水平差异无统计学意义(P>0.05),术后48 h两组均较麻醉前和术后即刻明显降低(P<0.01),而观察组的降低幅度较对照组更加明显(P<0.01)。结论氢吗啡酮用于麻醉诱导和超前镇痛能够较好的维持老年全麻病人血液流动力学稳定,减少术后躁动,缓解应激反应,减少疼痛和炎症介质的释放。

Objective To investigate the impact of hydromorphone anesthesia induction and preemptive analgesia on postoperative agitation and stress response in elderly patients with general anesthesia.Methods 122 patients undergoing cholecystectomy under general anesthesia were enrolled in Huadong Hospital Affiliated to Fudan University,from January 2017 to December 2018.They were randomly divided into observation group and control group,with 61 cases in each group.The observation group was performed with hydromorphone anesthesia induction and preemptive analgesia,and the control group was induced by fentanyl anesthesia.The mean arterial pressure(MAP),heart rate(HR)and blood oxygen saturation(SpO2)in the two groups were observed at the time of before anesthesia(T0),tracheal intubation(T1),beginning of surgery(T2),surgery(T3),and extubation(T4).The spontaneous breathing time,recovery time,extubation time,agitation score,sedation score,visual analog score(VAS)and comfort score(BCS)were observed in two groups after anesthesia.The prostaglandin E2(PGE2),serotonin(5-HT),β-endorphin(β-EP),substance P(SP),tumor necrosis factor(TNF)-α,interleukin(IL)-6,HMGB-1,MCP-1,renin,angiotensinⅡ,aldosterone and cortisol levels were observed at different time points after anesthesia.Results There were significant differences in time、time*group and group effect of MAP and HR using repeated measure analysis(P=0.000).In addition,we found that the observation group had lower MAP and HR at T1-T4 compared to the control group using T tests(P<0.01).There was no significant difference in spontaneous breathing time,recovery time,extubation time and sedation score between the two groups(P>0.05),while the agitation score(1.68±0.35 scores)and VAS(2.37±0.57 scores)in the observation group were significantly lower than the control group(2.76±0.24 scores,3.85±0.81 scores)(P<0.01),the BCS(3.15±0.53 scores)was significantly elevated compared with control group(2.24±0.42 scores)(P<0.01).There were no differences in PGE2,5-HT,β-EP,SP,TNF-α,IL-6,HMGB-1,MCP-1,renin,angiotensinⅡ,aldosterone and cortisol levels between the two groups before anesthesia and immediately after surgery,at 48 hours after operation,the those levels of two groups were significantly lower than those before anesthesia and immediately after surgery(P<0.01),while the decrease in the observation group was more significant than that in the control group(P<0.01).Conclusion Hydromorphone can improve the hemodynamic stability in elderly patients in anesthesia induction and preemptive analgesia,reduce postoperative agitation,relieve stress response,and reduce the release of pain and inflammatory mediators.