清醒镇静麻醉用于腹膜透析置管术的有效性及安全性的临床研究

The efficacy and safety of conscious sedation anesthesia in peritoneal dialysis catheterization

目的探讨清醒镇静(conscious sedation,CS)麻醉在腹膜透析(peritoneal dialysis,PD)置管术中的有效性和安全性。方法选取2017年1月~2020年5月在北京大学国际医院使用手术切开法行腹膜透析置管术的患者,根据麻醉方式不同分成2组:传统组(A组):术前30min肌肉注射盐酸哌替啶和盐酸异丙嗪,联合局部浸润麻醉。改良组(B组):手术开始时静脉使用芬太尼(B1)、舒芬太尼(B2)或瑞芬太尼(B3)联合局部浸润麻醉。比较两组患者的临床基线资料,手术过程中血压、心率,术中、术后疼痛以及不良反应。结果共94例患者纳入本研究,其中A组53例,B组41例。2组的人口学资料及相关的化验检查无差异,美国麻醉协会(american society of anesthesiologists,ASA)麻醉风险分级评估为IV级的高危风险患者比例分别占58.5%和68.3%(P=0.330)。B组患者术中疼痛比例明显低于A组患者(17%比39.6%,P=0.018);术后疼痛比例、静息疼痛评分及活动时疼痛评分无显著差异。A组有5例(9.4%)不良反应,其中3例出现了胃肠道反应,1例发生了低血压和1例出现意识障碍,B组有2例(4.8%)的患者出现不良反应均是胃肠道反应,但2组总不良反应发生率无显著差异(P=0.395)。进一步分析,在B1、B2和B3组患者使用不同的药物镇痛效果及不良反应无差异(P>0.05)。结论行腹膜透析置管术的患者存在麻醉高风险,采用清醒镇静麻醉能达到更好的镇痛效果,且安全性好,体现了舒适化医疗的理念。

Objective To investigate the efficacy and safety of conscious sedation(CS)in the operation of peritoneal dialysis(PD)catheterization.Methods Patients undergoing catherization for PD by surgical incision treated in Peking University International Hospital during the period from January 2017 to May 2020 were enrolled in this study.Patients were divided into two groups according to the anesthesia method:group A,intramuscular injection of pethidine hydrochloride and promethazine hydrochloride before operation combined with local infiltration anesthesia during operation;group B,one of the three analgesics,fentanyl(subgroup B1),sufentanil(subgroup B2)or remifentanil(subgroup B3)intravenously at the beginning of operation for conscious sedation combined with local infiltration anesthesia.Adverse reactions,clinical findings,and peri-operative blood pressure,heart rate and pain score were compared between the two groups.Results A total of 94 patients,53 cases in group A and 41 cases in group B,were enrolled in this study.There were no differences in demographic data and laboratory examinations between the two groups.The proportion of patients with high anesthesia risk(grade IV)based on the ASA assessment was 58.5%and 68.3%in group A and group B respectively(P=0.330).The proportion of intraoperative pain was lower in group B than in group A(17%vs.39.6%,P=0.018).There were no significant differences in rate of postoperative pain,resting pain score and exercise pain score between the two groups.Five cases in group A(9.4%)had adverse reactions,including gastrointestinal reactions in 3 cases,hypotension in one case,and consciousness disturbance in one case;two cases in group B(4.8%)had gastrointestinal reactions.However,there was no significant difference in the incidence of overall adverse reactions between the two groups(P=0.395).No significant differences in analgesic effects and gastrointestinal reactions were found among the three subgroups in group B(P>0.05).Conclusion Patients undergoing PD catheterization are at high risk of anesthesia.Conscious sedation anesthesia had better analgesic effect and safety,complying with the concept of comfortable medical treatment.