右美托咪定联合瑞芬太尼不同镇静深度 对吸脂手术患者呼吸抑制的影响

Effects of dexmedetomidine combined with remifentanil for different sedation levels on respiratory depression in patients with liposuction

目的比较右美托咪定联合瑞芬太尼不同镇静深度对吸脂手术患者呼吸抑制的影响。方法前瞻性选取2017年9月至2018年4月中国医学科学院整形外科医院收治的在操作镇静镇痛麻醉下行吸脂手术的60例患者,采用随机数字表法将患者分为中度镇静目标组和深度镇静目标组,每组各30例。2组均采用静脉泵注右美托咪定联合瑞芬太尼进行镇静镇痛,右美托咪定负荷剂量1μg/kg,15 min输注完毕,随之以0.2~1.0μg·kg-1·h-1持续泵注,术中调整输注速度以达到中度或深度镇静目标;同时靶控输注瑞芬太尼,初始效应室靶浓度为2.5 ng/mL,术中根据疼痛和呼吸情况每次上调或下调0.3 ng/mL。比较2组达到目标镇静水平的成功率,低氧血症、呼吸过缓、呼吸暂停和上呼吸道梗阻等呼吸抑制情况,并记录语言指令、托下颌、置入口咽通气道和面罩加压通气等呼吸干预情况。另外,记录和评估改良警觉/镇静评分(MOAA/S评分)、脑电双频指数(BIS)值、咪达唑仑补救、术中疼痛反应和患者满意度。结果中度目标组达到目标镇静水平的成功率(73.3%)低于深度目标组(93.3%),差异有统计学意义(P<0.05);中度目标组术中呼吸抑制、呼吸过缓、呼吸暂停发生率、咪达唑仑补救率(53.3%、50.0%、6.7%、46.7%)低于深度目标组(80.0%、80.0%、40.0%、83.3%),差异均有统计学意义(P<0.05);中度目标组低氧血症、上呼吸道梗阻、呼吸干预发生率(6.7%、10.0%、23.3%)与深度目标组(6.7%、6.7%、36.7%)比较,差异无统计学意义(P>0.05);中度目标组术中MOAA/S评分和BIS值[3.63(3.25,4.00)、74.25(68.81,77.50)]高于深度目标组[2.88(2.50,3.06)、70.00(65.00,73.50)],差异均有统计学意义(P<0.05);中度目标组术中疼痛反应、患者满意度(23.3%、100.0%)与深度目标组(23.3%、96.7%)比较,差异无统计学意义(P>0.05)。结论右美托咪定联合瑞芬太尼镇静用于吸脂手术时,中度目标镇静对呼吸抑制影响更小,但深度目标镇静并未增加气道干预的需求。

Objective To compare the effects of dexmedetomidine combined with remifentanil for different sedation levels on respiratory depression in patients with liposuction.Methods In this prospective study,60 patients scheduled for liposuction under procedural sedation and analgesia in Plastic Surgery Hospital,Chinese Academy of Medical Scicences and Peking Union Medical College from September 2017 to April 2018 were enrolled.They were randomly divided into moderate target group and deep target group according to ASA's definition on the continuum of depth of sedation.Intravenous dexmedetomidine combined with remifentanil were used in both groups for sedation and analgesia.For achieving the target sedation level,dexmedetomidine was administered with a loading dose of 1μg/kg over 15 min,followed by a continuous infusion with an adjustment range within 0.2~1.0μg·kg-1·h-1.Meantime,to maintain analgesia,target-controlled infusion of remifentanil was proceeded at an initial effective-site concentration of 2.5 ng/mL followed by a 0.3 ng/mL adjustment each time depending on the pain and respiration situation.The achieved target sedation rate,respiratory depression(hypoxemia,bradypnea,apnea,upper airway obstruction),and airway interventions(verbal command,jaw thrust,oropharyngeal airway placement,and bag-mask ventilation)were compared between two groups.MOAA/S,bispectral index(BIS)value,rescue midazolam medication,patients'perception of pain,and patients'satisfaction with the procedure were also compared between the two groups.Results The achieved target sedation rate was lower in the moderate target group(73.3%)than that in the deep target group(93.3%),the difference was statistically significant(P<0.05).The incidence of total respiratory depression,bradypnea,apnea,rescue midazolam medication was lower in the moderate target group(53.3%,50.0%,6.7%,46.7%)than those in the deep target group(80.0%,80.0%,40.0%,83.3%),the difference were statistically significant(P<0.05).There were no significant differences in hypoxemia,upper airway obstruction,and airway interventions(6.7%vs.6.7%,10.0%vs.6.7%,23.3%vs.36.7%)(P>0.05).Average MOAA/S and BIS value were higher in the moderate target group[3.63(3.25,4.00),74.25(68.81,77.50)]than that in the deep target group[2.88(2.50-3.06),70.00(65.00-73.50)],the difference was statistically significant(P<0.05).Patients'perception of pain and patients'satisfaction with the procedure showed no significant differences between the moderate target group(23.3%,100.0%)and the deep target group(23.3%,96.7%)(P>0.05).Conclusion Dexmedetomidine combined with remifentanil for moderate sedation has less influence on respiratory depression in patients with liposuction.However,deep sedation does not need more airway interventions than moderate sedation.