瑞马唑仑在经静脉心内置入性电子装置电极拔除术麻醉中的应用

Application of remimazolam in anesthesia for transvenous lead extraction of cardiac implantable electronic device

目的探讨瑞马唑仑在经静脉心内置入性电子装置电极拔除术(TLE)中的麻醉效果及安全性。方法选择拟行TLE的患者27例,随机分为PCS组15例(TLE中行苯磺酸瑞马唑仑自控镇静)和TIVA组12例(TLE中行全凭静脉麻醉)。比较两组TLE顺利完成率、患者术后随访相关指标(对手术过程中关键步骤的记忆和遗忘情况、自觉入睡情况、满意度评分、是否愿意再次选择该麻醉方式)、术者术后随访相关指标(满意度评分、是否愿意再次选择该麻醉方式)、不良事件发生率及离室时间,麻醉前(T_(0))、消毒铺巾(T_(1))、手术开始(T_(2))、放置鞘管(T_(3))、导线拔除(T_(4))、缝皮(T_(5))、手术结束(T_(6))和离室(T_(7))时的脑电双频指数(BIS)、平均动脉压(MAP)、呼吸频率(RR)、脉搏血氧饱和度(SpO_(2))和呼气末二氧化碳分压(P_(ET)CO_(2))。结果PCS组、TIVA组分别退出2、3例,最终分别纳入13、9例。PCS组11例(84.6%)顺利完成TLE,TIVA组为9例(100%),两组TLE顺利完成率比较无统计学差异(P>0.05)。与同组T_(0)时间点比较,PCS组T_(1)~T_(5)的BIS均降低,T_(2)~T_(7)的RR均降低,T_(2)~T_(6)的P_(ET)CO_(2)均升高,而TIVA组T_(1)~T_(6)的BIS及RR均降低、SpO_(2)均升高,T_(7)的SpO_(2)降低,T_(1)、T_(2)、T_(4)的MAP均降低,T_(3)~T_(5)、T_(7)的P_(ET)CO_(2)均降低,T_(7)的P_(ET)CO_(2)升高(P均<0.05)。与TIVA组同时间点比较,PCS组T_(1)~T_(7)的BIS均升高,T_(3)~T_(6)的RR、P_(ET)CO_(2)均升高,T_(1)~T_(3)的MAP均升高,T_(7)的SpO_(2)均升高(P均<0.05)。TIVA组遗忘3个及以上操作步骤、能自觉入睡的比例及离室时间均高于PCS组(P<0.05)。两组患者及术者愿意再次选择该麻醉方式的比例及满意度评分比较P均>0.05。PCS组不良事件发生率为15.4%(2/13),TIVA组为33.3%(3/9),两组比较P>0.05。结论TLE中采用瑞马唑仑的镇静成功率高、镇静效果确切、代谢速度快,能够促进患者快速苏醒,且对患者血流动力学影响较小。

Objectives To explore the anesthetic effect and safety of remimazolam in the transvenous lead extraction(TLE)of cardiac implantable electronic device.Methods Twenty-seven undergoing TLE were divided into the patientcontrolled sedation(PCS)group of 15 cases(benzenesulfonic acid and remimazolam were used in TLE)and total intravenous anesthesia(TIVA was used in TLE)group of 12 cases(TIVA).The successful complete rate of TLE,follow-up results of patients(memory and forgetting of key steps during the surgical process,consciousness of falling asleep,satisfaction score,and willingness to choose the anesthesia method again),follow-up results of surgeons(satisfaction score,and willingness to choose the anesthesia method again),the rate of adverse events,departure time,and indices including bispectral index(BIS),mean arterial pressure(MAP),respiratory rate(RR),saturation pulse oximetry(SpO_(2)),and end-expiratory carbon dioxide(P_(ET)CO_(2))in pre-anesthesia(T_(0)),disinfection and drape(T_(1)),surgery start(T_(2)),sheath placement(T_(3)),wire removal(T_(4)),suture(T_(5)),surgery end(T_(6)),and extubation(T_(7)).Results Two subjects in the PCS group and 3 subjects in the TIVA group were withdrawn.Thirteen subjects in the PCS group and 9 subjects in the TIVA group were recruited.Eleven subjects in the PCS group(84.6%)and 9 subjects in the TIVA group(100%)complete the TLE successfully.There was no significant difference in the successful complete rate of TLE(P>0.05).In the PCS group,compared with the T_(0),the BIS of T_(1) to T_(5) and the RR of T_(2) to T_(7) decreased,while the P_(ET)CO_(2) of T_(2) to T_(6) increased.In the TIVA group,compared with the T_(0),the BIS and RR of T_(1) to T_(6) decreased,while those of SpO_(2) increased.However,the SpO_(2) of T_(7),the MAP of T_(1),T_(2),and T_(4),and the P_(ET)CO_(2) of T_(3) to T_(5) and T_(7) decreased,while the P_(ET)CO_(2) of T_(7) increased(all P<0.05).Compared with the TIVA group at the same time point,the BIS of T_(1) to T_(7) increased,the RR and the P_(ET)-CO_(2) of T_(3) to T_(6) increased,the MAP of T_(1) to T_(3) increased,and the SpO_(2) of T_(7) increased(all P<0.05).The proportion of pa-tients who forgot three or more operating steps and were able to consciously fall asleep was higher in the TIVA group than in the PCS group(P<0.05).The departure time in the TIVA group was longer than that of the PCS group(P<0.05).There were no significant differences in the proportion of patients and surgeons willing to choose this anesthesia method again or satisfaction scores between the two groups(both P>0.05).The incidence of adverse events was 15.4%(2/13)in the PCS group and 33.3%(3/9)in the TIVA group(P>0.05).Conclusion The use of remimazolam in TLE has a high success rate of sedation,a definite sedative effect,and a fast metabolic rate,which can promote rapid recovery of patients and have a small impact on their hemodynamics.