SEDline镇静监测下瑞马唑仑静脉麻醉联合胸椎旁神经阻滞在胸腔镜肺叶切除术中的应用

Application of remimazolam toluene sulfonate combined with paravertebral nerve block in thoracoscopic lobectomy under SEDline monitoring

目的探讨在SEDline镇静监测仪监测下甲苯磺酸瑞马唑仑复合胸椎旁神经阻滞(TPVB)在胸腔镜肺叶切除术中的临床应用效果。方法前瞻性随机对照研究。纳入2021年6月—2022年5月蚌埠医学院第一附属医院择期行胸腔镜下肺叶切除术患者80例,其中男45例、女35例,年龄40~71岁。80例患者采用数字表法随机分为4组,其中采用甲苯磺酸瑞马唑仑静脉麻醉联合TPVB为TR组,采用甲苯磺酸瑞马唑仑静脉麻醉为R组,采用丙泊酚静脉麻醉联合TPVB为TB组,采用丙泊酚静脉麻醉为B组,每组20例。患者均在SEDline镇静监测仪监测下行胸腔镜肺叶切除术,术中根据患者大脑状态指数(PSI)调控麻醉药用量,PSI维持在25~50。观察指标:(1)比较4组患者性别、年龄、体质量指数(BMI)、术前血清同型半胱氨酸(Hcy)、术前简易精神状态检查量表(MMSE)认知功能评分等临床基线资料;(2)记录对比4组患者麻醉诱导前(T_(0))、切皮时(T_(1))、单肺通气30 min(T_(2))、术毕即刻(T_(3))的血氧饱和度(SPO_(2))、心率、平均动脉压(MAP),以及血清丙二醛(MDA)、晚期氧化蛋白产物(AOPP)水平;(3)记录对比4组患者手术时间、术中输液量、出血量和盐酸瑞芬太尼用量;(4)对比术后6、24 h疼痛VAS评分和Ramsay镇静评分,术后24 h血清Hcy水平、MMSE评分、镇痛泵按压次数。结果(1)4组患者性别、年龄、BMI、术前Hcy、术前MMSE评分等临床基线资料比较,差异均无统计学意义(P值均>0.05)。(2)组内比较:R组心率不同时间点差异有统计学意义(F=3.30,P=0.025),TR组、TB组、B组心率在不同时间点差异均无统计学意义(P值均>0.05);各组中的MAP、SPO_(2)、MDA、AOPP不同时间点差异均有统计学意义(P值均<0.05)。组间比较:在T_(0),4组间MAP、心率、SPO_(2)、MDA、AOPP差异均无统计学意义(P值均>0.05)。在T_(1)、T_(2),心率、MDA、AOPP差异均有统计学意义(P值均<0.05),其中TB组心率均最低,TR组MDA、AOPP均最低;而MAP、SPO_(2)差异均有统计学意义(P值均<0.05)。在T_(3),MAP、MDA、AOPP差异均有统计学意义(P值均<0.05),其中B组MAP最低,TR组MDA、AOPP均最低;而心率、SPO_(2)差异均无统计学意义(P值均>0.05)。(3)TR组、TB组患者术中盐酸瑞芬太尼用量较少,R组、B组较多,4组间比较差异有统计学意义(F=23.67,P<0.001);而手术时间、术中输液量、术中出血量4组间比较,差异无有统计学意义(P值均>0.05)。(4)4组患者术后6、24 h疼痛VAS评分和Ramsay镇静评分,以及术后24 h血清Hcy水平、MMSE认知功能评分、镇痛泵按压次数比较,差异均有统计学意义(P值均<0.05)。结论甲苯磺酸瑞马唑仑联合TPVB应用于胸腔镜肺叶切除术中,能更精准地控制麻醉状态,且患者循环指标波动范围较小,术后镇静、镇痛效果更有优势。

Objective This study aimed to explore the clinical value of remimzolam mesylate combined with thoracic paravertebral nerve block(TPVB)in thoracoscopic lobectomy under the monitoring of a SEDline sedation monitor.Methods A prospective randomized control study was conducted from June 2021 to May 2022.Eighty patients(45 males and 35 females,aged 40-71 years)who underwent thoracoscopic lobectomy in the First Affiliated Hospital of Bengbu Medical College were included.The patients were randomly divided into four groups by using the numerical table method.Among them,remimazolam mesylate intravenous anesthesia combined with TPVB was used as the TR group,remimazolam mesylate intravenous anesthesia was the R group,propofol intravenous anesthesia combined with TPVB was TB group,and propofol intravenous anesthesia was the B group,with 20 patients in each group.All patients underwent thoracoscopic lobectomy under the monitoring of a SEDline sedation monitor.During the operation,the anesthesia dosage was adjusted according to the patient's brain state index(PSI),which was maintained at 25-50.The observation indices were as follows.(1)The clinical baseline data of the four groups,including gender,age,body mass index(BMI),preoperative serum homocysteine(Hcy),and preoperative cognitive function score of the Mini Mental State Examination(MMSE)were compared.(2)Percutaneous arterial oxygen saturation(SPO_(2)),heart rate,mean arterial pressure(MAP),serum malondialdehyde(MDA),and advanced oxidation protein product(AOPP)were recorded and compared before anesthesia induction(T_(0)),at skin incision(T_(1)),after 30 min of one lung ventilation(T_(2)),and immediately after operation(T_(3))in the four groups.(3)The operation time,intraoperative infusion volume,bleeding volume,and remifentanil hydrochloride dosage of the four groups were recorded and compared.(4)The visual analog scale(VAS)score of pain and Ramsay sedation score at 6 and 24 h after operation were compared,and the serum Hcy level,MMSE cognitive function score,and times of pressing analgesia pump at 24 h after operation were compared.Results(1)No significant difference existed in clinical baseline data such as gender,age,BMI,preoperative Hcy,and preoperative MMSE score among the four groups(all P values>0.05).(2)The indices were compared at different time points in the group.Results showed that the heart rate of group R significantly differed at various time points(F=3.30,P=0.025),whereas the heart rate of group TR,TB,and B did not significantly differ at various time points(all P values>0.05).MAP,SPO_(2),MDA,and AOPP in the four groups significantly differed at various time points(all P values<0.05).Comparison between groups was also made at different time points.Results showed that at T_(0),no significant difference existed in MAP,heart rate,SPO_(2),MDA,and AOPP among the four groups(all P values>0.05).At T_(1)and T_(2),the difference in heart rate,MDA,and AOPP was statistically significant(all P values<0.05).The heart rate of the TB group was the lowest,whereas that of the TR group was the lowest.No significant difference existed in MAP and SPO_(2)(all P values>0.05).At T_(3),the difference in MAP,MDA,and AOPP was statistically significant(all P values<0.05).MAP in the B group was the lowest,whereas MDA and AOPP in the TR group were the lowest.No significant difference existed in heart rate and SPO_(2)(all P values>0.05).(3)The dosage of remifentanil hydrochloride during operation in the four groups was less in the TR and TB groups but was greater in the R and B groups,with a statistically significant difference(F=23.67,P<0.001).The operation time and intraoperative infusion volume were also analyzed.Results showed no significant difference in the amount of bleeding(all P values>0.05).(4)Significant difference existed among the four groups in terms of pain VAS score and Ramsay sedation score 6 and 24 h after operation,as well as the level of serum Hcy,MMSE cognitive function score,and number of times of pressing analgesia pump 24 h after operation(all P values<0.05).Conclusion Remimazolam toluenesulfonate combined with TPVB can more accurately control the anesthesia state during thoracoscopic lobectomy,and the patient's circulation fluctuation range was small.Accordingly,the sedation and analgesia effects after operation were more advantageous.