小剂量瑞芬太尼对鼻内镜手术患者苏醒质量及血流动力学的影响

Effect of low-dose remifentanil on quality of recovery from anesthesia and hemodynamics in patients undergoing endoscopic sinus surgery

目的 探讨麻醉苏醒期持续泵注小剂量瑞芬太尼对鼻内镜手术患者苏醒质量及血流动力学的影响。方法 选取2019年9月—2020年5月于山东第一医科大学第二附属医院择期行气管插管鼻内镜手术的60例成年患者,通过随机数字表法随机分为2组:瑞芬太尼组[麻醉苏醒期微量泵注瑞芬太尼0.05μg/(kg·min),n=30];生理盐水组(注射等体积生理盐水,n=30)。术毕患者均送麻醉后监测治疗室(postanesthesia care unit,PACU)继续吸氧、监测生命体征。由同一位麻醉医师监测患者苏醒,并采用Riker镇静-躁动评分表(sedation-agitation scale,SAS)对患者进行评估,当SAS≥5分时判定该患者发生苏醒期躁动(emergence agitation,EA)。瑞芬太尼组增大泵速至0.1μg/(kg·min)继续泵注,直至躁动消失;生理盐水组开始给予瑞芬太尼0.05μg/(kg·min)持续泵注,直至躁动消失。患者拔除气管导管后继续观察,满足出室标准后,送回病房。比较两组患者入PACU后自主呼吸恢复时间、拔除气管插管时间、PACU停留时间;患者咳嗽评分、疼痛评分以及拔管后不良反应;SAS及EA发生率;中重度EA发生时瑞芬太尼的追加泵注情况。结果 瑞芬太尼组EA发生率较生理盐水组低,差异具有统计学意义(χ^(2)=13.067,P<0.001)。瑞芬太尼组患者的SAS评分低于生理盐水组,差异有统计学意义(t=3.816,P<0.001)。瑞芬太尼组PACU停留时间较对照组明显缩短,差异有统计学意义(t=-3.935,P<0.001),拔管后疼痛评分与对照组差异有统计学意义(t=-5.692,P<0.001)。拔管即刻和拔管后15 min的血压、心率较对照组差异有统计学意义(P<0.05)。瑞芬太尼组及生理盐水组发生中重度躁动后追加泵注瑞芬太尼时间及追加使用剂量差异均有统计学意义(t=-8.497,P<0.001;t=-3.049,P=0.014)。结论 麻醉苏醒期小剂量泵注瑞芬太尼[0.05μg/(kg·min)]可以明显降低EA的发生率,并且不会导致苏醒延迟,不会增加术后不良反应的发生率。

Objective:To explore the effect of continuous remifentanil micro pump injection on emergence agitation of general anesthesia patients after endoscopic sinus surgery.Methods:Sixty patients aged from 19 to 59 with ASA grade I-II elective endoscopic sinus surgery under intubation and general anaesthesia in the Second Affiliated Hospital of Shandong First Medical University from September 2019 to May 2020 were enrolled.These cases were randomly divided into remifentanil group[micro pump injection remifentanil 0.05μg/(kg·min)during anesthesia recovery period,n=30],and saline group(injection of same volume of saline,n=30).All the patients were sent to the post-anesthesia care unit(PACU)after anesthesia.Then all patients were monitored by an anesthesiologist.Antagonistic drugs were given to the patients with residual muscle relaxation.The same one anesthesiologist monitored their recovery and evaluated the Riker sedation-agitation Score(SAS).According to the standard,when SAS was≥5 points,patients were considered to have emergence agitation.For patients with EA who were hard to dissuade by language the pump speed was increased to 0.1μg/(kg·min)and the pump was continued until the agitation disappeared in remifentanil group while in the saline group,remifentanil 0.05μg/(kg·min)was given continuously until the agitation disappeared.After extubation,the patients were escorted back to the ward by PACU nurses and surgeons when SpO2 was≥95%under air inhalation,and there was no continuous downward trend,Steward score was≥4.Results:The time of resuming spontaneous breathing was(10.63±2.735)min in remifentanil group and(11.03±2.236)min in saline Group(P>0.05);the time of extubation was(12.83±2.627)min in remifentanil group and(13.47±2.080)min in saline group(P>0.05);the time of staying in PACU was(46.53±7.215)min in remifentanil group and(54.77±8.908)min in saline group(P<0.05).2.The SBP at extubation time was(131.53±8.51)mmHg in remifentanil group and(147.6±9.37)mmHg in saline group;the DBP at extubation time was(81.17±6.41)mmHg in remifentanil group and(87.77±6.8)mmHg in saline group;the HR at extubation time was(84.2±5.7)times/min in remifentanil group and(95.73±8.51)times/min in saline group.These differences were statistically significant.The incidence rate of EA in remifentanil group was 26.7%,and among these,mild agitation accounted for 20%,moderate agitation accounted for 6.7%,and severe agitation accounted for 0%;the incidence rate of EA in saline group is 73.3%,and among these,mild agitation accounted for 43.3%,moderate agitation accounted for 20%,and severe agitation accounted for 10%.Obviously,remifentanil could reduce the incidence rate of EA after endoscopic sinus surgery.The pain score after extubation time in remifentanil group and saline group were significantly different(2.47±0.900 vs.3.83±0.950);the cough score after extubation time was(0.97±0.809)in remifentanil group and(1.13±0.819)in saline group(P<0.05);the incidence rate of other side effects,including nausea and vomiting,bradycardia,hypotension and respiratory depression had no significant difference.The time of pumping appended remifentanil used was(0.73±2.84)min in remifentanil group and(7.47±11.855)min in saline Group(P<0.05);the dosage of appended remifentanil used was(5.27±20.479)μg in remifentanil group and(24.8±40.048)μg in saline group(P<0.05);These differences were statistically significant.Remifentanil group continued to add less remifentanil.Conclusion:During the recovery period of general anesthesia,continuous pumping remifentanil 0.05μg/(kg·min)can significantly reduce the incidence rate of postoperative agitation in patients undergoing endotracheal intubation and sevoflurane inhalation,instead of prolonging the recovery time and increasing the in cidencerate of other adverse reactions.