基于患者状态指数确定子宫全切术患者丙泊酚和瑞芬太尼最佳配伍方案

Determination of the optimal compatibility program of propofol and remifentanil based on PSI in patients undergoing hysterectomy

目的探索在患者状态指数(patient state index,PSI)监测下,复合输注不同配伍浓度瑞芬太尼和丙泊酚对腹腔镜子宫全切术患者全身麻醉效果及复苏质量的影响,并确定丙泊酚和瑞芬太尼的最佳配伍方案。方法选择择期行腹腔镜下子宫全切术患者184例,研究分为两个部分。第1部分根据概率单位Probit回归分析法分别计算输注效应室浓度,采用随机数字表法将64例患者分为瑞芬太尼2μg/L组(Rl组,20例)、瑞芬太尼4μg/L组(Rm组,23例)和瑞芬太尼6μg/L组(Rh组,21例)。计算3组患者丙泊酚的半数效应浓度(median effective concentration,EC_(50))、95%效应浓度(95%effective concentration,EC95)及其95%CI。第2部分招募120例患者,按照瑞芬太尼和丙泊酚不同效应室浓度配伍方案,采用随机数字表法将患者分为3组(每组40例):瑞芬太尼2μg/L+丙泊酚3.9 mg/L组(Rl+Ph组)、瑞芬太尼4μg/L+丙泊酚组3.4 mg/L(Rm+Pm组)和瑞芬太尼6μg/L+丙泊酚2.7 mg/L组(Rh+Pl组)。记录3组患者手术时长、血流动力学不良事件、苏醒时长、拔管时长和PACU停留时长,记录拔管后15 min、30 min、1 h和术后24 h的VAS疼痛评分,记录拔管后24 h内的人工按压镇痛泵情况和补救镇痛药物使用情况,术后24 h恶心呕吐、术后躁动和术中知晓的发生率。按手术时间将3组患者再次分组,分别纳入上午组(8:00~12:00,64例)和下午组(12:00~18:00,49例),记录患者的苏醒时长、拔管时长和PACU停留时长。结果3组患者丙泊酚的EC_(50)及95%CI分别为3.0(2.52~3.79)、2.4(1.86~3.11)mg/L和2.1(1.63~2.42)mg/L,EC95及95%CI分别为3.9(2.44~8.79)、3.4(2.86~8.59)mg/L和2.7(2.35~5.22)mg/L。与Rl+Ph组和Rm+Pm组比较,Rh+Pl组的苏醒时长、拔管时长和PACU停留时长缩短(P<0.05);Rl+Ph组PACU停留时长多于Rm+Pm组(P<0.05)。3组患者手术时长、术中血流动力学不良事件(心动过缓、心动过速、高血压和低血压)比较差异无统计学意义(P>0.05)。3组患者拔管后15 min、30 min、1 h和术后24 h的VAS疼痛评分比较差异无统计学意义(P>0.05)。3组患者无需人工按压镇痛泵及使用补救镇痛药物。3组患者恶心呕吐、术后躁动发生率比较,差异无统计学意义(P>0.05),3组患者无术中知晓情况发生。上午组和下午组患者苏醒时长、拔管时长和PACU停留时长较比较,差异无统计学意义(P>0.05)。结论在PSI指导下,复合输注瑞芬太尼效应室浓度为6μg/L、丙泊酚效应室浓度为2.7 mg/L时患者能保持良好的麻醉效果,有利于术后早期苏醒,更快拔除气管导管,缩短PACU停留时间。

Objective To explore the effect of combined infusion of remifentanil and propofol at different concentrations on general anesthesia and recovery quality in patients undergoing laparoscopic hysterectomy based on patient state index(PSI)monitoring,and to investigate the optimal compatibility program of propofol and remifentanil.Methods A total of 184 patients who were scheduled for laparoscopic hysterectomy were selected.The study was divided into two parts.In part 1,the effect‑site concentration of propofol was calculated by the Probit method.According to the random number table method,the 64 patients were divided into three groups:a remifentanil 2μg/L group(group Rl,n=20),a remifentanil 4μg/L group(group Rm,n=23)and a remifentanil 6μg/L group(group Rh,n=21).Their values of propofol effective concentration(EC_(50)),95%effective concentration(EC95)and their 95%confidence interval(95%CI)were calculated.In part 2,120 patients were enrolled.According to different effect‑site concentration compatibility programs of propofol and remifentanil,they were divided into three groups using the random number table method(n=40):a remifentanil 2μg/L+propofol 3.9 mg/L group(group Rl+Ph),a remifentanil 4μg/L+propofol 3.4 mg/L group(group Rm+Pm),and a remifentanil 6μg/L+propofol 2.7 mg/L group(group Rh+Pl).The adverse hemodynamic events,the duration of operation,recovery time,extubation time,the length of post‑anesthesia care unit(PACU)stay time and the duration of surgery were recorded.Then,the Visual Analogue Scale(VAS)scores were also recorded 15 min,30 min,1 h,and 24 h after extubation.Besides,the pressure of analgesic pump,the consumption of rescue analgesics within 24 h after extubation,and the incidence of nausea and vomiting,postoperative agitation within 24 h after surgery and intraoperative awareness were recorded.The patients in the three groups were further divided into group morning(8:00‒12:00,n=64)and group afternoon(12:00‒18:00,n=49)according to the operation time,recorded recovery time,extubation time and PACU stay time.Results For patients in the three groups,the EC_(50) value of remifentanil and its 95%CI were 3.0(2.52‒3.79),2.4(1.86‒3.11)mg/L and 2.1(1.63‒2.42)mg/L,while the EC95 value of remifentanil and its 95%CI were 3.9(2.44‒8.79),3.4(2.86‒8.59)mg/L and 2.7(2.35‒5.22)mg/L.Compared with group Rl+Ph and group Rm+Pm,the recovery time,extubation time,and the length of PACU stay were shortened in group Rh+Pl(P<0.05);the length of PACU stay in the Rl+Ph group was longer than that in the Rm+Pm group(P<0.05).There was no statistical difference in adverse hemodynamic events(bradycardia,tachycardia,hypertension,and hypotension)among the three groups(P>0.05).There was no statistical difference in VAS score among the three groups 15 min,30 min,1 h after extubation and 24 h after operation(P>0.05).There was no case of analgesic pump pressing and rescue analgesics use in the three groups.There was no statistical difference in the incidence of nausea and vomiting,and postoperative agitation among the three groups(P>0.05).Retrospective investigation of the three groups showed that there was no intraoperative awareness.There was no statistical difference in recovery time,extubation time and PACU stay time between group morning and group afternoon(P>0.05).Conclusions Under the guidance of PSI,the combined infusion of remifentanil has an effect‑site concentration of 6μg/L and propofol with an effect‑site concentration of 2.7 mg/L,which can maintain a good anesthetic effect,and is conducive to reduce the time of awakening and extubation,and shorten the length of PACU stay.