全凭静脉麻醉下患者麻醉意识与血流动力学的关系及其临床应用价值

Relationship between Anesthesia Consciousness and Hemodynamics in Patients Under Total Intravenous Anesthesia and Its Clinical Value

目的探讨全凭静脉麻醉(total intravenous anesthesia,TIVA)手术患者的麻醉意识与血流动力学的变化情况及麻醉意识指数的临床应用价值。方法选择恩施土家族苗族自治州中心医院于2019年7月至2019年12月择期行TIVA手术的患者200例,年龄20~60岁,美国麻醉医师协会(American Society of Anesthesiologists,ASA)分级Ⅰ级或Ⅱ级。200例患者随机分为3组,分别为血流动力学监测组(A组)40例、麻醉意识监测组(B组)40例以及对照组(C组)120例。麻醉诱导的方式为静脉注射咪达唑仑、顺式阿曲库铵,靶控输注丙泊酚和瑞芬太尼,根据患者麻醉意识指数确定麻醉深度并调整麻醉药物量,使麻醉意识指数维持在40~60。记录麻醉诱导前(T_(0)),气管插管前(T_(1)),气管插管时(T_(2)),切皮时(T_(3)),手术结束时(T_(4)),拔管时(T_(5))患者的心率(heart rate,HR)、平均动脉压(mean arterial pressure,MAP)、麻醉指数(anesthesia index,Ai)、拔管时间、苏醒时间和不良反应,并以Pearson相关系数分析其相关性。结果C组患者Ai与MAP、HR均呈正相关(r=0.721、0.329,P<0.05);C组120例患者中,术中知晓率为1.66%。A组与B组患者的HR在T_(1)时刻最高,MAP在T_(4)时刻最高;与T_(0)时刻相比较,A组患者的HR在T_(1)和T_(4)时刻有所增快,MAP在T_(1)、T_(2)以及T_(4)时升高;与A组相比,在所有时刻B组患者的MAP均明显低于A组。A组患者的血糖浓度在T_(2)时刻最高。与T_(0)时刻相比,A组患者的血糖浓度在T_(2)和T_(3)时刻有较为明显的提高,皮质醇浓度则在T_(2)、T_(3)和T_(4)时刻有所提升。与A组患者相比,B组患者的血糖浓度在T_(2)和T_(3)时刻有较为明显的降低,平均降低了约0.10 mmol/L;皮质醇浓度在T_(2)、T_(3)和T_(4)时刻有较为明显的降低,平均降低了约103.03 mmol/L。A组患者术中知晓率为2.5%,B组患者的拔管时间比A组患者缩短约7.33 min;苏醒时间缩短约11.01 min;术后在监测室的停留时间缩短约11.58 min;B组丙泊酚用药量明显低于A组。结论TIVA下患者麻醉意识与血流动力学关系呈正相关,MAP能更好地反映患者的麻醉深度。维持患者的麻醉意识指数在50左右,能够有效地缩短患者的拔管时间、苏醒时间以及术后在监测室的停留时间,有利于患者减少麻醉恢复时间,降低丙泊酚用药量,维持血流动力学平稳。

Objectives To investigate the changes of anesthesia consciousness and hemodynamics in patients undergoing total intravenous anesthesia(TIVA)and the clinical value of anesthesia consciousness index.Methods Totally 200 patients,aged 20-60 years old,with American Society of Anesthesiologists(ASA)gradeⅠorⅡwere selected to undergo TIVA from July 2019 to December 2019 in the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture.The 200 patients were randomly divided into 3 groups:hemodynamics monitoring group(A group),anesthesia awareness monitoring group(B group),and control group(C group).Anesthesia was induced by intravenous injection of midazolam and cisatracurium,target controlled infusion of propofol and remifentanil.The depth of anesthesia was determined according to the patient′s anesthesia consciousness index and the amount of anesthetic drugs were adjusted to maintain the anesthesia consciousness index at 40-60.The heart rate(HR),mean arterial pressure(MAP),anesthesia index(AI),extubation time,recovery time and adverse reactions were recorded before anesthesia induction(T_(0)),before endotracheal intubation(T_(1)),during endotracheal intubation(T_(2)),during skin incision(T_(3)),at the end of operation(T_(4)),and at the time of extubation(T_(5)).The correlation was analyzed by Pearson correlation coefficient.Results AI positively correlated with MAP and HR in C group(r=0.721,0.329,P<0.05).Among the 120 patients in C group,the intraoperative awareness rate was 1.66%.The HRs of A group and B group were the highest at T_(1) and the MAPs were the highest at T_(4).Compared with time T_(0),HR of A group increased at T_(1) and T_(4),and MAP increased at T_(1),T_(2) and T_(4).Compared with A group,the MAP of B group was significantly lower than that of A group at all times.The blood concentration of glucose in A group was the highest at T_(2).Compared with time T_(0),the blood concentration of glucose in A group significantly increased at time T_(2) and T_(3),and the cortisol concentration increased at time T_(2),T_(3) and T_(4).Compared with A group,the blood concentration of glucose in B group decreased significantly at T_(2) and T_(3),with an average decrease of about 0.10 mmol/L.Cortisol concentration decreased significantly at T_(2),T_(3) and T_(4),with an average decrease of about 103.03 mmol/L.The intraoperative awareness rate of A group was 2.5%,and the extubation time of B group was about 7.33 min shorter than that of A group.The recovery time was shortened by 11.01 min.The stay time in the monitoring room was shortened by 11.58 min after operation.The dosage of propofol in B group was significantly lower than that in A group.Conclusions There is a positive correlation between anesthesia consciousness and hemodynamics under TIVA,and MAP could better reflect the anesthesia depth of patients.Maintaining the anesthesia consciousness index of the patients at about 50 can effectively shorten the extubation time,recovery time and post-operative stay time in the monitoring room,which is conducive to reducing the recovery time of anesthesia,reducing the dosage of propofol and maintaining stable hemodynamics.