右美托咪定喷鼻联合静脉泵注在口腔颌面外科手术中的应用

Application of dexmedetomidine nasal spray combined with intravenous pumping in oral and maxillofacial surgery

目的探讨右美托咪定预先喷鼻联合泵注与常规泵注的不同给药方式对口腔颌面外科手术患者术中瑞芬太尼和心率变异性(HRV)的影响。方法选择口腔颌面外科的择期手术患者90例,男43例,女47例,年龄18~64岁,BMI 18~25 kg/m^(2),ASAⅠ或Ⅱ级。采用随机数字表法将患者分为三组:预先喷鼻联合泵注组(PP组)、常规泵注组(CP组)和对照组(C组),每组30例。手术当日入室前45 min,PP组经鼻喷雾右美托咪定0.5μg/kg,CP组和C组经同样方法给予等量生理盐水。麻醉诱导前10 min,PP组经静脉泵注10 min右美托咪定0.5μg/kg,CP组经静脉泵注10 min右美托咪定1μg/kg,C组给予等量生理盐水。记录入室Ramsay镇静评分、手术时间、瑞芬太尼诱导和维持用量,入室时(T_(1))、插管即刻(T_(2))、切皮后10 min(T_(3))和拔管即刻(T_(4))相邻RR间期差值的均方根(RMSSD)、全部窦性RR间期的标准差(SDNN)、低频功率(LF)、高频功率(HF)、总功率(TP)、低频与高频(LF/HF)比值等HRV分析指标、HR、MAP和BIS。记录术后恶心呕吐例数和术后24 h内镇痛药使用情况。结果与C组比较,T_(1)时PP组MAP明显降低,RMSSD、SDNN和logTP明显升高,LF/HF比值明显降低(P<0.05),T_(2)—T_(4)时PP组和CP组LF/HF比值明显降低(P<0.05),PP组和CP组瑞芬太尼诱导用量、术后恶心呕吐发生率和24 h镇痛药使用率明显降低(P<0.05)。与CP组比较,T_(1)时PP组RMSSD、SDNN、logLF、logHF、logTP明显升高(P<0.05),T_(2)、T_(4)时PP组logHF明显升高,PP组入室Ramsay镇静评分明显升高,瑞芬太尼维持用量明显降低(P<0.05)。结论使用右美托咪定后,HRV分析中与应激水平相关的指标明显降低,并且可明显减少阿片类药物的用量,使用右美托咪定预先喷鼻联合泵注的方式能够进一步减少麻醉维持阶段的阿片类药物用量。

Objective To investigate the effect of different modes of administration of dexmedetomidine pre-nasal spray combined with pumping and conventional pumping on remifentanil and heart rate variability(HRV)in patients undergoing oral and maxillofacial surgery.Methods Ninety patients undergoing elective oral and maxillofacial surgery,43 males and 47 females,aged 18-64 years,BMI 18-25 kg/m^(2),ASA physical statusⅠorⅡ,were selected.The patients were divided into three groups by random number table method:pre-nasal spray combined with pump injection group(group PP),conventional pump injection group(group CP),and control group(group C),30 cases in each group.Patients in group PP were given a nasal spray of dexmedetomidine at a dose of 0.5μg/kg,group CP and group C were given the same amount of normal saline by the same method 45 minutes before entering the room on the day of surgery.Dexmedetomidine was injected intravenously in group PP at doses of 0.5μg/kg and in group CP at dose of 1μg/kg for 10 minutes,and group C was given the same amount of normal saline 10 minutes before induction of anesthesia.Ramsay sedation score on admission,duration of surgery,the dose of remifentanil during induction and maintenance of anesthesia,room admission(T_(1)),induction intubation(T_(2)),10 minutes after skin incision(T_(3)),and extubation(T_(4)),RMSSD,SDNN,LF,HF,TP,LF/HF ratio and other HRV analysis indicators,HR,MAP,and BIS values were recorded.The incidence of PONV and the use of analgesics within 24 hours after operation were recorded.Results Compared with group C,the MAP was si gnificantly reduced,RMSSD,SDNN,and logTP were significantly increased,and LF/HF was significantly decreased in group PP at T_(1)(P<0.05),the LF/HF were significantly reduced in groups PP and CP at T_(2)-T_(4)(P<0.05),the dosage of remifentanil during the anesthesia induction,the incidence of PONV,and the use rate of analgesic drugs in 24 hours were significantly reduced in groups PP and CP(P<0.05).Compared with group CP,the RMSSD,SDNN,logLF,logHF,and logTP were increased significantly in group PP at T_(1)(P<0.05),the logHF were increased significantly in group PP at T_(2) and T_(4)(P<0.05),the Ramsay sedative evaluation was increased significantly,the dosage of remifentanil was significantly reduced during the maintenance of anesthesia in group PP(P<0.05).Conclusion After the use of dexmedetomidine,the indicators related to stress level in HRV analysis were significantly reduced,and the dosage of opioids was significantly reduced.The use of dexmedetomidine pre-nasal spray combined with pump injection can further reduce the dosage of opioids during the anesthesia maintenance phase.