静脉输注右美托咪定联合靶控输注瑞芬太尼在老年患者ERCP麻醉中的临床应用

Clinical application of intravenous dexmedetomidine combined with target-controlled remifentanil in anesthesia of ERCP surgery in older adult patients

目的探讨静脉输注右美托咪定(Dex)联合靶控输注瑞芬太尼在老年患者经内镜逆行胰胆管造影术(ERCP)麻醉中的安全性及可行性。方法选择2021年1月至8月择期监测麻醉(MAC)下行ERCP的老年患者(年龄≥65岁)98例,随机分为丙泊酚-瑞芬太尼(TRP)组和Dex-瑞芬太尼(TRD)组。TRP组患者麻醉采用靶控输注丙泊酚-瑞芬太尼,TRD组患者麻醉采用静脉输注Dex联合靶控输注瑞芬太尼,2组均采用非气管插管的MAC麻醉。观察并记录患者在麻醉诱导前(T0)、麻醉诱导后即刻(T_(1))、进镜时(T_(2))、十二指肠乳头插管时(T_(3))、退镜时(T_(4))、留置鼻胆管结束时(T_(5))平均动脉压(MAP)、心率(HR)、脉博氧饱和度(SpO_(2))、呼吸频率(RR)、脑电双频指数(BIS)。于不同时点(术前、麻醉诱导后每隔15 min和苏醒即刻)采动脉血行血气分析,记录动脉血氧分压(PaO_(2))、动脉二氧化碳分压(PaCO_(2))、瑞芬太尼靶控输注浓度、手术时间、苏醒时间(停止输注瑞芬太尼至意识恢复时间)、麻醉恢复时间(意识恢复至离开手术室时间)、术中体动、离室Aldrete评分、术后60 min VAS评分、术后不良反应,以及麻醉医生、内镜医生和患者的满意度。结果2组患者的年龄、性别、BMI、ASA分级等一般资料均无统计学差异(P>0.05)。与TRP组比较,TRD组MAP在T_(1)和T_(3)时点增高(P<0.05),HR在T_(1)、T_(2)、T_(3)、T_(4)时点降低,SpO_(2)、RR在T_(1)、T_(2)、T_(3)、T_(4)时点增高,BIS在T_(2)、T_(3)、T_(4)、T_(5)时点增高,托下颌次数和低氧血症发生率降低,离室Aldrete评分增高,术后60 min VAS评分降低,麻醉医生、内镜医生及患者满意度增高,差异均有统计学意义(均P<0.05)。2组患者各时点PaO_(2)、PaCO_(2)、靶控输注瑞芬太尼浓度、手术时间、苏醒时间、麻醉恢复时间、术后不良反应发生率无统计学差异。结论与靶控输注丙泊酚-瑞芬太尼相比,静脉输注Dex联合靶控输注瑞芬太尼可降低老年患者在ERCP手术中低氧血症的发生率,麻醉方案能够满足ERCP手术的麻醉需求,安全可行。

Objective To explore the safety and feasibility of intravenous dexmedetomidine(Dex)combined with targeted infusion of remifentanil in endoscopic retrograde cholangiopancreatography(ERCP)anesthesia in older adult patients.Methods From January to August 2021,98 older adult patients(≥65 years old)undergoing ERCP were randomly divided into TRP and TRD groups.The TRP group was anesthetized with target-controlled infusion of propofol and remifentanil and the TRD group was treated with Dex combined with target-controlled infusion of remifentanil.mean arterial pressure(MAP),heart rate(HR),electrocardiogram(ECG),respiratory rate(RR),pulse oxygen saturation(SpO_(2)),bispectral index(BIS)before anesthesia induction(T0),immediately after induction of anesthesia(T_(1)),endoscopic introduction(T_(2)),duodenal papilla intubation(T_(3)),endoscopy withdrawal(T_(4))and postoperative awakening(T_(5))were observed.Arterial blood gas analysis at different time points(T0,every 15 min after anesthesia induction and T_(5)),PaO_(2),and PaCO_(2),were recorded at the above mentioned time points;and the remifentanil concentration in target-controlled infusion,operation time,recovery time(from infusion of remifentanil to consciousness recovery),anesthesia recovery time(from consciousness recovery to leaving the operating room),intraoperative body movement,Aldrete scores out of the room,Visual Analogue Scale(VAS)at 60 min after surgery,occurrence of postoperative adverse reactions,as well as the satisfaction of anesthesiologists,endoscopists,and patients were recorded.Results Compared with the TRP group,MAP at T_(1)and T_(3),SpO_(2)and RR at T_(1),T_(2),T_(3),and T_(4),and BIS at T_(2),T_(3),T_(4),and T_(5)increased,whereas HR at T_(1),T_(2),T_(3),and T_(4)decreased;the number of mandibular rests,incidence of hypoxemia,Aldrete score,and satisfaction increased,whereas the VAS score at 60 min after surgery decreased in the TRD group(P<0.05).There were no statistically significant differences in postoperative adverse reactions,PaO_(2)and PaCO_(2),target-controlled infusion remifentanil concentration,operation time,recovery time,and anesthesia recovery time between the two groups.Conclusion Compared with the target-controlled infusion of propofol-remifentanil,intravenous infusion of Dex combined with target-controlled infusion of remifentanil can reduce the incidence of hypoxemia in older adult patients during ERCP surgery,and the anesthesia regimen can meet the anesthesia needs of ERCP surgery,which is safe and feasible.