基于生命体征胃肠激素认知功能分析脑电小波监测下右美托咪定在内镜逆行胰胆管造影中的应用

Application of dexmedetomidine in ERCP under EEG wavelet monitoring based on vital signs, gastrointestinal hormones and cognitive function

目的探究脑电小波监测下右美托咪定在内镜逆行胰胆管造影(ERCP)中应用效果,基于生命体征、胃肠激素、认知功能等分析其最佳剂量选择。方法选取2022年1月至2023年1月嘉兴市第二医院102例拟行ERCP患者,分为高剂量组(34例)、中剂量组(34例)、小剂量组(34例),分别给予1.0μg/kg、0.7μg/kg、0.5μg/kg右美托咪定。统计3组围术期[入室时(T1)、右美托咪定输注完成后(T2)、进镜后(T3)、退镜后(T4)、清醒离室时(T5)]平均动脉压(MAP)、心率、动脉血氧饱和度(SpO_(2))、局部脑氧饱和度(rSO_(2))与术后1 d Ramsay评分,比较不同时间(术前、术后1 d、5 d)胃肠激素[胃动素(MLT)、胃泌素(GAS)]与心功能[肌钙蛋白I(cTnI)、肌酸激酶同工酶(CK-MB)],比较3组认知功能障碍发生率、病情相关指标及不良反应。结果T2、T3、T4时3组MAP、心率、rSO_(2)存在明显差异,且中剂量组各指标波动幅度小于小剂量组、高剂量组[T2时MAP:(80.8±6.6)mmHg、(86.6±6.9)mmHg、(81.1±5.6)mmHg;T2时心率:(66.6±4.5)次/min、(75.7±5.1)次/min、(66.2±5.8)次/min;T2时rSO_(2):(60.2±4.1)%、(68.5±4.7)%、(62.5±4.6)%](F=8.817、36.960、30.795)、[T3时MAP:(82.5±5.6)mmHg、(85.9±6.1)mmHg、(83.8±4.5)mmHg;T3时心率:(64.5±4.9)次/min、(75.1±4.8)次/min、(64.2±5.4)次/min;T3时rSO_(2):(61.6±4.5)%、(67.7±5.0)%、(62.2±4.6)%](F=3.311、51.809、17.454)、[T4时MAP:(70.7±4.1)mmHg、(82.6±4.8)mmHg、(74.6±5.6)mmHg;T4时心率:(67.7±5.3)次/min、(74.8±4.5)次/min、(68.1±4.7)次/min;T4时rSO_(2):(63.5±4.9)%、(68.0±5.1)%、(64.4±5.6)%](F=53.271、22.773、7.240)(P<0.05);术后1 d时,3组Ramsay评分比较差异均无统计学意义(U=1.909,P=0.591);术后1 d时3组血清MLT、GAS水平高于术前,且高剂量组血清MLT、GAS水平[(334±51)pg/ml、(29±5)pg/ml]低于中剂量组[(401±83)pg/ml、(32±5)pg/ml]和小剂量组[(471±96)pg/ml、(39±6)pg/ml](F=25.395、32.646,P<0.01);术后1 d时3组血清c TnI、CK-MB水平高于术前,且高剂量组[(0.35±0.04)μg/L、(13.72±2.15)U/L]低于中剂量组[(0.41±0.07)μg/L、(16.65±2.53)U/L]和小剂量组[(0.49±0.06)μg/L、(20.24±3.31)U/L](F=49.822、49.488,P<0.01);3组间躁动、谵妄、心动过缓发生率及术后5 d认知功能障碍发生率比较差异无统计学意义(χ^(2)=3.872,P=0.144);中、高剂量组丙泊酚用量[(260±60)mg、(252±57)mg]低于小剂量组[(287±64)mg],小、中剂量组恶心呕吐发生率[3%、6%]低于高剂量组(29%)(χ^(2)=12.871,P=0.002)。结论脑电小波监测下中高剂量右美托咪定在ERCP应用效果良好,可减轻围术期血流动力学、波动,保护患者心脏及胃肠道功能,减少丙泊酚用量,不增加躁动反应,而高剂量易增加恶心呕吐情况,可为临床实际应用提供参考。

Objective To explore the application effect of dexmedetomidine under EEG wavelet monitor-ing in endoscopic retrograde cholangiopancreatography(ERCP),and analyze the optimal dose selection based on vital signs,gastrointestinal hormones,cognitive function and other aspects.Methods A total of 102 patients with ERCP in our hospital from January 2022 to January 2023 were selected and divided into high-dose group(n=34),medium-dose group (n=34) and low-dose group (n=34) by randomized numerical table method, and were given 1.0 μg/kg, 0.7 μg/kg and 0.5 μg/kg dexmedetomidine, respectively. The perioperative mean arterial pressure (MAP), heart rate (HR), arterial oxygen saturation (SpO_(2)), local cerebral oxygen saturation (rSO_(2)) and Ramsay score 1 day after surgery were analyzed in the three groups [at entry (T1), after dexmedetomide infusion (T2), after admission (T3), after exit (T4), after exit (T5)] were counted. Gastrointestinal hormones [MLT, gastrin (GAS)] and cardiac function [troponin I (cTnI), myokinase isoenzyme (CK-MB)] were compared at different times (preoperative, post-operative 1 and 5 days), and the incidence of cognitive dysfunction, disease-related indexes and adverse reactions were compared among the three groups. Results There were significant differences in MAP, HR and rSO_(2) among the three groups at T2, T3 and T4, and the fluctuation range of each index in the medium-dose group was smaller than that in the low-dose group and high-dose group [MAP at T2: (80.8±6.6) mmHg, (86.6±6.9) mmHg, (81.1±5.6) mmHg;HR at T2: (66.6±4.5) times /min, (75.7±5.1) times /min, (66.2±5.8) times /min;rSO_(2) at T2: (60.2±4.1) %, (68.5±4.7) %, (62.5±4.6) %] (F=8.817, 36.960, 30.795), [T3 MAP: (82.5±5.6) mmHg, (85.9±6.1)mmHg, (83.8±4.5) mmHg;HR at T3: (64.5±4.9) times /min, (75.1±4.8) times /min, (64.2±5.4) times /min;rSO_(2) at T3: (61.6±4.5) %, (67.7±5.0) %, (62.2±4.6) %] (F=3.311, 51.809, 17.454), [T4 MAP: (70.7±4.1) mmHg, (82.6±4.8) mmHg, (74.6±5.6) mmHg;HR at T4: (67.7±5.3) times/min, (74.8±4.5) times /min, (68.1±4.7) times /min;rSO_(2) at T4: (63.5±4.9) %, (68.0±5.1) %, (64.4±5.6) %] (F=53.271, 22.773, 7.240) (P<0.05);At 1 day after surgery, there was no signifi-cant difference in the comparison of Ramsay scores among the 3 groups (U=1.909,P=0.591). The levels of serum MLT and GAS in 3 groups were higher than preoperative levels in the three groups at 1 d postoperatively. More-over, serum MLT and GAS levels in high-dose group [(334±51) pg/ml, (29±5) pg/ml] lower than medium dose group [(401±83) pg/ml, (32±5) pg/ml] lower than low-dose group [(471±96) pg/ml, (39±6) pg/ml] (F=25.395, 32.646, P<0.01). The levels of serum cTnI and CK-MB in three groups were higher than those before surgery in the three groups at 1 d postoperatively, and the high-dose group [(0.35±0.04) μg/L, (13.72±2.15) U/L] < the medi-um-dose group [(0.41±0.07) μg/L, (16.65±2.53) U/L] < the low-dose group [(0.49±0.06) μg/L, (20.24±3.31) U/L] (F=49.822, 49.488, P< 0.01). Serum cTnI and CK-MB levels of three groups at 1 d after surgery were higher than that before surgery, and high-dose groups were more sensitive to the effects of the high dose of cTnI and CK-MB. There were no significant differences in the incidence of agitation, delirium, bradycardia and cognitive dysfunc-tion 5 days after surgery among the three groups ( χ^(2)=3.872, P=0.144). The dosage of propofol in medium and high dose groups [(260±60) mg, (252±57) mg] was lower than that in small dose group [(287±64) mg]. The inci-dence of nausea and vomiting in small and medium dose groups [3%, 6%] was lower than that in high dose group [29%] ( χ^(2)=12.871, P=0.002). Conclusion The application of middle and high dose dexmedetomidine in ERCP under EEG wavelet monitoring has good effect, which can reduce perioperative hemodynamics and fluc-tuations, protect the cardiac and gastroin-testinal functions of patients, reduce the dosage of propofol, and do not increase agitation reaction, while high dose can easily increase nausea and vomiting, which can provide reference for clini-cal practical application.