右美托咪定复合丙泊酚与瑞芬太尼麻醉在腹腔镜胆囊切除术中的效果及对患者血流动力学的影响

Effect of dexmedetomidine combined with propofol and remifentanil in anesthesia during LC and influ-ence on hemodynamics of patients

目的探究右美托咪定复合丙泊酚与瑞芬太尼麻醉在腹腔镜胆囊切除术(LC)中的效果及对患者血流动力学的影响。方法回顾性分析2019年1月至2023年6月于浙江省嘉善县中医医院行LC的146例患者临床资料,按照用药方法分为丙泊酚组(73例,单号)和复合组(73例,双号),均给予静脉全身麻醉,丙泊酚组麻醉诱导及麻醉维持期使用丙泊酚+瑞芬太尼,复合组在丙泊酚组基础上,于麻醉诱导前10~15 min静脉输注0.5μg/kg右美托咪定,后以维持剂量0.2~0.8μg·kg^(-1)·h^(-1)输注至手术结束前30 min,比较2组于麻醉诱导前、气道插管后、切除手术时、手术结束时的血流动力学指标[中心静脉压(CVP)、平均动脉压(MAP)、心率]变化,比较2组麻醉效果(麻醉持续时间、呼吸气管置留时间、自主呼吸恢复时间、意识恢复时间),术后1、4、8、12 h镇痛效果[疼痛视觉模拟评分(VAS)、Ramsay镇静评分],术前、术后24 h疼痛应激指标[C反应蛋白(CRP)、皮质醇(COR)、促肾上腺皮质激素(ACTH)、总胆汁酸(TBA)],记录不良反应情况。结果MAP、CVP、心率不同组间、时间点及组间×时间点间比较,差异均有统计学意义(P<0.05),诱导前至切除时,MAP、CVP、心率丙泊酚组逐渐降低,至结束时有所升高(P<0.05),复合组切除时和结束时高于诱导前(P<0.05),其余时间点与诱导前差异无统计学意义(P>0.05),且复合组插管后MAP、CVP、心率分别为(88.3±4.0)mmHg、(0.77±0.15)kPa、(77.6±5.1)次/min和切除时(87.5±4.5)mmHg、(0.74±0.16)kPa、(76.8±5.1)次/min,高于丙泊酚组(85.8±3.2)mmHg、(0.71±0.18)kPa、(75.4±5.1)次/min和(83.3±2.6)mmHg、(0.61±0.16)kPa、(74.1±4.7)次/min(P<0.05);2组麻醉持续时间差异无统计学意义(P>0.05),复合组呼吸气管置留时间(5.5±1.1)min、自主呼吸恢复时间(4.9±1.1)min、意识恢复时间(6.0±1.1)min,低于丙泊酚组的(6.0±1.4)min、(5.3±1.3)min、(6.4±1.3)min(P<0.05);VAS评分、Ramsay镇静评分不同组间、时间点及组间×时间点间比较,差异均有统计学意义(P<0.05),术后1~8 h,2组VAS评分逐渐升高,至术后12 h有所降低(P<0.05),Ramsay评分术后1~8 h逐渐降低,术后12 h有所提升(P<0.05),且复合组术后1~12 h的VAS评分分别为(2.4±0.5)、(3.1±0.5)、(3.8±0.6)、(3.5±0.6),低于丙泊酚组的(2.5±0.6)、(3.5±0.6)、(4.2±0.6)、(3.9±0.6)(P<0.05),Ramsay镇静评分分别为(4.1±0.6)、(3.6±0.5)、(2.9±0.5)、(3.4±0.4),均高于丙泊酚组(3.9±0.5)、(3.4±0.5)、(2.7±0.5)、(3.2±0.4)(P<0.05);术后24 h,2组CRP、COR、ACTH、TBA均显著升高(P<0.05),复合组分别为(48.7±5.8)mg/L、(246.4±22.1)nmol/L、(89.7±6.5)pg/ml、(15.3±2.9)μmol/L,低于丙泊酚组(52.6±5.6)mg/L、(258.6±23.5)nmol/L、(93.8±6.3)pg/ml、(16.6±3.1)μmol/L(P<0.05);复合组麻醉相关不良反应9.6%与丙泊酚组的6.8%比较差异无统计学意义(χ^(2)=0.468,P>0.05)。结论右美托咪定复合丙泊酚与瑞芬太尼应用于LC术中麻醉效果良好,对患者血流动力学干扰较小,镇痛镇静效果更佳,安全性高,值得推荐。

Objective To explore the effect of dexmedetomidine combined with propofol and remifentanil in anesthesia during laparoscopic cholecystectomy(LC)and its influence on hemodynamics of patients.Methods A total of 146 patients who underwent LC in Jiashan Country Traclitional Chinese Medicine Hospital from January 2019 to June 2023 were selected as the study subjects.They were divided into two groups:the propofol group(n=73)and the combined group(n=73)according to treatment method.Both groups were intravenously induced general anesthesia.The control group was given propofol and remifentanil during anesthesia induction and anesthesia maintenance.On the basis of anesthesia in the control group,the combined group was intravenously infused with 0.5μg/kg dexmedetomidine at 10~15 min before anesthesia induction and then was infused with a maintenance dose of 0.2~0.8μg·kg^(-1)·h^(-1)until 30 min before the end of surgery.Compared the hemodynamic indicators[central venous pressure(CVP),mean arterial pressure(MAP),heart rate(HR)]in these two groups before the anesthesia induction,after the intubation,during the resection and at the end of surgery,and compared the anesthetic effect(anesthesia duration,extubation time,time of spontaneous breathing recovery,time of recovering consciousness),analgesic effect[Visual Analogue Scale(VAS),sedation(Ramsay sedation score)]at 1 hour,4 hours,8 hours and 12 hours after surgery in the two groups.Also compared the pain stress indicators[C-reactive protein(CRP),cortisol(COR),adrenocorticotropic hormone(ACTH),total bile acid(TBA)]before surgery and at 24 hours after surgery between the two groups.The adverse reactions were recorded.Results MAP,CVP,and HR were compared between groups,at time points,and interaction of between-group×time-point,and the differences were statistically significant(P<0.05).From anesthesia induction to the resection,MAP,CVP and HR in propofol group gradually decreased and increased at the end of surgery(P<0.05).MAP,CVP and HR in the combined group were significantly higher than those before induction and at the end of surgery during resection(P<0.05),and there was no significant difference between the other time points or before anesthesia induction(P>0.05).MAP,CVP and HR in combined group after intubation were(88.2±4.0)mmHg,(0.77±0.15)kPa,(77.6±5.1)times/min and the indicators during the resection were(87.5±4.5)mmHg,(0.74±0.16)kPa,(76.8±5.1)times/min,which were significantly higher than those in propofol group[(85.8±3.2)mmHg,(0.71±0.18)kPa,(75.4±5.1)times/min and(83.3±2.6)mmHg,(0.6±0.16)Kpa,(74.1±4.7)times/min](P<0.05).There was no significant difference in the anesthesia duration between the two groups(P>0.05).The time from the end of surgery to extubation,time of spontaneous breathing recovery,and time of recovering consciousness in the combined group were(5.5±1.1)min,(4.9±1.1)min,and(6.0±1.1)min,which were significantly shorter than those in propofol group[(6.0±1.4)min,(5.3±1.3)min and(6.4±1.3)min](P<0.05).VAS score and Ramsay sedation score were compared between groups,at time points,and between groups×time points,and the differences were statistically significant(P<0.05).The VAS score in the two groups gradually increased at 1~8 hours after surgery,and decreased at 12 h after surgery(P<0.05)while the Ramsay score gradually decreased at 1~8 hours after surgery and increased at 12 h after surgery(P<0.05).In the combined group,the VAS score at 1~12 hours after surgery were(2.4±0.5),(3.1±0.5),(3.8±0.6),and(3.5±0.6),which were significantly lower than that in propofol group[(2.5±0.6),(3.5±0.6),(4.2±0.6)and(3.9±0.6)](P<0.05).In comparison,the Ramsay sedation score were(4.1±0.6),(3.6±0.5),(2.9±0.5),and(3.4±0.4),which were significantly higher than that in propofol group[(3.9±0.5),(3.4±0.5),(2.7±0.5)and(3.2±0.4)](P<0.05).CRP,COR,ACTH,and TBA were significantly raised in both groups at 24 hours after surgery(P<0.05).CRP,COR,ACTH,and TBA in compound group were(48.7±5.8)mg/L,(246.4±22.1)nmol/L,(89.7±6.5)pg/ml and(15.3±2.9)μmol/L,which were significantly lower than those in propofol group at 24 hours after surgery[(52.6±5.6)mg/L,(258.6±23.5)nmol/L,(93.8±6.3)pg/ml and(16.6±3.1)μmol/L](P<0.05).The incidence of anaesthesia related adverse reactions was 9.6%in the combined group and 6.8%in the propofol group,with no significant difference between the two groups.(χ^(2)=0.468,P>0.05).Conclusion Dexmedetomidine combined with propofol and remifentanil has a good anesthetic effect during LC surgery.This anesthesia method has little hemodynamics intervention,good analgesic and sedative effect,and high safety,which is worthy of recommendation.