用不同浓度米库氯铵麻醉诱导对甲状腺手术患者术中肌电信号的影响

Effect of different concentrations of mⅣ acurium for anesthesia induction of signal under neural monitoring in patients undergoing thyroid surgery

目的评估喉返神经监测下甲状腺手术理想的米库氯铵麻醉诱导剂量。方法选取全身麻醉下该类型手术患者120例,美国麻醉医师协会分级Ⅰ或Ⅱ级。使用随机数生成器,随机分为四组,每组30例。实验患者麻醉诱导依次静脉给予咪唑安定0.05mg/kg、丙泊酚1.5mg/kg、依托咪酯0.2mg/kg、舒芬太尼0.5μg/kg;Ⅰ组患者未使用米库氯铵肌松药物,吸入地氟醚直至呼气末浓度达到1.5MAC后使用可视喉镜插入NIM管;Ⅱ组、Ⅲ组、Ⅳ组各自静脉注射米库氯铵0.08mg/kg、0.12mg/kg、0.16mg/kg,3min后利用可视喉镜插入喉返神经监测导管。术中利用地氟醚维持麻醉深度,MAC值维持在1.2-1.4之间,不追加任何肌肉松弛药物。收集麻醉诱导前1min、诱导后1min、插喉返神经监测管时、插入喉返神经监测管后1min、插入喉返神经监测管后5min的血压、心率;收集NIM管插管条件评分(Cooper评分);自麻醉诱导开始30min后,每隔5min采用神经肌电信号监测仪(Nerve Integrity Monitor3.0)收集神经肌电信号频率振幅数值,总计收集7次。结果除一例患者因声带息肉插管失败,其余患者全部一次性插管成功。Cooper评分:Ⅲ组、Ⅳ组数值明显高于Ⅰ、Ⅱ组(P<0.05);Ⅰ组与Ⅱ组之间差异对比无统计学意义(P>0.05),Ⅲ组、Ⅳ组之间差异对比无统计学意义(P>0.05);在插管瞬间Ⅰ、Ⅱ组血压、心率波动明显高于Ⅲ、Ⅳ组(P<0.05);神经肌电信号振幅值在各时点与Ⅰ、Ⅱ组相比较,Ⅲ组明显降低(P<0.05),但仍然满足术中喉返神经监测要求,Ⅳ组在30min、35min时点信号缺失,40min后各时点与Ⅲ组比较明显降低(P<0.05)。结论用0.12mg/kg的米库氯铵麻醉诱导对甲状腺手术能够提供比较满意的气管插管条件,无明显气管插管不良反应,同时满足术中神经监测要求,是神经监测甲状腺手术麻醉诱导的理想浓度。

Objective To evaluate the ideal anesthesia induction dose of micuronium bromide for thyroid surgery under the monitoring of recurrent laryngeal nerve.Methods a total of 120 patients with thyroid resection under neurologic monitoring under gennergal anesthesia were selected,ASAⅠorⅡ.Using a random number gennerator,the sample was randomly devided into four groups of 30 cases each.Experimental patient anesthesia was induced with midazolam0.05 mg/kg,propofol 1.5 mg/kg,etomidate 0.2 mg/kg,sulfentanil 0.5μg/kg for the four groups.groupⅠPatient did not use mivacurum,and were inhaled with desflurane until the expiration concentration reached 1.5 mac,the electromyographic endotracheal tube was intubated under glidescope after the end-tidal sevoflurane concentration reached 1.5 MAC.GroupⅡ,ⅢandⅣwas intravenously injected mivacurium 0.08 mg/kg,0.12 mg/kg,0.16 mg/kg later,the visual laingoscope was used to insert the recurrent larngeal nerve monitoring catheter.During the operation,deflurance was use to maintain the anesthesia depth,and anaintained between 1.2 and 1.4,and no muscle relaxants were added.Blood pressure and heart rate were recorded before and after induction,intubation immediately,1 min after intubation and 3 min after intubation.Cooper’s scores were also recorded.The nerve integrity Monitor 3.0 was used every 5 min to ceollect the frequency and amplitude values of the neuromyoeletric signals for totalof 7 times.Results All cases were successfully intubated once expect one patient who failed due to vocal polyp.Cooper’S score:groupⅢ,Ⅳare better than group I,Ⅱ(P<0.05);GroupⅠcompared with groupⅡhas no statistical significance(P>0.05),there was also no statistically significant difference in compared with groupⅢand groupⅣ(P>0.05).At intubation immediately,groupⅠ,Ⅱand groupⅢ,Ⅳcompared with the blood pressure,heart rate had significantly changes(P<0.05);Compared with group I and groupⅡ,the amplitude of neuromyoelectric signal significantly decreased in groupⅢat each time point(P<0.05),but the amplitude of neuromyoelectric signal could meet the monitoring requirements.The signal was absent at 30 min and 35 min in groupⅣ,and signal in each time point after 40 min significantly lower than groupⅢ(P<0.05).Conclusion 0.12 mg/kg of mivacurium for induction of thyroid surgery anesthesia can not only provide ideal conditions for endotracheal intubation without Obvious intubation response,but also meeting the requirements of intraoperative nerve monitoring,which is the appropriate dose for induction of anesthesia in this kind of surgery.