右美托嘧啶預(yù)防七氟醚吸入全麻下老年患者胃腸腫瘤術(shù)后寒戰(zhàn)的臨床效果

廖瑞哲 馮宇峰 孫彩虹

右美托嘧啶預(yù)防七氟醚吸入全麻下老年患者胃腸腫瘤術(shù)后寒戰(zhàn)的臨床效果

廖瑞哲 馮宇峰 孫彩虹

目的 探討右美托嘧啶(dexmedetomidine, Dex)用于七氟醚吸人全麻下老年胃腸腫瘤患者術(shù)后蘇醒期預(yù)防寒戰(zhàn)的效果與安全性。方法 選擇60例2011年06月~2012年05月在本院行胃腸腫瘤手術(shù)ASA I~Ⅱ級老年患者, 隨機均分為I組 (Dex, n=30)和Ⅱ組(生理鹽水, n=30)。兩組麻醉誘導(dǎo)方法相同, 插管成功后進行間歇正壓通氣；術(shù)中吸人七氟醚至縫合皮膚前30min。I組氣管插管后靜脈輸注Dex 0.5 μg·kg-1·h-1至關(guān)腹前1 h停藥；Ⅱ組則靜脈輸注等容量生理鹽水。觀察記錄兩組麻醉時間、拔管時間、術(shù)中腹腔沖洗量、輸液量、七氟醚用量、阿托品使用率、患者在PACU1 h內(nèi)意識狀態(tài)和寒戰(zhàn)發(fā)生情況。結(jié)果 兩組患者麻醉時間、拔管時間、術(shù)中腹腔沖洗量及輸液量差異無統(tǒng)計學(xué)意義。I組術(shù)中七氟醚用量、寒戰(zhàn)發(fā)生率明顯低于Ⅱ組 (P＜0.05)。I組阿托品使用率和安靜入睡者顯著高于Ⅱ組(P＜0.01)。結(jié)論 Dex可安全靜脈泵注用于七氟醚吸入全麻老年胃腸腫瘤手術(shù)患者, 能有效地預(yù)防術(shù)后發(fā)生寒戰(zhàn), 不影響蘇醒及拔管時間。

右美托咪定；七氟醚；寒戰(zhàn)；麻醉, 全身；老年患者；胃腸腫瘤

麻醉后發(fā)生寒戰(zhàn)較為常見, 其發(fā)生率為6.3%~66%, 可引起患者機體耗氧明顯增加, 對缺氧的耐受性降低, 增加患者蘇醒期的風(fēng)險。右美托嘧啶(Dexmedetomidine, Dex)是一種新型的強效高選擇性α2-腎上腺素受體(α2-AR)激動劑, 具有較強的鎮(zhèn)靜、鎮(zhèn)痛、抗焦慮、抑制交感神經(jīng)系統(tǒng)活動等作用,目前廣泛用于全身麻醉。筆者將Dex用于吸入全麻下胃腸腫瘤手術(shù)的老年患者, 旨在評價Dex在此類手術(shù)后蘇醒期間預(yù)防老年患者寒戰(zhàn)的效果。現(xiàn)報告如下。

1 資料與方法

1.1 一般資料 選擇2011年06月~2012年05月60例男36例, 女24例, ASAⅠ~Ⅱ級, 年齡60~77歲, 體重52~77 kg, 身高 156~174 cm, 擬在七氟醚吸入全麻下行胃腸腫瘤根治術(shù)老年患者, 其中結(jié)腸癌23例, 胃癌20例, 直腸癌17例；按隨機數(shù)字表法隨機分為Ⅰ組(Dex)和Ⅱ組(生理鹽水), 每組各30例。所有患者術(shù)前均無心動過緩、心臟傳導(dǎo)阻滯、嚴(yán)重心肺功能異常、嚴(yán)重貧血, 肝腎及神經(jīng)系統(tǒng)疾病。

1.2 麻醉方法 本研究經(jīng)過本院倫理委員會討論批準(zhǔn), 獲得患者及家屬書面知情同意并簽字。手術(shù)室溫度維持在23~25℃, 患者入室后建立靜脈通路輸液, 麻醉前30 min均靜注阿托品0.5 mg, 常規(guī)監(jiān)測SBP、DBP、HR、SpO2、ECG和PETCO2。麻醉誘導(dǎo)：靜注咪達唑侖0.1 mg/kg、順式阿曲庫銨0.2~0.3 mg/kg、芬太尼3~4 μg/kg及依托咪酯0.2 mg/kg, 待肌肉松弛插管成功后接麻醉機行間歇正壓通氣(IPPV), 設(shè)定潮氣量6~8 ml/kg, 通氣頻率 10~12次/min, 吸呼比1:2, 氧流量2 L/min, 吸氧濃度100 %, 維持PETCO235~40 mmHg。麻醉維持：微量泵靜注丙泊酚(Propofol, Pro.)4~8 mg·kg-1·h-1、瑞芬太尼4~8μg·kg-1·h-1、吸入2%~5 %七氟醚, 酌情靜脈注射順式阿曲庫銨維持麻醉。Ⅰ組在氣管插管后以0.5 μg·kg-1·h-1速率微量泵靜脈輸注Dex, 關(guān)腹前1h停止泵注。Ⅱ組則在相同時段內(nèi)靜脈輸注等容量生理鹽水。術(shù)中Bp低于基礎(chǔ)值30%者靜脈注射麻黃堿10 mg, HR<50次/min者靜脈注射阿托品0.5 mg, 術(shù)中輸液速率8~10 ml/kg, 關(guān)腹前用40~42℃無菌蒸餾水800~1000 ml沖洗腹腔。兩組患者縫合皮膚前30 min均停吸七氟醚。術(shù)畢帶氣管導(dǎo)管送恢復(fù)室(PACU)觀察,患者蘇醒后, 拔除導(dǎo)管, 生命體征平穩(wěn), 安全送回病房。

1.3 術(shù)中及在PACU觀察指標(biāo) ①記錄兩組手術(shù)時間、術(shù)中輸液量、腹腔沖洗量及拔管時間；②記錄兩組術(shù)中七氟醚用量及阿托品使用率；③記錄兩組患者蘇醒期 1 h內(nèi)意識狀態(tài)。④記錄兩組患者蘇醒期 1 h內(nèi)寒戰(zhàn)發(fā)生情況, 寒戰(zhàn)評價標(biāo)準(zhǔn)：0級, 無寒戰(zhàn)；l級, 面部或頸部輕微肌顫；2級, 一組以上肌群出現(xiàn)肌顫, 但未發(fā)生全身肌顫；3級, 全身的肌群均發(fā)生明顯的肌顫。

1.4 統(tǒng)計學(xué)方法 采用SPSS 13.0統(tǒng)計軟件進行統(tǒng)計學(xué)分析。所有計量資料以均數(shù)±標(biāo)準(zhǔn)差( x-±s)表示；組間計量資料比較采用t檢驗；計數(shù)資料以χ2檢驗；等級資料比較采用秩和檢驗。P＜0.05為差異有統(tǒng)計學(xué)意義。

2 結(jié)果

2.1 兩組患者麻醉時間、腹腔沖洗量、術(shù)中輸液量及拔管時間差異無統(tǒng)計學(xué)意義； Ⅰ組術(shù)中七氟醚明顯低于Ⅱ組(P＜0.05), Ⅰ組阿托品使用率明顯高于Ⅱ組 (P＜0.01), 見表1。

2.2 Ⅰ組蘇醒期安靜入睡明顯高于Ⅱ組, 差異有統(tǒng)計學(xué)意義(P＜0.05), 見表2。

2.3 Ⅰ組和Ⅱ組寒戰(zhàn)發(fā)生率分別為16.67%和73.33%, Ⅰ組寒戰(zhàn)發(fā)生率明顯低于Ⅱ組, 寒戰(zhàn)程度減輕 (P＜ 0.05), 見表3。

表1 兩組患者各項指標(biāo)比較( x-±s)

表2 兩組患者意識狀態(tài)比較［n (%)］

表3 兩組患者蘇醒期寒戰(zhàn)程度比較［n (%)］

3 討論

老年患者生理功能減退, 因患有胃腸腫瘤, 長期胃腸功能差消化不良, 術(shù)前禁食禁水、口服瀉藥、術(shù)中出血、腹腔臟器長時間暴露致水分丟失等引起血容量明顯不足, 術(shù)中需酌情擴容以維持血容量穩(wěn)定；而術(shù)中輸液輸血、手術(shù)室環(huán)境溫度低、腹腔液體沖洗使體熱丟失以及呼吸道排出揮發(fā)性麻醉藥帶走身體熱量, 易致深部體溫降低；抑制了體溫調(diào)節(jié)中樞, 降低寒戰(zhàn)的閾值和血管收縮閾值［1］導(dǎo)致術(shù)后寒戰(zhàn)。患者寒戰(zhàn)時可伴有HR增快, BP升高；肌肉顫抖導(dǎo)致心肌、機體耗氧明顯增加, 對缺氧的耐受性迅速降低, 這對老年患者尤其是合并有心肺功能下降的患者更為不利。因此, 預(yù)防麻醉術(shù)后寒戰(zhàn)對提高患者的安全性和舒適性都極為重要。

Dex有抑制寒戰(zhàn)作用［2］, 其分布半衰期約為6min, 消除半衰期約為2 h, 具有鎮(zhèn)靜鎮(zhèn)痛、交感神經(jīng)抑制等作用, 可減少術(shù)后躁動、寒戰(zhàn)、惡心嘔吐的發(fā)生［3］。文獻報道在手術(shù)時間<3 h的婦科腹腔鏡手術(shù)患者中, 以1 μg/kg負荷量泵注Dex, 再以0.5 μg·kg-1·h-1維持, 術(shù)后寒戰(zhàn)發(fā)生率明顯下降［4］。麻醉誘導(dǎo)前靶控輸注Dex(血漿靶濃度0.6 ng/ml), 可以使55~70歲的成年患者手術(shù)中七氟醚的用量降低17%［5］；本研究中Ⅰ組七氟醚吸入總量低于Ⅱ組(P＜0.05), 可以減少揮發(fā)性麻醉藥從機體排出后帶走的身體熱量。本組資料Ⅰ組寒戰(zhàn)發(fā)生率和寒戰(zhàn)發(fā)生程度均明顯低于Ⅱ組, 進一步說明Dex可以抑制體溫低所至的寒戰(zhàn)［6］, 對老年患者胃腸手術(shù)術(shù)后蘇醒期寒戰(zhàn)有明顯抑制作用。

Dex作用于中樞藍斑核α2-AR而發(fā)揮鎮(zhèn)靜催眠、抗焦慮作用［7］, 其產(chǎn)生的鎮(zhèn)靜效果與Pro相似, 當(dāng)兩者聯(lián)合使用時, Dex可明顯減少Pro的維持量, 使Pro的EC50由6.63 μg/ ml降至3.89 μg/ml［8］。本組資料中Ⅰ組患者蘇醒期安靜入睡的發(fā)生率明顯高于Ⅱ組；說明Dex的鎮(zhèn)靜催眠, 抗焦慮作用能明顯緩解老年患者術(shù)后緊張情緒和恐懼心理, 是其預(yù)防寒戰(zhàn)的另一作用機制。

另外, Dex通過激動中樞突觸后和交感神經(jīng)末梢的突觸前α2-AR, 抑制麻醉和手術(shù)操作引起的交感神經(jīng)發(fā)放沖動,使交感神經(jīng)張力和血漿兒茶酚胺濃度下降［9］；本研究中Ⅰ組阿托品使用率明顯高于Ⅱ組, 顯示Dex常見的不良反應(yīng)是心動過緩, 應(yīng)酌情對癥處理。

綜上所述, 老年胃腸腫瘤患者靜吸全麻維持期持續(xù)靜脈輸注Dex至關(guān)腹前1 h停止泵注, 能有效預(yù)防術(shù)后寒戰(zhàn)的發(fā)生, 不影響蘇醒及拔管時間, 但心動過緩的發(fā)生率高, 應(yīng)予以重視。

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Clinical efficiency of dexmedetomidine on prevention of the shiver during revival period of postoperative gastrointestinal tumors in old aged patients in general anesthesia with inhalation sevoflurane

LIAO Rui-zhe, FENG Yu-feng, SUN Cai-hong.
Department of Anesthesiology, The First Affiliated Hospital of Xiamen University, Xiamen 361003, China

Objective To investigate the clinical effects and safety of dexmedetomidine (Dex) on prevention of the shiver during revival period of postoperative gastrointestinal tumors in elderly patients in general anesthesia with inhalation sevoflurane．Methods 60 elective patients who were from Jun.2011 to May.2012 in our hospital, ASA grade I~II, undergoing gastrointestinal tumors surgery under general anesthesia were randomly allocated to two groups with 30 cases each.Group I (n=30)

Dex 0.5ug/kg and group II (n=30) received the same volume normal saline.The Methods of anesthesia introduction were the same and proceeded IPPV after intubation in two groups.Anesthesia maintains: the patients inhaled 2%~5% sevoflurane until before 30 min suture wound skin.The patients of group I after intubation were pumped Dex 0.5 μg·kg-1·h-1until before 1h suture abdomen skin and the patients of group Ⅱ were pumped the same volume normal saline at the same time.Anesthetic time、extubation time、wash volume in abdomen cavity、transfusion volume、sevoflurane dosage during operation、Atropine using rate、patients' consciousness in 1 hour and happened shiver circumstance during recovery room were observed and recorded.Results Anesthetic time、extubation time、wash volume in abdomen cavity and transfusion volume were not significantly different in the two groups(P＞0.05).Sevoflurane dosage and shiver occur rate in group I were found lower than that in group Ⅱ(P＜0.05).Atropine using rate and quiet fall asleep cases were found significantly higher in group I than those in groupⅡ(P＜0.01).Conclusion It is safety to pump intravenous injection Dex for gastrointestinal tumors surgery in old aged patients in general anesthesia with inhalation sevoflurane.It can be effective in preventing postoperative shivering.It does not delay revival time and extubation time.

Dexmedetomidine；Sevoflurane；Shiver；Anesthesia, General；Elderly patients；Gastrointestinal tumor

361003 廈門大學(xué)附屬第一醫(yī)院麻醉科

馮宇峰 E-mail: fengyufeng@hotmail.com