伍金紅　周曉潔　賈繼娥

(復(fù)旦大學(xué)附屬眼耳鼻喉科醫(yī)院麻醉科　上海　200031)

小劑量司可林復(fù)合瑞芬太尼用于支撐喉鏡下喉顯微手術(shù)的效果分析

伍金紅周曉潔賈繼娥△

(復(fù)旦大學(xué)附屬眼耳鼻喉科醫(yī)院麻醉科上海200031)

【摘要】目的評(píng)估小劑量司可林復(fù)合瑞芬太尼用于顯微喉鏡的有效性及優(yōu)越性。方法選擇年齡18～60歲,ASAⅠ～Ⅱ級(jí),2015年1至5月?lián)衿谛兄魏礴R下喉顯微手術(shù)患者167例。隨機(jī)分為3組:司可林0.6 mg/kg組(A組),司可林1 mg/kg組(B組),司可林0.6 mg/kg復(fù)合瑞芬太尼1.5 μg/kg組(R組)。采集患者基礎(chǔ)、誘導(dǎo)后、插管后即刻、懸吊喉鏡后即刻和拔管后即刻的心率、血壓;記錄誘導(dǎo)后肌顫、聲門開放情況、術(shù)中是否需要追加肌松藥、術(shù)后肌痛和手術(shù)時(shí)間等,并進(jìn)行統(tǒng)計(jì)分析。結(jié)果3組患者均順利地實(shí)施了氣管插管、懸吊支撐喉鏡等操作,且3組患者在肌顫、聲門開放、追加肌松藥、術(shù)后肌痛和手術(shù)時(shí)間等方面無(wú)明顯差異。循環(huán)方面表現(xiàn)為:R組患者誘導(dǎo)后、插管后、懸吊支撐喉鏡及拔管后心率和血壓的波動(dòng)明顯小于A組(P<0.05);R組在誘導(dǎo)后的血壓和懸吊喉鏡后的心率波動(dòng)明顯小于B組(P<0.05)。結(jié)論小劑量司可林復(fù)合瑞芬太尼能夠很好地用于支撐喉鏡下喉顯微手術(shù),且循環(huán)波動(dòng)小,對(duì)肌顫及術(shù)后肌痛無(wú)影響。

【關(guān)鍵詞】司可林;瑞芬太尼;顯微喉鏡;肌顫;術(shù)后肌痛

司可林是筒箭毒堿合成代用品,肌肉松弛作用快,持續(xù)時(shí)間短,易于控制。但在臨床實(shí)踐中,司可林引起肌顫、肌痛及眼內(nèi)壓升高等不良反應(yīng)突出,隨著近年來(lái)非去極化肌松藥相繼問(wèn)世,如快速起效的羅庫(kù)溴銨以及作用時(shí)間短暫的米庫(kù)氯銨等,司可林在臨床的應(yīng)用逐漸減少。但對(duì)于懷疑有困難氣道或需要快速誘導(dǎo)的飽胃患者來(lái)說(shuō),臨床上仍首選司可林[1],因?yàn)樗究闪植粌H作用時(shí)間短且肌松完全。對(duì)于高要求的支撐喉鏡下的喉顯微手術(shù),司可林仍是這類手術(shù)的首選肌松藥物。為了減少司可林相關(guān)的并發(fā)癥,2013年肌肉松弛藥合理應(yīng)用的專家共識(shí)提出預(yù)先注射小劑量非去極化肌松藥以減少司可林相關(guān)并發(fā)癥[2],但其可能導(dǎo)致自主呼吸恢復(fù)慢而影響快速拔管。司可林作為急救及短小手術(shù)快速插管的常用藥物,其95%有效劑量(effective dose 95%,ED95)為0.3 mg/kg,而專家共識(shí)建議的插管劑量為1～1.5 mg/kg。司可林隨著劑量的增加,肌顫及術(shù)后肌痛發(fā)生率增加;作用時(shí)間延長(zhǎng),自主呼吸恢復(fù)時(shí)間也相應(yīng)延長(zhǎng)。為了能夠讓使用司可林的困難氣道患者和孕婦等自主呼吸盡快恢復(fù),文獻(xiàn)報(bào)道0.6 mg/kg成功應(yīng)用于快速插管,并且與1 mg/kg司可林比較差異無(wú)統(tǒng)計(jì)學(xué)意義[3]。

瑞芬太尼是短效阿片受體激動(dòng)劑,起效快,作用時(shí)間短,抑制氣道及心血管反應(yīng)明顯[4]。有文獻(xiàn)報(bào)道4 μg/kg的瑞芬太尼用于無(wú)肌松插管可避免使用司可林引起的術(shù)后肌痛,但患者循環(huán)波動(dòng)明顯,且有部分患者氣管插管失敗[5]。對(duì)于支撐喉鏡下的喉顯微手術(shù),即使無(wú)肌松麻醉下氣管插管成功,也可能出現(xiàn)支撐喉鏡置入困難,或者聲門開放較差,進(jìn)而影響手術(shù)視野。且這類患者多數(shù)年齡較大,伴有牙齒松動(dòng)等不利條件,對(duì)肌松要求較高。也有研究顯示瑞芬太尼可以減少司可林引起的肌痛[6]。

為了減少使用常規(guī)劑量司可林引起的肌痛和肌顫,以及避免大劑量瑞芬太尼引起的循環(huán)波動(dòng),本研究探討了小劑量司可林復(fù)合瑞芬太尼用于支撐喉鏡下喉顯微手術(shù)的有效性和安全性。

資 料 和 方 法

研究對(duì)象經(jīng)復(fù)旦大學(xué)附屬眼耳鼻喉科醫(yī)院倫理委員會(huì)批準(zhǔn)和患者知情同意后,選擇2015年1—5月?lián)衿谛酗@微喉鏡手術(shù)的患者167例,ASA分級(jí)為Ⅰ～Ⅱ級(jí),年齡18～60歲,并排除心肺疾病、頸椎病、關(guān)節(jié)炎、頭面部外傷及可疑困難氣道的患者。隨機(jī)分為3組:司可林0.6 mg/kg組(A組，52例),司可林1 mg/kg組(B組，53例);司可林0.6 mg/kg復(fù)合瑞芬太尼1.5 μg/kg組(R組，62例)。

麻醉方法和觀察指標(biāo)患者入室后常規(guī)行心電圖、無(wú)創(chuàng)血壓、脈搏氧飽和度等監(jiān)測(cè),記錄患者基礎(chǔ)生命體征。麻醉誘導(dǎo):異丙酚2～2.5 mg/kg,舒芬太尼0.3 μg/kg靜脈推注,司可林0.6 mg/kg(A組)或司可林1 mg/kg(B組)或司可林0.6 mg/kg復(fù)合瑞芬太尼1.5 μg/kg(R組)。七氟烷吸入麻醉維持麻醉深度在1.3 MAC。記錄患者基礎(chǔ)、誘導(dǎo)后、插管后即刻、懸吊喉鏡后即刻和拔管后即刻的心率(H0、H1、H2、H3和H4)、平均動(dòng)脈壓(P0、P1、P2、P3和P4)。誘導(dǎo)后的血壓和心率作為基礎(chǔ)值,誘導(dǎo)后、插管后、懸吊喉鏡后和拔管后血壓波動(dòng)計(jì)算分別為|P0-P1|*100/P0、|P2-P1|*100/P1、|P3-P1|*100/P1和|P4-P1|*100/P1,心率變化計(jì)算分別為|H0-H1|*100/H0、|H2-H1|*100/H1、|H3-H1|*100/H1和|H4-H1|*100/H1;記錄誘導(dǎo)后肌顫、支撐喉鏡置入后聲門松弛評(píng)級(jí)、術(shù)中是否需要追加肌松藥、術(shù)后肌痛和手術(shù)時(shí)間等[6]。聲門張合、肌顫及肌痛評(píng)分見表1。聲帶出現(xiàn)張合運(yùn)動(dòng)或閉合時(shí),則需追加司可林0.5 mg/kg并計(jì)1分,未追加使用肌松藥計(jì)0分。隨訪術(shù)后第1天患者的肌肉酸痛程度。

統(tǒng)計(jì)方法利用IBM SPSS 21軟件做統(tǒng)計(jì)分析,性別、聲門張合、肌顫、肌痛及是否追加肌松藥等資料采用確切概率法χ2檢驗(yàn),手術(shù)時(shí)間采用Bonferroni單因素方差分析,年齡、體重、血壓和心率變化值等連續(xù)變量資料采用獨(dú)立樣本t檢驗(yàn)。

結(jié)果

一般資料及聲門開放、肌顫和術(shù)后肌痛的比較患者在性別、年齡、BMI及手術(shù)時(shí)間等差異無(wú)統(tǒng)計(jì)學(xué)意義(表2)?；颊卟骞軛l件及聲門開放程度、肌顫、肌痛等差異也無(wú)統(tǒng)計(jì)學(xué)意義(表3)。

表1　聲門張合、肌顫及肌痛評(píng)分

表2　患者一般情況比較

No significant difference was found among the groups in clinical characteristics (P>0.05).A:Group of succinylcholine 0.6 mg/kg;

B:Group of succinylcholine 1 mg/kg;R:Group of succinylcholine 0.6 mg/kg in combination with remifentanil 1.5 μg/kg.

表3　聲門張合、追加肌松、肌顫及肌痛評(píng)分結(jié)果

No significant difference in vocal cords opening levels,succinylcholine added,muscle fasciculation and postoperative myalgia was found among the groups (P> 0.05).

循環(huán)波動(dòng)的比較誘導(dǎo)后、插管后、懸吊支撐喉鏡及拔管后心率和血壓波動(dòng)R組明顯小于A組(P<0.05),懸吊喉鏡時(shí)心率波動(dòng)極顯著小于A組(P<0.001);R組在誘導(dǎo)后血壓(P<0.001)和懸吊喉鏡心率波動(dòng)明顯小于B組(P<0.05);B組在拔管時(shí)血壓波動(dòng)小于A組(P<0.05)(表4)。

表4　不同時(shí)間點(diǎn)心率、血壓的平均值及組間比較

Data were collected at the time of before (0),after induction (1),after tracheal intubation (2),suspension laryngoscope (3)and after extubation(4).Fluctuation of heart rate (bpm) and blood pressure (mmHg,1 mmHg=0.133 kPa) in the patients in group R was less than group A at the serial times (P<0.05),heart rate ranged extremely smaller compared with group A at suspension laryngoscope (P<0.001);Blood pressure after induction (P<0.001) and at suspension laryngoscope (P<0.05) in group R was lower compared with group B;Blood pressure ranged slightly in group B compared with group A at extubation (P<0.05).No other significant difference was found between Avs.B,Avs.R or Bvs.R (Pvalue was blank in the tab).

討論

顯微喉鏡手術(shù)屬于短小手術(shù),氣管插管和懸吊喉鏡刺激非常強(qiáng)烈,患者往往出現(xiàn)明顯的血壓升高和心動(dòng)過(guò)緩,甚至有少數(shù)患者會(huì)發(fā)生心跳驟停,因此為了抑制手術(shù)刺激,必須選擇合適的藥物并控制好麻醉深度,同時(shí)又不影響患者的快速蘇醒。本研究將小劑量司可林復(fù)合瑞芬太尼用于支撐喉鏡下喉顯微手術(shù)以達(dá)到插管和支撐喉鏡置入的肌松要求,且循環(huán)波動(dòng)小,臨床效果滿意。而單純使用0.6 mg/kg司可林雖能達(dá)到肌松要求,但是循環(huán)波動(dòng)明顯,插管和置入喉鏡時(shí)血壓升高、心率顯著降低;增加司可林用量到1 mg/kg ,行聲門暴露和支撐喉鏡置入時(shí)較單純使用0.6 mg/kg司可林無(wú)顯著改善,只是在拔管時(shí)循環(huán)波動(dòng)稍有降低。

司可林屬于去極化肌松藥,起效快、持續(xù)時(shí)間短,用于困難氣道、飽胃和快速自主呼吸恢復(fù)具有不可替代的優(yōu)勢(shì)。然而,由于其肌痛、肌顫和血鉀升高等不良反應(yīng),麻醉醫(yī)師不斷探索其有效的低劑量用藥方案,同時(shí)應(yīng)用低劑量司可林后為困難插管的患者提供了盡可能短的自主呼吸恢復(fù)時(shí)間。文獻(xiàn)報(bào)道注射0.56(0.43～0.73)mg/kg司可林60 s后約95% 的患者達(dá)到了滿意的氣管插管條件[7]。另一項(xiàng)研究顯示沒有必要增加司可林劑量到1.5 mg/kg以上即可達(dá)到良好的插管條件, 并且增加司可林劑量只會(huì)延長(zhǎng)呼吸暫停時(shí)間,并不會(huì)改善插管條件[8]。本研究A組和R組共115例患者均采用0.6 mg/kg司可林用于氣管插管和支撐喉鏡置入,未見插管和置入失敗。并且應(yīng)用0.6與1 mg/kg司可林插管時(shí)聲門暴露情況間差異無(wú)統(tǒng)計(jì)學(xué)意義。術(shù)后肌痛評(píng)分3組患者無(wú)顯著差異。但是本研究主要依據(jù)患者的主訴,并未檢測(cè)肌細(xì)胞相關(guān)酶及血清鉀等，無(wú)血清學(xué)數(shù)據(jù),因此存在一定的研究缺陷。

瑞芬太尼起效快、作用時(shí)間短,協(xié)助用于氣管插管,可以顯著減弱插管引起的血流動(dòng)力學(xué)劇烈波動(dòng)[9];有文獻(xiàn)報(bào)道瑞芬太尼的應(yīng)用也可以減少器質(zhì)性心臟疾病和先兆子患者誘導(dǎo)插管的循環(huán)波動(dòng)[10]。單純使用大劑量瑞芬太尼且不使用肌松藥可以滿足插管條件,但是容易出現(xiàn)明顯的低血壓,且明顯延長(zhǎng)呼吸暫停時(shí)間,因此本研究通過(guò)兩種藥物聯(lián)合使用并減小劑量，既滿足了插管條件又減少了藥物單獨(dú)應(yīng)用后所導(dǎo)致的不良反應(yīng)。

0.6 mg/kg司可林復(fù)合1.5 μg/kg瑞芬太尼用于支持喉鏡下喉顯微手術(shù),肌松條件良好且心血管反應(yīng)小,是臨床上一種安全有效的方法。

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The effects of a low dose of succinylcholine in combination with remifentanil for suspension microlaryngoscopy

WU Jin-hong, ZHOU Xiao-jie, JIA Ji-e△

(DepartmentofAnesthesiology,EyeandENTHospital,FudanUniversity,Shanghai200031,China)

【Abstract】ObjectiveTo evaluate the effects and superiority of a low dose of succinylcholine in combination with remifentanil for suspension microlaryngoscopy.MethodsA total of 167 patients of 18-60 years old and ASAⅠ-Ⅱ undergoing selective suspension microlaryngoscopy from Jan.to May in 2015 were enrolled .The patients were randomly divided into 3 groups:succinylcholine 0.6 mg/kg group (group A),succinylcholine 1 mg/kg group (group B),succinylcholine 0.6 mg/kg in combination with remifentanil 1.5 μg/kg group (group R).Heart rate and blood pressure were collected at the time points of before and after induction,after tracheal intubation,suspensing laryngoscope and after extubation.Muscle fasciculation during induction,vocal cords opening levels,succinylcholine added or not during the operation,postoperative myalgia and operation time were recorded.All the data were analyzed by statistical software.ResultsAll the 3 groups of patients were successfully undertaken trachea ntubation and suspension laryngoscope.There was no significance in muscle fasciculation,vocal cords opening levels,succinylcholine added during the operation,postoperative myalgia and operation time.On circulatory performance, fluctuation of heart rate and blood pressure in the patients in group R was less than group A (P<0.05)at the time points of after induction,after intubation,suspension laryngoscope and extubation,and also less than group B after induction (P<0.05).ConclusionsA low dose of succinylcholine in combination with remifentanil was effective in suspension microlaryngoscopy and superiority in stablity of circulation without muscle fasciculation and postoperative myalgia.

【Key words】succinylcholine;remifentanil;microlaryngoscope;muscle fasciculation;postoperative myalgia

【中圖分類號(hào)】R762

【文獻(xiàn)標(biāo)識(shí)碼】A

doi:10.3969/j.issn.1672-8467.2016.03.011

(收稿日期:2015-12-22;編輯:張秀峰)

△Corresponding authorE-mail:jiajie@eentanesthesia.com