• 中国科技论文统计源期刊
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Volume 44 Issue 4
Apr.  2019
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Application value of intravenous nitroglycerin controlled hypotension in the gastroscopy of high risk population with hypertension

  • Received Date: 2017-10-10
    Accepted Date: 2018-03-14
  • ObjectiveTo investigate the application value of intravenous nitroglycerin controlled hypotension in the gastroscopy of high risk population with hypertension, and compare the effects between nitroglycerin and nifedipine by oral in controlling blood pressure.MethodsOne hundred and twenty hypertensive patients treated with electronic gastroscopy were randomly divided into the group A(treatment with nifedipine by oral), group B(treatment with nitroglycerin by oral), and group C(treatment with intravenous nitroglycerin).Forty healthy people were set as control group.The blood pressure, heart rate, ECG and incidence rate of adverse reactions in four groups were observed through the whole process of gastroscopy inspection.ResultsBefore inspection, the levels of systolic blood pressure and heart rate in group A and group B were higher than those in control group(P < 0.05 to P < 0.01).During the inspection, the levels of systolic and diastole pressure in group A and group B, and heart rate in group A were higher than those in group C and control group(P < 0.05 to P < 0.01).After inspection, the level of systolic pressure and heart rate in group A were higher than those in group C and control group(P < 0.05 to P < 0.01).The level of systolic pressure before inspection and heart rate after inspection in group C were higher than those in control group(P < 0.01 and P < 0.05), and the differences of other indexes between group C and control group were not statistically significant(P>0.05).Before and after inspection, the differences of the incidence rates of sinus tachycardia, ST change, ectopic heart rhythm and conduction block among three groups were not statistically significant(P>0.05).During the inspection, the differences of ST change and ectopic heart rhythm among three groups were statistically significant(P < 0.05).The differences of the incidence rates of adverse reactions among four groups were not statistically significant(P>0.05).ConclusionsIntravenous nitroglycerin is a safe method in controlling the blood pressure during gastroscopy, the effect of which is better than that of nifedipine and nitroglycerin by oral.
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  • [1] ROSS R, NEWTON JL.Heart rate and blood pressure changes during gastroscopy in healthy older subjects[J].Gerontology, 2004, 50(3):182. doi: 10.1159/000076778
    [2] WANG L, HORIUCHI I, MIKAMI Y, et al.Use of intra-arterial nitroglycerin during uterine artery embolization for severe postpartum hemorrhage with uterine artery vasospasm[J].Taiwan J Obstet Gynecol, 2015, 54(2):187. doi: 10.1016/j.tjog.2014.05.006
    [3] DHARMA S, KEDEV S, PATEL T, et al.A novel approach to reduce radial artery occlusion after transradial catheterization:postprocedural/prehemostasis intra-arterial nitroglycerin[J].Catheter Cardiovasc Interv, 2015, 85(5):818. doi: 10.1002/ccd.25661
    [4] SAND L, LUNDIN S, RIZELL M, et al.Nitroglycerine and patient position effect on central, hepatic and portal venous pressures during liver surgery[J].Acta Anaesthesiol Scand, 2014, 58(8):961. doi: 10.1111/aas.2014.58.issue-8
    [5] CLARK DR, TESSENEER S, TRIBBLE CG.Nitroglycerin and sodium nitroprusside:potential contributors to postoperative bleeding[J].Heart Surg Forum, 2012, 15(2):92. doi: 10.1532/HSF98.20111109
    [6] 周冬喜, 储静红, 刘华, 等.右美托咪定联合硝酸甘油在腰椎手术控制性降压中的应用[J].现代医药卫生, 2015, 31(5):668. doi: 10.3969/j.issn.1009-5519.2015.05.011
    [7] 王静, 陈卫刚, 田书信, 等.高血压患者行无痛胃镜与普通胃镜检查的安全性分析120例[J].世界华人消化杂志, 2015, 23(5):788.
    [8] GU Q, WU C, GU L, et al.Comparison of the cardiovascular impacts of transnasal versus transoral gastroscopy in the aged patients with or without hypertension[J].Hepatogastroenterology, 2009, 56(94/95):1562.
    [9] FUJITA R, KUMURA F.Arrythmias and ischemic changes of the heart induced by gastric endoscopic procedures[J].Am J Gastroenterol, 1975, 64(1):44.
    [10] EBI M, SHIMURA T, NISHIWAKI H, et al.Management of systolic blood pressure after endoscopic submucosal dissection is crucial for prevention of post-ESD gastric bleeding[J].Eur J Gastroenterol Hepatol, 2014, 26(5):504. doi: 10.1097/MEG.0000000000000072
    [11] 刘力生, 吴兆苏, 朱鼎良, 等.中国高血压防治指南2010版[J].中国医学前沿杂志, 2011, 3(5):42. doi: 10.3969/j.issn.1674-7372.2011.05.011
    [12] 李秋荣, 郭晓文.硝酸甘油复合瑞芬太尼用于鼻内镜手术控制性降压效果观察[J].中国药物与临床, 2014, 14(1):85.
    [13] 潘志强, 刘庆, 程璠, 等.硝酸甘油控制性降压在局部麻醉下三叉神经根减压术中的应用[J].临床合理用药杂志, 2013, 6(9):37. doi: 10.3969/j.issn.1674-3296.2013.09.026
    [14] 陈曦, 程广书, 范军铭.中西医结合诊疗方案治疗中青年2级高血压病的多中心随机对照试验[J].中国中西医结合杂志, 2015, 35(7):801.
    [15] 刘旭东, 付坚, 封木忠, 等.金匮肾气丸联合硝苯地平控释片治疗老年脾肾阳虚型高血压的效果观察[J].中国中药杂志, 2015, 40(24):4908.
    [16] MANZUR-VERASTEGUI S, MANDEVILLE PB, GORDILLO-MOSCOSO A, et al.Efficacy of nitroglycerine infusion versus sublingual nifedipine in severe pre-eclampsia:a randomized, triple-blind, controlled trial[J].Clin Exp Pharmacol Physiol, 2008, 35(5/6):580.
    [17] 何裕科.硝苯地平舌下含服与硝酸甘油静脉滴注治疗高血压急诊患者的疗效[J].中国医学创新, 2016, 13(3):51. doi: 10.3969/j.issn.1674-4985.2016.03.016
    [18] 李建辉, 陈韶景, 梁雁芬.硝酸甘油静脉滴注与硝苯地平舌下含服院前急救高血压急症的比较观察[J].广东医学院学报, 2014, 32(4):538. doi: 10.3969/j.issn.1005-4057.2014.04.052
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Application value of intravenous nitroglycerin controlled hypotension in the gastroscopy of high risk population with hypertension

  • Department of Gastroenterology, Tongling Municipal Hospital, Tongling Anhui 244000, China

Abstract: ObjectiveTo investigate the application value of intravenous nitroglycerin controlled hypotension in the gastroscopy of high risk population with hypertension, and compare the effects between nitroglycerin and nifedipine by oral in controlling blood pressure.MethodsOne hundred and twenty hypertensive patients treated with electronic gastroscopy were randomly divided into the group A(treatment with nifedipine by oral), group B(treatment with nitroglycerin by oral), and group C(treatment with intravenous nitroglycerin).Forty healthy people were set as control group.The blood pressure, heart rate, ECG and incidence rate of adverse reactions in four groups were observed through the whole process of gastroscopy inspection.ResultsBefore inspection, the levels of systolic blood pressure and heart rate in group A and group B were higher than those in control group(P < 0.05 to P < 0.01).During the inspection, the levels of systolic and diastole pressure in group A and group B, and heart rate in group A were higher than those in group C and control group(P < 0.05 to P < 0.01).After inspection, the level of systolic pressure and heart rate in group A were higher than those in group C and control group(P < 0.05 to P < 0.01).The level of systolic pressure before inspection and heart rate after inspection in group C were higher than those in control group(P < 0.01 and P < 0.05), and the differences of other indexes between group C and control group were not statistically significant(P>0.05).Before and after inspection, the differences of the incidence rates of sinus tachycardia, ST change, ectopic heart rhythm and conduction block among three groups were not statistically significant(P>0.05).During the inspection, the differences of ST change and ectopic heart rhythm among three groups were statistically significant(P < 0.05).The differences of the incidence rates of adverse reactions among four groups were not statistically significant(P>0.05).ConclusionsIntravenous nitroglycerin is a safe method in controlling the blood pressure during gastroscopy, the effect of which is better than that of nifedipine and nitroglycerin by oral.

  • 研究[1]显示,胃镜检查可明显影响病人的血压水平,以及诱发心律失常、心肌梗死、脑卒中等,大大增加检查的危险性,而高血压高危病人则面临更大的风险。硝酸甘油静脉滴注控制性降压效果明显[2-5],但目前国内外尚未有将静脉滴注硝酸甘油控制性降压应用于高血压高危病人胃镜检查的前瞻性研究。因此,本研究探讨静滴硝酸甘油控制性降压在高血压高危病人行胃镜检查时的保护作用,并与口服硝苯地平及硝酸甘油片降压的效果进行比较。现作报道。

1.   资料与方法
  • 选取2014年6月至2016年6月在我院行胃镜检查的门诊及住院的原发性高血压病人120例,依据最新的《中国高血压防治指南》中高血压分级及危险度分层,评估出高危病人,选取120例为研究对象。排除由于紧张导致的暂时性血压增高者;排除心力衰竭、心律失常、肺心病、急性上呼吸道感染等检查禁忌症病人。将符合要求的120例受检者随机分成3组,各40例。A组舌下含服硝苯地平片,B组舌下含服硝酸甘油片,C组静脉滴注硝酸甘油。另抽取同期血压正常的受检者40名作为对照组,对照组不使用降血压药。4组受检者性别和年龄均具有可比性,3组高血压病人用药前的血压、心率(HR)和血氧饱和度(SpO2)具有可比性。本研究经我院医学伦理委员会批准,病人均签署知情同意书。

  • 在研究开展前对所有成员进行相关知识培训,统一高血压的诊治标准和内镜操作规范,应用统一的研究表格,明确各成员分工职责。参与本研究的医生均具有执业医师资格和内镜操作上岗证,具有5年以上的内镜检查经验。

  • 采用Olympus-GIF260型电子胃镜进行检查,同时配备心电监护仪、必要的抢救设备及急救药品,以及相关抢救人员及意外情况时的应急预案等。检查前禁食6~8 h,对受检者解释操作过程及相关检查细节,消除紧张、焦虑情绪,详细了解相关病史(既往是否有高血压病史,有高血压史者最高血压值、服用何种药物控制血压,血压控制情况如何等)及检查原因,记录受检者性别、年龄、体质量指数(BMI)等。插管前吞服利多卡因胶浆10 mL咽部局麻及祛除胃内泡沫。检查时取左侧卧位,常规插镜,由固定医师操作,检查时间为6~7 min。

    A组病人舌下含服硝苯地平片10 mg;B组病人舌下含服硝酸甘油片0.5 mg;C组病人检查前以5~10 μg/min的起始速度静脉滴注硝酸甘油(0.9%氯化钠注射液100 mL+硝酸甘油5 mg,每分钟2滴),根据血压监测情况调整用量,可每3~5 min增加5 μg/min,最大速度可至20 μg/min(每分钟8滴),当血压控制在理想范围时开始胃镜检查。对照组不用药。

  • 记录A、B、C组病人用药前15 min的血压、HR、SpO2,4组受检者检查前、检查中及检查后30 min的血压、心电图、HR、SpO2等指标变化情况,记录检查中出现的不适反应(包括恶心、呕吐、呛咳、流涎、体动等)及检查结果等。

  • 采用方差分析、q检验和χ2检验。

2.   结果
  • 检查前,A、B、C组病人收缩压(SBP)均明显高于对照组(P<0.01);A、B组病人HR均高于对照组(P<0.05)。检查过程中,A、B组病人SBP、舒张压(DBP)均明显高于C组和对照组(P<0.01);A组HR均高于C组和对照组(P<0.01和P<0.05)。检查后,A组SBP和HR均高于C组和对照组(P<0.05~P<0.01)。C组病人除检查前SBP和检查后HR高于对照组(P<0.01和P<0.05)外,各检查阶段的其他指标与对照组差异均无统计学意义(P>0.05)(见表 1)。

    分组 SBP/mmHg DBP/mmHg HR/(次/分) SpO2/%
    检查前
      A组 141.60±8.47 84.05±6.31 86.28±13.45 97.85±1.10
      B组 140.30±6.32 85.72±5.41 84.35±9.14 98.55±0.85
      C组 138.68±7.98 84.48±8.65 82.10±10.53 98.02±1.76
      对照组 133.22±6.60**##▲▲ 83.28±5.85 78.12±12.19*# 98.30±1.18
      F 9.93 0.94 3.75 2.37
      P <0.01 >0.05 <0.01 >0.05
      MS组内 54.731 44.532 130.980 1.606
    检查中
      A组 169.32±19.60 94.25±13.97 111.02±25.24 97.85±1.12
      B组 178.65±10.68* 97.38±10.52 102.68±13.28 96.02±14.14
      C组 152.05±17.21**## 86.58±11.60**## 97.05±15.82** 98.02±1.75
      对照组 151.90±19.71**## 84.40±11.30**## 98.68±18.78* 98.38±1.51
      F 23.81 10.69 4.40 0.86
      P <0.01 <0.01 <0.01 >0.05
      MS组内 295.723 142.020 354.094 51.634
    检查后
      A组 148.80±12.20 90.15±9.46 94.20±14.58 97.90±0.96
      B组 146.72±11.99 88.58±7.25 89.40±9.81 98.52±0.68
      C组 141.95±10.71* 85.92±8.03 85.60±10.00** 98.02±1.69
      对照组 140.20±14.12* 86.75±9.99 78.90±12.21**##▲ 98.40±1.39
      F 4.25 1.87 11.97 2.28
      P <0.01 <0.01 <0.01 >0.05
      MS组内 151.670 76.584 139.474 1.543
    q检验:与A组比较*P<0.05,**P<0.01;与B组比较#P<0.05,##P<0.01;与C组比较▲P<0.05,▲▲P<0.01
  • 检查前和检查后,3组病人窦性心动过速、ST改变、异位心律(包括房早、室早、室上性心动过速)、传导阻滞4种异常心电图发生率差异均无统计学意义(P>0.05)。检查过程中,3组ST改变和异位心律差异均有统计学意义(P<0.05)(见表 2)。

    分组 窦性心动过速 ST改变 异位心律 传导阻滞
    检查前
      A组 4 3 5 3
      B组 3 5 3 3
      C组 3 4 4 5
      χ2 0.22 0.56 0.56 0.80
      P >0.05 >0.05 >0.05 >0.05
    检查中
      A组 21 13 14 3
      B组 14 6 6 4
      C组 11 4 5 5
      χ2 5.57 7.21 7.38 0.56
      P >0.05 <0.05 <0.05 >0.05
    检查后
      A组 10 7 6 3
      B组 4 9 3 3
      C组 3 7 4 5
      χ2 5.89 0.43 1.21 0.80
      P >0.05 >0.05 >0.05 >0.05
  • 将病人在检查过程中发生的恶心、呕吐、呛咳、流涎、体动、头晕、面红、心慌等反应列为不良反应。A组病人发生不良反应(5.85±5.00)次,B组(5.62±2.73)次,C组(4.80±3.27)次,对照组(5.88±5.36)次,4组受检者不良反应发生次数差异无统计学意义(F=0.570,P>0.05, MS组内=17.969)。

3.   讨论
  • 电子胃镜已广泛应用于消化系统疾病检查,但是作为一项侵入性的检查手段,存在一定的风险。受检者由于缺乏对胃镜检查的了解,检查时精神紧张,易产生应激反应,导致血压升高、HR加快等[6-7]。高血压病人本身血压和HR偏高,在检查过程中较普通人群风险更大[8-9],有学者[10]发现,在用胃镜进行胃部肿瘤切除术时,高血压是导致术后出血的一个重要因素。高血压高危人群在行胃镜检查过程中心脑血管并发症的风险大大增加,因此,胃镜检查前血压在3级及以上水平的病人,应将血压平稳控制在在140/90 mmHg左右[11],才能进行胃镜检查,以期尽可能降低病人胃镜检查中的各种风险。

    硝酸甘油控制性降压应用于临床已有多年的历史。1917年CUSHING首次阐明麻醉期间应用控制性降压的优点,国内80年代以后也有多人报道硝酸甘油控制性降压应用于外科手术或检查中,均表现出良好的控制效果,并能减少不良反应的发生[6, 12-13]。硝酸甘油主要药理作用是松弛血管平滑肌,舌下含服生物利用度达80%,静脉滴注则能立即起效,代谢迅速且近乎完全,效果显著[2-3]。其常规用量以扩张静脉血管和肺血管为主,且不易产生药物耐受性,能在不影响心排出量、左房压、动脉血压等情况下选择性扩张肺血管,降低肺动脉楔压,明显改善心肌供血,降低心脏容量负荷,提高左室灌注压,增加心衰病人的心输出量。大剂量使用则降低外周血管阻力,使动脉血压下降。硝苯地平是第一代钙拮抗剂,常单独或与其他药物联用治疗高血压、心绞痛等循环系统疾病[14-15]。有研究[16-17]表明,硝酸甘油静脉滴注用于治疗高血压急症较舌下含服硝苯地平效果更佳。

    本研究结果显示,硝酸甘油静脉滴注比舌下含服硝苯地平片及舌下含服硝酸甘油片能更好地调节血压和HR,降压后保持血压在相对稳定范围,检查前、中、后3个阶段静脉滴注硝酸甘油组病人血压、HR波动幅度均小于口服硝苯地平片组,部分指标同时优于舌下含服硝酸甘油片组,与对照组处于相近水平。提示硝酸甘油静脉滴注的控压效果优于硝苯地平,与何裕科[17]研究结果一致,有助于避免胃镜检查过程中病人血压和HR波动过大带来的心脑血管并发症风险。心电图改变的统计结果显示,检查中硝酸甘油静脉滴注组的ST改变和异位心律发生例数明显少于舌下含服硝苯地平片组,亦少于舌下含服硝酸甘油片组,3组间ST改变和异位心律差异均有统计学意义,这可能与硝酸甘油静脉滴注可以有效地改善心肌供血有关。各组胃镜检查过程中不良反应发生差异无统计学意义,与李建辉等[18]研究结果一致。可能是因为胃镜作为一种侵入性检查,能普遍引起受检者不适,因此,高血压病人降压后发生不良反应的次数并未多于对照组。

    综上所述,硝酸甘油静脉滴注可以有效控制高血压高危病人在胃镜检查过程中的血压,使之维持在正常范围,并且也可以根据病人的血压水平随时调整滴速控制血压,大大降低了此类病人在行胃镜检查中心脑血管意外的发生率,保障了这类病人胃镜检查的安全性。但是静脉用药较口服药物程序复杂,费时较长且费用相对较高,需要医护人员实时观察以应对可能发生的降压过快或一系列输液反应,在医护人员数量紧张的就医环境下难以实现有效监控,可能成为临床推广应用的一个限制因素。临床上应根据病人心血管指标科学评估,选择合适的降压方案。

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