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喉返神经损伤是甲状腺手术常见的严重并发症之一。单侧损伤多表现为声音嘶哑,两侧损伤表现为失音、呼吸困难,严重者会出现窒息。在进行甲状腺手术时,使用神经监测能使喉返神经完整的功能得到有效保护,并降低喉返神经损伤的发生率[1-2]。术中神经电生理监测(intraoperative nerve monitoring,IONM)将解剖学与功能学相互结合,主要具有以下特点:术中导航,快速识别喉返神经走向;预测变异,保护喉返神经功能完整;降低喉返神经损伤的发生率;且其操作简单,是应对复杂手术的有效辅助工具[3-4]。但甲状腺手术中行IONM对麻醉有新的要求,需使用加强型的气管导管,插管位置需精确,麻醉深度适宜,且在术中不使用肌松药维持麻醉,避免对神经探测仪监测的结果造成影响[5]。本研究旨在探讨右美托咪定(DEX)复合瑞芬太尼与丙泊酚泵注应用于术中行IONM甲状腺病人的临床效果。现作报道。
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组内比较显示,观察组病人T1~T4时HR均明显低于T0(P < 0.01);对照组T3和T4时HR均低于T0(P < 0.01和P < 0.05)。组间比较显示,观察组病人T1~T4时HR均低于对照组各时点(P < 0.05~P < 0.01)(见表 1)。
时间 n T0 T1 T2 T3 T4 T5 F P MS组内 观察组 35 81.79±11.32 71.63±12.69** 73.26±9.80** 66.26±7.31** 69.55±11.85** 79.81±10.39 10.99 < 0.01 114.505 对照组 35 82.31±12.2 84.16±10.29 79.68±7.45 72.38±6.56** 75.52±9.76* 82.21±12.5 7.18 < 0.01 100.795 t — 0.19 4.6 3.13 3.74 2.33 0.89 — — — P — >0.05 < 0.01 < 0.01 < 0.01 < 0.05 >0.05 — — — Dunnett-t检验:与T0比较*P < 0.05, **P < 0.01 表 1 2组病人不同时点HR比较(x±s;次/分)
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组内比较显示,观察组病人T1~T4时MAP均低于T0(P < 0.05~P < 0.01);对照组T3时MAP低于T0(P < 0.05)。组间比较显示,观察组病人T1~T4时MAP均低于对照组各时点(P < 0.05~P < 0.01)(见表 2)。
时间 n T0 T1 T2 T3 T4 T5 F P MS组内 观察组 35 81.25±7.47 75.48±6.37* 76.23±6.21** 73.5±5.34** 75.65±8.27* 82.61±11.73 7.42 < 0.01 61.574 对照组 35 80.82±6.53 81.56±7.27 79.6±7.68 77.55±6.20* 75.65±8.27 82.61±11.73 2.26 < 0.05 63.481 t — 0.26 3.78 2.05 2.97 1.2 0.36 — — — P — >0.05 < 0.01 < 0.05 < 0.01 < 0.05 >0.05 — — — Dunnett-t检验:与T0比较*P < 0.05, **P < 0.01 表 2 2组病人不同时点MAP比较(x±s;mmHg)
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组内比较显示,观察组病人T1~T5时BIS均明显低于T0(P < 0.01);对照组T2~T5时BIS均明显低于T0(P < 0.01)。组间比较显示,观察组病人T1时BIS明显低于对照组(P < 0.01)(见表 3)。
分组 n T0 T1 T2 T3 T4 T5 F P MS组内 观察组 35 95.19±2.19 78.54±5.22** 49.38±3.58** 50.48±4.67** 51.53±3.76** 91.67±3.76** 1 027.47 < 0.01 15.824 对照组 35 95.35±2.36 95.59±2.64 50.66±4.14** 51.67±5.20** 52.30±2.69** 92.11±2.37** 1 664.71 < 0.05 11.595 t — 0.3 17.49 1.4 1.02 0.99 0.59 — — — P — >0.05 < 0.01 >0.05 >0.05 >0.05 >0.05 — — — Dunnett-t检验:与T0比较**P < 0.01 表 3 2组病人不同时间点BIS比较(x±s)
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2组病人均无术中知晓情况。观察组病人的丙泊酚和瑞芬太尼用量均明显少于对照组(P < 0.01);观察组苏醒期间烦躁发生率为5.71%,低于对照组的25.71%(P < 0.05);观察组术后BCS评分明显高于对照组(P < 0.01)。2组病人睁眼时间、拔管时间差异均无统计学意义(P>0.05)(见表 4)。
分组 n T0 T1 T2 T3 T4 T5 F P MS组内 观察组 35 95.19±2.19 78.54±5.22** 49.38±3.58** 50.48±4.67** 51.53±3.76** 91.67±3.76** 1 027.47 < 0.01 15.824 对照组 35 95.35±2.36 95.59±2.64 50.66±4.14** 51.67±5.20** 52.30±2.69** 92.11±2.37** 1 664.71 < 0.05 11.595 t — 0.3 17.49 1.4 1.02 0.99 0.59 — — — P — >0.05 < 0.01 >0.05 >0.05 >0.05 >0.05 — — — *示χ2值 表 4 2组病人用药量、清醒情况和BCS评分比较(x±s)
右美托咪定联合瑞芬太尼和丙泊酚泵注对甲状腺术中神经电生理监测的影响
Effect of the pump injection of dexmetomidine combined with remifentanil and propofol on intraoperative nerve monitoring during thyroidectomy
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摘要:
目的探讨右美托咪定(DEX)联合瑞芬太尼、丙泊酚泵注在行术中神经电生理监测(IONM)的甲状腺手术病人中的应用效果。 方法选取术中行IONM的甲状腺手术病人70例,随机分为观察组和对照组,各35例。观察组诱导前10 min静脉泵注0.6 μg/kg DEX预给量,随后持续泵注0.4 μg·kg-1·h-1 DEX,直至手术结束前30 min停止用药;对照组注射等量0.9%氯化钠溶液。2组病人均采用同样的药物快速诱导,为0.05 mg/kg咪达唑仑、2 mg/kg丙泊酚、0.4 μg/kg瑞芬太尼、0.3 mg/kg罗库溴铵,然后为病人插入神经专用导管。术中泵注瑞芬太尼与丙泊酚维持麻醉,不使用肌松药。记录2组注药前(T0)、麻醉诱导前(T1)、插管即刻(T2)、手术切皮即刻(T3)、分离甲状腺时(T4)、拔管后即刻(T5)的心率(HR)、平均动脉压(MAP)、脑电双频指数(BIS);记录丙泊酚和瑞芬太尼用量、病人麻醉恢复情况、术后舒适度、术中知晓情况。 结果组内比较显示,观察组病人T1~T4时HR和MAP均低于T0(P < 0.05~P < 0.01),T1~T5时BIS均明显低于T0(P < 0.01);对照组T3和T4时HR均低于T0,T3时MAP低于T0(P < 0.05),T2~T5时BIS均明显低于T0(P < 0.01)。组间比较显示,观察组病人T1~T4时HR和MAP均低于对照组各时点(P < 0.05~P < 0.01),T1时BIS明显低于对照组(P < 0.01)。2组病人均无术中知晓情况。观察组病人的丙泊酚和瑞芬太尼用量均明显少于对照组(P < 0.01);观察组苏醒期间烦躁发生率为5.71%(2/35),低于对照组的25.71%(9/35)(P < 0.05);观察组术后BCS评分明显高于对照组(P < 0.01)。2组病人睁眼时间、拔管时间差异均无统计学意义(P>0.05)。 结论DEX联合瑞芬太尼和丙泊酚应用于甲状腺手术病人,对术中IONM无影响,可满足手术需求,且具有降低苏醒期间烦躁和提高病人术后舒适程度等优势。 Abstract:ObjectiveTo investigate the clinical application effects of the pump injection of dexmetomidine(DEX) combined with remifentanil and propofol in intraoperative nerve monitoring(IONM) during thyroidectomy. MethodsSeventy thyroidectomy patients with IONM were randomly divided into the observation group and control group(35 cases in each group).The observation group was induced by intravenous pumping 0.6 g/kg DEX for the first 10 min, followed by continuous pumping 0.4 μg·kg-1·h-1 DEX, and the drug stopped before 30 min of the end of the surgery.The control group was injected with the same amount of 0.9% sodium chloride solution.Two groups were rapidly induced using the 0.05 mg/kg midazolam, 2 mg/kg propofol, 0.4 μg/kg remifentanil and 0.3 mg/kg rocuronium bromide, and a special nerve catheter was inserted into the patient.Remifentanil and propofol were pumped intraoperatively to maintain anesthesia without muscle relaxants.The heart rate(HR), mean arterial pressure(MAP) and bispectral(BIS) index in two groups were recorded before injection(T0), before anesthesia induction(T1), and at the time of intubation(T2), cutting skin(T3) and isloating thyroid gland(T4) and extubation(T5).The dosage of propofol and remifentanil, recovery of anesthesia, postoperative comfort and intraoperative awareness were recorded in two groups. ResultsThe HR and MAP in observation group at T1 to T4 were lower than those at T0(P < 0.05 to P < 0.01), and the BIS in observation group at T1 to T5 were significantly lower than that at T0(P < 0.01).The HR in control group at T3 and T4 were lower than that at T0(P < 0.05), and the BIS in control group at T2 to T5 were significantly lower than that at T0(P < 0.01).The HR and MAP in observation group at T1 to T4 were significantly lower than those in control group at each time-point(P < 0.05 to P < 0.01), and the BIS in observation group at T1 was significantly lower than that in control group(P < 0.01).Neither group had intraoperative knowledge.The dosage of propofol and remifentanil in observation group were significantly lower than those in control group(P < 0.01).The incidence rate of restlessness in observation group(5.71%)(2/35) was lower than that in control group(25.71%)(9/35)(P < 0.05).The BCS score in observation group after operation was significantly higher than that in control group(P < 0.01).The differences of the opening eye time and extubation time were not statistically significant between two groups(P>0.05). ConclusionsThe application of DEX combined with remifentanil and propofol in thyroidectomy does not affect the IONM, can meet with operation, reduce restlessness during recovery and improve postoperative comfort. -
Key words:
- anesthesia /
- intraoperative nerve monitoring /
- thyroidectomy /
- dexmedetomidine /
- remifentanil /
- propofol
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表 1 2组病人不同时点HR比较(x±s;次/分)
时间 n T0 T1 T2 T3 T4 T5 F P MS组内 观察组 35 81.79±11.32 71.63±12.69** 73.26±9.80** 66.26±7.31** 69.55±11.85** 79.81±10.39 10.99 < 0.01 114.505 对照组 35 82.31±12.2 84.16±10.29 79.68±7.45 72.38±6.56** 75.52±9.76* 82.21±12.5 7.18 < 0.01 100.795 t — 0.19 4.6 3.13 3.74 2.33 0.89 — — — P — >0.05 < 0.01 < 0.01 < 0.01 < 0.05 >0.05 — — — Dunnett-t检验:与T0比较*P < 0.05, **P < 0.01 表 2 2组病人不同时点MAP比较(x±s;mmHg)
时间 n T0 T1 T2 T3 T4 T5 F P MS组内 观察组 35 81.25±7.47 75.48±6.37* 76.23±6.21** 73.5±5.34** 75.65±8.27* 82.61±11.73 7.42 < 0.01 61.574 对照组 35 80.82±6.53 81.56±7.27 79.6±7.68 77.55±6.20* 75.65±8.27 82.61±11.73 2.26 < 0.05 63.481 t — 0.26 3.78 2.05 2.97 1.2 0.36 — — — P — >0.05 < 0.01 < 0.05 < 0.01 < 0.05 >0.05 — — — Dunnett-t检验:与T0比较*P < 0.05, **P < 0.01 表 3 2组病人不同时间点BIS比较(x±s)
分组 n T0 T1 T2 T3 T4 T5 F P MS组内 观察组 35 95.19±2.19 78.54±5.22** 49.38±3.58** 50.48±4.67** 51.53±3.76** 91.67±3.76** 1 027.47 < 0.01 15.824 对照组 35 95.35±2.36 95.59±2.64 50.66±4.14** 51.67±5.20** 52.30±2.69** 92.11±2.37** 1 664.71 < 0.05 11.595 t — 0.3 17.49 1.4 1.02 0.99 0.59 — — — P — >0.05 < 0.01 >0.05 >0.05 >0.05 >0.05 — — — Dunnett-t检验:与T0比较**P < 0.01 表 4 2组病人用药量、清醒情况和BCS评分比较(x±s)
分组 n T0 T1 T2 T3 T4 T5 F P MS组内 观察组 35 95.19±2.19 78.54±5.22** 49.38±3.58** 50.48±4.67** 51.53±3.76** 91.67±3.76** 1 027.47 < 0.01 15.824 对照组 35 95.35±2.36 95.59±2.64 50.66±4.14** 51.67±5.20** 52.30±2.69** 92.11±2.37** 1 664.71 < 0.05 11.595 t — 0.3 17.49 1.4 1.02 0.99 0.59 — — — P — >0.05 < 0.01 >0.05 >0.05 >0.05 >0.05 — — — *示χ2值 -
[1] 王冰, 田文, 王美祺, 等.甲状腺手术中喉返神经保护方法综述[J].解放军医学院学报, 2016, 37(9):1017. doi: 10.3969/j.issn.2095-5227.2016.09.027 [2] 朱明.甲状腺手术中避免喉返神经损伤的方法及效果观察[J].中国现代普通外科进展, 2016, 19(2):135. [3] 崔影, 陈静, 吴波.前列地尔注射液联合硫辛酸治疗糖尿病周围神经病变及神经电生理变化研究[J].湖南师范大学学报(医学版), 2017, 14(1):37. [4] 刘海云, 高进喜, 陈渊, 等.神经电生理监测异常肌肉反应在面神经微血管减压术中的应用[J].中国微创外科杂志, 2016, 16(6):532. doi: 10.3969/j.issn.1009-6604.2016.06.015 [5] 闫文杰.甲状腺肿瘤普外科微创手术治疗的临床观察[J].湖南师范大学学报(医学版), 2015, 42(4):77. [6] 高巍.腔镜下肺癌根治术手术早期NSCLC的效果分析[J].湖南师范大学学报(医学版), 2016, 13(5):66. [7] 臧宇, 田文, 姚京, 等.甲状腺术中神经监测信号缺失原因分析[J].中国实用外科杂志, 2017, 37(10):1173. [8] 苏庆长, 张桂华, 孙善平, 等.喉返神经监测技术在分化型甲状腺癌中央区淋巴结清扫术中的临床应用[J/CD].中华普通外科学文献: 电子版, 2016, 10(6): 441. [9] 曹培雨, 刘功俭.右美托咪定对可视喉镜气管插管时芬太尼抑制插管反应半数有效量的影响[J].徐州医学院学报, 2017, 37(7):428. doi: 10.3969/j.issn.1000-2065.2017.07.003 [10] WOJTCZAK B, KALISZEWSKI K, SUTKOWSKI K, et al.The learning curve for intraoperative neuromonitoring of the recurrent laryngeal nerve in thyroid surgery[J].Langenbecks Arch Surg, 2017, 402(4):701. doi: 10.1007/s00423-016-1438-8 [11] 申珍, 代志刚, 王胜, 等.肌松药对微血管减压术术中神经电生理监测和气管插管的影响[J].中国现代医药杂志, 2017, 19(11):6. doi: 10.3969/j.issn.1672-9463.2017.11.002 [12] 朱庆新, 孙志强, 张军, 等.尼卡地平、瑞芬太尼控制性降压期间对心率变异性影响的对比研究[J].中国现代药物应用, 2016, 10(8):16. [13] WATANABE K, KASHIWAGI K, KAMIYAMA T, et al.High-dose remifentanil suppresses stress response associated with pneumoperitoneum during laparoscopic colectomy[J].J Anesth, 2014, 28(3):334. [14] MANDEL JE, TANNER JW, LICHTENSTEIN GR, et al.A randomized, controlled, double-blind trial of patient-controlled sedation with propofol/remifentanil versus midazolam/fentanyl for colonoscopy.[J].Survey Anesthesiol, 2009, 53(4):147. [15] 汪晓强, 胡一鹏, 吴飞翔.右美托咪定在减轻缺血/再灌注损伤中的机制与作用研究进展[J].医学综述, 2016, 22(20):4025. doi: 10.3969/j.issn.1006-2084.2016.20.020