-
胸腔镜外科手术是通过胸腔镜摄像系统,用内镜器械完成某些胸部疾病手术,具有切口小、损伤小、并发症少、术后恢复快、住院时间短等特点[1]。随着胸腔镜技术的开展,对麻醉也提出了更高的要求,要求病人苏醒快,拔管快,术后恢复快,这就要求术中麻醉深度的监测更加精准,术后镇痛、镇静更加完善[2]。右美托咪定是一种α2肾上腺素受体激动剂,其具有镇痛、镇静、抗焦虑的作用[3]。SEDline镇静监测仪(Masimo Corporation,USA,型号:RDS7A)通过实时数据采集病人脑电图信号经过信号处理来监测大脑状态。此系统包含病人状态指数(PSI),即与麻醉药物作用相关的专有计算脑电波变量,从而反映手术过程中病人大脑的额叶皮质和前额叶皮质的电活动[4]。本研究通过SEDline镇静监测联合右美托咪定在胸腔镜肺叶切除术病人中应用的效果,以期为临床麻醉上选择更为安全有效的管理方法提供参考依据。
-
经病人知情同意,选择2019年择期行胸腔镜下肺叶切除术病人20例,ASA分级为Ⅰ或Ⅱ级。其中,男16例,女4例,年龄45~80岁。采用随机数字表法分为2组,每组10例。排除标准:既往存在严重心、肺疾病,如心力衰竭、慢性阻塞性肺疾病(COPD)等;术前存在明确的神经系统或精神疾病史;所有病人均无长期服用镇痛药物史及酗酒史。2组病人的性别、年龄、体质量、手术时间差异均无统计学意义(P>0.05)(见表 1),具有可比性。
分组 男 女 年龄/岁 体质量/kg 手术时间/min D组 8 2 64.00±7.60 64.00±9.35 158.00±40.22 N组 8 2 56.60±13.53 68.00±10.75 147.20±60.31 t 0.00* 1.51 0.89 0.47 P >0.05 >0.05 >0.05 >0.05 *示χ2值 表 1 2组病人一般情况比较(x±s)
-
2组病人均使用静吸复合全身麻醉进行手术,麻醉诱导由同一名高年资麻醉医生完成,方法为:静脉推注咪达唑仑0.02~0.05 mg/kg、舒芬太尼0.5 μg/kg、依托咪酯0.3 mg/kg、罗库溴铵0.6 mg/kg进行麻醉诱导,3 min后在纤维支气管镜定位下行双腔支气管插管,手术开始以后行单肺控制呼吸,呼气末二氧化碳分压维持在35~45 mmHg。术中全身麻醉维持方案:右美托咪定组(D组)200 μg右美托咪定(江苏恩华药业股份有限公司,批号:20190102)用0.9%氯化钠溶液稀释至50 mL,以0.4 μg·kg-1·h-1泵注,瑞芬太尼(宜昌人福药业,批号:90A09201)1 mg用0.9%氯化钠溶液稀释至50 mL,以6~10 μg·kg-1·h-1泵注,1%丙泊酚乳状注射液(AstraZeneca公司,批号:PK924),以4~6 mg·kg-1·h-1泵注,并吸入1%~2%七氟烷,间断推注顺式阿曲库铵维持肌松;对照组(N组):0.9%氯化钠溶液50 mL,以10 mL/h泵注,瑞芬太尼(宜昌人福药业,批号:90A09201)1 mg用0.9%氯化钠溶液稀释至50 mL,以6~10 μg·kg-1·h-1泵注,1%丙泊酚乳状注射液(AstraZeneca公司,批号:PK924),以4~6 mg·kg-1·h-1泵注,并吸入1%~2%七氟烷,间断推注顺式阿曲库铵维持肌松,手术结束前30 min,2组病人静脉均给予舒芬太尼5~10 μg。所有病人均连接SEDline镇静监测,维持术中PSI在25~50之间。术毕苏醒后行经静脉病人自控镇痛(patient controlled intravenous analgesia,PCIA),静脉镇痛泵配方为舒芬太尼1.5 μg/kg地佐辛20 mg+托烷司琼4 mg+0.9%氯化钠溶液稀释至100 mL,背景剂量2 mL/h,PCA剂量2 mL/h,锁定时间20 min。
-
记录2组病人麻醉诱导前(T0)、切皮时(T1)、单肺通气30 min(T2)、术毕即刻(T3)的平均动脉压(MAP)、心率(HR)、血氧饱和度(SpO2)、PSI;记录2组病人术中瑞芬太尼和丙泊酚的用量;以及术后6 h、24 h VAS评分和Ramsay评分。
-
采用独立样本t检验、配对t检验、方差分析和q检验。
-
与T0相比较,2组病人在T1、T2、T3时间点MAP均降低(P < 0.01),HR减慢(P < 0.01),PSI均降低(P < 0.01)。其中,N组在T2时间点MAP降低较D组更明显(P < 0.01),D组在T1时间点HR明显低于N组(P < 0.01),在T2时间点PSI明显低于N组(P < 0.01)(见表 2)。
分组 T0 T1 T2 T3 F P MS组内 MAP/mmHg D组 87.40±3.20 80.2±3.94** 73.60±2.88**## 82.70±3.20**△△ 29.87 < 0.01 11.075 N组 87.20±4.44 79.80±5.65** 69.20±3.33**## 82.60±2.67*△△ 33.39 < 0.01 17.464 t 0.12 0.18 3.16 0.08 — — — P >0.05 >0.05 < 0.01 >0.05 — — — HR/(次/分) D组 89.90±8.40 71.00±1.70** 68.60±2.46** 75.30±3.20**△ 40.61 < 0.01 22.435 N组 89.70±10.47 77.50±5.84** 66.80±4.32**## 75.30±3.37**△△ 20.57 < 0.01 43.437 t 0.05 3.38 1.15 0.00 — — — P >0.05 < 0.01 >0.05 >0.05 — — — SpO2/% D组 97.80±1.55 99.20±0.63* 97.20±1.62## 99.00±0.67*△ 6.27 < 0.01 1.468 N组 97.50±1.78 99.10±0.74 97.10±2.28# 98.70±0.95 3.69 < 0.05 2.454 t 0.40 0.33 0.11 0.82 — — — P >0.05 >0.05 >0.05 >0.05 — — — PSI D组 90.60±1.65 36.20±3.88** 32.50±3.54**# 39.80±2.70**#△△ 797.51 < 0.01 9.400 N组 90.30±1.89 34.50±4.74** 38.20±3.01**# 39.30±3.59**# 588.13 < 0.01 11.997 t 0.38 0.88 3.88 0.35 — — — P >0.05 >0.05 < 0.01 >0.05 — — — 与T0比较*P < 0.05,**P < 0.01;与T1比较#P < 0.05,##P < 0.01;与T2比较△P < 0.05,△△P < 0.01 表 2 2组病人术中MAP、HR、SpO2、PSI比较(x±s; ni=10)
-
术中瑞芬太尼和丙泊酚的用量D组均明显低于N组(P < 0.01)(见表 3)。
分组 术中瑞芬太尼用量/μg 术中丙泊酚用量/mg D组 695.00±79.90 354.00±36.27 N组 930.00±64.12 442.00±46.62 t 7.25 4.71 P < 0.01 < 0.01 表 3 2组病人术中瑞芬太尼和丙泊酚的用量(x±s; ni=10)
-
6 h、24 h VAS评分和Ramsay评分比较2组病人在术后6 h VAS评分D组明显低于N组(P < 0.01),术后6 h Ramsay评分D组明显高于N组(P < 0.01),术后24 h VAS评分和Ramsay评分差异2组均无统计学意义(P>0.05),D组术后24 h VAS评分高于术后6 h,N组术后24 h Ramsay评分高于术后6 h(P < 0.05)(见表 4)。
分组 VAS评分 Ramsay评分 术后6 h 术后24 h 术后6 h 术后24 h D组 1.80±1.03 3.00±1.05* 2.90±0.88 2.30±0.48 N组 4.30±1.34 3.40±1.07 1.60±0.52 2.20±0.63* t 4.68 0.84 4.04 0.40 P < 0.01 >0.05 < 0.01 >0.05 组内配对t检验:*P < 0.05 表 4 2组病人术后6 h、24 hVAS评分比较和Ramsay评分比较(x±s;ni=10;分)
SEDline镇静监测下右美托咪定在胸腔镜肺叶切除术病人中的应用
Application value of the dexmedetomidine under SEDline sedation monitoring in patients treated with thoracoscopic lobectomy
-
摘要:
目的通过SEDline镇静监测下右美托咪定在胸腔镜肺叶切除术病人中的应用,以期为麻醉选择更为安全有效的方法。 方法选择ASAⅠ或Ⅱ级的胸腔镜肺叶切除术病人20例,采用随机数字表法分为右美托咪定组(D组)和对照组(N组),每组10例。记录2组病人麻醉诱导前(T0)、切皮时(T1)、单肺通气30 min(T2)、术毕即刻(T3)的平均动脉压(MAP)、心率(HR)、血氧饱和度(SPO2)、病人状态指数(PSI);记录2组病人术中瑞芬太尼和丙泊酚的用量;以及术后6 h、24 h VAS评分和Ramsay评分。 结果2组病人在T1、T2、T3时间点MAP均降低(P < 0.01),HR减慢(P < 0.01),PSI均降低(P < 0.01)。其中,N组在T2时间点MAP降低较D组更明显(P < 0.01),D组在T1时间点HR低于N组(P < 0.01),在T2时间点PSI低于N组(P < 0.01);术中瑞芬太尼和丙泊酚的用量D组均明显低于N组;在术后6 h VAS评分D组低于N组(P < 0.01),术后6 h Ramsay评分D组高于N组(P < 0.01)。 结论胸腔镜肺叶切除术病人行右美托咪定联合SEDline镇静监测,术中病人麻醉状态得以控制,血流动力学更加平稳,术后镇静镇痛更加完善,无术后躁动,能对病人的快速康复起到一定的积极作用。 -
关键词:
- SEDline镇静监测 /
- 右美托咪定 /
- 胸腔镜 /
- 肺叶切除术
Abstract:ObjectiveTo evaluate the application value of dexmedetomidine under SEDline sedation monitoring in thoracoscopic lobectomy in order to provide a more safe and effective method for anesthesia. MethodsA total of 20 ASA Ⅰ or Ⅱ patients treated with thoracoscopic lobectomy were randomly divided into the dexmedetomidine group(group D)and control group(group N)(10 cases in each group).The MAP, HR, SpO2 and PSI in two groups before anesthesia induction(T0), during skin incision(T1), after 30 minutes of one lung ventilation(T2)and immediately after surgery(T3)were recorded.The dosage of remifentanil and propofol, and scores of VAS and Ramsay after 6 h and 24 h of operation were recorded. ResultsThe MAP, HR and PSI in two groups at T1, T2 and T3 decreased(P < 0.01), the decreasing degree of MAP in group N was more obvious compared with the group D at T2(P < 0.01), the HR in group D at T1was significantly lower than that in group N(P < 0.01), and the PSI in group D was lower than that in group N at T2(P < 0.01).The dosage of remifentanil and propofol in group D were significantly lower than these in group N.The scores of VAS and Ramsay in group D were lower and higher than that in group N after 6 h of operation, respectively(P < 0.01). ConclusionsThe dexmedetomidine under SEDline sedation monitoring in patients treated with thoracoscopic lobectomy can control the patient's anesthetic state, maintain the hemodynamics, improve the postoperative sedation and analgesia, and have no postoperative agitation, which can plays certain positive roles in the patient's quick recovery. -
Key words:
- SEDline sedation monitoring /
- dexmedetomidine /
- thoracoscopy /
- lobectomy
-
表 1 2组病人一般情况比较(x±s)
分组 男 女 年龄/岁 体质量/kg 手术时间/min D组 8 2 64.00±7.60 64.00±9.35 158.00±40.22 N组 8 2 56.60±13.53 68.00±10.75 147.20±60.31 t 0.00* 1.51 0.89 0.47 P >0.05 >0.05 >0.05 >0.05 *示χ2值 表 2 2组病人术中MAP、HR、SpO2、PSI比较(x±s; ni=10)
分组 T0 T1 T2 T3 F P MS组内 MAP/mmHg D组 87.40±3.20 80.2±3.94** 73.60±2.88**## 82.70±3.20**△△ 29.87 < 0.01 11.075 N组 87.20±4.44 79.80±5.65** 69.20±3.33**## 82.60±2.67*△△ 33.39 < 0.01 17.464 t 0.12 0.18 3.16 0.08 — — — P >0.05 >0.05 < 0.01 >0.05 — — — HR/(次/分) D组 89.90±8.40 71.00±1.70** 68.60±2.46** 75.30±3.20**△ 40.61 < 0.01 22.435 N组 89.70±10.47 77.50±5.84** 66.80±4.32**## 75.30±3.37**△△ 20.57 < 0.01 43.437 t 0.05 3.38 1.15 0.00 — — — P >0.05 < 0.01 >0.05 >0.05 — — — SpO2/% D组 97.80±1.55 99.20±0.63* 97.20±1.62## 99.00±0.67*△ 6.27 < 0.01 1.468 N组 97.50±1.78 99.10±0.74 97.10±2.28# 98.70±0.95 3.69 < 0.05 2.454 t 0.40 0.33 0.11 0.82 — — — P >0.05 >0.05 >0.05 >0.05 — — — PSI D组 90.60±1.65 36.20±3.88** 32.50±3.54**# 39.80±2.70**#△△ 797.51 < 0.01 9.400 N组 90.30±1.89 34.50±4.74** 38.20±3.01**# 39.30±3.59**# 588.13 < 0.01 11.997 t 0.38 0.88 3.88 0.35 — — — P >0.05 >0.05 < 0.01 >0.05 — — — 与T0比较*P < 0.05,**P < 0.01;与T1比较#P < 0.05,##P < 0.01;与T2比较△P < 0.05,△△P < 0.01 表 3 2组病人术中瑞芬太尼和丙泊酚的用量(x±s; ni=10)
分组 术中瑞芬太尼用量/μg 术中丙泊酚用量/mg D组 695.00±79.90 354.00±36.27 N组 930.00±64.12 442.00±46.62 t 7.25 4.71 P < 0.01 < 0.01 表 4 2组病人术后6 h、24 hVAS评分比较和Ramsay评分比较(x±s;ni=10;分)
分组 VAS评分 Ramsay评分 术后6 h 术后24 h 术后6 h 术后24 h D组 1.80±1.03 3.00±1.05* 2.90±0.88 2.30±0.48 N组 4.30±1.34 3.40±1.07 1.60±0.52 2.20±0.63* t 4.68 0.84 4.04 0.40 P < 0.01 >0.05 < 0.01 >0.05 组内配对t检验:*P < 0.05 -
[1] LIM E, BATCHELOR T, SHACKCLOTH M, et al. Study protocol for VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy for lung cancer, a UK multicentrerandomised controlled trial with an internal pilot(the VIOLET study)[J]. BMJ Open, 2019, 9(10): e029507. doi: 10.1136/bmjopen-2019-029507 [2] HUNG MH, CHAN KC, LIU YJ, et al. Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesiaand intercostal blockade: a retrospective cohort study of 238 cases[J]. Medicine, 2015, 94(13): e727. doi: 10.1097/MD.0000000000000727 [3] SAYED E, YASSEN KA.Intraoperative effect of dexmedetomidine infusion during living donorliver transplantation: a randomized control trial[J]. Saudi J Anaesth, 2016, 10(3): 288. doi: 10.4103/1658-354X.174914 [4] GOUDRA B, SINGH PM, GOUDA G, et al. Propofol and non-propofol based sedation for outpatient colonoscopy-prospective comparison of depth of sedation using an EEG based SEDline monitor[J]. J Clin Monit Comput, 2016, 30(5): 551. doi: 10.1007/s10877-015-9769-5 [5] ZHANG W, CHEN M, LI H, et al. Hypoxia preconditioning attenuates lung injury after thoracoscopic lobectomy in patients with lung cancer: a prospective randomized controlled trial[J]. BMC Anesthesiol, 2019, 19(1): 209. doi: 10.1186/s12871-019-0854-z [6] MARIJIC P, WALTER J, SCHNEIDER C, et al. Cost and survival of video-assisted thoracoscopic lobectomy versus open lobectomy in lung cancer patients: a propensity score-matched study[J]. Eur J Cardiothorac Surg, 2020, 57(1): 92. doi: 10.1093/ejcts/ezz157 [7] ASRI S, HOSSEINZADEH H, EYDI M, et al. Effect of dexmedetomidine combined with inhalation of isoflurane on oxygenation following one-lung ventilation in thoracic surgery[J]. Anesth Pain Med, 2020, 10(1): e95287. [8] PENG J, HE F, QIN C, et al. Intraoperative Dexmedetomidine versus midazolam in patients undergoing peripheral surgery with mild traumatic brain injuries: a retrospective cohort analysis[J]. Dose Response, 2020, 18(2): 1559325820916342. [9] KAYE AD, CHERNOBYLSKY DJ, THAKUR P, et al. dexmedetomidine in enhanced recovery after surgery(ERAS)protocols for postoperative pain[J]. Curr Pain Headache Rep, 2020, 24(5): 21. doi: 10.1007/s11916-020-00853-z [10] DUAN G, WANG K, PENG T, et al. The effects of intraoperative dexmedetomidine use and its different dose on postoperative sleep disturbance in patients who have undergone non-cardiac major surgery: a eal-world cohort study[J]. Nat Sci Sleep, 2020, 12: 209. doi: 10.2147/NSS.S239706 [11] CAPUTO TD, RAMSAY MA, ROSSMANN JA, et al. Evaluation of the SEDline to improve the safety and efficiency of conscious sedation[J]. Proc(Bayl Univ Med Cent), 2011, 24(3): 200. [12] OBARA S, KAKINOUCHI K, HONDA J, et al. Dexmedetomidine administration in a patient with status epilepticus under color density spectral array monitoring[J]. JA Clin Rep, 2019, 5(1): 12. doi: 10.1186/s40981-019-0234-1