• 中国科技论文统计源期刊
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Volume 44 Issue 11
Nov.  2019
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Effect of different doses of dexmedetomidine hydrochloride on the pressor effect in orthopedic general anesthesia patients

  • Received Date: 2016-11-16
    Accepted Date: 2017-05-10
  • ObjectiveTo investigate the effects of different doses of dexmedetomidine hydrochloride on the pressor effect in orthopedic general anesthesia patients.MethodsOne hundred and twenty surgical patients with ASA grade Ⅰ or Ⅱ were divided into the small dose group(Dex1 group, n=40), large dose group(Dex2 group, n=40) and control group(group C, n=40) according to random number table method.The Dex1 group, Dex2 group and control group were injected with 0.5 μg/kg of dexmedetomidine hydrochloride before anesthesia induction, 0.8 μg/kg of dexmedetomidine hydrochloride and equal amount of 0.9% sodium chloride solution, respectively.All patients were intravenously injected with 0.1mg/kg of ephedrine after 5 min of Laryngeal-mask-airway(LMA).The heart rate(HR), systolic blood pressure(SBP) and diastolic blood pressure (DBP) were compared among three groups after entering the operating room(T1), before anesthesia induction (T2), after 1min of anesthesia induction(T3), LMA(T4), and immediately after injection of ephedrine(T5).The time of the maximum HR and blood pressure(MtHR and MtBP) after 10 min of injection of ephedrine, and the differences value of the maximum value of HR, SBP and DBP to the value at T5(ΔHR, ΔDBP and ΔSBP) were compared among three groups.ResultsThe HR, SBP and DBP in Dex1 group and Dex2 group were lower than those in group C at T2, T3, T4 and T5(P < 0.01), the SBP and DBP in Dex2 group were lower than those in Dex1 group at T2, T3, T4 and T5(P < 0.01), and the differences of HR between Dex1 group and Dex2 group at T2, T3, T4 and T5 were not statistically significant(P>0.05).The ΔHR, ΔDBP and ΔSBP in Dex1 group and Dex2 group were significantly higher than those in group C(P < 0.01), and the MtHR and MtBP in Dex1 group and Dex2 group were significantly lower than those in group C(P < 0.01).The ΔHR, ΔDBP and ΔSBP in Dex2 group were lower than those in Dex1 group(P < 0.01), and there was no statistical significance in the MtHR and MtBP between the Dex1 group and Dex2 group(P>0.05).ConclusionsDexmedetomidine hydrochloride can enhance the the pressor effect and accelerate the response time, and the pressor effect of 0.8 μg/kg is significantly better than that of 0.5 μg/kg in orthopedic general anesthesia patients.
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  • [1] 杨惠英.手术患者平卧位与俯卧位无创血压监测的比较研究[J].中国实用护理杂志, 2010, 26(15):8. doi: 10.3760/cma.j.issn.1672-7088.2010.05.092
    [2] 雷钟, 段惠洁, 闫睿, 等.右美托咪定在脊柱肿瘤手术控制性降压中的应用[J].海南医学, 2015, 26(16):2382. doi: 10.3969/j.issn.1003-6350.2015.16.0859
    [3] 夏江燕, 孙永瀛, 袁静, 等.不同全身麻醉下麻黄碱升压效应的比较[J].中华麻醉学杂志, 2013, 33(9):1037. doi: 10.3760/cma.j.issn.0254-1416.2013.09.001
    [4] 于铁莉, 岳文慧, 王金城, 等.不同剂量右美托咪定对全身麻醉苏醒期应激反应的影响[J].重庆医学, 2014, 43(34):4664. doi: 10.3969/j.issn.1671-8348.2014.34.037
    [5] 何汉良.右美托咪定用于老年骨科手术全麻40例[J].中国中西医结合外科杂志, 2014, 20(4):427. doi: 10.3969/j.issn.1007-6948.2014.04.033
    [6] 沈浩, 张璇, 张宏, 等.连续无创与有创血流动力学监测在全身麻醉中的一致性分析[J].北京医学, 2016, 38(6):544.
    [7] 殷小容, 李莉莎, 邓小燕, 等.麻醉苏醒期血流动力学并发症的观察[J].华西医学, 2014, 29(3):537.
    [8] 高文龙.麻黄碱用于无痛胃镜检查术[J].现代中西医结合杂志, 2010, 19(17):2169. doi: 10.3969/j.issn.1008-8849.2010.17.064
    [9] 徐斐, 敖虎山.盐酸右美托咪定的临床应用[J].中国循环杂志, 2015, 30(4):401. doi: 10.3969/j.issn.1000-3614.2015.04.025
    [10] 范薇, 孙勇, 张钧, 等.右美托咪定对腹腔镜胆囊切除术中CO2气腹不同压力水平下老年患者术后认知功能的影响[J].实用医学杂志, 2015, 31(21):3577. doi: 10.3969/j.issn.1006-5725.2015.21.037
    [11] 中华心血管病杂志编委会心率变异性对策专题组.心率变异性检测临床应用的建议[J].中华心血管病杂志, 1998, 26(4):252.
    [12] 夏云, 严俨, 吴向宇, 等.不同剂量右美托咪定对全麻患者麻黄碱升压反应的影响[J].临床麻醉学杂志, 2015, 31(11):1077.
    [13] 查俊, 杨晓斌, 朱家明, 等.辅用右美托咪定全麻诱导对麻黄碱升压效应的影响[J].临床麻醉学杂志, 2014, 30(12):1199.
    [14] 王航, 周志鹏, 蔡迪盛.麻黄碱在不同全身麻醉方案下升压效应的对比分析[J].中国医师进修杂志, 2014, 38(2):143.
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Effect of different doses of dexmedetomidine hydrochloride on the pressor effect in orthopedic general anesthesia patients

  • Department of Anesthesiology, Suining Hospital of Traditional Chinese Medicine, Suining Sichuan 629000, China

Abstract: ObjectiveTo investigate the effects of different doses of dexmedetomidine hydrochloride on the pressor effect in orthopedic general anesthesia patients.MethodsOne hundred and twenty surgical patients with ASA grade Ⅰ or Ⅱ were divided into the small dose group(Dex1 group, n=40), large dose group(Dex2 group, n=40) and control group(group C, n=40) according to random number table method.The Dex1 group, Dex2 group and control group were injected with 0.5 μg/kg of dexmedetomidine hydrochloride before anesthesia induction, 0.8 μg/kg of dexmedetomidine hydrochloride and equal amount of 0.9% sodium chloride solution, respectively.All patients were intravenously injected with 0.1mg/kg of ephedrine after 5 min of Laryngeal-mask-airway(LMA).The heart rate(HR), systolic blood pressure(SBP) and diastolic blood pressure (DBP) were compared among three groups after entering the operating room(T1), before anesthesia induction (T2), after 1min of anesthesia induction(T3), LMA(T4), and immediately after injection of ephedrine(T5).The time of the maximum HR and blood pressure(MtHR and MtBP) after 10 min of injection of ephedrine, and the differences value of the maximum value of HR, SBP and DBP to the value at T5(ΔHR, ΔDBP and ΔSBP) were compared among three groups.ResultsThe HR, SBP and DBP in Dex1 group and Dex2 group were lower than those in group C at T2, T3, T4 and T5(P < 0.01), the SBP and DBP in Dex2 group were lower than those in Dex1 group at T2, T3, T4 and T5(P < 0.01), and the differences of HR between Dex1 group and Dex2 group at T2, T3, T4 and T5 were not statistically significant(P>0.05).The ΔHR, ΔDBP and ΔSBP in Dex1 group and Dex2 group were significantly higher than those in group C(P < 0.01), and the MtHR and MtBP in Dex1 group and Dex2 group were significantly lower than those in group C(P < 0.01).The ΔHR, ΔDBP and ΔSBP in Dex2 group were lower than those in Dex1 group(P < 0.01), and there was no statistical significance in the MtHR and MtBP between the Dex1 group and Dex2 group(P>0.05).ConclusionsDexmedetomidine hydrochloride can enhance the the pressor effect and accelerate the response time, and the pressor effect of 0.8 μg/kg is significantly better than that of 0.5 μg/kg in orthopedic general anesthesia patients.

  • 全麻是骨科手术中常用的一种麻醉方式,大多数手术病人会随着手术麻醉实施出现血压骤升或者骤降,导致有效血液循环量骤增或者骤减,大约40%的病人会出现不同程度血压降低,导致血容量不足,而严重者甚至出现低血压性休克,围手术期风险相对提高[1]。在临床中,常用麻黄碱等血管活性药物纠正手术病人麻醉期低血压,但受到手术、麻醉等应激刺激,部分病人血流动力学的波动较为明显,血压降低显著,如出现严重低血压时麻黄碱升压效果欠佳[2],此时需提高麻黄碱的升压效果,尽量维持病人血流动力学的稳定。研究[3]指出,右美托咪定能使麻黄碱的升压效应明显增强。右美托咪定属于α2肾上腺素能受体激动药,能够降低机体交感神经的活性,从而对自主神经活动产生影响,并具有不抑制呼吸、可控性好、镇痛作用强等优点[4-5]。本文就不同剂量盐酸右美托咪定对骨科全麻手术病人升压效应的影响作一报道。

1.   资料与方法
  • 选取2014-2015年我院收治的骨科手术病人120例作为研究对象,入选标准:(1)骨科手术病人,麻醉方式均为全身麻醉;(2)ASAⅠ级或Ⅱ级;(3)均使用麻黄碱;(4)体质量指数≤28 kg/m2;(5)对本研究用药均无禁忌证者。排除标准:(1)术前舒张压>100 mmHg或收缩压>160 mmHg;(2)术前应用β受体阻滞剂;(3)存在凝血功能障碍或严重心、肝、肾等功能障碍;(4)长期服用镇静镇痛药物。本研究经医院伦理委员会研究同意,并与病人及家属签署知情同意书。按照随机数字表法分为Dex1组、Dex2组和对照组(C组),每组各40例。Dex1组男29例,女11例;年龄34~77岁;ASAⅠ级27例,Ⅱ级13例;体质量48~81 kg。Dex2组男26例,女14例;年龄42~79岁;ASAⅠ级28例,Ⅱ级12例;体质量49~82 kg。C组男27例,女13例;年龄41~78岁;ASAⅠ级29例,Ⅱ级11例;体质量46~85 kg。3组病人年龄、性别、体质量等一般资料均具有可比性。

  • 入室后给予5 mL/kg复方乳酸钠输注,监测病人的脑电双频指数、心电图、脉搏血氧饱和度(SpO2)、平均动脉压(MAP),病人安静平卧5 min,在获得血压及心率(HR)的基础值之后,Dex1组、Dex2组于麻醉诱导前泵注0.5 μg/kg和0.8 μg/kg盐酸右美托咪定,C组则泵注等量0.9%氯化钠溶液。麻醉诱导用药:静脉注射0.8~1.2 mg/kg舒芬太尼、0.15~0.30 mg/kg依托咪酯、0.6 mg/kg罗库溴铵,通气3 min后置入喉罩;麻醉维持:静脉泵注顺式苯磺酸阿曲库铵、瑞芬太尼、丙泊酚以及吸入七氟烷,所有病人置入喉罩5 min后均静脉注射0.1 mg/kg麻黄碱。

  • 记录3组病人入室后(T1)、麻醉诱导前(T2)、麻醉诱导后1 min(T3)、置入喉罩(T4)、注射麻黄碱后即刻(T5)HR、收缩压(SBP)和舒张压(DBP);并比较3组病人注射麻黄碱10 min内HR、血压到达最大值的时间(MtHR和MtBP)以及HR、SBP、DBP的最大值与T5时刻的差值(ΔHR、ΔDBP和ΔSBP)。

  • 采用方差分析和q检验。

2.   结果
  • 3组病人T2、T3、T4、T5时刻HR、SBP和DBP差异均有统计学意义(P < 0.01);Dex1组、Dex2组T2、T3、T4、T5时刻HR、SBP和DBP均低于C组(P < 0.05),Dex2组T2、T3、T4、T5时刻SBP和DBP均低于Dex1组(P < 0.05);Dex1组、Dex2组T2、T3、T4、T5时刻HR差异均无统计学意义(P>0.05)(见表 1)。

    分组 n T1 T2 T3 T4 T5 F P MS组内
    SBP/mmHg
      Dex1组 40 130.7±10.2 121.2±10.4*▲ 109.1±8.9*▲ 111.5±9.3*▲ 107.5±9.1*▲ 31.04 < 0.01 24.251
      Dex2组 40 129.7±10.8 117.4±11.5*▲△ 103.5±8.2*▲△ 103.6±8.1*▲△ 101.2±7.3*▲△ 56.73 < 0.01 20.502
      C组 40 130.5±9.4 127.6±9.3 114.2±10.6* 117.6±10.5* 113.4±9.2* 22.89 < 0.01 36.089
      F 0.96 62.04 47.29 35.46 39.86
      P >0.05 < 0.01 < 0.01 < 0.01 < 0.01
      MS组内 45.749 16.059 22.243 25.257 12.508
    DBP/mmHg
      Dex1组 40 78.9±7.2 73.37±8.4*▲ 65.2±7.7*▲ 65.8±6.4*▲ 63.6±7.1*▲ 20.94 < 0.01 34.156
      Dex2组 40 80.1±9.6 70.1±7.4*▲△ 61.1±7.5*▲△ 60.3±7.3*▲△ 60.1±5.8*▲△ 13.39 < 0.01 63.081
      C组 40 77.8±9.7 76.3±9.2 67.4±8.7* 68.9±9.1* 66.4±9.5* 67.08 < 0.01 42.457
      F 0.54 70.23 56.23 40.31 32.47
      P >0.05 < 0.01 < 0.01 < 0.01 < 0.01
      MS组内 25.512 11.026 20.467 25.027 27.21
    HR/(次/分)
      Dex1组 40 77.5±10.1 66.7±8.5*▲ 63.3±6.6*▲ 64.7±5.8*▲ 62.3±4.9*▲ 18.72 < 0.01 22.17
      Dex2组 40 78.2±8.9 64.1±7.2*▲ 61.1±7.6*▲ 62.1±6.7*▲ 61.8±5.3*▲ 23.56 < 0.01 34.06
      C组 40 78.4±9.3 77.6±9.2 71.4±7.5* 73.2±7.8* 70.3±6.8* 56.74 < 0.01 73.19
      F 0.73 8.47 12.06 7.08 5.09
      P >0.05 < 0.01 < 0.01 < 0.01 < 0.01
      MS组内 36.027 35.251 28.243 32.158 38.126
    q检验:与T1时刻比较*P < 0.05;与C组比较▲P < 0.05;与Dex1组比较△P < 0.05
  • 3组病人ΔHR、ΔDBP、ΔSBP、MtHR和MtBP差异均有统计学意义(P < 0.01);Dex1组、Dex2组ΔHR、ΔDBP、ΔSBP均明显高于C组,MtHR和MtBP均明显低于C组(P < 0.05);Dex2组ΔHR、ΔDBP、ΔSBP均明显高于Dex1组(P < 0.05);Dex1组、Dex2组MtHR和MtBP差异均无统计学意义(P>0.05)(见表 2)。

    分租 n ΔHR/(次/分) ΔSBP/mmHg ΔDBP/mmHg MtHR/min MtBP/min
    Dex1组 40 15.4±6.9* 20.7±6.6* 16.4±4.6* 1.3±0.4* 2.3±0.6*
    Dex2组 40 19.8±8.3*▲ 26.2±7.1*▲ 20.5±6.9*▲ 1.4±0.3* 2.2±0.5*
    C组 40 9.6±4.8 13.8±5.4 9.6±3.7 1.6±0.3 3.2±0.8
    F 3.78 4.04 4.23 3.19 3.06
    P <0.01 <0.01 <0.01 <0.01 <0.01
    MS组内 0.365 0.318 0.302 0.692 0.719
    q检验:与C组比较*P < 0.05;与Dex1组比较▲P < 0.05
  • Dex1组、Dex2组病人均未出现呼吸抑制、窦性停搏、心动过缓等严重并发症,Dex2组出现口干2例,恶心1例,Dex1组出现恶心2例,均未给予特殊处理,经休息后自行缓解。

3.   讨论
  • 血压为反映机体生命体征的一个主要生理参数,同时也是美国麻醉医师协会规定的实施手术麻醉所必需监测的一个标准内容[6]。术中低血压为全身麻醉的一个常见并发症,与病人围手术期的肾功能损伤、脑梗死、心肌梗死及术后30 d死亡率等密切相关,是影响病人预后的一个重要因素,因此,及时纠正病人血压有助于改善其预后[7]。麻醉医师多采取使用血管升压药物、减浅麻醉或者加快输液速度等措施处理术中的低血压,不过减浅麻醉程度部分病人可能会出现术中知晓,加快输液速度可能会加重病人心肺负担,血管升压药物能够迅速有效改善病人低血压,其中麻黄碱为纠正及预防术中低血压的主要药物,属于拟肾上腺素药物的一种,能够直接激动肾上腺素受体,而且还能够促进肾上腺素等神经末梢增加去甲肾上腺素的释放,发挥间接激动作用,对于α受体及β受体均有激动的作用[8]

    盐酸右美托咪定具有以下几个方面的抗交感神经作用机制:(1)能够增强中枢神经系统孤束核突触后α2-AR活性,对脊髓前侧角的交感神经细胞所放出的兴奋信号进行抑制,从而降低了交感系统的兴奋性;能够激动交感神经末梢突触前α2-AR,从而反馈性地减少去甲肾上腺素释放。(2)与脑干蓝斑α2-AR结合之后,可对神经元去甲肾上腺素释放进行抑制,阻碍交感神经下行传导,使得肾上腺髓质所分泌的肾上腺素显著减少。(3)增强了压力感受性反射及迷走神经心脏反射[9-11]。本研究中,C组T3、T4、T5时刻的SBP、DBP、HR均明显低于T1时刻,表明在手术、麻醉等应激刺激下,病人血流动力学出现明显波动;其中Dex1组、Dex2组T2、T3、T4、T5时刻HR、SBP和DBP均低于C组,Dex2组T2、T3、T4、T5时刻SBP和DBP均低于Dex1组,表明盐酸右美托咪定抑制交感神经活性呈现剂量相关性,随着剂量增加,其抑制交感神经活性作用越强,与夏云等[12]的研究结果相近。

    查俊等[13]研究显示,全麻腹腔镜胆囊切除术病人中使用盐酸右美托咪定能够使得麻黄碱升压效果明显增强。本研究中,选择手术之前进行观察,避免了手术因素对盐酸右美托咪定升压效应的影响,同时,选用喉罩也对病人应激干扰减小。给予麻黄碱后3组病人的ΔDBP和ΔSBP均存在明显差异,其中Dex1组、Dex2组的ΔDBP和ΔSBP的升高程度明显高于C组,提示盐酸右美托咪定和麻黄碱之间有明显交互作用,能够明显提高麻黄碱升压效应;而且Dex2组升高程度较Dex1组增加,表明盐酸右美托咪定对麻黄碱升压效应的影响与剂量有关,剂量越高其升压效应越强。同时,本研究还发现,3组病人给予麻黄碱之后MtHR和MtBP并不一致,提示在骨科全麻手术病人中无明显异常情况时,病人HR达最大值的时间要快于血压,其原因可能与盐酸右美托咪定抑制β肾上腺素能张力和交感张力有关。由于盐酸右美托咪定是通过对去甲肾上腺素释放进行抑制,以及抑制交感神经活性来达到降低血压及心率的目的,因而盐酸右美托咪定增强麻黄碱升压效果可能和病人交感张力降低有关[14]。在本研究中,Dex2组对麻黄碱升压效应较Dex1组强,也间接说明了高剂量盐酸右美托咪定可促使交感神经张力降低更加明显,因此Dex2组麻黄碱升压效果更加显著。

    综上所述,盐酸右美托咪定能够增强骨科全麻手术病人升压效果,并加快了见效时间,剂量为0.8 μg/kg时的升压效果明显优于0.5 μg/kg,且未增加不良反应的发生风险,值得临床重视。但本研究样本量偏少,尚需在以后扩大样本量,进一步研究。

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