靶控输注异丙酚全凭静脉麻醉
发表时间:2009-12-21 浏览次数:543次
靶控输注异丙酚全凭静脉麻醉作者:柴 伟,于代华,高昌俊,杨永慧,孙绪德 摘 要:目的 观察靶控输注异丙酚全凭静脉麻醉诱导及术中血流动力学变化、术后苏醒时间及相应的效应室浓度,以指导临床合理用药. 方法 15例择期行腹腔镜胆囊切除术患者采用靶控输注异丙酚全静脉麻醉.设定诱导时效应室目标浓度为4mg?L-1 ,复合咪唑安定2mg,芬太尼2μg?kg-1 ,维库溴铵0.1mg?kg-1 气管插管,术中维持异丙酚浓度为2mg?L-1 ,记录诱导前、诱导后2min、插管即刻、插管后2min、切皮及气腹时心率(HR)、收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)及停药后苏醒时间,苏醒时相应的效应室浓度. 结果 插管即刻HR,SBP,DBP及MAP均与诱导前比较有显著差异(P<0.05),气腹后DBP,MAP也较诱导前有明显升高(P<0.05),平均苏醒时间为(8.6±2.7)min,相应效应室浓度为(1.48±0.24)mg?L-1 . 结论 采用靶控输注异丙酚全凭静脉麻醉诱导时和维持期血流动力学相对较为稳定,术后苏醒较为迅速. 关键词: 麻醉,静脉内;靶控输注;异丙酚 Target┐controlled infusion with propofol for total intravenous anesthesia CHAI Wei,YU Dai-Hua,GAO Chang-Jun,YANG Yong-Hui,SUN Xu-De Department of Anesthesiology,Tangdu Hospital,Fourth Military Medical University,Xi'an710038,China Keywords:anesthesia,intravenous;target-controlled infu-sion;propofol Abstract:AIM To observe the hemodynamic changes dur-ing induction and maintenance period,the wakening time af-ter operation and the corresponding effect site blood propofol concentration using target-controlled infusion(TCI)with propofol for total intravenous anesthesia.METHODS Fif-teen patients scheduled for laparascopic cholesystectomy un-der TCI with propofol for total intravenous anesthesia were studied.Target blood propofol concentration was initially set at4mg?L-1 ,anesthesia was induced with this propofol con-centration and midazolam2mg,fentanyl2μg?kg-1 ,ve-curonium0.1mg?kg-1 .In order to maintain anesthesia,the blood propofol concentration was set at2mg?L-1 .The heart rate(HR),systolic blood pressure(SBP),diastolic blood pressure(DBP),mean artery pressure(MAP)before induction,2min after induction,at endotracheal intubation,2min after intubation,at incision were recorded respectively.The wakening time after stopping propofol infusion and the corresponding blood propofol concentration at effect site were recorded too.RESULTS HR,SBP,DBP and MAP in-creased significantly after intubation(P<0.05),DBP and MAP after pneumoperitoneum were higher than those at in-duction(P<0.05).The mean wakening time was(8.6±2.7)min,the corresponding effect site blood propofol concentration was(1.48±0.24)mg?L-1 .CONCLUSION Hemodynamics were relatively stable during anesthesia induc-tion and maintenance period when TCI with propofol was used for total intravenous anesthesia,and the patients woke up soon after the operation.0 引言 靶控输注(target-controlled infusion,TCI)是一种新的静脉麻醉方法,近年来国内、外刚刚开始应用于临床,与传统泵注异丙酚的方法相比,TCI具有使用简便,能使血药浓度维持在较为稳定的水平的优点[1,2] .但采用TCI诱导、维持时对血流动力学影响如何及停药后患者的苏醒状态是临床普遍关心的问题,我们就此作一研究观察.1 对象和方法 1.1 对象 选择ASA I~II级、择期行腹腔镜胆囊切除术的成年患者25(男15,女10)例,年龄18~55(平均36)岁,排除有心、肺疾病患者.术前用药均采用阿托品0.5mg,安定10mg肌肉注射. 1.2 方法 采用靶控输注(Graseby3500型靶控输注泵)异丙酚全凭静脉麻醉,设定诱导时效应室浓度为4mg?L-1 ,待患者睫毛反射消失后静注咪唑安定2mg,芬太尼2μg?kg-1 ,维库溴铵0.1mg?kg-1 ,经口腔气管插管,术中维持靶浓度为2~4mg?L-1 ,依据血流动力学监测指标进行调节,不用其他麻醉药.术中监测ECG,SpO2 及无创血压,分别记录诱导前、诱导后2min、插管即刻、插管后2min、切皮及气腹后NBP和HR.停药后以呼之能睁眼作为患者苏醒指标,记录停药至苏醒时间及苏醒时效应室浓度. 统计学处理:所有参数以x ±s表示,采用本校SPLM软件包进行方差分析.2 结果 插管即刻HR,SBP,DBP和MBP与诱导前比较均升高,统计学处理有显著性差异(P<0.05),人工气腹后DBP和MBP也较诱导前有明显升高(P<0.05),其他各时点血流动力学参数与诱导前比较无显著差异(Tab1).停药至患者苏醒的平均时间为(8.6±2.7)min,相应效应室浓度为(1.48±0.24)mg?L-1 . 表1 诱导和维持期间血液动力学变化 略3 讨论 TCI只要求我们输入患者的年龄、体质量及效应室目标浓度,其他工作都由系统自动完成并维持在一定的血浆药物浓度范围内,使麻醉操作变得十分简便,与人工控制输注相比,TCI避免了输注速率的复杂计算,而将复杂的输注过程交给输注泵[3-7] ,且TCI能够平稳的控制血药浓度,改善了药物对循环及呼吸系统的影响.麻醉药的血药浓度比输注速率更能反应麻醉的深度,因此TCI提高了对麻醉的控制[8,9] ,因而深受麻醉医师的欢迎.我们选择腹腔镜胆囊切除术患者作为研究对象是因为该手术相对短小,往往只需一支异丙酚即可,患者经济负担较小. 通过观察发现,采用4mg?L-1 的效应室目标浓度诱导,诱导后2min血流动力学参数均无显著变化,但插管即刻HR和BP都有所升高,提示对插管时心血管反应的抑制尚不完全.插管后改用2mg?L-1 维持时,即使是切皮刺激也未出现HR和BP较大的变化.因而基本可以满足术中维持所需的麻醉深度.实验中发现,气腹后HR及SBP无变化,而DBP及MBP升高,可能与腹内压升高有关. 从2mg?L-1 浓度停药后,平均需8.6min患者即可睁眼,相应的效应室浓度平均为1.48mg?L-1 ,提示诱导时效应室目标浓度至少应达到1.5mg?L-1 才能使患者入睡. 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