【作者】 田刚；

【导师】 姚尚龙；

【作者基本信息】 华中科技大学 ， 麻醉学， 2011， 硕士

【摘要】 第一部分右美托咪定在癫痫手术麻醉中的镇静效应观察目的研究右美托咪定在癫痫手术麻醉中的镇静效应,同时观察其不良反应发生情况。方法经湖北医药学院附属人民医院伦理委员会批准,选择该院2009年10月至2010年4月择期行癫痫手术患者30例,ASAⅠ-Ⅱ级,,将病人随机分为两组:Dex镇静组(D组)和对照组(C组),各15例。D组静脉缓慢注射负荷剂量Dex 1μg/kg(用生理盐水配制成4μg/ml,10min注射完毕);C组静脉注射等容量的生理盐水。两组术中均吸入1-3%浓度七氟醚,微量泵静脉泵注丙泊酚、瑞芬太尼维持麻醉。D组术中持续静脉泵入Dex 0.4μg/kg/h,C组则泵入等容量生理盐水。监测所有患者的HR、MAP、RR、SPO2、以及OAA/S和Ramesay镇静评分,并记录术中血流动力学异常情况处理、丙泊酚及瑞芬太尼用量、自主呼吸恢复时间、苏醒时间、清醒拔管时间、不良反应发生情况。连续记录基础值(T0)、静脉注射Dex负荷剂量(生理盐水)即刻(T1)、Dex负荷剂量(生理盐水)10min后(T2)、诱导后插管前(T3)、插管成功后即刻(T4)、切皮前(T5)、切皮后2min(T6)、苏醒时刻(T7)、拔管后即刻(T8)上述各项指标。结果1、两组患者的一般情况(性别比例、年龄、ASA分级、体重)无统计学差异。2、Dex负荷剂量输注完毕及静脉维持期间,镇静效应明显,丙泊酚和瑞芬太尼用量明显减少(P<0.05);OAA/S镇静评分明显降低,Ramesay镇静评分明显升高(P<0.05)。3、D组患者的HR比基础值明显减慢(P<0.05),MAP有所下降(P>0.05);所有患者无明显呼吸抑制。4、D组患者的自主呼吸恢复时间、苏醒时间、清醒拔管时间较C组有所缩短,但无明显差别(P>0.05)。5、两组患者围术期不良反应的发生率都很低,且差异不显著(P>0.05)。结论右美托咪定负荷剂量输注完毕及静脉用药维持期间,可产生明显的镇静作用,有效的减少了丙泊酚、瑞芬太尼等麻醉药物的用量,而且未见严重不良事件发生,表明其在神经外科手术中的应用具有良好的安全性。第二部分右美托咪定在癫痫病灶切除术中对皮层脑电图的影响目的研究癫痫病灶切除术中持续输注右美托咪定对皮层脑电图的影响。方法经湖北医药学院附属人民医院伦理委员会批准,选择该院2010年5月至2010年12月择期行癫痫手术患者60例, ASAⅠ-Ⅱ级,随机分为A、B、C、D四组,每组15例。B、C、D三组静脉缓慢注射负荷剂量Dex1μg/kg(用生理盐水配制成4μg/ml,10min注射完毕),之后维持剂量分别为:B组0.2μg/kg/h,C组0.4μg/kg/h,D组0.6μg/kg/h。A组则静脉注射等容量的生理盐水。10min后依次静脉注射丙泊酚2mg/kg、芬太尼3μg/kg、维库溴铵0.1mg/kg麻醉诱导,气管插管后行纯氧间歇正压控制通气。四组患者术中微量泵持续泵注瑞芬太尼以及吸入1-3%七氟醚维持麻醉。四组患者术中均通过ECOG监测定位癫痫病灶部位,当需行ECOG监测时开始停用所有药物减浅麻醉(肌松剂除外),直至监测完毕。手术结束时,四组均停药。术后待患者自然清醒,自主呼吸恢复良好后拔出气管导管送回病房。记录术中停药至ECOG定位明确时的时间;记录术中ECOG波形及分级情况;选择基线稳定、无干扰的10S描记图为统计对象,由专业的脑电生理专家计算各脑电波形的出现数量,测量各脑电波波幅值。结果1、四组患者的一般情况(性别比例、年龄、身高、体重)无统计学差异。术中血流动力学均维持稳定。2、与A组相比,B、C两组术中停药至ECOG定位明确时的时间有所延长,但差异不显著,无统计学意义(P>0.05);而D组需要等待的时间明显延长,较A组差异显著(P<0.05)。3、B、C两组ECOG分级情况尤其是重度异常例数和所占比例与A组非常相似,差异不显著(P>0.05);而D组ECOG分级情况与A组有明显差异,重度异常例数和所占比例明显降低(P<0.05)。4、四组患者术中ECOG均有棘波出现。随着Dex剂量的增加,术中ECOG棘波的频率逐渐减少,但不明显,无统计学意义(P>0.05)。四组患者术中ECOG棘波波幅无明显变化。结论右美托咪定在癫痫病灶切除术麻醉中适宜的维持剂量为0.2—0.4μg/kg/h,此剂量对ECOG无明显诱发或抑制作用,不影响术中皮层电位监测,不会对癫痫病灶定位形成干扰。更多还原

【Abstract】 Part one The sedative effect of Dexmedetomidine in anesthesia during epilepsy operationObjectiveTo observe the sedative effect and adverse reaction of Dexmedetomidine in anesthesia during epilepsy operation.MethodsThirty epilepsy patients (ASAⅠ-Ⅱ) were randomly assigned into two groups (n=15 for each group), including Dexmedetomidine group (Group D) and control group (Group C). In Group D, a loading dose of 1μg/kg Dexmedetomidine was slowly injected in 10 minutes, followed by 0.4μg/kg/h Dexmedetomidine maintained until the end of surgery. In Group C, 0.9% normal saline were given as control. In two groups, inhaling sevoflurane with concentrations of 1-3% and pumping propofol and remifentanil maintain anesthesia. The HR, MAP, RR, SPO2, OAA/S scale, Ramesay scale were monitored, and intraoperative hemodynamics abnormalities, dose of propofol and remifentanil, time of spontaneously breathing recovery, awakening, consciousness and extubation, adverse reaction were recorded. The above parameters were continuous recorded at the time points of pre-infusion Dexmedetomidine(T0), after loading dose(T1), 10 minutes after loading dose(T2), after induction and before intubation(T3), after intubation(T4), before incising skin(T5), 2 minutes after incising skin(T6), awakening(T7), afer extubation(T8).Results1. There was no significant difference in general state of health among two groups, including sex ratio, age, ASA grade, body weight.2. After loading dose of Dexmedetomidine was given and during maintain continuous infusion, doses of propofol and remifentanil and OAA/S scale obviously decreased(P<0.05); Ramesay scale stepped up significantly (P<0.05), which showed the obvious sedative effects.3. HR of patients in Group D obviously decreased (P<0.05) compared with basal value, MAP descend (P>0.05); there was no respiratory depression.4. Time of breathing recovery, awakening, consciousness and extubation in Group D was short compared with Group C, but there was no significant difference between two groups (P>0.05).5. Incidence rate of adverse reaction in two groups was very low, there was no obvious difference between two groups (P>0.05). ConclusionAfter loading dose of Dexmedetomidine was given and during maintain continuous infusion, there was evident sedative effect, doses of propofol and remifentanil obviously decreased, there was no severe harmful incidence, which showed satisfactory safety.Part two The effect of Dexmedetomidine on electrocorticography in epilepsy lumpectomyObjectiveThe present study was to evaluate the effect of continuing infusion Dexmedetomidine on electrocorticography in epilepsy lumpectomy.MethodsSixty epilepsy patients (ASAⅠ-Ⅱ) were randomly assigned into four groups, including Group A,B,C and D, n=15 for each group. A loading dose of 1μg/kg Dexmedetomidine was slowly injected in 10 minutes for all patients. Then anesthesia was induced with propofol 2mg/kg, fentanyl 3μg/kg, vecuronium 0.1mg/kg and maintained with sevoflurane, remifentanil and Dexmedetomidine. The patients were mechanically ventilated after tracheal intubation with the parameters as follows: VT 8-10ml/kg, RR 12 bpm, I:E 1:1.5. The pressure of End-tidal CO2 was maintained at 30-35mmHg. The maintenance dose of Dexmedetomidine is: 0.2μg/kg/h in Group A, 0.4μg/kg/h in Group B, 0.6μg/kg/h in Group C and 0.8μg/kg/h in Group D respectively. For all patients, the electrocorticography is monitored to locate focus of epilepsy for all patients. All drugs were stopped (except of vecuronium) when electrocorticography is begin monitored. Time of drug discontinuance to electrocorticography location was recorded. Intraoperative electrocorticography waveform was recorded, amplitude and frequency of waves were measured.Results1. There was no significant difference in general state of health among four groups ( sex ratio, age, body height, body weight ).2. Compared with Group A, the time of drug discontinuance to electrocorticography location clearly in Group B and Group C extended, but there was no significant difference. However the time of waiting in Group D obviously extended, there was significant difference compared with Group A.3. Classification of electrocorticography, especially numbers and ratio of grossly abnormality in Group B and Group C were very similar with Group A. But there was obviously difference in electrocorticography classification between Group D and Group A, numbers and ratio of grossly abnormality obviously decreased in Group D.4. In four groups, there was spike wave in electrocorticography. Frequency of spike wave in electrocorticography gradually decreased when dose of Dexmedetomidine increased, but there was no significant difference (P>0.05). Amplitude of spike wave in electrocorticography has not markedly changed in four groups.ConclusionSuitable dose range of Dexmedetomidine in maintenance process of anesthesia is 0.2-0.4μg/kg/h in epilepsy lumpectomy, this dose doesn’t induce depressed electrocorticography, therefore it doesn’t effect the location of focus of epilepsy.更多还原