【作者】 杨丽；

【导师】 李李；

【作者基本信息】 中南大学 ， 麻醉学， 2013， 硕士

【摘要】 目的：比较不同时长全凭静脉麻醉手术患者顺式阿曲库铵间断静脉注射和持续静脉输注两种给药方式的肌松效应及停药后的肌松恢复情况。方法：择期全麻下行开腹妇科手术患者48例,ASA Ⅰ或Ⅱ级,根据手术时长分为A组(手术时间在2小时以内)和B组(手术时间3小时以上)。根据输注方式不同,A和B组再随机分别分为A1组和A2组(n=12),B1组和B2组(n=12)。麻醉诱导：四组均静脉注射咪达唑仑0.05mg/kg、丙泊酚1.5mg/kg、瑞芬太尼0.1ug/kg,待患者意识消失后,打开TOF-GUARD肌松监测仪,用AUTO1模式进行定标,待TOF(四个成串刺激)稳定在100%后,静脉注射顺式阿曲库铵0.15mg/kg(3倍ED95),待T1达到最大抑制时插入气管导管。麻醉维持：吸入氧流量1L/min,维持PETCO235-45mmHg,以TCI方式持续输注丙泊酚和瑞芬太尼,丙泊酚血浆靶浓度设定在2.0-4.0ug/ml范围,瑞芬太尼血浆靶浓度2.0-5.0ng/ml范围,使平均动脉压维持在术前基础值±15%左右。当术中T1>5%时,A1组和B1组静脉追加注射0.05mg/kg的顺式阿曲库铵；A2组和B2组采用微量输注泵开始持续输注顺式阿曲库铵3ug/kg/min,T1肖失后调整输注速度至1.5ug/kg/min,维持T1≤5%。关腹膜时,A2组和B2组停止输注顺式阿曲库铵,手术结束时停止丙泊酚和瑞芬太尼的靶控输注,所有患者均不给予肌松拮抗药,待其自然恢复。观察并记录麻醉诱导前(T1)、麻醉诱导后(T2)、气管导管插管后即刻(T3)、插管后30min (T4)、插管后1h(T5)、气管导管拔管前5min (T6)、拔管后即刻(T7)、拔管后5min (T8)各时间点的生命体征变化；记录各组顺式阿曲库铵的起效时间以及气管插管条件评分;记录最后一次给药或停止输注至T1恢复至25%和75%、恢复指数(RI)、 TOF恢复至75%的时间(TOFrO.75)及患者拔管时间,记录各组的手术时长及丙泊酚、瑞芬太尼、顺式阿曲库铵的用药量；记录四组病人的输液总量、出血量及尿量；记录各组患者不良事件发生情况。结果：四组患者的年龄、身高、体重、体重指数、术前血红蛋白比较无统计学差异(P>0.05)；四组患者术中出入量情况和手术时间比较差异无统计学意义(P>0.05)；四组患者的平均动脉压(MAP)、心率(HR)比较,A1组与A2组、B1组与B2组在同一时间点的组间比较差异无统计学意义(P>0.05),各组内比较诱导后即刻(T2)的MAP、HR明显小于T1时点,差异有统计学意义(P<0.05)。无一例患者术中出现皮肤潮红、皮疹、支气管痉挛等组胺释放反应。A1组和A2组比较,肌松起效时间和恢复指数无明显差异,A1组T1恢复至25%和75%、TOFr0.75的时间略长于A2组,但差异无统计学意义(P>0.05)；两组病人的顺式阿曲库铵的平均用药量亦无明显差异。Bl组和B2组比较,肌松起效时间和恢复指数亦无明显差异,B2组T1恢复至25%和75%、TOFr0.75的时间短于B1组,差异有统计学意义(P<0.05)；B2组顺式阿曲库铵的平均用药量明显小于B1组,差异有统计学意义(P<0.05)。术后随访,手术医师对术中的肌松满意度较高。结论：(1)顺式阿曲库铵作为一种新型的非去极化肌松药,既可以按间断静注的方式给药也可以持续输注,两种方式均可满足手术需要。(2)在短小手术中(<2h)间断静注与持续输注比较,停药后肌松的恢复时间、平均用药量无明显差异。(3)在长时程手术中(>3h)持续输注组在停药后肌松的恢复时间明显缩短、平均用药量也减少。提示长时程手术持续输注更占优势。更多还原

【Abstract】 Objective:To compare the effect of neuromuscular blockade and the recovery of cisatracurium between intermittent bolus injection and continuous infusion in patients experienced different length surgery under intravenous anesthesia.Methods:Forty-eight patients(ASAI-II) who had no neuromuscular disease and underwent selective surgery under intravenous anesthesia were randomly divided into group A(less than two hours of surgery) and B(more than three hours of surgery)(n=24). The group A and B were divided into subgroups(n=12) respectively:Al, A2, B1, B2. In group A1and B1, patients received cisatracurium by intermittent bolus injection and in group A2and B2,by continuous infusion. Anesthesia induction: midazolam0.05mg/kg,0.15mg/kg propofol,Remifentanil0.1ug/kg were used. Assisted respiration was carried out when the patients lost consciousness. At the same time, the TOF-GUARD muscle relaxant monitor was opened, selected AUTO1model calibration, stayed TOF (train-of-four) steady at100%followed by giving a single bolus of cisatracurium0.15mg/kg(3×ED95). After T1reached maximum blocking (response completely disappeared), tracheal intubation. Anesthesia maintain:All patients breathed in oxygen flow1L/min, were maintained PETCO2at35-45mmHg, were continuous infusion of propofol(target plasma concentration set in the range2.0-4.0μg/ml) and remifentanil (target plasma concentration set in the range2.0-5.0ng/ml) in TCI way, and were maintained the average arterial pressure based on the preoperative value plus or minus15%. When the post tetanic count of TOF at2,0.05mg/kg cisatracurium were injected in group A1and B1, and continuous infusion cisatracurium3ug/kg/min were started in group A2and B2, then adjusted speed to1-2ug/kg/min after15min after infusion, maintained the post tetanic count of TOF at1. Group A1and B1stoped bolus injection of cisatracurium, and group A2and B2stoped continuous infusion of cisatracurium at half an hour before the end of surgery, stoped propofol and remifentanil infusion while fastening the belly band. All patients recovered spontaneously without the rivalry of neuromuscle blockade. Recorded the change of MAP and HR at the moment of the base value(T1), after anesthesia induction(T2), after endotracheal tube intubation(T3), immediately after30min(T4) and lh(T5) after intubation, and5min before extubation (T6), immediately after extubation (T7),5min after extubation(T8); Recorded cisatracurium working time and endotracheal intubation conditions; Recorded T1reached25%and75%, recovery index (RI), TOF recovery to75%(TOFr0.75) and extubation time; Recorded operation duration and total dosage of propofol, remifentanil and cisatracurium respectively; Recorded amount of fluid and red cells infusion, and urine output; Recorded adverse events in patients in each group.ResultsrThere were no significant difference in age, body height and weight and preoperative hemoglobin level among the four groups(P>0.05). There were also no significant difference in loss of fluid volume and infusion quantity, and operation time length among the four groups(P>0.05). The hemodynamics was stable, ane no difference at the eight time-pionts mong the four groups(P>0.05),respectively, but MAP and HR at T2were lower than T1compared in every group. In48patients, no clinical manifestations of histamine release such as flushing, rash and bronchospasmoc curred.There was no significant difference in the onset time,duration of neuromuscular blockade, and the mean infuse rates between group A1and A2(P>0.05).There was no significant difference in the onset time and duration of neuromuscular blockade between group B1and B2(P>0.05).The mean infuse rate in group B2is less than that in group B1(P<0.05).Postoperative satisfaction measurement showed that the degreen of satisfaction of surgeons at operative muscle relaxant were high.Conclusion:(1)The effect of neuromuscular blockade and the recovery of cisatracurim as a new type of nondepolarizing muscle relaxant between intermittent bolus injection and continuous infusion were similar, and both were applied in different surgery time.(2)In short surgery (<2h), both intermittent bolus injection and continuous infusion of cisatracurium could meet the needs of the operation, and there was no significant difference in recovery of neuromuscular blockade.(3)In long surgery (>3h), there was no significant difference in recovery of neuromuscular blockade between intermittent bolus injection and continuous infusion of cisatracurium, but the mean infuse rate in continuous infusion group was less than that in intermittent bolus group, which showed continuous infusion of cisatracurium could have an advantage in long surgery.更多还原