【作者】 王倩；

【导师】 杜权；

【作者基本信息】 重庆医科大学 ， 临床医学（专业学位）， 2018， 硕士

【摘要】 目的对于手术患者,手术和心理等因素都可引起神经、代谢、炎症等应激改变,而术后恢复是这一系列应激反应恢复的过程。结直肠癌在消化道肿瘤发病率较高,当前主要治疗方式是以腹腔镜下手术切除为主的综合性治疗方式,如何促进这类患者的术后恢复、缩短住院时间、减少花费、增加医疗资源合理分配是个重要的课题。右美托咪定有镇静、镇痛、抗焦虑等优点,本研究以腹腔镜下结直肠癌根治手术为例,探讨右美托咪定在麻醉中的应用及其对术后疲劳、恢复质量的影响。方法选择重庆医科大学附属第二医院2017年4月至12月接受全身麻醉下行腹腔镜下结直肠癌根治术的择期患者共69例。研究对象随机分为试验组(34例)和对照组(35例),手术全程采取全凭静脉麻醉。试验组于麻醉诱导前15min静脉泵注0.5ug/kg右美托咪定(Dexmedetomidine,DEX),诱导药物起效后,于可视化纤维喉镜下行气管插管术,术中持续泵注0.2ug/kg/h的右美托咪定,于开始缝合皮肤时停止泵注。对照组于对应时间点同等剂量输注生理盐水。在术前1天(Pre)、术后第1天(Day1)、术后第2天(Day2)、术后第三天(Day3)进行问卷,包括恢复质量15项量表(15-item quality of recovery questionnaire,QoR-15)、疲劳严重程度得分(Fatigue severity score,FSS)、视觉模拟评分(Visual Analogue Score,VAS评分)及术后住院时间。记录诱导前15min(T0)、插管后即刻(T1)、切皮时(T2)、气腹建立(T3)、拔管即刻(T4)、出手术室时(T5)六个时间点的心率(heart rate,HR)和平均动脉压(mean arterial pressure,MAP)。记录麻醉苏醒时间,苏醒期呛咳、烦躁发生率及出手术室时的Ramsay镇静评分。记录术后24小时和48小时镇痛泵的按压次数,术后2天是否使用额外镇痛药物及术后24小时寒战、术后48小时恶心呕吐(postoperative nausea and vomiting,PONV)的发生。结果1两组患者的术前基本情况无显著差异(P>0.05)。2 QoR-15量表得分、FSS评分、术后住院时间:经两因素重复测量的方差分析,两组在QoR-15量表、FSS评分存在不同干预与时间的交互作用,差异具有统计学意义(P<0.05)。组内比较:两组患者的QoR-15量表得分在术后3天内的得分均低于术前,Day2、Day3得分高于Day1,Day2得分低于Day3,QoR-15量表得分随着时间的增加而增加;两组患者的FSS评分在术后3天均高于术前,Day2、Day3得分较Day1低,Day3得分低于Day2。组间比较:试验组和对照组在术前均相近,Day1、Day2、Day3试验组Qo R-15量表得分高于对照组,Day2、Day3试验组FSS评分低于对照组,QoR-15量表在Day2、FSS评分在Day3尤其明显(P<0.05)。对照组术后住院时间比试验组长1.43天(95%置信区间:0.28~2.58)。3麻醉期间HR和MAP:两因素重复测量的方差分析,两组患者不同处理措施和时间的交互作用对HR和MAP的影响无统计学意义,进而分析内因素的主效应。右美托咪定对HR和MAP的主效应具有统计学意义(P<0.05),试验组研究对象HR比对照组低4.178次/分(95%置信区间:1.818~6.538),试验组MAP比对照组低4.356mmHg(95%置信区间:1.094~7.617)。时间因素对HR和MAP的影响具有统计学意义(P<0.05)。对照组HR,T1和T4高于T0,差异有统计学意义(P<0.05);试验组各个时间点心率变化不明显(P>0.05)。对照组MAP,T1、T3和T4高于T0(P<0.05);试验组MAP,仅T4时高于T0(P<0.05)。4麻醉恢复期观察指标:两组苏醒时间无显著差别(P>0.05)。试验组拔管呛咳发生率(13.3%)明显低于对照组(70%),差异有统计学意义(P<0.05)。尽管苏醒期躁动发生率,对照组23.3%高于试验组的10%,但差异不具有统计学意义(P>0.05)。试验组Ramsay评分高于对照组(P<0.05)。5术后副反应观察指标:(1)VAS评分:两因素重复测量的方差分析提示:两组术后3天VAS评分差异均具有统计学意义(P<0.05)。组内比较:两组患者VAS评分在术后3天内的得分均高于术前,Day2、Day3得分低于Day1,Day2得分低于Day3,VAS评分随着时间的增加而减少。组间比较:在Day1时,试验组和对照组得分无明显差别(P>0.05),Day2、Day3试验组得分均低于对照组(P<0.05)。(2)术后24小时和48小时镇痛泵的按压次数,试验组较对照组少(P<0.05),同时试验组术后2天镇痛药物追加发生率低于对照组(P<0.05)。(3)试验组术后24小时寒战、术后48小时恶心呕吐(PONV)发生率均低于对照组(P<0.05)。结论1结直肠癌手术患者静脉输注右美托咪定能提高QoR-15得分,降低FSS得分,缩短术后住院时间,有利于术后恢复。2结直肠癌手术患者静脉输注右美托咪定能够抑制麻醉期间气管插管和拔管时的心率增加及血压升高,减少血流动力学的波动,保持麻醉的平稳。3结直肠癌手术患者静脉输注右美托咪定能够降低麻醉恢复期呛咳的发生率,有利于麻醉恢复。4结直肠癌手术患者静脉输注右美托咪定能减轻术后副反应,如疼痛,恶心、呕吐,寒战,有利于术后恢复。更多还原

【Abstract】 Object Surgery and concurrent psychological stressors can lead to a series of stress response,resulting in nervous,endocrine,and inflammatory changes.Postoperative recovery means that the body is getting back to ―normal‖ without stress response.Colorectal cancer is a high incidence of malignant tumor,which main treatment is in laparoscopic.How to promote this kind of patients with postoperative recovery to shorter hospital stay,reduce cost and increase medical resources reasonable allocation is an important subject.Dexmedetomidine has many characteristics,such as sedation,analgesia,anti-anxiety.In our study,we took laparoscopic colorectal cancer surgery for example to discusses the application of dexmedetomidine during anesthesia and the impact on the postoperative Fatigue severity score and Qo R-15 score.Methods A total of 69 patients were selected from the second hospital of Chongqing Medical University from April to December 2017,divided into the experimental group(34 cases)and the control group(35 cases)randomly.The experimental group was given 0.5 ug/kg dexmedetomidine 15 min before anesthesia induction;after intubation,intraoperative continuous pump 0.2 ug/kg/h to the skin began to sutured.The control group was given the same dose of saline at the same time.The questionnaire was conducted on the first day before surgery(Pre),the first day after surgery(Day1),the second day after surgery(Day2)and the third day after surgery(Day3),including Qo R-15 scale,fatigue severity score(FSS),VAS score and the length of hospitalization after surgery.The heart rate(HR)and mean arterial pressure(MAP)were both recorded respectively at the first 15 min before anesthesia induction(T0),intubation immediately(T1),cutting the skin(T2),pneumoperitoneum(T3),extubation(T4),leaving the operating room(T5).Record the recovery time,the incidence rate of bucking and agitation and the Ramsay sedation score before back to the ward.Record the number of analgesia pump compression in 24 and 48 hours,the postoperative shiver,nausea and vomiting,additional analgesic use.Results1 No significant difference between two groups in the baseline characters and perioperative parameters(P>0.05).2 The Qo R-15 scale score,FSS score and the length of hospitalization after surgery: through two factor analysis of repeated measurement,two groups in Qo R-15 scale,FSS score has interaction,the differences were significant(P<0.05).Comparison within group: two groups’ Qo R-15 scores within three days after surgery was lower than preoperative,the Day2 and Day3 score was higher than the Day1,the Day3 was higher than the Day2.The FSS score of both groups was higher in the three days after surgery,the scored of Day2 and Day3 was lower than Day1,Day3 was lower than Day2.Comparison between groups: in preoperative the score about two scales are similar,the experimental group scored Qo R-15 was higher and FSS was lower than control group during three days in postoperation,the Qo R-15 at Day2 and FSS score at Day3 were obvious(P<0.05).The length of hospitalization after surgery in the control group was 1.43 days longer than the test group(95% CI: 0.28~2.58).3 The HR and MAP during anesthesia: after two factor analysis of repeated measurement,there was no interaction of two groups with treatment and time,so we need to analysis the main effect factors.The HR 4.178 lower than the control group(95%CI:1.818 ~ 6.538).And the MAP of experimental group was 4.356 mm Hg lower than the control group(95%CI:1.094 ~ 7.617).In the control group,the HR was higher at T1 and T4 than T0(P<0.05);the change of HR in the test group was not obvious(P>0.05).In the control group,the MAP at T1,T3,T4 was higher than T0(P<0.05).In the test group,the MAP at T4 was higher than T0(P<0.05).4 Observation data during recovery from general anesthesia: there was no significant difference in waking time between two groups(P>0.05).The incidence of cough(13.3%)in the test group was significantly lower than that in control group(70%).The incidence of reactivity in the control group was 23.3%,which was higher than 10% in the experimental group,but the difference was meaningless(P>0.05).Ramsay score was higher in the test group(P<0.05).5 Postoperative adverse events:(1)the VAS score: interaction between two groups with different treatment and time(P<0.05).Comparison within group: The score of VAS in postoperative three days was higher than Pre;the score at Day2 and Day3 was lower than Day1;the score at Day3 was lower than Day2,we can conclude that the VAS score decreased as time goes on.Comparison between groups: at Day1,the score was no significant difference(P>0.05).But the scores at Day2 and Day3 in experimental group were lower than control group(P<0.05).(2)The number of analgesic pump compression was lower in the test group in 24 and 48 hours after surgery(P<0.05).And the analgesic drug supplementation after surgery was lower than the control group(P<0.05).(3)The incidence of postoperative shiver and PONV were lower in the experimental group(P<0.05).Conclusion1 In colorectal cancer surgery,DEX infusion can increase Qo R-15 scores,reduce FSS scores,shorten the length of hospital stay,and thus improve the postoperative recovery.2 In colorectal cancer surgery,DEX can inhibit the heart rate and blood pressure during intubation and extubation,reduce hemodynamic fluctuations,and provide stable anesthesia.3 In colorectal cancer surgery,DEX can reduce the incidence of cough in the convalescence period,which is conducive to the recovery of anesthesia.4 In colorectal cancer surgery,DEX can reduce the postoperative side effects,such as pain,nausea,vomiting,and shiver,which is conducive to postoperative recovery.更多还原