【作者】 张晓丰；

【导师】 陈鹏；

【作者基本信息】 吉林大学 ， 麻醉学（专业学位）， 2021， 硕士

【摘要】 目的:本文探讨脑电双频指数引导下地氟烷复合瑞芬太尼用于神经监测甲状腺切除术的麻醉效果,并对其术中血流动力学、用药量、术后清醒的拔管时间及不良反应等方面进行分析。方法:选取我院择期行神经监测甲状腺切除术患者90例,应用随机数字表法,将入选患者随机分为三组,地氟烷复合瑞芬太尼麻醉维持组（R组）、单纯地氟烷吸入麻醉维持组（D组）和丙泊酚复合瑞芬太尼麻醉维持组（P组）,每组30例。三组患者均采用靶控输注丙泊酚复合瑞芬太尼和静脉推注顺式阿曲库铵的麻醉诱导方式,诱导完成后进行气管插管。R组采用地氟烷复合瑞芬太尼的麻醉维持方法,根据BIS调整地氟烷用量,使BIS维持在45-60之间,同时根据血流动力学情况调整瑞芬太尼用量;D组采用全吸入地氟烷的麻醉维持方法,使术中麻醉深度维持在1.2-1.4 MAC;P组采用标准靶控输注丙泊酚复合瑞芬太尼的麻醉维持方式,丙泊酚和瑞芬太尼分别采用Schnider模型和Minto模型,丙泊酚效应室浓度（effect site concentration,Ce）为2.5-5μg/ml,瑞芬太尼Ce为2-6ng/ml,丙泊酚和瑞芬太尼分别根据BIS和血流动力学情况进行适当调整。三组患者均于手术结束前10分钟追加羟考酮注射液。记录患者的术中血流动力学情况:入室（T0）、插管即刻（T1）、切皮即刻（T2）、切除肿物时（T3）、拔管即刻（T4）的平均动脉压（MAP）、心率（HR）、Sp O₂和BIS;记录患者的术中地氟烷、瑞芬太尼的用药量和MAC值;记录患者的术后清醒的拔管时间;记录患者的不良反应的发生情况:恶心呕吐、躁动、呛咳、嗜睡、术中知晓等。结果:（1）术中血流动力学:在T3时刻,R组MAP低于D、P组,组间比较差异有统计学意义（P<0.05）,D、P组相比差异无统计学意义（P>0.05）;在T2、T3、T4时刻,D组心率快于R、P组（P<0.05）,R、P组相比差异无统计学意义（P>0.05）;三组BIS、Sp O₂差异无统计学意义（P>0.05）。（2）术中用药量:R组瑞芬太尼的用药量少于P组,组间比较差异有统计学意义（P<0.05）;R组地氟烷的用药量少于D组、术中MAC值低于D组（P<0.05）。（3）术后清醒拔管时间:R组清醒拔管时间明显短于P、D组,组间比较差异有统计学意义（P<0.05）。（4）术后不良反应情况:D组术后恶心呕吐发生率高于R、P组（P<0.05）,R、P组相比差异无统计学意义（P>0.05）;R组术后嗜睡发生率少于D、P组（P<0.05）,三组患者术后躁动情况和术中知晓,呛咳情况发生率均较低,组间比较差异无统计学意义（P>0.05）。结论:地氟烷复合瑞芬太尼和丙泊酚复合瑞芬太尼的麻醉维持方法均可满足神经监测甲状腺切除术患者的麻醉需要,但地氟烷复合瑞芬太尼组术中血流动力学更平稳,清醒拔管时间短,瑞芬太尼的用药量少,同时术后不良反应出现概率低。单纯地氟烷吸入与地氟烷复合瑞芬太尼的麻醉维持方法相比,血流动力学欠平稳,清醒拔管时间较长,地氟烷用药量大,恶心呕吐、嗜睡等术后不良反应发生率高。地氟烷复合瑞芬太尼的麻醉维持方法更适合神经监测下甲状腺切除术的麻醉。更多还原

【Abstract】 Objective:To investigate the anesthetic effect of desflurane combined with remifentanil guided by bispectral index in neuromonitoring thyroidectomy and analyze its hemodynamics,dosage,extubation time and adverse reactions.Methods:Using random number table,90 patients who underwent selective thyroidectomy with nerve monitoring in our hospital were selected and randomly divided into three groups: desflurane inhalation anesthesia maintenance group(group D),desflurane combined with remifentanil anesthesia maintenance group(group R)and propofol combined with remifentanil anesthesia maintenance group(group P),with 30 cases in each group.All patients in the three groups were induced by target-controlled infusion of propofol-remifentanil and intravenous injection of cis atracurium,and endotracheal intubation was performed after induction.In group D,desflurane was inhaled to maintain the MAC at 1.2-1.4.Anesthesia maintenance method of group R used desflurane combined with remifentanil,adjust the amount of desflurane according to BIS to keep BIS between 45 and 60,and adjust the dosage of remifentanil according to hemodynamics.while group P used propofol to maintain the depth of anesthesia,remifentanil was injected intravenously and its dosage was adjusted according to hemodynamics.All the patients in the three groups were given oxycodone 10 minutes before the end of the operation.The intraoperative hemodynamics of the patients were recorded: mean arterial(MAP),heart rate(HR),Sp O2 and BIS were recorded at entry(T0),intubation(T1),skin incision(T2),tumor resection(T3)and extubation(T4).The intraoperative dosage of desflurane and remifentanil were recorded.Record the dosage of desflurane and remifentanil during operation.The intraoperative MAC values of groups were recorded.Record the extubation time of the patient after waking up.The adverse reactions of the patients were recorded,such as nausea and vomiting,agitation,cough,lethargy and awareness.Results:(1)Intraoperative hemodynamics: at T3,MAP in R group was lower than that in D and P groups(P< 0.05),while heart rate in D group was faster than that in R and P groups at T2,T3,T4(P< 0.05),and there was no significant difference in BIS and Sp O2 among the three groups.(2)Drug dosage: the dosage of remifentanil in group R was less than that in group P(P< 0.05).The dosage of desflurane in group R was lower than that in group D,and the intraoperative MAC value was lower in group R than in group D.(3)the time of extubation after operation: the time of extubation in group R was significantly shorter than that in group P and D(P< 0.05),and there was no significant difference between groups D and P(P> 0.05).(4)adverse reactions: the incidence of postoperative nausea and vomiting in group D was higher than that in group R and P(P< 0.05),and there was no significant difference between groups R and P(P> 0.05).The incidence of lethargy in group R was lower than that in group D and P(P< 0.05).There was no significant difference in agitation,cough and awareness among the three groups.Conclusion:The anesthesia maintenance methods of desflurane combined with remifentanil and propofol combined with remifentanil could meet the anesthetic needs of patients undergoing thyroidectomy with nerve monitoring,In the desflurane combined with remifentanil group,the hemodynamics was more stable,the awake extubation time was shorter,the dosage of remifentanil was less,and the probability of postoperative adverse reactions was low.Compared with the maintenance method of desflurane combined with remifentanil anesthesia,the maintenance method of pure desflurane inhalation anesthesia had less stable hemodynamics,longer awake extubation time,large dosage of desflurane,The incidence of postoperative adverse reactions such as nausea,vomiting and lethargy was high.The anesthesia maintenance method of desflurane combined with remifentanil was more suitable for the anesthesia of thyroidectomy under nerve monitoring.更多还原