【作者】 王丽；

【导师】 李建国；

【作者基本信息】 武汉大学 ， 重症医学， 2018， 博士

【摘要】 第一部分:不同镇静药对口腔颌面外科术后留置气管导管患者的镇静作用目的:探讨不同镇静药对口腔颌面外科术后留置经鼻气管导管患者的镇静作用及其可能的不良反应方法:将口腔颌面外科术后留置经鼻气管导管患者60例按照随机数字表法为三组:咪达唑仑组(A组,20例)、丙泊酚组(B组,20例)、右美托咪定组(C组,20例)。患者入ICU后各组患者均采用氢吗啡酮4-8μg/kg.h-1持续泵注镇痛,A组咪达唑仑负荷剂量0.03～0.3mg/kg静脉推注,维持剂量0.04～0.2mg/(kg.h)持续泵注;B组(20例):丙泊酚负荷剂量0.5～3mg/kg静脉推注,维持剂量0.5～4mg/(kg.h)持续泵注;C组(20例):右美托咪定负荷剂量0.6～1 μg/(kg.h)静脉泵入10min,维持剂量0.2～0.7μg/(kg.h)持续泵注。分别记录入ICU镇静前(T0)和镇静开始后30min(T1)、1h(T2)、2h(T3)、6h(T4)、12h(T5)和拔管后 1Omin(T6)各时间点 Ramsay 镇静评分和BPS镇痛评分,以及手指氧饱和度(SpO2)、心率(HR)、平均动脉血压(MAP)、呼吸频率(RR);记录三组患者药物停用后病人拔管的时间;记录各组患者躁动发生率;记录各组患者心动过缓发生率、低血压发生率;拔管前抽取动脉血进行血气分析,记录pH、SpO2、PaCO2。结果:咪达唑仑、右美托咪定和丙泊酚均能使病人Ramsay评分达到2-4分,Ramsay评分差异无统计学意义(p＞0.05),镇静效果相似。在T3、T4、T5时,右美托咪啶组BPS评分均低于咪达唑仑组和丙泊酚组,差异有统计学意义(p<0.05);其他各时间点BPS评分比较,三组之间比较无明显差异(p＞0.05)。停药后拔管时间右美托咪定和丙泊酚组均较咪达唑仑组短(p<0.05)。三组患者低血压发生率差别无统计学意义(p>0.05);心动过缓发生率右美托咪啶组高于与丙泊酚和咪达唑仑组(p<0.05);右美托咪定组和丙泊酚组患者并发躁动的人数明显低于咪达唑仑组,差异具有统计学意义(p＜0.05)。结论:在一定剂量范围内,右美托咪啶和咪达唑仑、丙泊酚均能满足ICU患者的镇静需要并且患者生命体征平稳;停药后右美托咪定组比咪达唑仑组和丙泊酚组拔管时间短;右美托咪啶具有一定的镇痛作用;另外与咪达唑仑相比,右美托咪啶和丙泊酚可减少ICU患者的躁动发生率。第二部分不同镇静药对留置气管导管患者应激反应及炎症细胞因子的影响目的:观察不同镇静药对口腔颌面外科术后留置经鼻气管插管患者的应激反应及炎症细胞因子的影响。方法:将口腔颌面外科修复术后留置经鼻气管导管患者60例按照随机数字表法为三组:咪达唑仑联合氢吗啡酮组(A组,20例)、丙泊酚联合氢吗啡酮组(B组,20例)、右美托咪定联合氢吗啡酮组(C组,20例)。患者入ICU后各组患者均采用氢吗啡酮4-8μg/kg.h-1持续泵注镇痛,A组咪达唑仑负荷剂量0.03～0.3mg/kg静脉推注,维持剂量0.04～0.2mg/(kg.h)持续泵注;B组(20例):丙泊酚负荷剂量0.5～3mg/kg静脉推注,维持剂量0.5～4mg/(kg.h)持续泵注;C组(20例):右美托咪定负荷剂量0.6～1 μg/(kg.h)静脉泵入10min,维持剂量0.2～0.7μg/(kg.h)持续泵注。记录各组患者术中出血量和输入液体总量;记录入ICU镇静前(T0)和镇静开始后30min(T1)、1h(T2)、2h(T3)、6h(T4)、12h(T5)和拔管后 1Omin(T6)各时间点 Ramsay 镇静评分;检测手术开始前(t0)、手术结束后(t1)和ICU镇静停止拔管后(t2)各时间点患者血浆C反应蛋白(CRP)、皮质醇(Cor)、肿瘤坏死子-α(TNF-α)、白细胞介素-6(IL-6)水平。结果:在相同镇静深度下,右美托咪定对口腔颌面外科术后留置经鼻气管导管患者C反应蛋白、皮质醇、炎性细胞因子TNF-α和IL-6分泌均有明显抑制作用,并且这种抑制作用强于咪达唑仑和丙泊酚。结论:口腔颌面外科术后患者可出现明显的应激反应和炎性反应;在相同镇静深度下,右美托咪定对这种应激反应和炎性反应均有一定的抑制作用;右美托咪定这种抑制作用强于咪达唑仑和丙泊酚更多还原

【Abstract】 Part oneStudy on the Sedative Mode of Retention of Tracheal Intubation after Repair of Forearm Flap in Oral CancerObjective To investigate the sedative mode and effect of indwelling nasal tracheal duct in ICU after oral forearm flap repair.Method Sixty patients with nasal tracheal ducts who underwent oral forearm flap repair were divided into three groups randomly:midazolam combined with hydromorphone group(group A,n=20),propofol combined with hydromorphone group(group B,N=20),dexmedetomidine combined with hydromorphone group(group C,n=20).After the patients were admitted to the ICU,midazolam in dose of 0.05 mg/kg was injected into the group A for 10 minutes and then keep its injection rate of 0.04～0.2mg/(kg.h)mixed with hydromorphone in rate of 4-8μg/(kg.h);for group B,propofol is injected with dosage of 1.00-3.00 mg/kg in 10 minutes,and then keep injection rate of 0.5～4 mg/(kg.h)combined with hydromorphone in rate of 4-8μg/kg.h-1;for group C,dexmedetomidine is injected in rate of 1μg/kg.h-1 for 10 minutes,and then keep the injection rate of 0.2～0.7μg/(kg.h)mixed with hydromorphone in rate of 4-8pg/(kg.h).Three groups were rated by Ramsay sedation.And the dose of sedative analgesic medications are adjusted in order to make the Ramsay sedation score within 2-4 points.Patients can tolerate tracheal tube and have no cough,irritability,increased blood pressure and heart rate and so on.Record the sedative drug onset time to reach the target sedation range and the time the patients are awake after the drug has been withdrawn.Record the total dosage of the sedative drug for three groups.During indwelling endotracheal intubation,the Ramsay sedation score,VAS score,finger oxygen saturation(SpO2),heart rate(HR),mean arterial blood pressure(MAP),respiratory rate(RR)before using sedative(T0),30min(T1),1h(T2),2h(T3),6h(T4),12h(T5)after injection of sedative and 10min(T6)after extubation,were recorded,and the rate of incidences of adverse reactions,such as decreased respiratory rate,bradycardia and hypotension were calculated.Arterial blood was drawn before extubation to analyze blood gas,and pH,SpO2,and PaCO2 were recorded.Results Midazolam,dextromethorphan and propofol all resulted in a Ramsay score within 2-4,namely,they have similar sedative effect.There was no significant difference in the onset time of sedative drugs among the three groups(p>0.05).The recovery time of dexmedetomidine and propofol was significantly faster than that of midazolam(p<0.05).The total dose of analgesics required in the dexmedetomidine group was less than that in the propofol group and the midazolam group,and the differences were statistically significant(p<0.05).There was no statistically significant difference in the number of bradycardia and hypotension among the three groups(p>0.05).Batroxobin and midazolam may be more likely to cause respiratory depression during sedation compared to dexmedetomidine since the number of patients who needed to be assisted breathing in these two groups was significantly higher than that in the dexmedetomidine group.The number of patients with dexamethasone and propofol was significantly lower than that of midazolam,and the differences were statistically significant(p<0.05).There was no statistically significant difference in mortality among the three groups after sedation treatment.Conclusions In a certain range of dosage,dexmedetomidine and midazolam,propofol can meet the needs for sedation in ICU patients.And dexmedetomidine has analgesic effect,which may save the amount of analgesic drugs to reduce the occurrence of respiratory depression.In addition,compared with midazolam,dexmedetomidine and propofol can reduce the incidence of delirium in ICU patients.There was no difference in mortality among the three groups.Part twoObjective To investigate influences on the stress response and inflammatory cytokines of patients who had indwelling nasal tracheal duct in ICU after oral forearm flap repair.Method Sixty patients underwent oral forearm flap repair with nasal tracheal ducts were divided into three groups randomly in method of random number table:midazolam combined with hydromorphone group(group A,n=20),propofol combined with hydromorphone group(group B,N=20),dexmedetomidine combined with hydromorphone group(group C,n=20).After the patients were admitted to the ICU,midazolam in dose of 0.05 mg/kg was injected into the group A for 10 minutes and then keep its injection rate of 0.04～0.2mg/(kg.h)mixed with hydromorphone in rate of 4-8μg/(kg.h);for group B,propofol is injected with dosage of 1.00-3.00 mg/kg in 10 minutes,and then keep injection rate of 0.5～4 mg/(kg.h)combined with hydromorphone in rate of 4-8μg/kg.h-1;for group C,dexmedetomidine is injected in rate of lpg/kg.h-1 for 10 minutes,and then keep the injection rate of 0.2～0.7μg/(kg.h)mixed with hydromorphone in rate of 4-8μg/(kg.h).The Ramsay sedation score before using sedative(T0),30min(T1),1h(T2),2h(T3),6h(T4),12h(T5)after injection of sedative and 10min(T6)after extubation were recorded.The operation time,blood loss during operation,total amount of liquid input during operation and the indwelling time of tracheal intubation in ICU were recorded;The levels of plasma C reactive protein(CRP),cortisol(Cor),tumor necrosis factor alpha(TNF-a)and interleukin-6(IL-6)before the operation(t0),after the operation(t1)and after end of sedation in ICU(t2)were recorded.Results There was no difference among the three groups in the operation time,blood loss during operation,total amount of liquid input during operation and the indwelling time of tracheal intubation in ICU(p>0.05).The Ramsay score of three groups can lie within 2-4,namely,they have similar sedative effect(p>0.05).The levels of Cor,CRP,TNF-a and IL-6 of the three groups at t1 were significantly increased(p<0.05)compared to those at t0.And the levels of Cor,CRP,TNF-a and IL-6 of the three groups at t2 were significantly decreased(p<0.05)compared to those at t1.Especially,Cor,CRP,TNF-a and IL-6 of group C decreased more obviously compared to those of groups A and B.Conclusions The forearm flap repair of oral cancer can induce stress reaction of body,and then increase the secretion of CRP,Cor and inflammatory cytokines.Under the same sedation depth,dexmedetomidine has the inhibiting effect on secretion of CRP,Cor,TNF-a and IL-6,which is strong than that of propofol and midazolam.更多还原