右美托咪定对达芬奇机器人辅助胸外科手术患者术后恢复质量和智能精神状态的影响
|
摘要
目的评价右美托咪定对行达芬奇机器人辅助胸外科手术(RATS)患者术后恢复质量和智能精神状态的影响。方法择期在全身麻醉下行RATS的患者60例,性别不限,年龄20～70岁,BMI<30 kg/m~2,美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级。采用随机数字表法将患者随机分为对照组和研究组,每组30例。2组患者麻醉诱导和维持方法相同:依次静脉注射咪达唑仑0.04 mg/kg、舒芬太尼0.4μg/kg、丙泊酚1.5～2.0 mg/kg和罗库溴铵0.6 mg/kg进行麻醉诱导,气管插管后行机械通气;麻醉维持采用吸入体积分数为0.015～0.025的七氟烷,使最低肺泡有效浓度(MAC)维持在0.5,每隔30 min静脉注射罗库溴铵5 mg,靶控输注(TCI)丙泊酚1.0～1.5μg/mL,输注瑞芬太尼0.05～0.15μg/(kg·min),维持脑电双频指数(BIS)值40～60。研究组在气管插管后10 min内静脉输注右美托咪定1μg/kg,随后泵注右美托咪定0.4μg/(kg·h)至手术结束前30 min,对照组给予等容量0.9%氯化钠溶液。分别在患者入手术室吸氧后(T_0),单肺通气后10 min(T_1)、20 min(T_2)、30 min(T_3)、40 min(T_4),以及双肺通气后15 min(T_5)各时间点,记录患者的平均动脉压(MAP)、心率、脑血氧饱和度。记录术中失血量、尿量、手术时间、麻醉时间、丙泊酚总用量,以及使用麻黄素和阿托品的患者例数。于拔除气管导管后吸空气状态下记录呼吸频率,以及行动脉血气分析记录动脉血氧分压(p_aO_2)和二氧化碳分压(p_aCO_2)。记录拔除胸部引流管时间、住院天数和肺部并发症(肺不张、肺炎、肺持续漏气)的发生情况。分别于术前和术后第1、3天完成恢复质量量表(QoR-15量表)和简易智能精神状态检查量表(MMSE量表)的评定。结果两组患者间各时间点的MAP、心率、脑血氧饱和度的差异均无统计学意义(P值均>0.05)。两组患者间手术时间、麻醉时间、术中失血量和尿量、血管活性药物使用情况的差异均无统计学意义(P值均>0.05),研究组的丙泊酚总用量显著少于对照组(P<0.05)。拔除气管导管后吸空气状态下,研究组的呼吸频率显著低于对照组(P<0.05),p_aO_2显著高于对照组(P<0.05),但两组间p_aCO_2的差异无统计学意义(P>0.05)。术后48 h内,研究组患者自控静脉镇痛平均按压次数显著少于对照组(P<0.05)。两组患者间肺部并发症发生率的差异无统计学意义(P>0.05)。研究组拔除胸部引流管时间和住院天数均显著短于对照组(P值均<0.05)。两组患者间术前QoR-15量表和MMSE量表得分的差异均无统计学意义(P值均>0.05);术后第1天,研究组的QoR-15量表和MMSE量表得分均显著高于对照组(P值均<0.05);术后第3天,研究组的MMSE量表得分显著高于对照组(P<0.05),两组间QoR-15量表得分的差异无统计学意义(P>0.05)。结论 RATS术中使用右美托咪定可减少术中全身麻醉药用量,缩短患者住院天数,改善患者的术后恢复质量和智能精神状态。
Objective To evaluate the effect of dexmedetomidine on postoperative recovery and mental state in patients undergoing robotic-assisted thoracic surgery(RATS). Methods Sixty patients, American Society of the Anesthesiologists(ASA) grading Ⅰ or Ⅱ, aged 20-70 years, body mass index(BMI) <30 kg/m~2, scheduled for RATS under general anesthesia, were randomly divided into 2 groups(n=30 each): control group and dexmedetomidine group. Anesthesia was induced with 0.04 mg/kg midazolam, 0.4 μg/kg sulfentanyl, 1.5-2.0 mg/kg propofol and 0.6 mg/kg rocuronium in all the patients. Then tracheal intubation and mechanical ventilation were performed. The anesthesia was maintained with 0.015-0.025 sevoflurane inhalation by keeping the minimum alveolar concentration(MAC) at 0.5, continuous target controlled infusion(TCI) of propofol at 1-1.5 μg/mL and remifentanil at 0.05-0.15 μg/(kg·min), and injection of 5 mg rocuronium at 30 min intervals. Bispectral index(BIS) was maintained at 40-60. In dexmedetomidine group, 1 μg/kg dexmedetomidine was infused intravenously in 10 min after intubation followed by continuous infusion at 0.4 μg/(kg·h) until 30 min before the end of operation. Control group received the equal volume of normal saline. Mean arterial pressure(MAP), heart rate(HR) and cerebral oxygen saturation were recorded after oxygen uptaking in operation room(T_0), 10 min, 20 min, 30 min, 40 min after one-lung ventilation(T_1, T_2, T_3, T_4) and 15 min after two-lung ventilation(T_5). Blood loss, urine volume, operation time, anesthesia time, consumption of propofol, use of ephedrine and atropine, respiratory rate and arterial blood gas analysis at room air after extubation, time to chest tube removal, length of hospital stay and postoperative complication(atelectasis, pheumonia and prolonged air leakage) were observed and recorded. QoR-15 and MMSE were scored on preoperative day, postoperative day 1 and 3. Results There was no significant difference in MAP, HR or cerebral oxygen saturation between groups at any time points(all P>0.05). Neither was the operation time, anesthesia time, blood loss, urine volume or use of vasoactive agents(all P>0.05). Consumption of propofol in dexmedetomidine group was statistically lower than that in control group(P<0.05). Compared with control group, after extubation, respiratory rate was significantly decreased, while partial pressure of oxygen(p_aO_2) was significantly increased in dexmedetomidine group(both P<0.05). But there was no significant difference in partial pressure of carbon dioxide(p_aCO_2) between groups(P>0.05). Within 48 hours after surgery, the average press times of patient-controlled intravenous analgesia was significantly lower in dexmedetomidine group than that in control group(P<0.05). There was no significant difference in the incidence of postoperative complications between two groups(P>0.05). Time to chest tube removal and length of hospital day were significantly shorter in dexmedetomidine group than those in control group(all P<0.05). There was no significant difference in the scores of QoR-15 and MMSE on preoperative day(both P>0.05). The QoR-15 score on postoperative day 1 and MMSE score on postoperative day 1 and 3 were significantly higher in dexmedetomidine group than those in control group(all P<0.05). Conclusion Intraoperative application of dexmedetomidine can shorten hospital stay, improve postoperative recovery and mental state in patients undergoing RATS.
Objective To evaluate the effect of dexmedetomidine on postoperative recovery and mental state in patients undergoing robotic-assisted thoracic surgery(RATS). Methods Sixty patients, American Society of the Anesthesiologists(ASA) grading Ⅰ or Ⅱ, aged 20-70 years, body mass index(BMI) <30 kg/m~2, scheduled for RATS under general anesthesia, were randomly divided into 2 groups(n=30 each): control group and dexmedetomidine group. Anesthesia was induced with 0.04 mg/kg midazolam, 0.4 μg/kg sulfentanyl, 1.5-2.0 mg/kg propofol and 0.6 mg/kg rocuronium in all the patients. Then tracheal intubation and mechanical ventilation were performed. The anesthesia was maintained with 0.015-0.025 sevoflurane inhalation by keeping the minimum alveolar concentration(MAC) at 0.5, continuous target controlled infusion(TCI) of propofol at 1-1.5 μg/mL and remifentanil at 0.05-0.15 μg/(kg·min), and injection of 5 mg rocuronium at 30 min intervals. Bispectral index(BIS) was maintained at 40-60. In dexmedetomidine group, 1 μg/kg dexmedetomidine was infused intravenously in 10 min after intubation followed by continuous infusion at 0.4 μg/(kg·h) until 30 min before the end of operation. Control group received the equal volume of normal saline. Mean arterial pressure(MAP), heart rate(HR) and cerebral oxygen saturation were recorded after oxygen uptaking in operation room(T_0), 10 min, 20 min, 30 min, 40 min after one-lung ventilation(T_1, T_2, T_3, T_4) and 15 min after two-lung ventilation(T_5). Blood loss, urine volume, operation time, anesthesia time, consumption of propofol, use of ephedrine and atropine, respiratory rate and arterial blood gas analysis at room air after extubation, time to chest tube removal, length of hospital stay and postoperative complication(atelectasis, pheumonia and prolonged air leakage) were observed and recorded. QoR-15 and MMSE were scored on preoperative day, postoperative day 1 and 3. Results There was no significant difference in MAP, HR or cerebral oxygen saturation between groups at any time points(all P>0.05). Neither was the operation time, anesthesia time, blood loss, urine volume or use of vasoactive agents(all P>0.05). Consumption of propofol in dexmedetomidine group was statistically lower than that in control group(P<0.05). Compared with control group, after extubation, respiratory rate was significantly decreased, while partial pressure of oxygen(p_aO_2) was significantly increased in dexmedetomidine group(both P<0.05). But there was no significant difference in partial pressure of carbon dioxide(p_aCO_2) between groups(P>0.05). Within 48 hours after surgery, the average press times of patient-controlled intravenous analgesia was significantly lower in dexmedetomidine group than that in control group(P<0.05). There was no significant difference in the incidence of postoperative complications between two groups(P>0.05). Time to chest tube removal and length of hospital day were significantly shorter in dexmedetomidine group than those in control group(all P<0.05). There was no significant difference in the scores of QoR-15 and MMSE on preoperative day(both P>0.05). The QoR-15 score on postoperative day 1 and MMSE score on postoperative day 1 and 3 were significantly higher in dexmedetomidine group than those in control group(all P<0.05). Conclusion Intraoperative application of dexmedetomidine can shorten hospital stay, improve postoperative recovery and mental state in patients undergoing RATS.
引文
[1] SONG Y, SHIM J K, SONG J W, et al. Dexmedetomidine added to an opioid-based analgesic regimen for the prevention of postoperative nausea and vomiting in highly susceptible patients: a randomised controlled trial[J]. Eur J Anaesthesiol, 2016, 33(2): 75-83.
[2] ZABORA J, BRINTZENHOFESZOC K, CURBOW B, et al. The prevalence of psychological distress by cancer site[J]. Psychooncology, 2001, 10(1): 19-28.
[3] UEKI M, KAWASAKI T, HABE K, et al. The effects of dexmedetomidine on inflammatory mediators after cardiopulmonary bypass[J].Anaesthesia, 2014, 69(7): 693-700.
[4] BLAUDSZUN G, LYSAKOWSKI C, ELIA N, et al. Effect of perioperative systemic α2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials[J]. Anesthesiology, 2012, 116(6): 1312-1322.
[5] 高建瓴, 詹英, 杨建平, 等. 右美托咪定辅助全身麻醉患者的镇静及全身麻醉药物的节俭作用[J]. 上海医学, 2010, 33(6): 525-527.
[6] RIED M, SCHILLING C, POTZGER T, et al. Prospective, comparative study of the On-Q? PainBuster? postoperative pain relief system and thoracic epidural analgesia after thoracic surgery[J]. J Cardiothorac Vasc Anesth, 2014, 28(4): 973-978.
[7] BAUER C, HENTZ J G, DUCROCQ X, et al. Lung function after lobectomy: a randomized, double-blinded trial comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia[J]. Anesth Analg, 2007, 105(1): 238-244.
[8] STARK P A, MYLES P S, BURKE J A. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15[J]. Anesthesiology, 2013, 118(6): 1332-1340.
[9] GE D J, QI B, TANG G, et al. Intraoperative dexmedetomidine promotes postoperative analgesia and recovery in patients after abdominal colectomy: a CONSORT-prospective, randomized, controlled clinical trial[J/OL]. Medicine (Baltimore), 2015, 94(43): e1727[2015-10-01]. https://insights.ovid.com/pubmed?pmid=26512563.
[10] SCHEININ H, AANTAA R, ANTTILA M, et al. Reversal of the sedative and sympatholytic effects of dexmedetomidine with a specific alpha2-adrenoceptor antagonist atipamezole: a pharmacodynamic and kinetic study in healthy volunteers[J]. Anesthesiology, 1998, 89(3): 574-584.
[11] FOLSTEIN M F, FOLSTEIN S E, MCHUGH P R. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician[J]. J Psychiatr Res, 1975, 12(3): 189-198.
[12] HOFFMAN W E, KOCHS E, WERNER C, et al. Dexmedetomidine improves neurologic outcome from incomplete ischemia in the rat: reversal by the alpha 2-adrenergic antagonist atipamezole[J]. Anesthesiology, 1991, 75(2): 328-332.
[13] ESER O, FIDAN H, SAHIN O, et al. The influence of dexmedetomidine on ischemic rat hippocampus[J]. Brain Res, 2008, 1218: 250-256.
[14] SRIVASTAVA V K, AGRAWAL S, KUMAR S, et al. Comparison of dexmedetomidine, propofol and midazolam for short-term sedation in postoperatively mechanically ventilated neurosurgical patients[J]. J Clin Diagn Res, 2014, 8(9): GC04-GC07.
[15] 杨能力, 徐道妙, 明广峰, 等. 右旋美托咪啶对大鼠脑外伤后炎症反应的干预作用[J]. 实用预防医学, 2010, 17(2): 243-245.
[16] UEDA K, KANEDA Y, SAKANO H, et al. Obstacles for shortening hospitalization after video-assisted pulmonary resection for lung cancer[J]. Ann Thorac Surg, 2003, 76(6): 1816-1820.
[17] OXLAD M, STUBBERFIELD J, STUKLIS R, et al. Psychological risk factors for increased post-operative length of hospital stay following coronary artery bypass graft surgery[J]. J Behav Med, 2006, 29(2): 179-190.
[18] MYLES P S, HUNT J O, FLETCHER H, et al. Relation between quality of recovery in hospital and quality of life at 3 months after cardiac surgery[J]. Anesthesiology, 2001, 95(4): 862-867.
[2] ZABORA J, BRINTZENHOFESZOC K, CURBOW B, et al. The prevalence of psychological distress by cancer site[J]. Psychooncology, 2001, 10(1): 19-28.
[3] UEKI M, KAWASAKI T, HABE K, et al. The effects of dexmedetomidine on inflammatory mediators after cardiopulmonary bypass[J].Anaesthesia, 2014, 69(7): 693-700.
[4] BLAUDSZUN G, LYSAKOWSKI C, ELIA N, et al. Effect of perioperative systemic α2 agonists on postoperative morphine consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials[J]. Anesthesiology, 2012, 116(6): 1312-1322.
[5] 高建瓴, 詹英, 杨建平, 等. 右美托咪定辅助全身麻醉患者的镇静及全身麻醉药物的节俭作用[J]. 上海医学, 2010, 33(6): 525-527.
[6] RIED M, SCHILLING C, POTZGER T, et al. Prospective, comparative study of the On-Q? PainBuster? postoperative pain relief system and thoracic epidural analgesia after thoracic surgery[J]. J Cardiothorac Vasc Anesth, 2014, 28(4): 973-978.
[7] BAUER C, HENTZ J G, DUCROCQ X, et al. Lung function after lobectomy: a randomized, double-blinded trial comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia[J]. Anesth Analg, 2007, 105(1): 238-244.
[8] STARK P A, MYLES P S, BURKE J A. Development and psychometric evaluation of a postoperative quality of recovery score: the QoR-15[J]. Anesthesiology, 2013, 118(6): 1332-1340.
[9] GE D J, QI B, TANG G, et al. Intraoperative dexmedetomidine promotes postoperative analgesia and recovery in patients after abdominal colectomy: a CONSORT-prospective, randomized, controlled clinical trial[J/OL]. Medicine (Baltimore), 2015, 94(43): e1727[2015-10-01]. https://insights.ovid.com/pubmed?pmid=26512563.
[10] SCHEININ H, AANTAA R, ANTTILA M, et al. Reversal of the sedative and sympatholytic effects of dexmedetomidine with a specific alpha2-adrenoceptor antagonist atipamezole: a pharmacodynamic and kinetic study in healthy volunteers[J]. Anesthesiology, 1998, 89(3): 574-584.
[11] FOLSTEIN M F, FOLSTEIN S E, MCHUGH P R. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician[J]. J Psychiatr Res, 1975, 12(3): 189-198.
[12] HOFFMAN W E, KOCHS E, WERNER C, et al. Dexmedetomidine improves neurologic outcome from incomplete ischemia in the rat: reversal by the alpha 2-adrenergic antagonist atipamezole[J]. Anesthesiology, 1991, 75(2): 328-332.
[13] ESER O, FIDAN H, SAHIN O, et al. The influence of dexmedetomidine on ischemic rat hippocampus[J]. Brain Res, 2008, 1218: 250-256.
[14] SRIVASTAVA V K, AGRAWAL S, KUMAR S, et al. Comparison of dexmedetomidine, propofol and midazolam for short-term sedation in postoperatively mechanically ventilated neurosurgical patients[J]. J Clin Diagn Res, 2014, 8(9): GC04-GC07.
[15] 杨能力, 徐道妙, 明广峰, 等. 右旋美托咪啶对大鼠脑外伤后炎症反应的干预作用[J]. 实用预防医学, 2010, 17(2): 243-245.
[16] UEDA K, KANEDA Y, SAKANO H, et al. Obstacles for shortening hospitalization after video-assisted pulmonary resection for lung cancer[J]. Ann Thorac Surg, 2003, 76(6): 1816-1820.
[17] OXLAD M, STUBBERFIELD J, STUKLIS R, et al. Psychological risk factors for increased post-operative length of hospital stay following coronary artery bypass graft surgery[J]. J Behav Med, 2006, 29(2): 179-190.
[18] MYLES P S, HUNT J O, FLETCHER H, et al. Relation between quality of recovery in hospital and quality of life at 3 months after cardiac surgery[J]. Anesthesiology, 2001, 95(4): 862-867.
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |