瑞芬太尼联合硝酸甘油控制性降压在鼻内镜手术中的应用

目的比较瑞芬太尼和瑞芬太尼联合硝酸甘油在全麻下鼻内镜手术中控制性降压效果。方法鼻内镜下鼻息肉、鼻窦炎手术病人共40例,ASAⅠ或Ⅱ级,用随机数字表分为瑞芬组和瑞硝组,每组20例,咪达唑仑、丙泊酚、瑞芬太尼和维库溴铵静脉复合全麻气管插管,2组术中均以瑞芬太尼0.1～0.2μg·kg~(-1)·min~(-1)、丙泊酚2～5 mg·kg~(-1)·h~(-1)持续泵输,维库溴铵4 mg·h~(-1),静脉注射。瑞硝组加用硝酸甘油静脉滴注,开始剂量5μg·min~(-1),调节滴速使收缩压维持在12 kPa(90 mmHg)左右。观察降压前(T_0)、降压后5 min(T_1)、30 min(T_2)、60 min(T_3)和停止降压后5 min(T_4)的收缩压和心率,计算心肌氧耗指数,瑞芬太尼、丙泊酚用量,手术时间和病人苏醒时间。结果2组病人年龄、性别和体重间差别无统计学意义(P>0.05)。T_1时2组血压明显下降,与T_0比较,均P<0.01,且瑞硝组降压程度明显大于瑞芬组(P<0.01),降压后的T_1,T_2瑞硝组心率加快,与瑞芬组相比有非常显著意义(P<0.01);降压期的氧耗指数,瑞硝组低于瑞芬组(P<0.05,P<0.01);停止降压后,瑞芬组血压和心率变化与T_3比,无统计学意义(P>0.05),但瑞硝组血压和心率均明显增加(P<0.01);瑞芬组的瑞芬太尼、丙泊酚用量和手术时间明显大于瑞硝组(P<0.01),2组病人的苏醒时间差异无统计学意义(P>0.05)。结论鼻内镜手术瑞芬太尼在常用剂量范围内作控制性降压虽比较平稳,但难以达到目标血压,联合硝酸甘油后效果明显,并可减少麻醉药用量和手术时间,减少病人医疗费用。

Controlled hypotension with remifentanil combined nitroglycerin during intranasal endoscopic surgery

AIM To compare the controlled hypotensive efficacies between remifentanil and remifentanil combined with nitroglycerin during intranasal endoscopic surgery.METHODS Forty patients with nasal polyps and/or nasal sinusitis,ASAⅠorⅡscheduled for intransal endoscopic sinus surgery were randomly and equally divided into two groups(R and RN),20 for each.General anesthesia for tracheal intubation was induced with midazolam,propofol,remifentanil and vecuronium intravenously and followed by remifentanil 0.1-0.2μg·kg~(-1)·min~(-1) and propofol 2 - 5 mg·kg~(-1)·h~(-1) as continuous pumping and vecuronium 4 mg·h~(-1) for maintenance.In RN group,controlled hypotension was performed with nitroglycerin intravenously started with 5μg·min~(-1) until the systolic pressure decreased to around 12 kPa(90 mmHg).The systolic blood pressure (SB),heart rate(HR) and SB×HR products,were observed just before the controlled hypotension initiated (T_0),5 min(T_1),30 min(T_2),and 60 min(T_3) after hypotension emerged and 5 min(T_4) after the controlled hypotension ceased.The doses of remifentanil and propofol,the operation duration,and recovery time were recorded.RESULTS The differences in age,sex and body weight between the two groups were not significant(P > 0.05).SB decreased obviously in two groups 5min afterward comparing with T_0(P < 0.01 ) and the fall extent of RN group was more than that of R group(P < 0.01).HR of RN group increased at T_1,T_2 comparing with those of R group(P < 0.01 ) with conspicuous significance.The oxidation index of RN group was less than that of R group after controlled hypotension(P < 0.05,P < 0.01 ).There were no significant differences of SB and HR in R group in comparing those at T_4 with T_3(P > 0.05),but showing increase in RN group(P < 0.01 ).The dosages of remifentanil and propofol,the operation duration of R group were more than those of RN group(P < 0.01).There was no significant difference in awakening time between the two groups. (P > 0.05).CONCLUSION Remifentanil with routine anesthesia dosage shows stable effect on controlled hypotension but can hardly reach the appropriate level during intranasal endoscopic sinus surgery.However remifentanil combined with nitroglycerin provides prominent effects with furthermore decrease of anesthetics, duration of surgery and medical expenditure.