麻醉安全与质控

目的针对老年患者,在全麻诱导期联合不同血浆靶浓度的瑞芬太尼,设计不同的丙泊酚起始血浆靶浓度分步靶控诱导,选出最佳给药方案。方法选取安徽医科大学附属省立医院2017-04/2018-11期间择期全麻手术的老年患者80例,年龄65～79岁, ASA分级Ⅰ～Ⅲ级,随机分为4组。A组:丙泊酚起始血浆靶浓度1.5μg/mL,瑞芬太尼血浆靶浓度2.0 ng/mL; B组:丙泊酚起始血浆靶浓度2.0μg/mL,瑞芬太尼血浆靶浓度2.0 ng/mL; C组:丙泊酚起始血浆靶浓度1.5μg/mL,瑞芬太尼血浆靶浓度3.0 ng/mL; D组:丙泊酚起始血浆靶浓度2.0μg/mL,瑞芬太尼血浆靶浓度3.0 ng/mL。每组每60 s递增丙泊酚血浆靶浓度1.0μg/mL,直到患者意识消失(LOC)。监测LOC的时间; LOC时以及插管前丙泊酚血浆浓度、效应室浓度;诱导前(T₀)、 LOC时(T₁)、插管前(T₂)、插管后即刻(T₃)、 1 min(T₄)、 3 min(T₅)、 5 min(T₆)的平均动脉压(MAP)、心率(HR); T₀-T₄时点的脑电双频谱指数(BIS)值。结果与T₀相比, A、 B、 D 3组插管后T₃、 T₄时点MAP、 HR明显升高(P<0.05), C组MAP明显降低(P<0.05)、 HR无统计学意义(P>0.05);与T₂相比, A、 B、 C 3组插管后BIS值差异无统计学意义(P>0.05), D组有统计学意义(P<0.05)。D组意识消失最快(1.7±0.45) min; LOC时、插管前丙泊酚效应室浓度A与C组明显高于B与D组。结论在老年患者对比4种诱导方法中,丙泊酚起始血浆靶浓度为1.5μg/mL,瑞芬太尼血浆靶浓度为3.0 ng/mL时,诱导期血流动力学最平稳。

Objective To screen out the best drug delivery scheme of propofol step-by-step target controlled infusion combined with remifentanil of different plasma concentrations, suitable for elderly patients during induction of general anesthesia. Methods Eighty American Society of Anesthesiologists physical status Ⅰ-Ⅲ elderly patients, aged 65-79 years, scheduled for elective surgeries under general anesthesia in the Affiliated Provincial Hospital of Anhui Medical University from April 2017 to November 2018 were randomly divided into 4 groups(n=20 each) : group A(the initial target plasma concentration of propofol was 1.5 μg/mL, the target plasma concentration of remifentanil was 2.0 ng/mL), group B(the initial target plasma concentration of propofol was 2.0 μg/mL, the target plasma concentration of remifentanil was 2.0 ng/mL), group C(the initial target plasma concentration of propofol was 1.5 μg/mL, the target plasma concentration of remifentanil was 3.0 ng/mL) and group D(the initial target plasma concentration of propofol was 2.0 μg/mL, the target plasma concentration of remifentanil was 3.0 ng/mL). The propofol plasma target concentration was then increased by 1.0 μg/mL every 60 s until the patients lost their consciousness. The time of loss of consciousness was recorded; mean arterial pressure(MAP) and heart rate(HR) were recorded before induction(T₀), LOC(T₁), before tracheal intubation(T₂) and after intubation(T₃), 1 min(T₄), 3 min(T₅), and 5 min(T₆) afterwards. The propofol plasma concentrations and effect-site concentrations were recorded at T₁-T₂; BIS was recorded at T₀-T₄. Results Compared with T₀, MAP and HR in group A, B and D increased significantly at T₃ and T₄ after intubation(P<0.05), while MAP in group C decreased significantly(P<0.05) with no significant difference in HR(P>0.05). Compared with T₂, there was no significant difference in BIS values after intubation in group A, B and C(P>0.05), but there was a difference in group D(P<0.05). The time of loss of consciousness in group D was shortest, which was(1.7±0.45) min. Propofol effect-site concentrations in group A and group C were significantly higher than those in group B and group D. Conclusion When the initial target plasma concentration of propofol was 1.5 μg/mL and remifentanil was 3.0 ng/mL, the hemodynamics during induction was the most stable.