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    鞍麻下異丙酚使肛周手術患者意識消失的半數有效血漿靶濃度
    關鍵字:有效,消失,意識,手術,患者,CD,EF,GH,yz,wx, 發布時間:2011-08-20

    鞍麻下異丙酚使肛周手術患者意識消失的半數有效血漿靶濃度 韓曉玲時向軍 301700天津市武清區中醫醫院 doi:10.3969/j.issn.1007—614x.2010. 26.00l 鞍麻下異丙酚輔助鎮靜在臨床廣泛 應用,而異丙酚會產生低血壓、心動過緩 和呼吸抑制等不良反應。異丙酚使患者 意識消失的半數有效劑量為0.82mg/ kg【lo。異丙酚靶控輸注技術已廣泛用于 臨床,其輔助鞍區麻醉時使患者意識消失 的半數有效血漿靶濃度尚有待確定。本 研究擬確定鞍區麻醉下異丙酚使肛周手 術患者意識消失的半數有效血漿靶濃度, 為臨床用藥提供參考。 資料與方法 擇期擬行肛周手術的患者100例,年 齡40~50歲,體重52—76kg,身高154~ 167em,ASAI或Ⅱ級,既往無高血壓、冠 心病、糖尿病及中樞神經系統疾病病史, 無慢性腰痛及腰部手術史,無鞍麻穿刺禁 忌證。 入室后監測MAP、HR和腦電雙頻譜 指數(8is)。鞍區麻醉前20分鐘靜脈輸 注乳酸鈉林格氏液500ml。患者屈胸屈 膝側臥位,經k.。間隙行穿刺,穿刺成功 后見腦脊液注入0.75%鹽酸布比卡因重 比重液2.2ml,隨后取平臥位,立即測定 平面上界,維持T。:水平,不能維持T。:水 平的患者排除本研究。若術中出現低血 壓(收縮壓較基礎值降低30%或收縮壓 低于90mmHg),則靜脈注射麻黃堿6rag; 若出現心動過緩(HR<50次/分)或呼吸 抑制(呼吸頻率<12次/分),則靜脈注射 阿托品0.5—1.0rag或面罩加壓輔助呼 吸。 采用內置Marsh藥代學模型的 Cr螄b3r3500輸注泵以及DiprifusorTCl系 統靶控輸注異丙酚。以呼之不應和睫毛 反射消失作為意識消失的標準舊o。設置 異丙酚初始血漿靶濃度為2.3“g/IIll,按 序貫法給藥;即前1例出現意識消失,則 下l例選擇低一級的濃度;若前1例未出 現意識消失,則下1例選擇高一級的濃 度,依次類推,直至完成所有患者的研究, 相鄰濃度比值為1.18。根據序貫法公 式口1計算異丙酚半數有效血漿靶濃度及 其95%可信區間。于布比卡因給藥前即 刻(T1)、給藥結束后lO分鐘(T2)、異 丙酚給藥后2.5分鐘(T3)、5分鐘(T4) 時記錄MAP、HR和BIS,并記錄患者意 識消失的BIS。 統計處理:采用SPSSIO.0統計軟件 進行分析,計量資料以均數±標準差(x ±s)表示,不同時點各指標的比較采用 重復測量設計的方差分析,P<0.05為差 異存統計學意義。 結果 與T1時比較,異丙酚給藥后MAP和 BIS降低(P<O.05),HR差異無統計學意 義(P>0.05)。 患者意識消失時BIS平均為7l。異 丙酚使患者意識消失的半數有效血漿靶 濃度為3.2彬Illl,95%可信區間為2.1— 3.9p.g/ml。術中有3例意識消失時發生 低血壓,2例發生心動過緩,1例發生呼吸 抑制,對癥處理后均緩解。 討論 序貫法是確定半數有效濃度的經典 方法,由于濃度一效應曲線為對稱的“S” 形,半數有效濃度位于曲線陡直的中段, 藥物濃度稍有增減即可引起效應的明顯 變化,因此采用小樣本量即可得到較精確 的半數有效濃度。 既往研究表明,靶控輸注異丙酚使患 者意識消失的半數有效血漿靶濃度為 3.8py,/ml拉J,高于本研究結果,可能與椎 管內麻醉的鎮靜作用有關。椎管內麻醉 的感覺和運動神經阻滯可降低網狀激活 系統一丘腦一皮層興奮性,降低其維持覺 醒的作用。椎管內麻醉可減少鎮靜催眠 藥如異丙酚的用量HJ。 異丙酚引起的血壓下降與其對血管 的擴張作用及對心肌的抑制作用有關,而 其中擴張血管作用主要與異丙酚對交感 神經的抑制和對阻力血管的直接擴張作 用有關”J。靜脈注射異丙酚后約2—3分 鐘鎮靜效應達高峰哺J,也是循環最不穩 定的時期,因此本研究觀察時間為靶控輸 注異丙酚5分鐘之內。鞍區麻醉時,局麻 藥能節段性地阻滯交感神經傳出纖維,引 起阻力血管及容量血管擴張,回心血量減 少,心排血量下降,導致低血壓。本研究 中意識消失時有3例發生低血壓,2例發 生心動過緩,1例發生呼吸抑制,提示椎 管內麻醉下異丙酚輔助鎮靜時要嚴密監 測患者的循環和呼吸情況。 BIS與異丙酚劑量相關性好,可準確 反映其鎮靜水平。既往研究表明,異丙酚 使患者意識消失的半數有效濃度相對應 的BIS值為74【7J,與本研究結果相近。 椎管內麻醉對BIS有無影響尚無定論。 研究表明,椎管內麻醉對BIS無影響哺1。 亦有研究表明,椎管內麻醉60分鐘時BIS 明顯下降,其原因可能是由于局麻藥向頭 端擴散所致。本研究結果顯示,鞍區麻醉 前后BIS無改變,考慮主要與研究對象采 用鞍區麻醉,擴散至頭端的局麻藥量較少 有關。 綜上所述,鞍區麻醉下肛周手術患者 采用異丙酚鎮靜時,患者意識消失的半數 有效血漿靶濃度為3.2tw,/ml,其95%可 信區間為2.1—3.9彬fnl,臨床肛周手術 患者可選擇1.2—1.3倍的半數有效血漿 靶濃度的異丙酚輔助鎮靜。 參考文獻 l張忱,岳云.椎管內麻醉下使病人意識消失 的異丙酚ED50.國際麻醉學與復蘇雜志, 2007.28:6—9. 2劉芳,徐志鵬,岳云,等.靶控輸注異丙酚意 識消失時血漿和效應室靶濃度的EC50與 腦電雙頻譜指數的關系一多中心大樣本臨 床研究.中華麻醉學雜志,2007,27:324— 327. 3蔣知儉,主編.醫學統計學.北京:人民衛生 出版社,1997:140—141. 4 TverskoyM.FleyBhmanG。BaehrakL,eta1. Effectofbupivacaineindueed∞iIlalblock∞ hypnoticrequirementofpropc901.Anaesthesia, 1996。51:652—653. 5MillerRD.edAnesthesia.5thedn.NewYork: ChurchillLivingstone,2001:253. 6 NakayanaM,IchinoeeH,YamamotoS,eta1. Theeffectoffentanylonhemodynamieand bispe測indexchangesduringanesthesia in- ductionWitlIpropof01.JClinAnesth,2002.14: 146—149. 7郁麗娜,謝俊然,張焰。等.異丙酚靶控輸注 患者的麻醉深度監測.中華麻醉學雜志。 2004.24:877—878. 8 PoflockJE,NealJM,uuSS,eta1.Sedation during spinalanesthesia.Anesthesiology, 2000.93:728~734. 中國社區醫師?醫學專業2010年第細期(蕈12卷總第箱期)151 萬方數據 換頁

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