瑞芬太尼对小儿七氟烷全麻诱导期QT间期的影响

发布时间：2018-07-10 17:50

本文选题：瑞芬太尼 + 七氟烷　；参考：《河北北方学院》2012年硕士论文

【摘要】：七氟烷是一种新型吸入麻醉剂,具有诱导迅速、苏醒快、无刺激性气味、对呼吸和心血管系统影响较小、体内代谢率低及排除迅速等优点,近年来有逐步取代异氟烷而成为临床上广泛应用的吸入麻醉药的趋势,无肌松条件下高浓度吸入七氟烷诱导气管插管已成为小儿日间手术的主要麻醉方法之一。瑞芬太尼是一种新型的μ受体激动剂,其起效迅速、持续时间短、清除快速、代谢不依赖肝肾功能、重复或长期应用无明显蓄积作用,是具有良好可控性的阿片类镇痛药,被麻醉学誉为21世纪的阿片类药。 QT间期是指心电图上从QRS波起始至T波结束的一段时间,代表心室肌除极和复极的全过程,围麻醉期患者如存在影响QT间期的危险因素,可大大增加诱发尖端扭转型室性心动过速(torsade de pointes, TdP)的可能性,手术麻醉的风险随之加大,已引起了学术界广泛的关注和重视。瑞芬太尼对小儿七氟烷诱导麻醉插管期QT间期有无影响尚未见报道。本临床研究观察静注瑞芬太尼对小儿七氟烷吸入诱导麻醉插管期QT间期和血流动力学参数的影响,比较不同剂量瑞芬太尼对QT间期及血流动力学的影响,旨在探索应用瑞芬太尼的最佳剂量,为小儿寻求一种安全的麻醉方法提供理论依据。研究对象选择拟在气管插管全麻下行手术的男性患儿60例,ASAⅠ级,年龄(3-6)岁,体重(14-25)kg,随机分为3组：S组(插管前2mins给予生理盐水)、R0.5组(插管前2mins给予瑞芬太尼0.5μg·kg-1)和R1.0组(插管前2mins给予瑞芬太尼1.0μg·kg-1)。麻醉诱导：所有患儿均不给术前药。麻醉诱导前排空贮气囊,七氟烷挥发罐刻度调至8%,预充麻醉回路60s后行麻醉诱导,麻醉医生指导患儿深呼吸,在一次最大呼气后,将面罩紧扣患儿面部,嘱其继续深呼吸,患儿入睡后七氟烷吸入浓度减为3%～4%,氧流量4L·min-1,必要时给予辅助呼吸,建立液路。于诱导5mins时三组分别于30s内给予生理盐水1mL (Group S)、瑞芬太尼0.5μg·kg-1mL (Group R0.5)、瑞芬太尼1.0μg·kg-11mL (Group R1.0), lmin后行气管插管,插管后连接麻醉机行机械通气,七氟烷吸入浓度减至2%,氧流量2L·min-1,潮气量(8～10)mL·kg-1,吸呼比1:2,呼吸频率16beat·min-1。观察并记录患儿围麻醉插管过程中各时间点(诱导Omin(T1),诱导1min时(T2),诱导3mins时(T3),诱导5mins时(T4),给予等量瑞芬太尼或生理盐水后1min即诱导6.5min时(T5),插管前即刻即诱导7min时(T6)和插管后1min即8.5min时(T7))的QT间期和校正QT间期(corrected QT interval, QTc)及平均动脉压(mean arterial pressure, MAP)和心率(heart rate, HR)的变化。QT间期取Ⅱ导联连续6次心电图记录的QT间期和QTc的平均值。研究结果显示：QTc的变化：(1)给予生理盐水或瑞芬太尼(T5)之前：与诱导0min(T1基础值相比,三组在诱导lmin (T2)时均无明显变化,诱导3mins (T3)和5mins (T4)时三组的QT间期与T1相比均明显延长(P0.01),三组间T3和T4时段的QT间期比较无统计学意义(P0.05)：(2)给予生理盐水或瑞芬太尼(T5)之后：Group S给予生理盐水后1min(T5)QT间期与同组T3,T4无明显差异,Group R0.5给予瑞芬太尼0.5μg·kg-1后1min (T5) QT间期相对于同组T3,T4明显缩短(P0.05),与基础值相比仍延长(P0.05), GroupR1.0给予瑞芬太尼1.0μg·kg-1后1min(T5) QT间期比同组T3,T4明显缩短(P0.01),与基础值相比无明显差异,Group R1.0T5的QT间期比Group R0.5T5的QT间期缩短(P0.05),插管前即刻(T6)时三组的QT间期与各自组内T5时的QT间期无明显差异,组间差异同T5时段,插管后1min时Group S QT间期比同组T3-T6时段明显延长(P0.05),Group R0.5和Group R1.0T7的QT间期与本组T5,T6无明显差异,Group R0.5和Group R1.0组间比较有差异(P0.05),两组比Group S均明显缩短(P0.01)。HR和MAP的变化：三组HR和MAP在T2-T4时段比基础值略下降,组间、组内差异均无统计学意义(P0.05)。S组T5,T6时HR和MAP与基础值无明显差异,插管后1min(T7)均明显增加(P0.05)。Group R0.5和Group R1.0T5～T7时段HR和MAP与基础值相比明显下降(P0.05),与自身插管前后相比HR和MAP较平稳,组间比较无明显差异。经分析研究结果得出以下结论：(1)高浓度七氟烷吸入麻醉诱导3mins和5mins时QTc明显延长,但均未见致命性心律失常的发生：(2)插管前给予瑞芬太尼静注可有效抑制小儿七氟烷吸入麻醉诱导插管期QTc间期和MAP,HR的改变；(3)瑞芬太尼1.0μg·kg-1静注减轻QTc间期改变的作用更完善,优于瑞芬太尼0.5μg·kg-1静注。
[Abstract]:Seven fluorothane is a new type of inhalation anesthetic, which has the advantages of rapid induction, quick awakening, no irritation smell, less influence on the respiratory and cardiovascular system, low metabolic rate in the body and rapid elimination. In recent years, it has gradually replaced isoflurane and became a trend of inhalation anesthetics widely used in clinical practice, with high concentration of seven inhalation without muscle relaxation. Halothane induced tracheal intubation has become one of the main anesthetic methods in children's daytime surgery. Remifentanil is a new type of muon receptor agonist. It has rapid effect, short duration, rapid clearance, metabolism without liver and kidney function, repeated or long-term application without obvious accumulative effect. It is an opioid analgesic with good controllability and is anesthetized. It is known as the opioid in twenty-first Century.
QT interval refers to a period of time from the beginning of the QRS wave to the end of the T wave on the electrocardiogram, representing the whole process of depolarization and repolarization of the ventricular muscle. The peri anaesthesia patients, such as the risk factors affecting the QT interval, can greatly increase the possibility of inducing torsional ventricular tachycardia (torsade de pointes, TdP), and the risk of surgical anesthesia increases. It has attracted wide attention and attention from academia. It has not been reported whether remifentanil has any effect on the QT interval in children undergoing seven flurane induction anesthesia.
The effect of remifentanil on QT interval and hemodynamic parameters during the intubation of seven halothane anesthesia in children was observed. The effects of remifentanil on QT interval and hemodynamics were compared to explore the optimal dosage of remifentanil to provide a theoretical basis for children to seek a safe anesthetic method. According to it.
Subjects were selected 60 male children, ASA I, age (3-6) years and weight (14-25) kg, randomly divided into 3 groups: group S (before intubation 2mins was given saline), group R0.5 (before intubation 2mins gave remifentanil 0.5 g kg-1) and R1.0 group (before intubation of remifentanil 1 mu g kg-1). Anesthesia induction: All the children were not given preoperatively. The air bag was emptied before anesthesia induction, the scale of seven Fluoroalkane volatilization tank was adjusted to 8%, the anesthetic circuit was induced after 60s, and the anesthesiologist instructed the children to take deep breathing. After a maximum exhalation, the mask was kept close to the child's face and continued to breathe deeply, and the concentration of seven Fluoroalkane inhalation decreased to 3% to 4% after falling asleep. Oxygen was reduced to 3% to 4%. The flow of 4L / min-1 was given when necessary. The three groups were given 1mL (Group S) in 30s, remifentanil 0.5 mu g. Kg-1mL (Group R0.5), remifentanil 1 mu g. 2%, oxygen flow 2L / min-1, tidal volume (8~10) mL / kg-1, absorption ratio 1:2, respiratory frequency 16beat min-1., observed and recorded every time point during the perioperative anesthesia intubation of children (Omin (T1), 1min (T2) induction, inducement of 3mins, induction and induction. The interval of QT interval and the correction of the QT interval (corrected QT interval, QTc) and the changes of the mean arterial pressure (corrected QT interval, QTc) and the heart rate (T7) after the induction of 7min (T6) and after the intubation of 1min, that is, 8.5min (T7), and the changes in the mean arterial pressure (mean) and heart rate are taken as the intervals of the interval and the average of the 6 consecutive electrocardiogram records of the second lead.
The results of the study showed that: (1) prior to the induction of saline or Reventa Ni (T5), there was no significant change in the induction of lmin (T2) with the induced 0min (T1 base), and the QT interval between the three groups of 3mins (T3) and 5mins (T4) was prolonged when compared with the induced 0min (T1). The intervals between the three groups were not statistically significant. Meaning (P0.05): (2) after giving physiological saline or Reventa Ni (T5): after Group S was given physiological saline, 1min (T5) QT interval was not significantly different from that of the same group of T3 and T4, Group R0.5 gave Reventa Ni the interval relative to the same group. The 1min (T5) QT interval of 1min (T5) QT is shorter than that of the same group T3 and T4 (P0.01). The QT interval of Group R1.0T5 is shorter than that of the base value, and the Group R1.0T5 QT interval is shorter than that of the Group. There is no obvious difference between the intervals of the three groups and the intervals in the respective groups. The P S QT interval was significantly longer than that of the same group (P0.05), and the QT interval of Group R0.5 and Group R1.0T7 was not significantly different from that of this group. The two groups were significantly shorter than those of the T3-T6 group. There was no significant difference (P0.05) in group.S (P0.05), and there was no significant difference between HR and MAP at T6, and 1min (T7) significantly increased (P0.05) after intubation (P0.05).Group R0.5.
The results of the analysis were as follows: (1) QTc was prolonged significantly when high concentration of seven halothane induced 3mins and 5mins, but no fatal arrhythmia was found: (2) Reventa Ni intravenous infusion before intubation could effectively inhibit the QTc interval of QTc and the changes of MAP and HR in the induction of tracheal intubation in children; (3) Reventa Ni 1 The effect of intravenous injection of g kg-1 on QTc interval is more perfect than that of remifentanil 0.5 g kg-1.
【学位授予单位】：河北北方学院
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R726.1

【参考文献】