麻醉深度监测（IoC1和IoC2）在乳腺癌改良根治术患者全凭静脉麻醉中的应用研究

发布时间：2018-05-27 13:23

本文选题：麻醉深度监测(IoC1和IoC_2) + 丙泊酚　；参考：《山东大学》2016年博士论文

【摘要】：研究背景全身麻醉深度的监测和判断,是麻醉学科的一个基本问题,同时它也是麻醉医生普遍关注而且亟待解决的问题。外科手术等伤害性刺激可以引起机体的应激反应过程,即交感和内分泌系统激素水平的变化,麻醉深度实际上是在意识消失后麻醉药物对这种应激反应的抑制程度。比较理想的麻醉状态是：1、患者意识消失,无术中知晓,术后无麻醉和手术相关的不良记忆；2、术中血流动力学平稳,麻醉和手术操作引起的疼痛／伤害性刺激得到有效控制；3、肌肉松弛,便于外科医师进行手术操作；4、不良神经反射得到抑制,如胆心反射、眼心反射等；5、呼吸和循环等功能得到最大程度的保护,术后患者的各项生理功能可以迅速完全地恢复。只有准确地监测和判断麻醉深度,才能使患者达到比较理想的麻醉状态。麻醉深度的判断有以临床体征观察为依据的判断方法和以麻醉监测设备为依据的判断方法。麻醉监测设备有脑电双频指数(bispectral index, BIS)、熵指数(entropy of the EEG)、Narcortrend分级监测、听觉诱发电位(auditory evoked potential,AEP)、事件相关电位(event-related potential, ERP)、正电子发射断层扫描(positron emission computed tomography, PET)和功能磁共振成像(functional magnetic resonance imaging, fMRI)等,但是由于受监测原理、局限性和经济性等各方面因素的制约,目前尚无一种设备能够非常理想地应用于麻醉深度监测。BIS能够反映大脑皮层功能的兴奋和抑制状态,是目前应用比较广泛、评估意识状态的敏感而客观的量化指标。但是BIS主要反映的是丙泊酚、依托咪酯和吸入麻醉药等抑制大脑皮层所产生的镇静作用,而对全身麻醉的镇痛作用监测效果不佳。意识指数(indexes of consciousness,IoC)是一种新型的麻醉深度监测技术,它是以数万例进行全身麻醉患者的临床OAAS值和RASS值为基础经过综合分析得出来的,其中IoC1代表镇静指数,本研究用以指导镇静药物丙泊酚的使用,IoC2代表镇痛／抗伤害指数,本研究用以指导镇痛药物瑞芬太尼的使用。有文献报道,术前接受化疗的患者在全凭静脉麻醉中,麻醉药物丙泊酚和瑞芬太尼的用量与未接受化疗的患者相比有一定的差异。因此,本研究第二部分选取接受化疗的患者进行研究,从而了解术前化疗对乳腺癌患者麻醉敏感性的影响。本研究第一部分探讨麻醉深度监测(IoC1和IoC2)在乳腺癌改良根治术患者全凭静脉麻醉中对丙泊酚和瑞芬太尼用量的影响；第二部分探讨术前化疗对乳腺癌改良根治术患者麻醉敏感性的影响。第一部分麻醉深度监测(IoC1和IoC2)在乳腺癌改良根治术患者全凭静脉麻醉中对丙泊酚和瑞芬太尼用量的影响目的：探讨麻醉深度监测(IoCl和IoC2)在乳腺癌改良根治术患者全凭静脉麻醉中对丙泊酚和瑞芬太尼用量的影响。方法：选取择期在全凭静脉麻醉下行单侧乳腺癌改良根治术患者120例。根据由SPSS17.0统计学软件生成的随机数字卡,将患者随机分为2组：研究组(T组,n=60)和对照组(C组,n=60)。所有患者均行常规无创血压(NBP)、心电图(ECG)、脉搏血氧饱和度(SpO2)、呼气末二氧化碳分压(PETCO2)监测。T组行麻醉深度监测IoC1(镇静指数)和IoC2(镇痛/抗伤害指数),麻醉期间,麻醉医师依据IoC1和IoC2的数值和变化对丙泊酚、瑞芬太尼的用量进行调节。C组不行麻醉深度监测,麻醉期间,麻醉医师根据临床经验通过观察血压、心率等生命体征变化对丙泊酚、瑞芬太尼用量进行调节,将患者血压、心率控制在波动≤20%基础值作为参考范围。记录主要指标：丙泊酚和瑞芬太尼的靶浓度调整次数、输注时间及平均用量；次要指标：术中不良事件(高血压、低血压、心动过速、心动过缓和体动反应)及麻醉恢复质量(自主睁眼时间、拔管时间、苏醒评分和术中知晓)。结果：T组与C组丙泊酚靶浓度调整次数、丙泊酚输注时间、丙泊酚平均用量、瑞芬太尼输注时间、自主睁眼时间、拔管时间、苏醒评分无明显差异(P0.05)；与C组比较,T组患者麻醉期间瑞芬太尼靶浓度调整次数(2.9±.9 vs2.0±1.2次/手术,P0.05)和瑞芬太尼平均用量(285±36 vs 203±19μg, P0.05)显著增多,但是不良事件总数[26(48%) vs 36(68%),(P0.05)]显著减少。结论：全凭静脉麻醉期间行麻醉深度监测(IoC1和IoC2)时,乳腺癌患者丙泊酚的靶浓度调整次数、丙泊酚输注时间和丙泊酚的平均用量无明显变化,而瑞芬太尼的靶浓度调整次数和平均用量明显增加,但是高血压、低血压、心动过速等不良事件总数减少,麻醉过程更加平稳,提高了麻醉的可控性。第二部分术前化疗对乳腺癌改良根治术患者麻醉敏感性的影响目的：评价术前化疗对乳腺癌改良根治术患者麻醉敏感性的影响。方法：选取择期在全凭静脉麻醉下行单侧乳腺癌改良根治术患者90例。将患者分为2组：术前接受化疗的为化疗组(preoperative chemotherapy group, PC组,n=45),术前未接受化疗的为非化疗组(non preoperative chemotherapy group, nPC组,n=45)。除常规无创血压(NBP)、心电图(ECG)、脉搏血氧饱和度(Sp02)、呼气末二氧化碳分压(PErCO2)监测外,2组患者均实施麻醉深度监测IoCl(镇静指数)和IoC2(镇痛/抗伤害指数)。手术期间,麻醉医师根据麻醉深度监测IoCl和IoC2的数值和变化对丙泊酚、瑞芬太尼的用量进行调节。将患者血压、心率控制在波动≤20%基础值作为参考范围。记录主要指标：丙泊酚和瑞芬太尼的靶浓度调整次数、输注时间及平均用量；次要指标：术中不良事件(高血压、低血压、心动过速、心动过缓)及麻醉恢复质量(自主睁眼时间、拔管时间、苏醒评分和术中知晓)。结果：与nPC组相比,PC组丙泊酚靶浓度调整次数(2.0±1.0 vs 2.7±1.5次/手术,P0.05)、丙泊酚平均用量(732±65 vs 921±74mg, P0.05)、瑞芬太尼靶浓度调整次数(2.9±1.8 vs 4.4±2.6次/手术,P0.05)和瑞芬太尼平均用量(201±32 vs 270±41μg,P0.05)显著减少；PC组和nPC组丙泊酚输注时间、瑞芬太尼输注时间、自主睁眼时间、拔管时间和苏醒评分无明显差异(P0.05)；PC组心动过缓发生率低于nPC组[4(9.7%)vs 7(17.5%),P0.05],但是两组患者总体不良事件发生率无明显差异(P0.05)。结论：术前接受化疗的乳腺癌患者,在全凭静脉麻醉中丙泊酚靶浓度调整次数、丙泊酚平均用量、瑞芬太尼靶浓度调整次数、瑞芬太尼平均用量明显减少,而麻醉恢复质量和总体不良事件发生率无明显差异,说明术前化疗能够增强患者对丙泊酚和瑞芬太尼的敏感性。
[Abstract]:The monitoring and judgment of the depth of general anesthesia is a basic problem in the anesaesthesia, and it is also a common concern and urgent problem to be solved by the anesthesiologists. The surgical procedure, such as surgical procedures, can cause the body's stress reaction, that is, the changes in the level of the sympathetic and endocrine system, and the depth of anesthesia is actually in the case of the changes in the level of the sympathetic and endocrine system. The degree of inhibition of the stress reaction after the disappearance of consciousness. The ideal state of anesthesia was: 1, the patient's consciousness disappeared, no intraoperative awareness, no anaesthesia and surgical related bad memory after the operation; 2, the hemodynamics was smooth during the operation, and the pain and nociceptive stimulation caused by anesthesia and operation were effectively controlled; 3, muscle loosening. It is easy for surgeons to operate. 4, the reflex of bad nerves is suppressed, such as bile heart reflex, eye reflex, etc.; 5, the functions of respiration and circulation are protected to the greatest extent, and the physiological functions of the patients can be recovered quickly and completely. Only by accurately monitoring and judging the depth of anesthesia, can the patient achieve comparison. The anesthetic state. The judgment of the depth of anesthesia was based on the clinical sign observation and the method based on the anesthesia monitoring equipment. The anesthesia monitoring equipment had the bispectral index (BIS), the entropy index (entropy of the EEG), the Narcortrend grading monitoring, and the auditory evoked potential (auditory evoked potential,) AEP), event related potential (event-related potential, ERP), positron emission tomography (positron emission computed tomography, PET) and functional magnetic resonance imaging (functional magnetic resonance), etc. but there is not a kind of equipment due to the constraints of the monitoring principle, limitation and economy. The very ideal application of.BIS to the monitoring of the depth of anesthesia can reflect the excitation and inhibition of cerebral cortex function. It is a sensitive and objective quantitative index for the assessment of the state of consciousness. However, BIS mainly reflects the sedative effect of propofol, etomidate and inhaled narcotic drugs on the cerebral cortex. Indexes of consciousness (IoC) is a new technique for monitoring the depth of anesthesia. It is based on a comprehensive analysis of the clinical OAAS value and RASS value of tens of thousands of patients with general anesthesia, and IoC1 represents the sedative index. This study is used to guide the town. The use of propofol, IoC2 representing analgesic / anti injury index, is used to guide the use of remifentanil, an analgesic drug. It is reported that the dosage of propofol and remifentanil in patients undergoing preoperative chemotherapy is different from those in the patients who have not been treated. The second part selected patients receiving chemotherapy to study the effect of preoperative chemotherapy on the sensitivity of the patients with breast cancer. The first part of this study was to explore the effect of depth monitoring of anesthesia (IoC1 and IoC2) on the dosage of propofol and remifentanil during total intravenous anesthesia for patients with modified radical mastectomy; the second part of the study The effect of pre chemotherapy on the anesthetic sensitivity of patients with modified radical mastectomy. Part 1 Effect of IoC1 and IoC2 on the dosage of propofol and remifentanil during total intravenous anesthesia in patients with modified radical mastectomy for breast cancer: To explore the total intravenous injection of anesthesia depth monitoring (IoCl and IoC2) in patients with modified radical mastectomy The effect of anesthesia on the dosage of propofol and remifentanil. Methods: 120 patients with modified radical mastectomy under total intravenous anesthesia were selected. According to the random digital card generated by SPSS17.0 statistics software, the patients were randomly divided into 2 groups: the study group (group T, n=60) and the control group (group C, n=60). Blood pressure (NBP), electrocardiogram (ECG), pulse oxygen saturation (SpO2), end expiratory carbon dioxide partial pressure (PETCO2) monitoring.T group to monitor the depth of anesthesia IoC1 (sedative index) and IoC2 (analgesic / anti injury index). During anesthesia, the anesthesiologist adjusted the dosage of propofol and remifentanil based on the values and changes of IoC1 and IoC2 for the dosage of propofol and remifentanil in the.C group. During the depth monitoring, during the anesthesia, the anesthesiologist adjusted the propofol and remifentanil by observing the changes of blood pressure, heart rate and other life signs according to the clinical experience. The blood pressure and heart rate were controlled in the fluctuation less than 20% basis as the reference range. The main index: the target concentration adjustment times of propofol and remifentanil and the infusion time And the average dosage; secondary indexes: intraoperative adverse events (hypertension, hypotension, tachycardia, tachycardia, tachycardia reaction) and the quality of anesthesia recovery (independent eye opening time, extubation time, awakening score and intraoperative awareness). Results: the number of target concentrations of propofol in group T and C, propofol infusion time, propofol, Reifen There was no significant difference between TnI infusion time, independent eye opening time, extubation time and awakening score (P0.05). Compared with group C, the number of reifentanil target concentration adjustment times (2.9 +.9 vs2.0 + 1.2 times / operation, P0.05) and remifentanil in group T were significantly increased (285 + 36 vs 203 + 19 u g, P0.05), but the total number of adverse events was [26 (48%) vs. 36 (68%), (P0.05)] significantly reduced. Conclusion: the target concentration adjustment times of propofol, the time of propofol infusion and the average dosage of propofol in the patients with breast cancer were not significantly changed, while the target concentration adjustment times and the average dosage of remifentanil increased significantly, but the hypertension was low. The total number of adverse events, such as blood pressure and tachycardia, is reduced, the anesthesia process is more stable, and the controllability of anesthesia is improved. Second part of the effect of preoperative chemotherapy on the anesthetic sensitivity of patients with modified radical mastectomy: To evaluate the effect of preoperative chemotherapy on the anesthetic sensitivity of patients with modified radical mastectomy. 90 patients were treated with modified radical mastectomy under pulse anesthesia. The patients were divided into 2 groups: chemotherapy group (preoperative chemotherapy group, group PC, n=45) before operation, and non chemotherapy group (non preoperative chemotherapy group, nPC group, n=45) before operation. Oxygen saturation (Sp02), end expiratory carbon dioxide partial pressure (PErCO2) monitoring, 2 groups of patients were monitored by the depth of anesthesia IoCl (sedative index) and IoC2 (analgesic / anti injury index). During the operation, the anesthesiologist adjusted the dosage of propofol and remifentanil according to the value and changes of IoCl and IoC2 monitoring in the depth of anesthesia. Control in the fluctuation less than 20% base value as the reference range. Record the main indexes: the target concentration adjustment times of propofol and remifentanil, infusion time and average dosage; secondary index: intraoperative adverse events (hypertension, hypotension, tachycardia, bradycardia) and quality of anaesthesia recovery (self opening time, extubation time, awakening score) Results: compared with group nPC, the frequency of target concentration adjustment of propofol in group PC (2 + 1 vs 2.7 + 1.5 times / operation, P0.05), the average dosage of propofol (732 + 65 vs 921 + 74mg, P0.05), the frequency of target concentration adjustment of remifentanil (2.9 + 1.8 vs 4.4 + 1 / operation, P0.05) and the average dosage of remifentanil (201 + 32 vs 270 + + G, P0.05) In group PC and group nPC, the time of propofol infusion, remifentanil infusion time, independent eye opening time, extubation time and awakening score were not significantly different (P0.05), and the incidence of bradycardia in group PC was lower than [4 (9.7%) vs 7 (17.5%), P0.05], but there was no significant difference in the incidence of total ungood events in the two groups (P0.05). Conclusion: preoperative acceptance The frequency of propofol target concentration adjustment in total intravenous anesthesia, the average dosage of propofol, the frequency of reifentanil target concentration adjustment, the average dosage of remifentanil decreased significantly, while the quality of reifentanil and the incidence of general adverse events were not significantly different, which indicated that preoperative chemotherapy could enhance patients with propofol and Reifen too. Nei's sensitivity.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R614.24;R737.9

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