右美托咪定作为辅助用药在术中磁共振环境下唤醒麻醉中的应用

发布时间：2018-06-21 15:27

本文选题：唤醒麻醉 + 皮层定位　；参考：《复旦大学》2014年硕士论文

【摘要】：目的现有研究发现,接受大脑功能区手术的患者,特别是临近语言区的肿瘤病患,可能从术中磁共振和／或唤醒麻醉技术中获益,即最大程度地切除病灶并减少神经功能的缺失。然而,术中磁共振扫描的应用明显延长了手术和麻醉时间,如何确保患者术中气道通畅、平稳唤醒和提高患者的舒适度,这些都要求我们制定个性化的麻醉方案。目前丙泊酚复合瑞芬太尼靶控输注在开颅手术的唤醒麻醉中应用较为广泛。右美托咪定作为高选择性的α。受体激动剂,具有剂量依赖性的镇静、抗焦虑和镇痛作用,且几乎无呼吸抑制作用。然而,右美托咪定作为辅助用药用于开颅手术唤醒麻醉的相关研究鲜有报道,本研究将探讨右美托咪定作为辅助用药在术中磁共振环境下唤醒麻醉中应用。方法将40例语言区或邻近语言区胶质瘤患者随机分为2组,即：丙泊酚+瑞芬太尼组(P组,n=20)和右美托咪定+丙泊酚+瑞芬太尼(D组,n=20)。两组患者均给予头皮神经阻滞、MAC (Monitered Anesthesia Care)唤醒麻醉和术中磁共振扫描。分别于麻醉前(T0)、诱导完成即刻(OAA/S评分达到1分,T0)、切皮即刻(T0)、唤醒后开始皮层定位时(T3),关硬膜时(T0)记录患者动脉收缩压(SBP)和心率(HR)。记录达到目标镇静深度以及切皮时丙泊酚靶浓度和瑞芬太尼的输注速率；记录开颅结束以及手术结束时丙泊酚和瑞芬太尼的用量；比较两组镇静前后的PaC02值；记录停用丙泊酚至患者达到OAA/S评分4分的所需时间；评价两组患者硬膜剪开后的脑松弛度；记录手术过程中发生的不良事件。结果D组达到目标镇静深度及切皮时所需的丙泊酚效应室浓度显著低于P组(P0.05)。开颅结束和手术结束时,D组丙泊酚用量也显著少于比P组(P0.05)。在唤醒后进行皮层定位(T3)时D组患者收缩压显著低于P组(P0.05)。在诱导完成(T0)、切皮(T2)、唤醒后皮层定位(T0)时,D组患者心率比显著慢于P组(P0.05)。镇静完成后两组PaC02均高于基础值(P0.05),镇静后D组患者的PaC02显著高于比P组(P0.05)。两组患者均可顺利唤醒并进行大脑皮层定位,在唤醒时间上无统计学差异(P0.05)。D组患者术中高血压和心动过速的发生率低于比P组。其他术中不良事件两组间无显著性差异(如术中低血压、心动过缓、PaC0255mmHg、疼痛、恶心呕吐、寒战、癫痫发作以及脑膨胀)。结论右美托咪定作为辅助用药,能使患者较好地耐受在术中磁共振环境下的唤醒麻醉。右美托咪定的使用,可以显著降低镇静所需丙泊酚靶浓度,并减少丙泊酚用量,使患者在唤醒开颅手术过程中循环更为平稳,减少了术中高血压、心动过速的发生率,且不影响唤醒质量和唤醒时间。对于保留自主呼吸的患者,复合给予右美托咪定可增加高碳酸血症的发生。
[Abstract]:Objective current studies have found that patients undergoing surgery in the functional areas of the brain, especially cancer patients near the language area, may benefit from intraoperative magnetic resonance imaging and / or arousal anesthesia. This is to remove the lesion to the maximum extent and to reduce the loss of nerve function. However, the application of intraoperative magnetic resonance scan can obviously prolong the operation and anesthesia time. How to ensure the airways unobstructed, wake up smoothly and improve the comfort of the patients during the operation, all of which require us to establish a personalized anesthetic scheme. At present, propofol combined with remifentanil is widely used in arousal anesthesia during craniotomy. Dexmetomidine is a highly selective 伪. Receptor agonists, with dose-dependent sedation, anti-anxiety and analgesic effects, and almost no respiratory inhibition. However, there are few reports on the use of dexmetomidine as an adjunct in arousal anesthesia in craniotomy. This study will explore the application of dexmetomidine as an adjunctive drug in arousal anesthesia in magnetic resonance field. Methods 40 patients with glioma in language area or adjacent language area were randomly divided into two groups: propofol remifentanil group (group P) and dexmetomidine propofol remifentanil group (group D). Both groups were anesthetized by scalp nerve block and magnetic resonance imaging (MRI). Before anaesthesia, the OAA / S score was 1 min, the skin incision was T0, and T _ 3 and T _ 0 were recorded respectively. The systolic blood pressure (SBP) and heart rate (HRV) were recorded at the beginning of cortical localization after arousal, and at the time of closing the dura (T _ 0), and the arterial systolic blood pressure (SBP) and heart rate (HRV) were recorded. The dose of propofol and remifentanil at the end of craniotomy and at the end of operation were recorded, and the values of PaC02 before and after sedation were compared between the two groups. To record the time to stop propofol from propofol to reach OAA / S score 4; to evaluate the brain relaxation after dural clipping in both groups; and to record the adverse events during the operation. Results the concentration of propofol effect chamber in group D was significantly lower than that in group P (P 0.05). The dosage of propofol in group D was significantly lower than that in group P (P 0.05) at the end of craniotomy and operation. The systolic blood pressure in group D was significantly lower than that in group P (P 0.05). The heart rate ratio of group D was significantly slower than that of group P (P 0.05). After sedation, the PaC02 of both groups was higher than that of basic value (P0.05), and that of group D after sedation was significantly higher than that of group P (P 0.05). The incidence of hypertension and tachycardia in group D was lower than that in group P (P 0.05). There was no significant difference in other adverse events between the two groups (such as intraoperative hypotension, bradycardia PaC0255mm Hg, pain, nausea and vomiting, shivering, seizures and brain expansion. Conclusion dexmetomidine as an adjuvant drug can make patients tolerate arousal anesthesia in magnetic resonance field. The use of dexmetomidine can significantly reduce the target concentration of propofol for sedation and the dosage of propofol, thus making the circulation of patients more stable during arousal craniotomy, reducing the incidence of hypertension and tachycardia during the operation. And does not affect the arousal quality and wake-up time. In patients with spontaneous respiration, combined administration of dexmetoimidine increased the risk of hypercapnia.
【学位授予单位】：复旦大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614

【共引文献】