右美托咪定在成人功能区癫痫手术清醒期的镇静作用及对皮层脑电的影响

发布时间：2018-07-05 19:00

本文选题：右美托咪啶 + 癫痫　；参考：《广州中医药大学》2014年硕士论文

【摘要】：目的：观察唤醒麻醉下行脑功能区癫痫病灶切除术的成年难治性癫痫患者,在术中唤醒后清醒时期连续泵注右美托咪定(dexmedetomidine, Dex)的镇静效果,同时定性及定量分析右美托咪定对成年癫痫病人背景脑电及癫痫波的影响。方法：拟在唤醒麻醉下行脑功能区癫痫病灶切除的成人患者48例,ASA1-2级,男30例,女18例,根据术中清醒时期镇静方法的不同,随机分为四组,分别给予静脉泵注低浓度的丙泊酚(LP)及不同剂量的右美托咪定(LD、MD、HD)镇静。所有病人均不使用镇静类术前药物,诱导采用静脉麻醉工作站(Orchestra,费森尤斯卡比,法国)双通道靶控输注丙泊酚(得普利麻,10mg/ml,阿斯利康)3.0～4.0μg/ml和瑞芬太尼(20μg/ml,宜昌人福)3.0～4.0ng/ml,待病人意识消失,对疼痛刺激无反应后,置入喉罩(LMA, SupremeTM, Singapore),采用同步间歇指令通气模式(SIMV)控制呼吸。在诱导过程中心率低于50次/min时,静脉给予阿托品0.2-0.5mmg；收缩压低于80mmHg时,给予麻黄碱10～30mg。头钉及切口处用0.25%罗哌卡因(总量3mg/kg)行局部浸润麻醉。全程使用Narcotrend监测意识深度,使用保温毯维持体温在36-37摄氏度。开颅期调整丙泊酚靶浓度,维持Narcotrend分级在D1～EO,NI值在30-46。打开硬脑膜前减浅麻醉,将丙泊酚靶浓度减至0.5μg/ml,瑞芬太尼靶浓度减至10mg/ml,当病人自主呼吸恢复良好、呼唤睁眼后,拔出喉罩,同时停止丙泊酚及瑞芬太尼泵注,待病人定向力完全恢复后,开始给予与分组相应的药物进行镇静。丙泊酚组设定丙泊酚血浆靶浓度(Cp)为1.5μg/ml;右美托咪定组均在10min内静脉泵注右美托咪定负荷量0.5μg/kg,随后根据分组,分别接受低剂量(0.2ug/kg/h,LD)、中剂量(0.4ug/kg/h, MD),高剂量(0.6ug/kg/h, HD)右美托咪定静脉持续泵注。采用Narcotrend指数(NI)和改良清醒镇静评分方法(Modified Observer's Assessment of Alertness/Sedation, OAA/S)评价病人意识,采用数字评分法评价病人疼痛程度,用脑功能区手术定位时态表评价唤醒质量。记录各组病人在唤醒时、开始镇静时(T0)丙泊酚及瑞芬太尼的效应室浓度(Ce)、Narcotrend指数(NI)；分别记录TO和TO后10min (T1)、20min (T2)、30min(T3)、40min (T4)、50min (T5)、60min (T6)各时间点的改良清醒镇静评分OAA/S、疼痛数字评分、Narcotrend指数(NI)、心率(HR)、平均动脉血压(MAP)、呼吸次数(RR)、经皮脉氧饱和度(SPO2),以及恶心、呕吐、寒战、疼痛等不良事件。患者术前均经过视频脑电检查,确定主要癫痫病灶,诱导后采用数字脑电图机(Bio-logic,美国)持续描记头皮脑电数据,手术开颅后,置入深部电极监测皮层脑电。由固定专业电生理医生采用视频定量分析法进行背景脑电、癫痫波的判读,并分析计算镇静前(t0)、镇静后10min (t1)、20min (t2)、30min (t3)及40min(t4)时脑电6波(0-4Hz)、0波(4-8Hz)、α波(8-13Hz)、p波(13～30Hz)频谱和每分钟内癫痫病灶放电次数。结果： 1.T0-T6各时间点各组间的平均动脉压(MAP)、呼吸次数(RR)和经皮脉搏氧饱和度(SP02)无明显差异(P0.05)；T1-T5时间点右美各组心率(HR)明显低于丙泊酚组(P0.05)。 2.四组NI值在T1时均开始下降,明显低于开始镇静前(P0.05),右美托咪定各组下降幅度小于丙泊酚组,LD、MD、HD三组间在这个时间点的差异无统计学意义(P0.05)；T2后LD组与丙泊酚组NI改变不明显,但LD组始终高于丙泊酚组,MD、HD组病人NI进一步下降,T4降至最低点,明显低于T0(P0.01)；HD组从T3开始,各时间点NI显著低于其它组(P0.01)。 3.T1后各时间点的改良清醒镇静评分(OAA/S),丙泊酚组均明显低于右美托咪定各组；LD组、MD组、丙泊酚组的镇静评分随时间改变不明显；HD组的镇静评分在T2时最低,然后逐渐升高,至T6时仍低于LD组和MD组,但差异不再明显(P0.05)。 4.各组疼痛数字评分与镇静前比都有一定程度下降,镇静后丙泊酚组和LD组高于MD、HD组,但组间差异不明显(P0.05)。 5.LD组和丙泊酚组清醒期寒战发生率明显高于MD和HD组(P0.05),LD组和丙泊酚组之间则无显著差异(P0.05)。 6.清醒期使用右美托咪定镇静后,患者皮层脑电出现类似Ⅱ相睡眠的特征性改变,出现频率、波幅与剂量无关；α、β、0波明显增加(P0.05),δ波的改变不明显(P0.05)；癫痫波的出现频率没有明显增加或降低,也没有新的尖波、棘波出现。 7.丙泊酚组皮层脑电表现为大量快波增加,α、β波大幅增加(P0.01),有2例病人由于背景波改变太大,无法准确完成脑电图判读,观察30min后,终止实验。结论： 1.成年难治性癫痫病人在唤醒开颅手术中,清醒期采用右美托咪定作为唯一镇静药物,可以达到手术镇静需求,并无明显不良反应。三组剂量均可提供满意的镇静效果,但与0.2ug/kg/h的较低剂量相比,采用中(0.4ug/kg/h)、高(0.6ug/kg/h)剂量右美托咪定的癫痫患者寒战发生率更低。 2.常用剂量的右美托咪定,可以对术中皮层脑电的背景活动造成影响,但不干扰对现有癫痫波的观察,不影响癫痫病灶定位和手术切除效果的评价。
[Abstract]:Objective:
To observe the sedative effects of dexmedetomidine (Dex) in the wake of awakening and the effects of right metoimidin on the background electroencephalogram and epileptic waves of adult epileptic adults.
Method:
48 adult patients, ASA1-2, 30 men and 18 women, were randomly divided into four groups according to the different sedative methods during the waking period, which were given low concentration of propofol (LP) and right metomomidine (LD, MD, HD) at different doses. All patients did not use sedation. Preoperatively, the two channel target controlled infusion of propofol (Orchestra, 10mg/ml, AstraZeneca), 3 to 4 mu g/ml and remifentanil (20 mu g/ml, Yichang people) 3 to 4.0ng/ml were used to induce the two channel target controlled infusion of propofol (LMA, SupremeTM, S). Ingapore) used synchronous intermittent instruction ventilation mode (SIMV) to control respiration. When the center rate of the induction process was less than 50 times /min, the intravenous administration of atropine 0.2-0.5mmg was given. When the systolic pressure was lower than 80mmHg, the local infiltration anesthesia was given to 10 ~ 30mg. head nailing and 0.25% ropivacaine (total 3mg/ kg) at the incision. Know depth, maintain temperature at 36-37 degrees centigrade with heat insulation blanket. Adjust the target concentration of propofol at the craniotomy period, maintain Narcotrend classification at D1 to EO, NI value at 30-46. to open the subdural anaesthesia, reduce the target concentration of propofol to 0.5 u g/ml, remifentanil target concentration to 10mg/ml, when the patient's spontaneous breathing recovery is good, call after open eye, pull out larynx At the same time, the propofol and remifentanil pump were stopped, and after the patient's directing force was completely restored, the propofol group was set up to be sedative. The propofol group set the propofol target concentration (Cp) for 1.5 u g/ml; right metoimidin group in 10min intravenous pump right metoimidin load of 0.5 mu, followed by group, respectively accepted. Low dose (0.2ug/kg/h, LD), medium dose (0.4ug/kg/h, MD), high dose (0.6ug/kg/h, HD) right metomomidin intravenous continuous infusion. The Narcotrend index (NI) and improved sober sedation score (Modified Observer's Assessment of) were used to evaluate the patient's consciousness, and the degree of pain was evaluated by the digital score method. The quality of awakening was evaluated by the temporal table in the functional area of the brain. The effect room concentration (Ce) of propofol and remifentanil (T0) and the Narcotrend index (NI) were recorded at the time of awakening, and the 10min (T1), 20min (T2), 30min (T3), 30min (T3), NI, and the improved sober sedation score at each time point were recorded. A/S, pain digital score, Narcotrend index (NI), heart rate (HR), mean arterial blood pressure (MAP), respiratory times (RR), percutaneous pulse oxygen saturation (SPO2), and nausea, vomiting, chills, pain and other adverse events.
The patients were subjected to video EEG before operation to determine the main epileptic focus. After induction, the digital electroencephalograph (Bio-logic, the United States) was used to continuously trace the scalp EEG data. After craniotomy, the deep electrode was placed to monitor the cortical electroencephalogram. The fixed professional electrophysiologists used the visual frequency quantitative analysis to carry out the background EEG, the interpretation of epileptic wave. Analysis and calculation of pre sedation (T0), 10min (T1), 20min (T2), 30min (T3) and 40min (T4) 6 wave (0-4Hz), 0 wave (4-8Hz), alpha wave (8-13Hz), 20min (13 ~) and the number of epileptic discharges per minute.
Result:
There was no significant difference in mean arterial pressure (MAP), respiration frequency (RR) and percutaneous pulse oxygen saturation (SP02) at each time point of 1.T0-T6 (P0.05), and the heart rate (HR) in each group at T1-T5 time point (HR) was significantly lower than that of propofol group (P0.05).
2. the value of NI in the four groups began to decline at T1, obviously lower than that before the beginning of sedation (P0.05), and the decrease of all groups in right metomomomidin was less than that of propofol group, and there was no significant difference between the three groups of LD, MD and HD at this time point (P0.05). The NI changes of the LD group and the propofol group were not obvious after T2, but the LD group was always higher than the propofol group. MD The T4 decreased to the lowest point, significantly lower than that of T0 (P0.01); HD group started from T3, and NI at each time point was significantly lower than that in other groups (P0.01).
The improved sober sedation score (OAA/S) at each time point after 3.T1 was significantly lower in the propofol group than in the right metomomidine group. The sedative score of the group LD, the MD group and the propofol group was not obvious with time; the sedative score in the HD group was the lowest at T2 and then gradually increased, but it was still lower than the LD and MD groups at T6, but the difference was no longer obvious (P0.05).
4. the pain score and sedation ratio of both groups decreased to a certain extent. After sedation, propofol group and LD group were higher than those of MD group and HD group, but there was no significant difference between groups (P0.05).
The incidence of shivering in group 5.LD and propofol was significantly higher than that in group MD and HD (P0.05), but there was no significant difference between LD group and propofol group (P0.05).
6. after the use of dexmedetomidin in the sober period, the patient's cortical electroencephalogram appeared characteristic changes like phase II sleep, appearing frequency, amplitude and dose independent; alpha, beta, 0 waves increased significantly (P0.05), the change of delta wave was not obvious (P0.05); the frequency of epileptic waves did not increase or decrease, and there was no new sharp wave, spinous wave appeared.
In the 7. propofol group, the cortical electroencephalogram showed a large increase in fast wave and a significant increase in alpha and beta waves (P0.01). 2 cases were unable to accurately complete the EEG interpretation because of the large changes in the background wave. After observing 30min, the experiment was terminated.
Conclusion:
In 1. adult intractable epilepsy patients, right metoomidine was used as the only sedative in awakening craniotomy, which could reach the operation sedation demand without obvious adverse reactions. The three groups could provide satisfactory sedative effect, but compared with the lower dose of 0.2ug/kg/h, the use of middle (0.4ug/kg/h), and high (0.6ug/kg/h) dose right beauty The incidence of chills in the epileptic patients with amidazine is lower.
2. the normal dose of dexmedetomidin can affect the background activity of the cerebral cortex, but it does not interfere with the observation of the current epileptic waves, and does not affect the evaluation of the location of the epileptic focus and the effect of surgical excision.
【学位授予单位】：广州中医药大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614

【参考文献】