右美托咪定清醒镇静在甲状腺射频消融术中的效果

发布时间：2018-04-18 21:44

  本文选题：右美托咪定 + 咪达唑仑　； 参考：《郑州大学》2017年硕士论文

【摘要】：背景随着微创介入手术的发展,越来越多的患者选择行甲状腺射频消融术(RFA)来治疗良性甲状腺疾病。与传统开放性手术相比,射频消融术虽是微创,患者的焦虑与紧张却并没有减少,而这会给手术医生造成一定程度的困扰,不利于手术的顺利进行。监护下的清醒镇静可以有效地减轻患者疼痛,缓解其紧张、焦虑的情绪,抑制机体的不良应激反应,它介于全身麻醉和局部麻醉之间,可以在保留患者对语言及触觉刺激的同时,不影响其循环及呼吸功能,降低神经损伤的发生率,提高患者的舒适度和便于外科手术操作。清醒镇静用药的靶目标是遗忘、抗焦虑和合作,是较理想的状态。甲状腺射频消融术治疗甲状腺良性结节的原理是将电极针在超声的引导下穿刺进入结节内,通过电极针导入高频交流电产生射频波,射频波导致结节内的极性分子和离子极速振动,它们相互间产生摩擦,将电能转变为热能,从而局部结节组织因高温凝固、坏死,最终灭活甲状腺结节。在整个过程中,RFA的原理是摩擦和传导热引发的热损伤。近年来,射频消融技术因并发症少、创伤小、恢复快而渐渐被应用于甲状腺良性疾病的治疗。右美托咪定是最新的一种高选择性α2肾上腺素能受体(α2:α1=1620:1)激动剂,通过激动大脑中枢神经系统内α2受体最密集的区域:脑干蓝斑(负责调控睡眠与觉醒),而产生催眠、镇静作用,引发并维持自然睡眠状态(非动眼睡眠期)。而这种镇静睡眠状态可以被外部语言或刺激唤醒,醒后神智清楚,可按照指令配合操作,且镇静过程中,无呼吸抑制,但其抑制去甲肾上腺素释放和增强迷走神经活动的作用,又会引起心率减慢、血压下降。有文献证明健康志愿者静脉使用后具有镇静、镇痛和抗焦虑的作用。术后机械通气的病人应用后能产生良好的镇静作用,即易唤醒,情绪较稳定。其镇静、镇痛和抗焦虑作用是剂量依赖性的,且几乎无呼吸抑制。健康自愿者注射小剂量右美托咪定后,其镇静作用易被语言刺激逆转。右美托咪定因具有镇痛、恢复快、较少认知功能损伤和无呼吸抑制,可能比咪达唑仑更适合用于微创手术的镇静。本试验旨在探讨右美托咪定用于短期微创手术甲状腺射频消融术清醒镇静的情况下其用药的剂量、效果(镇静、镇痛、抗焦虑、患者和外科医生满意度)和安全性,从而为优化临床用药提供理论依据。方法选择拟于日间门诊行甲状腺射频消融术的患者88例,美国麻醉医师协会(ASA)I级或II级,女73例,男15例。排除有通气功能障碍,严重心肝肾功能不全患者,且所有患者对本试验所用药物无过敏反应及禁忌。将所有患者随机分为四组:DL组、DH组、S组、M组,每组22人。入室后开放上肢静脉,输注复方林格氏液5 ml/(kg·h),连接ECG,监测无创动脉血压(NIBP)、血氧饱和度(SPO2),用脑电双频指数(BIS)监测镇静深度。手术开始前10min DL组静脉泵入右美托咪定0.5μg/kg,DH组静脉泵入右美托咪定1.0μg/kg,S组静脉泵入同容量的生理盐水,M组静脉泵入咪达唑仑0.04mg/kg,药品均用生理盐水配制,输注时间10min。记录四组患者入手术室时(T0),给药后1min(T1),5min(T2),10min(T3),20min(T4),30min(T5),60min(T6)的BIS值、MAP、HR、SPO2;评估并记录患者术中配合度评分,手术医生对该手术镇静满意度评分、OAA/S、手术时间和不良事件。结果1.各组患者的一般情况如性别、年龄、体重、ASA分级、手术时间、生命体征基础参数等差异均无统计学意义(P0.05)。2.血流动力学比较:与T0相比,DH组T2~T6时点MAP、HR显著降低,差异有统计学意义(P0.05)。与T0相比,S组T3、T4时点HR显著升高,差异有统计学意义(P0.05)。而DL组和M组T2~T6时点MAP、HR与T0相比,差异无显著变化(P0.05)。在T2~T6时点DH组的MAP、HR显著低于其他组,差异有统计学意义(P0.05)。3.以SPO295%作为轻度呼吸抑制标准,本研究记录的各组各个时点的SPO2来分析,DL组有2例(9%)发生呼吸抑制,DH组有5例(23%)发生了呼吸抑制,S组无呼吸抑制发生,M组有15例(68%)发生了呼吸抑制。从SPO2的趋势来看,M组在T2和T3时点下降明显,但均经面罩吸氧或刺激后缓解,M组的呼吸抑制发生率明显高于其他组(P0.05)。4.DL组、DH组和M组T2~T6时点与入手术室(T0)组内比较,BIS值均有显著降低(P0.05)。S组T2~T6时点与T0组内比较,BIS值无显著变化(P0.05)。M组在T3、T4时点与DH组和DL组相比,BIS值差异显著(P0.05)。5.DL组、DH组与M组、S组相比,OAA/S,患者术中配合度更高,手术医生对该手术镇静满意度更高,差异有统计学意义(P0.05)。结论1.作为一种有效的基础镇静剂,0.5μg/kg和1.0μg/kg的右美托咪定具有优于临床推荐剂量咪达唑仑的清醒镇静效应。2.与咪达唑仑相比,右美托咪定镇静中更易唤醒,呼吸抑制发生率低。3.0.5μg/kg与1.0μg/kg的右美托咪定相比,血压和心率更平稳,更安全。
[Abstract]:Background with the development of minimally invasive surgery, more and more patients underwent thyroid ablation (RFA) for the treatment of benign thyroid diseases. Compared with traditional open surgery, radiofrequency ablation is a minimally invasive, anxious and nervous patients did not reduce, and this will cause a certain degree of distress to the surgeon, is not conducive to the operation smoothly. Under the monitor of sedation can effectively relieve pain, relieve tension, anxiety, bad inhibit the stress response, which is between general anesthesia and local anesthesia, can stimulate the retention of language and tactile in patients at the same time, does not affect the circulatory and respiratory function, reduce nerve injury the incidence rate, improve patient comfort and easy surgical operation. Target sedation medication is forgotten, anti anxiety and cooperation, is the ideal state. Thyroid shot The principle of frequency ablation in the treatment of benign thyroid nodules is the needle electrode in ultrasound guided puncture into nodules, through the needle electrode into the high-frequency alternating current generated RF wave, polar molecule and ion induced vibration speed of RF waveguide nodule, their mutual friction, convert electrical energy into heat energy, thus the local organization for nodule high temperature solidification, necrosis, final inactivation of thyroid nodules in the whole process, the principle of RFA is thermal damage caused by friction and heat. In recent years, radiofrequency ablation technology because of fewer complications, less trauma, faster recovery and treatment gradually be applied to benign thyroid diseases. Dexmedetomidine is a high the latest 2 selective alpha adrenergic receptor (alpha 2: alpha 1=1620:1) agonist, by activating the brain central nervous system receptor alpha 2 most densely populated regions: brainstem locus coeruleus (responsible for the regulation of sleep and sleep wake), and. Sleep, sedation, initiation and maintenance of natural sleep (non REM sleep period). And this kind of sedation can be external stimulation language or wake up, wake up after the all clear, can be matched with the operation according to the instruction, and during sedation without respiratory inhibition, but the inhibition of noradrenaline release and increased vagal activity that will cause the heart rate, blood pressure decreased. It is reported that there are healthy volunteers after intravenous sedative, analgesic and anxiolytic effects. After undergoing mechanical ventilation to produce good sedation, which is easy to wake up, the mood is stable. The sedative, analgesic and anxiolytic effect is dose dependent, and almost no respiratory depression in healthy volunteers. The injection of small dose of dexmedetomidine sedation, easy language stimulation reversed. Dexmedetomidine has analgesic, fast recovery, less injury and cognitive function No respiratory depression, than midazolam is more suitable for minimally invasive surgery. This experiment was conducted to investigate the sedative effects of dexmedetomidine for sedation medication dose the short-term minimally invasive surgical radiofrequency ablation of thyroid conditions, effects (sedation, analgesia, anti anxiety, patient and surgeon satisfaction) and safety, so as to provide theory the basis for the optimization of clinical medication. Methods 88 cases in outpatient thyroid ablation patients, American Society of anesthesiologists (ASA) grade I or II grade, 73 cases were female, 15 were male. Rule out the serious heart ventilation dysfunction in patients with renal insufficiency, and all patients in this trial for drug allergy the effects and taboos. All patients were randomly divided into four groups: DL group, DH group, S group, M group, each group of 22 people. After entering the open upper limb vein infusion of compound Ringer's solution 5 ml/ (kg - H), connect ECG, noninvasive arterial blood pressure monitoring (N IBP),琛，

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