右美托咪定与硬膜外麻醉复合全麻在胃癌根治术中的应用研究

发布时间：2018-04-20 02:02

本文选题：右美托咪定 + 硬膜外麻醉　；参考：《安徽医科大学》2016年博士论文

【摘要】：目的:在围术期,手术、失血、术后疼痛、缺氧、精神紧张、焦虑不安、麻醉以及创伤等相关因素对机体的刺激,会引起机体发生应激反应。应激的生物学反应主要包括蓝斑-交感-肾上腺髓质轴系统兴奋、下丘脑-垂体-肾上腺皮质激素轴系统功能增强以及炎症免疫反应等,可引起机体一系列的改变,对机体稳态的维持起重要作用;但严重的应激反应会对机体造成一定程度的损害,导致生理功能的紊乱、器官功能的改变以及术后并发症的发生,引起围术期并发症和死亡率的增加,严重影响患者的远期预后和转归。因此,围术期如何通过麻醉药物及方法来合理调控患者的应激状态,减少或降低手术患者的生理及心理创伤应激,对降低术后并发症的发生率、促进患者术后顺利恢复具有很重要的临床意义。硬膜外麻醉复合全身麻醉被广泛应用于临床,如胸部、腹部手术以及骨科手术等,可以有效抑制交感神经活性,减轻术中应激反应,减少全麻药的用量,促进术后快速恢复等,但硬膜外麻醉本身具有相关的风险和并发症。右美托咪定是一种新型且具有高选择性的α2肾上腺素受体激动剂,具有更强的镇痛、抗焦虑及血流动力学的稳定作用,可减轻手术引起的应激反应,减少麻醉药的用量,减少全麻后的术后并发症等优点;而且相对硬膜外麻醉其输注操作简单方便。因此,本实验旨在研究右美托咪定与硬膜外麻醉复合全身麻醉在胃癌根治术中的应用比较,观察其对患者应激反应和术后的恢复情况等影响。方法:选择择期全麻下经腹胃癌根治术患者,美国麻醉医师协会(ASA)分级Ⅰ~Ⅱ级,年龄25~65岁,心功能Ⅰ~Ⅱ级;无长期服用药物,无硬膜外麻醉及右美托咪定输注禁忌。随机分为3组(每组30例):右美托咪定组(D组)、硬膜外组(E组)和对照组(C组)。硬膜外组(E组)患者,于T8-9椎间隙行硬膜外麻醉,试验量1.6%利多卡因4ml,随后给予0.375%罗哌卡因5ml硬膜外推注和0.375%罗哌卡因5ml/h持续硬膜外输注。右美托咪定组(D组)患者,于全麻诱导前给予负荷量右美托咪定0.6μg/kg静脉泵注15min,随后给予0.4μg/kg/h持续静脉泵注至关闭腹膜时。硬膜外组(E组)和对照组(C组)在全麻诱导前同样给予0.9%生理盐水静脉泵注15min,随后持续静脉泵注至关闭腹膜时。全麻诱导和维持均用全凭静脉麻醉(TIVA)。选择输注右美托咪定或硬膜外麻醉前(T0)、全麻诱导前(T1)、气管插管前(T2)、插管后即刻(T3)、切皮时(T4)、腹腔探查时(T5)及拔管后即刻(T6)为观察时间点;分别记录相应时间点BIS、MAP、HR,记录麻醉药物及血管活性药物的用量,观察术后苏醒情况(包括睁眼时间、拔管时间、躁动),术后1h、6h、12h、24h、48h患者VAS评分,测量不同的观察时间点患者血液中应激激素肾上腺素(E)、去甲肾上腺素(NE)、皮质醇(Cor)的浓度,以及肿瘤坏死因子-α(TNF-α)、白介素-6(IL-6)、白介素-10(IL-10)的浓度;记录患者术后排气时间、进食时间、住院时间及相关的并发症。结果:三组患者年龄、性别、体重、身高、麻醉时间、手术时间、术中输液量、出血量比较差异无统计学意义(P0.05)。D组患者BIS值在输注右美托咪定后,即T1时较C组和E组明显降低(P0.01)。与C组比较,D组在右美托咪定输注后的各时间点(T1-T6)患者的心率明显降低(P0.01或P0.05);与T0比较,D组T1-T6时和E组T4、T5时的心率显著降低(P0.01)。与C组比较,E组T3、T4时和D组T4时MAP明显降低(P0.05)。术中E组患者出现低血压且需药物处理的患者11例(36.7%),较D组4例(13.3%)和C组3例(10.0%)显著增多(P0.05)。与C组比较,D组和E组丙泊酚和瑞芬太尼的用量明显减少(P0.01或P0.05);而D组和E组组间比较丙泊酚和瑞芬太尼的用量差异无统计学意义(P0.05)。三组患者的睁眼时间、拔管时间组间比较差异无统计学意义(P0.05)。麻醉苏醒期,与C组比较,D组患者躁动的发生率显著降低(P0.05);而D组和E组组间比较差异无统计学意义(P0.05)。与E组比较,D组患者在不同时间点E、NE、Cor的浓度组间比较差异无统计学意义(P0.05)。与C组比较,E组和D组在T3-T6时E、NE的浓度及T5、T6时Cor的浓度明显降低(P0.01或P0.05)。与C组比较,D组和E组T5、T6时TNF-α、IL-6的浓度及IL-6/IL-10比值均明显降低(P0.01或P0.05)。IL-10在不同时间点三组组间比较差异均无统计学意义(P0.05)。与E组比较,D组T0、T4、T5、T6时TNF-α、IL-6、IL-10的浓度及IL-6/IL-10比值组间比较差异无统计学意义(P0.05)。与C组比较,D组和E组术后6h、12h、24h、48h静息时VAS评分均显著降低(P0.01或P0.05);D组术后1h、6h、12h、24h和E组术后1h、6h、12h、24h、48h运动时VAS评分均显著降低(P0.01或P0.05);而D组和E组在术后不同时间点VAS评分组间比较差异均无统计学意义(P0.05)。三组患者术后恶心呕吐、疼痛干预及嗜睡发生率组间比较差异均无统计学意义(P0.05)。与C组比较,D组和E组患者术后排气时间、进食时间、住院时间均缩短(P0.05),而术后外科并发症及肺部的并发症发生率组间比较差异均无统计学意义(P0.05)。结论:在胃癌根治术全麻中,静脉输注右美托咪定可产生硬膜外麻醉同等程度的应激反应抑制作用;且术中血流动力学更为平稳;右美托咪定或硬膜外麻醉复合全麻均可改善术后的镇痛效果,缩短术后排气时间、进食时间和住院时间。
[Abstract]:Objective: in the perioperative period, surgery, blood loss, postoperative pain, anoxia, stress, anxiety, anaesthesia, and trauma and other related factors to the body, it will cause stress response. The biological response of stress mainly includes the locus coeruleus sympathetic adrenal medulla axis excitation, the hypothalamus hypophysis adrenocortical hormone axis system work Enhanced and inflammatory immune responses can cause a series of changes in the body and play an important role in the maintenance of the body's homeostasis. However, severe stress responses can cause some damage to the body, resulting in disorders of the physiological function, changes in organ function and the occurrence of postoperative complications, resulting in an increase in perioperative complications and mortality. Plus, it seriously affects the long-term prognosis and prognosis of the patients. Therefore, how to regulate the patient's stress state rationally and reduce or reduce the physiological and psychological trauma stress in the operation patients by narcotic drugs and methods is of great clinical significance to reduce the incidence of postoperative complications and promote the smooth recovery of the patients after operation. Anesthesia combined general anesthesia is widely used in the clinic, such as chest, abdominal surgery and Department of orthopedics surgery, which can effectively inhibit sympathetic activity, reduce stress response in the operation, reduce the dosage of total anesthetic and promote rapid recovery after operation. But epidural anesthesia itself has the risk and complications. The high selective alpha 2 adrenergic receptor agonist, which has stronger analgesic, anti anxiety and hemodynamic stability, can reduce the stress reaction caused by surgery, reduce the dosage of anesthetics and reduce postoperative complications after general anesthesia, and it is simple and convenient for the infusion operation of epidural anesthesia. Therefore, this experiment is aimed at this experiment. The effects of right metodetomidine and epidural anesthesia combined with general anesthesia in radical gastrectomy for gastric cancer were compared, and the effects on the patients' stress response and postoperative recovery were observed. Methods: patients undergoing radical resection of gastric cancer under general anesthesia were selected, American anesthesiologist Association (ASA) grade I ~ II, age 25~65 years, and cardiac function I - II grade; 3 groups (group D), epidural group (group E) and control group (group C), epidural group (group E), epidural anesthesia in T8-9 intervertebral space, 1.6% lidocaine 4ml, and 0.375% ropivacaine 5ml epidural infusion, followed by 0.375% ropivacaine 5ml epidural infusion, and 0.375% ropivacaine group (group E). And 0.375% ropivacaine 5ml/h continuous epidural infusion. Right metomomimidin group (group D) patients were given a load dose of right metomomidin 0.6 u 15min before induction of general anesthesia, followed by 0.4 mu g/kg/h continuous intravenous pump to close the peritoneum. The epidural group (group E) and the control group (group C) were given 0.9% normal saline before the induction of general anesthesia. Pulse pump 15min, then continuous intravenous pump to close peritoneum. General anesthesia induction and maintenance of all intravenous anesthesia (TIVA). Selection infusion right metoimidin or epidural anesthesia (T0) before induction (T1), before endotracheal intubation (T2), immediate (T3) after intubation (T4), peritoneal exploration (T5) and immediately after extubation (T6) as the observation time point; Record the corresponding time points BIS, MAP, HR, record the dosage of narcotic drugs and vasoactive drugs, observe the postoperative recovery (including opening time, extubation time, restlessness), postoperative 1H, 6h, 12h, 24h, 48h patients VAS score, measure the stress hormone adrenaline (E), norepinephrine (NE), cortisol (Co), and cortisol (Co) in patients with different observation time points. The concentration of R), the concentration of tumor necrosis factor - alpha (TNF- alpha), interleukin -6 (IL-6), and interleukin -10 (IL-10); recorded the postoperative exhaust time, feeding time, hospitalization time and related complications. Results: there was no statistical difference between the three groups of patients' age, sex, weight, height, time of anesthesia, operation time, intraoperative infusion volume, and volume of bleeding. The BIS value of group P0.05.D was significantly lower than that of the C group and the E group after infusion of right metoomidin (P0.01). Compared with the C group, the heart rate of the D group at each time point (T1-T6) after the infusion of right metomomidin was significantly lower (P0.01 or P0.05). In group D T4, MAP decreased significantly (P0.05). In group E, 11 patients with hypotension and drug treatment (36.7%), 4 cases (13.3%) and 3 cases (10%) in group D were significantly increased (P0.05). Compared with group C, the dosage of propofol and remifentanil in D and E group decreased significantly (P0.01 or remifentanil). There was no statistically significant difference in the dosage of Nepal (P0.05). There was no significant difference between the three groups of patients' opening time and the time of extubation (P0.05). Compared with group C, the incidence of restlessness in group D was significantly lower (P0.05), but there was no statistical difference between group D and E group (P0.05). Compared with group E, the patients in the D group were different. The concentration of E, NE and Cor at the time point had no significant difference (P0.05). Compared with the C group, the concentration and T5 concentration of E and D groups at T3-T6 were significantly lower than those in the T3-T6 group. There was no significant difference between group groups (P0.05). Compared with group E, there was no significant difference in TNF- a, IL-6, IL-10 concentration and IL-6/IL-10 ratio in group D T0, T4, T5, T6. The VAS score of post 1H, 6h, 12h, 24h and 48h decreased significantly (P0.01 or P0.05), but there was no significant difference between the D group and E group at different time points after the operation (P0.05). There was no significant difference between the three groups of postoperative nausea and vomiting, pain intervention and the incidence of somnolence. The postoperative exhaust time, feeding time and hospitalization time were shortened (P0.05), but there was no significant difference between the postoperative surgical complications and the incidence of pulmonary complications (P0.05). Conclusion: in the general anesthesia for radical gastrectomy, intravenous infusion of right metoamidin can produce an equal degree of stress response inhibition of epidural anesthesia; and The hemodynamics was more stable, and dexmedetomidine or epidural anesthesia combined with general anesthesia could improve the postoperative analgesic effect, shorten the postoperative exhaust time, eat time and stay in hospital.

【学位授予单位】：安徽医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R614;R735.2

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