比较瑞芬太尼预处理不同麻醉方式下胸腔镜手术患者单肺通气的血流动力学和镇痛效果

孙华; 吴萧男; 郭永馨

doi:10.3969/j.issn.2095-5227.2020.12.009

比较瑞芬太尼预处理不同麻醉方式下胸腔镜手术患者单肺通气的血流动力学和镇痛效果

Remifentanil preconditioning on hemodynamic changes and analgesic outcomes in patients undergoing thoracic surgery with one-lung ventilation under intravenous or inhalationanesthesia

摘要

摘要:
目的比较瑞芬太尼预处理静脉与吸入麻醉方式下胸腔镜手术患者单肺通气的血流动力学和镇痛效果。
方法选取2017年6月- 2019年6月本中心胸外科收治的行胸腔镜下肺叶切除术患者72例，按照麻醉维持方式及插管前是否使用瑞芬太尼分为四组，两组为静脉麻醉组，分别为丙泊酚组(P1)，瑞芬太尼+丙泊酚组(P2)；另两组为吸入麻醉组，分别为七氟烷组(S1)，瑞芬太尼+七氟烷组(S2)。收集患者的一般情况和手术情况，比较四组患者在诱导前(T1)、诱导后(T2)、切皮后(T3)、单肺通气后(T4)及缝皮时(T5)的血流动力学变化，分析患者术后呼吸恢复时间、睁眼时间、拔管时间、躁动例数和术后视觉模拟评分(visual analogue scale，VAS)。
结果四组患者的一般情况无差异，手术时间、单肺通气时间、术中出血量和尿量亦无统计学差异(P＞0.05)。麻醉诱导前四组患者动脉收缩压(systolic blood pressure，SBP)、动脉舒张压(diastolic blood pressure，DBP)、平均动脉压(mean arterial pressure，MAP)、心率(heart rate，HR)差异均无统计学意义(P＞0.05)。P2组诱导后T2时间点DBP与MAP显著低于同时间点P1组(P＜0.05)，T3时间点SBP、MAP、HR显著低于同时间点P1组(P＜0.05)，T4及T5时间点SBP、HR显著低于同时间点P1组(P＜0.05)；S2组在T2时间点SBP、DBP、MAP、HR显著低于同时间点S1组(P＜0.05)，T3、T4及T5时间点SBP、MAP、HR显著低于同时间点S1组(P＜0.05)；P2、S2组血流动力学指标在不同时间点变化较小。P2组术后呼吸恢复时间、睁眼时间、拔管时间均显著低于P1组(P＜0.05)，S2组术后呼吸恢复时间、拔管时间显著低于S1组(P＜0.05)。P2、S2组的术后VAS评分分别显著低于P1、S1组(P＜0.05)。
结论瑞芬太尼预处理能够维持静脉和吸入麻醉下胸腔镜手术患者单肺通气血流动力学的稳定，缩短术后恢复时间，增强镇痛效果，安全有效。

Abstract:
Objective To observe the effect of remifentanil preconditioning on hemodynamics and postoperative analgesia in patients undergoing thoracic surgery with one-lung ventilation under intravenous or inhalation anesthesia.
Methods Seventy-two patients undergoing thoracoscopic lobectomy from June 2017 to June 2019 in the First Medical Center of Chinese PLA General Hospital were enrolled in the study. Patients were divided into intravenous anesthesia group and inhalation anesthesia group, subsequently subdivided into propofol group (P1), remifentanil+propofol group (P2), sevoflurane group (S1) and remifentanil+sevoflurane group (S2) according to remifentanil preconditioning. The general data and operation condition were collected and hemodynamic changes at these time-points of pre-induction (T1), post-induction (T2), post-incision (T3), one-lung ventilation (T4) and skin suture (T5) were analyzed. Also, the time to spontaneous ventilation, time to eye opening and time to extubation, agitation and VAS score were compared.
Results There was no significant difference in general data and operation time, one-lung ventilation time, intraoperative blood loss and urine volume between the four groups, and no significant difference was found in SBP, DBP, MAP and HR between the four groups before anesthesia induction. DBP, MAP in the P2 group were significantly lower than those in the P1 group at T2 (P＜0.05). SBP, MAP and HR in the P2 group were significantly lower than those in the P1 group at T3 (P＜0.05), SBP and HR in the P2 group were significantly lower than those in the P1 group at T4 and T5. SBP, DBP, MAP and HR in S2 group were also significantly lower than those in the S1 group at T2 (P＜0.05). SBP, MAP and HR in the the S2 group were also significantly lower than those in the S1 group at T3, T4 and T5 (P＜0.05), and the hemodynamic parameters in the P2 and the S2 groups changed slightly at different time points. The time to spontaneous ventilation, time to eye opening and time to extubation in the P2 group were significantly lower than those in the P1 group (P＜0.05), and respiratory recovery time and tracheal extubation time in the S2 group were significantly less than those in the S1 group (P＜0.05). The VAS scores in the P2 and the S2 groups were significantly lower than those in the P1 and the S1 groups, respectively ( P＜0.05).
Conclusion Remifentanil preconditioning can maintain the hemodynamic stability, shorten the postoperative recovery time and enhance analgesic effect in patients undergoing thoracic surgery with one-lung ventilation under intravenous or inhalation anesthesia.

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