咪达唑仑伍用不同镇痛药在腰-硬联合麻醉下妇科经腹手术中的应用

目的观察比较咪达唑仑伍用不同静脉镇痛药在腰-硬联合麻醉(CSEA)下妇科经腹手术中的镇静镇痛效果和安全性。方法择期妇科手术80例,均行腰-硬联合麻醉,根据咪达唑仑联合不同镇痛药随机分为4组:芬太尼组(FM组)、哌替啶组(PM组)、布托啡诺组(BM组)、地佐辛组(DM组)。4组患者均在切皮前15 min静脉缓慢推注咪达唑仑0.05 mg/kg,随后分别在FM组予芬太尼1μg/kg,PM组予哌替啶0.8 mg/kg,BM组予布托啡诺0.04 mg/kg,DM组予地佐辛0.1 mg/kg缓慢静脉推注。术中患者Ramsay镇静评分小于2分者,酌情追加咪达唑仑和各组镇痛药,剂量为首次的1/2～2/3。记录4组患者切皮时(T0)、打开腹膜上腹腔撑开器时(T1)、分离结扎盆腔脏器时(T2)、术毕清理腹腔时(T3)、关闭腹膜时(T4)和缝皮时(T5)的Ramsay镇静评分;记录4组术中舌后坠、呼吸抑制、低血压、心动过缓、牵拉痛发生率;术后24 h内随访,记录4组患者对手术操作过程的遗忘程度及头晕、嗜睡、恶心呕吐、寒战发生率。结果 FM、PM组在T0-T5各时点Ramsay镇静评分均明显高于BM和DM组(P0.05);FM、PM组舌后坠、呼吸抑制发生率明显高于BM和DM组(P0.01),PM组血压下降发生率明显高于其他3组(P0.05);4组心率减慢和牵拉痛发生率无明显差异(P0.05);术后24 h内随访,4组完全遗忘率均明显高于无遗忘率和不全遗忘率(P0.01);FM、PM组头晕、嗜睡、恶心呕吐发生率明显高于BM和DM组(P0.01)。4组寒战发生率无明显差异(P0.05)。结论布托啡诺或地佐辛伍用咪达唑仑辅助腰-硬联合麻醉下行妇科手术,术中镇静镇痛效果好,完全遗忘率高,生命体征平稳,术后不良反应少,较芬太尼或哌替啶与咪达唑仑配伍更安全有效。

Application of combined spinal-epidural anesthesia by midazolam combined with different pain-killers for abdomen operation in gynecological patients

Objective To observe the efficacy and safety of mitigation and analgesia of combined spinal-epidural anesthesia(CSEA) by midazolam combined with different pain-killers in gynecological patients undergoing abdomen operation.Methods Eighty gynecological patients undergoing elective abdomen operation by CSEA were randomly divided into four groups according to different pain-killers combined with midazolam: fentanyl group(FM group),pethidine group(PM group),butorphanol group(BM group) and dezocine group(DM group).Midazolam 0.05mg/kg was slowly given to all patients iv 15 min before skin incision.Sequently fentanyl 1ug/kg,pethidine 0.8mg/kg,butorphanol 0.04mg/kg and dezocine 0.1mg/kg were slowly given to the patients in FM group,PM group,BM group and DM group iv,respectively.If during operation Ramsay sedation scale <2,pain-killers were boosted.Ramsay sedation scale in the time points of skin incision(T0),applying brace instrument(T1),organ isolation and deligation(T2),clearing abdominal cavity(T3),closing abdominal cavity(T4) and skin suturation(T5) was recorded.The incidences of respiratory depression,glossocoma,bradycardia,hypotension and drag pain in the four groups were recorded.The incidences of the extent to lapsus memoriae of operative procedure,dizziness,nausea,vomiting,lethargy and chill within 24h after operation were also recorded.Results Ramsay sedation scales at each time point of T0～T5 in FM group and PM group were significantly higher than those in BM group and DM group(P<0.05).The incidences of respiratory depression and glossocoma in FM group and PM group were significantly higher than those in BM group and DM group(P<0.01).The incidence of hypotension in PM group was significantly higher than that in the other groups(P<0.05).There was no significant difference in the incidences of bradycardia and drag pain among the four groups(P>0.05).The incidence of complete lapsus memoriae in the four groups were significantly higher than that of no lapsus memoriae and incomplete lapsus memoriae(P<0.01).The incidences of dizziness,nausea,vomiting and lethargy in FM group and PM group were significantly higher than those in BM group and DM group(P<0.01).There was no significant difference in the incidence of chill among the four groups(P>0.05).Conclusion Compared midazolam combined with fentanyl and pethidine,midazolam combined with butorphanol and dezocine used in CSEA undergoing gynecological operation may bring better effect of mitigation and analgesia,higher incidence of complete lapsus memoriae,more stable vital sign and less occurrence of adverse reaction.Thus,the efficacy and safety of midazolam combined with butorphanol and dezocine may be better.