右美托咪定联合利多卡因持续泵注对小脑幕下肿瘤手术患者血流动力学及术野的影响

目的 探讨右美托咪定联合利多卡因持续泵注对小脑幕下肿瘤手术患者血流动力学及术野的影响.方法 择期行小脑幕下肿瘤切除术80例,随机分为右美托咪定组(D组)、利多卡因组(L组)、右美托咪定和利多卡因联合组(LD组)及生理盐水组(N组),每组20例.D组麻醉诱导前泵注右美0.6 μg/kg 15 min,随后以0.2 μg/(kg·h)维持至手术结束前20 min停药;L组诱导时静推2％利多卡因1.5 mg/kg,90 s注射完毕后,术中以2 mg/(kg·h)静脉维持至拔除气管导管;LD组右美托咪定和利多卡因按上述剂量及方法联合应用;N组泵注等量的生理盐水.记录麻醉前(T0),插管后1 min(T1),切开脑膜时(T2),缝合脑膜时(T3),术毕拔管时(T4),拔管后1 min (T5)各时点平均动脉压(MAP)、心率(HR)值;记录丙泊酚及瑞芬太尼的用量;记录脑组织松弛情况、术后清醒时间、拔管时间、拔管时呛咳的例数;记录患者术后恶心呕吐及呼吸抑制的发生例数;记录拔管后躁动的发生率,采用Riker镇静和躁动(SAS)评分,＞5分则视为躁动,可给予曲马多0.1 mg/kg.记录患者术后外科重症监护室(SICU)驻留时间、术后住院时间.结果 ①与N组比较,L组、D组和LD组T1、T4、和T5时MAP和HR降低(P＜0.05);与L组相比,D组和LD组T1、T4、和T5时点的HR降低(P＜0.05);②与N组比较,L组、D组和LD组脑组织松弛良好,拔管及清醒时间短,SAS评分低,给予曲马多例数少,丙泊酚和瑞芬太尼的单位体重用量少,拔管时呛咳发生率低(P＜0.05);③脑组织松弛情况、拔管及清醒时间、SAS评分、给予曲马多例数以及丙泊酚和瑞芬太尼的单位体重用量LD组优于L组和D组(P＜0.05),而L组和D组之间差异无统计学意义;4组之间恶心呕吐及呼吸抑制的发生率差异无统计学意义.与N组比较,LD组患者SICU驻留时间短(p＜0.05),N组、L组和D组三组患者SICU驻留时间差异无统计学意义.4组患者的术后住院时问差异无统计学意义.结论 右美托咪定联合利多卡因持续泵注可较好地维持小脑幕下肿瘤患者术中血流动力学的稳定,脑松弛情况良好,为外科医师创造了良好的手术视野.其效果优于右美托咪定和利多卡因单独应用.

The effects of continuous intravenous of dexmedetomidine and lidocaine on visual operative field and haemodynamics of patients undergoing the tentorium cerebelli tumor operation

Objective To investigate the effects of continuous intravenous of dexmedetomidine and lidocaine on visual operative field and haemodynamics of patients undergoing the tentorium cerebelli tumor operation.Methods 80 patients with elected operation of the tentorium cerebelli tumor were allocated into four groups (n--20),group dexmedetomidine(Group D),group lidocaine(Group L),group dexmedetomidine and lidocaine (Group LD),and group normal saline(Group N).In group D,the dexmedetomidine was administrated at the rate of 0.6 μg/kg for 15 min,then continuous intravenous at the rate of 0.2 μg/(kg · h) to 20 min before the end of the surgery.Patients in the group L were treated with lidocaine 1.5 mg/kg for 90 s in the period of induction then maintained at the rate of 2 mg/(kg · h) until extubation.The doses and time administration of dexmedetomidine and lidocaine in group LD were as the same as group D and group L,as well as in group N.Both mean arterial pressure(MAP) and heart rate(HR) were investigated before anesthesia induction(T0),1 min after intubation(T1),at times of meninges incision(T2) and suture (T3),extubation (T4) and 1 min after extubation (T5).The doses of propofol and remifentany were recorded.Looseness score of brain tissue,extubation time,awake time,cases of bucking during extubation and the postoperative outcomes were also recorded.The Ramsay and SAS score were assessed at PACU,and tramadol(0.1 mg/kg) was used when SAS ＞5.The duration in surgical intensive care unit(SICU) and length of stay of inpatients after operation were also recorded.Results ① Compared with group N,MAP and HR at T1,T4 and T5 decreased in other three group(P ＜ 0.05);Compared with group L,MAP and HR at T1,T4 and T5 also decreased in group D and group LD(P ＜0.05);② Compared with group N,the looseness score of brain tissue was better,extubation and awake time were shorter,SAS score lower,the dose of anesthetics was less,tramadol-used cases and extubation-induced bucking cases decreased in other three groups(P ＜0.05);③ Compared with group L and group D,the looseness score of brain tissue,extubation and awake time,SAS score,traradol-used cases and the anesthetics doses were improved in group LD (P ＜ 0.05).There were no statistical differences between group L and group D.The incidences of nausea and vomiting and respirator depression among the four groups showed no statistical differences.Compared with group N,the duration in SICU of group LD was shorter(P ＜ 0.05).There were no statistical differences among the duration in SICU of group N,group L and group D.There were no statistical differences in length of stay of inpatients after operation among the four groups.Conclusion The combination of dexmedetomidine and lidocaine not only maintain the haemodynamic of patients stability but also provide the surgeon with a good surgical field under the tentorium cerebelli tumor operation,which is better than any single use.