麻醉状态下拔除气管导管-置入鼻咽通气道预防高血压患者拔管反应的效果

目的 评价麻醉状态下拔除气管导管-置入鼻咽通气道预防高血压患者拔管反应的效果.方法 择期全麻下行腹腔镜胆囊切除术的高血压患者80例,随机分为气管导管组(Ⅰ组)和气管导管-鼻咽通气道组(Ⅱ组),每组40例.两组麻醉诱导气管插管后行机械通气,术中靶控输注异丙酚(血浆靶浓度3～4 μg/L)和舒芬太尼(血浆靶浓度0.2～0.4 ng/L)维持麻醉,维持脑电双频指数40～50.术毕调整异丙酚血浆靶浓度至1 μg/L、舒芬太尼靶浓度至0.1 ng/L,待呼吸恢复后停止输注,Ⅱ组拔除气管导管,置入鼻咽通气道辅以面罩给氧,待患者完全苏醒后拔除;Ⅰ组待患者完全苏醒后拔除气管导管;于麻醉诱导前即刻(T_0)、置入鼻咽通气道后即刻(T_1)、2 min(T_2)、拔除后即刻(T_3)、2 min(T_4)时记录收缩压(SP)、舒张压(DP)、心率(HR)、脉搏血氧饱和度(SpO_2),记录拔管过程中血液动力学指标的最大值(SP_(max)、DP_(max)及HR_(max)),计算拔管前后的差值(△SP、△DP及△HR),并测定血浆肾上腺素(AD)、去甲肾上腺素(NE)浓度,观察呛咳、躁动的发生情况.结果 与T_0时比较,Ⅰ组T_(3,4)时SP、DP、HR、血浆AD及NE浓度升高,Ⅱ组T_(1,3,4)时SP和DP,T_(2,3)时HR降低(P<0.05);与Ⅰ组比较,Ⅱ组T_(2～4)时SP、DP、HR、血浆AD及NE浓度降低,SP_(max)、DP_(max)、HR_(max)及△SP、△DP、△HR降低.拔管反应发生率降低(P<0.05).结论 麻醉状态下拔除气管导管-置入鼻咽通气道可有效预防高血压患者全麻恢复期的拔管反应.

Efficacy of thracheal extubation-insertion of nasopharyngeal airway for preventing response to extubation under anesthesia in patients with hypertension

Objective To evaluate the efficacy of thracheal extubation-insertion of the nasopharyngeal airway for preventing the response to extubation under anesthesia in patients with hypertension. Methods Eighty ASA Ⅱ or Ⅲ patients with hypertension, scheduled for laparoscopic cholecystectomy under general anesthesia were randomly allocated into 2 groups with 40 patients in each group: tracheal tube group (group Ⅰ ) and tracheal tube-nasopharyngeal airway group (group Ⅱ). Anesthesia was induced with midazolam 0.05 mg/kg, sufentanil 0.4 μg/kg, cisatracurium besylate 0.15 mg/kg and propofol 2 mg/kg. The patients were tracheal intubated and mechanically ventilated. Anesthesia was maintained with TCI of propofol (target plasma concentration 3-4 μg/L) and sufentanil (target plasma concentration 0.2-0.4 μg/L). BIS was maintained at 40-50. Target plasma concentrations of propofol and sufentanil were adjusted to 1 μg/L and 0.1 ng/L respectively after operation and the infusion was stopped after recovery of breathing. In group Ⅱ, extubation was performed, and then the nasopharyngeal airway was inserted and oxygen was inhaled by mask, and the airway was removed after recovery of consciousness. In group Ⅰ , extubation was performed after recovery of cousciousness. The SP, DP, HR and SpO_2 were recorded immediately before anesthesia induction (T_0), immediately and 2 min after insertion of the nasopharyngeal airway (T_(1,2)), and immediately and 2 rain after removal of the tube or airway (T_(3,4)). The maximal value of SP (SP_(max)), DP (DP_(max)) and HR (HR_(max)) were also recorded during extubation. The differences in SP (△SP), DP (△DP) and HR (△HR) before and after extubation were calculated. The plasma concentrations of AD and NE were determined. The coughing and restlessness were observed. Results The SP, DP, HR and plasma concentrations of AD and NE were significantly higher at T_(3,4) in group Ⅰ and the SP, DP at T_(1,3,4) and HR at T_(2,3) were significantly lower in group Ⅱ than those at T_0 (P<0.05). The SP, DP, HR and plasma concentrations of AD and NE were significantly lower at T_(2-4) in group Ⅱ than in group Ⅰ (P<0.05). The SP_(max), DP_(max), HR_(max), △SP, ADP and △HR were significantly lower in group Ⅱ than in group Ⅰ (P<0.05). The incidence of coughing and restlessness was obviously lower in group Ⅱ than in group Ⅰ (P<0.05). Conclusion Thracheal extubation-insertion of the nasopharyngeal airway under anesthesia can effectively prevent the patients' response to extubation during emergence from anesthesia.