右美托咪定联合瑞芬太尼和丙泊酚泵注对甲状腺术中神经电生理监测的影响

目的探讨右美托咪定（DEX）联合瑞芬太尼、丙泊酚泵注在行术中神经电生理监测（IONM）的甲状腺手术病人中的应用效果。方法选取术中行IONM的甲状腺手术病人70例，随机分为观察组和对照组，各35例。观察组诱导前10 min静脉泵注0.6 μg/kg DEX预给量，随后持续泵注0.4 μg·kg-1·h-1 DEX，直至手术结束前30 min停止用药；对照组注射等量0.9%氯化钠溶液。2组病人均采用同样的药物快速诱导，为0.05 mg/kg咪达唑仑、2 mg/kg丙泊酚、0.4 μg/kg瑞芬太尼、0.3 mg/kg罗库溴铵，然后为病人插入神经专用导管。术中泵注瑞芬太尼与丙泊酚维持麻醉，不使用肌松药。记录2组注药前（T₀）、麻醉诱导前（T₁）、插管即刻（T₂）、手术切皮即刻（T₃）、分离甲状腺时（T₄）、拔管后即刻（T₅）的心率（HR）、平均动脉压（MAP）、脑电双频指数（BIS）；记录丙泊酚和瑞芬太尼用量、病人麻醉恢复情况、术后舒适度、术中知晓情况。结果组内比较显示，观察组病人T₁~T₄时HR和MAP均低于T₀（P < 0.05~P < 0.01），T₁~T₅时BIS均明显低于T₀（P < 0.01）；对照组T₃和T₄时HR均低于T₀，T₃时MAP低于T₀（P < 0.05），T₂~T₅时BIS均明显低于T₀（P < 0.01）。组间比较显示，观察组病人T₁~T₄时HR和MAP均低于对照组各时点（P < 0.05~P < 0.01），T₁时BIS明显低于对照组（P < 0.01）。2组病人均无术中知晓情况。观察组病人的丙泊酚和瑞芬太尼用量均明显少于对照组（P < 0.01）；观察组苏醒期间烦躁发生率为5.71%（2/35），低于对照组的25.71%（9/35）（P < 0.05）；观察组术后BCS评分明显高于对照组（P < 0.01）。2组病人睁眼时间、拔管时间差异均无统计学意义（P>0.05）。结论DEX联合瑞芬太尼和丙泊酚应用于甲状腺手术病人，对术中IONM无影响，可满足手术需求，且具有降低苏醒期间烦躁和提高病人术后舒适程度等优势。

Effect of the pump injection of dexmetomidine combined with remifentanil and propofol on intraoperative nerve monitoring during thyroidectomy

ObjectiveTo investigate the clinical application effects of the pump injection of dexmetomidine(DEX) combined with remifentanil and propofol in intraoperative nerve monitoring(IONM) during thyroidectomy.MethodsSeventy thyroidectomy patients with IONM were randomly divided into the observation group and control group(35 cases in each group).The observation group was induced by intravenous pumping 0.6 g/kg DEX for the first 10 min, followed by continuous pumping 0.4 μg·kg-1·h-1 DEX, and the drug stopped before 30 min of the end of the surgery.The control group was injected with the same amount of 0.9% sodium chloride solution.Two groups were rapidly induced using the 0.05 mg/kg midazolam, 2 mg/kg propofol, 0.4 μg/kg remifentanil and 0.3 mg/kg rocuronium bromide, and a special nerve catheter was inserted into the patient.Remifentanil and propofol were pumped intraoperatively to maintain anesthesia without muscle relaxants.The heart rate(HR), mean arterial pressure(MAP) and bispectral(BIS) index in two groups were recorded before injection(T₀), before anesthesia induction(T₁), and at the time of intubation(T₂), cutting skin(T₃) and isloating thyroid gland(T₄) and extubation(T₅).The dosage of propofol and remifentanil, recovery of anesthesia, postoperative comfort and intraoperative awareness were recorded in two groups.ResultsThe HR and MAP in observation group at T₁ to T₄ were lower than those at T₀(P < 0.05 to P < 0.01), and the BIS in observation group at T₁ to T₅ were significantly lower than that at T₀(P < 0.01).The HR in control group at T₃ and T₄ were lower than that at T₀(P < 0.05), and the BIS in control group at T₂ to T₅ were significantly lower than that at T₀(P < 0.01).The HR and MAP in observation group at T₁ to T₄ were significantly lower than those in control group at each time-point(P < 0.05 to P < 0.01), and the BIS in observation group at T₁ was significantly lower than that in control group(P < 0.01).Neither group had intraoperative knowledge.The dosage of propofol and remifentanil in observation group were significantly lower than those in control group(P < 0.01).The incidence rate of restlessness in observation group(5.71%)(2/35) was lower than that in control group(25.71%)(9/35)(P < 0.05).The BCS score in observation group after operation was significantly higher than that in control group(P < 0.01).The differences of the opening eye time and extubation time were not statistically significant between two groups(P>0.05).ConclusionsThe application of DEX combined with remifentanil and propofol in thyroidectomy does not affect the IONM, can meet with operation, reduce restlessness during recovery and improve postoperative comfort.