雷米芬太尼对上腹部手术患者心率变异性的影响

目的观察雷米芬太尼对上腹部手术患者心率变异性(HRV)的影响。方法择期胃癌手术患者40例,年龄35~60岁,随机均分为雷米芬太尼全麻组(R组)和硬膜外阻滞复合全麻组(E组)。观察麻醉前(T0)、麻醉诱导后插管前(T1)、腹腔探查时(T2)、手术1h(T3)、2h(T4)和拔管后10min(T5)的平均动脉压(MAP)、心率(HR)和HRV各参数:低频功率(LF)、高频功率(HF)、低频功率/高频功率比(LF/HF)、总功率(TP)。结果与T0时相比,E组T3和T4时TP下降(P<0.05),低频百分率(LFR)、高频百分率(HFR)、LF/HF变化不明显;R组TP、LFR均明显下降(P<0.01),LFR、LF/HF低于E组(P<0.05或P<0.01)。E组T2时HFR明显下降(P<0.01),TP、LF/HF升高不明显;R组TP、HFR明显升高(P<0.01),而LFR、LF/HF明显下降(P<0.01)。E组HR在T2时与术中比有明显升高(P<0.01),R组HR在T2~T4时明显下降(P<0.01)。结论硬膜外复合全麻可维持植物神经的均衡性。雷米芬太尼显著兴奋迷走神经,易致交感-迷走神经失平衡。     

心率变异性监测雷米芬太尼在老年患者麻醉诱导期安全性的评价

由于社会年龄的日益老龄化,老年人口所占比例及需要外科手术治疗日益增加,据统计老年手术死亡率2%与麻醉有关[1]。全麻气管插管对老年人的心血管系统是一个强烈的刺激,可增加心血管并发症的发生,为了提高老年患者麻醉诱导期的安全性,我们将心率变异性(HRV)应用于雷米芬太尼对老     

两种控制性降压方法对老年患者心率变异性的影响

目的 观察雷米芬太尼或硝酸甘油复合七氟醚控制性降压对老年患者心率变异性(HRV)的影响.方法 40例行鼻内窥镜手术患者,年龄60～74岁,静吸复合全麻,分为A、B两组,A组(n=22)以0.2 μg·kg-1·min-1持续输注雷米芬太尼,B组(n=18)以0.5 ng·kg-1·min-1持续输注硝酸甘油.根据血压变化调整速度及七氟醚呼末浓度,将SBP降低至基础值的70%左右.记录降压过程中HRV及SBP、HR,术毕记录苏醒时间及呼吸恢复情况.结果 降压过程中A组HR较降压前明显减慢,B组明显增快;复压后A组HR无明显变化,B组明显减慢(P<0.01);降压过程中A组LF、HF、LF/HF均较降压前显著下降,B组LF、HF较降压前显著下降,但LF/HF显著升高(P<0.01);复压后两组LF、HF较复压前明显升高,但A组LF/HF无明显变化,B组LF/HF显著下降;A组有2例拔管后出现呼吸抑制.结论 雷米芬太尼复合七氟醚降压更适用于老年患者,但术后应加强呼吸管理.     

雷米芬太尼对肝硬化后脾切除术患者苏醒的影响

目的观察雷米芬太尼在肝硬化患者脾切除手术的应用中对其麻醉苏醒的影响。方法选择肝炎后肝硬化合并脾功能亢进患者40例,随机均分为雷米芬太尼组(Ⅰ组)和芬太尼组(Ⅱ组)。分别以雷米芬太尼和芬太尼作为麻醉镇痛药,观察两组手术结束停药后患者呼之睁眼时间、自主呼吸恢复时间、拔管时间、定向力恢复时间,观察患者拔管后即刻、拔管后30min和1h的意识状态(OAA/S评分)。结果Ⅰ组患者的呼之睁眼时间、自主呼吸恢复时间、拔管时间、定向力恢复时间均短于Ⅱ组(P<0.05)。结论雷米芬太尼用于肝功能不全的患者安全、有效,而且代谢快,有利于术后恢复,是一种更理想的麻醉镇痛药。     

雷米芬太尼和芬太尼用于老年患者全凭静脉麻醉的临床比较

目的比较雷米芬太尼及芬太尼用于老年患者全凭静脉麻醉(TIVA)诱导、维持及苏醒的效果。方法40例择期行胆囊手术及胃部手术的患者,随机均分为雷米芬太尼组(RF组)及芬太尼组(F组),分别以雷米芬太尼和芬太尼为TIVA的麻醉性镇痛药,观察两组诱导前(T0)、插管前即刻(T1)、插管后1min(T2)、5min(T3)、切皮后5min(T4)、30min(T5)的BP及HR的变化以及苏醒时的咽喉反射恢复时间、睁眼时间和拔管时间。结果与T0时相比,T1、T2和T4时RF组的SBP、DBP下降均比F组显著(P<0.05或P<0.01);在麻醉恢复期,RF组患者咽喉反射恢复时间、睁眼时间和拔管时间均显著短于F组(P<0.01)。结论与芬太尼相比,雷米芬太尼是更理想的全麻镇痛药。     

芬太尼透皮贴剂的镇痛效果和对心率变异性及机体应激状态的影响

目的：评价芬太尼贴剂的镇痛效果,和对心率变异性（HRV）及机体应激状态的影响。方法：本研究为前瞻、开放试验。40例晚期癌痛患者作为研究对象,试验前口服吗啡的患者按100：1的比例转换为芬太尼贴剂;未用阿阿片类药物者,初始芬太尼剂量为25μg/h贴剂。透皮系统每72h更换一次,剂量根据患者疼痛自我评份（VAS）和对注射吗啡的需要量调整。结果芬太尼贴剂治疗期间患者疼痛明显缓,VAS评分与治疗前相比明显降低（P＜0．01）。治疗2周时,问卷调查显示,患者的睡眠、精神状态以及日常生活与治疗前相比明显降低（P＜0．01）,治疗2周时,问卷调查显示患者的睡眠、精神状以及日常生活生活较治疗前明显改善,贴剂治疗24h后HRV的低频功率（LF）与高频功率（HF）之比明显低于治疗前,而应激激素促肾上腺皮质激素（ACTH）、β-内啡肽和胰岛素也明显降低（P＜0．01）,但生长激素波动不明显,无一例发生呼吸抑制,便秘、恶心呕吐及皮肤瘙发生率,用药前后均无显著性变化。结论芬太尼贴剂用于治疗晚期癌痛有效,安全、副作用小,其良好的镇痛效果对机体的应激反应和植物神经功能平衡均产生有益影响。     

丙泊酚诱导时雷米芬太尼对老年患者意识消失的影响

目的研究靶控输注丙泊酚麻醉诱导时雷米芬太尼对老年人意识消失的影响。方法30名老年患者,随机分两组靶控输注雷米芬太尼4ng/ml组(R组)和生理盐水对照组(C组)。10min后同时靶控输注丙泊酚,效应浓度逐步上升(1,2,4μg/ml)。记录BIS、OAA/S、血液动力学变化、丙泊酚效应浓度及用量。结果OAA/S1分时,R组BIS值为62±18,C组为61±11。R组丙泊酚效应浓度为(1·1±0·4)μg/ml,C组为(2·0±0·4)μg/ml(P<0·05)。R组丙泊酚用量为(63±24)mg,C组为(141±34)mg(P<0·01)。结论雷米芬太尼能协同丙泊酚加强对老年人意识消失的作用。     

术毕应用芬太尼对丙泊酚-雷米芬太尼麻醉恢复的影响

目的探讨术毕应用芬太尼对丙泊酚-雷米芬太尼麻醉恢复的影响。方法45例实施腹腔镜胆囊切除术患者随机均分成F1、F1.5和F2三组,手术结束前10min分别给予芬太尼1、1.5和2μg/kg,评定拔管后疼痛和镇静程度,记录呼吸恢复、意识恢复和拔管时间以及拔管后的不良事件。结果F2组的VAS显著低于F1、F1.5组[(0.2±0.4)分vs.(2.1±1.2)分和(1.2±1.2)分](P<0.05);F2组Ramsay评分显著高于F1和F1.5组[(4.5±0.5)分vs.(3.1±0.3)分和(3.2±0.6)分](P<0.01)。F2组的呼吸恢复、意识恢复和拔管时间分别为(21.5±0.5)min,(19.5±1.5)min和(24.0±2.1)min,显著延长于F1组的(10.9±3.1)min,(12.2±3.1)min和(15.2±4.8)min和F1.5组的(11.9±3.2)min,(14.3±4.4)min和(16.7±4.5)min(P<0.01)。结论在腹腔镜胆囊切除术手术结束前10min应用1或1.5μg/kg芬太尼可减轻雷米芬太尼停药后的疼痛反应,但不显著延长苏醒和拔管时间。     

雷米芬太尼控制性降压对颅脑手术患者血液动力学的影响

目的观察神经外科手术中雷米芬太尼控制性降压对血液动力学的影响。方法20例ASAⅠ~Ⅱ级择期行颅脑手术患者,采用全凭静脉复合麻醉,术中持续泵注雷米芬太尼行控制性降压,维持MAP 60~70 mmHg,观察降压前(T0)、降压达目标时(T1)、维持降压15 min(T2)、30 min(T3)、停降压15 min(T4)3、0 min(T5)6个时点的MAP、HR、心输出量(CO)、心脏指数(CI)、心室收缩加速度指数(ACI)、左心做功(LCW)、外周血管阻力(SVR)的变化。结果与T0比较,T1、T2、T3时点MAP、SVR、LCW均显著降低(P<0.01);HR亦明显减慢(P<0.05);CO、CI、ACI无明显降低。结论神经外科手术中行雷米芬太尼控制性降压安全、有效,具有对心功能影响小的优点。     

雷米芬太尼对老年患者气管插管心血管反应的影响

目的观察不同剂量雷米芬太尼微量泵输注对老年患者气管插管时的心血管反应。方法 60例全麻老年患者随机均分为六组。泵注丙泊酚33 mg/min至意识消失后,Ⅰ、Ⅱ、Ⅲ组分别输注雷米芬太尼0.15、0.20、0.25μg.kg-1.min-1,持续6 min;Ⅳ、Ⅴ、Ⅵ组分别输注雷米芬太尼0.15、0.20、0.25μg.kg-1.min-1,持续8 min。丙泊酚维持量0.12 mg.kg-1.min-1。雷米芬太尼输注结束时静注罗库溴铵0.6 mg/kg,气管插管。记录诱导前(T0)、气管插管前1 min(T1)、气管插管后1 min(T2)、2 min(T3)、3 min(T4)、4 min(T5)、5 min(T6)的SBP、DBP和HR变化。结果与T0时比较,T1时六组SBP、DBP明显下降、HR明显减慢(P0.05或P0.01),T2和T4时Ⅲ、Ⅴ、Ⅵ组HR均明显减慢(P0.05或P0.01)。与T1时比较,T2~T3时Ⅰ、Ⅱ组SBP和DBP、T2~T4时Ⅳ组SBP均明显升高(P0.05或P0.01);Ⅰ、Ⅳ、Ⅴ组T2~T6时、Ⅱ组T2~T3时、Ⅲ组T3~T6时和Ⅵ组T3~T5时的HR明显增快(P0.05或P0.01)。结论老年患者气管插管时,雷米芬太尼复合丙泊酚微量泵输注时,雷米芬太尼以0.20或0.25μg.kg-1.min-1的速度,泵注6 min以上可以有效地抑制气管插管时的心血管反应。     

右美托咪定对老年患者全麻诱导过程中心率变异性的影响

目的探讨右美托咪定对老年患者全麻诱导过程中心率变异性(HRV)的影响。方法选择全麻老年患者50例,随机均分为两组:D组麻醉诱导前给予右美托咪定负荷量0.5μg/kg稀释至20ml泵注,10min输注完毕,再以0.3μg·kg-1·h-1泵注至插管后5min。C组静脉泵注等量生理盐水。记录入室后(T0)、右美托咪定负荷量结束后(T1)、气管插管前(T2)及插管后1min(T3)、3min(T4)、5min(T5)时HRV指标:总频(TP)、低频(LF)、高频(HF)及低频/高频(LF/HF)。结果与T1时比较,D组T3～T5时LF,T4、T5时HF,T5时TP明显升高(P0.05);T3～T5时LF/HF明显降低(P0.05)。与C组比较,T3～T5时D组LF,T2～T5的HF和TP明显升高(P0.05),T1～T5时D组LF/HF明显降低(P0.05)。结论全麻诱导过程中给予右美托咪定能够升高HRV,可以有效地调节交感-迷走神经张力的均衡性,稳定心血管功能。     

瑞芬太尼对腹腔镜胆囊切除术气腹时心率变异性的影响

目的观察不同剂量的瑞芬太尼对腹腔镜胆囊切除术气腹时心率变异性的影响。方法选择全麻下行腹腔镜胆囊切除手术患者45例,ASAI级,随机分成3组(每组15例):R2、R4、R6组。麻醉诱导后,维持吸入1.0MAC地氟醚。在气腹前5分钟分别血浆靶控输注瑞芬太尼2ng/ml、4ng/ml、6ng/ml,并记录气腹前5分钟(T0)、人工气腹即时(T1)、人工气腹后5分钟(T2)的心率(HR)、平均动脉压(MAP)及计算心率变异性(HRV)。结果与T0比较,R2组T1,T2上的HR,MAP,低频(LF)低频/高频(L/H)高于T0(P0.05);R4组各时间点上的HR,MAP,LF和L/H与T0相比差异无统计学意义(P0.05);R6组T2上HR,MAP,LF和L/H低于T0(P0.05)。与T1比较,R2和R6组T2时的HR,MAP,LF和L/H低于T1(P0.05);与R2组比较,R4、R6组在T1上HR,MAP,LF和L/H低于R2组(P0.05)。与R4组比较,R6组在T2上HR,MAP,LF和L/H低于R4组(P0.05)。结论血浆靶控4ng/ml瑞芬太尼能保持腹腔镜胆囊切除术气腹时的血流动力学平稳及交感迷走张力的均衡性。     

七氟醚和丙泊酚对老年冠心病患者麻醉诱导期心率变异性的影响

目的 观察七氟醚和丙泊酚对老年冠心病患者全麻诱导期心率变异性(HRV)的影响.方法 40例择期行上腹部手术老年冠心病患者,年龄60～80岁,ASAⅡ或Ⅲ级,随机均分为七氟醚(S组)和丙泊酚(P组):分别予4%七氟醚或靶控输注丙泊酚3μg/ml行麻醉诱导.分别记录麻醉前(基础值)、诱导后5、10、15、20 min SBP、DBP、HR及HRV的变化.结果 与麻醉前比较,诱导后5、10 min两组SBP、DBP下降,HR减慢(P＜0.05).诱导后5、15 min P组SBP、DBP显著低于S组,P组HR快于S组(P＜0.05).在麻醉诱导中,S组主要是低频(LF)逐渐降低,P组则是高频(HF)逐渐降低.结论 与靶控输注丙泊酚麻醉比较,七氟醚吸入麻醉对血流动力学影响较轻,诱导相对平稳,更适合老年冠心病患者的麻醉诱导.     

右美托咪定对老年患者全麻恢复期心率变异性的影响

目的研究右美托咪定（Dex）对老年患者全麻后恢复期心率变异性（HRV）的影响。方法 86例择期全麻下行腹部手术的老年患者（≥65岁）,随机均分为Dex组（D组）和对照组（C组）。手术结束前10min（缝皮时）D组以Dex0.5μg/kg稀释至10ml并以恒速10min输注完毕,C组以同样方法输注等容量生理盐水。分别于给药前（T₀）、给药后5min（T₁）、10min（T₂）、拔管时（T₃）、拔管后5min（T₄）、30min（T₅）记录两组患者MAP和HR;并测定血浆肾上腺素（E）、去甲肾上腺素（NE）和皮质醇（Cor）浓度;以频域分析法测定HRV各指标:总功率（TP）、低频功率（LF）、高频功率（HF）,同时计算LF/HF。结果 T₂～T₅时C组MAP、E、NE明显高于、HR明显快于T₀时和D组（P<0.05）;T₃、T₄时D组Cor明显高于T₀时,且T₂～T₄时C组高于T₀时和D组（P<0.05）。T₂～T₅时TP、LF、HF两组均高于T₀时;D组HF升高更明显,T₃～T₅时C组TP、LF高于D组,T₂～T₄时C组HF明显低于D组,T₂～T₅时C组LF/HF明显高于T₀时和D组（P<0.05）。结论右美托咪定用于老年患者全静脉麻醉恢复期,可有效抑制拔管期应激反应,促进HRV的恢复、改善心脏自主神经的均衡性。     

雷米芬太尼静脉全麻诱导期血流动力学变化

目的 比较霄米芬太及芬太尼静脉全麻诱导对患者血流动力学的影响.方法 60例ASA.Ⅰ或Ⅱ级的择期手术患者,年龄18～65岁.随机均分成雷米芬太尼组(R组)和芬太尼组(F组),分别以雷米分太尼1 μg/kg或芬太尼3/μg/kg进行麻醉诱导,用胸阻抗法监测麻醉诱导前(T0)、插管前(T1)、插管即刻(T2)、插管后1 min(T3)、5 min(T4)时的HR、SBP、DBP、心排血量(CO)、外周血管阻力(SVR)、加速度指数(ACI)、胸腔液体水平(TFC)和左心作功(LCW)的变化.结果 T1时两组HR、SBP、DBP、CO、SVR、LCW均低于T0时(P<0.05或P<0.01),T4时F组HR、SBP、DBP、CO、LCW显著低于T0时和R组(P<0.05或P<0.01).R组T2、T3时,F组T2～T4时SVR均高于T0时(P<0.05).结论 1μg/kg雷米芬太尼较3 μg/kg芬太尼更能有效维待全麻诱导期气管插管血流动力学平稳.     

Effects of three anesthetic induction techniques on heart rate variability.

STUDY OBJECTIVE: To investigate the effects of different clinical induction techniques on heart rate variability (HRV). DESIGN: Two studies are reported. Study 1 prospectively compared the effects of two induction techniques (etomidate vs. thiopental sodium) known to have widely disparate effects on cardiovascular reflexes. Study 2 specifically investigated whether the vagotonic effects of sufentanil cause an increase in vagally mediated HRV. SETTING: Elective surgery in a university-affiliated hospital. PATIENTS: Study 1: 18 ASA physical status I patients having minor surgery; Study 2: 10 ASA physical status III and IV patients having cardiac surgery. INTERVENTIONS: In Study 1, anesthesia was induced with either etomidate 0.3 mg/kg or thiopental sodium 4 mg/kg with 60% nitrous oxide in oxygen. In Study 2, anesthesia was induced with a sufentanil infusion (total dose 2.9 +/- 0.2 micrograms/kg). MEASUREMENTS AND MAIN RESULTS: The electrocardiogram-derived heart rate signal was subjected to power spectral analysis (similar to electroencephalographic analysis) to obtain measurements of (1) absolute HRV power [units of (beats per minute)2] within defined frequency ranges (HRVLO = power between 0 and 0.125 Hz; HRVHI = power between 0.126 and 0.5 Hz; HRVTOT = HRVLO + HRVHI) and (2) normalized HRV power (the percentage of total power) within these same frequency ranges [e.g., %HRVHI = (HRVHI/HRVTOT) x 100%]. In Study 1, both techniques caused large reductions in HRVTOT. The reduction caused by the thiopental sodium technique (-89% +/- 2%) significantly exceeded that caused by the etomidate technique (-58% +/- 13%, p less than 0.02). In Study 2, sufentanil decreased absolute power measurements of vagally mediated HRV (-69 +/- 12 change in HRVHI) but increased corresponding normalized measurements of vagally mediated HRV (90% +/- 30% increase in %HRVHI). CONCLUSIONS: In Study 1, the greater reduction in HRV with the thiopental sodium technique provides evidence that the depressant effects of anesthetics on HRV are related in part to their effects on cardiovascular reflexes. However, the significant depression in HRV caused by the etomidate technique suggests that mechanisms other than baroreflex depression (e.g., impaired consciousness) also are important in these depressant effects. In Study 2, the decrease in HRVHI caused by sufentanil documents that absolute power measurements of vagally mediated HRV are not correlated with changes in parasympathetic tone during a potent opioid induction. This lack of a correlation may result from the decrease in total HRV observed with loss of consciousness. The increase in %HRVHI suggests that normalized measurements of HRV may still provide an index of changes in sympathetic-parasympathetic balance, even when total HRV is decreased following anesthetic administration.     

Analysis of heart rate variability to assess hemodynamic alterations following induction of anesthesia

Extensive changes in hemodynamics and cardiac rhythm during induction of anesthesia may be mediated by altered responses of the autonomic nervous system to anesthetic agents. Analysis of the power spectrum of the heart rate (PSHR) variability can supply information about the autonomic nervous system, and may be used in order to assess this phenomenon. In this study, 78 patients undergoing coronary artery bypass graft surgery were evaluated. Anesthesia was induced with sufentanil, and neuromuscular blockade with vecuronium, a combination that may cause a decrease in heart rate. Before and after induction of anesthesia, the heart rate (HR), blood pressure (BP), cardiac output (CO), cardiac index (CI), and PSHR components were recorded. PSHR was obtained by using a special algorithm and data acquisition system for real-time spectral analysis. A low-frequency component (LFa, mainly sympathetic) was analyzed from a band of 0.04 Hz to 0.1 Hz. A high-frequency component (RFa, parasympathetic) was identified by the respiratory frequency spectrum. Alterations of the heart rate after induction of anesthesia were defined in order to separate the patient population into two groups: slow heart rate (slow-HR) and stable heart rate (stable-HR). Slow heart rate was defined as a decrease in HR of more than 20% of the baseline value. The variables were analyzed and compared between the slow-HR (n = 25) and stable-HR (n = 53) groups in order to verify the possibility of identifying patients prone to hemodynamic changes after anesthesia induction. There were no differences in preoperative HR, BP, CO, or CI between groups before anesthesia induction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pre-operative measurement of heart rate variability predicts hypotension during general anesthesia

BACKGROUND: Peri-operative hymodynamic instability is one of the major concerns for anesthesiologists when performing general anesthesia for individuals with autonomic dysfunction. The purpose of this study was to examine the potential usage of pre-operative measurement of heart rate variability (HRV) in identifying which individuals, with or without diabetes, may be at risk of blood pressure (BP) instability during general anesthesia. METHODS: We studied 46 patients with diabetes and 87 patients without diabetes ASA class II or III undergoing elective surgery. Participants' cardiovascular autonomic function and HRV were assessed pre-operatively, and hymodynamic parameters were monitored continuously intra-operatively by an independent observer. RESULTS: Only 6% of the participants were classified as having cardiovascular autonomic neuropathy (CAN) based on traditional autonomic function tests whereas 15% experienced hypotension. Total power (TP, P = 0.006), low frequency (LF, P = 0.012) and high frequency (HF, P = 0.028) were significantly lower in individuals who experienced hypotension compared with those who did not. Multivariate logistic regression analysis revealed that TP [odds ratio (OR) = 0.15, 95% confidence interval (CI) = 0.05-0.47, P = 0.001] independently predicted the incidence of hypotension, indicating that each log ms2 increase in total HRV lowers the incidence of hypotension during general anesthesia by 0.15 times. After stepwise multiple linear regression analysis (R2= 11.5%), HF (beta = -11.1, SE = 2.79, P < 0.001) was the only independent determinant of the magnitude of systolic blood pressure (SBP) reduction at the 15th min after tracheal intubation. CONCLUSIONS: Spectral analysis of HRV is a sensitive method for detecting individuals who may be at risk of BP instability during general anesthesia but may not have apparent CAN according to traditional tests of autonomic function.