异丙酚与瑞芬太尼靶控输注全凭静脉麻醉用于鼻内窥镜手术控制性降压的效果

目的：探讨异丙酚与瑞芬太尼靶控输注全凭静脉麻醉用于鼻内窥镜手术控制性降压的可行性。方法：选择慢性鼻窦炎择期行鼻内窥镜手术的病人40例,采用随机单盲的方法分为2组：静吸复合麻醉组（对照组）和全凭静脉麻醉组（试验组）,每组20例。手术开始后进行控制性降压,对照组降压用硝酸甘油,试验组则使用靶控输注异丙酚和瑞芬太尼。术中有创平均动脉压维持在60～65mmHg（1mmHg=0.133kPa）,直至手术主要步骤结束。术中连续监测心电图（ECG）、血压（BP）、指脉搏血氧饱和度（SPO2）、脑电双频指数（BIS）、呼气末二氧化碳分压（PETCO2）。分别记录麻醉诱导前（T1）、插管后即刻（T2）、手术开始后15min（T3）、手术开始后30min（T4）、停止降压后5min（T5）、拔管前（T6）和拔管后3min（T7）的心率、平均动脉压（MAP）和BIS值,并抽取动脉血进行血乳酸测定。记录诱导时间、降至目标血压时间、清醒时间和停药至拔管时间。结果：与对照组比较,试验组手术时间短、手术视野清晰。两组病人均能在短时间内达靶目标血压,对照组在手术结束后（18.3±5.4）min内拔除气管导管,而试验组仅需（7.0±2.1）min。对照组降压过程中心率增快明显,停药后有反跳性高血压（P〈0.05）;试验组降压过程平稳,停止降压后血压和心率与麻醉前比较差异无统计学意义。两组病人围术期BIS和Lac值组间比较差异无统计学意义,术后随访均无术中知晓。两组病人血乳酸值差异无统计学意义（P〉0.05）。结论：异丙酚与瑞芬太尼靶控输注全凭静脉麻醉用于鼻内窥镜手术降压时起效快,过程平稳,无反射性心动过速和反跳性高血压,术后苏醒快,无术中知晓,安全、有效。

Effects of total intravenous anesthesia of target-controlled infusion (TCI)with propofol and remifentanil during endoscopic nasal sinus surgery

AIM：To determine the efficacy and safety of total intravenous anesthesia of target-controlled infusion（TCI）with propofol and remifentanil during endoscopic nasal sinus surgery.METHODS：Forty ASA physical status I-II patients（male 21,female 19）aged（18-60）yr weighting（40-75）kg without heart and pulmonary disease,hypertension etal undergoing endoscopic nasal sinus surgery were randomly divided into two groups：breathing and intravenous anesthesia group（Control group,n=20）and total intravenous anesthesia group（Experiment group,n=20）.Proportion of sex,age,weight operation region,ASA physical status were not different between two groups.Controlled hypotension was induced before the main procedure of surgery.All patients assigned to control group were infused by a constant infusion of 2-5 μg·kg-1·min-1 nitroglycerin until the target pressure was reached,then infusion rate was adapted in order to sustain hypotension.In experiment group,remifentanil were delivered with a infusion rate of 0.1-0.2 μg·kg-1·min-1 in order to induce controlled hypotension that was considered effective,then the rate was adapted according to hypotension.MAP was sustainted at 60-65 mm Hg（1 mm Hg=0.133 kPa）till the main procedure of surgery was finished.HR,MAP,ECG,BIS and PETCO2 were monitored at time of 5 minutes before anesthesia（T1）,after intubation（T2）,15 minutes after surgical incision（T3）,30 minutes after surgical incision（T4）,5 minutes afte controlled hypotension over（T5）,before extubation（T6）and 3 minutes after extubation（T7）.Blood samples were gathered from artery to detect lac concentration.The quality of surgical field in terms of blood loss and dryness was rated by the same attending surgeon who was unware of the pharmacological treatments.RESULTS：The control group was decreased significantly than the experiment group with regard to duration of surgery and the surgical field rating（P0.05）.Controlled hypotension was achieved at the target pressure of 60-65 mm Hg within（4.7±2.7）min,（4.4±2.5）min for control group and experiment group respectively.Cases in control group had longer postanesthetic recovery compared with those in experiment group （18.3±5.4）min vs（7.0±2.1）min,P0.05].In experiment group,remifentanil induced and sustained hypotension without reflexible tachycardia and rebounding hypertension.As regard to BIS value and Lac concentration during perioperation period,there were no significant difference between two groups（P0.05）.CONCLUSION：Total intravenous anesthesia（TIVA）of target-controlled infusion（TCI）with propofol combined with remifentanil could induce and sustain controlled hypotension,reduce blood loss,during endoscopic nasal sinus surgery without reflexible tachycardia and rebounding hypertension.