瑞芬太尼和芬太尼在老年患者泌尿外科腔镜手术麻醉中的应用比较

目的在脑电双频指数(BIS)的监测下,比较老年患者泌尿外科腔镜手术中瑞芬太尼和芬太尼的效果,探讨目前老年患者手术麻醉的难点和可行的解决方法。方法32例ASAⅠ~Ⅱ级的老年病人(65~82岁),随机分成芬太尼组(F组,n=16)和瑞芬太尼组(R组,n=16)。除镇痛药外两组麻醉诱导及维持用药均相同,诱导时F组静注芬太尼2~3μg/kg;R组静注瑞芬太尼1~2μg/kg。维持时R组以0.2~0.5μg/(kg.min)的速率静脉输注瑞芬太尼,F组根据术中需要单次追加芬太尼,每次1~2μg/kg,均用丙泊酚靶控输注(TCI)维持术中BIS值在45~60。分别记录诱导给药前后(T0)、气管插管前后(T1)、切皮前后(T2)、CO2气腹前后(T3)、关腹缝皮前后(T4)和拔除气管导管前后(T5)的平均动脉压变化值(⊿MAP)、心率(⊿HR)和⊿BIS值,同时记录患者术后清醒时间,术中知晓、术中高血压、术后恶心、呕吐、寒颤、躁动和认知功能障碍等并发症的发生情况。结果R组比F组血流动力学稳定,F组T0的MAP下降较R组更明显(P<0.05),心率下降情况却相反(P<0.05),但接受刺激时(T1、T2、T3、T4)MAP增高和HR增快变化F组比R组更明显,更容易发生术中高血压(P<0.05),F组T5的MAP较R组稳定(P<0.05),F组T2和T4的BIS较R组容易波动(P<0.05),F组患者清醒时间及拔除气管导管时间比R组明显延长(P<0.05)。术后随访两组均无术中知晓等事件发生,F组有1例发生认知功能障碍,恶心呕吐情况无明显差异。结论在BIS监测下,老年患者应用瑞芬太尼复合丙泊酚麻醉,能减少围术期血压的剧烈波动,苏醒快拔管时间短,术后并发症少,具有较大的临床应用价值。

Comparison of Effects of Remifentanil and Fentanyl on Aged Patients with Urinary Laparoscopic Surgery Anesthesiology

Objective To compare the effects of remifentanil with fentanyl on elders with urinary laparoscopic surgery by use of Bispectral index(BIS) monitoring,meanwhile,to discuss the present difficulties and available methods in anesthesia of aged patients.Methods 32 patients aged from 65 to 82,ASA physical status Ⅰ-Ⅱ,were randomly divided into two groups,fentanyl(group F,n=16) and remifentanil(group R,n=16).All patients were induced and maintained with the same medicine except analgesics.Group F was given intravenous injection of fentanyl 2-3/kg during induction,and superadded 1-2/kg at each dose in need during anesthesia;while group R was given remifentanil at the dose of 1-2/kg during induction,and maintained at the speed of 0.2-0.5·kg-1·min-1 during anesthesia.BIS of both group was controlled at 45-60 with target controlled infusion(TCI) of propofol for maintenance.Meanwhile,data of difference value of mean artery pressure(⊿MAP),heart rate(HR) and ⊿BIS value were recorded before and after anesthesia(T0),before and after anesthetic incubation(T1),before and after skin incision(T2),before and after CO2 pneumoperitoneum(T3),before and after skin closure(T4),before and after extubation(T5).The wake-up time were also recorded,so were the incidence of intraoperative hypertension,postoperative nausea,vomit,shivering,dysphoria and cognitive dysfunction(POCD) of two groups.Results The hemodynamics during anaesthesia of group F were more variable than those of group R(P<0.05).MAP in group F decreased more than group R at T0(P<0.05),and decrease of HR was opposite(P<0.05),but MAP and BIS value after stimulation(T2,T3,T4,T5) and wakeup time in group F increase more obviously than those in group R,so was the incidence of intraoperative hypertension(P<0.05).MAP at T5 in group F was more stable(P<0.05),but BIS at T2 and T4 was more fluctuating(P<0.05).The wake-up time was longer in group F(P<0.05).There is no case with intraoperative awareness,but one that is diagnosed as POCD in group F.Conclusion Under the monitoring of BIS,the reasonable administration of remifentanil and propofol for aged patients can not only maintain stable hemodymanics,but also reduce complications during perioperative period,such as delayed recovery,intraoperative awareness,therefore,it has great clinic value for aged people.