不同通气方式对髋关节置换高血压患者应激反应的影响

背景：髋关节置换患者全麻时，气管插管可造成咽喉和气管感受器的物理刺激，会引起患者的应激反应增强，尤其是高血压患者。Supreme喉罩能够减轻围术期患者心血管应激反应，降低气道并发症。目的：观察Supreme喉罩和气管插管对高血压患者髋关节置换应激反应的影响。方法：取2010年1月至2014年9月于江苏省沭阳仁慈医院行人工髋关节置换的患者45例，采用随机数字表法将患者均分为两组，喉罩组23例，气管插管组22例。两组患者均采用相同的麻醉诱导和维持方法，置换过程中连续监测患者的收缩压、舒张压、心率及血氧饱和度，分别记录两组麻醉诱导前(T0)、插管(喉罩)后即刻(T1)、5 min(T2)、15 min(T3)时收缩压、舒张压、血氧饱和度、心率及血糖、血浆肾上腺素、去甲肾上腺素、血清皮质醇、血管紧张素Ⅱ及心钠素水平。结果与结论：喉罩组患者收缩压与舒张压在T1-T3时间点较T0时明显降低(P < 0.05)；心率、血氧饱和度在T0-T3各时间点比较平稳，差异无显著性意义(P > 0.05)。气管插管组患者收缩压、舒张压在T1时较T0时显著升高，收缩压在T2、T3时较T0明显降低，舒张压在T3时较T0显著降低(P < 0.05)，心率、血氧饱和度在T1时间点显著升高(P < 0.05)。与T组比较，喉罩组患者收缩压与舒张压在T1-T3时间点显著降低(P < 0.05)，心率在T1、T2较T组明显减慢(P < 0.05)，血氧饱和度在T1显著高于T组(P < 0.05)。与T0时比较，T1-T3时气管插管组血糖、血浆肾上腺素、去甲肾上腺素浓度和皮质醇含量明显升高，且显著高于喉罩组(P < 0.05)。T1-T3时气管插管组血管紧张素Ⅱ水平较T0时显著增高，且均高于喉罩组。T1-T3时两组心钠素含量明显升高，气管插管组显著高于喉罩组(P < 0.05)。可见喉罩对于这些与应激相关的生化指标的影响较小，这也是其对患者血流动力学影响较小的生理基础。提示与气管插管比较，喉罩可明显减轻高血压患者全麻状态下髋关节置换时的应激反应。中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Effects of different ventilation modes on stress reaction of hypertensive patients treated with hip arthroplasty

BACKGROUND:When hip replacement patients treated with general anesthesia, intubation can cause physical stimulus of receptors of throat and trachea, which can increase stress response of patients, especially in patients with hypertension. LMA Supreme laryngeal mask can lessen cardiovascular stress response of perioperative patients and reduce airway complications. OBJECTIVE:To investigate the effects of Supreme laryngeal mask and endotracheal intubation on stress response of hypertensive patients with hip arthroplasty.  METHODS:A total of 45 patients treated with hip arthroplasty in the Shuyang Renci Hospital from January 2010  to September 2014 were enrolled in this study. They were divided into laryngeal mask group (23 cases) and endotracheal intubation group (22 cases). The same protocol for induction and maintenance of general anesthesia was used in the two groups. During arthroplasty, systolic blood pressure, diastolic blood pressure, heart rate and blood oxygen saturation were monitored in patients. Systolic blood pressure, diastolic blood pressure, blood oxygen saturation, heart rate, blood glucose, plasma epinephrine, norepinephrine, serum cortisol, angiotensin II and atrial natriuretic factor levels were recorded before induction (T0), immediately (T1), 5 minutes (T2) and 15 minutes (T3) after intubation in the two groups. RESULTS AND CONCLUSION:Systolic blood pressure and diastolic blood pressure were significantly reduced in the T1-T3 compared with T0 in the laryngeal mask group (P < 0.05); blood oxygen saturation and heart rate were stable in T0-T3 (P > 0.05). Systolic blood pressure and diastolic blood pressure were significantly increased at T1 compared with T0, systolic blood pressure was significantly reduced at T2 and T3 compared with T0, and diastolic blood pressure was significantly diminished at T3 compared with T0 in the endotracheal intubation group (P < 0.05). Blood oxygen saturation and heart rate were significantly higher at T1 (P < 0.05). Compared with endotracheal intubation group, systolic blood pressure and diastolic blood pressure were significantly lower at T1-T3 (P < 0.05), and heart rate was significantly slower at T1 and T2 (P < 0.05) in the laryngeal mask group. Blood oxygen saturation was significantly higher at T1 in the laryngeal mask group than in the endotracheal intubation group (P < 0.05). Compared with T0, blood glucose, plasma epinephrine, norepinephrine and cortisol contents were significantly higher at T1-T3 in the endotracheal intubation group, and above indexes were higher in the endotracheal intubation group than in the laryngeal mask group (P < 0.05). Angiotensin II levels were significantly higher at T1-T3 compared with T0 in the endotracheal intubation group, and it was significantly higher in the endotracheal intubation group than in the laryngeal mask group (P < 0.05). Atrial natriuretic factor levels were increased at T1-T3 in the two groups, and it was significantly higher in the endotracheal intubation group than in the laryngeal mask group (P < 0.05). These results confirm that laryngeal mask slightly impacted stress-related biochemical indicators, which is a physiological basis for slight effect of laryngeal mask on hemodynamics. Compared with endotracheal intubation, laryngeal mask obviously lessened stress reaction of hypertensive patients under general anesthesia treated with hip arthroplasty.