本文選題：麻醉深度監(jiān)測(cè)(IoC1和IoC_2) + 丙泊酚��； 參考：《山東大學(xué)》2016年博士論文

【摘要】：研究背景全身麻醉深度的監(jiān)測(cè)和判斷,是麻醉學(xué)科的一個(gè)基本問(wèn)題,同時(shí)它也是麻醉醫(yī)生普遍關(guān)注而且亟待解決的問(wèn)題。外科手術(shù)等傷害性刺激可以引起機(jī)體的應(yīng)激反應(yīng)過(guò)程,即交感和內(nèi)分泌系統(tǒng)激素水平的變化,麻醉深度實(shí)際上是在意識(shí)消失后麻醉藥物對(duì)這種應(yīng)激反應(yīng)的抑制程度。比較理想的麻醉狀態(tài)是：1、患者意識(shí)消失,無(wú)術(shù)中知曉,術(shù)后無(wú)麻醉和手術(shù)相關(guān)的不良記憶；2、術(shù)中血流動(dòng)力學(xué)平穩(wěn),麻醉和手術(shù)操作引起的疼痛／傷害性刺激得到有效控制；3、肌肉松弛,便于外科醫(yī)師進(jìn)行手術(shù)操作；4、不良神經(jīng)反射得到抑制,如膽心反射、眼心反射等；5、呼吸和循環(huán)等功能得到最大程度的保護(hù),術(shù)后患者的各項(xiàng)生理功能可以迅速完全地恢復(fù)。只有準(zhǔn)確地監(jiān)測(cè)和判斷麻醉深度,才能使患者達(dá)到比較理想的麻醉狀態(tài)。麻醉深度的判斷有以臨床體征觀察為依據(jù)的判斷方法和以麻醉監(jiān)測(cè)設(shè)備為依據(jù)的判斷方法。麻醉監(jiān)測(cè)設(shè)備有腦電雙頻指數(shù)(bispectral index, BIS)、熵指數(shù)(entropy of the EEG)、Narcortrend分級(jí)監(jiān)測(cè)、聽(tīng)覺(jué)誘發(fā)電位(auditory evoked potential,AEP)、事件相關(guān)電位(event-related potential, ERP)、正電子發(fā)射斷層掃描(positron emission computed tomography, PET)和功能磁共振成像(functional magnetic resonance imaging, fMRI)等,但是由于受監(jiān)測(cè)原理、局限性和經(jīng)濟(jì)性等各方面因素的制約,目前尚無(wú)一種設(shè)備能夠非常理想地應(yīng)用于麻醉深度監(jiān)測(cè)。BIS能夠反映大腦皮層功能的興奮和抑制狀態(tài),是目前應(yīng)用比較廣泛、評(píng)估意識(shí)狀態(tài)的敏感而客觀的量化指標(biāo)。但是BIS主要反映的是丙泊酚、依托咪酯和吸入麻醉藥等抑制大腦皮層所產(chǎn)生的鎮(zhèn)靜作用,而對(duì)全身麻醉的鎮(zhèn)痛作用監(jiān)測(cè)效果不佳。意識(shí)指數(shù)(indexes of consciousness,IoC)是一種新型的麻醉深度監(jiān)測(cè)技術(shù),它是以數(shù)萬(wàn)例進(jìn)行全身麻醉患者的臨床OAAS值和RASS值為基礎(chǔ)經(jīng)過(guò)綜合分析得出來(lái)的,其中IoC1代表鎮(zhèn)靜指數(shù),本研究用以指導(dǎo)鎮(zhèn)靜藥物丙泊酚的使用,IoC2代表鎮(zhèn)痛／抗傷害指數(shù),本研究用以指導(dǎo)鎮(zhèn)痛藥物瑞芬太尼的使用。有文獻(xiàn)報(bào)道,術(shù)前接受化療的患者在全憑靜脈麻醉中,麻醉藥物丙泊酚和瑞芬太尼的用量與未接受化療的患者相比有一定的差異。因此,本研究第二部分選取接受化療的患者進(jìn)行研究,從而了解術(shù)前化療對(duì)乳腺癌患者麻醉敏感性的影響。本研究第一部分探討麻醉深度監(jiān)測(cè)(IoC1和IoC2)在乳腺癌改良根治術(shù)患者全憑靜脈麻醉中對(duì)丙泊酚和瑞芬太尼用量的影響；第二部分探討術(shù)前化療對(duì)乳腺癌改良根治術(shù)患者麻醉敏感性的影響。第一部分麻醉深度監(jiān)測(cè)(IoC1和IoC2)在乳腺癌改良根治術(shù)患者全憑靜脈麻醉中對(duì)丙泊酚和瑞芬太尼用量的影響目的：探討麻醉深度監(jiān)測(cè)(IoCl和IoC2)在乳腺癌改良根治術(shù)患者全憑靜脈麻醉中對(duì)丙泊酚和瑞芬太尼用量的影響。方法：選取擇期在全憑靜脈麻醉下行單側(cè)乳腺癌改良根治術(shù)患者120例。根據(jù)由SPSS17.0統(tǒng)計(jì)學(xué)軟件生成的隨機(jī)數(shù)字卡,將患者隨機(jī)分為2組：研究組(T組,n=60)和對(duì)照組(C組,n=60)。所有患者均行常規(guī)無(wú)創(chuàng)血壓(NBP)、心電圖(ECG)、脈搏血氧飽和度(SpO2)、呼氣末二氧化碳分壓(PETCO2)監(jiān)測(cè)。T組行麻醉深度監(jiān)測(cè)IoC1(鎮(zhèn)靜指數(shù))和IoC2(鎮(zhèn)痛/抗傷害指數(shù)),麻醉期間,麻醉醫(yī)師依據(jù)IoC1和IoC2的數(shù)值和變化對(duì)丙泊酚、瑞芬太尼的用量進(jìn)行調(diào)節(jié)。C組不行麻醉深度監(jiān)測(cè),麻醉期間,麻醉醫(yī)師根據(jù)臨床經(jīng)驗(yàn)通過(guò)觀察血壓、心率等生命體征變化對(duì)丙泊酚、瑞芬太尼用量進(jìn)行調(diào)節(jié),將患者血壓、心率控制在波動(dòng)≤20%基礎(chǔ)值作為參考范圍。記錄主要指標(biāo)：丙泊酚和瑞芬太尼的靶濃度調(diào)整次數(shù)、輸注時(shí)間及平均用量；次要指標(biāo)：術(shù)中不良事件(高血壓、低血壓、心動(dòng)過(guò)速、心動(dòng)過(guò)緩和體動(dòng)反應(yīng))及麻醉恢復(fù)質(zhì)量(自主睜眼時(shí)間、拔管時(shí)間、蘇醒評(píng)分和術(shù)中知曉)。結(jié)果：T組與C組丙泊酚靶濃度調(diào)整次數(shù)、丙泊酚輸注時(shí)間、丙泊酚平均用量、瑞芬太尼輸注時(shí)間、自主睜眼時(shí)間、拔管時(shí)間、蘇醒評(píng)分無(wú)明顯差異(P0.05)；與C組比較,T組患者麻醉期間瑞芬太尼靶濃度調(diào)整次數(shù)(2.9±.9 vs2.0±1.2次/手術(shù),P0.05)和瑞芬太尼平均用量(285±36 vs 203±19μg, P0.05)顯著增多,但是不良事件總數(shù)[26(48%) vs 36(68%),(P0.05)]顯著減少。結(jié)論：全憑靜脈麻醉期間行麻醉深度監(jiān)測(cè)(IoC1和IoC2)時(shí),乳腺癌患者丙泊酚的靶濃度調(diào)整次數(shù)、丙泊酚輸注時(shí)間和丙泊酚的平均用量無(wú)明顯變化,而瑞芬太尼的靶濃度調(diào)整次數(shù)和平均用量明顯增加,但是高血壓、低血壓、心動(dòng)過(guò)速等不良事件總數(shù)減少,麻醉過(guò)程更加平穩(wěn),提高了麻醉的可控性。第二部分術(shù)前化療對(duì)乳腺癌改良根治術(shù)患者麻醉敏感性的影響目的：評(píng)價(jià)術(shù)前化療對(duì)乳腺癌改良根治術(shù)患者麻醉敏感性的影響。方法：選取擇期在全憑靜脈麻醉下行單側(cè)乳腺癌改良根治術(shù)患者90例。將患者分為2組：術(shù)前接受化療的為化療組(preoperative chemotherapy group, PC組,n=45),術(shù)前未接受化療的為非化療組(non preoperative chemotherapy group, nPC組,n=45)。除常規(guī)無(wú)創(chuàng)血壓(NBP)、心電圖(ECG)、脈搏血氧飽和度(Sp02)、呼氣末二氧化碳分壓(PErCO2)監(jiān)測(cè)外,2組患者均實(shí)施麻醉深度監(jiān)測(cè)IoCl(鎮(zhèn)靜指數(shù))和IoC2(鎮(zhèn)痛/抗傷害指數(shù))。手術(shù)期間,麻醉醫(yī)師根據(jù)麻醉深度監(jiān)測(cè)IoCl和IoC2的數(shù)值和變化對(duì)丙泊酚、瑞芬太尼的用量進(jìn)行調(diào)節(jié)。將患者血壓、心率控制在波動(dòng)≤20%基礎(chǔ)值作為參考范圍。記錄主要指標(biāo)：丙泊酚和瑞芬太尼的靶濃度調(diào)整次數(shù)、輸注時(shí)間及平均用量；次要指標(biāo)：術(shù)中不良事件(高血壓、低血壓、心動(dòng)過(guò)速、心動(dòng)過(guò)緩)及麻醉恢復(fù)質(zhì)量(自主睜眼時(shí)間、拔管時(shí)間、蘇醒評(píng)分和術(shù)中知曉)。結(jié)果：與nPC組相比,PC組丙泊酚靶濃度調(diào)整次數(shù)(2.0±1.0 vs 2.7±1.5次/手術(shù),P0.05)、丙泊酚平均用量(732±65 vs 921±74mg, P0.05)、瑞芬太尼靶濃度調(diào)整次數(shù)(2.9±1.8 vs 4.4±2.6次/手術(shù),P0.05)和瑞芬太尼平均用量(201±32 vs 270±41μg,P0.05)顯著減少；PC組和nPC組丙泊酚輸注時(shí)間、瑞芬太尼輸注時(shí)間、自主睜眼時(shí)間、拔管時(shí)間和蘇醒評(píng)分無(wú)明顯差異(P0.05)；PC組心動(dòng)過(guò)緩發(fā)生率低于nPC組[4(9.7%)vs 7(17.5%),P0.05],但是兩組患者總體不良事件發(fā)生率無(wú)明顯差異(P0.05)。結(jié)論：術(shù)前接受化療的乳腺癌患者,在全憑靜脈麻醉中丙泊酚靶濃度調(diào)整次數(shù)、丙泊酚平均用量、瑞芬太尼靶濃度調(diào)整次數(shù)、瑞芬太尼平均用量明顯減少,而麻醉恢復(fù)質(zhì)量和總體不良事件發(fā)生率無(wú)明顯差異,說(shuō)明術(shù)前化療能夠增強(qiáng)患者對(duì)丙泊酚和瑞芬太尼的敏感性。
[Abstract]:The monitoring and judgment of the depth of general anesthesia is a basic problem in the anesaesthesia, and it is also a common concern and urgent problem to be solved by the anesthesiologists. The surgical procedure, such as surgical procedures, can cause the body's stress reaction, that is, the changes in the level of the sympathetic and endocrine system, and the depth of anesthesia is actually in the case of the changes in the level of the sympathetic and endocrine system. The degree of inhibition of the stress reaction after the disappearance of consciousness. The ideal state of anesthesia was: 1, the patient's consciousness disappeared, no intraoperative awareness, no anaesthesia and surgical related bad memory after the operation; 2, the hemodynamics was smooth during the operation, and the pain and nociceptive stimulation caused by anesthesia and operation were effectively controlled; 3, muscle loosening. It is easy for surgeons to operate. 4, the reflex of bad nerves is suppressed, such as bile heart reflex, eye reflex, etc.; 5, the functions of respiration and circulation are protected to the greatest extent, and the physiological functions of the patients can be recovered quickly and completely. Only by accurately monitoring and judging the depth of anesthesia, can the patient achieve comparison. The anesthetic state. The judgment of the depth of anesthesia was based on the clinical sign observation and the method based on the anesthesia monitoring equipment. The anesthesia monitoring equipment had the bispectral index (BIS), the entropy index (entropy of the EEG), the Narcortrend grading monitoring, and the auditory evoked potential (auditory evoked potential,) AEP), event related potential (event-related potential, ERP), positron emission tomography (positron emission computed tomography, PET) and functional magnetic resonance imaging (functional magnetic resonance), etc. but there is not a kind of equipment due to the constraints of the monitoring principle, limitation and economy. The very ideal application of.BIS to the monitoring of the depth of anesthesia can reflect the excitation and inhibition of cerebral cortex function. It is a sensitive and objective quantitative index for the assessment of the state of consciousness. However, BIS mainly reflects the sedative effect of propofol, etomidate and inhaled narcotic drugs on the cerebral cortex. Indexes of consciousness (IoC) is a new technique for monitoring the depth of anesthesia. It is based on a comprehensive analysis of the clinical OAAS value and RASS value of tens of thousands of patients with general anesthesia, and IoC1 represents the sedative index. This study is used to guide the town. The use of propofol, IoC2 representing analgesic / anti injury index, is used to guide the use of remifentanil, an analgesic drug. It is reported that the dosage of propofol and remifentanil in patients undergoing preoperative chemotherapy is different from those in the patients who have not been treated. The second part selected patients receiving chemotherapy to study the effect of preoperative chemotherapy on the sensitivity of the patients with breast cancer. The first part of this study was to explore the effect of depth monitoring of anesthesia (IoC1 and IoC2) on the dosage of propofol and remifentanil during total intravenous anesthesia for patients with modified radical mastectomy; the second part of the study The effect of pre chemotherapy on the anesthetic sensitivity of patients with modified radical mastectomy. Part 1 Effect of IoC1 and IoC2 on the dosage of propofol and remifentanil during total intravenous anesthesia in patients with modified radical mastectomy for breast cancer: To explore the total intravenous injection of anesthesia depth monitoring (IoCl and IoC2) in patients with modified radical mastectomy The effect of anesthesia on the dosage of propofol and remifentanil. Methods: 120 patients with modified radical mastectomy under total intravenous anesthesia were selected. According to the random digital card generated by SPSS17.0 statistics software, the patients were randomly divided into 2 groups: the study group (group T, n=60) and the control group (group C, n=60). Blood pressure (NBP), electrocardiogram (ECG), pulse oxygen saturation (SpO2), end expiratory carbon dioxide partial pressure (PETCO2) monitoring.T group to monitor the depth of anesthesia IoC1 (sedative index) and IoC2 (analgesic / anti injury index). During anesthesia, the anesthesiologist adjusted the dosage of propofol and remifentanil based on the values and changes of IoC1 and IoC2 for the dosage of propofol and remifentanil in the.C group. During the depth monitoring, during the anesthesia, the anesthesiologist adjusted the propofol and remifentanil by observing the changes of blood pressure, heart rate and other life signs according to the clinical experience. The blood pressure and heart rate were controlled in the fluctuation less than 20% basis as the reference range. The main index: the target concentration adjustment times of propofol and remifentanil and the infusion time And the average dosage; secondary indexes: intraoperative adverse events (hypertension, hypotension, tachycardia, tachycardia, tachycardia reaction) and the quality of anesthesia recovery (independent eye opening time, extubation time, awakening score and intraoperative awareness). Results: the number of target concentrations of propofol in group T and C, propofol infusion time, propofol, Reifen There was no significant difference between TnI infusion time, independent eye opening time, extubation time and awakening score (P0.05). Compared with group C, the number of reifentanil target concentration adjustment times (2.9 +.9 vs2.0 + 1.2 times / operation, P0.05) and remifentanil in group T were significantly increased (285 + 36 vs 203 + 19 u g, P0.05), but the total number of adverse events was [26 (48%) vs. 36 (68%), (P0.05)] significantly reduced. Conclusion: the target concentration adjustment times of propofol, the time of propofol infusion and the average dosage of propofol in the patients with breast cancer were not significantly changed, while the target concentration adjustment times and the average dosage of remifentanil increased significantly, but the hypertension was low. The total number of adverse events, such as blood pressure and tachycardia, is reduced, the anesthesia process is more stable, and the controllability of anesthesia is improved. Second part of the effect of preoperative chemotherapy on the anesthetic sensitivity of patients with modified radical mastectomy: To evaluate the effect of preoperative chemotherapy on the anesthetic sensitivity of patients with modified radical mastectomy. 90 patients were treated with modified radical mastectomy under pulse anesthesia. The patients were divided into 2 groups: chemotherapy group (preoperative chemotherapy group, group PC, n=45) before operation, and non chemotherapy group (non preoperative chemotherapy group, nPC group, n=45) before operation. Oxygen saturation (Sp02), end expiratory carbon dioxide partial pressure (PErCO2) monitoring, 2 groups of patients were monitored by the depth of anesthesia IoCl (sedative index) and IoC2 (analgesic / anti injury index). During the operation, the anesthesiologist adjusted the dosage of propofol and remifentanil according to the value and changes of IoCl and IoC2 monitoring in the depth of anesthesia. Control in the fluctuation less than 20% base value as the reference range. Record the main indexes: the target concentration adjustment times of propofol and remifentanil, infusion time and average dosage; secondary index: intraoperative adverse events (hypertension, hypotension, tachycardia, bradycardia) and quality of anaesthesia recovery (self opening time, extubation time, awakening score) Results: compared with group nPC, the frequency of target concentration adjustment of propofol in group PC (2 + 1 vs 2.7 + 1.5 times / operation, P0.05), the average dosage of propofol (732 + 65 vs 921 + 74mg, P0.05), the frequency of target concentration adjustment of remifentanil (2.9 + 1.8 vs 4.4 + 1 / operation, P0.05) and the average dosage of remifentanil (201 + 32 vs 270 + + G, P0.05) In group PC and group nPC, the time of propofol infusion, remifentanil infusion time, independent eye opening time, extubation time and awakening score were not significantly different (P0.05), and the incidence of bradycardia in group PC was lower than [4 (9.7%) vs 7 (17.5%), P0.05], but there was no significant difference in the incidence of total ungood events in the two groups (P0.05). Conclusion: preoperative acceptance The frequency of propofol target concentration adjustment in total intravenous anesthesia, the average dosage of propofol, the frequency of reifentanil target concentration adjustment, the average dosage of remifentanil decreased significantly, while the quality of reifentanil and the incidence of general adverse events were not significantly different, which indicated that preoperative chemotherapy could enhance patients with propofol and Reifen too. Nei's sensitivity.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類(lèi)號(hào)】：R614.24;R737.9

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