本文選題：右美托咪啶 + 癲癇��； 參考：《廣州中醫(yī)藥大學(xué)》2014年碩士論文

【摘要】：目的： 觀察喚醒麻醉下行腦功能區(qū)癲癇病灶切除術(shù)的成年難治性癲癇患者,在術(shù)中喚醒后清醒時期連續(xù)泵注右美托咪定(dexmedetomidine, Dex)的鎮(zhèn)靜效果,同時定性及定量分析右美托咪定對成年癲癇病人背景腦電及癲癇波的影響。 方法： 擬在喚醒麻醉下行腦功能區(qū)癲癇病灶切除的成人患者48例,ASA1-2級,男30例,女18例,根據(jù)術(shù)中清醒時期鎮(zhèn)靜方法的不同,隨機(jī)分為四組,分別給予靜脈泵注低濃度的丙泊酚(LP)及不同劑量的右美托咪定(LD、MD、HD)鎮(zhèn)靜。所有病人均不使用鎮(zhèn)靜類術(shù)前藥物,誘導(dǎo)采用靜脈麻醉工作站(Orchestra,費森尤斯卡比,法國)雙通道靶控輸注丙泊酚(得普利麻,10mg/ml,阿斯利康)3.0～4.0μg/ml和瑞芬太尼(20μg/ml,宜昌人福)3.0～4.0ng/ml,待病人意識消失,對疼痛刺激無反應(yīng)后,置入喉罩(LMA, SupremeTM, Singapore),采用同步間歇指令通氣模式(SIMV)控制呼吸。在誘導(dǎo)過程中心率低于50次/min時,靜脈給予阿托品0.2-0.5mmg；收縮壓低于80mmHg時,給予麻黃堿10～30mg。頭釘及切口處用0.25%羅哌卡因(總量3mg/kg)行局部浸潤麻醉。全程使用Narcotrend監(jiān)測意識深度,使用保溫毯維持體溫在36-37攝氏度。開顱期調(diào)整丙泊酚靶濃度,維持Narcotrend分級在D1～EO,NI值在30-46。打開硬腦膜前減淺麻醉,將丙泊酚靶濃度減至0.5μg/ml,瑞芬太尼靶濃度減至10mg/ml,當(dāng)病人自主呼吸恢復(fù)良好、呼喚睜眼后,拔出喉罩,同時停止丙泊酚及瑞芬太尼泵注,待病人定向力完全恢復(fù)后,開始給予與分組相應(yīng)的藥物進(jìn)行鎮(zhèn)靜。丙泊酚組設(shè)定丙泊酚血漿靶濃度(Cp)為1.5μg/ml;右美托咪定組均在10min內(nèi)靜脈泵注右美托咪定負(fù)荷量0.5μg/kg,隨后根據(jù)分組,分別接受低劑量(0.2ug/kg/h,LD)、中劑量(0.4ug/kg/h, MD),高劑量(0.6ug/kg/h, HD)右美托咪定靜脈持續(xù)泵注。采用Narcotrend指數(shù)(NI)和改良清醒鎮(zhèn)靜評分方法(Modified Observer's Assessment of Alertness/Sedation, OAA/S)評價病人意識,采用數(shù)字評分法評價病人疼痛程度,用腦功能區(qū)手術(shù)定位時態(tài)表評價喚醒質(zhì)量。記錄各組病人在喚醒時、開始鎮(zhèn)靜時(T0)丙泊酚及瑞芬太尼的效應(yīng)室濃度(Ce)、Narcotrend指數(shù)(NI)；分別記錄TO和TO后10min (T1)、20min (T2)、30min(T3)、40min (T4)、50min (T5)、60min (T6)各時間點的改良清醒鎮(zhèn)靜評分OAA/S、疼痛數(shù)字評分、Narcotrend指數(shù)(NI)、心率(HR)、平均動脈血壓(MAP)、呼吸次數(shù)(RR)、經(jīng)皮脈氧飽和度(SPO2),以及惡心、嘔吐、寒戰(zhàn)、疼痛等不良事件。 患者術(shù)前均經(jīng)過視頻腦電檢查,確定主要癲癇病灶,誘導(dǎo)后采用數(shù)字腦電圖機(jī)(Bio-logic,美國)持續(xù)描記頭皮腦電數(shù)據(jù),手術(shù)開顱后,置入深部電極監(jiān)測皮層腦電。由固定專業(yè)電生理醫(yī)生采用視頻定量分析法進(jìn)行背景腦電、癲癇波的判讀,并分析計算鎮(zhèn)靜前(t0)、鎮(zhèn)靜后10min (t1)、20min (t2)、30min (t3)及40min(t4)時腦電6波(0-4Hz)、0波(4-8Hz)、α波(8-13Hz)、p波(13～30Hz)頻譜和每分鐘內(nèi)癲癇病灶放電次數(shù)。 結(jié)果： 1.T0-T6各時間點各組間的平均動脈壓(MAP)、呼吸次數(shù)(RR)和經(jīng)皮脈搏氧飽和度(SP02)無明顯差異(P0.05)；T1-T5時間點右美各組心率(HR)明顯低于丙泊酚組(P0.05)。 2.四組NI值在T1時均開始下降,明顯低于開始鎮(zhèn)靜前(P0.05),右美托咪定各組下降幅度小于丙泊酚組,LD、MD、HD三組間在這個時間點的差異無統(tǒng)計學(xué)意義(P0.05)；T2后LD組與丙泊酚組NI改變不明顯,但LD組始終高于丙泊酚組,MD、HD組病人NI進(jìn)一步下降,T4降至最低點,明顯低于T0(P0.01)；HD組從T3開始,各時間點NI顯著低于其它組(P0.01)。 3.T1后各時間點的改良清醒鎮(zhèn)靜評分(OAA/S),丙泊酚組均明顯低于右美托咪定各組；LD組、MD組、丙泊酚組的鎮(zhèn)靜評分隨時間改變不明顯；HD組的鎮(zhèn)靜評分在T2時最低,然后逐漸升高,至T6時仍低于LD組和MD組,但差異不再明顯(P0.05)。 4.各組疼痛數(shù)字評分與鎮(zhèn)靜前比都有一定程度下降,鎮(zhèn)靜后丙泊酚組和LD組高于MD、HD組,但組間差異不明顯(P0.05)。 5.LD組和丙泊酚組清醒期寒戰(zhàn)發(fā)生率明顯高于MD和HD組(P0.05),LD組和丙泊酚組之間則無顯著差異(P0.05)。 6.清醒期使用右美托咪定鎮(zhèn)靜后,患者皮層腦電出現(xiàn)類似Ⅱ相睡眠的特征性改變,出現(xiàn)頻率、波幅與劑量無關(guān)；α、β、0波明顯增加(P0.05),δ波的改變不明顯(P0.05)；癲癇波的出現(xiàn)頻率沒有明顯增加或降低,也沒有新的尖波、棘波出現(xiàn)。 7.丙泊酚組皮層腦電表現(xiàn)為大量快波增加,α、β波大幅增加(P0.01),有2例病人由于背景波改變太大,無法準(zhǔn)確完成腦電圖判讀,觀察30min后,終止實驗。 結(jié)論： 1.成年難治性癲癇病人在喚醒開顱手術(shù)中,清醒期采用右美托咪定作為唯一鎮(zhèn)靜藥物,可以達(dá)到手術(shù)鎮(zhèn)靜需求,并無明顯不良反應(yīng)。三組劑量均可提供滿意的鎮(zhèn)靜效果,但與0.2ug/kg/h的較低劑量相比,采用中(0.4ug/kg/h)、高(0.6ug/kg/h)劑量右美托咪定的癲癇患者寒戰(zhàn)發(fā)生率更低。 2.常用劑量的右美托咪定,可以對術(shù)中皮層腦電的背景活動造成影響,但不干擾對現(xiàn)有癲癇波的觀察,不影響癲癇病灶定位和手術(shù)切除效果的評價。
[Abstract]:Objective:
To observe the sedative effects of dexmedetomidine (Dex) in the wake of awakening and the effects of right metoimidin on the background electroencephalogram and epileptic waves of adult epileptic adults.
Method:
48 adult patients, ASA1-2, 30 men and 18 women, were randomly divided into four groups according to the different sedative methods during the waking period, which were given low concentration of propofol (LP) and right metomomidine (LD, MD, HD) at different doses. All patients did not use sedation. Preoperatively, the two channel target controlled infusion of propofol (Orchestra, 10mg/ml, AstraZeneca), 3 to 4 mu g/ml and remifentanil (20 mu g/ml, Yichang people) 3 to 4.0ng/ml were used to induce the two channel target controlled infusion of propofol (LMA, SupremeTM, S). Ingapore) used synchronous intermittent instruction ventilation mode (SIMV) to control respiration. When the center rate of the induction process was less than 50 times /min, the intravenous administration of atropine 0.2-0.5mmg was given. When the systolic pressure was lower than 80mmHg, the local infiltration anesthesia was given to 10 ~ 30mg. head nailing and 0.25% ropivacaine (total 3mg/ kg) at the incision. Know depth, maintain temperature at 36-37 degrees centigrade with heat insulation blanket. Adjust the target concentration of propofol at the craniotomy period, maintain Narcotrend classification at D1 to EO, NI value at 30-46. to open the subdural anaesthesia, reduce the target concentration of propofol to 0.5 u g/ml, remifentanil target concentration to 10mg/ml, when the patient's spontaneous breathing recovery is good, call after open eye, pull out larynx At the same time, the propofol and remifentanil pump were stopped, and after the patient's directing force was completely restored, the propofol group was set up to be sedative. The propofol group set the propofol target concentration (Cp) for 1.5 u g/ml; right metoimidin group in 10min intravenous pump right metoimidin load of 0.5 mu, followed by group, respectively accepted. Low dose (0.2ug/kg/h, LD), medium dose (0.4ug/kg/h, MD), high dose (0.6ug/kg/h, HD) right metomomidin intravenous continuous infusion. The Narcotrend index (NI) and improved sober sedation score (Modified Observer's Assessment of) were used to evaluate the patient's consciousness, and the degree of pain was evaluated by the digital score method. The quality of awakening was evaluated by the temporal table in the functional area of the brain. The effect room concentration (Ce) of propofol and remifentanil (T0) and the Narcotrend index (NI) were recorded at the time of awakening, and the 10min (T1), 20min (T2), 30min (T3), 30min (T3), NI, and the improved sober sedation score at each time point were recorded. A/S, pain digital score, Narcotrend index (NI), heart rate (HR), mean arterial blood pressure (MAP), respiratory times (RR), percutaneous pulse oxygen saturation (SPO2), and nausea, vomiting, chills, pain and other adverse events.
The patients were subjected to video EEG before operation to determine the main epileptic focus. After induction, the digital electroencephalograph (Bio-logic, the United States) was used to continuously trace the scalp EEG data. After craniotomy, the deep electrode was placed to monitor the cortical electroencephalogram. The fixed professional electrophysiologists used the visual frequency quantitative analysis to carry out the background EEG, the interpretation of epileptic wave. Analysis and calculation of pre sedation (T0), 10min (T1), 20min (T2), 30min (T3) and 40min (T4) 6 wave (0-4Hz), 0 wave (4-8Hz), alpha wave (8-13Hz), 20min (13 ~) and the number of epileptic discharges per minute.
Result:
There was no significant difference in mean arterial pressure (MAP), respiration frequency (RR) and percutaneous pulse oxygen saturation (SP02) at each time point of 1.T0-T6 (P0.05), and the heart rate (HR) in each group at T1-T5 time point (HR) was significantly lower than that of propofol group (P0.05).
2. the value of NI in the four groups began to decline at T1, obviously lower than that before the beginning of sedation (P0.05), and the decrease of all groups in right metomomomidin was less than that of propofol group, and there was no significant difference between the three groups of LD, MD and HD at this time point (P0.05). The NI changes of the LD group and the propofol group were not obvious after T2, but the LD group was always higher than the propofol group. MD The T4 decreased to the lowest point, significantly lower than that of T0 (P0.01); HD group started from T3, and NI at each time point was significantly lower than that in other groups (P0.01).
The improved sober sedation score (OAA/S) at each time point after 3.T1 was significantly lower in the propofol group than in the right metomomidine group. The sedative score of the group LD, the MD group and the propofol group was not obvious with time; the sedative score in the HD group was the lowest at T2 and then gradually increased, but it was still lower than the LD and MD groups at T6, but the difference was no longer obvious (P0.05).
4. the pain score and sedation ratio of both groups decreased to a certain extent. After sedation, propofol group and LD group were higher than those of MD group and HD group, but there was no significant difference between groups (P0.05).
The incidence of shivering in group 5.LD and propofol was significantly higher than that in group MD and HD (P0.05), but there was no significant difference between LD group and propofol group (P0.05).
6. after the use of dexmedetomidin in the sober period, the patient's cortical electroencephalogram appeared characteristic changes like phase II sleep, appearing frequency, amplitude and dose independent; alpha, beta, 0 waves increased significantly (P0.05), the change of delta wave was not obvious (P0.05); the frequency of epileptic waves did not increase or decrease, and there was no new sharp wave, spinous wave appeared.
In the 7. propofol group, the cortical electroencephalogram showed a large increase in fast wave and a significant increase in alpha and beta waves (P0.01). 2 cases were unable to accurately complete the EEG interpretation because of the large changes in the background wave. After observing 30min, the experiment was terminated.
Conclusion:
In 1. adult intractable epilepsy patients, right metoomidine was used as the only sedative in awakening craniotomy, which could reach the operation sedation demand without obvious adverse reactions. The three groups could provide satisfactory sedative effect, but compared with the lower dose of 0.2ug/kg/h, the use of middle (0.4ug/kg/h), and high (0.6ug/kg/h) dose right beauty The incidence of chills in the epileptic patients with amidazine is lower.
2. the normal dose of dexmedetomidin can affect the background activity of the cerebral cortex, but it does not interfere with the observation of the current epileptic waves, and does not affect the evaluation of the location of the epileptic focus and the effect of surgical excision.
【學(xué)位授予單位】：廣州中醫(yī)藥大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R614

【參考文獻(xiàn)】

相關(guān)期刊論文 前2條

1 何洹;施沖;張春梅;吳群林;劉中華;曾因明;;靶控輸注丙泊酚與瑞芬太尼復(fù)合Narcotrend監(jiān)測在喚醒開顱中的應(yīng)用[J];中國微侵襲神經(jīng)外科雜志;2009年04期

2 欒翰林;何洹;張春梅;孫梅;施沖;屠偉峰;;靶控輸注丙泊酚和雷米芬太尼復(fù)合右旋美托咪啶在高齡患者腦功能區(qū)喚醒麻醉中的臨床效果觀察[J];中國藥物與臨床;2012年12期

，

本文編號：2101394