本文選題：右美托咪定 + 咪達(dá)唑侖�。� 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：背景隨著微創(chuàng)介入手術(shù)的發(fā)展,越來越多的患者選擇行甲狀腺射頻消融術(shù)(RFA)來治療良性甲狀腺疾病。與傳統(tǒng)開放性手術(shù)相比,射頻消融術(shù)雖是微創(chuàng),患者的焦慮與緊張卻并沒有減少,而這會(huì)給手術(shù)醫(yī)生造成一定程度的困擾,不利于手術(shù)的順利進(jìn)行。監(jiān)護(hù)下的清醒鎮(zhèn)靜可以有效地減輕患者疼痛,緩解其緊張、焦慮的情緒,抑制機(jī)體的不良應(yīng)激反應(yīng),它介于全身麻醉和局部麻醉之間,可以在保留患者對(duì)語言及觸覺刺激的同時(shí),不影響其循環(huán)及呼吸功能,降低神經(jīng)損傷的發(fā)生率,提高患者的舒適度和便于外科手術(shù)操作。清醒鎮(zhèn)靜用藥的靶目標(biāo)是遺忘、抗焦慮和合作,是較理想的狀態(tài)。甲狀腺射頻消融術(shù)治療甲狀腺良性結(jié)節(jié)的原理是將電極針在超聲的引導(dǎo)下穿刺進(jìn)入結(jié)節(jié)內(nèi),通過電極針導(dǎo)入高頻交流電產(chǎn)生射頻波,射頻波導(dǎo)致結(jié)節(jié)內(nèi)的極性分子和離子極速振動(dòng),它們相互間產(chǎn)生摩擦,將電能轉(zhuǎn)變?yōu)闊崮?從而局部結(jié)節(jié)組織因高溫凝固、壞死,最終滅活甲狀腺結(jié)節(jié)。在整個(gè)過程中,RFA的原理是摩擦和傳導(dǎo)熱引發(fā)的熱損傷。近年來,射頻消融技術(shù)因并發(fā)癥少、創(chuàng)傷小、恢復(fù)快而漸漸被應(yīng)用于甲狀腺良性疾病的治療。右美托咪定是最新的一種高選擇性α2腎上腺素能受體(α2:α1=1620:1)激動(dòng)劑,通過激動(dòng)大腦中樞神經(jīng)系統(tǒng)內(nèi)α2受體最密集的區(qū)域:腦干藍(lán)斑(負(fù)責(zé)調(diào)控睡眠與覺醒),而產(chǎn)生催眠、鎮(zhèn)靜作用,引發(fā)并維持自然睡眠狀態(tài)(非動(dòng)眼睡眠期)。而這種鎮(zhèn)靜睡眠狀態(tài)可以被外部語言或刺激喚醒,醒后神智清楚,可按照指令配合操作,且鎮(zhèn)靜過程中,無呼吸抑制,但其抑制去甲腎上腺素釋放和增強(qiáng)迷走神經(jīng)活動(dòng)的作用,又會(huì)引起心率減慢、血壓下降。有文獻(xiàn)證明健康志愿者靜脈使用后具有鎮(zhèn)靜、鎮(zhèn)痛和抗焦慮的作用。術(shù)后機(jī)械通氣的病人應(yīng)用后能產(chǎn)生良好的鎮(zhèn)靜作用,即易喚醒,情緒較穩(wěn)定。其鎮(zhèn)靜、鎮(zhèn)痛和抗焦慮作用是劑量依賴性的,且?guī)缀鯚o呼吸抑制。健康自愿者注射小劑量右美托咪定后,其鎮(zhèn)靜作用易被語言刺激逆轉(zhuǎn)。右美托咪定因具有鎮(zhèn)痛、恢復(fù)快、較少認(rèn)知功能損傷和無呼吸抑制,可能比咪達(dá)唑侖更適合用于微創(chuàng)手術(shù)的鎮(zhèn)靜。本試驗(yàn)旨在探討右美托咪定用于短期微創(chuàng)手術(shù)甲狀腺射頻消融術(shù)清醒鎮(zhèn)靜的情況下其用藥的劑量、效果(鎮(zhèn)靜、鎮(zhèn)痛、抗焦慮、患者和外科醫(yī)生滿意度)和安全性,從而為優(yōu)化臨床用藥提供理論依據(jù)。方法選擇擬于日間門診行甲狀腺射頻消融術(shù)的患者88例,美國麻醉醫(yī)師協(xié)會(huì)(ASA)I級(jí)或II級(jí),女73例,男15例。排除有通氣功能障礙,嚴(yán)重心肝腎功能不全患者,且所有患者對(duì)本試驗(yàn)所用藥物無過敏反應(yīng)及禁忌。將所有患者隨機(jī)分為四組:DL組、DH組、S組、M組,每組22人。入室后開放上肢靜脈,輸注復(fù)方林格氏液5 ml/(kg·h),連接ECG,監(jiān)測無創(chuàng)動(dòng)脈血壓(NIBP)、血氧飽和度(SPO2),用腦電雙頻指數(shù)(BIS)監(jiān)測鎮(zhèn)靜深度。手術(shù)開始前10min DL組靜脈泵入右美托咪定0.5μg/kg,DH組靜脈泵入右美托咪定1.0μg/kg,S組靜脈泵入同容量的生理鹽水,M組靜脈泵入咪達(dá)唑侖0.04mg/kg,藥品均用生理鹽水配制,輸注時(shí)間10min。記錄四組患者入手術(shù)室時(shí)(T0),給藥后1min(T1),5min(T2),10min(T3),20min(T4),30min(T5),60min(T6)的BIS值、MAP、HR、SPO2;評(píng)估并記錄患者術(shù)中配合度評(píng)分,手術(shù)醫(yī)生對(duì)該手術(shù)鎮(zhèn)靜滿意度評(píng)分、OAA/S、手術(shù)時(shí)間和不良事件。結(jié)果1.各組患者的一般情況如性別、年齡、體重、ASA分級(jí)、手術(shù)時(shí)間、生命體征基礎(chǔ)參數(shù)等差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。2.血流動(dòng)力學(xué)比較:與T0相比,DH組T2~T6時(shí)點(diǎn)MAP、HR顯著降低,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。與T0相比,S組T3、T4時(shí)點(diǎn)HR顯著升高,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。而DL組和M組T2~T6時(shí)點(diǎn)MAP、HR與T0相比,差異無顯著變化(P0.05)。在T2~T6時(shí)點(diǎn)DH組的MAP、HR顯著低于其他組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。3.以SPO295%作為輕度呼吸抑制標(biāo)準(zhǔn),本研究記錄的各組各個(gè)時(shí)點(diǎn)的SPO2來分析,DL組有2例(9%)發(fā)生呼吸抑制,DH組有5例(23%)發(fā)生了呼吸抑制,S組無呼吸抑制發(fā)生,M組有15例(68%)發(fā)生了呼吸抑制。從SPO2的趨勢來看,M組在T2和T3時(shí)點(diǎn)下降明顯,但均經(jīng)面罩吸氧或刺激后緩解,M組的呼吸抑制發(fā)生率明顯高于其他組(P0.05)。4.DL組、DH組和M組T2~T6時(shí)點(diǎn)與入手術(shù)室(T0)組內(nèi)比較,BIS值均有顯著降低(P0.05)。S組T2~T6時(shí)點(diǎn)與T0組內(nèi)比較,BIS值無顯著變化(P0.05)。M組在T3、T4時(shí)點(diǎn)與DH組和DL組相比,BIS值差異顯著(P0.05)。5.DL組、DH組與M組、S組相比,OAA/S,患者術(shù)中配合度更高,手術(shù)醫(yī)生對(duì)該手術(shù)鎮(zhèn)靜滿意度更高,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論1.作為一種有效的基礎(chǔ)鎮(zhèn)靜劑,0.5μg/kg和1.0μg/kg的右美托咪定具有優(yōu)于臨床推薦劑量咪達(dá)唑侖的清醒鎮(zhèn)靜效應(yīng)。2.與咪達(dá)唑侖相比,右美托咪定鎮(zhèn)靜中更易喚醒,呼吸抑制發(fā)生率低。3.0.5μg/kg與1.0μg/kg的右美托咪定相比,血壓和心率更平穩(wěn),更安全。
[Abstract]:Background with the development of minimally invasive surgery, more and more patients underwent thyroid ablation (RFA) for the treatment of benign thyroid diseases. Compared with traditional open surgery, radiofrequency ablation is a minimally invasive, anxious and nervous patients did not reduce, and this will cause a certain degree of distress to the surgeon, is not conducive to the operation smoothly. Under the monitor of sedation can effectively relieve pain, relieve tension, anxiety, bad inhibit the stress response, which is between general anesthesia and local anesthesia, can stimulate the retention of language and tactile in patients at the same time, does not affect the circulatory and respiratory function, reduce nerve injury the incidence rate, improve patient comfort and easy surgical operation. Target sedation medication is forgotten, anti anxiety and cooperation, is the ideal state. Thyroid shot The principle of frequency ablation in the treatment of benign thyroid nodules is the needle electrode in ultrasound guided puncture into nodules, through the needle electrode into the high-frequency alternating current generated RF wave, polar molecule and ion induced vibration speed of RF waveguide nodule, their mutual friction, convert electrical energy into heat energy, thus the local organization for nodule high temperature solidification, necrosis, final inactivation of thyroid nodules in the whole process, the principle of RFA is thermal damage caused by friction and heat. In recent years, radiofrequency ablation technology because of fewer complications, less trauma, faster recovery and treatment gradually be applied to benign thyroid diseases. Dexmedetomidine is a high the latest 2 selective alpha adrenergic receptor (alpha 2: alpha 1=1620:1) agonist, by activating the brain central nervous system receptor alpha 2 most densely populated regions: brainstem locus coeruleus (responsible for the regulation of sleep and sleep wake), and. Sleep, sedation, initiation and maintenance of natural sleep (non REM sleep period). And this kind of sedation can be external stimulation language or wake up, wake up after the all clear, can be matched with the operation according to the instruction, and during sedation without respiratory inhibition, but the inhibition of noradrenaline release and increased vagal activity that will cause the heart rate, blood pressure decreased. It is reported that there are healthy volunteers after intravenous sedative, analgesic and anxiolytic effects. After undergoing mechanical ventilation to produce good sedation, which is easy to wake up, the mood is stable. The sedative, analgesic and anxiolytic effect is dose dependent, and almost no respiratory depression in healthy volunteers. The injection of small dose of dexmedetomidine sedation, easy language stimulation reversed. Dexmedetomidine has analgesic, fast recovery, less injury and cognitive function No respiratory depression, than midazolam is more suitable for minimally invasive surgery. This experiment was conducted to investigate the sedative effects of dexmedetomidine for sedation medication dose the short-term minimally invasive surgical radiofrequency ablation of thyroid conditions, effects (sedation, analgesia, anti anxiety, patient and surgeon satisfaction) and safety, so as to provide theory the basis for the optimization of clinical medication. Methods 88 cases in outpatient thyroid ablation patients, American Society of anesthesiologists (ASA) grade I or II grade, 73 cases were female, 15 were male. Rule out the serious heart ventilation dysfunction in patients with renal insufficiency, and all patients in this trial for drug allergy the effects and taboos. All patients were randomly divided into four groups: DL group, DH group, S group, M group, each group of 22 people. After entering the open upper limb vein infusion of compound Ringer's solution 5 ml/ (kg - H), connect ECG, noninvasive arterial blood pressure monitoring (N IBP),琛，

本文編號(hào)：1770215