本文選題：右美托咪定 + 硬膜外麻醉　； 參考：《安徽醫(yī)科大學(xué)》2016年博士論文

【摘要】：目的:在圍術(shù)期,手術(shù)、失血、術(shù)后疼痛、缺氧、精神緊張、焦慮不安、麻醉以及創(chuàng)傷等相關(guān)因素對機體的刺激,會引起機體發(fā)生應(yīng)激反應(yīng)。應(yīng)激的生物學(xué)反應(yīng)主要包括藍斑-交感-腎上腺髓質(zhì)軸系統(tǒng)興奮、下丘腦-垂體-腎上腺皮質(zhì)激素軸系統(tǒng)功能增強以及炎癥免疫反應(yīng)等,可引起機體一系列的改變,對機體穩(wěn)態(tài)的維持起重要作用;但嚴(yán)重的應(yīng)激反應(yīng)會對機體造成一定程度的損害,導(dǎo)致生理功能的紊亂、器官功能的改變以及術(shù)后并發(fā)癥的發(fā)生,引起圍術(shù)期并發(fā)癥和死亡率的增加,嚴(yán)重影響患者的遠期預(yù)后和轉(zhuǎn)歸。因此,圍術(shù)期如何通過麻醉藥物及方法來合理調(diào)控患者的應(yīng)激狀態(tài),減少或降低手術(shù)患者的生理及心理創(chuàng)傷應(yīng)激,對降低術(shù)后并發(fā)癥的發(fā)生率、促進患者術(shù)后順利恢復(fù)具有很重要的臨床意義。硬膜外麻醉復(fù)合全身麻醉被廣泛應(yīng)用于臨床,如胸部、腹部手術(shù)以及骨科手術(shù)等,可以有效抑制交感神經(jīng)活性,減輕術(shù)中應(yīng)激反應(yīng),減少全麻藥的用量,促進術(shù)后快速恢復(fù)等,但硬膜外麻醉本身具有相關(guān)的風(fēng)險和并發(fā)癥。右美托咪定是一種新型且具有高選擇性的α2腎上腺素受體激動劑,具有更強的鎮(zhèn)痛、抗焦慮及血流動力學(xué)的穩(wěn)定作用,可減輕手術(shù)引起的應(yīng)激反應(yīng),減少麻醉藥的用量,減少全麻后的術(shù)后并發(fā)癥等優(yōu)點;而且相對硬膜外麻醉其輸注操作簡單方便。因此,本實驗旨在研究右美托咪定與硬膜外麻醉復(fù)合全身麻醉在胃癌根治術(shù)中的應(yīng)用比較,觀察其對患者應(yīng)激反應(yīng)和術(shù)后的恢復(fù)情況等影響。方法:選擇擇期全麻下經(jīng)腹胃癌根治術(shù)患者,美國麻醉醫(yī)師協(xié)會(ASA)分級Ⅰ~Ⅱ級,年齡25~65歲,心功能Ⅰ~Ⅱ級;無長期服用藥物,無硬膜外麻醉及右美托咪定輸注禁忌。隨機分為3組(每組30例):右美托咪定組(D組)、硬膜外組(E組)和對照組(C組)。硬膜外組(E組)患者,于T8-9椎間隙行硬膜外麻醉,試驗量1.6%利多卡因4ml,隨后給予0.375%羅哌卡因5ml硬膜外推注和0.375%羅哌卡因5ml/h持續(xù)硬膜外輸注。右美托咪定組(D組)患者,于全麻誘導(dǎo)前給予負荷量右美托咪定0.6μg/kg靜脈泵注15min,隨后給予0.4μg/kg/h持續(xù)靜脈泵注至關(guān)閉腹膜時。硬膜外組(E組)和對照組(C組)在全麻誘導(dǎo)前同樣給予0.9%生理鹽水靜脈泵注15min,隨后持續(xù)靜脈泵注至關(guān)閉腹膜時。全麻誘導(dǎo)和維持均用全憑靜脈麻醉(TIVA)。選擇輸注右美托咪定或硬膜外麻醉前(T0)、全麻誘導(dǎo)前(T1)、氣管插管前(T2)、插管后即刻(T3)、切皮時(T4)、腹腔探查時(T5)及拔管后即刻(T6)為觀察時間點;分別記錄相應(yīng)時間點BIS、MAP、HR,記錄麻醉藥物及血管活性藥物的用量,觀察術(shù)后蘇醒情況(包括睜眼時間、拔管時間、躁動),術(shù)后1h、6h、12h、24h、48h患者VAS評分,測量不同的觀察時間點患者血液中應(yīng)激激素腎上腺素(E)、去甲腎上腺素(NE)、皮質(zhì)醇(Cor)的濃度,以及腫瘤壞死因子-α(TNF-α)、白介素-6(IL-6)、白介素-10(IL-10)的濃度;記錄患者術(shù)后排氣時間、進食時間、住院時間及相關(guān)的并發(fā)癥。結(jié)果:三組患者年齡、性別、體重、身高、麻醉時間、手術(shù)時間、術(shù)中輸液量、出血量比較差異無統(tǒng)計學(xué)意義(P0.05)。D組患者BIS值在輸注右美托咪定后,即T1時較C組和E組明顯降低(P0.01)。與C組比較,D組在右美托咪定輸注后的各時間點(T1-T6)患者的心率明顯降低(P0.01或P0.05);與T0比較,D組T1-T6時和E組T4、T5時的心率顯著降低(P0.01)。與C組比較,E組T3、T4時和D組T4時MAP明顯降低(P0.05)。術(shù)中E組患者出現(xiàn)低血壓且需藥物處理的患者11例(36.7%),較D組4例(13.3%)和C組3例(10.0%)顯著增多(P0.05)。與C組比較,D組和E組丙泊酚和瑞芬太尼的用量明顯減少(P0.01或P0.05);而D組和E組組間比較丙泊酚和瑞芬太尼的用量差異無統(tǒng)計學(xué)意義(P0.05)。三組患者的睜眼時間、拔管時間組間比較差異無統(tǒng)計學(xué)意義(P0.05)。麻醉蘇醒期,與C組比較,D組患者躁動的發(fā)生率顯著降低(P0.05);而D組和E組組間比較差異無統(tǒng)計學(xué)意義(P0.05)。與E組比較,D組患者在不同時間點E、NE、Cor的濃度組間比較差異無統(tǒng)計學(xué)意義(P0.05)。與C組比較,E組和D組在T3-T6時E、NE的濃度及T5、T6時Cor的濃度明顯降低(P0.01或P0.05)。與C組比較,D組和E組T5、T6時TNF-α、IL-6的濃度及IL-6/IL-10比值均明顯降低(P0.01或P0.05)。IL-10在不同時間點三組組間比較差異均無統(tǒng)計學(xué)意義(P0.05)。與E組比較,D組T0、T4、T5、T6時TNF-α、IL-6、IL-10的濃度及IL-6/IL-10比值組間比較差異無統(tǒng)計學(xué)意義(P0.05)。與C組比較,D組和E組術(shù)后6h、12h、24h、48h靜息時VAS評分均顯著降低(P0.01或P0.05);D組術(shù)后1h、6h、12h、24h和E組術(shù)后1h、6h、12h、24h、48h運動時VAS評分均顯著降低(P0.01或P0.05);而D組和E組在術(shù)后不同時間點VAS評分組間比較差異均無統(tǒng)計學(xué)意義(P0.05)。三組患者術(shù)后惡心嘔吐、疼痛干預(yù)及嗜睡發(fā)生率組間比較差異均無統(tǒng)計學(xué)意義(P0.05)。與C組比較,D組和E組患者術(shù)后排氣時間、進食時間、住院時間均縮短(P0.05),而術(shù)后外科并發(fā)癥及肺部的并發(fā)癥發(fā)生率組間比較差異均無統(tǒng)計學(xué)意義(P0.05)。結(jié)論:在胃癌根治術(shù)全麻中,靜脈輸注右美托咪定可產(chǎn)生硬膜外麻醉同等程度的應(yīng)激反應(yīng)抑制作用;且術(shù)中血流動力學(xué)更為平穩(wěn);右美托咪定或硬膜外麻醉復(fù)合全麻均可改善術(shù)后的鎮(zhèn)痛效果,縮短術(shù)后排氣時間、進食時間和住院時間。
[Abstract]:Objective: in the perioperative period, surgery, blood loss, postoperative pain, anoxia, stress, anxiety, anaesthesia, and trauma and other related factors to the body, it will cause stress response. The biological response of stress mainly includes the locus coeruleus sympathetic adrenal medulla axis excitation, the hypothalamus hypophysis adrenocortical hormone axis system work Enhanced and inflammatory immune responses can cause a series of changes in the body and play an important role in the maintenance of the body's homeostasis. However, severe stress responses can cause some damage to the body, resulting in disorders of the physiological function, changes in organ function and the occurrence of postoperative complications, resulting in an increase in perioperative complications and mortality. Plus, it seriously affects the long-term prognosis and prognosis of the patients. Therefore, how to regulate the patient's stress state rationally and reduce or reduce the physiological and psychological trauma stress in the operation patients by narcotic drugs and methods is of great clinical significance to reduce the incidence of postoperative complications and promote the smooth recovery of the patients after operation. Anesthesia combined general anesthesia is widely used in the clinic, such as chest, abdominal surgery and Department of orthopedics surgery, which can effectively inhibit sympathetic activity, reduce stress response in the operation, reduce the dosage of total anesthetic and promote rapid recovery after operation. But epidural anesthesia itself has the risk and complications. The high selective alpha 2 adrenergic receptor agonist, which has stronger analgesic, anti anxiety and hemodynamic stability, can reduce the stress reaction caused by surgery, reduce the dosage of anesthetics and reduce postoperative complications after general anesthesia, and it is simple and convenient for the infusion operation of epidural anesthesia. Therefore, this experiment is aimed at this experiment. The effects of right metodetomidine and epidural anesthesia combined with general anesthesia in radical gastrectomy for gastric cancer were compared, and the effects on the patients' stress response and postoperative recovery were observed. Methods: patients undergoing radical resection of gastric cancer under general anesthesia were selected, American anesthesiologist Association (ASA) grade I ~ II, age 25~65 years, and cardiac function I - II grade; 3 groups (group D), epidural group (group E) and control group (group C), epidural group (group E), epidural anesthesia in T8-9 intervertebral space, 1.6% lidocaine 4ml, and 0.375% ropivacaine 5ml epidural infusion, followed by 0.375% ropivacaine 5ml epidural infusion, and 0.375% ropivacaine group (group E). And 0.375% ropivacaine 5ml/h continuous epidural infusion. Right metomomimidin group (group D) patients were given a load dose of right metomomidin 0.6 u 15min before induction of general anesthesia, followed by 0.4 mu g/kg/h continuous intravenous pump to close the peritoneum. The epidural group (group E) and the control group (group C) were given 0.9% normal saline before the induction of general anesthesia. Pulse pump 15min, then continuous intravenous pump to close peritoneum. General anesthesia induction and maintenance of all intravenous anesthesia (TIVA). Selection infusion right metoimidin or epidural anesthesia (T0) before induction (T1), before endotracheal intubation (T2), immediate (T3) after intubation (T4), peritoneal exploration (T5) and immediately after extubation (T6) as the observation time point; Record the corresponding time points BIS, MAP, HR, record the dosage of narcotic drugs and vasoactive drugs, observe the postoperative recovery (including opening time, extubation time, restlessness), postoperative 1H, 6h, 12h, 24h, 48h patients VAS score, measure the stress hormone adrenaline (E), norepinephrine (NE), cortisol (Co), and cortisol (Co) in patients with different observation time points. The concentration of R), the concentration of tumor necrosis factor - alpha (TNF- alpha), interleukin -6 (IL-6), and interleukin -10 (IL-10); recorded the postoperative exhaust time, feeding time, hospitalization time and related complications. Results: there was no statistical difference between the three groups of patients' age, sex, weight, height, time of anesthesia, operation time, intraoperative infusion volume, and volume of bleeding. The BIS value of group P0.05.D was significantly lower than that of the C group and the E group after infusion of right metoomidin (P0.01). Compared with the C group, the heart rate of the D group at each time point (T1-T6) after the infusion of right metomomidin was significantly lower (P0.01 or P0.05). In group D T4, MAP decreased significantly (P0.05). In group E, 11 patients with hypotension and drug treatment (36.7%), 4 cases (13.3%) and 3 cases (10%) in group D were significantly increased (P0.05). Compared with group C, the dosage of propofol and remifentanil in D and E group decreased significantly (P0.01 or remifentanil). There was no statistically significant difference in the dosage of Nepal (P0.05). There was no significant difference between the three groups of patients' opening time and the time of extubation (P0.05). Compared with group C, the incidence of restlessness in group D was significantly lower (P0.05), but there was no statistical difference between group D and E group (P0.05). Compared with group E, the patients in the D group were different. The concentration of E, NE and Cor at the time point had no significant difference (P0.05). Compared with the C group, the concentration and T5 concentration of E and D groups at T3-T6 were significantly lower than those in the T3-T6 group. There was no significant difference between group groups (P0.05). Compared with group E, there was no significant difference in TNF- a, IL-6, IL-10 concentration and IL-6/IL-10 ratio in group D T0, T4, T5, T6. The VAS score of post 1H, 6h, 12h, 24h and 48h decreased significantly (P0.01 or P0.05), but there was no significant difference between the D group and E group at different time points after the operation (P0.05). There was no significant difference between the three groups of postoperative nausea and vomiting, pain intervention and the incidence of somnolence. The postoperative exhaust time, feeding time and hospitalization time were shortened (P0.05), but there was no significant difference between the postoperative surgical complications and the incidence of pulmonary complications (P0.05). Conclusion: in the general anesthesia for radical gastrectomy, intravenous infusion of right metoamidin can produce an equal degree of stress response inhibition of epidural anesthesia; and The hemodynamics was more stable, and dexmedetomidine or epidural anesthesia combined with general anesthesia could improve the postoperative analgesic effect, shorten the postoperative exhaust time, eat time and stay in hospital.

【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R614;R735.2

【參考文獻】

相關(guān)期刊論文 前10條

1 張玉輝;高亞坤;肖連波;楊明;周繼梧;高海艷;;右美托咪啶對體外循環(huán)下心臟瓣膜置換術(shù)患者心肌缺血再灌注損傷的影響[J];臨床心血管病雜志;2015年11期

2 張子斌;高成杰;王瑞雯;王惠霞;徐魯峰;;右美托咪定對非體外循環(huán)冠狀動脈旁路移植術(shù)患者血流動力學(xué)及應(yīng)激反應(yīng)的影響[J];國際麻醉學(xué)與復(fù)蘇雜志;2015年08期

3 魏紅芳;陳永學(xué);王飛;李書河;王新波;楊曉彬;;右美托咪定對膿毒癥患者全麻時肺保護作用[J];中華麻醉學(xué)雜志;2015年02期

4 喻紅彪;李剛;楊毅;閆磊;徐桂萍;;右美托咪定對肺葉切除術(shù)患者單肺通氣時中性粒細胞NF-κB活性的影響[J];中華麻醉學(xué)雜志;2014年11期

5 陸斌;張序忠;胡世特;鄭圣舟;吳安生;;右美托咪定對肢體缺血再灌注致患者肺損傷的影響[J];中華麻醉學(xué)雜志;2014年09期

6 萬占海;張紅;冷玉芳;劉永強;呂興華;;右美托咪定對大鼠肺缺血再灌注損傷的影響[J];中華麻醉學(xué)雜志;2014年09期

7 王東昕;闞紅莉;于曉東;劉卓;;右美托咪定對肺癌根治術(shù)患者單肺通氣時的肺保護作用[J];中華麻醉學(xué)雜志;2014年06期

8 吳周晏;吉杰梅;谷萬杰;劉文志;劉敬臣;;右美托咪定預(yù)處理對脂多糖誘導(dǎo)大鼠急性肺損傷的保護作用[J];國際麻醉學(xué)與復(fù)蘇雜志;2014年06期

9 李遠強;王志剛;宮本晶;李岱;李爽;;不同劑量右美托咪定對體外循環(huán)下心內(nèi)直視手術(shù)患兒肺損傷的影響[J];中華麻醉學(xué)雜志;2014年05期

10 蔣麗麗;齊擇優(yōu);李李;沈金美;;鹽酸右美托咪定對H_2O_2誘導(dǎo)的肺泡巨噬細胞氧化應(yīng)激的影響[J];中南大學(xué)學(xué)報(醫(yī)學(xué)版);2013年10期

，

本文編號：1775723