盐酸右美托咪定对老年患者腹腔镜腹股沟疝修补术后残余肌松效应的影响

杜彦茹, 韩霜, 张秀果

河北省人民医院麻醉科,石家庄 050051

DU Yanru^,, HAN Shuang, ZHANG Xiuguo

Departmennt of Anesthesiology, Hebei Genneral Hospital, Shijiazhuang 050051, China

作者简介杜彦茹(1970-),女,河北石家庄人,副主任医师,硕士,研究方向:老年患者麻醉学。E-mail:hs19860412@126.com。

基金资助: 河北省2011年医学科学研究重点科题(20110212)

中图分类号: R971.2;R256.45 文献标识码: B 文章编号: 1004-0781(2018)08-0964-03

摘要:

目的观察术中持续输注盐酸右美托咪定对老年患者腹腔镜腹股沟疝修补术后残余肌松效应的影响。方法择期行腹腔镜腹股沟疝修补术老年患者60例,年龄65~85岁,体质量指数19~25 kg·(m²)^-1,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将患者随机分为2组:对照组(C组)和盐酸右美托咪定组(M组),每组30例。M组麻醉诱导后输注盐酸右美托咪定1 μg·kg^-1·h^-1,随后以0.5 μg·kg^-1·h^-1速率持续静脉泵注至手术结束前10 min,C组泵注等容量的0.9%氯化钠注射液。上肢前臂尺神经两侧连接加速度肌松监测仪,监测拇内收肌颤搐情况。记录临床时效(第一个肌颤搐恢复到25%时间)、恢复指数(t₁从25%恢复至75%的时间)、拔除气管插管30 min后及术后3 h残余肌松效应发生率(TOFR<0.9表示发生残余肌松效应)。结果 C组和M组临床时效分别为(24.0±2.7)和(23.6±3.1) min;恢复指数分别为(63±6)和(60±5);拔管后30 min残余肌松效应发生分别为26和25例;术后3 h残余肌松效应发生分别为3和2例。与C组比较,M组恢复指数、拔管30 min后及术后3 h残余肌松发生率均差异无统计学意义(P>0.05)。结论术中持续输注盐酸右美托咪定对腹腔镜腹股沟疝修补术老年患者残余肌松效应发生率无影响。

关键词: 右美托咪定 ; 盐酸 ; 患者 ; 老年 ; 残余肌松 ; 腹股沟疝修补术

Abstract:

Objective To observe the influence of continuous infusion of dexmedetomidine in elderly patients on residual neuromuscular blockade after laparoscopic inguinal hernia repair. Methods Sixty ASA physical status Ⅰ or Ⅱ patients of both sexes, aged 65-85 years, body mass index 19-25 kg·(m²)^-1, scheduled for laparoscopic inguinal hernia repair, were randomly divided into two groups (n=30 each) by using a random number table: control group (group C) and dexmedetomidine group (group M). In group M, dexmedetomidine 1 μg·kg^-1·h^-1 and 0.5 μg·kg^-1·h^-1 was infused intravenously after induction of anesthesia until 10 min before the end of operation, while the equal volume of 0.9% sodium chloride solution was given into the group C. Clinical effect, the index of recovery, the rate of residual neuromuscular blockade 30 min after extubation and 1 h after operation (TOFR<0.9 represents residual neuromuscular blockade) were recorded. Results Clinical time limit was (24.0±2.7) and (23.6±3.1) min in group C and group M, respectively. Recovery index was (63±6) and (60±5), respectively; postoperative residual curarization appeaved in 26 and 25 cases, respectively 30 min after extubation, and it appeared in 3 and 2 cases, respectively 3 h after the surgery in group C and group M.There were no significant differences in recovery index and the rate of residual neuromuscular blockade 30 min after extubation and 3 h after the operation (P>0.05). Conclusion Continuous infusion of dexmedetomidine in elderly patients has no effects on residual neuromuscular blockade.

Key words: Dexmedetomidine ; hydrochloride ; Patients ; elderly ; Residual neuromuscular blockade ; Laparoscopic inguinal hernia repair

肌松药术后残余神经肌肉阻滞作用(residual neuromuscular block,RNMB)逐渐被发现和受到重视。研究发现,术后残余肌松可引起多种临床并发症,主要表现为上呼吸道梗阻、术后缺氧、肺部并发症,通气量不足和吞咽功能不全等,甚至威胁生命^[1,2]。对腹腔镜手术,有文献指出,术中维持深度肌松可以在较低的气腹压力下为手术医师提供更广阔的手术视野,更充足的操作空间,减少气腹压力对腹腔肌群的损伤,减少并发症^[3]。但老年患者肝肾功能减退,药物血浆清除率降低,生理、病理、药动学及药效学均有其独特之处,因此老年患者更易发生残余肌松效应,术后发生呼吸抑制的风险较高,危害患者生命。盐酸右美托咪定具有镇静、镇痛及抗交感神经作用,对循环呼吸抑制小,可降低心肌缺血发生率,对老年患者尤为适用^[4,5]。但其对老年患者残余肌松效应的影响尚有待探讨,笔者探讨术中持续输注盐酸右美托咪定对腹腔镜腹股沟疝修补术老年患者术后残余肌松效应的影响,为临床提供参考。

1 资料与方法

1.1 临床资料

择期行腹腔镜腹股沟疝修补术患者60例,年龄65~85岁,体质量指数19~25 kg·(m²)^-1,美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级,心肺功能未见明显异常,肝肾及神经系统功能未见异常。采用随机数字表法,将患者随机分为对照组(C组)和盐酸右美托咪定组(M组),每组30例。

1.2 方法

麻醉方法术前禁食8 h,禁饮4 h,均未用术前药。入室后常规面罩吸氧,氧流量为5 L·min^-1,开放上肢静脉,输注乳酸钠林格液8~10 mL·kg^-1·h^-1,采用Cicero EM型麻醉机(Drager公司,德国)监测BP、P_ETCO₂、ECG、SpO₂和体温,上肢前臂尺神经两侧连接TOF.watch SX型加速度肌松监测仪(爱尔兰欧加农),监测拇内收肌颤搐情况。麻醉诱导依次静脉注射咪达唑仑0.05 mg·kg^-1,舒芬太尼0.3 μg ·kg^-1,丙泊酚1.5~2 mg·kg^-1,患者意识消失后,静脉注射顺阿曲库铵0.15 mg·kg^-1,当患者第1个肌颤搐t₁为0时进行气管插管,并进行机械通气。调节呼吸机参数,维持P_ETCO₂在35~45 mmHg(1 mmHg=0.133 kPa),氧流量1.5 L·min^-1。维持患者体温>36 ℃。麻醉诱导完成后,M组输注盐酸右美托咪定(江苏恒瑞医药股份有限公司,批准文号:国药准字H20090248,规格:2 mL:200 μg)1 μg·kg^-1·h^-1,随后以0.5 μg·kg^-1·h^-1速率持续静脉泵注至手术结束前10 min,C组泵注等容量0.9%氯化钠注射液。麻醉维持:持续静脉泵注丙泊酚4~12 mg·kg^-1·h^-1、瑞芬太尼0.1~0.2 μg·kg^-1·h^-1、当患者的第1个肌颤搐t₁恢复至10%时,持续输注顺苯磺酸阿曲库铵0.5 mg·kg^-1·h^-1,术中采用Aspect-2000型脑电活动监测仪(Aspect公司,美国)测定 BIS值,维持BIS值40~60。术毕前10 min停止输注盐酸右美托咪定,术毕前15 min停止输注顺苯磺酸阿曲库铵。拔管时机及返回病房时机根据临床征象(抬头或举臂≥5 s,听到命令睁眼,吸气负压≥1.96 kPa或肺活量>15 mL·kg^-1)。记录临床时效(第一个肌颤搐恢复到25%时间)、恢复指数(第一个肌颤搐从25%至75%的时间)、拔除气管插管30 min后及术后3 h残余肌松效应发生率(TOFR<0.9即发生残余肌松效应,TOFR=4个成串刺激比值)。

1.3 统计学方法

采用SPSS 16.0版统计学软件包进行数据分析,计量资料以均数±标准差( $\bar{x}$ ±s)表示,组间比较采用成组t检验,计数资料比较采用χ²检验,以P<0.05为差异有统计学意义。

2 结果

患者一般情况及术中失血量、术中补液量及麻醉时间比较差异无统计学意义(P>0.05),见表1;与C组比较,M组患者临床时效、恢复指数、拔管30 min后残余肌松发生率及术后3 h残余肌松发生率差异无统计学意义(P>0.05),见表2。

组别	年龄/ 岁	身高/ cm	体质量/ kg	术中补液量	术中失血量
C组	67.3±3.4	165±3	67±3	900±170	30±10
M组	66.9±2.6	166±4	65±5	980±150	40±10

表1 两组患者临床资料和术中情况比较

Tab.1 Comparison of general data and intraoperative situation between two groups of patients x¯±s,n=30

组别	临床时效/ min	恢复指数	残余肌松效应发生/例
C组	24.0±2.7	63±6	26	3
M组	23.6±3.1	60±5	25	2

表2 两组患者治疗后3项指标比较

Tab.2 Comparison of three indexes between two groups of patients after treatment x¯±s,n=30

3 讨论

TOFR即第4个肌颤搐高度与第1个肌颤搐高度的比值T4/T1。有研究表明,TOFR=0.9时喉部功能才可恢复至基础水平,误吸发生率降低^[6]。当TOFR至少达到0.9才能保证所有肌肉功能全部恢复,术后呼吸不良事件发生率和持续低氧血症的发生率减少^[7]。因此,TOFR≥0.9可作为神经肌肉功能恢复的金标准^[8]。且以此为标准术后2 h患者仍存在肌松残余效应^[9]。本试验的研究对象是老年患者,采用4个成串刺激比值TOFR值作为监测肌松方法,残余肌松效应的标准定于TOFR<0.9更为妥当。

研究表明,持续输注顺苯磺酸阿曲库铵肌松恢复时间延长,肌松残余效应无影响,且对于腹腔镜手术要求的深度肌松更恒定^[10]。因此本研究选择术中持续输注顺式阿曲库铵。

本研究应用周围神经刺激仪并仔细判断临床征象,拔管时及拔管后30 min残余肌松效应发生率仍然较高。本研究结果表明术后3 h,患者回到病房后也存在残余肌松效应。因此,通过临床征象判断肌松恢复情况并不安全。也许因为肌松药在喉内收肌较拇内收肌起效快,作用时间短,恢复迅速。术毕患者各项呼吸参数基本恢复,呛咳反射强烈时,拇内收肌的肌张力却未完全恢复。

本研究结果表明,与C组比较,M组老年患者肌松效应恢复到25%的时间、恢复指数、拔管30 min后及术后3 h残余肌松发生率差异无统计学意义。可能因为顺式阿曲库铵主要通过Hofmann方式消除,不依赖肝肾功能。盐酸右美托咪定是一种高选择性α₂-肾上腺素受体激动药,具有中枢性镇静、镇痛、抗焦虑的作用、抑制交感神经活性,维持围术期血流动力学稳定^[11,12],抑制围术期应激反应,改善缺血-再灌注损伤^[13],降低术后寒战发生且呼吸抑制轻微等优点,但对顺式阿曲库铵的药效学无影响。且多项研究表明,盐酸右美托咪定对于顺苯磺酸阿曲库铵的肌松效应无影响^[14,15]。

综上所述,术中持续输注盐酸右美托咪定对腹腔镜疝修补术老年患者残余肌松效应无影响。

The authors have declared that no competing interests exist.

参考文献

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Residual neuromuscular blockade:inciden-ce,assessment and relevance in the postoperative period

2006

... 肌松药术后残余神经肌肉阻滞作用(residual neuromuscular block,RNMB)逐渐被发现和受到重视.研究发现,术后残余肌松可引起多种临床并发症,主要表现为上呼吸道梗阻、术后缺氧、肺部并发症,通气量不足和吞咽功能不全等,甚至威胁生命^[1,2].对腹腔镜手术,有文献指出,术中维持深度肌松可以在较低的气腹压力下为手术医师提供更广阔的手术视野,更充足的操作空间,减少气腹压力对腹腔肌群的损伤,减少并发症^[3].但老年患者肝肾功能减退,药物血浆清除率降低,生理、病理、药动学及药效学均有其独特之处,因此老年患者更易发生残余肌松效应,术后发生呼吸抑制的风险较高,危害患者生命.盐酸右美托咪定具有镇静、镇痛及抗交感神经作用,对循环呼吸抑制小,可降低心肌缺血发生率,对老年患者尤为适用^[4,5].但其对老年患者残余肌松效应的影响尚有待探讨,笔者探讨术中持续输注盐酸右美托咪定对腹腔镜腹股沟疝修补术老年患者术后残余肌松效应的影响,为临床提供参考. ...

residual paraly-sis after emergence from anesthesia

2010

The role of deep neuro muscular blockade in surgical procedures

2013

Effects of intraven-ous dexmedetomidine on low-dose bupivacaine spinal anaesthesia in elderly patients

2012

Effect of dexmedetomi-dine on patient-controlled intravenous analgesia with fentanyl in elderly patients after total hip replacement

2011

Reversal with sugammadex in the absence of monitoring did not preclude residual neuro muscular block

2013

... TOFR即第4个肌颤搐高度与第1个肌颤搐高度的比值T4/T1.有研究表明,TOFR=0.9时喉部功能才可恢复至基础水平,误吸发生率降低^[6].当TOFR至少达到0.9才能保证所有肌肉功能全部恢复,术后呼吸不良事件发生率和持续低氧血症的发生率减少^[7].因此,TOFR≥0.9可作为神经肌肉功能恢复的金标准^[8].且以此为标准术后2 h患者仍存在肌松残余效应^[9].本试验的研究对象是老年患者,采用4个成串刺激比值TOFR值作为监测肌松方法,残余肌松效应的标准定于TOFR<0.9更为妥当. ...

Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesiacare unit

2008

Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers

1997

Postoperative residual block in postanesthesia care unit more than two hours after the administration of a single intubating dose of atracurium

2011

腹腔镜手术中持续输注与间断静注顺式阿曲库铵维持深度肌松的药效学比较

2016

... 研究表明,持续输注顺苯磺酸阿曲库铵肌松恢复时间延长,肌松残余效应无影响,且对于腹腔镜手术要求的深度肌松更恒定^[10].因此本研究选择术中持续输注顺式阿曲库铵. ...

Dexmedetomidine:current role in anesthesia and intensive care

2012

... 本研究结果表明,与C组比较,M组老年患者肌松效应恢复到25%的时间、恢复指数、拔管30 min后及术后3 h残余肌松发生率差异无统计学意义.可能因为顺式阿曲库铵主要通过Hofmann方式消除,不依赖肝肾功能.盐酸右美托咪定是一种高选择性α₂-肾上腺素受体激动药,具有中枢性镇静、镇痛、抗焦虑的作用、抑制交感神经活性,维持围术期血流动力学稳定^[11,12],抑制围术期应激反应,改善缺血-再灌注损伤^[13],降低术后寒战发生且呼吸抑制轻微等优点,但对顺式阿曲库铵的药效学无影响.且多项研究表明,盐酸右美托咪定对于顺苯磺酸阿曲库铵的肌松效应无影响^[14,15]. ...

Dexmedetomidine atte-nuates tourniquet-induced hyperdymamic response in patients undergoing lower limb surgeries:a randomized controlled study

2013

Dexme-detomidine preconditioning activates pro-survival kinases and attenuates regional ischemia/reperfusion injury in rat heart

2012

右美托咪定对老年人膝关节置换术顺苯磺酸阿曲库铵肌松效应的影响观察

2016

右美托咪定对腹腔镜妇科手术患者顺式阿曲库铵肌松效应的影响

2011