，海霞，，

(1.濟(jì)南軍區(qū)總醫(yī)院，山東 濟(jì)南 250031；2.山東省濰坊市臨朐縣九山中心衛(wèi)生院，山東 濰坊 262608)

全麻剖宮產(chǎn)患者術(shù)前泵注右美托咪定對(duì)其應(yīng)激反應(yīng)和血流波動(dòng)的影響

宋強(qiáng)1，宋海霞2，邊洪春1，高成杰1

(1.濟(jì)南軍區(qū)總醫(yī)院，山東濟(jì)南250031；2.山東省濰坊市臨朐縣九山中心衛(wèi)生院，山東濰坊262608)

目的觀(guān)察全麻剖宮產(chǎn)患者術(shù)前泵注右美托咪定對(duì)其應(yīng)激反應(yīng)和血流動(dòng)力學(xué)的影響。方法選取于2014年8月至2016年7月來(lái)濟(jì)南軍區(qū)總醫(yī)院就診的全麻剖宮產(chǎn)患者60例，按照隨機(jī)數(shù)表法將所有患者分為實(shí)驗(yàn)組和對(duì)照組，每組30例患者。實(shí)驗(yàn)組患者在全麻誘導(dǎo)前20min靜脈泵入右美托咪定0.8μg·kg-1·h-1，對(duì)照組患者在全麻誘導(dǎo)前20min靜脈泵入生理鹽水0.8μg·kg-1·h-1。記錄泵藥前、泵藥后20min、氣管插管時(shí)、切皮、胎兒娩出時(shí)和拔管后10min時(shí)患者的心率和平均動(dòng)脈壓；胎兒娩出后，記錄新生兒出生后1min和5min時(shí)的Apgar評(píng)分，抽取臍靜脈血進(jìn)行血?dú)夥治觥＝Y(jié)果實(shí)驗(yàn)組和對(duì)照組患者的年齡、身高、體重、胎兒剖出時(shí)間、出生體重、孕周、麻醉時(shí)間的比較差異無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)。實(shí)驗(yàn)組和對(duì)照組兩組患者泵藥前心率和平均動(dòng)脈壓比較，差異無(wú)統(tǒng)計(jì)學(xué)意義(t值分別為0.000、0.701，均P>0.05)。泵藥后20min及之后的時(shí)間點(diǎn)實(shí)驗(yàn)組的心率明顯低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(t值分別為-9.874、-9.548、-7.789、-8.886、-12.241，均P<0.05)，泵藥后20min及之后時(shí)間點(diǎn)實(shí)驗(yàn)組患者的平均動(dòng)脈壓明顯低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(t值分別為-4.747、-6.111、-6.393、-5.720、-4.562，均P<0.05)。實(shí)驗(yàn)組患者新生兒臍帶血血?dú)夥治鲋械膒H、PaCO2、PaO2、SaO2與對(duì)照組的比較差異無(wú)統(tǒng)計(jì)學(xué)意義(t值分別為1.711、-1.603、-1.019、-0.771，均P>0.05)。兩組患者新生兒出生后1min和5min時(shí)的Apgar評(píng)分比較差異無(wú)統(tǒng)計(jì)學(xué)意義(t=0.000，P>0.05)。結(jié)論全麻剖宮產(chǎn)患者術(shù)前泵注右美托咪定有利于穩(wěn)定母體的血流動(dòng)力學(xué)，減弱患者的應(yīng)激反應(yīng)，同時(shí)對(duì)新生兒無(wú)不良影響。

全身麻醉；剖宮產(chǎn)；右美托咪定；應(yīng)激反應(yīng)

多數(shù)剖宮產(chǎn)患者術(shù)前麻醉均選擇椎管內(nèi)阻滯的方式，當(dāng)患者由于病情或恐懼手術(shù)而不能進(jìn)行椎管內(nèi)阻滯時(shí)，也會(huì)采用全身麻醉的方式對(duì)剖宮產(chǎn)患者進(jìn)行術(shù)前麻醉。右美托咪定是一種新型α2腎上腺素能受體激動(dòng)劑，具有鎮(zhèn)靜、抑制交感神經(jīng)、抗焦慮的作用，單次注射或持續(xù)泵注均能引起血流動(dòng)力學(xué)波動(dòng)和應(yīng)激反應(yīng)[1]。右美托咪定有利于維持術(shù)中血流動(dòng)力學(xué)的穩(wěn)定，持續(xù)泵注右美托咪定可有效減少低血壓和心動(dòng)過(guò)緩的發(fā)生率，本研究通過(guò)探討分析全麻剖宮產(chǎn)患者術(shù)前泵注右美托咪定對(duì)其應(yīng)激反應(yīng)和血流動(dòng)力學(xué)的影響，為臨床右美托咪定的使用提供理論依據(jù)，現(xiàn)將結(jié)果報(bào)道如下。

1資料和方法

1.1一般資料

選取于2014年8月至2016年7月來(lái)濟(jì)南軍區(qū)總醫(yī)院就診的全麻剖宮產(chǎn)患者60例，按照隨機(jī)數(shù)表法將所有患者分為實(shí)驗(yàn)組和對(duì)照組，每組30例患者。所有患者均符合病例納入標(biāo)準(zhǔn)和病例排除標(biāo)準(zhǔn)。病例納入標(biāo)準(zhǔn)：①懷孕36周以上的患者；②單胎；③患者年齡為21～35歲；④美國(guó)麻醉醫(yī)師學(xué)會(huì)(American Society of Anesthesiologists，ASA)分級(jí)Ⅰ級(jí)或Ⅱ級(jí)的患者。病例排除標(biāo)準(zhǔn)：①心臟傳導(dǎo)阻滯的患者；②伴有肝腎功能明顯異常的患者；③對(duì)右美托咪定過(guò)敏的患者；④濫用藥物或酒精的患者；⑤懷疑胎兒宮內(nèi)缺氧的患者；⑥伴有糖尿病、妊娠期高血壓疾病的患者。所有患者及家屬均知情同意，均簽署知情同意書(shū)。本研究經(jīng)本院醫(yī)學(xué)倫理學(xué)委員會(huì)批準(zhǔn)。

1.2麻醉方法

產(chǎn)婦均于術(shù)前6h開(kāi)始禁食?；颊哌M(jìn)入手術(shù)室后，常規(guī)監(jiān)測(cè)患者心電圖、心率、無(wú)創(chuàng)血壓、血氧飽和度等。實(shí)驗(yàn)組患者在全麻誘導(dǎo)前20min靜脈泵入右美托咪定0.8μg·kg-1·h-1，對(duì)照組患者在全麻誘導(dǎo)前20min靜脈泵入生理鹽水0.8μg·kg-1·h-1。隨后對(duì)患者進(jìn)行麻醉誘導(dǎo)，充分預(yù)氧5min后，靜脈注射羅庫(kù)溴胺0.6mg/kg，丙泊酚2.5mg/kg，壓迫環(huán)狀軟骨，1min后氣管插管。胎兒娩出后，改用瑞芬太尼0.15μg·kg-1·min-1，丙泊酚100～150μg·kg-1·min-1維持麻醉完成手術(shù)。所有手術(shù)均由一名經(jīng)驗(yàn)豐富的產(chǎn)科醫(yī)師完成。

1.3觀(guān)察指標(biāo)

記錄泵藥前及泵藥后20min、氣管插管時(shí)、切皮、胎兒娩出時(shí)和拔管后10min時(shí)患者的心率和平均動(dòng)脈壓，若患者血壓低于麻醉前30%給予麻黃堿5～10mg，若患者心率低于60次/分鐘給予阿托品0.2～0.3mg；胎兒娩出后，記錄新生兒出生后1min和5min Apgar評(píng)分，抽取臍靜脈血進(jìn)行血?dú)夥治觥?/p>

1.4統(tǒng)計(jì)學(xué)方法

2結(jié)果

2.1一般資料比較

實(shí)驗(yàn)組和對(duì)照組患者的年齡、身高、體重、胎兒剖出時(shí)間、出生體重、孕周、麻醉時(shí)間比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)，見(jiàn)表1。

2.2平均動(dòng)脈壓和心率比較

實(shí)驗(yàn)組和對(duì)照組兩組患者泵藥前心率和平均動(dòng)脈壓比較差異無(wú)統(tǒng)計(jì)學(xué)意義(t值分別為0.000、0.701，均P>0.05)。泵藥后20min及之后時(shí)間點(diǎn)實(shí)驗(yàn)組患者的心率明顯低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(t值分別為-9.874、-9.548、-7.789、-8.886、-12.241，均P<0.05)。泵藥后20min及之后時(shí)間點(diǎn)實(shí)驗(yàn)組患者的平均動(dòng)脈壓明顯低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(t值分別為-4.747、-6.111、-6.393、-5.720、-4.562，均P<0.05)，見(jiàn)表2、表3。

項(xiàng)目實(shí)驗(yàn)組(n=30例)對(duì)照組(n=30例)tP年齡(歲)27.63±4.3227.48±5.09 0.1010.920身高(cm)160.22±7.91162.38±9.25-0.9720.335體重(kg)61.29±3.2661.05±3.20 0.2320.818孕周(周)31.21±5.0731.42±4.12-0.1400.889胎兒剖出時(shí)間(min)8.44±1.578.89±1.97-0.9780.332麻醉時(shí)間(min)57.32±13.2759.42±14.93-0.5760.567新生兒出生體重(kg)3.27±0.433.32±0.29-0.5280.599

項(xiàng)目實(shí)驗(yàn)組(n=30)對(duì)照組(n=30)tP泵藥前94±1094±13 0.0001.000泵藥后20min67±893±12-9.874<0.001氣管插管時(shí)82±9114±16-9.548<0.001切皮87±11117±18-7.789<0.001胎兒娩出時(shí)85±9112±14-8.886<0.001拔管后10min84±6116±13-12.241<0.001

項(xiàng)目實(shí)驗(yàn)組(n=30)對(duì)照組(n=30)tP泵藥前106±12104±10 0.7010.486泵藥后20min90±9103±12-4.747<0.001氣管插管時(shí)100±11119±13-6.111<0.001切皮99±12118±11-6.393<0.001胎兒娩出時(shí)97±11114±12-5.720<0.001拔管后10min99±12115±15-4.562<0.001

2.3新生兒臍帶血?dú)夥治龊虯pgar評(píng)分比較

實(shí)驗(yàn)組患者新生兒臍帶血血?dú)夥治鲋械膒H、PaCO2、PaO2、SaO2與對(duì)照組患者比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(t值分別為1.711、-1.603、-1.019、-0.771，均P>0.05)。兩組患者新生兒出生后1min和5min Apgar評(píng)分比較差異均無(wú)統(tǒng)計(jì)學(xué)意義(均P>0.05)，見(jiàn)表4。

Table 4 Comparison of neonatal umbilical cord blood gas analysis and Apgar score(±S)

3討論

全身麻醉通過(guò)鎮(zhèn)痛、鎮(zhèn)靜和肌松作用抑制交感神經(jīng)興奮性，同時(shí)配合呼吸機(jī)支持，能夠更好的改善患者氧氣供應(yīng)，保證母體供氧。由于誘導(dǎo)麻醉迅速，麻醉效果確切，有利于對(duì)機(jī)體血容量的調(diào)控[2]。為了減少對(duì)胎兒的影響，全麻剖宮產(chǎn)時(shí)，常選用小劑量的麻醉藥，因而手術(shù)的應(yīng)激性較強(qiáng)，術(shù)中血流動(dòng)力學(xué)波動(dòng)較大。應(yīng)激反應(yīng)過(guò)高會(huì)導(dǎo)致患者血壓升高、心率加快，降低胎盤(pán)血流灌注，導(dǎo)致新生兒剖出后Apgar評(píng)分降低。本次研究通過(guò)探討全麻剖宮產(chǎn)術(shù)前泵注右美托咪定對(duì)其應(yīng)激反應(yīng)和血流波動(dòng)的影響，為臨床全麻剖宮產(chǎn)用藥提供理論依據(jù)。

3.1右美托咪定的藥理作用

右美托咪定是一種新型α2腎上腺能受體激動(dòng)劑，具有鎮(zhèn)痛、鎮(zhèn)靜、降低應(yīng)激反應(yīng)、抗交感神經(jīng)反射的作用，對(duì)呼吸無(wú)明顯抑制作用[3]。右美托咪定通過(guò)激動(dòng)藍(lán)斑核內(nèi)的突觸前膜α2受體，抑制去甲腎上腺素的釋放，降低突觸后膜的興奮性，有效抑制交感神經(jīng)活性，從而有效抑制大腦皮質(zhì)的覺(jué)醒反應(yīng)[4]。右美托咪定可以穩(wěn)定患者血流動(dòng)力學(xué)水平，能夠有效減少鎮(zhèn)痛藥和麻醉藥的用量，減少患者的惡心嘔吐、寒戰(zhàn)、躁動(dòng)。右美托咪定具有半衰期短的特點(diǎn)，鎮(zhèn)靜水平容易調(diào)節(jié)，已廣泛應(yīng)用于ICU長(zhǎng)時(shí)間的鎮(zhèn)靜，有著較高的安全性和可靠性。同時(shí)，患者處于類(lèi)似正常睡眠的鎮(zhèn)靜狀態(tài)，被鎮(zhèn)靜同時(shí)可被喚醒，撤除喚醒的刺激患者很快可回到被鎮(zhèn)靜狀態(tài)[5]。

3.2本研究結(jié)果分析

本研究結(jié)果表明，實(shí)驗(yàn)組和對(duì)照組兩組患者泵藥前心率和平均動(dòng)脈壓無(wú)差異，泵藥后20min及以后時(shí)間點(diǎn)實(shí)驗(yàn)組患者的心率和平均動(dòng)脈壓都明顯低于對(duì)照組。提示右美托咪定能夠有效減少手術(shù)期間各種強(qiáng)烈刺激所引起的循環(huán)反應(yīng)，這一研究結(jié)果與鄧超等人于2015年的研究結(jié)果一致。右美托咪定能夠有效維持患者術(shù)中循環(huán)的穩(wěn)定，同時(shí)可減弱血流動(dòng)力學(xué)反應(yīng)。麻醉誘導(dǎo)前靜脈泵注右美托咪定對(duì)患兒出生后1min和5min Apgar評(píng)分無(wú)明顯影響，未見(jiàn)明顯嚴(yán)重不良反應(yīng)。這一研究結(jié)果與右美托咪定的清醒鎮(zhèn)靜效應(yīng)有關(guān)，被娩出后新生兒有著被刺激時(shí)自然喚醒的可能。實(shí)驗(yàn)組患者新生兒臍帶血血?dú)夥治鲋械膒H、PaCO2、PaO2、SaO2與對(duì)照組患者比較差異無(wú)統(tǒng)計(jì)學(xué)意義，兩組患者的血?dú)夥治鱿嗨疲崾韭樽碚T導(dǎo)前靜脈泵注右美托咪定不影響新生兒的胎盤(pán)血流，不影響胎兒氧供。這與研究結(jié)果中新生兒Apgar評(píng)分相同的結(jié)果一致。這一研究結(jié)果與韓傳寶等[6]的研究結(jié)果一致。本次研究結(jié)果表明，全麻剖宮產(chǎn)患者術(shù)前泵注右美托咪定對(duì)新生兒無(wú)不良影響。

3.3結(jié)論

綜上所述，全麻剖宮產(chǎn)患者術(shù)前泵注右美托咪定有利于穩(wěn)定母體的血流動(dòng)力學(xué)，減弱患者的應(yīng)激反應(yīng)，同時(shí)對(duì)新生兒無(wú)不良影響。

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[專(zhuān)業(yè)責(zé)任編輯：陳 寧]

Effects of preoperative infusion of dexmedetomidine on stress response and hemodynamics of patients undergoing cesarean section under general anesthesia

SONG Qiang1, SONG Hai-xia2, BIAN Hong-chun1, GAO Cheng-jie1

(1.GeneralHospitalofJinanMilitaryArea,ShandongJinan250031,China; 2.LinquCountyNineMountainCentralHospital,ShandongWeifang262608,China)

ObjectiveTo observe the effects of preoperative infusion of dexmedetomidine on stress response and hemodynamics of patients undergoing cesarean section under general anesthesia.MethodsA total of 60 cases undergoing cesarean section under general anesthesia from August 2014 to July 2016 in General Hospital of Jinan Military Area were selected, and they were divided into experimental group and control group according to random number table method with 30 patients in each group. Patients in the experimental group were intravenously pumped with 0.8μg/(kg·h) of dexmedetomidine at 20mins before induction of general anesthesia, and patients in the control group were intravenously pumped with 0.8μg/(kg·h)of normal saline at 20mins before induction of general anesthesia. Heart rate and mean arterial blood pressure before drug infusion, at 20mins after infusion, at tracheal intubation, skin incision, fetal disengagement, and 10min after extubation were recorded. After delivery of fetus, the Apgar score of newborns at 1min and 5mins were recorded, and umbilical vein blood was extracted for blood gas analysis.ResultsThere was no significant difference in age, height and weight of patients, fetal dissection time, birth weight, gestational age and anesthesia time between two groups (allP>0.05). There was no significant difference in heart rate and mean arterial blood pressure before drug infusion between two groups (tvalue was 0.000 and 0.701, respectively, bothP>0.05). Heart rate of patients in the experimental group was significantly lower than that in the control group at 20min and later time points after drug administration, and differences were statistically significant (tvalue was -9.874, -9.548, -7.789, -8.886 and -12.241, respectively, allP<0.05). Mean arterial pressure in the experimental group was significantly lower than that in the control group at 20min and later time points after pumping of drug, and differences had statistical significance (tvalue was -4.747, -6.111, -6.393, -5.720 and -4.562, respectively, allP<0.05). Differences in PH, PaCO2, PaO2and SaO2in neonatal umbilical cord blood gas analysis were not significant between two groups (t value was 1.711, -1.603, -1.019 and -0.771, respectively, allP>0.05). There was no significant difference in the Apgar scores of newborns at 1min and 5mins after birth between two groups (t=0.000,P>0.05).ConclusionPump infusion of dexmedetomidine before operation is beneficial for maternal hemodynamics in patients undergoing cesarean section under general anesthesia. It can reduce patient’s stress response, and no adverse effects is made on newborns.

general anesthesia; cesarean section; dexmedetomidine; stress response

2017-01-06

宋 強(qiáng)(1982—)，男，住院醫(yī)師，主要從事臨床麻醉工作。

高成杰，主任醫(yī)師。

10.3969/j.issn.1673-5293.2017.09.038

R719.8

A

1673-5293(2017)09-1154-03