【作者】 李志刚；

【导师】 张丽红；

【作者基本信息】 中国医科大学 ， 麻醉学， 2007， 硕士

【摘要】 目的观察在腹腔镜胆囊切除术（Laparoscopic cholecystectomy，LC）中应用靶控输注（Target-controlled influsion，TCI）丙泊酚和雷米芬太尼对呼吸、循环、血清皮质醇（cortisol,COR）、白细胞介素-6（Interleukin-6，IL-6）、恶心呕吐发生率的影响，并评价脑电双频指数（Bispectral index BIS）在麻醉监测中的意义。方法一、一般资料择期行腹腔镜胆囊切除术的患者60例，ASAⅠ-Ⅱ，年龄20-60岁，体重指数（BMI）<25kg/m²。排除患有心肺疾病史和其他重要系统疾病史的患者。二、分组所有病例随机分为两组：（P组）靶控输注丙泊酚和雷米芬太尼全凭静脉麻醉组30例，行靶控诱导和维持；（Ⅰ组）常规麻醉诱导术中复合吸入维持组30例。术中通过调节异氟烷吸入浓度或丙泊酚和雷米芬太尼靶控浓度，使麻醉期间BIS值维持在45±5之间，MAP和HR波动在基础值的±20％范围内。两组均以维库溴铵术中间断静注维持肌松。三、观察指标（1）MAP、HR：观察并记录入室静卧10 min（T₀基础值）、气腹开始（T₁）、气腹后5min（T₂）、气腹后10men（T₃）、15min（T₄）、20 min（T₅）、气腹停止时（T₆）各时点的监测值：（2）P_ETCO₂、MV、PIP：观察并记录T₁、T₂、T₃、T₄、T₅、T₆各时点的监测值（3）脑电双频指数（BIS）：观察并记录T₁、T₂、T₃、T₄、T₅、T₆各时点的监测值（4）术中知晓调查：手术结束后及术后8-12小时询问麻醉后有无不良感受和记忆。（5）术后24小时恶心呕吐发生率评定。（6）测定入室后10min（t₁）及气腹20min（t₂）时点血清皮质醇（COR）、白细胞介素-6（IL-6）水平。四、统计分析计量资料以均数±标准差（（?）±S）表示，使用SPSS11.0软件系统进行统计学处理。组内行配对t检验，组问行单因素方差分析，率的检验采用Ridit分析。P<0.05认为差别具有显著性意义。结果1、对呼吸循环功能影响的比较与T_i比较气腹后P组及Ⅰ组T₂-T₅时点PIP均明显升高，T₃-T₆时点P_ETCO₂明显升高而MV在T₂-T₅时点则明显降低（P<0.05）；组间比较未见明显差异（P>0.05）。T₁-T₆时点的MAP HR与T₀比较，P组无显著性差异（P>0.05），Ⅰ组MAPT₂-T₅时点与T₀比较，则有显著性差异（P<0.05）；T₂-T₅时点P组较Ⅰ组有显著性差异（P<0.05）。2、血清COR IL-6水平P组t₂时点COR和IL-6较t₁时点无明显差异（P>0.05），Ⅰ组t₂时点COR和IL-6较t₁时点明显升高（P<0.05）；组间比较，t₂时点P组明显低于Ⅰ组，有明显统计学差异（P<0.05），t₁点两组无明显差异（P>0.05）。3、BIST₁-T₆时点两组内、组间无显著性差异（P>0.05）。4、术中知晓调查手术结束后及术后8-12小时询问患者，麻醉后和术中均无不良感受和知晓。5、术后24小时恶心呕吐发生率评定P组PONV发生率明显少于Ⅰ组（P<0.05）。结论1、丙泊酚和雷米芬太尼靶控输注全凭静脉麻醉下，可以有效地抑制腹腔镜胆囊切除术引起的应激反应，维持血流动力学的相对稳定。2、在监测血流动力学的同时联合应用BIS可以更好地反映麻醉过程中麻醉深度的动态变化，预防术中知晓和麻醉过深。3、腹腔镜胆囊切除术采用丙泊酚和雷米芬太尼靶控输注全凭静脉麻醉较吸入麻醉比较明显减少术后恶心呕吐的发生。更多还原

【Abstract】 To observe the effect of two anesthesitic methods of propofol and remifentanyltarget-controlled influsion （ TCI ） or isoflurane and nitrous oxide inhalation onthe function of respiratory, circulation systems, airway pressure, nausea, vomitting, thelevel of cortisol （COR） & Interleukin-6 （IL-6） during laparoscopic cholecystectomy（ LC ） , meanwhlie to evaluate the Bispectral index （BIS） under the monitoring ofgeneral anesthesia.Methods1、General materialsSixity ASAⅠ-Ⅱpatients for elective LC were randomly divided into twogroups.Their age range is 40-60, body weight index〈25kg/m²,all excluded respiratory、circulation and other system diseases.2、GroupingThe patients were randomly allocated to two groups.Group P （ n=30 ） : thepatients were intubated after induced and maintained through Total intravenousanesthesia （TIVA） with propofol and remifentany TCI.Group I （ n=30 ） : the patientswere intubated after induced and maintained with inhalation intubation of isofluraneand nitrous oxide, adjust the concentration of isoflurane inhalation or propofol andremifentany TCI to control the MAP、HR within the range of±20% the basiclevels.Intravenous injecting vecuronium interruptedly so as to maintain musclerelaxation. Anesthetics of all patients of two group after operation would be stopped.3、Targets observedBlood samples were taken and recorded targets and BIS at six time points :10minafter patients entered the operation room（baseline） （T0） , starting aeroperitoneum （T1）、 5（T2）、10（T3）、15（T4）、20min（T5） during the pneumoperitoneum and immediately afterthe pneumoperitoneum （T6） . Targets observed were as followings.（1） record MAP andHR.at patients entering romm（T0） , starting aeroperitoneum （T1） , afteraeroperitoneum5min （T2） ,10（T3） , 15（T4） , 20min（T5） and release gas （T6） （2） PETCO2,Mv and PIP at starting aeroperitoneum （T1） , after aeroperitoneum5min（T2） ,10（T3） , 15（T4） , 20min（T5） and release gas （T6） respectively. （3） Bispectral index（BIS）. （4） awareness. （5） Incidence of the postoperative nausea, vomiting（PONV）at 24 hafter the operation. （6） level of cortisol （COR） & Interleukin-6 （IL-6） at 10min patientsentered and after 20min of aeroperitoneum.4、Statistical analysisSPSS 11．0 software was used to analysize all quantitative data. Mean±standarddeviation indicated quantitative data,and use t-test to analyse. P<0．05 were consideredsignificant difference.Results1 Comparision of the effect to the function of of respiratory &circulatory system.PIP significantly enhanced at T2-T5 and PETCO2 significantly enhanced atT3-T6 both Group P and group I （P<0．05） .but MV significantly decreased afteraeroperitoneum at T2-T5 both Group P and group I （P<0．05） . PETCO2、PIP and MVwere not significant diffenence at any time between the two groups （P>0．05） , but MVwas not different obviously（P>0．05） .MAP and/or HR at T1-T6 afterpneumoperitoneum was no diffenent in group P （P>0．05） but significant different ingroup I（P<0．05） at T2-T5 in comparison with T0．2 The level of COR and IL-6There was no significant diffence between at t2 and t1 in group P （P>0．05） butsignificant diffence in group I（P<0．05） .3 Bispectral index BISThere are no significant diffence at T₁-T₆ between the two group and nosignificant differece within each group（P>0．05） .4 awareness No awareness occurred 8-12hr after operation.5 The incidence of the postoperative nausea and vomitiing（PONV）The incidence and the severity of the PONV was significantly less in Group P thanin Group I （P<0．05） .Conclusions1 The anaesthesia through TIVA with propofol and remifentany TCI caneffectively suppress the effect of of stress leaded by operation and pneumoperitoneumin laparoscopic cholecystectomy and maintained the stabilization of hemodynamicsand respiratory,which is better than inhalational anesthesia2 Hemodynamics monitoring associated BIS can provide us a morecomprehensive the depth of anesthesia,thus we can regulate the dosage of anesthetics inthe aim of avoiding awareness or extremely deep anesthesia.3 The anaesthesia through TIVA with propofol and remifentany TCI can reducethe incidence and the severity of the postoperative nausea and vomiting moreeffectively than inhalational anesthesia.更多还原