【作者】 任囝囡；

【导师】 张倩；

【作者基本信息】 中国医科大学 ， 麻醉学， 2008， 硕士

【摘要】 目的观察三种不同全麻方法复合硝普钠控制性降压时，口腔颌面部整形患者血液动力学和血浆白介素-6（Interleukins-6，IL-6）、白介素-10（Interleukins-10，IL-10）水平的变化，比较不同全麻方法复合硝普钠控制性降压对机体细胞免疫功能的影响。方法选择择期口腔颌面部整形患者30例，ASAⅠ～Ⅱ级，随机分为三组：芬太尼复合异氟烷吸入麻醉组（Ⅰ组）、芬太尼和丙泊酚复合异氟烷吸入麻醉组（Ⅱ组）、瑞芬太尼复合丙泊酚全凭静脉麻醉组（Ⅲ组），每组各10例患者。三组均用硝普钠行控制性降压，将平均动脉压（mean arterial pressure，MAP）降低30％左右，维持40分钟以上。分别记录麻醉前（T₀）、麻醉后降压前（基础值，T₁）、降压后10分（T₂）、20分（T₃）、40分（T₄）、停止降压后2分（T₅）、5分（T₆）、10分（T₇）、15分（T₈）、20分（T₉）的收缩压（systolic blood pressure，SBP）、舒张压（diastolic blood pressure，DBP）、MAP、心率（heart rate，HR）、率压积（rate pressure product，RPP，即SBP×HR）、脉搏血氧饱和度（pulse oxygen saturation，SpO₂）、呼气末二氧化碳分压（end-tidal carbondioxide partial pressure，PETCO₂）。于T₁、T₄及T₇三个时间点，分别抽取病人动脉血标本5ml，采用放射免疫法检测IL-6和IL-10的水平。结果1、MAP：在停止降压后的T₅、T₇时，Ⅲ组明显低于Ⅰ组（P<0．05）；T₆时，Ⅲ组明显低于Ⅰ组、Ⅱ组（P<0．05）；与T₁相比，Ⅰ组患者的MAP在T₅、T₆、T₇、T₈时，均显著升高（P<0．05）；Ⅱ组患者的MAP从T₆时开始升高，在T₇、T₈时均高于基础水平（P<0．05）。2、HR：控制性降压开始后T₂、T₃、T₄时，与T₁相比，三组的HR均升高（P均<0．05）；但Ⅲ组明显低于Ⅰ组、Ⅱ组（P<0．05）。3、RPP：在控制性降压开始后T₂、T₃、T₄时，直至停止降压后T₅、T₆、T₇时，与T1相比，Ⅰ组、Ⅱ组患者的RPP均明显高于基础水平（P<0．05）。在控制性降压过程中，即T₂、T₃、T₄时，Ⅲ组患者的RPP明显低于Ⅰ组、Ⅱ组（P<0．05）；在停止降压后T₅、T₆、T₇时，Ⅲ组患者的RPP仍明显低于Ⅰ组（P<0．05）。4、IL-6和IL-10：与T₁相比，在T₄、T₇时三组患者的IL-6均显著升高（P<0．05）；在T₇时，Ⅲ组患者IL-6的水平明显低于Ⅰ组、Ⅱ组（P<0．05）。与T₁相比，在T₄、T₇时三组患者的IL-10均显著升高（P<0．05）；在T₇时，Ⅰ组患者IL-6的水平明显低于Ⅱ组、Ⅲ组（P<0．05）。结论不同全麻方法和麻醉药物对手术期间的血流动力学反应和细胞免疫功能有不同的影响。瑞芬太尼复合丙泊酚全凭静脉麻醉能够减轻手术刺激和硝普钠引起的有害的血流动力学反应，提供稳定的血流动力学状态。并且，瑞芬太尼复合丙泊酚全凭静脉麻醉较之芬太尼复合异氟烷吸入麻醉和芬太尼-丙泊酚复合异氟烷吸入麻醉，使血浆IL-6水平降低IL-10水平升高，从而有利于围手术期机体的细胞免疫功能。更多还原

【Abstract】 ObjectiveTo observe the change of haemodynamics and plasma interleukins-6, interleukins-10 made by three different methods of general anesthesia combined with controlled hypotension induced by sodium nitroprusside（SNP） in oral and maxillofacial plastic surgery patients. To compare the effects of different general anesthesia combined with controlled hypotension induced by sodium nitroprusside on cellular immune function.MethodsThirty patients, ASAⅠ～Ⅱ, scheduled for oral and maxillofacial plastic surgery, were randomly divided into three groups: fentanyl-isoflurane group （groupⅠ, n=10）; fentanyl-propofol-isoflurane group （groupⅡ, n=10）; remifentanil-propofol group （groupⅢ, n=10）. All of them were controlled hypotension induced by sodium nitroprusside. Mean arterial pressure （MAP） will be reduced about 30%, maintain more than 40 minutes. Before anesthesia（T₀）; after anesthesia before hypotension （basic value, T₁）; 10 minutes（T₂）, 20 minutes（T₃）, 40 minutes（T₄） after hypotension; 2 minutes（T₅）, 5 minutes（T₆）, 10 minutes（T₇）, 15 minutes（T₈）, 20 minutes（T₉） after stopped hypotension, record the date of systolic blood pressure （SBP）, diastolic blood pressure （DBP）, MAP and heart rate（HR）, rate pressure product（RPP, SBP×HR）, pulse oxygen saturation（SpO₂）, end-tidal carbon dioxide partial pressure(P_ETCO₂). The 5ml samples of artery blood were collected at T₁, T₄, T₇. The levels of interleukins-6 and interleukins-10 in the plasma were measured by radioimmunoassay （RIA）.Results1. MAP: In groupⅢ, MAP was significantly lower than that of groupⅠat T₅, T₇ （P<0.05）. In groupⅢ, MAP was significantly lower than that of groupⅠand groupⅡat T₆（P<0.05）. In groupⅠ, MAP was significantly increased than that of groupⅡat the T₅, T₆, T₇, T₈ （P<0.05）. In groupⅡ, MAP began to increase at T₆, and still higher than base level at T₇, T₈ （P<0.05）.2. HR: At T₂, T₃, T₄, HR was higher in all three groups compared with that at T₁ （P<0.05）. But in the groupⅢ, HR was significantly lower than that of groupⅠand groupⅡ（P<0.05）.3. RPP: In groupⅠand groupⅡ, RPP was significantly higher than the basis level at T₂, T₃, T₄, T₅, T₆, T₇ （P<0.05）. In groupⅢ, RPP was significantly lower than that of groupⅠand groupⅡat T₂, T₃, T₄ （P<0.05）. In groupⅢ, RPP was still significantly lower than that of groupⅠat T₅, T₆, T₇（P<0.05）.4. Interleukins-6 and interleukins-10: At T₄ and T₇, interleukins-6 and interleukins-10 were significantly increased compared with them at T₁ （P<0.05）. In groupⅢ, interleukins-6 was significantly lower than that of groupⅠandⅡat T₇ （P<0.05）. In groupⅠ, interleukins-10 was significantly lower than that of groupⅡandⅢat T₇ （P<0.05）.ConclusionDifferent anesthetic methods and anesthetic drugs had different effects on hemodynamic response and cellular immune function during surgical operation. TIVA with propofol-remifentanil appears to mitigate potentially hazardous hemodynamic responses from operative stimuli and side effects of controlled hypotension induced by sodium nitroprusside（SNP）. Interleukins-6 levels were increased and interleukins-10 levels were decreased in patients anesthetized with propofol-remifentanil compared to anesthetized with isoflurane-fentanyl or propofol-isoflurane-fentanyl. Therefore, it is conducive to perioperative cellular immune function.更多还原