【作者】 潘晨宇；

【导师】 李少岩；

【作者基本信息】 延边大学 ， 麻醉学， 2008， 硕士

【摘要】 目的:探讨七氟醚对阿曲库铵的药效作用强度,临床作用时间以及肌松恢复的影响。方法:45例择期腹部肿瘤手术全麻患者,ASA分级Ⅰ-Ⅱ级,年龄40-60岁,无神经肌肉系统疾病病史,肝肾功能正常,术前未用已知的可影响神经肌肉传导功能的药物。将病人随机分为三组:P组:异丙酚+阿曲库铵肌松维持组;I组:异氟醚+阿曲库铵肌松维持组;S组:七氟醚+阿曲库铵肌松维持组。术前30分钟肌肉注射0.5mg阿托品。麻醉诱导前建立稳定的肌松监测,在TOF模式监测下,麻醉诱导:咪达唑仑0.04-0.05mg/kg,舒芬太尼0.5ug/kg,依托咪酯0.3mg/kg,病人入睡推注阿曲库铵0.6mg/kg（20秒注毕）,待T₁降至5%以下时行气管内插管。麻醉维持:异丙酚持续血浆靶控输注1-4ug/ml,复合瑞芬太尼0.25ug/kg/min输注（P组n=15）;异氟醚呼气末浓度维持在1.2MAC（I组n=15）,术中必要时追加舒芬太尼0.3-0.5ug/kg;七氟醚呼气末浓度维持在1.2MAC（S组n=15）,术中必要时追加舒芬太尼0.3-0.5ug/kg,阿曲库铵在三组均在阿曲库铵首次剂量注毕后,至T₁术值恢复到25%时,启动阿曲库铵恒速输注,剂量为0.5mk/kg/h。毕前20分钟左右停止输注阿曲库铵,此后任其自然恢复,不予任何拮抗药。术毕时停止异丙酚输注,异氟醚、七氟醚吸入,待病人完全恢复（即TOFR＞0.7,潮气量＞400ml,且能呼之睁眼并持续抬头5秒以上）即可常规吸痰拔除气管导管。三组在诱导过程及麻醉维持中,BIS值控制在45-55范围内,HR和MAP的值控制在HR（80-120次/min）,MAP（60-90mmHg）范围内,P_ETCO₂维持在35-45mmHg。术中记录:T₁降至5%的时间及此时的气管插管条件:麻醉诱导时（T1）、气管插管前即刻（T2）、气管插管后即刻（T3）、气管插管后5min（T4）、T₁ 25%（T5）、启动阿曲库铵恒速输注后5min（T6）、术前20分钟停止输注阿曲库铵（T7）、T₁75%（T8）、TOFR0.7（T9）九个时间点的MAP、HR、SpO₂、P_ETCO₂、BIS值以及食道温度的变化。并记录起效时间（即阿曲库铵注毕至T₁降至0%的时间）、临床维持时间（T₁25%.即阿曲库铵注毕至T₁恢复到25%的时间）、T₁75%（即阿曲库铵注毕至T₁恢复到75%的时间）、恢复指数（T₁高度从25%到75%的时间）以及TOFR0.7的时间（T₄/T₁=0.7）。结果:1、麻醉诱导麻醉诱导注入阿曲库铵0.6mg/kg后,当T₁＜5%时行气管插管,插管条件满意评分8.64±0.5（根据Krirg改良法评分）;P组、I组和S组三组内T2-T8与T1比较血压降低（P＜0.05）;三组内T2与T1比较心率降低（P＜0.05）。2、阿曲库铵的起效阿曲库铵的起效在P组、I组和S组比较无统计学意义（P＞0.05）。3、阿曲库铵的维持时间P组、I组和S组的首剂阿曲库铵从注射到T₁为25%,各组之间比较,均有统计学意义（均P＜0.05）,在I组和S组肌松时间延长,S组肌松时间延长更长（P＜0.05）。4、阿曲库铵的肌松恢复P组、I组和S组各组的恢复指数之间比较,均有统计学意义（均P＜0.05）,I组和S组时间延长,I组时间延长更长（P＜0.05）;各组的TOFR0.7两两之间比较,均有统计学意义（均P＜0.05）,在I组和S组时间延长,I组时间延长更长（P＜0.05）。结论:1、1.2 MAC七氟醚、异氟醚维持麻醉可延长阿曲库铵的肌松时间和肌松恢复时间。2、七氟醚维持麻醉延长阿曲库铵的肌松时间较异氟醚长,且麻醉结束时肌松恢复时间较异氟醚短。更多还原

【Abstract】 Purpose:To discuss the influnce of sevoflurane anesthesia to the randomized styudy,dose-response relationship and nuromuscular recover of atracurium.Methods:Forty-five patients of abdominal surgery,ASA physical statusⅠorⅡ,cheduled to undergo elective surgical procedures were studied. Patients with hepatic,renal or neuromuscular diseases and those on med-Ications known to affect neuomuscular blocking drugs were excluded. Forty-five patients were randomly divided into three groups:Group P,propofol and atracurium;Group I,isoflurane and atracurium;Group S,sevoflurane and inatracurium.Patients were premedicated with injection atropine 0.01mg/kg intramuscularly30 minutes before surgery,anesthesia was induce with midazolam0.04-0.05mg/kg,sulfentanyl 0.5ug/kg,followed by etomidate 0.3mg/ kg and maintained with oxygen100%,Afert bolus dose of atracurium 0.6mg/kg,intubation was performed as soon as the fiest response to TOF stimulus T₁ fell below 5%.After tracheal intubation, propofol 1-4ug/ml and supplements of remifentanil 0.25 ug/kg/min（group P:n=15）;end-tidal concentrations 1.2MAC isoflurane（group I:n=15） endtidal concentrations 1.2MAC sevoflurane（group S:n=15）.The atracuriums infusion was discontinued approximately 20-min before termination of the operation.Let it recover in nature,do not give any reversal drug.When the surgery is over,the propofol’s influsion and isoflurane,sev oflurane’s inhalation was discontinued approximately.Spontaneous recovery of muscular function was then allowed to proceed.The criteria for full recovery form neuromuscular blochade were a measured tidal volume of greater than 400 ml,and the ability to sustain a head lift for 5s,and the TOF ratio geater than 70%.During nesthesia induction and maintenance,the range of BIS was form 45 to 55,MAP was form 60mmHg to90mmHg,HR was form 60 to 120 and P_ETCO₂ was form 35mmHg to 45mmHg.Record after blous does of atracurium 0.6mg/kg intubation was performed as soon as the first response to TOF stimulus T₁ fell below 5%.The variations of MAP,HR,SpO₂ and P_ETCO₂ were recorded at nine time points:anesthesia intubation（T1）;the moment just before intubation（T2）;the moment just after intu-bation（T3）;five minutes after intubation（T4）;T₁ recover to 25%（T5）;Five minutes after to add the atracurium at first（T6）;The time of the atracurium’s infusion was discontinued approximately 20-min before termination of the operation （T7）;T₁ recover to 75%（T8）;TOFR 0.7（T9）.The TOF mode of stimulation was used.The variables recorded were as follows:onset time（time form drug administration to maximum effects）,time recovery of T₁ to 25%and 75%of control,recovery index（time form T₁ 25%to 75%） and TOFR0.7（T₄/T₁）.Results:1.Tracheal intubation was achieved after injective of a bolus dose of atracurium 0.6mg/kg;In the three groups,the blood pressure at T2-T8 was lower than at T1（P＜0.05）;the HR at T2 was less than at T1,T3-T9 （P＜0.05）.2.The onset time of atracurium in the three groups,the onset was not different.（P＞0.05）.3.The clinical duration of atracurium of the first dose was found to be longer in the groups and group I than in the group P（P＜0.05）,and also in the group S was longer than in the group I（P＜0.05）.4.The recovery of atracurium was longer in the groupS and group I than in the group P（P＜0.05）;and also in the group I was longer than in the group S（P＜0.05）;The TOFR0.7 was longer in the group I and group S than in the group P（P＜0.05）,and also in the group I was longer than in the group S（P＜0.05）.Conclusions:1.Maintenance sevoflurane at 1.2MAC and isoflurane at 1.2 AC end-tital concentrations can prolong the clinical duration,and the recovery index.2.Maintenance sevoflurane oncentrations can prolong the clinical durationat is longer than isoflurane,and the recovery index is shorter than isoflurane when the anesthesia is over.更多还原