【作者】 赖坚；

【导师】 刘敬臣；

【作者基本信息】 广西医科大学 ， 麻醉科， 2009， 硕士

【摘要】 目的:探讨全麻患者术前疼痛敏感度与气管插管、切皮应激反应的相关性,为全身麻醉的个体化用药提供参考。方法:选择ASAⅠ～Ⅱ级,年龄20～55岁,拟行气管插管全麻下开腹手术的女性患者50例。手术前一天用电刺激痛阈测试仪测定患者的疼痛敏感度(痛阈和耐痛阈),用状态-特质焦虑量表评估患者的心理状态。患者入手术室后开放静脉通道并行连续监测:心电图、心率(HR)、脉搏血氧饱和度以及动脉血压(收缩压SBP、舒张压DBP、平均动脉压MAP)。采用全凭静脉麻醉,靶控持续输注异丙酚,靶浓度为4μg/ml,待患者意识消失后给予芬太尼3μg/kg(30秒钟内匀速静脉注射),维库溴铵0.1mg/kg,3分钟后行气管插管。气管插管后待血压、心率都恢复到基础值时,调节靶控浓度为2μg/ml,每隔30分钟给予维库溴铵0.05mg/kg。切皮前3分钟异丙酚靶控浓度上调至3μg/ml,并静脉注射芬太尼1.5μg/kg。记录基础值(入室后平静10分钟)、插管前即刻、插管后2分钟、切皮前即刻、切皮后2分钟的MAP、HR,并于相应时点抽取动脉血标本测定去甲肾上腺素(NE)的浓度。计量资料采用均数±标准差(x±s)表示,采用SPSS13.0统计软件进行分析处理,使用Pearson相关分析检验术前状态焦虑指数、特质焦虑指数、痛阈、耐痛阈与气管插管、切皮前后MAP、HR、NE差值的相关关系,用stepwise多重线性回归分析得出有统计学意义的变量与各指标差值的回归方程。结果:50例患者痛阈为0.90±0.40mA,耐痛阈为2.53±0.77mA,状态焦虑指数为47.22±7.98,特质焦虑指数为41.14±6.21。气管插管前后MAP差值为25.46±7.56mmHg、HR差值为16.08±7.33bpm、NE差值为295.56±99.55pg/ml;切皮前后MAP差值为19.10±6.40mmHg、HR差值为8.86±4.80bpm、NE差值为131.68±46.59pg/ml。患者术前状态焦虑指数、特质焦虑指数与术前痛阈、耐痛阈无相关(P>0.05),也与气管插管、切皮前后MAP、HR、NE差值无相关(P>0.05)。患者术前痛阈与气管插管前后MAP、HR、NE差值无相关(r=-0.161, P=0.264; r=-0.232, P=0.106; r=-0.239, P=0.094);痛阈与切皮前后MAP、HR、NE差值无相关(r=-0.217, P=0.130; r=-0.178, P=0.216; r=-0.262, P=0.066)。耐痛阈与气管插管前后MAP、HR、NE差值呈显著负相关(r =-0.766, P<0.05; r =-0.703, P<0.05; r =-0.781, P<0.05);耐痛阈与切皮前后MAP、HR、NE差值呈显著负相关(r =-0.688, P<0.05; r =-0.638, P<0.05; r =-0.710, P<0.05)。应用stepwise多重线性回归分析术前状态焦虑指数、特质焦虑指数、痛阈、耐痛阈与气管插管、切皮前后各指标差值的关系中,剔除了状态焦虑指数、特质焦虑指数和痛阈,引入了耐痛阈作为回归方程的变量,所得回归方程分别为:y(插管前后MAP差值)=-7.72x(耐痛阈)+44.56;y(插管前后HR差值)=-6.87x(耐痛阈)+33.08;y(插管前后NE差值)=-103.77x(耐痛阈)+552.33;y(切皮前后MAP差值)=-5.87x(耐痛阈)+33.62;y(切皮前后HR差值)=-4.05x(耐痛阈)+18.87;y(切皮前后NE差值)=-44.14x(耐痛阈)+240.91。结论:从血压、心率和血浆去甲肾上腺素水平上证实术前耐痛阈与气管插管、手术切皮所引起的应激反应强度呈显著负相关。更多还原

【Abstract】 Objective: To investigate whether preoperative pain sensitivity predict patients, stress response and opioids consumption during anesthetic intubation and skin incision.Methods: Fifty women(ASA physical statusⅠ～Ⅱ)aged 20～55, undergoing elective abdominal surgery requiring at least a 10-cm-long skin incision, needed general anesthesia were studied. We used the electricity dolorimeter to meaure patients, pain sensitivity, inlcuding pain threshold and pain tolarance, a State Trait Anxiety Inventory (STAI) was also used to examine the mental state the day before surgery. During anesthesia, total intravenous anesthesia, we used propofol with target controlled infusion(TCI), the target concentration was 4μg/ml, vecuronium 0.1mg/kg and fentanyl 3μg/kg for intubation. After intubation, propofol was maintained at 2μg/ml with TCI. 3min before incision, the propofol target concentration was up to 3μg/ml, fentanyl 1.5μg/kg was used for intravenous injection. Mean arterial blood pressure(MAP), heart rate(HR) electrocardiogram(ECG) and pulse oximentry(Spo2) were measured, and arterial blood sample for plasma concentrations of norepinephrine(NE) was drawed at 10min after entering operationroom(T1), immediately before intubation(T2), 2min after intubation(T3), immediately before incision(T4), 2min after incision(T5). We use the SPSS statistics software to analyze the correlation between STAI, pain threshold, pain tolanrance and the changes of MAP, HR , NE before and after intubation and incision.Results: Fifty women were enrolled. Their preoperative pain threshold and pain tolerance were 0.90±0.40mA and 2.53±0.77mA, respectively. The mean raw STAI score for state anxiety was 47.22±7.98, trait anxiety was 41.14±6.21. The STAI score was not correlated with pain threshold and pain tolerance(P>0.05), and was not correlated with the changes of MAP, HR and NE(P>0.05). Pain tolerance not pain threshlod had significant inverse correlation with the changes of MAP, HR, NE before and after intubation (r =-0.766, P<0.05. r =-0.703, P<0.05. r =-0.781, P<0.05) and skin incision(r =-0.688, P<0.05. r =-0.638, P<0.05. r =-0.710, P<0.05).Conclusion: Pain tolarance had significant inverse correlation with stress response during anesthetic intubation and skin incision.更多还原