【作者】 司俊丽；

【导师】 肖建斌；

【作者基本信息】 广州中医药大学 ， 麻醉学， 2010， 硕士

【摘要】 研究背景针刺麻醉自应用于临床以来,积极的推动着临床麻醉的发展。随着针麻的发展,经皮穴位电刺激(TEAS)作为针麻的重要手段之一,由于操作简单、疗效肯定、方便安全,在临床中得到了广泛应用,因而值得进一步研究。目前较多研究集中在TEAS的镇痛机制方面,部分研究集中在TEAS的刺激参数(频率及强度),而对其效能评价方面研究较少。我们在前期研究中发现,经皮穴位电刺激(TEAS)具有较强的镇痛作用。如何更加客观地评价TEAS的镇痛、镇静效能及探索不同手术中,更加有效的穴位组合是有待研究的课题。本研究拟在乳腺手术中,用TEAS结合靶控输注技术(TCI),以脑电双频谱指数(BIS)及不同时点血浆生化指标(Ad、β-EP)的改变等对TEAS的效能进行综合评价研究,以探讨在此类手术的麻醉中,最佳的穴位组合及静脉麻醉中镇静镇痛药的最佳用量,为临床针药复合麻醉提供理论依据和参考。研究目的评估经皮穴位电刺激(TEAS)结合靶控输注技术(TCI)在乳腺手术的麻醉中对丙泊酚-芬太尼静脉麻醉的辅助作用。研究方法以广东省中医院90例择期行单侧乳腺肿物切除术的患者,ASA分级Ⅰ～Ⅱ级,年龄20-65岁,体重40-65 kg,均为女性,无精神疾病,无长期使用镇静药和吸毒史,无肝肾功能障碍疾病的患者为研究对象。采用随机软件,随机分为3组,A组：Propofol+Fentanyl(对照组)；B组：对照组基础上加经皮穴位电刺激病侧内关穴、合谷穴；C组：对照组基础上加经皮穴位电刺激病侧内关透外关穴、合谷透劳宫穴、双侧肩井穴。患者入室后连接监测仪,进行ECG、血压、脉搏血氧饱和度(SpO2)监测,同时连续动态监测脑电双频谱指数(BIS),并在麻醉诱导前的各时间点进行Ramsay镇静深度评分。组B、C,用LH402韩氏穴位电刺激仪连接电极片至所选穴位处,波形选用疏密波(2／100HZ),刺激强度由弱至强,逐渐调节至患者能耐受的最大值,诱导时间为30 min,后行静脉全麻。经皮穴位电刺激持续至术毕。靶控输注丙泊酚(靶浓度为3μg／ml),芬太尼静脉推注(2μg／kg),以BIS值(55±5)、切皮及手术刺激无体动反应为标准进行药物剂量的调整。观察并记录TEAS前(A组为入室)(T1), TEAS 30min后(A组为入室后30 min)(T2)、诱导后5 min(T3)、诱导后10 min(T4)、切皮后5 min(T5)、术毕(T6)、清醒(T7)各时间点的BIS值、心率(HR)、脉搏血氧饱和度(SpO2)、平均动脉血压(MAP)的变化及切皮时体动反应、苏醒质量。并在麻醉药物诱导前的各时点进行Ramsay镇静评分,及在T1、T2、T5、T7各时间点抽取动脉血液各3 mL,3000 r／min离心10 min,分离血浆置于-30℃冰箱保存备用。用酶联免疫法测定肾上腺素(Ad)和β-内啡肽(β-EP)的含量。研究结果1.三组病人的年龄、体重、例数、手术持续时间等指标组间比较未见统计学差异(P＞0.05)。2.三组患者入室后(T1)BIS值组间比较无明显差异(P＞0.05)；TEAS(或入室)后30 min(T2),三组BIS值比较,B、C组较A组的BIS值明显降低,差异显著(P<0.01),C组较B组下降明显(P＜0.05)。给药5分钟(T3)至术毕(T6)BIS值均明显降低,但三组之间无差异(P＞0.05)；而在苏醒时(T7),三组BIS值有差异(P＜0.05),进一步组间比较,B、C两组均较A组BIS值高,且C组较B组高(P＜0.05)。3.三组在各时点进行Ramsay镇静评分,患者在TEAS前(或入室)时点评分无差异,均为2分；在TEAS(或入室)10 min、TEAS(或入室)20 min时点,三组评分有变化,差异不显著(P＞0.05),无统计学意义；TEAS(或入室)30 min时,三组间变化明显,B、C两组镇静评分升高,较A组差异显著(P＜0.05),进一步比较发现,C组较B组升高显著(P＜0.05)。4.三组患者入室后(T1)MAP、HR无明显差异(P＞0.05)。TEAS9或入室)后30 min(T2),三组MAP、HR不同,差异有统计学意义(P＜0.05)；进一步组间比较, B、C组较A组的MAP、HR明显降低,C组较B组下降显著(P＜0.05)；切皮5 min(T5)时,三组HR差异显著(P＜0.05),B、C两组较A组明显降低(p＜0.05),B、C之间差异不明显(P＞0.05)；给药后、术毕、清醒(T3、T4、T6、T7)三组HR差异不明显(P＞0.05)；T3至术毕(T7)时,三组MAP之间差异无统计学意义(P＞0.05)。5.丙泊酚靶控浓度的变化,诱导时(S1),三组丙泊酚靶浓度均为3μg／ml,在各时点达到BIS值(55±5)时,所需靶浓度三组之间差异显著(P＜0.05)。组间比较,B、C两组丙泊酚靶浓度明显低于A组(P＜0.05), C组明显低于B组(P＜0.05)。6.麻醉全过程丙泊酚及芬太尼的总用量,三组比较,差异显著(P＜0.05)。组间比较,B组、C组比A组减少(P＜0.05),而C组明显低于B组(P＜0.05)。7.入室后(T1),三组之间β-EP水平差异不明显(P＞0.05),无统计学意义。TEAS或入室30 min后(T2)、清醒时(T7),A组β-EP水平变化不明显(P＞0.05),而B、C两组,β-EP水平两组均升高(P＜0.05)。组间比较,C组较B组β-EP水平升高明显(P＜0.05)。三组的肾上腺素水平在各时间点,均有变化,但差异不显著(P＞0.05)。研究结论(一)经皮穴位电刺激可以强化镇痛,协同镇静效应,能显著减少Propofol和fentanyl的用量,有全麻辅助作用。(二)TEAS可使血液中β-内啡肽明显增高,而肾上腺素水平无明显变化。(三)全身麻醉下行乳腺手术,TEAS病侧合谷透劳宫穴、内关透劳宫穴及双侧肩井穴的组合是有效的针刺辅助麻醉方法之一。更多还原

【Abstract】 BackgroundEver since its application in clinical practice, the acupuncture anesthesia promots the development of clinical anesthesia. With the perfection of acupuncture anesthesia, the transcutaneous electrical acupoint stimulation (TEAS), one of the main means of acupuncture anesthesia, has been widely applied because of its simple operation, definite effect, convenience and safety. It is worthy of a further research. Most of the current researches are focused on the analgesia mechanism of TEAS, or its stimulation parameters (frequency and strength), rather than its effectiveness. In our pilot studies we got that the TEAS has a strong analgesia action and a synergistic effect with sedation drugs. It needs further researches to objectively evaluate its performance in analgesia and sedation, and to explore a more effective acupoint combination in surgery. This research focuses on a comprehensive evaluation of the performance of TEAS, combined with the target infusion technology (TCI), in breast surgeries through analyzing changes of the bispectral index (BIS) and the plasma hormone (Ad,β-EP), finding out the best combination of acupoints, the optimal dosage of tranquilizer and antalgics in breast surgery, providing evidences for clinical usage of acupuncture combined anesthesia.ObjectiveTo evaluate the facilitative effects of transcutaneous electrical acupoint stimulation (TEAS) on propofol-fentanyl anesthesia in partial mastcctomy.MethodsNinety patients undergoing partial mastcctomy in Guangdong provincial hospital of TCM were included and randomly divided into 3 groups by computer program (n=30). Group A:Anesthesia with propofol and fentanyl (control group). Target control infusion of propofol and fentanyl, propofol infusion is 3 u g/ml and fentanyl infusion is 2μg/kg at begin for each patient, target level of propofol and fentanyl is adjusted according to BIS(55±5)and no body movement during operation. Group B:TEAS (homolateral HeGu acupoint, NeiGuan acupoint) plus control group. Group C:TEAS (homolateral HeGu direct to LaoGong acupoint, NeiGuan direct to WaiGuan acupoint, bilateral Jianjing acupoints) plus control group. All these patients were ASA classⅠ～Ⅱ, aged between 20 to 65 years, female, no mental disorder, no longtime use of sedatives or drug abuse history, no liver or kidney functional abnormality.Blood pressure, Saturation of pulse oxygen (SpO2), electro-cardiogram and bispectrial index(BIS) were continuously monitored after patients entered operation room. TEAS were conducted for each patients in group B and C usque ad surgery finished. Bispectrial index (BIS), heart rate (HR), Saturation of pulse oxygen (SpO2), mean arterial pressure (MAP), the reaction of patients during operation and awakening quality were observed at following time point:T1(before TEAS for group B and C, enter operation room for group A), T2 (30min after TEAS for group B and C,30min after T1 for group A),T3(5min after anesthesia induction), T4(10min after anesthesia induction), T5(5min after incision), T6(surgery finished), T7(palinesthesia time). Ramsay depth of sedation score were evaluated before the induction of anesthesia. Blood specimen were collected from the dorsal artery of the foot for detection of plasma Adrenaline and Beta-endorphin levels by using the euzymelinked immunosorbent assay at these time point:T1, T2, T5and T7.Result1.Age, weight, cases and operation duration among three groups are not significantly different (P>0.05)2. BIS at T1 are not significantly different among three groups (P> 0.05) At T2, BIS in group B are lower than group A (P<0.05), BIS in group C are lower than group B (P<0.05); BIS at T3 to T6 decrease apparently but not significantly different among three groups (P>0.05); At T7, BIS in group B are higher than group A (P<0.05), BIS in group C are higher than group B (P<0.05) 3. Ramsay depth of sedation score at t1 is 2 for each patient; At t4, Ramsay depth of sedation score in group B and C increase compare to group A (P<0.05) group C is higher than group B (P<0.05); At T2 and T3, Ramsay depth of sedation score are not significantly different among three groups (P>0.05)4. MBP and HR at T1 are not significantly different among three groups (P>0.05); At T2, MBP and HR in group B are lower than group A (P<0.05) MBP and HR in group C is lower than group B (P<0.05); At T5, HR in group B and C are lower than group A (P<0.05), but the difference between group B and C are not significantly (P>0.05);At T3, T4, T6, T7, the differences of HR among three groups are not significantly (P>0.05); MBP at T3 to T7 are not significantly different among three groups (P>0.05)5. Before anesthesia induction, propofol infusion is 3μg/ml for each patients. For maintaining BIS between 55±5, target infusion amount of propofol are significantly different among three groups (P<0.05). Group B is lower than group A, group C is lower than group B (P<0.05, respectively)6. Total amounts of propofol and fentanyl are significantly different among three groups (P<0.05). Group B is lower than group A, group C is lower than group B (P<0.05, respectively)7.β-EP at T1 are not significantly different among three groups (P> 0.05); At T2 and T7, change ofβ-EP level in group A are not significant (P>0.05),β-EP in group B is higher than group A (P<0.05),β-EP in group C are higher than group B (P<0.05). Changes of Adrenaline level in three groups are not significantly different (P>0.05)Conclusion1. TEAS could strengthen the effective of analgesia. It has synergistic effect on sedation. It could facilitate analgesia effect of propofol-fentanyl anesthesia and has auxiliary function.2. TEAS leads to a considerable increase ofβ-EP in blood, while there is no obvious changes in the levels of Adrenaline.3. TEAS (homolateral HeGu direct to LaoGong acupoint, NeiGuan direct to WaiGuan acupoint, bilateral Jianjing acupoints) is one of satisfactory assist method for anesthesia in partial mastcctomy.更多还原