【作者】 徐光红；

【导师】 汪凯；

【作者基本信息】 安徽医科大学 ， 神经病学， 2012， 博士

【摘要】 全身麻醉药物丙泊酚和七氟醚由于起效快、苏醒快且平稳已广泛用于门诊手术。全身麻醉药物的应用既减轻了病人的痛苦,增加病人的耐受和提高了病人的舒适度,预防不愉快的手术事件的回忆,又为手术的开展提供了便利的条件。然而,七氟醚和丙泊酚镇静下梦的发生非常常见,梦有时会使病人感到悲伤、窘迫和痛苦,并影响病人术后的满意度。到目前为止,像无痛胃镜和无痛人工流产术这样短小手术镇静中有关梦的发生与影响还未见报道。因此,本研究就短时镇静下七氟醚和丙泊酚两种不同全身麻醉药物以及不同手术类型和性别差异对梦的影响做一研究,以进一步提高病人的舒适度和满意度,为临床提供参考。目的研究七氟醚和丙泊酚两种不同全身麻醉药在无痛人流术中短时镇静下对梦的影响及可能的机制；研究在丙泊酚短时镇静下女性病人在不同性质器官手术(无痛人流术和无痛胃镜术)刺激下对梦的影响；研究在丙泊酚短时镇静下不同性别的病人在无痛胃镜术中对梦的影响及可能的机制；研究病人从镇静中苏醒的时间是否是影响梦发生率的决定性因素,并研究病人的满意度是否受梦的发生率、内容和梦的性质以及不同的全身麻醉药物选择的影响。方法选择自愿接受无痛胃镜检查和无痛人工流产术的病人,并根据研究要求分为不同的组别。采用警觉/镇静评分法评估病人的镇静深度,当病人从镇静中苏醒且对定向力(时间、地点、人物)恢复后,立即采用改良的Brice问卷进行调查评估梦的发生率,对梦者继续采用五点Likert评分对梦进行调查评估梦的“质”。记录梦的发生率、梦的内容和性质,并记录病人术后的满意度。结果在七氟醚和丙泊酚镇静的无痛人工流产术中：七氟醚镇静组和丙泊酚镇静组梦的发生率有统计学差异(p=0.000)。七氟醚镇静组梦的发生率为60%(60/100)明显高于丙泊酚镇静组的33%(33/100),然而两组病人的复苏时间没有明显的差异。七氟醚镇静组与丙泊酚镇静组相比,大多数梦者报告梦的内容中没有声音(p=0.03)和运动(p=0.001)且大多数梦者不能够记住梦的内容(p=0.02)。两组梦者报告梦的内容大多数为简单的、快乐的正性情绪内容的梦,两组病人都有较高的术后满意度且无明显的统计学差异,梦者和非梦者之间术后满意度也没有明显的差异。在丙泊酚镇静的无痛胃镜检查组(组Ⅰ)和无痛人工流产术组(组Ⅱ)中：两组梦的发生率有统计学差异(p=0.015)。无痛人工流产术组(组Ⅱ)中梦的发生率为33%(33/100)明显高于无痛胃镜检查术组(组Ⅰ)中18%(18/100),尽管两组病人的复苏时间没有明显的差异。两组中梦者报告梦的大多数内容都是简单、熟悉和有意义的,没有明显的性幻想和性梦。两组病人都有较高的术后满意度且无明显的统计学差异。在丙泊酚镇静的无痛胃镜检查术中：男性病人和女性病人两组梦的发生率有统计学差异(p=0.02)。男性病人组梦的发生率为31%(31/100)明显高于女性病人组17%(17/100),男性和女性病人从镇静中复苏的时间没有明显的统计学差异。然而45%(14/31)的男性梦者报告正性情绪的梦即“高兴的、快乐的、美”梦,6%(2/31)男性梦者报告负性情绪的梦即“悲伤、窘迫、不快乐的”的梦；女性梦者报告正性情绪的梦只有18%(3/17),29%(5/17)女性梦者报告为负性情绪的梦,两组梦的性质差异有统计学意义(P=0.04)。男性梦者报告梦的内容更加有意义、生动、熟悉且男性梦者更容易记住梦的内容,男性梦者和女性梦者两组间差异有统计学意义(p<0.01)。然而男性梦者和女性梦者两组中梦的情绪性体验强度没有明显的统计学差异,且两组病人都表现为较高的术后满意度,病人术后的满意度不受梦的发生及不同性别的影响。结论在七氟醚和丙泊酚短时镇静下病人的复苏时间不是决定梦发生率的关键因素。七氟醚组短时镇静下梦的发生率明显高于丙泊酚组。病人的术后满意度不受梦的发生率以及丙泊酚和七氟醚两种镇静药物选择的影响。因此,丙泊酚和七氟醚两种镇静药物均可以用于无痛人工流产术。不同性质的器官手术可以影响梦的发生率。无痛人工流产术较无痛胃镜检查术能明显增加梦的发生率,但大多数梦的内容都是比较简单的、熟悉的,涉及个人的日常生活,梦中没有明显的性相关性内容且对病人术后的满意度没有明显的影响。在丙泊酚镇静的无痛胃镜检查术中梦的发生率存在明显的性别差异,男性病人有较高梦的发生率。特别是男性病人更容易报告正性情绪的梦即“高兴的、快乐的、美”梦,女性病人更容易报告负性情绪的梦即“悲伤、窘迫、不快乐的”的梦。然而男、女性梦者术后的满意度没有明显的统计学差异,男、女性病人都表现为较高的术后满意度,且不受性别差异和梦的发生影响。更多还原

【Abstract】 Background General anesthesia drugs sevoflurane and propofol are used hypnotic for the patients during outpatient surgeries with the shortest onset time and intermediate duration of action and cardiovascular stability in the clinical use. Sedation with sevoflurane and propofol are often performed to alleviate the sufferings of the patient and increase patient acceptance or the degree of comfort of surgeries, improve surgical conditions, or prevent the recall of unpleasant events during surgery. However, deaming during sedation or anesthesia with sevoflurane and propofol is a common. Dreaming is sometimes distressing to patients and may decrease satisfaction with care. To date, the difference between the upper gastrointestinal endoscopy and the first-trimester surgical abortion in the incidence of dreaming for short procedures has not been compared. So the objective of the study is to observe different anesthetic drugs, types of operations and gender influence on the dreaming during sevoflurance or propofol short-term sedation and given to contribute to the useage of the clinic.Objective To study the potentiation effect and the possible mechanisms of the dreaming during sevoflurane or propofol short-term sedation in the first-trimester surgical abortion. To study the potentiation effect of the situation of different organ specific procedures on the dreaming during short propofol sedation in the first-trimester surgical abortion. To study the potentiation effect and the possible mechanisms of the dreaming under the gender differences during short propofol sedation in the upper gastrointestinal endoscopy. To investigates whether dreaming is affected by recovery time and and whether the incidence of dream, dream content or nature and choice of sedative drug affect patient satisfaction with sedation.Methods Patients undergoing upper gastrointestinal endoscopy or first-trimester surgical abortion were screened. All participants were divided into different groups according to the different studies. Anesthesiologists were instructed to target the depth of sedation using an Observer’s Assessment of Alertness/Sedation (OAA/S) score. Patients were interviewed immediately after they emerged from sedation and orientated to time, place and person using the modified Brice questionnaire to evaluate the incidence of dreaming. If dreaming was reported, and the dreamers were immediately asked to complete a five-point Likert scales regarding the dream. The dream content, the incidence of dream and satisfaction were also assessed.Results In the first-trimester surgical abortion during short-term sedation with sevoflurane or propofol:the incidence of dreaming was significantly different between sedative groups with60%(60/100) of the sevoflurane group and33%(33/100) of the propofol group (p=0.000). However, recovery time did not significantly differ between groups. In the sevoflurane group, a greater number of dreamers could not recall what they had dreamed about (p=0.02) and more patients reported dreams that had no sound (p=0.03) or movement (p=0.001) compared with dreamers in the propofol group. Most participants reported dreams with positive emotional content, patients had the higher satisfaction and these did not significantly differ between two groups. There were no significant differences in satisfaction with sedation care between the dreamers and the non-dreamers. In the first-trimester surgical abortion and the upper gastrointestinal endoscopy during propofol short sedation. There were significant differences in the incidence of dream between the two groups. The proportions of dreamers were18%(18/100) in group Ⅰ and33%(33/100) in group Ⅱ (p=0.015) despite similar recovery time. Most dreams were simple, meaningful and had no significant sexual content during propofol short sedation. Patient higher satisfaction was comparable between the two groups.In the operation of the upper gastrointestinal endoscopy during propofol short-sedation. There were significant differences in the incidence of dream between the male group and female group. The incidence of dreaming was significantly higher in men (31%) than in women (17%)(P=0.02), but recovery time was similar. In males,45%(14/31) of dreamers reported positive emotional content and only6%(2/31) reported negative emotional content. In contrast, in females,18%(3/17) were positive and29%(5/17) were negative (P=0.04). Males reported dreams that were more vivid, meaningful, familiar and memorable (P<0.01). No significant gender differences were observed in the emotional intensity of dreams, and emotional content of the dream did not influence patients’satisfaction. Patient had the higher satisfaction with sedation care between the two groups.Conclusion The incidence of dreaming was not affected by recovery time during sevoflurane or propofol short-term sedation. The incidence of dreaming was significantly higher in patients administered sevoflurane than in those administered propofol during first trimester surgical abortion. Patient satisfaction was not influenced by sedative and/or by the occurrence of dreaming during sevoflurane or propofol short-term sedation. Therefore, anesthetic choice for patients undergoing first-trimester abortion is trivial.Different organ specific procedures could affect the incidence of dreaming intrasedation. First-trimester surgical abortion did increase the incidence of dreaming during propofol short sedation. Most dreams were simple and pleasant, about everyday life, no significant sexual dreams and no influence on patient’s satisfaction.Gender differences were found in the incidence and content of dreams during short propofol sedation, despite similar recovery times. Specifically, males reported dreaming more frequently and had a higher incidence of recall for their dream narratives. Males reported significantly more positive emotional content, less negative emotional content and more meaningful content. However, male and female dreamer postoperative satisfaction was no significant difference. Patient satisfaction was not influenced by gender or the occurrence of dreaming during propofol short-sedation.更多还原