【作者】 赵丽艳；

【导师】 谢红；

【作者基本信息】 苏州大学 ， 麻醉学， 2007， 硕士

【摘要】 目的随着国际老龄化趋势的日渐明显,老年手术患者成为一个重要的特殊麻醉群体,但尚缺乏在不同年龄段的老年患者靶控输注丙泊酚和瑞芬太尼时如何选取合适靶浓度的详细资料。本研究旨在探求国人60～69岁和70～79岁年龄段老年患者靶控输注丙泊酚意识消失的半数有效血浆浓度(EC_P50),以及联合丙泊酚靶控输注瑞芬太尼抑制插管反应和切皮刺激的半数有效血浆浓度(EC_R50),为临床麻醉提供参考。方法选取151例60～79岁, ASAⅠ-Ⅲ级,需在全麻气管插管下行择期手术的老年患者为研究对象,依年龄分为两组:Ⅰ组60～69岁,Ⅱ组70～79岁。第一部分共40例病人,采用Dixon改良序贯法测定EC_P50。两组第一例病人丙泊酚血浆靶浓度设为2.5μg/ml,第一步浓度梯度为0.5μg/ml,出现≥3个阴阳反应的交替波形后,第二步浓度梯度减小为0.2μg/ml,直到再次出现≥6个阴阳反应的交替波形。通过计算两组第二步各阴阳反应交替中点的均值来获得EC_P50。第二部分共111例病人,依据接受刺激（插管或切皮）的不同进一步分为四组:Ⅰ-TI组（60～69岁插管组）30例,Ⅱ-TI组（70～79岁插管组）30例,Ⅰ-SI组（60～69岁切皮组）26例,Ⅱ-SI组（70～79岁切皮组）25例。与第一部分同样采用Dixon改良序贯法测定各组的EC_R50,第一步浓度梯度为0.5ng/ml,第二步浓度梯度减小为0.2 ng/ml。丙泊酚血浆靶浓度初步设为第一部分所测得的EC_P50,进一步调节浓度达到BIS在50～60之间。TI组第一例病人和SI组所有病人瑞芬太尼血浆靶浓度均设为3.5 ng/ml,SI组病人在插管后即将瑞芬太尼浓度下调至预设浓度,SI组第一例病人瑞芬太尼血浆靶浓度设为2.5ng/ml,此后病人瑞芬太尼浓度依据上一例病人的反应而增减。计算方法同第一部分,可分别获得Ⅰ-TI组、Ⅱ-TI组、Ⅰ-SI组、Ⅱ-SI组的EC_R50。结果国人60～69岁年龄段老年患者意识消失时EC_P50为2.22μg/ml,在丙泊酚输注,BIS稳定在50～60时,抑制TI和SI的EC_R50分别为2.90ng/ml和1.90ng/ml;70～79岁年龄段老年患者意识消失EC_P50为1.81μg/ml,比Ⅰ组明显降低（P<0.05） ,抑制TI和SI的EC_R50分别为3.16ng/ml和1.77ng/ml,与Ⅰ组相比无统计学差异（P>0.05）。结论不同年龄段的老年患者靶控输注丙泊酚和瑞芬太尼时靶浓度的选择应注意个体化,精细化。在60～79岁年龄段的老年患者,随着年龄的增加,EC_P50逐渐降低;在联合丙泊酚靶控输注抑制TI和SI时,瑞芬太尼血浆靶浓度应根据患者的具体情况作调整,注意对循环系统的影响。对于高龄和危重症病人丙泊酚和瑞芬太尼靶浓度的选取还有待于进一步研究。更多还原

【Abstract】 ObsjectiveThe elderly patients have been an important and special group with population aging in the world. However, there are not detailed information about a proper target concentration of propofol and remifentanil in the elderly patients in different age. We try to determine the effective plasma concentration of propofol(EC_P50) by TCI for loss of consciousness（LOC） in 50% of elderly patients aged 60～69yr and 70～79yr, and the effective plasma concentration of reminfentanil(EC_R50) by TCI combining propofol to prevent response to tracheal intubation（TI） and skin incision（SI） in 50% of elderly patients of that population, wish to provide some information for clinical anesthesia.MethodsWe recruited 151 ASAⅠ-Ⅲpatients aged 60～79yr, scheduled for elective surgery requiring tracheal intubation. They were divided into two groups according to their age: groupⅠ（60～69yr） and groupⅡ（70～79yr）. In the first part of the study enrolling 40 patients, EC_P50 were determined with a modified Dixon’s up-and-down method in two stages. The test space in the first stage was 0.5μg/ml,and the first patient in each group received an initial plasma concentration of propofol of 2.5μg/ml. After 3 or more negative-positive up-and-down crossovers, the initial test space was reduced to 0.2μg/ml. There were 6 or more negative-positive up-and-down crossovers in the second stage. EC_P50 were obtained by calculating the mean values for crossover midpoints in the second stage of each group. 111 patients in the second part of the study were divided into four groups according to receiving different stimuli （TI or SI）:30 in groupⅠ-TI（TI of 60～69yr） , 30 in groupⅡ-TI（TI of 70～79yr）, 26 in groupⅠ-SI（SI of 60～69yr） and 25 in groupⅡ-SI（SI of 70～79yr）. Same to the first part, EC_R50 were determined with a modified Dixon’s up-and-down method. The initial test space in the first stage was 0.5 ng/ml,and was reduced to 0.2 ng/ml in the second stage. The target plasma concentration of propofol was EC_P50 from the first part, and it might be adjusted with BIS value between 50 and 60. The first patient in group TI and all patients in group SI received an initial plasma concentration of reminfentanil of 3.5 ng/ml. After TI, the plasma concentration of reminfentanil in group SI was set at the designed concentration according to the up-and-down sequence, and the first patient in group SI received an plasma concentration of reminfentanil of 2.5 ng/ml. Then EC_R50 in groupⅠ-TI,Ⅱ-TI,Ⅰ-SI andⅡ-SI were calculated as the first part.ResultsTo patients aged 60～69yr, EC_P50 was 2.22μg/ml,and combining propofol with BIS value between 50 and 60,EC_R50 of group TI and group SI were 2.90ng/ml and 1.90ng/ml respectively. To patients aged 70～79yr, EC_P50 was 1.81μg/ml,decreasing compared with groupⅠ（P<0.05） , and EC_R50 of group TI and group SI were 3.16ng/ml and 1.77ng/ml respectively, similar to groupⅠ（P>0.05）.ConclusionThe elderly patients in different age should be administered an accurate plasma concentration of propofol and remifentanil individually by TCI. To patients aged 60～79yr, EC_P50 descends with aging, and the plasma concentration of remifentanil combining propofol to prevent response to TI and SI could be adjusted according to status of individual patient, and influence on hemodynamics should be cautioned. Further studies are needed to seek proper concentration of propofol and remifentanil in patients of advanced age and with critical cardiovascular or pulmonary disease.更多还原