針?biāo)帍?fù)合麻醉應(yīng)用右美托咪定對(duì)甲狀腺切除術(shù)后嘔吐的影響

李連紅,王永強(qiáng),傅國(guó)強(qiáng),袁嵐,葛茂軍

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針?biāo)帍?fù)合麻醉應(yīng)用右美托咪定對(duì)甲狀腺切除術(shù)后嘔吐的影響

李連紅,王永強(qiáng),傅國(guó)強(qiáng),袁嵐,葛茂軍

(上海中醫(yī)藥大學(xué)附屬曙光醫(yī)院,上海 201203)

觀察針?biāo)帍?fù)合麻醉應(yīng)用右美托咪定對(duì)甲狀腺切除術(shù)后嘔吐的影響。將70例行甲狀腺切除術(shù)患者隨機(jī)分為A組和B組,每組35例。兩組均采用電針合谷、內(nèi)關(guān)和扶突配合術(shù)前20 min開(kāi)始靜脈滴注枸櫞酸舒芬太尼注射液(0.3mg/kg)進(jìn)行針?biāo)帍?fù)合麻醉。其中A組在前10 min內(nèi)微泵恒速輸注鹽酸右美托咪定注射液(0.5mg/kg),術(shù)中維持0.4mg/kg/min。B組術(shù)前10 min開(kāi)始輸注生理鹽水。觀察兩組不同時(shí)間點(diǎn)[術(shù)前入室平臥5 min(T0)、手術(shù)開(kāi)始前(T1)、手術(shù)開(kāi)始后30 min(T2)、手術(shù)開(kāi)始后60 min(T3)和手術(shù)結(jié)束時(shí)(T4)]的觀察者警覺(jué)/鎮(zhèn)靜評(píng)分(OAA/S)評(píng)分。記錄兩組術(shù)中舒芬太尼追加次數(shù)與總使用量,使用艾司洛爾、烏拉地爾的例數(shù),術(shù)后2 h內(nèi)及術(shù)后2～24 h內(nèi)發(fā)生嘔吐的例數(shù)。兩組舒芬太尼追加次數(shù)及總使用量比較差異均具有統(tǒng)計(jì)學(xué)意義(＜0.01)。A組術(shù)中艾司洛爾和烏拉地爾使用率分別為31.4%和14.3%,對(duì)照組分別為77.1%和65.7%,兩組比較差異具有統(tǒng)計(jì)學(xué)意義(＜0.01)。A組術(shù)后2 h內(nèi)及術(shù)后2～24 h嘔吐發(fā)生率分別為20.0%和17.1%,對(duì)照組分別為54.3%和42.9%,兩組比較差異具有統(tǒng)計(jì)學(xué)意義(＜0.01)。兩組不同時(shí)間點(diǎn)(T1、T2、T3、T4)OAA/S評(píng)分比較差異均具有統(tǒng)計(jì)學(xué)意義(＜0.01)。針?biāo)帍?fù)合麻醉應(yīng)用右美托咪定能減少甲狀腺切除術(shù)中追加舒芬太尼的次數(shù)及使用劑量,降低患者術(shù)后嘔吐的發(fā)生率。

針刺療法;電針;針刺麻醉;手術(shù)后惡心和嘔吐;針?biāo)帍?fù)合麻醉;甲狀腺切除術(shù);右美托咪定;舒芬太尼

針?biāo)帍?fù)合麻醉是將針刺麻醉與現(xiàn)代麻醉方法相結(jié)合的一種麻醉方法。針?biāo)帍?fù)合麻醉下行甲狀腺切除術(shù)具有術(shù)中麻醉藥物用量少、術(shù)后蘇醒時(shí)間短等優(yōu)點(diǎn)[1-3],但若要達(dá)到理想的鎮(zhèn)痛、鎮(zhèn)靜效果仍需配合使用輔助藥物。而術(shù)后惡心嘔吐是除術(shù)后疼痛外最常見(jiàn)的并發(fā)癥[4]。甲狀腺切除術(shù)后嘔吐可能造成切口開(kāi)裂,是術(shù)后出血的危險(xiǎn)因素[5]。

本研究采用前瞻性隨機(jī)對(duì)照方法觀察右美托咪定用于針?biāo)帍?fù)合麻醉對(duì)甲狀腺切除術(shù)患者術(shù)后嘔吐發(fā)生率的影響,現(xiàn)報(bào)道如下。

1 臨床資料

1.1 一般資料

70例患者均為2014年1—3月上海中醫(yī)藥大學(xué)附屬曙光醫(yī)院普外科住院患者,均明確診斷為甲狀腺腺瘤、甲狀腺癌、甲亢、單純性甲狀腺腫,且需行甲狀腺切除術(shù)。采用查隨機(jī)數(shù)字表法將患者分為A組和B組,每組35例。兩組性別、年齡、身體質(zhì)量指數(shù)(body mass index, BMI)及美國(guó)麻醉醫(yī)師協(xié)會(huì)(American society of anesthesiologists, ASA)麻醉風(fēng)險(xiǎn)評(píng)級(jí)比較差異無(wú)統(tǒng)計(jì)學(xué)意義(＞0.05),具有可比性。詳見(jiàn)表1。

表1 兩組一般資料比較

1.2 納入標(biāo)準(zhǔn)

①ASA麻醉風(fēng)險(xiǎn)評(píng)級(jí)為Ⅰ級(jí)或Ⅱ級(jí);②術(shù)前心功能為Ⅰ級(jí)或Ⅱ級(jí);③無(wú)麻醉藥物使用禁忌證;④自愿加入本研究,并簽署知情同意書。

1.3 排除標(biāo)準(zhǔn)

①術(shù)前心電圖提示有房室傳導(dǎo)阻滯、束支傳導(dǎo)阻滯、病竇綜合征、竇緩等心律失?；颊?②年齡＞75歲或＜18歲者;③妊娠期或哺乳期患者;④糖尿病或低血容量患者。

2 治療方法

兩組患者進(jìn)入手術(shù)室后均采用鼻導(dǎo)管吸氧,開(kāi)放外周靜脈滴注乳酸鈉林格氏液,并靜脈注射氟哌利多注射液2.5 mg。取雙側(cè)合谷、內(nèi)關(guān)、扶突穴。常規(guī)消毒后,采用0.30 mm×40 mm毫針進(jìn)行針刺,得氣后連接電針治療儀,合谷、內(nèi)關(guān)用2 Hz,扶突用2/100 Hz,共誘導(dǎo)30 min[6]。術(shù)前20 min開(kāi)始滴注枸櫞酸舒芬太尼注射液(1 mL:50mg)0.3mg/kg,要求在2～10 min內(nèi)緩慢滴注。A組術(shù)前10 min開(kāi)始用微量泵輸注鹽酸右美托咪定注射液 (2 mL:200mg,江蘇恒瑞醫(yī)藥股份有限公司生產(chǎn))負(fù)荷劑量0.5mg /kg,要求10 min內(nèi)輸注完畢,術(shù)中維持泵注0.4mg/kg/min。B組術(shù)前10 min開(kāi)始用微量泵輸注氯化鈉溶液(生理鹽水),泵注速度與A組相同。術(shù)中患者訴疼痛難忍且經(jīng)調(diào)整電針刺激強(qiáng)度等措施無(wú)效后,可追加枸櫞酸舒芬太尼注射液,每次0.1mg/kg。當(dāng)患者術(shù)中血壓、心率升高超過(guò)基礎(chǔ)值30%時(shí),可分別用鹽酸烏拉地爾注射液、鹽酸艾司洛爾注射液、硫酸阿托品注射液等進(jìn)行調(diào)控維持。

3 治療效果

3.1 觀察指標(biāo)

觀察兩組不同時(shí)間點(diǎn)[術(shù)前入室平臥5 min(T0)、手術(shù)開(kāi)始前(T1)、手術(shù)開(kāi)始后30 min(T2)、手術(shù)開(kāi)始后60 min(T3)和手術(shù)結(jié)束時(shí)(T4)]的觀察者警覺(jué)/鎮(zhèn)靜評(píng)分(the observer’s assessment of alertness/ sedation scale, OAA/S)評(píng)分。記錄兩組術(shù)中舒芬太尼追加次數(shù)與總使用量,使用艾司洛爾、烏拉地爾的例數(shù),術(shù)后2 h內(nèi)及術(shù)后2～24 h內(nèi)發(fā)生嘔吐的例數(shù)。

3.2 統(tǒng)計(jì)學(xué)方法

所有數(shù)據(jù)采用SAS9.4軟件進(jìn)行統(tǒng)計(jì)分析。符合正態(tài)分布的計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差表示,采用檢驗(yàn);不服從正態(tài)分布的計(jì)量資料以中位數(shù)表示,采用秩和檢驗(yàn)。計(jì)數(shù)資料采用-秩和檢驗(yàn)。二分類資料采用秩和檢驗(yàn),95%可信區(qū)間()顯示檢驗(yàn)效度。以＜0.05表示差異具有統(tǒng)計(jì)學(xué)意義。

3.3 治療結(jié)果

3.3.1 兩組舒芬太尼追加次數(shù)與總使用量比較

由表2可見(jiàn),兩組舒芬太尼追加次數(shù)與總使用量經(jīng)秩和檢驗(yàn),＜0.01,差異均具有統(tǒng)計(jì)學(xué)意義。

表2 兩組舒芬太尼追加次數(shù)與總使用量比較

注:與B組比較1)＜0.05

3.3.2 兩組術(shù)中艾司洛爾、烏拉地爾使用率比較

由表3可見(jiàn),A組術(shù)中艾司洛爾和烏拉地爾使用率分別為31.4%和14.3%,對(duì)照組分別為77.1%和65.7%,兩組比較差異具有統(tǒng)計(jì)學(xué)意義(＜0.01),提示A組術(shù)中艾司洛爾和烏拉地爾使用率均明顯低于B組。

表3 兩組術(shù)中艾司洛爾、烏拉地爾使用率比較 [例(%)]

注:與B組比較1)＜0.05

3.3.3 兩組術(shù)后2 h內(nèi)及術(shù)后2～24 h嘔吐發(fā)生率比較

由表4可見(jiàn),A組術(shù)后2 h內(nèi)及術(shù)后2～24 h嘔吐發(fā)生率分別為20.0%和17.1%,對(duì)照組為54.3%和42.9%,兩組比較差異具有統(tǒng)計(jì)學(xué)意義(＜0.01,＜0.05)。

表4 兩組術(shù)后2 h內(nèi)及術(shù)后2～24 h嘔吐發(fā)生率比較(例)

注:與B組比較1)＜0.01,2)＜0.05

3.3.4 兩組不同時(shí)間點(diǎn)OAA/S評(píng)分比較

由表5可見(jiàn),兩組不同時(shí)間點(diǎn)(T1、T2、T3、T4)OAA/S評(píng)分經(jīng)秩和檢驗(yàn),＜0.01,差異均具有統(tǒng)計(jì)學(xué)意義。

表5 兩組不同時(shí)間點(diǎn)OAA/S評(píng)分比較 (例)

4 討論

術(shù)后惡心嘔吐在普外科手術(shù)中整體發(fā)生率為20%～30%[7-8]。對(duì)于甲狀腺手術(shù)來(lái)說(shuō),術(shù)后惡心嘔吐能增加胸腹腔壓力引起頸部手術(shù)創(chuàng)面出血風(fēng)險(xiǎn)。術(shù)后惡心嘔吐的病理生理復(fù)雜,涉及多種通路和受體反應(yīng),如化學(xué)受體激發(fā)區(qū)域、消化系統(tǒng)迷走神經(jīng)通路、前庭系統(tǒng)神經(jīng)元途徑、大腦皮層反應(yīng)輸入?yún)^(qū)域和中腦傳入系統(tǒng)。目前對(duì)于術(shù)后惡心嘔吐多采用聯(lián)合使用多種止吐藥物進(jìn)行治療[4]。

得氣是針刺效果的一種反射,得氣時(shí)患者在針刺穴位以及局部會(huì)有酸麻脹重痛等感覺(jué),施針者也會(huì)感覺(jué)到針下沉緊、滯澀等感覺(jué)。中醫(yī)學(xué)認(rèn)為,針刺得氣感與針刺的效果密切相關(guān)[9]。因此,本研究在實(shí)施針刺時(shí)必須在患者出現(xiàn)得氣感后再進(jìn)行持續(xù)電刺激。

針?biāo)帍?fù)合麻醉應(yīng)用于甲狀腺切除術(shù)能減少麻醉藥物用量,縮短患者術(shù)后蘇醒時(shí)間[2-3,6,10-11],但術(shù)中牽拉、交感神經(jīng)興奮等因素仍需要追加輔助用藥。舒芬太尼有較寬泛的安全劑量范圍,但仍可引起與劑量相關(guān)的呼吸抑制和術(shù)后惡心嘔吐風(fēng)險(xiǎn)[12]。而右美托咪定具有鎮(zhèn)靜、催眠、抗焦慮、鎮(zhèn)痛和抑制交感神經(jīng)興奮性等作用[13-14],同時(shí)還能改善手術(shù)中血液動(dòng)力學(xué)的穩(wěn)定性和降低心肌缺血的發(fā)生率[15-17]。故舒芬太尼聯(lián)合右美 托咪定已應(yīng)用于多種術(shù)后鎮(zhèn)痛方案[18-21]。本研究結(jié)果顯示,A組舒芬太尼追加次數(shù)與總使用量明顯少于B組,且艾司洛爾、烏拉地爾使用率以及術(shù)后2 h內(nèi)、術(shù)后2～24 h嘔吐發(fā)生率明顯低于B組,其原因一方面可能是因?yàn)锳組患者舒芬太尼的用量更少,從而降低舒芬太尼的致吐作用;另一方面,針刺內(nèi)關(guān)穴本身就有鎮(zhèn)靜、止吐的功效[22],二者效應(yīng)聯(lián)合增加了對(duì)術(shù)后惡心嘔吐的預(yù)防效果。

綜上所述,右美托咪定能減少針?biāo)帍?fù)合麻醉下甲狀腺切除術(shù)中追加舒芬太尼的次數(shù)及使用劑量,減少患者術(shù)后的嘔吐風(fēng)險(xiǎn)。此外,由于針刺的效果必須建立在得氣的基礎(chǔ)上,故本研究難以建立針刺的盲法來(lái)評(píng)價(jià)模擬穴位和實(shí)際穴位的效果,筆者將進(jìn)行深入研究。

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Influence of Dexmedetomidine Applied in Combined Acupuncture-medication Anesthesia on Vomiting After Thyroidectomy

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To observe the influence of dexmedetomidine applied in combined acupuncture-medication anesthesia on vomiting after thyroidectomy.Seventy patients who were going to receive thyroidectomy were randomized into group A and B, with 35 cases in each group. Combined acupuncture-medication anesthesia [electro- acupuncture at Hegu (LI4), Neiguan (PC6) and Futu (ST32) plus intravenous infusions of sufentanil citrate injection (0.3mg/kg) 20 minutes before operation] was adopted in both groups. Group A was additionally intervened by constant- velocity micropump infusion of dexmedetomidine hydrochloride injection (0.5mg/kg) within 10 minutes before operation and remaining 0.4mg/kg/min during operation, while group B was intervened by infusion of normal saline 10 minutes before operation. The observer's assessment of awareness/sedation (OAA/S) scores at different time points [lying in bed for 5 minutes before operation (T0), before the beginning of the operation (T1), 30 minutes after operation (T2), 60 minutes after operation (T3) and at the end of operation (T4)] in the two groups were observed. The additional times and total dose of sufentanil during operation, the number of cases using esmolol and urapidil, and the number of vomiting cases occurred within 2 hours after operation and 2~24 hours after operation in the two groups were recorded.The additional times and total dose of sufentanilduring operation in group A were significantly different from those in group B (＜0.01). The utilization rate of esmolol and urapidil were respectively 31.4% and 14.3% in group A versus 77.1% and 65.7% in group B, and the between-group differences were statistically significant (＜0.01). The incidence of vomiting within 2 hours after operation and 2~24 hours after operation were respectively 20.0% and 17.1% in group A versus 54.3% and 42.9% in group B, and the between-group differences were statistically significant (＜0.01). The OAA/S scores at different time points (T1, T2, T3and T4) in group A were significantly different from those in group B (＜0.01).Dexmedetomidine applied in combined acupuncture- medication anesthesia can reduce the additional times and total dose of sufentanil duringthyroidectomy, and it can reduce the incidence of postoperative vomiting as well.

Acupuncture therapy; Electroacupuncture; Acupuncture anesthesia; Postoperative nausea and vomiting; Combined acupuncture medication anesthesia; Thyroidectomy; Dexmedetomidine; Sufentanil

1005-0957(2019)02-0198-04

R246.2

A

10.13460/j.issn.1005-0957.2019.02.0198

2018-09-03

上海中醫(yī)藥發(fā)展三年行動(dòng)計(jì)劃高層次中西醫(yī)結(jié)合人才培養(yǎng)項(xiàng)目;上海市教育委員會(huì)科技創(chuàng)新項(xiàng)目(2012JW44);上海市科委自然科學(xué)基金項(xiàng)目(16ZR1437900)

李連紅(1971—),女,主治醫(yī)師,Email:llh71716@163.com

葛茂軍(1972—),男,副主任醫(yī)師,Email:gemaojun@hotmail.com