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末梢灌注指数监测腹腔镜胆囊切除患者应激反应的评价2010.4.8

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DOI:
作者:
丛海涛
Cong Haitao
作者单位:
浙江省台州医院
Taizhou Hosptial
关键词:
体积描记术 胆囊切除术 腹腔镜 麻醉 全身 应激
摘要:
摘 要 目的：观察末梢灌注指数（TPI）与有创动脉压（SBP、DBP）、心率（HR）和双频谱指数（BIS）以及血浆中去甲肾上腺素（NE）和肾上腺素（E）浓度在不同性质刺激下的变化，分析TPI在监测患者应激反应方面的价值。方法：选择30例ASAⅠ～Ⅱ级择期行腹腔镜下胆囊切除手术病人。入室后给予心电、TPI测、BIS和皮温监测。咪唑安定0.05mg/kg、芬太尼5μg/kg、维库溴铵0.12mg/kg、丙泊酚TCI输注效应室浓度4.5μg/ml进行麻醉诱导。丙泊酚TCI输注效应室浓度3.0μg/ml、瑞芬太尼0.25 μg∙kg-1∙min-1行麻醉维持。麻醉诱导后进行气管插管，确认气管导管位置后接麻醉机行机械通气。观察并记录患者麻醉诱导前（T0）、麻醉诱导后插管前（T1）、气管插管完成即刻（T2）、气管插管完成后5min（T3）、切皮即刻（T4）、气腹后1min（T5）、气腹后5min（T6）、胆囊牵拉即刻（T7）、停止气腹1min（T8）、拔管即刻（T9）和拔管后5min（T10）共11个时点的SBP、DBP、HR、TPI、BIS、皮温T值以及血浆中NE和E值。结果：BIS值在麻醉诱导后降低，拔管后恢复到麻醉前水平。TPI值在气管插管、切皮和气腹后降低。而SBP、HR和DBP值在气管插管、切皮和气腹后升高。围手术期皮温T均无显著性变化。NE值在麻醉诱导后降低，在气管插管、切皮和气腹后增高。E值在气腹后升高。相关性分析示TPI与SBP、DBP、HR呈负相关，相关系数r分别为-0.963、-0.908、-0.957（P<0.05）；TPI与NE和E负相关，相关系数分别是－0.845（P<0.05）和－0.324（P<0.05）。TPI与BIS和T无相关性，相关系数r分别为-0.188、0.067（P>0.05）。结论： TPI能无创、实时、连续地反应围术期应激引起的交感张力变化，可作为一项方便而有效的应激反应监测指标指导临床麻醉管理。
ABSTRACT Object:To observe the change and relativity of TPI and SBP, DBP, HR , BIS ( bispectral index) , NE(noradrenaline)and E (norepinephrine) in the blood under different stimulations, evaluate the clinical value of TPI in monitoring the stress response during the operation of laparoscopic cholecystectomy. Methods: Thirty ASAⅠ～Ⅱpatients undergoing laparoscopic cholecystectomy under general anesthesia were enrolled in this study. After entering operation room the patients were monitored with SBP, DBP, HR, TPI, BIS， the skin temperature of finger，NE and E. Anesthesia was induced with midazolan 0.05 mg/kg, fentanyl 5 μg/kg and propofol TCI with effect room 4.5μg/ml by TCI. Tracheal intubation was facilitated with vecuronium 0.12mg/kg. Anesthesia was maintained with TCI of propofol (targeted effective room concentration was set at 3.0 μg/ml) and remifentanil 0.25 μg/kg/min. The patients were mechanically ventilated. The TPI, the skin temperature of finger, BIS, SBP, DBP , HR , NE and E were observed and recoeded at the time point as following: before induction of anesthesia(T0), after induction of anesthesia and before intubation(T1) , immediately intubation(T2) , 5 min after intubation(T3), immediately skin incision(T4), 1 min after pneumoperitoneum (T5)and 5 min after pneumoperitoneum(T6), immediately straw Cholecy(T7), 1 min after stopping pneumoperitoneum (T8), immediately extubation (T9), 5 min after extubation(T10). Results: BIS value was decreased after induction of anesthesia, and increased after extubation.TPI value was decreased after intubation, skin incision,pneumoperitoneum,while SBP,DBP and HR value were increased.The skin temperature of the finger tip has no significant difference during the whole operation.NE value was decrease after induction of anesthesia and increased after intubation, skin incision, pneumoperitoneum.E value was increased after pneumoperitoneum.TPI was negatively correlated with SBP, DBP, HR ，NE and E(r=--0.963, -0.908, -0.957, －0.845 and －0.324 respectively p<0.05) . There is no relation between TPI and BIS (r=-0.188、0.067, respectively P>0.05). Conclusion: TPI could be used to monitor the sympathetic reactively noninvasively, instantly and continuously during general anesthesia.

 

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