【摘要】 目的 探讨腰硬联合麻醉复合丙泊酚恒速输注清醒镇静的可行性、理想的药物剂量、术中知晓情况以及麻醉质量和效果。 方法 收集2009年3-12月480例美国麻醉医师协会（ASA）Ⅰ～Ⅲ级拟在腰硬联合麻醉下行下腹部、会阴部、下肢手术的患者480例，随机分为咪达唑仑组（M组）、丙泊酚Ⅰ组（PA组）、丙泊酚Ⅱ组（PB组）、丙泊酚Ⅲ组（PC组），每组各120例。四组患者均于腰2-3或腰3-4行腰硬联合麻醉，蛛网膜下腔注入轻比重0.2 %布比卡因12～15 mg，麻醉平面确切后，M组予以咪达唑仑0.04~0.06 mg/kg，PA组先予以负荷量丙泊酚0.50 mg/kg再以2.00 mg/（kg•h）剂量持续泵注，PB组予以负荷量丙泊酚0.75 mg/kg再以3.00 mg/（kg•h）剂量持续泵注，PC组予以负荷量丙泊酚1.00 mg/kg再以3.75 mg/（kg•h）剂量持续泵注。观察患者给药前（T0）、给药1（T1）、3（T2）、5（T3）、10（T4）、30（T5）、60 min（T6）各时点血流动力学平均动脉血压（MAP）、心率（HR）的变化、脑电双频指数（BIS）值及镇静评分、术中所看到的图片的回忆及不良反应。 结果 各组在给予镇静药后MAP、HR均有所下降，但测量值的变化在正常范围内；在T3时间点，各组BIS值及镇静/警醒OAA/S评分降低，与T0比较，差异有统计学意义（Plt;0.05）；与其他3组比较，在T4、T5、T6时点PC组BIS值与OAA/S评分降低，差异有统计学意义（Plt;0.05），PC组的镇静遗忘满意率高于其他3组；各组间未见发生严重的舌后坠、呼吸暂停和血氧饱和度（SpO2）lt;90%。 结论 在下腹部、下肢手术中，应用腰硬联合麻醉复合1.00 mg/kg负荷量的丙泊酚继而以3.75 mg/（kg•h）剂量持续泵注，可取得良好的镇静效果，不良反应小。【Abstract】 Objective To investigate the feasibility, ideal dose, intra-operative awareness as well as the quality and effectiveness of constant infusion of propofol under combined spinal-epidural anesthesia (CSEA) for conscious sedation. Methods A total of 480 patients at ASA grade Ⅰ-Ⅲ to be operated in the lower abdomen, perineum and lower limbs under CSEA from March to December 2009 were randomly divided into four groups: midazolam group (M group), propofol group Ⅰ (PA group), propofol group Ⅱ (PB group), and propofol group Ⅲ (PC group), with 120 patients in each group. All four groups of patients underwent CSEA at L2-3 or L3-4 and accepted pinal injection of 12-15 mg of 0.2% hypobaric bupivacaine. After the anesthetic plane was confirmed, patients in M group accepted 0.04-0.06 mg/kg of midazolam; patients in PA group accepted propofol at a loading dose of 0.50 mg/kg followed by continuous infusion at a dose of 2.00 mg/(kg•h); patients in PB group accepted propofol at a loading dose of 0.75 mg/kg followed by continuous infusion at a dose of 3.00 mg/(kg•h); patients in PC group accepted propofol at a loading dose of 1.00 mg/kg followed by continuous infusion at a dose of 3.75 mg/(kg•h). The change of hemodynamics including the mean arterial pressure (MAP) and the heart rate (HR), bispectral index (BIS) values, sedation scores, memory of pictures seen during operation and adverse effects before drug administration (T0), at minute 1 (T1), 3 (T2), 5 (T3), 10 (T4), 30 (T5) and 60 (T6) after drug administration were observed. Results MAP and HR decreased in all the four groups after administration of sedatives, but the changes of measured values were within normal ranges. BIS value and the Observer’s Assessment of Alertness and Sedation (OAA/S) scale decreased in all groups at T3, compared with those at T0 (Plt;0.05). Compared with the other 3 groups, BIS valueand OAA/S scale were significantly lower in PC group at T4, T5 and T6 (Plt;0.05), and the satisfaction rate of sedation and amnesia was much higher. No serious glossocoma, apnea and SpO2 below 90% was observed in all the four groups. Conclusion During the surgery of lower abdomen and lower limbs, application of CSEA combined with propofol at a loading dose of 1.00 mg/kg followed by continuous infusion at a dose of 3.75 mg/(kg•h) can achieve a good sedative effect, with little side effect.
目的:探讨老年手术患者椎管内麻醉后应用异丙酚镇静,脑电双频指数、异丙酚血药浓度和镇静深度之间的相关性［1］。方法:48例ASAⅠ~Ⅱ级择期手术患者,分为老年组(65~85岁)和年轻组(18~40岁),每组24例。为尽快达到稳态血药浓度,采用靶控输注方式给药。异丙酚靶浓度从0.5 μg/mL起逐渐增加,直至患者对轻推无反应(意识消失),每个浓度维持5min。连续记录EEG参数,在每一稳态血药浓度末,记录BIS、95%SEF, 桡动脉取血(高效液相色谱法测定异丙酚血药浓度),并评定镇静深度(OAA/S评分法)。用Spearman’s等级相关进行相关分析,并计算预测概率 (Pk) 值。结果:两组BIS (r=0.935~0.955) 与镇静水平的相关性优于血药浓度(r =0.849~0.870)和95%SEF(r =0.503~0.571),BIS的Pk值高(0.942~0.972)。在同一镇静评分(OAA/S 4~1)时,老年组BIS值明显高于年轻组(Plt;0.01),而血药浓度低于年轻组(Pgt;0.05)。结论:BIS在监测异丙酚镇静水平及预测意识消失方面有重要价值,在同一镇静评分时,老年人BIS值高于年轻人。
目的 观察酒石酸布托啡诺与芬太尼合用于术后静脉自控镇痛（PCIA）的效果及最佳混合比例。 方法 2010年8月－2011年1月100例妇科手术患者，随机分为5组，每组20例。均全身麻醉术后采用负荷量+持续背景剂量+PCIA方案镇痛。根据不同配方分为F组：芬太尼1 mg+生理盐水至100 mL；B组：酒石酸布托啡诺10 mg+生理盐水至100 mL；BFⅠ组：芬太尼0.6 mg+酒石酸布托啡诺3 mg+生理盐水至90 mL；BFⅡ组：芬太尼0.5 mg+酒石酸布托啡诺5 mg+生理盐水至100 mL；BFⅢ组：芬太尼0.3 mg+酒石酸布托啡诺6 mg+生理盐水至90 mL。观察术后各时点视觉模拟评分（VAS）及镇静评分，患者满意度以及不良反应情况。 结果 术后早期BFⅢ组和B组VAS评分大于F组；镇静评分B组大于F组；B组满意度优良率小于其余各组；恶心呕吐发生率F组高于BFⅠ组及BFⅡ组。 结论 酒石酸布托啡诺和芬太尼合用于PCIA，镇痛效果确切，不良反应发生率低。推荐配比：BFⅠ组和BFⅡ组。
ObjectiveTo explore the efficacy and safety of different sedative and analgesic methods in emergent endotracheal intubations in RICU. Methods110 cases of tracheal intubation in critically ill patients were divided into 5 groups randomly: ① control group(given no sedative or analgesic drug before intubation); ② fentanyl group(given intravenous fentanyl 2 μg/kg before intubation,followed by fentanyl 2 μg·kg-1·h-1 maintenance); ③ dexmedetomidine hydrochloride+fentanyl group(given dexmedetomidine hydrochloride 1 μg/kg+fentanyl 2 μg/kg before intubation,followed by dexmedetomidine hydrochloride 0.5 μg·kg-1·h-1+fentanyl 2 μg·kg-1·h-1 maintenance); ④ midazolam+fentanyl group(given midazolam 0.05 mg/kg+fentanyl 2 μg/kg before intubation,followed by midazolam 0.05 mg·kg-1·h-1+fentanyl 2 μg·kg-1·h-1 maintenance); ⑤ Propofol+fentanyl group(given propofol 1 mg/kg+fentanyl 2 μg/kg before intubation,followed by propofol 0.4 mg·kg-1·h-1+fentanyl 2 μg·kg-1·h-1 maintenance).The mean arterial pressure(MAP),heart rate(HR),respiratory frequency(RR),PaO2/FiO2,Riker sedation score and agitation were monitored before,during and after intubations.The one-time success rate of intubation and severe arrhythmia (sinus bradycardia,frequent ventricular premature,ventricular fibrillation,and cardiac arrest) incidence rate were recorded. ResultsThe one-time success rates of intubations of the propofol+fentanyl group (95.4%) and the midazolam+fentanyl group (90.9%) were higher than that in the dexmedetomidine hydrochloride+fentanyl group (86.4%,P<0.05),while one-time intubation success rate of three groups were higher than that of the fentanyl group (45.4%) and the control group (31.8%,P<0.05).5 minutes after intubation,the PaO2/FiO2 index of 5 groups of patients were higher than those before intubation,but the PaO2/FiO2 index of the control group and the fentanyl group were lower than those in the other three groups(P<0.05).The occurrence of serious arrhythmia rate in the dexmedetomidine hydrochloride+fentanyl group (0%),the midazolam+fentanyl group (9%) and the propofol+fentanyl group (9%) were lower than that in the control group (13.6%) and the fentanyl group (18.2%).The MAP during intubation and 2 minutes after intubation of the propofol+fentanyl group and the midazolam+fentanyl group were lower than that in the other three groups(P<0.05).The proportion of patients with Riker sedation and agitation score≤4 at intubation in the dexmedetomidine hydrochloride+fentanyl group (68.2%) was lower than that in the propofol+fentanyl group(90.9%) and the midazolam+fentanyl group (86.4%,P<0.05),but higher than those in the fentanyl group(22.7%)and the control group(18.2%,P<0.05). ConclusionPropofol,midazolam or dexmedetomidine hydrochloride with fentanyl are all effective and safe methods of sedation and analgesia in emergent endotracheal intubation in RICU.Dexmedetomidine hydrochloride with fentanyl is an ideal sedative relatively with less influence on cardiovascular system and less myocardial oxygen consumption.
【摘要】 目的 观察丙泊酚在重症监护室（ICU） 外科术后对患者的镇静效果及作用。 方法 2006年7月-2008年7月，对行外科手术后在ICU观察室采用丙泊酚镇静的45例患者的镇静效果、停药苏醒时间及给药前后呼吸、循环参数的变化进行观察，并与治疗前进行比较。 结果 丙泊酚镇静起效快，镇静治疗后大多数患者开始血压有所下降（Plt;0.05）但不久恢复正常，所有患者心率、呼吸频率、血氧饱和度无明显变化（Pgt;0.05），停药后苏醒快。 结论 丙泊酚是外科术后患者较理想的镇静剂，但应根据患者情况调整给药速度、剂量及时间。 【Abstract】 Objective To observe the sedative effect of propofol on the patients after surgical operations in intensive care unit (ICU). Methods Forty-five patients underwent the injection with propofol after surgical operations in ICU from July 2006 to July 2008. The sedative efficacy, recovery time after the propofol administration, and changes of respiratory, circulate parameter before and after medication were observed, which were compared with those before the treatment. Results The sedative reactive time of propofol was short. Most of the patients had decreased blood pressure after injection with propofol (Plt;0.05) but recovered soon. The heart rate, respiratory rate, and pulse oxygen saturation did not significantly changed (Pgt;0.05). The recovery time was short after propofol administration was stopped. Conclusion Propofol is an effective sedative for the patients after surgical operations in ICU, but the medicated speed, amount and time according to state of the patients should be adjusted.
ObjectiveTo observe the effect of dexmedetomidine combined with etomidate on the clinical safety and the tracheal extubation response after general anesthesⅠa in elderly patient undergoing thyroidectomy. MethodsFifty patients (aged between 65 and 75 years, ASAⅠor Ⅱ) scheduled for thyroid surgery between July 2012 and January 2013 were randomly divided into two groups:dexmedetomidine group (group D) and control group (group C) with 25 patients in each group. Group D received dexmedetomidine of 0.5 μg/(kg·h) through intravenous infusion after anesthesia induction, and the intravenous infusion was stopped five minutes before the end of surgery. Normal saline was infused at the same volume in group C at the same time. Patients were induced with etomidate at 0.2 mg/kg for anesthesia, and etomidate and remifentanil were used for the anesthesia maintenance during the operation. Heart rate (HR), systolic blood pressure SBP), diastolic blood pressure (DBP) and bispectral index (BIS) were recorded 5 (T1), 15 (T2) and 30 (T3) minutes after the beginning of the operation, and 15 (T4) and 5 (T5) minutes before the end of the operation. Moreover, the time of eye opening, time of extubation, the number of patients with restlessness and etomidate requirement were recorded. ResultsCompared with group C, HR and MAP at the time points of T2 and T5 in group D did not obviously change, but the number of restlessness patients in group D was significantly less than in group C (P<0.05). There was no statistically significant difference in time of eye opening and time of extubation between the two groups (P>0.05). Etomidate requirement in group D was[(8.6±2.1) μg/(kg·min)], which was significantly lower than that in group C[(14.4±3.4) μg/(kg·min)] (P<0.05). ConclusionDexmedetomidine combined with etomidate is efficient and safe for elderly patients undergoing thyroidectomy, and this method can effectively reduce cardiovascular responses to tracheal extubation, decrease the incidence of postoperative restlessness, and reduce the requirement of etomidate during the operation.
Objective To evaluate the sedative and analgesic efficacy and adverse effect of dexmedetomidine versus propofol on the postoperative patients in intensive care unit (ICU). Methods The relevant randomized controlled trials (RCTs) were searched in The Cochrane Library, MEDLINE, PubMed, SCI, SpringerLinker, ScinceDirect, CNKI, VIP, WanFang Data and CBM from the date of their establishment to November 2011. The quality of the included studies was evaluated after the data were extracted by two reviewers independently, and then the meta-analysis was performed by using RevMan 5.1. Results Ten RCTs involoving 793 cases were included. The qualitative analysis results showed: within a certain range of dosage as dexmedetomidine: 0.2-2.5 μg/(kg·h), and propofol: 0.8-4 mg/(kg·h), dexmedetomidine was similar to propofol in sedative effect, but dexmedetomidine group needed smaller dosage of supplemental analgesics during the period of sedative therapy. The results of meta-analysis showed: the percentage of patients needing supplemental analgesics in dexmedetomidine group was less than that in propofol group during the period of sedative therapy (OR=0.24, 95%CI 0.08 to 0.68, P=0.008). Compared with the propofol group, the duration of ICU stay was significantly shorter in the dexmedetomidine group (WMD= –1.10, 95%CI –1.88 to –0.32, P=0.006), but the mechanical ventilated time was comparable between the two groups (WMD=0.89, 95%CI –1.15 to 2.93, P=0.39); the incidence of adverse effects had no significant difference between two groups (bradycardia: OR=3.57, 95%CI 0.86 to 14.75, P=0.08; hypotension: OR=1.00, 95%CI 0.30 to 3.32, P=1.00); respiratory depression seemed to be more frequently in propofol group, which however needed further study. Mortalities were similar in both groups after the sedative therapy (OR=1.03, 95%CI 0.54 to 1.99, P=0.92). Conclusion Within an exact range of dosage, dexmedetomidine is comparable with propofol in sedative effect. Besides, it has analgesic effect, fewer adverse effects and fewer occurrences of respiratory depression, and it can save the extra dosage of analgesics and shorten ICU stay. Still, more larger-sample, multi-center RCTs are needed to provide more evidence to support this outcome.
Sedation and analgesia is an essential part of the emergency work. Presently, for adults, clinical assessment and application of sedation and analgesia has been gradually perfect, but in the face of pediatric patients, clinicians would always concern drug-related adverse reactions as well as a variety of uncontrollable factors, leading to reducing and even ignoring the sedation and analgesia in children. This review focuses on the current research status and relevant evidence of pediatric sedation depth and risk assessment, pain assessment, as well as the principles, application methods, advantages and disadvantages of various commonly used clinical drugs, and the aim is to provide evidence for higher quality sedation and analgesia for children.
Objective To evaluate the sedative effects of fentanyl on ventilated patients in intensive care unit (ICU ).Methods Thirty orotracheal intubated and mechanical ventilated medical patients in ICU were randomly divided into two groups，ie.Midazolam group (group M) and midazolam combined with fentanyl group with a proportion of 100∶1 (group M+F) The sedatives were continuously intravenously infused to achieve a target motor activity assessment scale (MAAS) of 3 and ventilator synchrony score of adaptation to the intensive care environment (ATICE) ≥3 after loading dose of midazolam.The sedation level was evaluated and the infusion rate was adjusted to maintain the target sedation goal every 2 h and the hemodynamic，respiratory and sedative parameters were recorded simultaneously.The oxygenation index were measured at 12 and 24 h.The infusion were ceased after 24 h,then the sedative degree was assessed every 30 min until MAAS ≥3 and the recover time were recorded.Results There were no significant differences in blood pressure，oxygenation index and adjustive frequency of drugs between the two groups (all Pgt;0.05).The heart rate，respiratory rate and airway pressure in group M+F decreased significantly than those in Group M (Plt;0.05).The amount of midazolam used and cost of sedatives were lower than those in group M (Plt;0.05).Satisfactory degree of sedation or ventilator synchrony and awakeness score of ATICE in group M+F were higher than those in group M.The recover time was shorter in groupM+F (Plt;0.05).Conclusion In medical ventilated patients, fentanyl improves the sedative effect of midazolam and reduces the dose of midazolam,hence,reduce the total cost of sedatives.
Objective To investigate the applied significance of adjustable low-concentration of mixed oxygenand nitrous oxide inhalation sedation combined with lidocaine local anesthesia in anorectal surgery. Methods Three hundreds patients underwent anorectal surgery in our hospital were divided into control group （n=154） and observation group （n=146）. Patients of control group underwent pure lidocaine local anesthesia， and patients of observation group underwent mixed oxygen and nitrous oxide sedation analgesia combined with lidocaine local anesthesia. Vital signs before and after operation as well as results of sedation and analgesia were compared between the 2 groups. Results Anorectal surgeries of all patients were performed successfully. There were no significant differences on change of heart rate， blood pressure， and oxygen saturation between the 2 groups before and after operation （P＞0.05）. The operation time between the control group 〔（36.3±6.8） min〕 and observation group 〔（35.4±6.5） min〕 had no statistically significant difference（t=-0.607， P=0.544）. The analgesic effects （Z=-6.859， P=0.000） and sedative effects （Z=-5.275， P=0.000） of obser-vation group were both better than those of control group. Conclusions Low-concentration of mixed oxygen and nitrous oxide inhalation sedation combined with lidocaine local anesthesia can relieve the discomfort of fear and pain， no side-impacts on vital sign before and after operation were observed，and it has better effects of sedation and analgesia， therefore it can be recommended to clinical application.