2018 年第 3 期 第 13 卷

加速康复外科理念指导下胃肠手术围术期舒芬太尼临床剂量的优化

The optimistic dose of sufentanil during perioperative period of gastrointestinal surgery with the guidance of enhanced recovery after surgery

作者：齐择优马骏林多茂

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单位：100029首都医科大学附属北京安贞医院麻醉中心

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• 摘要：

• 目的    基于加速康复外科的理念，观察开腹胃肠手术中不同剂量舒芬太尼对围术期患者血流动力学波动、麻醉药物用量及苏醒质量的影响。方法    选取2016年5月至2017年7月在首都医科大学附属北京安贞医院择期行开腹胃肠癌根治术的患者70例，依据随机数字表法将患者分为A组和B组，每组35例。以同样方式行麻醉诱导（舒芬太尼0.5 μg/kg、依托咪酯0.2 mg/kg、咪达唑仑0.05 mg/kg、维库溴铵0.1 mg/kg），待消毒铺巾完成后，A组追加舒芬太尼0.5 μg/kg，B组追加等量0.9%氯化钠注射液。记录麻醉诱导前(基础值)、诱导后、追加舒芬太尼（或0.9%氯化钠注射液）后、切皮时、进入腹腔探查时、切皮后30、60、90、120 min、手术结束时、入麻醉后监护室（PACU）时、苏醒时、拔管时、出PACU时的平均动脉压和心率。记录麻醉手术过程中丙泊酚和瑞芬太尼的用量，拔管后疼痛视觉模拟量表（VAS）评分和改良警觉/镇静评分，因术后疼痛出现躁动而使用曲马多止痛例数，以及术后并发症发生情况。结果    2组诱导后及追加舒芬太尼（或0.9%氯化钠注射液）后平均动脉压和心率均明显低于基础值(均P＜0.05)，此时组间比较差异无统计学意义（P＞0.05）。A组手术过程中各时点心率均明显低于基础值；B组切皮时、进入腹腔探查时、手术结束时的平均动脉压和心率明显高于基础值和A组，其他时点心率明显低于基础值(均P＜0.05)。苏醒期间2组平均动脉压均明显高于基础值，A组均明显低于B组（均P<0.05）。A组术中瑞芬太尼用量明显少于B组［（0.80±0.07）mg比（1.22±0.34）mg］(P＜0.05)。拔管后A组静息及运动状态下VAS评分明显低于B组［（2.6±0.9）分比（4.0±1.1）分、（3.7±0.9）分比（4.6±1.4）分］(均P＜0.05)。A组躁动发生率和曲马多使用率明显低于B组［17.1%（6/35）比37.1%（13/35）、17.1%（6/35）比37.1%（13/35)］(P＜0.05)。结论    与0.5 μg/kg相比，切皮前应用1.0 μg/kg舒芬太尼于开腹胃肠手术麻醉，围术期血流动力学更加平稳，麻醉效果更好，且能降低麻醉期间瑞芬太尼的用量及其可能导致术后痛觉过敏的风险，患者苏醒质量更高。

• Objective    To investigate the effects of different doses of sufentanil on hemodynamic fluctuation, anesthetic dosage and anesthesia recovery quality in patients undergoing open gastrointestinal surgery. Methods    Seventy patients undergoing radical resection of gastrointestinal carcinoma from May 2016 to July 2017 in Beijing Anzhen Hospital, Capital Medical University were randomly divided into group A and group B, with 35 patients in each group. After the same anesthesia induction（sulfentanyl 0.5 μg/kg, etomidate 0.2 mg/kg, midazolam 0.05 mg/kg, vecuronium bromide 0.1 mg/kg）, the group A group was added sufentanil 0.5 μg/kg and the group B was added 0.9% sodium chloride injection before skin incision. Mean arterial pressure（MAP） and heart rate（HR） were recorded before induction（baseline level）, after induction, after adding sufentanil/0.9% sodium chloride injection, during incision, at the beginning of abdominal exploration, 30, 60, 90, 120 min after incision, at the end of operation, at the enter of post-anesthesia care unit（PACU）, during anesthesia recovery, during extubation and at the discharge of PACU. Dosages of propofol and remifentanil during anesthesia and operation, scores of the Visual Analogue Scale（VAS） for pain and the Modified Observer′s Assessment of Alertness/Sedation Scale after extubation, occurrence of agitation due to unbearable pain and use of analgesic tramadol, occurrence of postoperative complications were recorded. Results    MAP and HR after induction and after adding sufentanil/0.9% sodium chloride injection were significantly lower than the baselines(P＜0.05), and there were no significant differences between groups（P＞0.05）. HR in group A during operation was significantly lower than the baseline; MAP and HR during incision, at the beginning of abdominal exploration and at the end of operation in group B were significantly higher than the baselines and those in group A(P＜0.05). During anesthesia recovery, MAP was significantly higher than the baseline in both groups; MAP in group A was significantly lower than that in group B(P＜0.05). Dosage of remifentanil in group A was significantly less than that in group B［（0.80±0.07）mg vs （1.22±0.34）mg］(P＜0.05). The VAS scores in group A were significantly lower than those in group B［at rest: （2.6±0.9）points vs（4.0±1.1）points, during exercise: （3.7±0.9）points vs （4.6±1.4）points］(P＜0.05). Incidence of agitation and use rate of tramadol in group A were significantly lower than those in group B［17.1%（6/35） vs 37.1%（13/35）, 17.1%（6/35） vs 37.1%（13/35)］(P＜0.05). Conclusion    Compared to 0.5 μg/kg, sufentanil 1.0 μg/kg used for general anesthesia before skin incision in open gastrointestinal surgery has more stable perioperative hemodynamics and better anesthetic effect; it can reduce intraoperative dosage of remifentanil and postoperative risk of hyperalgesia.