降低心脏手术血流动力学反应的研究.doc

小剂量瑞芬太尼降低心脏手术血流动力学反应的研究 【摘要】目的 研究国产瑞芬太尼用于心脏手术一个较低的有效剂量。方法 选择68例首次接受心脏择期手术患者，ASA≤Ⅲ级,根据四个不同剂量的瑞芬太尼0.1,0.2,0.3或0.4ug kg-1min-1，随机分为四组（即R1,R2,R3或R4组）。以BIS监测指导依托咪酯的恒速输注，分别复合不同剂量的瑞芬太尼持续泵注的全凭静脉麻醉，研究心脏手术转流前各种伤害性刺激（如气管插管、切皮、锯胸骨）的血流动力学变化，并分别记录各事件点前后的平均动脉压（MAP）、心率（HR）、心脏指数（CI）、每搏指数（SI）、外周血管阻力指数（SVRI）、加速度指数（ACI）以及脑电双频指数（BIS）值。MAP ，HR或二者同时增加超过基础值的20%，我们视为有临床意义，表明这些患者对伤害性刺激有反应。结果 四组间及各事件点前后的CI, SI, SVRI, ACI和BIS值无统计学意义。R3和R4组能较好地预防MAP和HR的增加（P﹤0.05）。结论 瑞芬太尼0.3或0.4ug kg-1min-1复合依托咪酯恒速输注在体外循环转流前期间可以减轻应激刺激的血流动力学反应，并可等同于来自文献的更高剂量的瑞芬太尼而不影响心脏泵的功能。 【关键词】 瑞芬太尼；持续输注；小剂量；心脏手术麻醉；血流动力学反应 Low-dose remifentanil to suppress haemodynamic responses to noxious stimuli in cardiac surgery 【Abstract】 Objective To study an optimal lower remifentanil dose, which should be accompanied by fewer adverse events, that still effectively suppresses haemodynamic responses to typical stressful stimuli. Methods Total i.v. anaesthesia consisted of continuous infusion of remifentanil and etomidate.68 patients (ASA≤Ⅲ)were allocated to receive either a constant infusion of remifentanil at 0.1ug kg-1 min-1 or up-titration to 0.2,0.3 or 0.4ug kg-1 min-1, respectively, 5 min before each stimulus. Subsequently, changes in MAP, HR, CI, SI, SVRI and ACI were recorded for 5 min. Increases exceeding 20% of baseline were considered to be of clinical relevance. Patients who exhibited these alterations were termed responders. BIS value was monitored and directed to show the level of anesthesia during the period. Results The number of responders was less with the two higher remifentanil dosages(P＜0.05）,no severe haemodynamic depression was observed. BIS values, CI, SI, SVRI and ACI showed no significant difference among four groups at each time point. Conclusion Remifentanil at 0.3 and 0.4ug kg-1 min-1 in combination with continuous infusion of etomidate in the pre-bypass period is well tolerated. It appears to mitigate potentially hazardous haemodynamic responses from stressful stimuli equally well as higher doses when comp