右美托咪定不同给药方式对患者经鼻清醒气管插管应激反应的对比研究

A comparative study of stress response on patients with awake nsal intubation in different administration methods of Dexmedetomidine

摘要:

目的评价右美托咪定不同给药方式在全身麻醉患者经鼻纤维支气管镜气管插管中的应用效果。方法选取行颌面骨骨折或口腔肿瘤手术患者，美国麻醉医师协会分级Ⅰ、Ⅱ级，Mallampati气道分级为Ⅲ、Ⅳ级，年龄18～69 岁，随机数字表法分为4 组（n =20）：表面麻醉组（C 组）、表面麻醉+1μg/kg 右美托咪定喷鼻组（D1 组）、表面麻醉+2 μg/kg右美托咪定喷鼻组（D2 组）、表面麻醉+ 右美托咪定静脉注射组（DV 组）。D1组和D2组鼻腔内分别喷入右美托咪定1和2μg/kg（2 ml），20 min后静脉输注生理盐水20 ml，输注时间10 min；D3组鼻腔内喷入生理盐水2 ml，20 min后静脉输注右美托咪定1μg/kg，输注时间10 min；C组分别经鼻腔喷入、静脉输注生理盐水；经较通畅的一侧鼻腔用1%丁卡因进行鼻腔、口咽表面麻醉后，4 组常规麻醉诱导。于入室后（T0）、药物喷鼻后30 min（T1）、气管导管过鼻咽即刻（T2）、气管导管进入声门即刻（T3）、插管成功后1 min（T4）、3 min（T5）和5 min（T6）记录患者平均动脉压（MAP）、心率（HR）和插管期间Ramsay 值，并于T0、T3～6时间检测血浆皮质醇浓度（Cor）、肾上腺素（E）和去甲肾上腺素（NE）水平。记录气管插管时间、患者气管插管条件和患者Koung 评分。结果C组MAP、HR、血浆Cor、N、NE水平在经鼻气管插管后升高（P <0.05）；D1 组、D2 组和DV 组在T1时刻HR 降低，气管插管成功后MAP、HR、血浆Cor、N 和NE 水平波动较C 组轻（P <0.05），与D1、DV组比较，D2组血浆Cor、N和NE浓度在T4～T5时间降低（P <0.05）。与C 组比较，D2组、D1组和DV组插管条件评分升高，Koung 评分降低，气管插管时间缩短（P <0.05），D2 组与D1、DV 组相比，Koung 评分降低（P <0.05）。结论右美托咪定2 种给药方式可安全有效地用于经鼻清醒气管插管，减少血流动力学波动，且2μg/kg右美托咪定鼻腔喷药效果更佳。

Abstract:

Objective To compare the stress response on patients with awake nasal intubation in different administration methods of Dexmedetomidine. Methods Patients with ASA I or Ⅱand Mallampati Ⅲor Ⅳ,aged 18～69 years old, were randomly dividied into 4 groups according to the random number table ( n= 20): topical nasal anesthesia group (group C), topical nasal anesthesia and 1μg/kg Dexmedetomidine by intranasal administration group (group D1), topical nasal anesthesia and 2 μg/kgDexmedetomidine intravenous group (group DV).Dexmedetomidine were given 1μg/kg and 2μg/kg in 2 ml by intranasal administration in group D1 and group D2 respectively and after 20 minutes 20 ml of nomal saline (NS) was injected intravenously within 10 min before induction of anesthesia in both group D1 and group D2; in group DV, 2 ml NS was given intranasally and Dexmedetomidine 1 μg/kg in 20 ml was injected intravenously in the same way; and NS was given intranasally and intravenously respectively in the same way in group C. All the patients received surface anesthesia of nasal cavity, pharynx and larynx with 1%tetracaine. General anesthesia induction was taken when the injection was finished. MAP, HR and Ramsay sedation scores were recorded at the time of entering the operating room (T0), 30 minutes after intranasal administration (T1), tracheal tube passing through nasopharynx (T2) and glottis (T3), 1 minute (T4), 3 minutes (T5) and 5 minutes (T6) after endotracheal intubation. Blood samples were taken at T0, T3～6 to detect the concentration level of plasma cortisol, norepinephrine and epinephrine. The time of intubation, intubating responses and Koung scores were recorded. Results MAP, HR and the concentration level of plasma cortisol, norepinephrine and epinephrine in group C were higher after endotracheal intubation (P < 0.05); HR decreased at T1 in group D2, group D1 and group DV; and MAP, HR and the concentration level of plasma cortisol, norepinephrine and epinephrine fluctuated less in group D2,group D1 and group DV (P < 0.05) than that in group C. The concentration level of plasma cortisol,norepinephrine and epinephrine was lower at T4～5 in group D2 than both group D1 and group DV ( < 0.05).In group D2, group D1 and group DV, the time of intubation were shorter and Koung scores were lower than group C (P < 0.05); and compared with group D1 and group DV, the Koung scores in group D2 were significantly lower (P < 0.05). Conclusions Both administration methods of Dexmedetomidine can reduce the stress response on patients with awake nasal intubation, and the effect of 2μ g/kg Dexmedetomidine intranasally is better.