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门诊无痛内镜术中脑电双频谱和血液动力学变化的研究

时间:2010-08-24 11:35:15  来源:  作者:

A clinical Study on the Changes of  BIS and Hemodyamic During Outpatients Undergoing Gastroduodenoscopy <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

 

徐明 张芝芳

上海市第八人民医院麻醉科,上海 200235

Ming Xu,Zhi-fang Zhang

Department of Anesthesiology,Eight People's Hospital of Shanghai,Shanghai 200235,China

 

ABSTRACT

Objective:To study the changes and the relationship between BIS and hemodyamic during outpatients undergoing gastroduodenoscopy,evaluate the effects of BIS on monitoring anesthesia depth.

Methods:Thirty-five ASA III selective outpatients undergoing gastroduodenoscopy were administrated 1mg/kg fentanyl and propofol 1.5mg/kg. In operation,propofol were added in 4560 sec with body movement. BISHRBP and SpO2 were recorded at the time point of before induction (T0),1 minute after induction(T1),after intubation(T2),end of operation end(T3) and  emergence(T4).

Results:(1)The BIS at T1(40.83±5.24) was significantly lower than that at T0(97.33±0.78)(P<0.01); At T2-4BIS increased greatly than that at T1(P<0.05).(2)The tendency of blood pressure(BP) changes was similar to that of bispectral index(BIS). BIS had a high positive correlation to BP(P<0.01). (3) The changes in HR were less significant. (4)No awareness happened during operation.

Conclusion:Using BIS has certain significance in keeping hemodynamics stable and avoiding consciousness,which can predict anesthesia depth strongly.

Key words:Bispectral index; Hemodynamics; Intravenous anesthetics; Monitoring

Corresponding Author:Ming Xu; Tel: 021-64363101;  E-mail:mmdmn@163.com

 

脑电双频指数(BIS)是一个非常好的反映镇静作用的指标,临床常用来评价麻醉深度,指导麻醉用药,避免术中知晓[1]。门诊麻醉强调周期短、安全性高。因此,十分重视麻醉深度的监测。本文研究在门诊麻醉中使用脑电双频谱指数与血液动力学指标监测麻醉深度的意义。

一、资料和方法<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

1. 一般资料

选择35例拟在静脉麻醉下行胃镜检查术的患者,ASA I-II级,无药物过敏史,年龄38~77岁,体重46~75kg 。

 

2. 麻醉方法

患者测得体重,取左侧卧位。常规鼻吸氧,开放上肢静脉,连接监护设备。先予芬太尼1mg/kg,丙泊酚1.5mg/kg静脉诱导。患者入睡后即开始手术。术中根据患者体动追加丙泊酚维持麻醉,每次0.5mg/kg,均予45~60秒内推入。

 

3. 监测

分别于诱导前(T0),入睡后(T1)、插镜过声门 (T2)、退镜完毕(T3)、清醒(T4)五个时点用Datex多功能监护仪同步监测HR、NIBP、SpO2及BIS。

 

4. 统计分析

各组数据均采用均数±标准差(x±s)表示,SAS软件包处理数据。采用单因素方差分析检验。P<0.05为有显著差异,P<0.01有极显著性差异。

 

二、结果

BIS、SBP、DBP变化趋势一致: T0 BIS(97.33±0.78),T1明显降低至(40.83±5.24)(P<0.01),T2- T4BIS值均较T0显著下降(P<0.01),但较T1增高(P<0.05)。T0、T1、及T4 BIS较T2有差异(P<0.05)。BIS与BP变化呈正相关(BIS: SBP,r=0.6273,P=0.0001; BIS: DBP,r=0.5252,P=0.0001)。HR术中无明显变化,与BIS变化无相关性(P>0.05)。

所有患者术后随访均无术中知晓。

 

三、讨论

一般认为,麻醉不同的成分具有不同的生理机制,麻醉药对意识的阻滞作用发生在皮层,而对刺激后体动反应的阻滞部位在脊髓和更高级中枢,这与意识不直接相关[2]

BIS可较为准确地反映大脑皮层功能状态,可作为监测镇静深度的指标[3]。Liu等[4]用BIS监测术中异丙酚的镇静深度,表明BIS能将镇静深度定量化且BIS值变化与镇静程度有良好的相关性。Iselin-Chaves等[5]发现,BIS对镇静与意识的预报可能性均大于0.93,优于丙泊酚的靶浓度输注与血药浓度监测,认为BIS与麻醉的催眠成分有很好的相关性。而加入鸦片后,对BIS镇静深度变化的预测值影响无统计学意义。

机体对手术等伤害性刺激,会产生运动、血液动力学及内分泌等变化,这些变化与意识状态相关不明显,是发生在皮质下中枢的反应。麻醉深度不够引起的运动反应,因用肌肉松弛药而掩盖,而临床最明显的表现是血液动力学变化[6]。<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

关于BIS用于判断麻醉深度及血液动力学的变化,目前仍存在争议。本研究显示: BIS诱导后下降,诱导前后(T0-T1)有明显差异(P<0.01)。插镜过声门时BIS值上升(T1-T2P<0.05),术程中(插镜过声门至退镜完毕)变化平稳,手术操作时点(T2; T3)与非操作时点(T0;T1;T4) BIS值有统计学意义(P<0.05)。这一过程表明BIS能较好地反映手术过程,并提示患者清醒时间。有人对全麻诱导时BIS、95%SEF、平均信息(ApEn)、HRV作了比较,得出BIS对觉醒和睡眠有最强的预测作用,其灵敏性为97.3%、特异性为94.4%[7]。期间,BIS变化与血压变化趋势一致,相关性良好,提示BIS预测血压变化有一定的意义。使用BIS可以减少血液动力学波动,使麻醉过程中血压更加平稳。

本研究所有患者术后随访均无术中知晓,而术中BIS均值大于60。杨宾侠等[8]发现病人神志消失时BIS值为71±8,此时的镇静深度对循环抑制轻微,且术后迅速清醒而平稳。我们认为门诊手术中BIS值维持在60~70左右较为适度,能够满足安全手术,快速清醒的要求。

 

参考文献 

1.Glass PS,Bloom M,Kearse L,et al. Bispectral analysis measures sedation and memory effects of propofol,midazolam,isoflurane,and alfentanyl in healthy volunteers. Anesthesiology,1 997; 86(4);836-847.

2.Eger EI 2nd,Koblin DD,Harris RA,et al. Hypothesis: inhaled anaesthetics produce immobility and amnesia by different mechanisms at different sites. Anesth Analg,1997; 84(4);915-918.

3.Barr G,Jakosson JG,Owall A,et al. Nitrous oxide does not alter bispectral index : study with nitrous oxide as sole agent and as an adjunct to iv anaesthesia. Br J Anaesth,1999; 82(6);827-830.

4.Liu J,Singh H,White PF,Electroencephalographic bispectral index  correlates with intraoperative recall and depth of propofol-induced sedation. Anesth Analg,1997; 84(1);185-189.  

5. Iselin-Chaves IA,Flaishon R,Sebel PS,et al. The effect of the interaction of propofol and alfentanil on recall,loss of consciousness and the bispectral index. Anesth Analg,1998; 87(4):949-955.

6.于布为彭章龙。BIS预测切皮心血管反应的可靠性。临床麻醉学杂志2002; 18(11): 581-584.

7.Sleigh JW,Donovan J. Comparison of  bispectral index ,95% spectral edge frequency and approximate entropy of the EEG,with the change in heart rate variability during induction of general anaesthesia. Br J Anaesth,1999; 82(5): 666-671.

8.杨宾侠,王保国。异丙酚静脉麻醉镇痛催眠深度的研究。中华麻醉学杂志,1998; 18(11): 662-664.

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