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Application of Remifentanil by TCI without Muscle Relaxant for TrachealIntubation in Elderly Patients

周仁龙 杭燕南

上海交通大学医学院附属仁济医院麻醉科，上海200001

Ren－long Zhou，Yan－nan Hang

Department of Anesthesiology，<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Renji Hospital Affiliated to Shanghai Jiaotong University Medical College，Shanghai 200001，China

ABSTRACT

　　Objective：To observe the tracheal intubation conditions and hemodynamic changes during remifentanil target controlled infusion （TCI） at different plasma concentrations combined with propofol.

　　Methods：Thirty－six patients were randomly allocated into three groups. Remifentanil were given using TCI at plasma concentration of 2 ng/ml，3ng/ml and 4ng/ml in each group respectively and after 5－min remifentanil infusion，propofol was given with TCI at plasma concentration 2.5μg/ml. Ten minutes later，inserting laryngoscope and tracheal intubation were tried and intubation conditions were recorded. If failed，the remifentanil concentration was increased by 1 ng/ml and once more intubation was tried ten minutes later. The heart rate and blood pressure at baseline，after remifentanil infusion，before intubation and one minute after intubation were recorded. Meanwhile，the intubation scores and side effects during induction were recorded.

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　　Results：The intubation scores at first attempt were 10.4±2.7，7.7±2.4 and 5.8±1.0 in three groups，and success ratio were 7/12（52％），10/12（83％） and 12/12（100％），respectively. The ratio in the second attempt were 2/5（40％） and 1/2（50％） in two low dose groups. Blood pressure was reduced following infusion of remifentanil at 4 ng/ml. Heart rates were lowered significantly，especially in 3～4ng/ml groups. Compared with pre－intubation，heart rate and blood pressure in 2ng/ml group were significantly increased after intubation. However，atropine and adrenaline were more administered in the high concentration group.

　　Conclusion：Combined with propofol TCI at 2.5μg/ml，tracheal intubation may be facilitated by remifentanil TCI at 3～4 ng/ml. Tracheal intubation successful rate may be elevated with increasing plasma concentrations of remifentanil，but heart rates be also lowered down significantly.

　　Key words：Remifentanil；Propofol；Tracheal intubation；Cardiovascular response；Elder

　　瑞芬太尼是一种较新的超短效阿片类药物，可被非特异性酯酶代谢。由于其作用时间极短，可控性佳，故在门诊手术、短小手术及有些诊断或治疗性操作中有很好的应用前景^[1－3]，在以往的研究中^［4］我们对于成年国人不使用肌松的插管进行了探讨；而本文旨在观察老年病人不使用肌松剂条件下，靶控输注丙泊酚与不同浓度瑞芬太尼时，实施气管插管的难易度及心血管反应情况。

材料与方法

　　36例ASA I～II择期全麻老年手术病人，术前无明显插管困难征象（Wilson综合评分?3分），无阿片类药物及丙泊酚过敏史，随机分为3组，每组12例。

　　麻醉前30min肌注东莨菪碱0.3m g。进入手术室后监测无创动脉压、心电图、脉搏氧饱和度。开放中心静脉靶控输注瑞芬太尼，外周静脉用于靶控输注丙泊酚。

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　　三组病人分别设定瑞芬太尼血浆靶控浓度为2、3、4n g/m l，输注5min后开始靶控输注丙泊酚，血浆目标浓度设为2.5μ g/m l，10min后置入喉镜，男性病人使用8#，女性使用7.5#气管导管，尝试进行气管插管，如果失败，则增加瑞芬太尼目标浓度1ng/ml，10min后重复插管操作，若再次失败则退出本研究，但其已有数据仍进入分析。

　　于瑞芬太尼输注前的基础时刻点、丙泊酚开始时刻点、置入喉镜前即刻、插管后1min，分别记录动脉压和心率，如有二次插管，则加记第二次插管前与插管后1min时刻点。同时记录气管插管评分、不良反应及辅助药物使用量。

　　插管条件采用Grant评分办法^[5]（表1）。若心率减慢＜45次/min时静注阿托品0.3m g，动脉平均压＜基础值30％时静注麻黄素10mg，如有必要可重复给药。

　　数据统计使用SPSS10.0统计软件，各资料以表示，计量资料组间比较采用方差分析，计数资料采用卡方分析，P<0.05认为有统计学差异。

结　果

　　各组病人一般情况见表3。

　　三组病人插管评分与插管成功率、阿托品与麻黄素的使用例数见表2。病人血压的变化见图1，插管前即刻与基础时刻点相比，三组血压均有显著性下降，插管后1min与插管前相比，2n g/m l组血压有显著性上升，与另两组相比有统计学差异（P<0.05）。各组病人心率的变化见图2，丙泊酚开始输注点与基础时刻点相比，3n g/m l和4n g/m l组心率均有显著性减慢，4n g/m l组更明显。插管后1min与插管前相比，2n g/m l组心率有显著性增快，另两组无明显改变。

讨　论

　　瑞芬太尼是较新的阿片类μ受体的激动剂，药效强、起效迅速、可控性佳。由于含有酯结构，所以该药主要在血液与组织中经非特异性酯酶分解代谢，不受肝肾功能的影响，即使长时间连续输注其时量相关半衰期也仅为3～5min^[1－3]。正因如此，在门诊手术和短小手术及诊断或治疗性操作中瑞芬太尼具有一定的优势。以往的研究中^[4]，我们已经探讨了成年病人不使用肌松药行气管插管时，如丙泊酚TCI血浆浓度定为3μg/ml，瑞芬太尼在4ng/ml血浆浓度基本可满足插管需要。因为老年病人可能存有更多的伴发疾病，系统功能贮备下降，特别是肝肾功能水平的降低多可引起老年人药效与药代动力学的改变，所以本研究进一步探讨老年病人不使用肌松剂气管插管的一些药物条件。

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