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右美托咪定作为罗哌卡因佐剂超声引导颈浅丛阻滞在甲状腺手术中的应用 ?

2019-04-22曲鹰刘国华李俊霞

中外医学研究 2019年34期
关键词:甲状腺手术右美托咪定超声

曲鹰 刘国华 李俊霞

【摘要】 目的:评估在甲状腺手术中,右美托咪定作为罗哌卡因佐剂超声引导双侧颈浅丛阻滞时的安全性和有效性。方法:选取择期行甲状腺手术患者60例,随机分为D组和R组,两组全麻成功后,在超声引导下行双侧颈浅丛神经阻滞(SCPB),D组单侧使用含有0.375%罗哌卡因(Rop)10 ml和右美托咪定(Dex)25 μg的混合液,R组单侧使用含有0.375% Rop 10 ml和等量0.9%氯化钠注射液的混合液。记录两组术后首次使用地佐辛时间、术后24 h地佐辛总量、术中芬太尼及丙泊酚用量;评估两组术后2、4、6、8、12、24 h VAS评分;记录两组术后24 h内不良反应。结果:D组首次使用地佐辛时间晚于R组,术后24 h地佐辛总量少于R组,术中芬太尼用量少于R组(P<0.05);D组术后6、8、12、24 h VAS评分均显著低于R组(P<0.05);D组恶心呕吐发生率显著低于R组(P<0.05)。结论:在超声引导双侧SCPB甲状腺手术中,Dex作为Rop佐剂,能够使镇痛效果增强、镇痛时间延长、阿片类药物消耗降低、不良反应减少,值得临床推广。

【关键词】 右美托咪定 超声 颈浅丛阻滞 甲状腺手术

[Abstract] Objective: To evaluate the safety and efficacy of Dexmedetomidine as Ropivacaine adjuvant for ultrasound-guided bilateral superficial cervical plexus block in thyroid surgery. Method: Sixty patients who underwent thyroid surgery were randomly divided into the group D and the group R. After induction of general anesthesia, both groups were performed bilateral superficial cervical plexus block (SCBP) under ultrasound guidance. The group D was treated unilaterally with a mixture containing 0.375% Ropivacaine (Rop) 10 ml and Dexmedetomidine (Dex) 25 μg, and the group R was treated unilaterally with a mixture containing 0.375% Rop 10 ml and the same amount of 0.9% Sodium Chloride Injection. The time of the first use of Dezocine, the total amount of Dezocine 24 h after surgery, the intraoperative dose of Fentanyl and Propofol in the two groups were recorded. The VAS scores were assessed at 2, 4, 6, 8, 12 and 24 h after surgery. Adverse reactions within 24 h after surgery were recorded in both groups. Result: The time of the first use of Dezocinein the group D was later than that of the group R, the total amount of Dezocine 24 h after surgery in the group D was less than that of the group R, and intraoperative dose of Fentanyl in the group D was less than that of the group R (P<0.05). The VAS scores at 6, 8, 12, 24 h after surgery in the group D were significantly lower than those of the group R (P<0.05). The incidence of nausea and vomiting in the group D was significantly lower than that of the group R (P<0.05). Conclusion: Ultrasound-guided bilateral SCPB in thyroid surgery, Dex as an adjuvant of Rop can enhance the analgesic effect, prolong the analgesic time, reduce Opioid consumption and reduce adverse reaction, which is worthy of clinical promotion.

甲狀腺手术中牵拉易引起血流动力学变化,甚至诱发重度心律失常而危及生命,术后患者常有中重度疼痛感。颈浅丛阻滞是降低应激反应的最佳镇痛技术,在超声引导下可使操作更加精准、安全、有效[1-2]。右美托咪定(Dexmedetomidine,Dex)是一种高选择性α2肾上腺素能受体激动剂,临床常用作镇静剂和镇痛剂。研究报道,右美托咪定作为佐剂可延长局麻药的作用时间,具有更高的血流动力学稳定性[3]。本研究拟评估在甲状腺手术中,Dex作为罗哌卡因(Ropivacaine,Rop)佐剂超声引导双侧SCPB时的镇痛效果和副作用,以验证其安全性及有效性,为临床应用提供参考。

Dex具有中枢性抗交感神经作用,可激活迷走神经,降低血浆儿茶酚胺水平,具有剂量相关的降低血压和心率作用,从而提供稳定的血流动力学[9-10]。本研究中,两组HR和MBP比较没有显著差异。

本研究中,D组恶心呕吐发生率较R组明显减少,主要是因为D组联合使用Dex增强镇痛效果,阿片类药物使用量降低;也可能因为Dex与蓝斑中的α2突触前抑制性肾上腺素受体结合,降低肾上腺素能活性,产生止吐效果。另外,有研究显示,Dex可抑制交感神经兴奋和儿茶酚胺释放减少PONV的发生[11]。与Cai等[12]研究结果一致,双侧SCPB可减少恶心呕吐发生率。

本研究尚存在不足之处:(1)右美托咪定最佳安全有效的配伍剂量需要进一步研究;(2)复合颈深丛阻滞的安全性与有效性也需要进一步探讨。

综上所述,在超声引导双侧SCPB甲状腺手术中,Dex作为Rop佐剂,能够使镇痛效果增强、镇痛时间延长、阿片类药物消耗降低、副作用减少,值得临床推广。

参考文献

[1]王东,陈彪,高满海,等.双侧颈浅丛阻滞联合静脉全身麻醉在甲状腺手术患者中的应用[J].中外医学研究,2017,15(12):10-12.

[2] Kim J S,Ko J S,Bang S,et al.Cervical plexus block[J].Korean Journal of Anesthesiology,2018,71(4):274-288.

[3] Santosh B S,Mehandale S G.Does Dexmedetomidine improve analgesia of superficial cervical plexus block for thyroid surgery?[J].Indian Journal of Anaesthesia,2016,60(1):34.

[4]陈汉文,陈彦威,刘晓磊,等.右美托咪定复合罗哌卡因超声引导下颈丛阻滞对甲状腺手术术后镇痛的影响[J].广东医学,2016,37(23):2593-2595.

[5]陈凤萍,唐培佳.超声引导颈神经通路阻滞联合喉罩全麻在甲状腺手术中的应用效果[J].广西医学,2018,40(12):1326-1328.

[6] Uusalo P,J?tinvuori H,L?yttyniemi E,et al.Intranasal low-dose Dexmedetomidine reduces postoperative opioid requirement in patients undergoing hip arthroplasty under general anesthesia[J].Journal of Arthroplasty,2019,34(3):686-692.

[7] Karthikeyan V S,Sistla S C,Badhe A S,et al.Randomized controlled trial on the efficacy of bilateral superficial cervical plexus block in thyroidectomy[J].Pain Practice,2013,13(7):539-546.

[8] Lee M J,Koo D J,Choi Y S,et al.Dexamethasone or Dexmedetomidine as local anesthetic adjuvants for ultrasound-guided axillary brachial plexus blocks with nerve stimulation[J].The Korean Journal of Pain,2016,29(1):29-33.

[9] Li Y,Wang H,Deng Y,et al.Effect of Dexmedetomidine on supraclavicular brachial plexus block:a randomized double blind prospective study[J].Journal of Peking University:Health Sciences,2018,50(5):845-849.

[10] Kang M H,Lee H J,Lim Y J,et al.Preoperative Dexmedetomidine attenuates hemodynamic responses to hydrodissection in patients undergoing robotic thyroidectomy[J].Journal of Anesthesia,2015,30(2):191-197.

[11] Bakri M H,Ismail E A,Ibrahim A.Comparison of Dexmedetomidine and Dexamethasone for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy[J].Korean Journal of Anesthesiology,2015,68(3):254-260.

[12] Cai H D,Lin C Z,Yu C X,et al.Bilateral superficial cervical plexus block reduces postoperative nausea and vomiting and early postoperative pain after thyroidectomy[J].Journal of International Medical Research,2012,40(4):1390-1398.

(收稿日期:2019-07-10) (本文編辑:李盈)

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