黄重峰+焦丰+潘英芳+李铨华+郭名文+吴文鴶

【摘要】 目的：探讨右美托咪定（Dex）对全麻经皮肾镜取石术患者循环及应激反应的影响。方法：选取2014年8月-2016年3月本院收治的择期全麻下行经皮肾镜取石术患者75例作为研究对象，按随机数字表法分为Dex低剂量组（D1组）、高剂量组（D2组）及对照组（C组），每组25例。D1、D2组于麻醉诱导前10 min内分别给予负荷剂量0.5 μg/kg、1.0 μg/kg，术中维持速度分别为0.2 μg/（kg·h）、0.4 μg/（kg·h）；C组给予等量生理盐水。记录三组患者麻醉前（T0）、气管插管即刻（T1）、经尿道置入输尿管时（T2）、体位变成俯卧位后10 min（T3）、进行肾脏穿刺时（T4）、碎石30 min（T5）、碎石60 min（T6）、气管拔管后5 min（T7）各时点心率（HP）、收缩压（SBP）、舒张压（DBP），测定T0、T1、T4、T5、T6、T7血浆肾上腺素（E）、去甲肾上腺素（NE）、血浆皮质醇（Cor）及血糖（Glu）浓度，并根据躁动评分记录患者术后发生躁动例数。结果：与T0时比较，C组T1、T4～T7时SBP、DBP均显著升高（P<0.05），与T0时比较，C组T1～T7时HR均显著升高（P<0.05）。D1、D2组各时点SBP、DBP、HR比较差异均无统计学意义（P>0.05）。与C组比较，D1、D2组T1、T4～T7时SBP、DBP均显著降低，D1、D2组T1～T7时HR均显著降低（P<0.05）。与D1组比较，D2组T2、T5时HR显著降低（P<0.05）。三组患者T1、T4～T7时E、NE及Cor浓度均显著高于T0时（P<0.05），与C组比较，D1、D2组T1、T4～T7时E、NE及Cor浓度均显著降低（P<0.05），与T0比较，C组T1、T4～T7时Glu浓度均明显升高（P<0.05），D1、D2组T4～T7时Glu浓度均明显升高（P<0.05），与C组比较，D1、D2组T1、T4～T7时Glu浓度均明显降低（P<0.05）。D1、D2组躁动评分0～1分分别为21例（84%）和22例（88%），均明显多于C组的14例（56%）（P<0.05）。结论：Dex能够增加围术期血流动力学的稳定，较为有效地降低全麻下经皮肾镜取石术引起的应激反应，为手术创造有利条件。

【关键词】 右美托咪定； 经皮肾镜取石术； 血流动力学； 应激反应

【Abstract】 Objective：To investigate the effect of Dexmedetomidine on circulation and stress reaction in patients undergoing percutaneous nephrolithotomy with general anesthesia.Method：From August 2014 to March 2016，75 cases of undergoing percutaneous nephrolithotomy with general anesthesia in our hospital were selected as the research objects，they were randomly divided into the Dex low dose group（group D1），high dose group（group D2） and control group（group C），each group had 25 cases.Group D1 and D2 were given 0.5 μg/kg and 1.0 μg/kg loading dose of Dex within 10 min before endotrachael intubation，while 0.2 μg/（kg·h） and 0.4 μg/（kg·h） were pumped with micropump until the end of the operation.Group C was offered the same amount of physiological saline.The parameters of heart rate（HR），systolic blood pressure（SBP），diastolic blood pressure（DBP） were recorded before anesthesia induction（T0），immediately after intubation（T1），insertion of ureter by urethra（T2），10 min after prone position（T3），when renal puncture（T4），30 min started lithotripsy（T5），60 min started lithotripsy（T6） and 5 min after extubation（T7）.Concentrations of blood epinephrine（E），norepinephrine（NE），cortisol（Cor）and glucose（Glu） were measured at T0，T1，T4，T5，T6 and T7 time.The number of restless were occurred after operation according to the agitation score.Result：Compared with T0，SBP and DBP at T1，T4-T7 and HR at T1-T7 in group C were increased significantly（P<0.05），and there were no significant differences at T1-T7 in group D1 and D2.Compared with group C，SBP and DBP at T1，T4-T7 and HR at T1-T7 in group D1 and D2 were decreased significantly（P<0.05）.Compared with group D1，HR at T2 and T5 in group D2 was decreased significantly（P<0.05）.Concentrations of blood E，NE and Cor at T1，T4-T7 were increased significantly in three groups than T0.Compared with group C，concentrations of blood E，NE and Cor at T1，T4-T7 in group D1 and D2 were decreased significantly（P<0.05）.Compared with T0，concentrations of blood Glu at T1，T4-T7 in group C and at T4-T7 in group D1 and D2 were increased significantly（P<0.05）.Compared with group C，concentrations of blood Glu at T4-T7 in group D1 and D2 were decreased significantly（P<0.05）.21 cases（84%） and 22 cases （88%）agitation score respectively were 0-1 in group D1 and D2，all more than 14 cases（56%） in group C（P<0.05）.Conclusion：Dexmedetomidine can increase hemodynamic stability during perioperative period，effectively reduce the stress reaction undergoing percutaneous nephrolithotomy with general anesthesia，create a favorable condition for the operation.

【Key words】 Dexmedetomidine； Percutaneous nephrolithotomy； Hemodynamics； Stress reaction

First-authors address：Ganzhou Municipal Hospital，Ganzhou 341000，China

doi：10.3969/j.issn.1674-4985.2016.30.023

经皮肾镜取石术（percutaneous nephrolithotomy，PCNL）因其创伤小、结石取出率高、术后恢复快及并发症少等优点而深受医患双方欢迎，成为目前治疗泌尿系统结石最为有效的一种微创手术方法[1-2]。然而经皮肾镜手术围术期2次体位改变和术中大量灌洗液的持续灌注，可引起机体代谢、神经内分泌及血流动力学改变，加之麻醉和手术等因素刺激可导致全身应激反应，甚至出现全身炎性反应综合征从而使机体出现各种并发症，严重者可诱发冠状动脉痉挛、心律失常等可能，继而影响患者的转归及预后[3-7]。因此，保证术中循环稳定和抑制围术期应激反应成为临床麻醉中一个重要课题。……