不同麻醉方法在支气管镜检查中的麻醉效果及对顺行性遗忘的影响

Anesthetic effects and anterograde amnesia of different anesthetic methods for bronchoscopy

摘要:

目的 比较术中生命体征变化和顺行性遗忘在咪达唑仑联合舒芬太尼麻醉（咪唑组）、丙泊酚联合瑞芬太尼麻醉（丙泊酚组）支气管镜检查中的差异，探讨无痛清醒支气管镜检查发生顺行性遗忘的影响因素。方法 选取2020年1月－2020年3月中南大学湘雅医院110例常规行支气管镜检查的患者，随机分为咪唑组（n = 68）及丙泊酚组（n = 42），记录两组患者麻醉诱导前（T₁）、麻醉诱导后（T₂）、内镜经过声门时（T₃）、内镜检查中（T₄）及术毕时（T₅）心率（HR）、呼吸频率（RR）、收缩压（SBP）、舒张压（DBP）和经皮动脉血氧饱和度（SpO₂）的变化、顺行性遗忘程度及不良反应等。结果 咪唑组与丙泊酚组的HR、RR、SBP、DBP和SpO₂比较，差异均有统计学意义（F = 40.73、F = 58.11、F = 58.66、F = 48.89和F = 30.19，P = 0.000）。与丙泊酚组相比，咪唑组T₂～T₅时点的HR、RR、SBP和DBP均明显升高（P = 0.000），咪唑组Steward苏醒评分（Z = 4.65，P = 0.000）、检查费用（t = 25.91，P = 0.000）明显优于丙泊酚组。丙泊酚组顺行性遗忘程度优于咪唑组（U = 504.00，P = 0.000）。两组患者插管抵抗评分比较，差异无统计学意义（Z = -1.17，P = 0.241）。咪唑组中，年龄 > 60岁（OR＾ = 3.005，95%CI：1.118～8.077）、咪达唑仑 > 2.0 mg（OR＾ = 5.090，95%CI：1.374～18.859）、HR ≤ 88.6次/min（OR＾ = 3.916，95%CI：1.434～10.694）是顺行性遗忘效果较好的独立影响因素。结论 行支气管镜检查时使用咪达唑仑联合舒芬太尼，患者血流动力学稳定性、Steward苏醒评分、检查费用优于丙泊酚组，但丙泊酚组顺行性遗忘效果、咳嗽评分、喘憋发生情况优于咪唑组。年龄、咪达唑仑用量和镇静程度是顺行性遗忘的影响因素，临床中可以根据患者不同需求选择相应的麻醉方法及剂量。

Abstract:

Objective To compare the hemodynamic response and anterograde amnesia in midazolam combined with sufentanil and propofol combined with remifentanil in bronchoscopy, and investigate the influencing factors of anterograde amnesia in bronchoscopy with midazolam and sufentanil.Methods 110 patients underwent bronchoscopy from January 2020 to March 2020 were randomly divided into two groups: midazolam combined with sufentanil (midazolam group) (n = 68) and propofol combined with remifentanil (propofol group) (n = 42). Changes of heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP), percutaneous arterial oxygen saturation (SpO₂), the degree of anterograde amnesia and adverse reactions were recorded at five time points: before induction of anesthesia (T₁), 1 min after anaesthetic administration (T₂), when bronchoscope passes through the glottis (T₃), during bronchoscopy (T₄) and after operation (T₅).Results There were significant differences in HR, RR, SBP, DBP and SpO₂ between midazolam group and propofol group (F = 40.73, F = 58.11, F = 58.66, F = 48.89, F = 30.19, P = 0.000). The HR, RR, SBP and DBP in midazolam group at T₂ ~ T₅ were significantly higher than those in propofol group (P = 0.000). The midazolam group had better Steward recovery score (Z = 4.65, P = 0.000) and lower examination cost (t = 25.91, P = 0.000) than the propofol group. Anterograde amnesia in the propofol group was better than that in the midazolam group (U = 504.00, P = 0.000). There was no significant difference in intubation resistance score between the two groups (Z = -1.17, P = 0.241). In the midazolam group, older than 60 years (OR＾ = 3.005, 95%CI: 1.118~8.077), dosage of midazolam > 2.0 mg (OR＾ = 5.090, 95%CI: 1.374~18.859), HR ≤ 88.6 beats/min (OR＾ = 3.916, 95%CI: 1.434 ~ 10.694) were all independent influencing factors of better anterograde amnesia.Conclusion During bronchoscopy, midazolam combined with sufentanil was superior to the propofol group in terms of hemodynamic stability, Steward recovery score and cost, but the propofol group was superior to the midazolam group in terms of anterograd amnesia, cough score and the incidence of dyspnea. Age, dosage of midazolam and degree of sedation are the influencing factors of anterograde amnesia. Anesthesia methods and doses can be selected according to different needs of patients in clinical practice.