腹腔鏡下子宮全切術(shù)45例患者不同麻醉方法的應(yīng)激反應(yīng)比較

1、腹腔鏡下子宮全切術(shù)45例患者不同麻醉方法的應(yīng)激反應(yīng)比較         11-02-10 09:25:00     作者：黃澤波    編輯：studa20【摘要】  目的：探討不同麻醉方法對(duì)機(jī)體的應(yīng)激反應(yīng)情況。方法：對(duì)2008年6月2009 年1月在我院擇期行腹腔鏡下子宮全切術(shù)45例患者，隨機(jī)分為全麻復(fù)合硬膜外麻醉組(A組)23例和全麻組(B組)22例，比較兩組患者在麻醉前、麻醉后5min、術(shù)中、術(shù)畢等不同時(shí)間點(diǎn)的腎素、血管

2、緊張素、醛固酮、皮質(zhì)醇、胰島素、血糖、生長素等指標(biāo)的變化情況。結(jié)果：兩組血糖均于麻醉5min后下降，與麻醉前比差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)；術(shù)中A組血糖恢復(fù)至麻醉前水平, 差異無統(tǒng)計(jì)學(xué)意義（P>0.05）;而B組則較麻醉前顯著增高(P<0.05)；術(shù)畢兩組血糖均較麻醉前顯著升高,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。A組患者在術(shù)中及術(shù)畢的血糖變化與B組比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；兩組患者麻醉前內(nèi)分泌各指標(biāo)（腎素、血管緊張素、醛固酮、皮質(zhì)醇、胰島素、生長素）水平比較，差異均無統(tǒng)計(jì)學(xué)意義（P>0.05）。麻醉后A組患者的血管緊張素、醛固酮、皮質(zhì)醇、

3、胰島素、生長素和B組的血管緊張素、醛固酮等指標(biāo)在不同時(shí)間點(diǎn)的變化與與麻醉前比，差異均無統(tǒng)計(jì)學(xué)意義(P>0.05）；而在麻醉5min、術(shù)中、術(shù)畢時(shí)，A組患者腎素活性則均較麻醉前有所下降,而B組腎素活性則在術(shù)中時(shí)較麻醉前升高,差異均有統(tǒng)計(jì)學(xué)意義（P<0.05）。B組皮質(zhì)醇、生長素則于術(shù)中、術(shù)畢較麻醉前顯著升高,胰島素則在術(shù)中、術(shù)畢時(shí)較麻醉前顯著降低，差異有統(tǒng)計(jì)學(xué)意義（P<0.05）。術(shù)中A組腎素、皮質(zhì)醇、胰島素、生長素水平與B組比較，差異均有統(tǒng)計(jì)學(xué)意義（P<0.05）。結(jié)論：兩種麻醉方法均引起應(yīng)激反應(yīng),但全麻復(fù)合硬膜外麻醉較單純?nèi)橐鸬膽?yīng)激反應(yīng)輕，利于患者術(shù)后轉(zhuǎn)歸。 【關(guān)

4、鍵詞】  硬膜外麻醉；全身麻醉；內(nèi)鏡，子宮切除術(shù)；應(yīng)激反應(yīng)ABSTRACT Objective: To observe stress responses in patients anaesthetized by different methods during laparoscopic hysterectomy. Methods: Forty five patients that underwent scheduled laparoscopic hysterectomy June 2008 January 2009 in our hospital were randomly divi

5、ded into general anesthesia combined with epidural anesthesia group (group A, 23 cases) and general anesthesia group (group B, 22 cases). Changes in parameters including renin, angiotensin , aldosterone, cortisol, insulin, glucose, growth hormone were recorded and compared before the start of anesth

6、esia, 5 min after anesthesia, during the surgery. Results: Blood glucose decreased 5 min after anesthesia in both groups showing significant differences compared that before anesthesia (P<0.05); however, it came back to the original levels in group A (P>0.05) and even higher than the original

7、one in group B during the surgery (P<0.05). When the surgery ended, blood glucose were higher than that before the operation in both groups (P<0.05). The original levels of renin, angiotensin , aldosterone, cortisol, insulin, glucose, growth hormone were not significant different between group

8、 A and group B. In group A, no changes in these parameters were found (P>0.05) except for rennin, which decreased significantly 5 min at the observed time points. On the contrary, rennin increased significant in group B (P<0.05). During the surgery, levels of renin, cortisol, insulin, growth h

9、ormone in group A were significant different from that in group B (P<0.05). Conclusion: Stress responses can be induced by both general anesthesia combined with epidural anesthesiaand general anesthesia, but less by the former one, which is favorable for the patients prognosis.   

10、KEY WORDS Epidural anesthesia; General anesthesia; Endoscopic hysterectomy; Stress response     應(yīng)激反應(yīng)是機(jī)體在突然受到強(qiáng)烈有害刺激(如創(chuàng)傷、手術(shù)、饑餓等)時(shí)，通過下丘腦引起血中促腎上腺皮質(zhì)激素濃度迅速升高，糖皮質(zhì)激素大量分泌，是機(jī)體對(duì)外界刺激的一種非特異性防御反應(yīng)，屬生理現(xiàn)象1,2。手術(shù)和麻醉均會(huì)引起機(jī)體的應(yīng)激反應(yīng)，而麻醉方法的不同對(duì)應(yīng)激反應(yīng)的影響也不相同，為此，探討不同麻醉方法對(duì)患者應(yīng)激反應(yīng)的影響有利降低患者并發(fā)癥的發(fā)生率，促進(jìn)患者術(shù)后恢復(fù)。我院2008年

11、6月2009 年1月?lián)衿谛懈骨荤R下子宮全切術(shù)45例，本文分析了不同麻醉方法對(duì)患者術(shù)中應(yīng)激反應(yīng)的影響，現(xiàn)報(bào)道如下。1  資料與方法1.1  一般資料    2008年6月2009 年1月在我院擇期行腹腔鏡下子宮全切術(shù)45例患者，年齡3060歲，按美國麻醉學(xué)會(huì)( american society of anesthesiologists, ASA)分級(jí)為12級(jí)。無嚴(yán)重肝腎功能異常，無內(nèi)分泌疾病及未進(jìn)行過影響內(nèi)分泌功能治療。隨機(jī)分為全麻復(fù)合硬膜外麻醉組(A組)23例和全麻組(B組)22例，兩組患者ASA分級(jí)、年齡、體重、身高、麻醉時(shí)間、手術(shù)時(shí)間等一般

12、資料比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，具有可比性。1.2  方法    術(shù)前30min兩組患者均肌肉注射苯巴比妥鈉0.1g及阿托品0.5mg, A 組穿刺點(diǎn)選擇L2-3 椎間隙，注入2%利多卡因3mL后，頭向置管，確認(rèn)出現(xiàn)相對(duì)麻醉平面后，往硬膜外腔注入0.5%羅哌卡因15mL，全麻誘導(dǎo)采用咪達(dá)唑侖0.06mg/kg，芬太尼46g/kg，異丙酚2mg/kg，維庫溴銨0.10.2mg/kg 依次緩慢靜脈推注進(jìn)行，麻醉誘導(dǎo)氣管插管后接麻醉機(jī)行機(jī)械通氣，潮氣量(VT)810mL/kg,吸呼比(I/E)11.5,呼吸頻率(RR)12次/min。全麻以異

13、氟醚維庫溴銨進(jìn)行維持。B組除無需硬膜外阻滯外，其余方法與A組同，但異氟醚濃度加大。術(shù)中靜脈輸液以林格氏液為主, 均不輸血。1.3  觀察指標(biāo)    黃澤波.腹腔鏡下子宮全切術(shù)45例患者不同麻醉方法的應(yīng)激反應(yīng)比較  兩組患者分別于麻醉前、麻醉后5min、術(shù)中、術(shù)畢不同時(shí)間點(diǎn)抽取5mL/次靜脈血,進(jìn)行血?dú)夥治?，測定血糖變化。采用放射免疫法監(jiān)測患者內(nèi)分泌指標(biāo)變化同時(shí)監(jiān)測各時(shí)點(diǎn)的血壓、心率、脈搏氧飽和度等血流動(dòng)力學(xué)指標(biāo)變化。1.4  統(tǒng)計(jì)學(xué)處理    數(shù)據(jù)以±s 表示,采用SASS 10.0軟件包行統(tǒng)計(jì)

14、學(xué)處理,組間比較分析采用t檢驗(yàn)，P<0.05為差異有統(tǒng)計(jì)學(xué)意義。2  結(jié)果2.1  兩組血糖各時(shí)間點(diǎn)的變化    兩組患者血糖均于麻醉5min后下降，與麻醉前比差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);術(shù)中A組血糖恢復(fù)至麻醉前水平, 差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，而B組則較麻醉前顯著增高(P<0.05)；術(shù)畢兩組血糖均較麻醉前顯著升高,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。A組患者在術(shù)中及術(shù)畢的血糖變化與B組比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見表1。表1  兩組患者不同時(shí)間點(diǎn)血糖變化情況 mmol/L（±s）   組別n麻醉前麻醉5min術(shù)中術(shù)畢A組235.4