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重度高血压伴心肌缺血行腹部急诊手术的麻醉处理
http://www.100md.com 《第四军医大学学报》 2000年第5期
     作者:白晓光 董辉 熊利泽 侯立朝 侯丽宏 杨新雷

    单位:白晓光(第四军医大学西京医院麻醉科,陕西 西安 710033);董辉(第四军医大学西京医院麻醉科,陕西 西安 710033);熊利泽(第四军医大学西京医院麻醉科,陕西 西安 710033);侯立朝(第四军医大学西京医院麻醉科,陕西 西安 710033);侯丽宏(第四军医大学西京医院麻醉科,陕西 西安 710033);杨新雷(第四军医大学西京医院麻醉科,陕西 西安 710033)

    关键词:高血压;心肌缺血;外科手术

    第四军医大学学报000547 摘 要: 目的 探讨高血压伴心肌缺血在全麻下行急诊腹部手术时应用佩尔地平、艾司洛尔及硝基甘油治疗的临床效果. 方法 上述患者24例,于诱导插管前及术毕拔管前,静注艾司洛尔、佩尔地平,分别观察静注后至30 min和20 min时收缩压(SBP), 舒张压(DBP), 心率(HR)的变化. 术中观察静滴硝基甘油至60 min及停药后至30 min, SBP, DBP, HR的变化. 结果 诱导插管前静注药物后2 min, SBP, DBP, HR即显著下降,SBP于25 min回升至原水平,HR于30 min回升至原水平. 术毕拔管前静注药物后,SBP, DBP, HR显著下降,且维持至20 min. 术中静滴硝基甘油时,SBP, DBP显著下降,且维持至停药后30 min,而HR无显著改变. 结论 应用佩尔地平、艾司洛尔及硝基甘油能显著降低高血压及心率增快,维持全麻诱导、拔管时血压、心率的平稳,维持术中血流动力学的稳定,且能减少各自用药量及其毒副反应.
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    中图号:R543.2 文献标识码:A

    文章编号:1000-2790(2000)05-S0090-03

    Anesthetic treatment for acute abdomen surgery complicated with severe hypertension and myocardial ischemia

    BAI Xiao-Guang, DONG Hui, XIONG Li-Ze, HOU Li-Chao, HOU Li-Hong, YANG Xin-Lei

    (Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an 710033, China)
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    Abstract: AIM To determine the clinical curative effect of perdipine, esmolol and nitroglycerin used in severe hypertension and myocardial ischemia complicated by acute abdomen surgery under general anesthesia. METHODS Twenty-four patients were observed. Before induction and intubation of anesthesia and extubation, esmolol and perdipine were in-fused and then the changes of systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) were observed from start to 20 or 30 minutes. During the operation, these changes were also observed from the start of venous dropping of nitroglycerin to 60 minutes and to 30 minutes after the stop of dropping nitroglycerin. RESULTS After infusion of esmolol and perdipine before induction and intubation of anesthesia, SBP, DBP and HR decreased from 2 to 20 minutes significantly, with SBP recovery in 25 minutes and HR recovery in 30 minutes. After infusion of those drugs before extubation, SBP, DBP and HR decreased significantly and were maintained for 20 minutes. During operation and continuously dropping nitroglycerin in veins, SBP and DBP decreased significantly from the start to 30 minutes, but HR didn't decrease. CONCLUSION Perdipine, esmolol and nitroglycerin can decrease hypertension and tachycardia significantly, maintain blood pressure and HR stability during induction and intubation of anesthesia and extubation, keep haemodynamics stable during operation and finally decrease the dosage of each drug and its side effects.
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    Keywords: hypertension; myocardial ischemia; surgery

    0 引言

    围术期伴重度高血压及心肌缺血对于非心脏手术患者是一个严重的临床问题[1-3],血压过高增加心肌耗氧,易诱发心肌梗死,脑血管意外而致死. 迅速控制高血压及心动过速能大大提高麻醉与手术安全性. 我们对24例患急性胆道疾病、梗阻性黄疸、肠梗阻等腹部疾患,术前伴高血压、心肌缺血及心动过速患者行全麻处理,麻醉过程中应用佩尔地平、艾司洛尔、硝酸甘油进行治疗,并观察其疗效及安全性.

    1 对象和方法

    1.1 对象 24(男14,女10)例,患腹部急性疾病患者,年龄51~76岁,体质量49~84 kg,患高血压病1~30 a伴心肌缺血、心动过速,在全麻下行急诊手术,术前30 min im东莨菪碱0.005 mg.kg-1(或成人0.3 mg),盐酸哌替啶50 mg,非那根25 mg. 入室后静脉输液、监测心电图、脉搏氧饱和度、血压、吸入氧浓度、呼末CO2浓度、尿量,全麻诱导时静注芬太尼2~4 μg.kg-1,异丙酚2 mg.kg-1,万可松0.08~0.1 mg.kg-1,插管后以Sulla 909呼吸机控制呼吸,吸入异氟醚15~30 g.L-1,芬太尼1~2 μg.kg-1.h-1 iv,万可松0.03~0.05 mg.kg-1维持麻醉与肌松.
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    1.2 方法 分别于诱导前给予静注佩尔地平10~20 μg.kg-1,艾司洛尔0.4~1.2 mg.kg-1,诱导后30 min始,静滴20 g.L-1硝基甘油10~20 μg.kg-1.h-1维持血压平稳,术毕停药后,以佩尔地平10~20 mg.kg-1及艾司洛尔0.4~1.2 mg.kg-1维持拔管血压及心率稳定. 观察诱导、插管前用药后0, 2, 5, 10, 15, 20, 25, 30 min,静滴硝基甘油后10, 20, 30, 60 min,停止静滴后10, 20, 30 min,拔管前给予艾司洛尔,佩尔地平后0, 3, 5, 10, 20 min, SBP, DBP, HR的变化.

    统计学处理: 所有数据均以±s表示,P<0.05为显著差异.
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    2 结果

    诱导时用药前后(Tab 1),硝基甘油静滴时(Tab 2)及拔管时(Tab 3) SBP, DBP和HR均有明显改变. 术毕,由于麻醉减浅,患者逐渐清醒,呼吸开始恢复,此时SBP, DBP及HR回升至较高水平.应用佩尔地平及艾司洛尔0, 3, 5, 10, 20 min,SBP, DBP和HR均显著下降(P<0.01).

    表1 诱导时用药前后SBP, DBP, HR的变化

    Tab 1 The changes of SBP, DBP, HR when infusion before induction (n=24, ±s) t/min

    p(SB)/kPa
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    p(DB)/kPa

    HR/

    (beat.min-1)

    0(control)

    24.9±1.8

    15.1±0.6

    119±6

    2(induction)

    20.1±0.9b

    12.2±0.3b

    74±5b
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    5(intubation)

    21.1±0.5b

    12.6±0.4b

    76±4b

    8

    19.5±1.2b

    11.9±0.9b

    75±6b

    10

    20.8±0.8b
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    10.9±0.5b

    75±6b

    15

    18.3±0.6b

    9.4±0.8b

    77±5b

    20

    16.9±0.2b

    10.1±0.9b

    79±7b
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    25

    24.1±1.1

    10.3±0.7b

    110±9b

    30

    23.9±0.8

    12.1±0.9

    116±5

    bP<0.01 vs control.

    SB: systolic blood; DB: diastolic blood.

, 百拇医药     3 讨论

    高血压伴心肌缺血患者,急诊手术围术期因紧张及应激常伴血压严重升高,且心率加快,心肌耗氧增加. 全麻诱导插管,手术中刺激及拔管时麻醉减浅均十分危险. 实验证明仅靠加深麻醉控制高血压易引起心肌抑制,冠脉窃血及术后低血压,故非最佳手段. 佩尔地平为钙通道阻滞剂,对伴有冠心病,心律失常,心肌缺血有重要作用[4-6]. 但也有报道其无防治心肌缺血作用,且易致心动过速,因而对急诊高血压伴心动过速患者,单用佩尔地平反而增加心脏做功及氧耗. 艾司洛尔为超短效高选择性β1受体阻滞剂,能有效防治围术期心肌缺血,减慢心率,降低心肌氧耗,有报道对术后中度高血压疗效较为理想,但对急诊异常高血压作用不稳定,剂量过大反致明显低血压[7,8]. 硝基甘油对心肌无抑制,静滴时作用迅速,可扩张冠脉,降低心室前、后负荷及血压,停药后无明显反跳性血压增高,但其不抑制心率,甚至引起代偿性心动过速,故对心肌缺血无明显减轻作用[9].
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    表2 硝基甘油静滴时SBP,DBP及HR变化

    Tab 2 The changes of SBP DBP HR during

    intravenous dropping nitroglycerin (n=24, ±s) t/min

    p(SB)/kPa

    p(DB)/kPa

    HR/

    (beat.min-1)

    0(control)
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    24.0±0.9

    13.2±0.9

    120±8

    10

    20.8±0.5b

    10.1±0.5b

    115±6

    20

    18.1±0.6b

    9.0±0.7b

    120±8
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    30

    19.8±0.4b

    9.9±0.3b

    110±8

    60

    17.4±0.9b

    8.1±0.7b

    115±7

    0(stop dropping)

    17.9±0.4b

    8.9±0.5b
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    118±8

    10

    18.4±0.8b

    9.1±0.4b

    115±7

    20

    19.0±0.8b

    9.3±0.9b

    120±7

    30

    19.8±0.3b
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    9.1±0.8b

    117±6

    bP<0.01 vs control. SB, DB: The same as Tab 1.表3 拔管时SBP,DBP,HR的变化

    Tab 3 The changes of SBP DBP HR when extubation (n=24, ±s) t/min

    p(SB)/kPa

    p(DB)/kPa

    HR/

    (beat.min-1)
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    0(control)

    23.6±0.8

    14.0±0.6

    117±5

    3

    19.4±1.1b

    10.1±0.5b

    80±6b

    5(extubation)

    20.0±0.5b

    10.7±0.4b
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    81±7b

    10

    18.4±0.7b

    9.7±1.1b

    78±4a

    20

    18.5±0.8b

    10.2±0.9b

    83±6b

    aP<0.05, bP<0.001 vs control.
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    SB, DB: The same as Tab 1.

    我们联合应用艾司洛尔及佩尔地平,治疗急腹症伴发异常高血压心肌缺血,心率增快患者,控制麻醉诱导插管及拔管时的刺激反应,并于术中以硝基甘油静滴治疗术中高血压,结果表明艾司洛尔、佩尔地平合用时能有效降低血压及心率,从而改善心肌供血及供氧,防止心肌梗死、脑血管意外的发生,且可减少二者药量及各自副作用. 术中硝基甘油持续静滴不仅降低高血压,且扩张冠脉,保护心肌,维持术中血压平稳,与用药前相比有显著差别. 值得注意的是,术中硝基甘油对心率无作用,且高血压伴心肌缺血围术期心肌梗死的峰值多发生于术后次日晚上[10],机制有待进一步临床观察和研究.

    作者简介:白晓光(1963-), 男(汉族), 陕西省西安市人. 硕士, 主治医师, 讲师. Tel.(029)3375343;3375337

    参考文献:
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    [1] Mangano DT, Dennis T. Perioperative cardiac morbidity [J]. Anesthesiology, 1990;72(1):153-184.

    [2] Eagle KA, Brundage BH, Chaitman BR et al. Guidelines for perioperative cardicvascular evaluation for noncardiac surgery [J]. Circulation, 1996;93(8):1278-1311.

    [3] Edward J, Roccella PM. Joint national committee on detection, evaluation, and treatment of high blood pressure, fifth report [J]. Arch Intern Med, 1998;153(2):154-183.
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    [4] Lambert CR, Pepine CJ. Effects of intravenous and intracoronary nicardipine [J]. Am J Cardiol, 1989;64(15):8H-15H.

    [5] Wallin JD, Cook ME, Blanski L et al. Intravenous nicardipine for treatment of severe hypertension [J]. Am J Med, 1998;85(2):331-335.

    [6] 张艳华, 顾 虎. 佩尔地平控制术后高血压的临床观察[J]. 临床麻醉学杂志, 1999;6,15(3):183.

    [7] Gray RJ, Bateman TM, Czer LS et al. Esmolol a new ultra-short acting beta-adrenergic blocking agent for rapid control of heart rate in postoperative supraventricular arrhythmias [J]. J Am Coll Cardiol, 1985;5(11):1451-1456.
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    [8] Kapnoudhis P, Vaaghadia H, Jenkins ZC et al. Esmolol versus fentanyl for preventing haemodynamic response to intubation in cardiovascular disease [J]. Can J Anesth, 1999;37(Suppl):145.

    [9] Dodds TM, Stone JG, Coromilas JS et al. Prophylactic nitroglycerin infusion during noncardiac surgery does not reduce perioperative ischemia [J]. Anesth Analg, 1993;76(5):705-713.

    [10] Brown MD, Teresa V, Norick BN et al. Myocardial infarction after noncardiac surgery [J]. Anesthesiology, 1998;88(4):572-578.

    收稿日期:2000-01-21; 修回日期:2000-03-01, http://www.100md.com