Application of Different Doses of Remifentanil Combined with Sevoflurane in Ambulatory Laparoscopic Cholecystectomy under Pain Threshold Index Monitoring
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摘要:
目的 探讨镇痛指数（PTi）监测下不同剂量瑞芬太尼复合七氟烷在日间腹腔镜胆囊切除术中的应用价值。 方法 选取2023年12月至2024年6月在昆明医科大学第二附属医院全麻下行腹腔镜胆囊切除术日间患者152例，采用随机数字表法分为R1组（n = 38）、R2组（n = 38）、R3组（n = 38）、R4组（n = 38）。在七氟烷0.7最小肺泡内有效浓度（MAC）的基础上，R1～R4组患者分别复合0.1、0.2、0.3、0.4 μg/.（kg·min）瑞芬太尼。比较四组患者不同时间点PTi改变，术前、术后血液应激指标[皮质醇（Cor）、去甲肾上腺素（NE）、血糖（Glu）浓度]变化，并记录四组患者术中高血压、低血压、心动过速、心动过缓发生率和术后恶心、呕吐发生情况。 结果 与R1组比较，R2组、R3组、R4组在手术开始（T3）～拔管后5 min（T11）时刻的PTi均下降（P < 0.05）；与R2组比较，R3组、R4组在T3～T11时刻的PTi均低于R2组（P < 0.05）；与R3组比较，R4组在不同时刻PTi的变化差异无统计学意义（P > 0.05）。术后四组患者Cor、NE、血糖浓度值比较差异均具有统计学差异（P < 0.001），但术前均无统计学意义（P > 0.05）。相比于术前，四组患者的Cor、NE和Glu值均显著增加（P < 0.001），且R1组>R2组>R4组>R3组。四组患者术中高血压、低血压、心动过缓、心动过速发生率均具有统计学差异（P < 0.001），且R4>R1>R2=R3。四组患者术后恶心和呕吐的发生率具有统计学差异（P < 0.001），且R1组>R4组>R2组>R3组。 结论 0.7MAC七氟烷复合0.3 μg/（kg·min）瑞芬太尼对日间腹腔镜胆囊切除术患者具有较好的镇痛效果，减少了应激反应，且安全性高，值得临床推广使用。 Abstract:Objective To investigate the application value of different doses of remifentanil combined with sevoflurane under pain threshold index （PTi） monitoring in ambulatory laparoscopic cholecystectomy. Methods 152 patients undergoing laparoscopic cholecystectomy under general anesthesia were selected from December 2023 to June 2024 at the Second Affiliated Hospital of Kunming Medical University. Patients were randomly divided into R1 group （n = 38）, R2 group （n = 38）, R3 group （n = 38）, and R4 group （n = 38） using a random number table. On the basis of sevoflurane at 0.7 minimum alveolar concentration （MAC）, patients in R1～R4 groups were combined with 0.1, 0.2, 0.3, and 0.4 μg/kg·min remifentanil, respectively. The changes in PTi at different time points, pre- and post-operative blood stress indicators [cortisol （Cor）, norepinephrine （NE）, and blood glucose （Glu） concentrations] were compared, and the incidence of intraoperative hypertension, hypotension, tachycardia, bradycardia, and postoperative nausea and vomiting were recorded. Results Compared with R1 group, PTi in R2, R3, and R4 groups decreased from the start of surgery （T3） to 5 min after extubation （T11） （P < 0.05）; compared with R2 group, PTi in R3 and R4 groups was lower at T3～T11 （P < 0.05）; no statistically significant difference was found in PTi changes between R3 and R4 groups at different time points （P > 0.05）. Postoperative Cor, NE, and Glu concentrations showed statistically significant differences among the four groups （P < 0.001）, but no significant difference was found preoperatively （P > 0.05）. Compared with preoperative values, Cor, NE, and Glu levels significantly increased in all groups （P < 0.001）, with R1 group > R2 group > R4 group > R3 group. The incidence of intraoperative hypertension, hypotension, bradycardia, and tachycardia showed statistically significant differences （P < 0.001）, with R4 > R1 > R2 = R3. The incidence of postoperative nausea and vomiting also showed statistically significant differences （P < 0.001）, with R1 group > R4 group > R2 group > R3 group. Conclusion Sevoflurane at 0.7 MAC combined with 0.3 μg/kg·min remifentanil provides good analgesic effects for patients undergoing ambulatory laparoscopic cholecystectomy, reduces stress response, and has high safety, making it worthy of clinical promotion. -
Key words:
- Sevoflurane /
- Remifentanil /
- General anesthesia /
- Pain threshold index /
- Laparoscopy /
- Cholecystectomy
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表 1 四组患者一般资料比较[（$ \bar x \pm s $）/n（%）]
Table 1. Comparison of general data among the four groups[（$ \bar x \pm s $）/n（%）]
资料 R1（n=38） R2（n=38） R3（n=38） R4（n=38） χ2/F P 性别 6.314 0.097 男 14（36.84） 7（18.42） 14（36.84） 17（44.74） 女 24（63.16） 31（81.58） 24（63.16） 21（55.26） 年龄（岁） 41.84 ± 11.58 38.29 ± 12.24 42.97 ± 12.02 46.18 ± 11.53 2.075 0.106 BMI （kg/m2） 22.60 ± 2.35 23.28 ± 3.82 24.24 ± 2.22 23.97 ± 2.82 2.494 0.062 ASA分级 0.927 0.988 I级 12（31.58） 11（28.95） 14（36.84） 13（34.21） Ⅱ级 14（36.84） 16（42.10） 13（34.21） 15（39.47） Ⅲ级 12（31.58） 11（28.95） 11（28.95） 10（21.32） 手术时间（min） 50.47 ± 17.57 45.26 ± 15.82 51.29 ± 12.55 51.68 ± 15.08 1.435 0.235 
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表 2 四组患者PTi比较（$ \bar x \pm s $）
Table 2. Comparison of PTi value among the four groups （$ \bar x \pm s $）
组别 R1（n=38） R2（n=38） R3（n=38） R4（n=38） F P PTi （T0） 96.00 ± 2.32 93.89 ± 4.37## 93.71 ± 5.23## 92.71 ± 4.60### 3.920 0.010* PTi （T1） 65.42 ± 7.66&&& 67.13 ± 3.91&&& 65.71 ± 4.39&&& 63.71 ± 6.19&&& 2.276 0.082 PTi （T2） 63.39 ± 5.21&&& 64.21 ± 5.22&&& 63.61 ± 4.95&&& 62.95 ± 3.86&&& 0.447 0.720 PTi （T3） 62.45 ± 5.22&&& 60.95 ± 5.95&&& 57.66 ± 2.52&&&### 55.87 ± 4.97&&&### 14.642 <0.001* PTi （T4） 64.26 ± 5.73&&& 62.89 ± 6.06&&& 57.11 ± 4.65&&&###$$$ 56.97 ± 3.11&&&###$$$ 21.959 <0.001* PTi （T5） 64.89 ± 4.22&&& 62.84 ± 6.54&&& 57.58 ± 4.69&&&###$$$ 57.05 ± 4.97&&&###$$$ 21.358 <0.001* PTi （T6） 62.74 ± 4.75&&& 58.84 ± 13.17&&&### 57.55 ± 3.05&&&###$$$ 52.34 ± 12.13&&&###$$$ 7.946 <0.001* PTi （T7） 64.89 ± 4.40&&& 62.89 ± 2.69&&& 55.68 ± 4.21&&&###$$$ 52.42 ± 12.19&&&###$$$ 24.220 <0.001* PTi （T8） 68.00 ± 4.30&&& 66.29 ± 4.91&&& 60.53 ± 6.62&&&###$$$ 58.87 ± 4.29&&&###$$$ 28.171 <0.001* PTi （T9） 89.03 ± 6.03&&& 86.13 ± 7.17&&& 88.97 ± 7.35&&& 87.71 ± 7.47&&& 1.428 0.237 PTi （T10） 91.24 ± 6.13&&& 90.23 ± 7.94&&& 90.32 ± 6.76&&& 90.00 ± 7.06&&& 0.229 0.876 PTi （T11） 90.61 ± 5.55&&& 88.92 ± 7.78&&& 89.53 ± 6.53&&& 88.68 ± 6.85&&& 0.618 0.605 F 250.973 139.702 209.979 318.503 P <0.001* <0.001* <0.001* <0.001* *P < 0.05；与T0时点比较，&&&P < 0.001；与R1组比较，##P < 0.01，###P < 0.001；与R2组比较，$$$P < 0.001。
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表 3 四组患者术前术后应激指标对比（$ \bar x \pm s $）
Table 3. Comparison of preoperative and postoperative stress indicators among the four groups （$ \bar x \pm s $）
项目 R1（n=38） R2（n=38） R3（n=38） R4（n=38） F P Cor （μg/L） 术前 88.37 ± 0.91 88.69 ± 1.00 88.78 ± 0.76 88.63 ± 0.96 1.409 0.243 术后 97.48 ± 0.85 97.08 ± 0.64a 95.26 ± 0.61ab 95.38 ± 0.51ab 113.548 <0.001* t −45.021 −43.603 −41.160 −33.364 P <0.001* <0.001* <0.001* <0.001* NE （μg/L） 术前 26.33 ± 0.99 26.83 ± 0.74 26.97 ± 0.70 27.22 ± 1.88a 3.876 0.011* 术后 32.03 ± 0.62 31.53 ± 0.69a 29.09 ± 0.67ab 29.22 ± 0.55ab 219.829 <0.001* t −30.220 −28.749 −13.517 −6.304 P <0.001* <0.001* <0.001* <0.001* Glu （mmol/L） 术前 5.93 ± 1.17 5.83 ± 1.38 5.95 ± 1.09 6.26 ± 1.08 0.921 0.432 术后 9.59 ± 0.68 8.90 ± 0.55a 6.81 ± 1.04ab 6.87 ± 0.97ab 109.745 <0.001* t −16.689 −12.692 −3.484 −2.564 P <0.001* <0.001* <0.001* 0.006* *P < 0.05；与R1组比较，aP < 0.05；与R2组比较，bP < 0.05；与R3组比较，cP < 0.05。
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表 4 四组患者术中高血压、低血压、心动过缓、心动过速发生率对比[n（%）]
Table 4. Comparison of the incidence of intraoperative hypertension，hypotension，bradycardia，and tachycardia among the four groups [n（%）]
组别 高血压 低血压 心动过缓 心动过速 合计 R1（n=38） 14 （36.84） 2 （5.26） 3 （7.89） 2 （5.26） 21 （70.00） R2（n=38） 6 （15.79） 2 （5.26） 3 （7.89） 1 （2.63） 12 （31.58） R3（n=38） 0 （0.00）ab 7 （18.42） 5 （13.16） 0 （0.00） 12 （31.58） R4（n=38） 0 （0.00）ab 18 （47.37）abc 12 （31.58）ab 0 （0.00） 30 （78.95） χ2 30.400 29.105 11.219 3.740 23.451 P <0.001* <0.001* 0.011* 0.291 <0.001* *P < 0.05；与R1组比较，aP < 0.05；与R2组比较，bP < 0.05；与R3组比较，cP < 0.05。
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表 5 四组患者术后24 h内并发症对比[n（%）]
Table 5. Comparison of postoperative complications within 24 h among the four groups[n（%）]
组别 恶心 呕吐 总发生率 R1（n=38） 16 （42.10） 10 （26.32） 26 （68.42） R2（n=38） 7 （18.42）a 3 （7.89）a 10 （26.32） R3（n=38） 6 （15.79）a 2 （5.26）a 8 （21.05） R4（n=38） 15 （39.47）bc 9 （23.68）c 24 （63.16） χ2 10.492 9.896 27.675 P 0.015* 0.019* <0.001* *P < 0.05；与R1组比较，aP < 0.05；与R2组比较，bP < 0.05；与R3组比较，cP < 0.05。
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[1] Greene B,Tsang M,Jayaraman S. The inferior boundary of dissection as a novel landmark for safe laparoscopic cholecystectomy[J]. HPB (Oxford),2021,23(7):981-983. doi: 10.1016/j.hpb.2021.02.004 [2] Balciscueta I,Barberà F,Lorenzo J,et al. Ambulatory laparoscopic cholecystectomy: Systematic review and meta-analysis of predictors of failure[J]. Surgery,2021,170(2):373-382. doi: 10.1016/j.surg.2020.12.029 [3] 田德明,胡文晟. 腹腔镜胆囊切除术应用七氟烷复合瑞芬太尼麻醉的效果研究[J]. 中国实验诊断学,2024,28(8):951-953. doi: 10.3969/j.issn.1007-4287.2024.08.017 [4] 郑磊. 七氟烷吸入麻醉与丙泊酚泵注麻醉用于腹腔镜下胆囊切除术的麻醉效果比较[J]. 基层医学论坛,2024,28(1):94-96+120. [5] 吕兰清,李烨华,沈丹萍. 腹腔镜胆囊切除术中七氟烷与丙泊酚麻醉效果比较研究[J]. 系统医学,2024,9(22):56-59. [6] 王晓阁,丁萌,孙瑜,等. 瑞芬太尼的临床应用进展[J]. 天津药学,2023,35(6):67-71. doi: 10.3969/j.issn.1006-5687.2023.06.016 [7] Hughes L M,Irwin M G,Nestor C C. Alternatives to remifentanil for the analgesic component of total intravenous anaesthesia: A narrative review[J]. Anaesthesia,2023,78(5):620-625. doi: 10.1111/anae.15952 [8] 苏双,刘敏,刘丹丹. 七氟烷联合瑞芬太尼静吸复合全麻对腹腔镜子宫肌瘤剔除术麻醉效果的影响[J]. 系统医学,2024,9(20):9-12. [9] Takaki R,Yokose M,Mihara T,et al. Hypotension after general anaesthesia induction using remimazolam or propofol in geriatric patients undergoing sevoflurane anaesthesia with remifentanil: A single-centre,double-blind,randomised controlled trial[J]. Br J Anaesth,2024,133(1):24-32. doi: 10.1016/j.bja.2024.04.013 [10] 纪学武,张伶俐,夏迎静,等. 七氟烷联合瑞芬太尼对腹股沟斜疝腹腔镜手术患儿苏醒质量、应激反应和细胞免疫功能的影响[J]. 现代生物医学进展,2024,24(17):3256-3259+3305. [11] 沈子珒,王智渊,顾珏,等. 麻醉全深度监护仪疼痛指数在食管癌术后疼痛评估的临床应用[J]. 上海医学,2019,42(9):562-565. [12] 朱青青,岳维,姜敬男,等. 镇痛指数指导瑞芬太尼靶控输注在腹腔镜下胃大部切除术中的应用[J]. 临床麻醉学杂志,2020,36(7):634-637. doi: 10.12089/jca.2020.07.002 [13] 《腹腔镜肝胆胰手术操作指南》制定委员会. 腹腔镜肝胆胰手术操作指南[J]. 中华腔镜外科杂志,2019,12(1):1405. [14] Alexeev M,Fedorov E,Kuleshov O,et al. Carbon dioxide embolism during posterior retroperitoneal adrenalectomy[J]. Anaesth Rep,2022,10(1):e12164. doi: 10.1002/anr3.12164 [15] Özkan D,Cemaloğlu S,Catma F M,et al. Effects of suprascapular and axillary nerve block on postoperative pain relief sevoflurane consumption and visual clarity in arthroscopic shoulder surgery[J]. Agri,2020,32(1):1-7. [16] Alipour M,Sharifian Attar A,Akbari A,et al. Intra-articular remifentanil on postoperative pain in knee art hroscopic surgery; A double blind randomized clinical trial[J]. J Orthop Sci,2023,28(5):1082-1086. doi: 10.1016/j.jos.2022.08.007 [17] Jung J,Jung W,Ko E Y,et al. Impact of bilateral subcostal plus lateral transversus abdominis plane block on quality of recovery after laparoscopic cholecystectomy: A randomized placebo-controlled trial[J]. Anesth Analg,2021,133(6):1624-1632. doi: 10.1213/ANE.0000000000005762 [18] Koch S,Rupp L,Prager C,et al. Incidence of epileptiform discharges in children during induction of anaesthesia using propofol versus sevoflurane[J]. Clin Neurophysiol,2018,129(8):1642-1648. doi: 10.1016/j.clinph.2018.05.013 [19] Yoon H K,Kim Y J,Lee H S,et al. A randomised controlled trial of the analgesia nociception index for intra-operative remifentanil dose and pain after gynaecological laparotomy[J]. Anaesthesia,2023,78(8):988-994. doi: 10.1111/anae.16008 [20] Alifier M,Olsson B,Andreasson U,et al. Cardiac surgery is associated with biomarker evidence of neuronal damage[J]. J Alzheimers Dis,2020,74(4):1211-1220. doi: 10.3233/JAD-191165 [21] Toleska M,Dimitrovski A. Is opioid-free general anesthesia more superior for postoperative pain versus opioid general anesthesia in laparoscopic cholecystectomy?[J]. Pril (Makedon Akad Nauk Umet Odd Med Nauki),2019,40(2):81-87. [22] Stevens J L,Feelisch M,Martin D S. Perioperative oxidative stress: The unseen enemy[J]. Anesth Analg,2019,129(6):1749-1760. doi: 10.1213/ANE.0000000000004455 [23] Argüelles J,Echaniz M,Bowen J,et al. The impact of a stress-reducing protocol on the quality of pre-anaesthesia in cats[J]. Vet Rec,2021,188(12):e138. doi: 10.1002/vetr.138 [24] Sidiropoulou I,Tsaousi G G,Pourzitaki C,et al. Impact of anesthetic technique on the stress response elicited by laparoscopic cholecystectomy: A randomized trial[J]. J Anesth,2016,30(3):522-525. doi: 10.1007/s00540-016-2148-7 [25] Zhao P,Cui Y,Sun L,et al. Inhalation of low-dose desflurane prevents the hemodynamic instability caused by target-controlled infusion of remifentanil and propofol during laparoscopic gynecological surgery: A randomized controlled trial[J]. Exp Ther Med,2021,21(1):54. [26] Pan T,Lei Y,Lei Z,et al. Clinical study on anesthesia with remifentanil and propofol in patients with high hemodynamics[J]. Altern Ther Health Med,2022,28(4):44-49. [27] Gan T J,Belani K G,Bergese S,et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting[J]. Anesth Analg,2020,131(2):411-448. doi: 10.1213/ANE.0000000000004833 -
