丙泊酚复合纳布啡对无痛肠镜检查患者膈肌运动的影响
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摘要
目的探讨超声监测下丙泊酚复合纳布啡对肠镜检查患者膈肌运动的影响。方法选择择期行无痛肠镜检查患者40例,男21例,女19例,年龄18～65岁,BMI 18～25kg/m2,ASAⅠ或Ⅱ级,采用随机数字表法将患者均分为两组(n=20)∶丙泊酚组(P组)和丙泊酚复合纳布啡组(F组)。F组患者在丙泊酚输注前1min静脉推注纳布啡0.1mg/kg,P组给予等容量的生理盐水。两组患者TCI模式给予丙泊酚,初始血浆靶浓度为2μg/ml,逐渐调整靶浓度,直至Ramsay镇静评分为5分,开始肠镜检查。肠镜检查中根据Ramsay评分调整丙泊酚靶浓度。超声监测患者右侧膈肌运动情况。记录患者入室平静呼吸时(T0)、丙泊酚输注后Ramsay评分5分时(T1)以及肠镜检查结束后Ramsay评分2分时(T2)的SpO2、MAP、HR、PETCO2、RR、膈肌运动幅度(DM)、吸气末膈肌厚度(TEI)、呼气末膈肌厚度(TEE),计算膈肌厚度变化率(DTF)=(TEI-TEE)/TEI。记录心动过缓、低血压、体动、呼吸抑制等不良反应。结果与T0时比较,两组T1时MAP和SpO2明显降低,HR和RR明显减慢,PETCO2明显升高(P <0.05);P组丙泊酚用量明显多于F组(P <0.05);T1、T2时F组DM明显长于,T1时DTF明显高于P组(P <0.05)。P组2例发生体动反应,F组1例出现窦性心动过缓。两组均未发生低血压、呼吸抑制和反流误吸等不良反应。结论与单用丙泊酚比较,丙泊酚复合纳布啡一定程度上可以减轻对无痛肠镜检查患者膈肌运动的抑制程度。
Objective To investigate the effects of propofol combined with nalbuphine on diaphragmatic movement monitored by ultrasound in patients undergoing colonoscopy.Methods Forty patients,males 21 and females 19,aged 18-65 years,BMI 18-25 kg/m2,ASA physical status I or II,were recruited and scheduled to undergo elective painless colonoscopy.All patients were randomly divided into two groups(n =20):propofol group(group P)and propofol combined with nalbuphine group(group F).Patients in group F received nalbuphine 0.1 mg/kg intravenously 1 min before propofol administration,and patients in group P received same volume of normal saline.Propofol was infused by TCI and the initial target plasma concentration was set at 2μg/ml in all patients.The target concentration was adjusted gradually until the Ramsay sedation score reached 5.Then colonoscopy was started.During the colonoscopy,the propofol concentration was adjusted according to the Ramsay score.Ultrasound was used to monitor the movement of the right diaphragm of the patients.SpO2,MAP,HR,PETCO2,RR,diaphragmatic movement(DM),diaphragmatic thickness at the end of inspiration(TEI)and diaphragmatic thickness at the end of expiration(TEE)were recorded under calm breathing after entering the room(T0),Ramsay sedation score 5 points after propofol administration(T1),and Ramsay sedation score 2 after endoscopy(T2).The diaphragmatic thickening fraction(DTF)was calculated:DTF=(TEI-TEE)/TEI.Adverse reactions such as bradycardia,hypotension,body movement,and respiratory depression were recorded.Results Compared with T0,MAP,SpO2,HR and RR decreased,and PETCO2 increased at T1 time point in patients of the two groups(P<0.05).Compared with group F,the dose of propofol increased in group P(P<0.05).DM at T1 and T2,DTF at T1 were obviously higher in group F than those in group P(P<0.05).There were two cases had body movement in group P,and one case had bradycardia in group F.There was no case suffered from hypotension,respiratory depression and reflux aspiration in two groups.Conclusion Compared with propofol alone,propofol combined with nalbuphine can attenuate the dysfunction of the diaphragm.
Objective To investigate the effects of propofol combined with nalbuphine on diaphragmatic movement monitored by ultrasound in patients undergoing colonoscopy.Methods Forty patients,males 21 and females 19,aged 18-65 years,BMI 18-25 kg/m2,ASA physical status I or II,were recruited and scheduled to undergo elective painless colonoscopy.All patients were randomly divided into two groups(n =20):propofol group(group P)and propofol combined with nalbuphine group(group F).Patients in group F received nalbuphine 0.1 mg/kg intravenously 1 min before propofol administration,and patients in group P received same volume of normal saline.Propofol was infused by TCI and the initial target plasma concentration was set at 2μg/ml in all patients.The target concentration was adjusted gradually until the Ramsay sedation score reached 5.Then colonoscopy was started.During the colonoscopy,the propofol concentration was adjusted according to the Ramsay score.Ultrasound was used to monitor the movement of the right diaphragm of the patients.SpO2,MAP,HR,PETCO2,RR,diaphragmatic movement(DM),diaphragmatic thickness at the end of inspiration(TEI)and diaphragmatic thickness at the end of expiration(TEE)were recorded under calm breathing after entering the room(T0),Ramsay sedation score 5 points after propofol administration(T1),and Ramsay sedation score 2 after endoscopy(T2).The diaphragmatic thickening fraction(DTF)was calculated:DTF=(TEI-TEE)/TEI.Adverse reactions such as bradycardia,hypotension,body movement,and respiratory depression were recorded.Results Compared with T0,MAP,SpO2,HR and RR decreased,and PETCO2 increased at T1 time point in patients of the two groups(P<0.05).Compared with group F,the dose of propofol increased in group P(P<0.05).DM at T1 and T2,DTF at T1 were obviously higher in group F than those in group P(P<0.05).There were two cases had body movement in group P,and one case had bradycardia in group F.There was no case suffered from hypotension,respiratory depression and reflux aspiration in two groups.Conclusion Compared with propofol alone,propofol combined with nalbuphine can attenuate the dysfunction of the diaphragm.
引文
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[7]Corbellini C,Boussuges A,Villafane JH,et al.Diaphragmatic Mobility Loss in Subjects With Moderate to Very Severe COPD May Improve After In-Patient Pulmonary Rehabilitation.Respir Care,2018,63(10):1271-1280.
[8]陈文佳,詹英,解进,等.非胸腹部手术拔管时右侧膈肌运动的超声评价.国际麻醉学与复苏杂志.2017,38(2):128-132.
[9]Rocco M,Maggi L,Ranieri G,et al.Propofol sedation reduces diaphragm activity in spontaneously breathing patients:ultrasound assessment.Minerva Anestesio,2017,83(3):266-273.
[10]张振,罗辉宇,徐阳,等.丙泊酚分别复合盐酸纳布啡、地佐辛、舒芬太尼用于无痛胃镜的效果比较.中国药房,2017,28(3):315-318.
[11]杨鹤,刘缚鲲,郑莉,等.纳布啡和舒芬太尼分别复合丙泊酚用于门诊无痛胃肠镜检查的临床观察.临床和实验医学杂志,2018,17(12):1340-1343.
[12]Testa A,Soldati G,Giannuzzi R,et al.Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects.Ultrasound Med Biol,2011,37(1):44-52.
[13]李明秋,郭瑞君,张谱,等.M型超声观察膈肌运动与肺功能的相关性研究.首都医科大学学报,2014,35(2):189-193.
[14]龚菊,张碧波.左、右侧膈肌移动度变化值对机械通气患者撤机预测价值的比较.临床内科杂志,2016,33(8):539-541.
[2]Houston JG,Angus RM,Cowan MD,et al.Ultrasound assessment of normal hemidiaphragmatic movement:relation to inspiratory volume.Thorax,1994,49(5):500-503.
[3]Powers SK,Wiggs MP,Sollanek KJ,et al.Ventilator-induced diaphragm dysfunction:cause and effect.Am J Physiol Regul Integr Comp Physiol,2013,305(5):R464-R477.
[4]Schepens T,Verbrugghe W,Dams K,et al.The course of diaphragm atrophy in ventilated patients assessed with ultrasound:a longitudinal cohort study.Crit Care,2015,19:422.
[5]Zhang XJ,Yu G,Wen XH,et al.Effect of propofol on twitch diaphragmatic pressure evoked by cervical magnetic stimulation in patients.Br J Anaesth,2009,102(1):61-64.
[6]Bruells CS,Maes K,Rossaint R,et al.Sedation using propofol induces similar diaphragm dysfunction and atrophy during spontaneous breathing and mechanical ventilation in rats.Anesthesiology,2014,120(3):665-672.
[7]Corbellini C,Boussuges A,Villafane JH,et al.Diaphragmatic Mobility Loss in Subjects With Moderate to Very Severe COPD May Improve After In-Patient Pulmonary Rehabilitation.Respir Care,2018,63(10):1271-1280.
[8]陈文佳,詹英,解进,等.非胸腹部手术拔管时右侧膈肌运动的超声评价.国际麻醉学与复苏杂志.2017,38(2):128-132.
[9]Rocco M,Maggi L,Ranieri G,et al.Propofol sedation reduces diaphragm activity in spontaneously breathing patients:ultrasound assessment.Minerva Anestesio,2017,83(3):266-273.
[10]张振,罗辉宇,徐阳,等.丙泊酚分别复合盐酸纳布啡、地佐辛、舒芬太尼用于无痛胃镜的效果比较.中国药房,2017,28(3):315-318.
[11]杨鹤,刘缚鲲,郑莉,等.纳布啡和舒芬太尼分别复合丙泊酚用于门诊无痛胃肠镜检查的临床观察.临床和实验医学杂志,2018,17(12):1340-1343.
[12]Testa A,Soldati G,Giannuzzi R,et al.Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects.Ultrasound Med Biol,2011,37(1):44-52.
[13]李明秋,郭瑞君,张谱,等.M型超声观察膈肌运动与肺功能的相关性研究.首都医科大学学报,2014,35(2):189-193.
[14]龚菊,张碧波.左、右侧膈肌移动度变化值对机械通气患者撤机预测价值的比较.临床内科杂志,2016,33(8):539-541.