Sun H T, Xu M, Chen G L, He J
Department of Anesthesiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
Zhonghua Yi Xue Za Zhi. 2018 Feb 27;98(8):576-580. doi: 10.3760/cma.j.issn.0376-2491.2018.08.004.
This study aimed to compare dexmedetomidine with remifentanil for conscious sedation in patients undergoing radiofrequency ablation of hepatocellular carcinoma. Sixty patients, who were aged 41 to 73 years with American Society of Anesthesiologists (ASA) physical status Ⅰ-Ⅱ, and scheduled for elective radiofrequency ablation of hepatocellular carcinoma under conscious sedation in National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, from January 2014 to June 2016, were allocated randomly to receive dexmedetomidine maintenance regimen(group D, =30)or remifentanil maintenance regimen(group R, =30)by random digital table. Subjects in group D received dexmedetomidine at a loading dose of 0.5 μg/kg over 10 min followed by 0.2-1.0 μg·kg(-1)·h(-1) infusion until Ramsay sedation scale reached 3-4. Patients in group R received a loading dose of remifentanil 1 μg/kg followed by remifentanil 4-10 μg·kg(-1)·h(-1) infusion and propofol 1-2 mg·kg(-1)·h(-1) infusion until Ramsay sedation scale reached 3-4. Haemodynamic variables, respiratory rate(RR), pulse oxygen saturation (SpO(2))and numeric rating scales(NRS) in each group were collected at entrance(T(0)), puncturing(T(1)), 15 min after beginning of radiofrequency ablation(T(2)), the end of radiofrequency ablation(T(3)) and 30 min after operation(T(4)). Efficacy of anesthesia, incidences of intraoperative respiratory depression, postoperative nausea and vomiting, patient and surgeon satisfaction were evaluated. Compared with group D, the arterial blood pressure and heart rate at T(2) [(92.2±15.7)mmHg vs (102.4±16.7)mmHg, (69.7±15.3) beats/min vs (79.4±17.7) beats/min] and respiratory rate at T(1), T(2) and T(3) [(10.1±1.9) breaths/min vs(12.3±1.7) breaths/min, (10.8±1.5) breaths/min vs(13.6±1.6) breaths/min, (13.4±1.6) breaths/min vs(14.5±1.4)breaths/min] were significantly lower in group R (=-2.437, -2.271, -4.726, -6.993, -2.834, all <0.05). With less sulfentanil consumption(23.2±8.3)μg vs( 35.5±11.7)μg, group R got less NRS at T(2) and T(3)(2.4±1.1) vs(3.5±1.2), (2.4±1.3) vs(3.6±1.1), and higher NRS at T(4)(3.4±1.1) vs( 2.1±0.9) than group D(=-4.696, -3.701, -3.860, 5.010, all <0.05). Compared with group R, the incidence of intraoperative respiratory depression was significantly lower (23.3% vs 56.7%)and the incidence of inadequate anesthesia(20% vs 0) was significantly higher in group D(χ(2)=5.625, 4.630, both <0.05). Both dexmedetomidine and remifentanil can be successfully used for conscious sedation in patients undergoing radiofrequency ablation of hepatocellular carcinoma. Remifentanil maintenance regimen provides better intraoperative analgesia and operative condition, while dexmedetomidine is superior to remifentanil in reducing intraoperative respiratory depression and postoperative pain.
本研究旨在比较右美托咪定与瑞芬太尼用于肝细胞癌射频消融患者清醒镇静的效果。2014年1月至2016年6月期间，在中国医学科学院肿瘤医院（国家癌症中心），将60例年龄在41至73岁、美国麻醉医师协会（ASA）身体状况分级为Ⅰ-Ⅱ级、计划在清醒镇静下接受择期肝细胞癌射频消融术的患者，通过随机数字表法随机分为接受右美托咪定维持方案组（D组，n = 30）或瑞芬太尼维持方案组（R组，n = 30）。D组患者先静脉注射负荷剂量右美托咪定0.5 μg/kg，持续10分钟，随后以0.2 - 1.0 μg·kg⁻¹·h⁻¹的速度静脉输注，直至Ramsay镇静评分达到3 - 4分。R组患者先静脉注射负荷剂量瑞芬太尼1 μg/kg，随后以4 - 10 μg·kg⁻¹·h⁻¹的速度静脉输注瑞芬太尼，并以1 - 2 mg·kg⁻¹·h⁻¹的速度静脉输注丙泊酚，直至Ramsay镇静评分达到3 - 4分。分别于入室时（T₀）、穿刺时（T₁）、射频消融开始后15分钟（T₂）、射频消融结束时（T₃）及术后30分钟（T₄）记录两组患者的血流动力学指标、呼吸频率（RR）、脉搏血氧饱和度（SpO₂）及数字评分量表（NRS）评分。评估麻醉效果、术中呼吸抑制发生率、术后恶心呕吐发生率、患者及术者满意度。与D组相比，R组在T₂时的动脉血压和心率[（92.2±15.7）mmHg比（102.4±16.7）mmHg，（69.7±15.3）次/分钟比（79.4±17.7）次/分钟]以及在T₁、T₂和T₃时的呼吸频率[（10.1±1.9）次/分钟比（12.3±1.7）次/分钟，（10.8±1.5）次/分钟比（13.6±1.6）次/分钟，（13.4±1.6）次/分钟比（14.5±1.4）次/分钟]均显著降低（P均<0.05）。R组舒芬太尼用量较少[（23.2±8.3）μg比（35.5±11.7）μg]，在T₂和T₃时NRS评分较低[（2.4±1.1）比（3.5±1.2），（2.4±1.3）比（3.6±1.1）]，但在T₄时NRS评分高于D组[（3.4±1.1）比（2.1±0.9）]（P均<0.05）。与R组相比，D组术中呼吸抑制发生率显著较低（23.3%比56.7%），麻醉不足发生率显著较高（20%比0）（χ² = 5.625、4.630，P均<0.05）。右美托咪定和瑞芬太尼均可成功用于肝细胞癌射频消融患者的清醒镇静。瑞芬太尼维持方案可提供更好的术中镇痛及手术条件，而右美托咪定在降低术中呼吸抑制及术后疼痛方面优于瑞芬太尼。
