目的 应用序贯法探讨丙泊酚或不同剂量瑞马唑仑对舒芬太尼抑制老年患者气管插管反应的半数有效剂量(50%effective dose,ED50)的影响.方法 选择2022年10至12月在气管插管全身麻醉下接受择期手术的老年患者,美国麻醉医师协会(American Society of Anesthesiologists,ASA)分级Ⅰ、Ⅱ级,年龄65～80岁,将患者采用随机数字表法分为4组:丙泊酚组(P组,诱导时给予丙泊酚 2mg/kg)和瑞马唑仑组(R1、R2、R3 组,诱导时分别静脉注射瑞马唑仑 0.2、0.3、0.4mg/kg).麻醉诱导时给予 Dixon 序贯法设定剂量的舒芬太尼后,静脉注射丙泊酚或相应剂量瑞马唑仑及顺式阿曲库铵0.15mg/kg,待4个成串刺激(train of four,TOF)计数为0时行气管插管.若气管插管反应阳性,则下一例患者舒芬太尼剂量提高1个浓度梯度,否则降低1个浓度梯度,各相邻浓度之间的比为1∶1.1,直至出现7个转折点终止研究.采用Probit回归分析计算舒芬太尼抑制老年患者气管插管反应ED50和95%有效剂量(95%effective dose,ED95)以及相应的95%置信区间(confidence interval,CI).记录所有患者低血压、心动过缓、注射痛等不良反应的发生情况.结果 本研究共纳入老年患者113例,P、R1、R2、R3组分别24、28、30、31例.丙泊酚2mg/kg或0.2、0.3、0.4mg/kg瑞马唑仑时舒芬太尼抑制老年患者气管插管反应的ED50和ED95及相应 95%CI分别为:P组ED50为 0.236μg/kg(95%CI:0.218～0.256),ED95为0.266μg/kg(95%CI:0.250～0.398);R1组ED50为0.284μg/kg(95%CI:0.265～0.309),ED95为0.329μg/kg(95%CI:0.306～0.478);R2组ED50为0.239μg/kg(95%CI:0.221～0.260),ED95为0.282μg/kg(95%CI:0.261～0.415);R3组ED50为0.198μg/kg(95%CI:0.182～0.211),ED95为 0.231μg/kg(95%CI:0.216～0.303).与P组相比,R1、R2、R3 组低血压、心动过缓、注射痛发生率较低(P<0.05).R2 组舒芬太尼ED50与P组相类似,但低血压、注射痛发生率与P组相比较低.结论 随着瑞马唑仑剂量的增加,舒芬太尼抑制老年患者气管插管反应的ED50 逐渐降低;在ED50 相近的情况下,瑞马唑仑相较于丙泊酚诱导的低血压、心动过缓、注射痛发生率更低,因而在老年患者气管插管全身麻醉中,使用瑞马唑仑诱导更具有优势.
Effect of propofol or different doses of remimazolam on median effective dose of sufentanil for suppressing tracheal intubation response in elderly patients
Objective To investigate the effect of propofol or different doses of remimazolam on effective dose(ED50)of sufentanil in elderly patients with tracheal intubation response by sequential method.Methods Elderly patients,American Society of Anesthesiologists(ASA)Ⅰ and Ⅱ,aged 65-80 years,undergoing elective surgery under general anesthesia with endotracheal intubation from October to December 2022 were selected and randomly divided into 4 groups:Group P(propofol 2mg/kg)and group R1,R2 and R3(remimazolam 0.2,0.3 and 0.4mg/kg)were administered intravenously.During anesthesia induction,sufentanil was given with the dose set by Dixon sequential method,followed by intravenous injection of propofol or corresponding dose of remimazolam and cisatracurium 0.15mg/kg.Tracheal intubation was performed when train of four(TOF)count was 0.If the tracheal intubation response is positive,the sufentanil dose of the next patient is increased by 1 concentration gradient,otherwise,the sufentanil dose is decreased by 1 concentration gradient,and the ratio between adjacent concentrations is 1∶1.1,until 7 turning points appear and the study is terminated.Probit regression analysis was used to calculate the median ED50 and 95%effective dose(ED95)of sufentanil for suppressing tracheal intubation response in elderly patients,and the corresponding 95%CI.The incidence of hypotension,bradycardia,injection pain and other adverse reactions were recorded.Results A total of 113 elderly patients were included in this study,including 24,28,30 and 31 patients in P,R1,R2 and R3 groups,respectively.The ED50 and ED95 and corresponding 95%CI of sufentanil for suppressing tracheal intubation response in elderly patients with propofol 2 mg/kg or remimazolam 0.2,0.3,0.4mg/kg were:The ED50 and ED95 of group P were 0.236μg/kg(95%CI:0.218-0.256)and 0.266μg/kg(95%CI:0.250-0.398),respectively.The ED50 and ED95 of group R1 were 0.284μg/kg(95%CI:0.265-0.309)and 0.329μg/kg(95%CI:0.306-0.478),respectively.The ED50 and ED95 of R2 group were 0.239μg/kg(95%CI:0.221-0.260)and 0.282μg/kg(95%CI:0.261-0.415),respectively.The ED50 and ED95 of R3 group were 0.198μg/kg(95%CI:0.182-0.211)and 0.231μg/kg(95%CI:0.216-0.303),respectively.The incidence of hypotension,bradycardia and injection pain in R1,R2 and R3 groups were lower than those in P group(P<0.05).The ED50 of sufentanil in group R2 was similar to that in group P,but the incidence of hypotension and injection pain in group R2 was lower than that in group P.Conclusion With the increase of the dose of remimazolam,the ED50 of sufentanil to inhibit tracheal intubation reaction in elderly patients gradually decreased,and in the case of similar ED50,the incidence of hypotension,bradycardia and injection pain induced by remimazolam was lower than that induced by propofol,so remimazolam induction was more advantageous in general anesthesia for tracheal intubation in elderly patients.
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