瞳孔测量对老年患者腹腔镜胆囊切除术全身麻醉质量的影响

Effect of Pupil Measurement on General An-esthesia Quality in Elderly Patients Undergoing Laparoscopic Cholecystectomy

摘要: 背景：老年患者手术日益增多，高龄、衰弱、并存疾病等因素的影响，使老年患者的疼痛用药管理成为难题。瞳孔测量为精准评估疼痛程度、降低阿片类药物相关不良反应及提高全身麻醉质量带来新希望。目的：探讨瞳孔直径(pupil diameter, PD)测量对老年腹腔镜胆囊切除术中瑞芬太尼使用的指导意义，为实现个体化镇痛提供理论参考。方法：选择拟行择期腹腔镜胆囊手术的老年患者60例，ASA分级I~II级，年龄在65~85岁之间，使用计算机随机分配法分为观察组(瞳孔组)和对照组(非瞳孔组)，每组各30例。记录术中PD、有创动脉收缩压SAP和心率HR的变化，将两组喉罩置入后5 min (T0)时的PD、SAP和HR定义为基础值，手术切皮时(T1)、气腹建立时(T2)、气腹后每10 min和术毕缝皮时(T3)的各项指标与基础值的差值绝对值定义为波动幅度Δ，术中补液、出血量、手术时间、苏醒时间和瑞芬太尼总量、PACU停留时间、PACU停留期间恶心呕吐(PONV)的发生率，以及术中丙泊酚、顺阿曲库铵和血管活性药物的使用量。结果与结论：与对照组比较，观察组术中瑞芬太尼使用量更少(P < 0.05)；苏醒时间更短(P < 0.05)，PACU停留时间更短(P < 0.05)；术后PONV发生率更低(P < 0.05)；PD、SAP和HR的波动幅度更小，血管活性药物用量更少(P < 0.05)。术中PD测量指导镇痛水平可减少老年腹腔镜胆囊切除术术中瑞芬太尼的使用量，减少术后PONV发生，更有益于维持血流动力学平稳，提高手术安全性，增加患者满意度。

Abstract: Background: With the increasing number of operations in elderly patients, the management of pain medication in elderly patients has become a difficult problem due to the influence of factors such as age, frailty and co-existing diseases. Pupil measurement provides new hope for accurately evaluat-ing pain, reducing opioid-related adverse reactions and improving the quality of general anesthesia. Objective: To investigate the guiding significance of pupil diameter (PD) measurement in the use of remifentanil in elderly patients undergoing laparoscopic cholecystectomy, so as to provide theoret-ical reference for individualized analgesia. Methods: Sixty elderly patients, ASA grade I~II, aged 65~85 years, who were scheduled for elective laparoscopic gallbladder surgery, were randomly di-vided into observation group (pupil group) and control group (non-pupil group) by computer ran-dom assignment, with 30 cases in each group. The changes of PD, invasive arterial systolic blood pressure (SAP) and heart rate (HR) during the operation were recorded. PD, SAP and HR at 5 min (T0) after laryngeal mask insertion were defined as the basic values. The difference between the absolute value of each index and the base value at the time of surgical skin resection (T1), the time of pneumoperitoneum establishment (T2), every 10 min after pneumoperitoneum and the time of skin suture after surgery (T3) was defined as the fluctuation amplitude Δ, intraoperative fluid re-placement, blood loss, operation time, recovery time and remifentanil total, PACU stay time, the in-cidence of nausea and vomiting (PONV) during PACU stay, and the amount of propofol, cisatracuri-um and vasoactive drugs used during the operation. Results and Conclusion: Compared with the control group, the observation group used less remifentanil during operation (P < 0.05). The recov-ery time was shorter (P < 0.05), and the residence time of PACU was shorter (P < 0.05). The inci-dence of PONV after operation was lower (P < 0.05). PD, SAP, and HR have even smaller fluctuations, the dosage of vasoactive drugs was lower (P < 0.05). Intraoperative PD measurement and guidance of analgesia level can reduce the use of remifentanil during laparoscopic cholecystectomy in elderly patients, reduce the incidence of postoperative PONV, more conducive to maintaining hemodynamic stability, improve the safety of surgery, and increase patient satisfaction.