| ObjectiveWith social development, the aging trend of society is common now. Owing to the gradually improved medical conditions, more and more elderly patients suffering from surgical diseases can be treated by procedures. Almost all of their organ systems relate to anesthesia occur degenerative changes, especially the circulation system, respiratory system and nervous system. Because the elderly increases with age, their whole body organ function impairment and the histiocytic degenerative change and the change of physiology and pathology, etc. All these degenerations may cause the changes in pharmacokinetics and pharmacodynamics of anesthetic. So the elders’ tolerance of operation and anesthesia reduced, the risk of operation and anesthesia is greatly increased. So how to choose the anesthesia induction way and anaesthetic, maintain the depth of anesthesia and the hemodynamic stability during induction period for the elderly is an vital.Sufentanil, as a popular new type of opioid analgesics, is the N-4thiophene base derivatives of fentanyl. It is more suitable for the elderly patients with many advantages. For example, work fast, abirritation strong, nice cardiovascular stability, little respiratory depression, no histamine release, little probability of nausea and vomiting and its analgesic valence is as5-10times as fentanyl. Etomidate, is the derivatives of imidazole. Etomidate has less effects of breathe blood pressure and heart rate. Moreover, it has certain protection of the central nervous system, such as reduces cerebral oxygen metabolism rate, cerebral blood flow (CBF) and intracranial pressure. It is the first choice of general anesthesia induction intravenous anesthetics for eldly patients. Etomidate do not affect the sympathetic nervous system, do not affect pressure sensor, do not inhibit the stress reaction of induction intubation in general anesthesia. Sufentanil can inhibit intubation reaction, which can complement with the characteristics of etomidate. But few studies were focus on different effect-site concentrations of sufentanil combined with etomidate by target controlled infusion(TCI) during induction of general anesthesia for the elderly.Arterial Pressure-based cardiac output(APCO) is a minimally invasive and comprehensive index and dynamic new monitoring technology for cardiac outp ut(CO). It can integrated computation CO and other hemodynamic changes acc ording to the patient’s own blood vessel compliance. And it doesn’t need calib ration through other ways. APCO is more suitable for the hemodynamic monit oring of old patients.This study is a prospective, randomized, double-blind study, designed to discuss the effects on hemodynamics from different effect-site concentrations of sufentanil combined with etomidate by TCI during induction of general anesthesia for elderly patients.MethodsAfter obtaining the approval of our institutional ethics committee and writing informed consents. We enrolled forty-nine ASA physical status Ⅱ or Ⅲ patients who were75～90years old and scheduled for general anesthesia under tracheal intubation. Exclusion criteria:body mass index>30kg·m-2or<18kg·m-2, serious heart, liver, kidney, and cerebrovascular diseases, without the laws of the treatment of poorly controlled hypertension (≥2, preoperative systolic blood pressure>160mmHg or diastolic blood pressure>110mmHg), sinus bradycardia, nodal tachycardia, atrial fibrillation, diabetes, asthma, chronic obstructive pulmonary disease, pneumonia, psychiatric disorders or cognitive dysfunction, taking compound hypotensive tables, the Mallampati airway classification grade Ⅲ～Ⅳ or limited mouth opening suggestive of a difficult intubation, and refused to participate in the researcher.Forty-nine patients were randomly divided into three groups. Each group received a fixed sufentanil effect-site concentration of0.30μg·L-1(group Ⅰ, n=16),0.35μg·L-1(group Ⅱ,n=17)and0.40μg·L-1(group Ⅲ,n=16).This study is double blind, an anesthesiologist is responsible to input the related information of the patients with height, weight, age, and gender, and choose the effect-site concentration of sufentanil. He starts the program, and give the record at the beginning of the test. The other anesthesiologist is responsible for the Anesthesia operation.In preoperative these patients who took antihypertensive drug can continue the early morning on operation without premedication. After arrival in the operating room, upper limbs venous channel was sited with a venous cannula, and8mL·kg-1·h-1compound sodium chloride injection was infused. Standard monitoring included electrocardiogram, pulse oxyhaemoglobin saturation(SpO2), non-invasive arterial blood pressure and the depth of anesthesia monitored using the bispectral index(BIS) monitor. All patients were pre-oxygenated using100%oxygen with a normal tidal volume for3L·min-1.Left radial artery was punctured with local anesthesia, connected cardiac output monitor. Fundamental vital signs were recorded after5minutes.Induction of anesthesia was initiated by TCI sufentanil with the Gepts pharmacokinetic model in Fresenius Kabi pump at target effect-site concentration. In the process if SpO2<95%patients were given mask auxiliary breathing. After the sufentanil between plasma concentration and target effect-site concentration was administered by TCI in the three groups at the beginning. Then etomidate was used by TCI in the TCI-Ⅰ type infusion pump at the plasma concentration of0.5mg·L-1. At the moment of loss of consciousness, cis-atracurium0.2mg·kg-1was administered. Tracheal intubation was performed after the balance of etomidate between plasma concentration and effect-site concentration. After the success of the intubation, mechanical ventilation was carried out, and stop sufentanil infusion at once, and stop etomidate by TCI in5minutes later. The amount of sufentani and etomidate was recorded respectively. Patients inhaled sevoflurane in volume fraction of1%.During induction, if the systolic blood pressure<70%of baseline, intravaneous ephedrine was given0.1mg·kg-1, if the heart rate<50bpm, intravaneous atropine was given0.05mg·kg-1. If the systolic blood pressure>170mmHg,5mg of urapidil hydrochloride injection was given, if the heart rate>110bpm,20mg of esmolol hydrochloride injection was given. They can be repeated if necessary.Mean arterial pressure(MAP), heart rate(HR), BIS, CO, cardiac index(CI), stroke volume(SV) were recorded at the following times:before anesthesia(To), the balance of Ce and Cp with sufentanil(T1), the balance of Cp and Ce with etomidate(T2), at intubation(T3), at1min(T4),3min(T5) and5min(T6) after intubation. And the dosage of sufentanil and etomidate, the times of application of vasoactive drugs in each group were recorded respectively. All patients were interviewed in the postoperative anesthesia care unit to access memory recall and the the first postoperative day, to assess whether there were intraoperative awareness and dizziness, nausea, vomiting, cognition impairment and so on.Statistical analysis was performed using SPSS version13.0(SPSS Inc., Chicago, IL). The measurement data were expressed as mean±standard deviation. Changes in values with different time points of every group were analyzed with repeated measures of ANOVA. Comparison of different groups was One-way ANOVA. The enumeration data were expressed as Chi-square test. A p value<0.05was considered statistically significant.ResultsForty-nine eldly patients were involved this study, but four cases were exclused of this study (one case occurred muscle rigidity in group Ⅲ during sufentanil TCI, one case in group Ⅰ and one case in group Ⅱ were difficult tracheal intubation, and one case in group Ⅱ was muscle vibration).Comparisons among three groups:Comparison of general data and MAP, HR, CO, CI and SV in To of the three groups shown no significant difference (P>0.05). HR of group Ⅲ was significantly lower than those of group Ⅰ and group Ⅱ at T1(P<0.05), however, CO and SV of group Ⅲ were higher than those of group Ⅰ and group Ⅱ (P<0.05). At T2CO and SV of group Ⅲ were higher than those of group Ⅰ and group Ⅱ (P<0.05). MAP,HR,CO,CI,SV of group Ⅰ were significantly higher than those of group Ⅱ and Ⅲ at T3, T4andTs. MAP, CO,CI,SV of group Ⅲ were significantly lower than those of group Ⅰ and group Ⅱ at T6(P<0.05). There was no significant difference of BIS in three groups at every time points (P>0.05).Comparisons at each time point in every group:Compared to To, MAP of all three groups and CO, SV of group Ⅲ higher, but HR of group Ⅲ lower. At T2MAP, HR, CO, CI of three groups were significantly lower than those at To. At T3and T4, MAP and HR of group Ⅰ, and CO, CI, SV of three groups were significantly higher than those at To. MAP of three groups and HR, CO,CI,SV at T5, and MAP of three groups and CO,CI,SV at T6were significantly lower than those at To. Compared to T2, at T3and T4, MAP, HR, CO, CI, SV of three groups were significantly higher than those at T2. MAP and SV of group Ⅱ, Ⅲ at T5were significantly lower than those at T2, but HR, CO, CI of group I at T5were significantly higher than those at T2. At T6MAP, CO, CI, SV of group Ⅲ were significantly lower than those at T2.The average doses and the average doses of per kilogram of etomidate for three groups in the induction process were not significant different. But the difference of the sufentanil in three groups was significant. The doses of etomidate were (19.4±2.4) mg and (0.34±0.03)mg·kg-1in group Ⅰ,(18.6±3.6)mg and (0.34±0.04)mg·kg-1in group Ⅱ,(19.4±1.7)mg and (0.34±0.03)mg·kg-1in group Ⅲ. The doses of sufentanil were (23.5±1.0)μg and (0.42±0.05)μg·kg-1in group Ⅰ,(26.6±0.9)μg and (0.50±0.09)μg·kg-1in group Ⅱ,(33.1±0.7)μg and (0.59±0.04)μg·kg-1in group Ⅲ.The application of vasoactive drugs in three groups:There were two cases of group Ⅲ at T1, T2, T6each time point whose HR was less than50bpm, intravaneous atropine were given. There was one case of each group I and group II at T3whose SBP was higher than170mmHg, urapidil hydrochloride injection were given. The total induction time of the three groups:(17.8±0.6)min in Group Ⅰ,(18.0±0.7)min in Group Ⅱ,(18.1min±0.6)min in Group Ⅲ. There were no significant differences among the three groupsNo cases were intraoperative awareness and dizziness, nausea, vomiting, cognition impairment in the postoperative anesthesia care unit and the first postoperative day.ConclusionThe hemodynamic of elderly patients in general anesthesia was the most stable when combining sufentanil in effect-site concentration0.35μg·L-1with the plasma concentration of etomidate in0.5mg·L-1, which is suitable for tracheal intubation of elderly patients. |
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