舒芬太尼復(fù)合異丙酚在急性心肌梗死鎮(zhèn)痛中的應(yīng)用研究

談媛媛

舒芬太尼復(fù)合異丙酚在急性心肌梗死鎮(zhèn)痛中的應(yīng)用研究

談媛媛

目的探討舒芬太尼復(fù)合異丙酚麻醉在急性心肌梗死鎮(zhèn)痛中的應(yīng)用效果。方法按隨機(jī)數(shù)字表法將118例急性心肌梗死鎮(zhèn)痛患者分為舒芬太尼組與瑞芬太尼組，每組59例。舒芬太尼、瑞芬太尼初始靶效應(yīng)室濃度分別為0.25、2ng/ml，均復(fù)合初始血漿靶濃度為2μg/ml的異丙酚，每2min增加0.5μg/ml，直至患者意識(shí)消失。比較兩組患者在麻醉誘導(dǎo)前(T0)、插管前(T1)、插管后即刻(T2)、插管后2min(T3)、術(shù)畢(T4)和拔管(T5)時(shí)的血流動(dòng)力學(xué)變化以及兩組麻醉情況、蘇醒時(shí)間、術(shù)后鎮(zhèn)痛效果、并發(fā)癥發(fā)生情況。結(jié)果兩組收縮壓(SBP)和舒張壓(DBP)于T0–T2時(shí)逐漸下降，T2–T5時(shí)逐漸上升，心率(HR)于T0–T1時(shí)逐漸下降，T1–T5時(shí)逐漸上升，但瑞芬太尼組波動(dòng)較舒芬太尼組更為明顯。兩組SBP和DBP于T1–T5時(shí)有顯著性差異，HR于T1、T2和T5時(shí)有顯著性差異(P＜0.05)。兩組麻醉時(shí)間、意識(shí)消失時(shí)間、意識(shí)消失時(shí)異丙酚劑量和異丙酚總劑量無顯著性差異(P＞0.05)；舒芬太尼組自主呼吸恢復(fù)時(shí)間、呼之睜眼時(shí)間、拔管時(shí)間和定向力恢復(fù)時(shí)間均明顯長(zhǎng)于瑞芬太尼組(P＜0.05)，VAS評(píng)分顯著高于瑞芬太尼組，鎮(zhèn)痛藥使用率及并發(fā)癥發(fā)生率明顯低于瑞芬太尼組(P＜0.05)。OAA/S評(píng)分兩組間比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。結(jié)論與瑞芬太尼相比，舒芬太尼復(fù)合異丙酚麻醉用于急性心肌梗死鎮(zhèn)痛患者，血流動(dòng)力學(xué)更加平穩(wěn)，術(shù)后蘇醒質(zhì)量更優(yōu)，并發(fā)癥更少，值得臨床推廣應(yīng)用。

心肌梗死；舒芬太尼；瑞芬太尼；異丙酚；麻醉

近年來，隨著心臟大血管技術(shù)的提高及老齡化人口的增加，心臟大血管手術(shù)患者數(shù)量日益增多，由于患者多存在多種心腦血管疾病，耐受性低，對(duì)手術(shù)麻醉提出了更高的要求。王竹梅等[1]報(bào)道瑞芬太尼復(fù)合異丙酚靶控輸注用于急性心肌梗死患者鎮(zhèn)痛，麻醉誘導(dǎo)平穩(wěn)，術(shù)后恢復(fù)快且安全性高。本研究以瑞芬太尼為對(duì)照，探討等效劑量的舒芬太尼復(fù)合異丙酚麻醉對(duì)急性心肌梗死鎮(zhèn)痛患者血流動(dòng)力學(xué)及蘇醒質(zhì)量的影響，以期為臨床應(yīng)用提供參考。

1 資料與方法

1.1 一般資料 選取2012年1月－2014年6月安徽醫(yī)科大學(xué)第一附屬醫(yī)院收治的擇期行急性心肌梗死手術(shù)的患者118例，男65例，女53例，年齡70.5±3.2(65～85)歲，體重61.2±4.6(45～75)kg。其中心肌梗死64例，冠心病24例，缺血缺氧型心臟病30例。按隨機(jī)數(shù)字表法分為舒芬太尼組(n=59)與瑞芬太尼組(n=59)，兩組患者性別、年齡、體重、疾病類型等一般資料比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)，具有可比性。

1.2 納入及排除標(biāo)準(zhǔn) 納入標(biāo)準(zhǔn)：年齡65歲以上，ASA分級(jí)Ⅰ－Ⅲ級(jí)，無阿片類的藥物、異丙酚過敏史，術(shù)前未服用影響血糖、血壓及代謝藥物。排除嚴(yán)重心肺肝腎功能不全及血液系統(tǒng)疾病患者。本研究經(jīng)醫(yī)院倫理委員會(huì)批準(zhǔn)，患者均簽署知情同意書。

1.3 方法 手術(shù)前30min肌注阿托品0.5mg，苯巴比妥鈉0.1g，開放靜脈通路，采用DatexOhmeda監(jiān)護(hù)儀常規(guī)監(jiān)測(cè)血壓(BP)、心率(HR)、血氧飽和度(SpO2)。靜脈注射咪唑安定0.05mg/kg，維庫溴銨0.1mg/kg，舒芬太尼0.3～0.5μg/kg或瑞芬太尼3～5μg/kg，異丙酚2～2.5mg/kg麻醉誘導(dǎo)。吸氧3～5min后行氣管插管，接麻醉機(jī)行機(jī)械通氣，呼吸頻率12次/min，吸呼比1:2，潮氣量8～10ml/kg，氣腹前呼吸末CO2分壓30～35mmHg (1mmHg=0.133kPa)。誘導(dǎo)時(shí)舒芬太尼、瑞芬太尼初始靶效應(yīng)室濃度分別為0.25、2ng/ml，異丙酚初始血漿靶濃度為2μg/ml，每2min增加0.5μg/ml，直至患者意識(shí)消失。兩組術(shù)中根據(jù)BP、HR調(diào)整舒芬太尼、瑞芬太尼血漿靶濃度，維持腦電雙頻指數(shù)(BIS)50～60。若收縮壓(SBP)＜90mmHg或低于基礎(chǔ)血壓20%，則靜注麻黃堿5～10mg；若HR＜60次/min，則靜注阿托品0.3～0.5mg。所有患者均不采用任何麻醉性藥物的拮抗藥促醒。兩組局麻處理均由同一麻醉醫(yī)師完成，且未被告知患者分組情況。

1.4 效果評(píng)價(jià) ①血流動(dòng)力學(xué)變化：監(jiān)測(cè)兩組患者麻醉誘導(dǎo)前(T0)、插管前(T1)、插管后即刻(T2)、插管后2min(T3)、術(shù)畢(T4)和拔管(T5)時(shí)的HR、平均動(dòng)脈壓(MAP)和SpO2；②麻醉情況：記錄兩組麻醉時(shí)間、意識(shí)消失時(shí)間、意識(shí)消失時(shí)異丙酚劑量及異丙酚總劑量；③蘇醒時(shí)間：記錄兩組自主呼吸恢復(fù)時(shí)間、呼之睜眼時(shí)間、拔管時(shí)間、定向力恢復(fù)時(shí)間；④鎮(zhèn)痛效果及并發(fā)癥：記錄兩組術(shù)后30min疼痛視覺模擬評(píng)分(VAS)、警覺/鎮(zhèn)靜評(píng)分(OAA/S)、鎮(zhèn)痛藥使用率以及圍術(shù)期惡心、嘔吐、躁動(dòng)等并發(fā)癥發(fā)生情況。

1.5 統(tǒng)計(jì)學(xué)處理 采用SPSS 13.0軟件進(jìn)行統(tǒng)計(jì)分析，計(jì)量資料以表示，組間比較采用F檢驗(yàn)或χ2檢驗(yàn)，P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

表1 兩組麻醉期間血流動(dòng)力學(xué)情況比較(±s，n=59)Tab.1 Comparison of hemodynamic indexes during anesthesia between two groups (±s,n=59)

表1 兩組麻醉期間血流動(dòng)力學(xué)情況比較(±s，n=59)Tab.1 Comparison of hemodynamic indexes during anesthesia between two groups (±s,n=59)

T0. Pre-anesthesia induction; T1. Pre-intubation; T2. Immediately after intubation; T3. 2min after intubation; T4. End of operation; T5. Extubation; (1)P<0.05 compared with sufentanil group; (2)P<0.05 compared with T0; (3)P<0.05 compared with T1; (4)P<0.05 compared with T2; (5)P<0.05 compared with T3; (6)P<0.05 compared with T4

Remifentanil group SBP(mmHg) DBP(mmHg) HR(/min) SBP(mmHg) DBP(mmHg) HR(/min) T0 135.7±9.3 80.8±8.1 78±8 135.2±9.7 80.2±8.4 77±9 T1 129.8±8.2(2) 76.5±9.3(2) 71±6(2) 120.3±7.4(1)(2) 70.2±9.0(1)(2) 63±5(1)(2)T2 124.2±7.8(2)(3) 71.4±8.9(2)(3) 77±8 112.3±6.2(1)(2)(3) 64.2±8.0(1)(2)(3) 70±7(1)(2)T3 125.5±6.8(2)(3) 74.5±6.0(2)(3)(4) 76±9(3) 120.4±7.1(1)(2)(4) 69.3±7.8(1)(2)(4) 76±9(3)(4)T4 129.1±9.5(2)(4)(5) 79.2±7.2(2) (3)(4)(5) 78±8 125.5±8.0(1)(2)(3)(4)(5) 74.2±8.5(1)(2)(3)(4)(5) 76±11(3)(4)T5 132.7±4.5(2)(3)(4)(5)(6) 79.2±7.2(3)(4)(5)(6) 80±9(3)(4)(5) 139.5±5.2(1)(2)(3)(4)(5)(6) 87.4±7.6(1)(2)(3)(4)(5)(6) 87±7(1)(2)(3)(4)(5)(6)Time point Sufentanil group

2 結(jié) 果

2.1 兩組血流動(dòng)力學(xué)變化 兩組SBP和舒張壓(DBP)于T0–T2時(shí)逐漸下降，T2–T5時(shí)逐漸上升，HR 于T0–T1時(shí)逐漸下降，T1–T5時(shí)逐漸上升，但瑞芬太尼組波動(dòng)較舒芬太尼組更為明顯，T1–T5時(shí)SBP和DBP組間比較有顯著性差異，T1、T2和T5時(shí)HR組間比較有顯著性差異(P＜0.05，表1)。

2.2 兩組麻醉情況比較 與瑞芬太尼組比較，舒芬太尼組麻醉時(shí)間、意識(shí)消失時(shí)間、意識(shí)消失時(shí)異丙酚劑量和異丙酚總劑量之間的差異均無統(tǒng)計(jì)學(xué)意義(P>0.05，表2)。

2.3 兩組蘇醒時(shí)間比較 舒芬太尼組自主呼吸恢復(fù)時(shí)間、呼之睜眼時(shí)間、拔管時(shí)間和定向力恢復(fù)時(shí)間均明顯長(zhǎng)于瑞芬太尼組，差異有統(tǒng)計(jì)學(xué)意義(P＜0.05，表3)。

2.4 兩組術(shù)后鎮(zhèn)痛鎮(zhèn)靜效果及并發(fā)癥比較 舒芬太尼組VAS評(píng)分顯著高于瑞芬太尼組(P＜0.05)，鎮(zhèn)痛使用率及并發(fā)癥發(fā)生率明顯低于瑞芬太尼組(P＜0.05)，OAA/S評(píng)分兩組間比較差異無顯著性意義(P＞0.05，表4)。

表2 兩組麻醉情況比較(±s，n=59)Tab.2 Comparison of anesthesia condition between two groups (±s,n=59)

表2 兩組麻醉情況比較(±s，n=59)Tab.2 Comparison of anesthesia condition between two groups (±s,n=59)

Group Anesthesia time (min) Unconsciousness time (min) The dose of propofol when consciousness disappears (mg) Total dose of propofol (mg) Sufentanil group 92.3±15.6 3.8±1.0 70.7±14.5 591.7±204.2 Remifentanil group 91.8±17.6 3.6±0.7 69.2±13.4 587.5±195.3

表3 兩組蘇醒時(shí)間比較(±s，n=59)Tab.3 Comparison of awakening time between two groups (±s，n=59)

表3 兩組蘇醒時(shí)間比較(±s，n=59)Tab.3 Comparison of awakening time between two groups (±s，n=59)

(1)P<0.05 compared with sufentanil group

Group Time of spontaneous breathing recovery (min) Time to eye-opening (min) Extubation time (min) Time of directional force recovery (min) Sufentanil group 6.1±1.3 9.1±1.1 15.7±1.5 17.3±1.3 Remifentanil group 4.6±1.5(1) 7.2±1.2(1) 12.2±1.4(1) 13.1±1.6(1)

表4 兩組術(shù)后鎮(zhèn)痛效果及并發(fā)癥比較(±s，n=59)Tab.4 Comparison of postoperative analgesia effect and complications between two groups (±s,n=59)

表4 兩組術(shù)后鎮(zhèn)痛效果及并發(fā)癥比較(±s，n=59)Tab.4 Comparison of postoperative analgesia effect and complications between two groups (±s,n=59)

(1)P<0.05 compared with sufentanil group

Group VAS score OAA/S score Analgesic utilization (%) Complication rate (%) Sufentanil group 16.1±7.3 4.9±0.3 6.7(2/30) 10.0(3/30) Remifentanil group 10.6±9.3(1) 4.8±0.2 26.7(8/30)(1) 33.3(10/30)(1)

3 討 論

急性心肌梗死鎮(zhèn)痛需要行CO2氣腹并持續(xù)保持一定壓力，加之頭低足高位，對(duì)呼吸及循環(huán)系統(tǒng)均有一定不良影響，故要求麻醉必須快速起效，術(shù)后迅速蘇醒，以避免氣腹性生理損害，減少術(shù)后疼痛及其引起的血流動(dòng)力學(xué)變化和并發(fā)癥[2]。同時(shí)，由于患者多合并有多種慢性疾病，各種生理功能衰退，麻醉和手術(shù)耐受性較差，易發(fā)生嚴(yán)重呼吸和循環(huán)改變，導(dǎo)致心血管意外，故麻醉不僅要達(dá)到足夠深度，保證鎮(zhèn)痛和肌松充分，有效抑制傷害性應(yīng)激反應(yīng)，而且必須對(duì)生理功能干擾小，保持心血管系統(tǒng)的穩(wěn)定[3-4]。

靶控靜脈輸注是一種新的靜脈輸注方式，通過調(diào)節(jié)目標(biāo)藥物濃度控制麻醉深度，相比傳統(tǒng)的恒速靜脈輸注，能更有效地抑制插管和手術(shù)引起的應(yīng)激反應(yīng)[5-6]。姚東旭等[7]研究證實(shí)，瑞芬太尼靶控濃度2ng/ml時(shí)麻醉效果滿意，可維持血流動(dòng)力學(xué)穩(wěn)定，氣管插管與切皮反應(yīng)較輕。另有研究表明，等效劑量瑞芬太尼的效應(yīng)室濃度為舒芬太尼的8倍[8]。故本研究采用靶控輸注方式給藥探討2ng/ml的瑞芬太尼與濃度為0.25ng/ml的舒芬太尼在急性心肌梗死鎮(zhèn)痛患者中的應(yīng)用效果。

本研究結(jié)果顯示，兩組麻醉時(shí)間、意識(shí)消失時(shí)間、意識(shí)消失時(shí)異丙酚劑量和異丙酚總劑量均無明顯差別，顯示出良好的麻醉效果，但瑞芬太尼組SBP、DBP和HR波動(dòng)更為明顯(P＜0.05)，表明瑞芬太尼較舒芬太尼更易引起血流動(dòng)力學(xué)劇烈波動(dòng)。周仁龍等[9]的研究也得出了相同的結(jié)論。本研究對(duì)麻醉恢復(fù)的觀察顯示，舒芬太尼組自主呼吸恢復(fù)時(shí)間、呼之睜眼時(shí)間、拔管時(shí)間和定向力恢復(fù)時(shí)間均明顯長(zhǎng)于瑞芬太尼組(P＜0.05)，VAS評(píng)分顯著高于瑞芬太尼組(P＜0.05)，鎮(zhèn)痛藥使用率及并發(fā)癥發(fā)生率明顯低于瑞芬太尼組(P＜0.05)。分析原因?yàn)槿鸱姨岚胨テ诙蹋瑑H為4～6min，起效迅速，時(shí)量相關(guān)半衰期不受輸注時(shí)間長(zhǎng)短影響[10]，故蘇醒較快，術(shù)后鎮(zhèn)痛作用消失迅速；而舒芬太尼半衰期長(zhǎng)，時(shí)量相關(guān)半衰期隨著輸注時(shí)間的增加而延長(zhǎng)，故作用時(shí)間更持久，鎮(zhèn)痛作用更強(qiáng)，利于抑制機(jī)體應(yīng)激反應(yīng)。

綜上所述，與瑞芬太尼相比，舒芬太尼復(fù)合異丙酚麻醉用于急性心肌梗死鎮(zhèn)痛患者，血流動(dòng)力學(xué)更加平穩(wěn)，術(shù)后蘇醒質(zhì)量更優(yōu)，并發(fā)癥更少，值得臨床推廣應(yīng)用。但值得注意的是，舒芬太尼長(zhǎng)時(shí)間、大劑量輸注給藥容易蓄積而發(fā)生呼吸抑制。因此，在手術(shù)結(jié)束前應(yīng)適度降低靶濃度值，以預(yù)防呼吸抑制引起CO2蓄積[11]。但同時(shí)也要注意滿足術(shù)后鎮(zhèn)痛需要。故本研究在手術(shù)結(jié)束前30min將舒芬太尼靶濃度設(shè)定為0.2ng/ml，取得較好效果，無一例發(fā)生呼吸抑制，術(shù)后VAS評(píng)分高，鎮(zhèn)痛藥使用率低。

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The use of sufentanil combined with propofol for analgesia in patients with acute myocardial infarction

TAN Yuan-yuan
Department of Emergency, First Hospital Affiliated to Anhui Medical University, Hefei 230022, China

ObjectiveTo explore the efficacy of sufentanil and propofol for analgesia in patients with acute myocardial infarction (AMI).MethodsAccording to the random number table, 118 AMI patients were divided into sufentanil group and remifentanil group, with 59 in each group. The initial target effect concentrations of sufentanil and remifentanil were 0.25ng/ml and 2ng/ml respectively, and both of them were combined with propofol, initial target plasma concentration of which was 2μg/ml, with an increase of 0.5μg/ml every 2min till the loss of consciousness. Hemodynamic changes at pre-anesthesia induction (T0), preintubation (T1), immediately after intubation (T2), 2min after intubation (T3), end of operation (T4), and extubation (T5), and anesthetic condition, awakening time, postoperative analgesic effect, and complications were compared between two groups.Results

Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were lowered at T0-T2in both groups, and they gradually rose at T2-T5. HR was lowered at T0-T1, and it rose gradually at T1-T5, but SBP and DBP fluctuation was more obvious in remifentanil group than in sufentanil group, with a significant difference at T1-T5, and a significant difference in HR at T1, T2and T5(P<0.05) between two groups. There was no significant difference between two groups in anesthesia time, awakening time, propofol dose, and total dose of propofol during loss of consciousness (P>0.05). The time for recovery of spontaneous breathing, time for eyeopening, upon calling, time of extubation and orientation recovery time were significantly longer in the sufentanil group than those in the remifentanil group (P<0.05). VAS score was significantly higher in sufentanil group than in remifentanil group (P<0.05), but analgesic use rate of the latter and incidence of complications were significantly lower in sufentanil group than in remifentanil group (P<0.05). No significant difference in OAA/S score was found between two groups (P>0.05).ConclusionAs compared with remifentanil, sufentanil combined with propofol is used for analgesia in AMI patients resulting in more stable hemodynamics, better postoperative awakening quality, and fewer complications, thus it is worthy of wider clinical use.

myocardial infarction; sufentanil; remifentanil; propofol; anesthesia

R542.22

A

0577-7402(2015)07-0587-04

10.11855/j.issn.0577-7402.2015.07.15

2015-03-20；

2015-06-05)

(責(zé)任編輯：熊曉然)

談媛媛，醫(yī)學(xué)碩士，主治醫(yī)師。主要從事急診醫(yī)學(xué)方面的研究

230022 合肥 安徽醫(yī)科大學(xué)第一附屬醫(yī)院急診科(談媛媛)