文章摘要
不同剂量丙泊酚在抑郁症患者改良电休克治疗中的应用
Application of different doses of propofol in depression undergoing modified electroconvulsive therapy
  
DOI：10.12089/jca.2019.07.007
中文关键词: 丙泊酚  脑电双频指数  改良电休克  抑郁症  合适剂量
英文关键词: Propofol  Bispectral index  Modified electroconvulsive therapy  Depression  Appropriate dose
基金项目:
作者单位E-mail
李宏琴 410011,长沙市,中南大学湘雅二医院麻醉科  
汤依旸 410011,长沙市,中南大学湘雅二医院麻醉科  
徐军美 410011,长沙市,中南大学湘雅二医院麻醉科  
李卉 410011,长沙市,中南大学湘雅二医院麻醉科  
邹娟 410011,长沙市,中南大学湘雅二医院精神科  
曹丽君 410011,长沙市,中南大学湘雅二医院麻醉科 hivit1103@163.com 
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中文摘要:
      
目的 通过脑电双频指数(BIS)监测测定丙泊酚在抑郁症患者改良电休克治疗(MECT)中的峰效应时间（TTPE）和合适剂量。
方法 选择拟行首次MECT的抑郁症患者135例，男46例，女89例，年龄18~65岁，BMI 18~30 kg/m2，ASA Ⅰ或Ⅱ级。随机分为丙泊酚0.8 mg/kg组（P0.8组），丙泊酚1.0 mg/kg组（P1.0组）和丙泊酚1.2 mg/kg组（P1.2组），分别给予丙泊酚0.8、1.0、1.2 mg/kg，复合琥珀酰胆碱1.0 mg/kg全凭静脉麻醉。当BIS值下降速率逐渐变缓至平台期且能维持4 s，患者意识消失时立即给予MECT。记录患者基础HR、MAP、BIS，MECT中电击后最快HR、电击后最高MAP和BIS最低值。记录患者丙泊酚峰效应时间（TTPE）、癫痫持续时间（SD）、呼吸恢复时间和意识恢复时间。记录患者术前汉密尔顿抑郁量表（HAMD）评分和首次MECT 24 h后 HAMD评分。记录患者住院时间和住院期间行MECT总次数。记录麻醉过深（BIS<40）、麻醉过浅（BIS>60）、呼吸抑制、术中知晓、过敏和术后谵妄等不良反应发生情况。
结果 P0.8组电击后最快HR明显快于P1.0组和P1.2组（P<0.01），P0.8组电击后最高MAP明显高于P1.0组和P1.2组（P<0.01），P0.8组和P1.0组呼吸恢复时间和意识恢复时间明显短于P1.2组（P<0.01），且P0.8组呼吸恢复时间明显短于P1.0组（P<0.05）。与术前HAMD评分比较，三组首次MECT 24 h后HAMD评分明显降低（P<0.05）。三组TTPE、SD、住院时间、MECT总次数差异无统计学意义。P0.8组麻醉过深（BIS<40）的发生率明显低于P1.2组（P<0.05）。P0.8组麻醉过浅（BIS>60）的发生率明显高于P1.0组和P1.2组（P<0.01）。P0.8组和P1.0组呼吸抑制的发生率明显低于P1.2组（P<0.05）。三组过敏发生情况差异无统计学意义，三组无一例发生术中知晓和术后谵妄。
结论 抑郁症改良电休克治疗中静脉推注丙泊酚1.0 mg/kg较0.8 mg/kg血流动力学更平稳，与1.2 mg/kg比较，麻醉过深的不良反应发生率较小，对脑电抑制的影响更小。因此，静脉推注丙泊酚1.0 mg/kg 更有利于抑郁症改良电休克治疗安全、有效的实施。
英文摘要:
      
Objective To determine the appropriate dose of propofol in the modified electroconvulsive therapy (MECT) of patients with depression under the monitoring of bispectral index.
Methods A total of 135 patients with depression who intend to receive the first time modified electroconvulsive therapy, including 46 males and 89 females, aged 18 - 65 years, BMI 18 - 30 kg/m2, ASA physical status Ⅰ to Ⅱ. The patients were randomly divided into three groups: propofol 0.8 mg/kg (group P0.8), propofol 1.0 mg/kg （group P1.0）, and propofol 1.2 mg/kg （group P1.2）. Each group was respectively injected propofol with a dose of 0.8 mg/kg, 1.0 mg/kg, and 1.2 mg/kg, combined with succinylcholine with a dose of 1.0 mg/kg by using total intravenous anesthesia. When the rate of decline in the bispectral index of electroencephalogram gradually slowed down to the plateau and could maintain four seconds, the patients are immediately given the modified electroconvulsive therapy when the consciousness disappears. The heart rate, mean arterial pressure, bispectral index, Hamilton depression scale score, seizure time, respiratory and consciousness recovery time, and adverse reactions were recorded. The basic heart rate, mean arterial blood pressure, bispectral index when the patient enters the treatment room were recorded. The fastest heart rate, the highest mean arterial blood pressure and the lowest value of the bispectral index were recorded after the modified electroconvulsive therapy. The time to peak effect of propofol, seizure duration, respiratory recovery time and recovery time of consciousness were recorded. The Hamilton depression scale scores were recorded before treatment and 24 hours after the first modified electroconvulsive therapy. The length of hospital stay and the total number of modified electroconvulsive therapy administered during hospitalization were recorded. Adverse reactions such as lower depth of anesthesia (BIS < 40), higher depth of anesthesia (BIS > 60), respiratory depression, intraoperative awareness, allergies, and postoperative delirium were recorded.
Results After modified electroconvulsive therapy, comparison of three groups of patients, the fastest heart rate of group P0.8 was significantly faster than the group P1.0 and group P1.2 (P < 0.01), the highest mean arterial pressure of group P0.8 was significantly higher than the group P1.0 and group P1.2 (P < 0.01), the respiratory recovery time and consciousness recovery time of group P0.8 and group P1.0 were significantly shorter than the group P1.2(P < 0.01), and the respiratory recovery time of group P0.8 was significantly shorter than the group P1.0 (P < 0.05). Compared with the Hamilton depression scale score before the treatment, the three groups were significantly reduced twenty-four hours after the first modified electroconvulsive therapy (P < 0.05). There were no statistically significant differences among the three groups in terms of the time to peak effect of propofol, seizure time, length of hospital stay and total number of the modified electroconvulsive therapy. The incidence of lower depth of anesthesia in group P0.8 was significantly lower than the group P1.2 (P < 0.05). The incidence of higher depth of anesthesia in group P0.8 was significantly higher than the group P1.0 and group P1.2 (P < 0.01). The incidence of respiratory depression in group P0.8 and group P1.0 was significantly lower than the group P1.2 (P < 0.05). There was no statistically significant difference in the incidence of allergy among the three groups, and no intraoperative awareness and postoperative delirium occurred in the three groups.
Conclusion The hemodynamics of depression in the modified electroconvulsive therapy with intravenous propofol 1.0 mg/kg was more stable than 0.8 mg/kg. Compared with the 1.2 mg/kg, the incidence of adverse reactions caused by the lower depth of anesthesia and the inhibition effect on brainwave attack were smaller. Therefore, intravenous propofol 1.0 mg/kg in depressed patients is more beneficial to perform the safe and effective modified electroconvulsive therapy.
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