肖凌燕

右美托咪定對七氟醚復(fù)合麻醉斜視矯正術(shù)患兒蘇醒期躁動(dòng)的影響

肖凌燕

目的觀察右美托咪定對七氟醚復(fù)合麻醉斜視矯正術(shù)患兒蘇醒期躁動(dòng)的影響。方法40例擇期擬行斜視矯正術(shù)的患兒, 采用隨機(jī)數(shù)字表法分成兩組：生理鹽水對照組(Ⅰ組, n=20)和右美托咪定組(Ⅱ組, n=20)。靜脈注射芬太尼2 μg/kg, 異丙酚3 mg/kg完成誘導(dǎo)插入喉罩, 術(shù)中吸入2％～3.5％七氟醚維持麻醉。插入喉罩即刻Ⅱ組輸注右美托咪定0.2 μg/(kg·h), Ⅰ組輸注等劑量的生理鹽水。手術(shù)結(jié)束時(shí)停止輸注右美托咪定和生理鹽水。記錄兩組手術(shù)時(shí)間、拔管時(shí)間、麻醉后恢復(fù)室(PACU)停留時(shí)間、PACU期間記錄躁動(dòng)發(fā)生情況, 采用小兒蘇醒期煩躁量表(PAED)評價(jià)躁動(dòng)程度。結(jié)果兩組手術(shù)時(shí)間、拔管時(shí)間差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)；與Ⅰ組相比, Ⅱ組患者麻醉后PACU停留時(shí)間短, 躁動(dòng)發(fā)生率低,躁動(dòng)評分低, 差異具有統(tǒng)計(jì)學(xué)意義(P＜0.05)。結(jié)論右美托咪定可減少七氟醚復(fù)合麻醉斜視矯正術(shù)患兒蘇醒期躁動(dòng)發(fā)生率, 蘇醒質(zhì)量高。

右美托咪定；七氟醚；麻醉恢復(fù)期；精神運(yùn)動(dòng)性激動(dòng)

小兒手術(shù)麻醉恢復(fù)期躁動(dòng)(emergence agitation, EA)發(fā)生率高[1］, 術(shù)后躁動(dòng)影響手術(shù)效果及患兒恢復(fù)。七氟醚具有起效快、麻醉平穩(wěn)及可控性強(qiáng)等優(yōu)點(diǎn), 但患兒復(fù)蘇期躁動(dòng)發(fā)生率高[2］。因此, 抑制或減少復(fù)蘇期躁動(dòng)的發(fā)生有利于患兒術(shù)后恢復(fù)。右美托咪定是選擇性的COX2受體激動(dòng)藥, 具有鎮(zhèn)靜、鎮(zhèn)痛作用, 對呼吸抑制輕。本研究擬觀察右美托咪定對七氟醚復(fù)合麻醉斜視矯正術(shù)患兒蘇醒期躁動(dòng)的影響。

1 資料與方法

1.1 一般資料 擇期擬行斜視矯正術(shù)患兒40例, 性別不限,年齡3 ～7歲, 體重13～25 kg, ASAⅠ級, 近期無上呼吸道感染病史。采用隨機(jī)數(shù)字表將其分成兩組：生理鹽水對照組(Ⅰ組, n=20)和右美托咪定組(Ⅱ組, n =20)。

1.2 麻醉方法 所有患兒術(shù)前禁食8 h, 禁飲4 h, 術(shù)前30 min肌內(nèi)注射阿托品0.01 mg/kg。入室后常規(guī)連續(xù)監(jiān)測心電圖、心率、平均動(dòng)脈壓和脈搏血氧飽和度。靜脈注射芬太尼2 μg/kg, 異丙酚3 mg/kg完成誘導(dǎo)插入喉罩, 術(shù)中吸入2％～3.5％七氟醚維持麻醉。插入喉罩后即刻Ⅱ組輸注右美托咪定0.2 μg(kg·h), Ⅰ組輸注等劑量的生理鹽水, 手術(shù)結(jié)束停止輸注右美托咪定和生理鹽水。術(shù)中采用 Aspect-1000 監(jiān)測腦電雙頻指數(shù) (bispectral index, BIS), 使BIS 維持在45～60。插入喉罩后行機(jī)械通氣調(diào)整呼吸參數(shù)維持呼氣末二氧化碳分壓(PETCO2)維持在35～45 mm Hg(1 mm Hg=0.133 kPa), 手術(shù)結(jié)束時(shí)停止麻醉, 待患兒自主呼吸恢復(fù)時(shí)拔除喉罩。

1.3 觀察項(xiàng)目 記錄手術(shù)時(shí)間、拔管時(shí)間、麻醉后恢復(fù)室(PACU)停留時(shí)間；PACU期間記錄躁動(dòng)發(fā)生情況, 并采用Craver 等[3］指定的小兒蘇醒期煩躁量表(PAED)評價(jià)躁動(dòng)程度。PAED評價(jià)標(biāo)準(zhǔn)如下:服從指令并可交流；行動(dòng)具有目的性;關(guān)注周圍環(huán)境;不安寧;哭鬧無法被安撫。每項(xiàng)分為5個(gè)等級, 前三項(xiàng)依次為無(4分), 差(3分), 良(2分), 好(1分),極好(0分)；后兩項(xiàng)依次為極重(4分), 重(3分), 中(2分),輕(1分), 無(0分), 取分值總和為 PAED評分, 分?jǐn)?shù)越高反映蘇醒期躁動(dòng)的程度越重。

1.4 統(tǒng)計(jì)學(xué)方法 應(yīng)用SPSS13.0 軟件進(jìn)行分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(±s)表示, 采用成組t檢驗(yàn); 計(jì)數(shù)資料采用χ2檢驗(yàn)比較。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 兩組患兒性別比、年齡、體重、手術(shù)時(shí)間及拔管時(shí)間差異無統(tǒng)計(jì)學(xué)意義(P＞0.05), 與Ⅰ組相比, Ⅱ組PACU停留時(shí)間短, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。見表1。

表1 兩組患兒一般情況及手術(shù)情況各指標(biāo)的比較(n,±s)

表1 兩組患兒一般情況及手術(shù)情況各指標(biāo)的比較(n,±s)

注：與Ⅰ組相比,aP＜0.05

組別 例數(shù) 性別(男/女) 年齡(歲) 體重(kg) 手術(shù)時(shí)間(min)拔管時(shí)間(min)PACU停留時(shí)間(min)Ⅰ組 20 13/7 4.5±1.5 20±7 18±7 6.5±1.6 35±11Ⅱ組 20 11/9 4.3±1.7 19±8 16±5 6.3±1.2 22±8a

2.2 Ⅱ組PAED評分及躁動(dòng)發(fā)生率低于Ⅰ組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05), 見表2。

表2 兩組患兒PAED評分和躁動(dòng)發(fā)生率的比較(±s, ％)

表2 兩組患兒PAED評分和躁動(dòng)發(fā)生率的比較(±s, ％)

注：與Ⅰ組相比,aP＜0.05

組別 例數(shù) PAED評分(分) 躁動(dòng)發(fā)生率Ⅰ組 20 10.9±1.8 75Ⅱ組 20 7.9±1.6a 30a

3 討論

蘇醒期躁動(dòng)為麻醉蘇醒期的一種不恰當(dāng)行為, 表現(xiàn)為并存的興奮、躁動(dòng)和定向障礙, 患者可出現(xiàn)哭喊或呻吟、肢體的無意識動(dòng)作、掙扎等表現(xiàn)。蘇醒期躁動(dòng)可能造成意外傷害,影響手術(shù)效果及患者術(shù)后恢復(fù)。蘇醒期躁動(dòng)的發(fā)生與多種因素有關(guān), 兒童斜視矯正術(shù)術(shù)后雙眼遮蓋無法視物引起的恐懼也是引起躁動(dòng)原因之一[4］。研究表明[5］,3～7 歲小兒術(shù)后躁動(dòng)發(fā)生率較高。據(jù)此, 本研究選擇的患兒均在此年齡范圍內(nèi),排除了年齡因素對躁動(dòng)的影響。七氟醚麻醉術(shù)后躁動(dòng)的機(jī)制目前尚不十分明確。有研究表明[6］：全身麻醉藥物對中樞神經(jīng)系統(tǒng)的抑制程度不同, 吸入七氟醚后小兒的神經(jīng)系統(tǒng)在恢復(fù)過程中出現(xiàn)了不同步現(xiàn)象, 此時(shí)大腦皮層尚處于抑制狀態(tài)仍未完全恢復(fù), 這種功能完整性的缺失可能引起躁動(dòng)。右美托咪定是腎上腺α2受體激動(dòng)劑, 可以激動(dòng)突觸前膜的α2受體, 從而抑制去甲腎上腺素釋放, 終止疼痛信號的傳導(dǎo), 避免疼痛對患兒的刺激而誘發(fā)的躁動(dòng)；也可以與脊髓內(nèi)的α2受體結(jié)合, 發(fā)揮鎮(zhèn)痛和鎮(zhèn)靜作用[7］。與對照組相比, 右美托咪定組拔管時(shí)間沒有差別, 可能是停藥后其鎮(zhèn)靜作用立即消失[8］, 且PACU停留時(shí)間比對照組短。

綜上所述, 右美托咪定可降低七氟醚復(fù)合麻醉小兒斜視術(shù)后恢復(fù)期躁動(dòng), 值得臨床推廣應(yīng)用。

[1]Silva LM, Braz LG, Modolo NS. Emergenceagitation in pediatric anesthesia: currentfeatures. J Pediatr (Rio J),2008,84(2):107-113.

[2]Weldn BC, Bell M, Craddock T. The effect of caudal analgesia on emergence agitation in children after sevoflurane versus halothane anesthesia. Anesth Analg,2004,98(2):321-326.

[3]Craver JP, Beach M, Dodge CP, et al. Emergencecharacteristics of sevofluranecompared to halothane in pediatricpatientsundergoin gbilateralpressureequalizationtubeinsertion. J Clin Anesth,2000,12(5):397-401.

[4]郭玉清.護(hù)理干預(yù)對小兒斜視矯正術(shù)的影響.現(xiàn)代中西醫(yī)結(jié)合雜志,2013,22(3):313-314.

[5]Bergendahl HT, Lonnqvist PA, Eksborg S, et al. Clonidine vs. midazolam as premedication in childrenundergoing adenotonsillectomy: a prospective, randomized, controlled clinical trial. ActaAnesthesiol Scand,2004,48(10):1292-1300.

[6]Cohen IT, Finkel JC, Hannallah RS, et al. Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children: a comparison with propofol. Paediatr Anaesth,2003,13(1):63-67.

[7]Phan H, Nahata MC. Clinical uses of dexmedetetomidine in pediatric patients. Pediatr Drugs,2008,10(1):49-69.

[8]Souter MJ, Rozet I, Ojemann JG, et al. Dexmedetomidine sedation during awake craniotomy for seizure resection: effects on electrocorticography. J Neurosurg Anesthesiol,2007,19(1):38-44.

Influence of dexmedetomidine on emergence agitation of children undergoing strabismus surgery by sevoflurane anesthesia

XIAO Ling-yan. Department of anesthesiology, Shenyang City the Forth People’s Hospital, Shenyang110031, China

ObjectiveTo observe the influence of dexmedetomidine on emergence agitation of children undergoing strabismus surgery by sevoflurane anesthesia.MethodsA total of40 children undergoing strabismus surgery were divided into two groups by random number table as normal saline control group (group Ⅰ, n=20) and dexmedetomidine group (group Ⅱ, n=20). Anesthesia was induced with2 μg/kg of fentanyl and3 mg/kg of propofol, and maintained with2％～3.5％ of sevoflurane. At the moment laryngeal mask intubation was performed, groupⅡ received 0.2 μg/(kg·h) of dexmedetomidine, and groupⅠ received normal saline. The operation time, extubation time, postanesthesia care unit (PACU) stays time, and agitation during PACU were recorded, and pediatric anesthesia emergence delirium (PAED) was used to assess their agitation degree.ResultsThere were no statistically significant differences of the operation time and extubation time between the two groups (P>0.05). The PACU stays time was shorter, incidence of agitation and PEAD scores were lower in Group Ⅱ than in Group Ⅰ, and the difference had statistical significance (P<0.05).ConclusionDexmedetomidine can reduce the incidence of agitation of children who undergo strabismus surgery by sevoflurane anesthesia, and they can also gain high wake quality.

Dexmedetomidine; Sevoflurane; Anesthesia recovery period; Psychomotor agitation

10.14164/j.cnki.cn11-5581/r.2015.02.007

2014-10-20］

110031 沈陽市第四人民醫(yī)院麻醉科