李占軍,劉多輝,安麗娜,董 蘭,譚殿學(xué),楊樹(shù)峰
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右美托咪定與丙泊酚復(fù)合氯胺酮用于視網(wǎng)膜母細(xì)胞瘤患兒經(jīng)股動(dòng)脈穿刺行局部化療的麻醉效果比較
李占軍,劉多輝,安麗娜,董 蘭,譚殿學(xué),楊樹(shù)峰
目的 評(píng)價(jià)右美托咪定與丙泊酚單獨(dú)復(fù)合或聯(lián)合復(fù)合氯胺酮用于視網(wǎng)膜母細(xì)胞瘤(retinoblastoma,RB)患兒經(jīng)股動(dòng)脈穿刺行眼動(dòng)脈局部化療的麻醉效果,比較幾種用藥方法的安全性與可行性。方法 擇期經(jīng)股動(dòng)脈穿刺行眼動(dòng)脈局部化療的RB患兒60例,隨機(jī)分為3組(n=20):D組、P組和DP組。所有患兒入室后靜脈注射阿托品0.02 mg/kg和氯胺酮2.0 mg/kg麻醉誘導(dǎo),同時(shí)D組給予右美托咪定1.0 μg/(kg·h), P組給予丙泊酚10 mg/(kg·h) ,DP組給予右美托咪定0.5 μg/(kg·h) 復(fù)合丙泊酚5 mg/(kg·h) ,分別泵注維持至術(shù)畢。記錄患兒入室(T0)、手術(shù)開(kāi)始即刻(T1)、手術(shù)后10 min(T2)、化療藥注射即刻(T3)、術(shù)畢即刻(T4)、蘇醒即刻(T5)各時(shí)間點(diǎn)患兒BIS、NBP、HR、RR和SpO2,記錄各組患兒氯胺酮總用量和阿托品追加次數(shù)、手術(shù)時(shí)間、蘇醒時(shí)間、呼吸抑制和術(shù)后躁動(dòng)等不良反應(yīng)的發(fā)生情況。 結(jié)果 與T0比較,三組患兒在T2,3,4時(shí)BIS值降低(P<0.05),P組T3,4時(shí)NBP降低(P<0.05)。三組HR、RR和SpO2各時(shí)間點(diǎn)差異無(wú)統(tǒng)計(jì)學(xué)意義。與D組比較,P組和DP組氯胺酮總用量減少(P<0.05),追加次數(shù)減少(P<0.01)。P組呼吸抑制率明顯高于D組與DP組(P<0.01)。三組手術(shù)時(shí)間、蘇醒時(shí)間及阿托品使用率比較差異無(wú)統(tǒng)計(jì)學(xué)意義。所有患兒均未發(fā)生蘇醒期躁動(dòng)。 結(jié)論 在RB患兒經(jīng)股動(dòng)脈行眼動(dòng)脈局部化療的手術(shù)中,采用氯胺酮誘導(dǎo),繼以右美托咪定0.5 μg/(kg·h)與丙泊酚5 mg/(kg·h)聯(lián)合泵注維持可產(chǎn)生良好的鎮(zhèn)靜鎮(zhèn)痛效果,且不良反應(yīng)發(fā)生率低,是較適宜的麻醉組合。
右美托咪啶;丙泊酚;氯胺酮;小兒;視網(wǎng)膜母細(xì)胞瘤;化療
視網(wǎng)膜母細(xì)胞瘤(retinoblastoma,RB)是一種常見(jiàn)的先天性腫瘤,其全身化療的不良反應(yīng)較大、針對(duì)性不強(qiáng)。近年來(lái),經(jīng)股動(dòng)脈穿刺行眼動(dòng)脈局部化療的技術(shù)開(kāi)展?jié)u漸增多,其操作精細(xì),需要絕對(duì)制動(dòng),但因小兒一般不能耐受股動(dòng)脈穿刺時(shí)的疼痛以及離開(kāi)家長(zhǎng)后的恐慌,不能安靜地配合手術(shù),常需在全身麻醉下進(jìn)行。丙泊酚與右美托咪定都是臨床常用的鎮(zhèn)靜藥,各有優(yōu)缺點(diǎn),在應(yīng)用過(guò)程中還需探討其合適的用法用量。本研究擬評(píng)價(jià)右美托咪定與丙泊酚單獨(dú)復(fù)合或聯(lián)合復(fù)合氯胺酮用于患兒視母細(xì)胞瘤介入治療的麻醉效果,探尋此種手術(shù)適宜的麻醉用藥方法。
1.1 對(duì)象 選擇我院2014-03至2015-01,擬在全身麻醉下經(jīng)股動(dòng)脈穿刺行眼動(dòng)脈局部化療的視網(wǎng)膜母細(xì)胞瘤患兒60例,ASA分級(jí)Ⅰ或Ⅱ級(jí),性別不限,年齡2~5歲,體重12~31 kg,無(wú)藥物過(guò)敏史,肝腎功能未見(jiàn)異常,無(wú)呼吸道等其他系統(tǒng)疾病史?;純喊淳驮\順序進(jìn)行編號(hào),采用隨機(jī)數(shù)字表法,將其分為3組,每組20例,即D組、P組和DP組。
1.2 麻醉方法 患兒入室后靜脈注射阿托品0.02 mg/kg,氯胺酮2.0 mg/kg行麻醉誘導(dǎo),同時(shí)D組給予右美托咪定(批號(hào):13030832,廠(chǎng)商:江蘇恒瑞醫(yī)藥股份有限公司)1.0 μg/(kg·h),P組給予丙泊酚(批號(hào):KV277,廠(chǎng)商:Corden Pharma S.P.A.)10 mg/(kg·h),DP組給予右美托咪定0.5 μg/(kg·h)復(fù)合丙泊酚5 mg/(kg·h)泵注維持至術(shù)畢,患兒入睡后行股動(dòng)脈穿刺進(jìn)行局部化療。手術(shù)全程給予低流量(2 L/min)鼻導(dǎo)管吸氧,術(shù)中有體動(dòng)等麻醉變淺情況時(shí)追加氯胺酮0.5 mg/kg, 心率<60次/min時(shí)追加阿托品0.01 mg/kg,發(fā)生呼吸抑制(SpO2<93%或RR<12次/min)時(shí)給予輔助呼吸至完全恢復(fù)。
1.3 觀察指標(biāo) 記錄患兒入室(T0)、氯胺酮給藥后3 min即手術(shù)開(kāi)始即刻(T1)、手術(shù)開(kāi)始后10 min(T2)、化療藥物注射開(kāi)始(T3)、術(shù)畢即停麻醉藥即刻(T4)、蘇醒即刻(T5)各時(shí)間點(diǎn)患兒BIS、NBP、HR、RR和SpO2,記錄各組患兒氯胺酮總用量、氯胺酮和阿托品追加次數(shù)、手術(shù)時(shí)間、停藥后蘇醒時(shí)間,呼吸抑制和術(shù)后躁動(dòng)等不良反應(yīng)的發(fā)生情況。
三組性別構(gòu)成比、年齡和體重比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05,表1)。與T0時(shí)比較,三組T2,3,4時(shí)BIS值降低(P<0.05),P組T3,4時(shí)NBP降低(P<0.05),D組與DP組各時(shí)間點(diǎn)NBP和變化無(wú)統(tǒng)計(jì)學(xué)意義。三組HR、RR、SpO2各時(shí)間點(diǎn)差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05,表2)。三組手術(shù)時(shí)間、停藥后蘇醒時(shí)間、阿托品使用率比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。所有患兒均未發(fā)生蘇醒期躁動(dòng)。與D組比較,DP組和P組氯胺酮總用量減少(P<0.05),氯胺酮追加率降低(P<0.01)。與P組比較,D組與DP組呼吸抑制發(fā)生率降低(P<0.01,表3)。
表1 視網(wǎng)膜母細(xì)胞瘤三組患兒一般資料各指標(biāo)的比較 (n=20;
表2 視網(wǎng)膜母細(xì)胞瘤三組患兒NBP、HR、SpO2和BIS值的比較 (n=20;
續(xù)表
注:與T0時(shí)比較,①P<0.05
表3 視網(wǎng)膜母細(xì)胞瘤三組患兒氯胺酮和阿托品用藥情況、手術(shù)時(shí)間、停藥后蘇醒時(shí)間及不良反應(yīng)發(fā)生情況的比較 (n=20;
注:與D組比較,①P<0.05,② P<0.01;與P組比較,③P<0.01
丙泊酚是臨床最常用的靜脈全麻藥,但因其有劑量依賴(lài)性的呼吸循環(huán)抑制而限制了其應(yīng)用。右美托咪定是一種高選擇性α2-腎上腺素受體激動(dòng)藥,與其他鎮(zhèn)靜鎮(zhèn)痛藥相比,右美托咪定對(duì)呼吸的抑制最小[1],且在蘇醒期無(wú)躁動(dòng)發(fā)生[2],但因其鎮(zhèn)靜較淺,不能很好的抑制手術(shù)刺激,使其應(yīng)用也有一定的限制。氯胺酮是唯一具有鎮(zhèn)痛作用的靜脈全麻藥,且小劑量的氯胺酮具有良好的鎮(zhèn)痛作用[3],因此本研究中選擇了此三種常用藥的常用劑量相應(yīng)配伍進(jìn)行觀察。
本研究中,首先以氯胺酮和阿托品靜脈誘導(dǎo),同時(shí)以不同的麻醉藥配伍進(jìn)行輸注維持,發(fā)現(xiàn)P組T3,4時(shí)點(diǎn)NBP降低,說(shuō)明丙泊酚有一定的劑量依賴(lài)性循環(huán)抑制作用。各組患兒心率在誘導(dǎo)后均一過(guò)性升高,這與氯胺酮和阿托品的作用直接有關(guān),5min后心率逐漸恢復(fù)并相對(duì)穩(wěn)定于入室水平,說(shuō)明此三種方法對(duì)心率的影響都沒(méi)有臨床意義。
以往的研究中,氯胺酮與右美托咪定復(fù)合用于小兒椎管內(nèi)麻醉時(shí)的鎮(zhèn)靜有明顯的優(yōu)勢(shì)[4],氯胺酮誘導(dǎo)繼以右美托咪定1.0μg/(kg·h)維持即可滿(mǎn)足小兒微創(chuàng)手術(shù)的操作[5],而本研究中,D組7例、P組和DP均有1例患兒在術(shù)中需額外追加氯胺酮才能完成手術(shù),且所有需要追加氯胺酮者均發(fā)生于遠(yuǎn)心端操作中需追加造影劑時(shí),說(shuō)明右美托咪定1.0μg/(kg·h)的維持量不能很好的抑制造影劑的直接刺激,可能是因眼動(dòng)脈較細(xì)、導(dǎo)管及造影劑的局部刺激較強(qiáng)而導(dǎo)致。P組中有6例患兒發(fā)生呼吸抑制,說(shuō)明丙泊酚對(duì)呼吸的抑制作用是劑量依賴(lài)性的。三組患兒停藥后蘇醒時(shí)間無(wú)差異,可能因手術(shù)時(shí)間較短,右美托咪定與丙泊酚的用藥總量不大,對(duì)患兒蘇醒沒(méi)有產(chǎn)生明顯的影響。
綜上所述,患兒在經(jīng)股動(dòng)脈穿刺行眼動(dòng)脈局部化療過(guò)程中,采用氯胺酮誘導(dǎo)繼以右美托咪定0.5μg/(kg·h)聯(lián)合丙泊酚5mg/(kg·h)維持可產(chǎn)生良好的鎮(zhèn)靜鎮(zhèn)痛效果,且不良反應(yīng)小,是較適宜的麻醉組合。
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(2016-01-16收稿 2016-05-20修回)
(責(zé)任編輯 梁秋野)
Effects of dexmedetomidine and propofol used alone or combined with ketamine in local chemotherapy through ophthalmic artery of retinoblastoma in pediatric patients
LI Zhanjun, LIU Duohui, AN Lina, DONG Lan , TAN Dianxue, and YANG Shufeng. Department of Anesthesiology, General Hospital of Chinese People’s Armed Police Force, Beijing 100039,China
Objective To evaluate the clinical value of dexmedetomidine and propofol used separately or in combination with ketamine in local chemotherapy through ophthalmic artery of retinoblastoma in pediatric patients. Methods 60 children with retinoblastoma were randomly divided into three groups: group D, group P and group DP. Subjects in each group were given atropine 0.02 mg/kg and ketamine 2.0 mg/kg as induced anesthesia. The dose of each anesthetic was maintainted at the same time. Femoral artery puncture began soon after the children fell asleep. BIS, BP, HR, RR and SpO2of these patients were recorded at different time points. The total amount of ketamine, cases who needed additional ketamine and atropine,the operation time and awakening time were recorded as well. Also, the incidence of adverse events such as respiratory depression and postoperative agitation was observed. Results Compared to T0, BIS decreased from T2to T4in these groups, while NBP was reduced from T3to T4in group P. There was no significant difference of HR, RR and SpO2between these three groups at each time point. Compared to group D, the total amount and additional injection of ketamine was significantly reduced in group P and DP (P<0.05 orP<0.01). There were far more respiratory depression events in group P than in the other two groups. There was no significant difference in postoperative recovery status between these groups. Conclusions During local chemotherapy through ophthalmic artery in pediatric patients of RB, ketamine, when combined with dexmedetomidine andmaintained at the dose of 0.5 μg/(kg·h) or with propofol maintained at the dose of 5 mg/(kg·h), can produce effective sedation and analgesia with few adverse reactions. This should be a suitable combination of anesthesia in operations of this kind.
dexmedetomidine; propofol; ketamine; child; retinblastoma;, chemotherapy
李占軍,碩士,主治醫(yī)師。
100039 北京,武警總醫(yī)院麻醉科
董 蘭,E-mail:dlchina2000@126.com
R614.24