不同劑量地佐辛對(duì)小兒七氟醚復(fù)合麻醉蘇醒期躁動(dòng)的影響

章艷君，李　榕，劉金柱

(天津市兒童醫(yī)院麻醉科　300700)

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論著·臨床研究

不同劑量地佐辛對(duì)小兒七氟醚復(fù)合麻醉蘇醒期躁動(dòng)的影響

章艷君，李榕，劉金柱

(天津市兒童醫(yī)院麻醉科300700)

[摘要]目的評(píng)價(jià)不同劑量地佐辛對(duì)小兒七氟醚復(fù)合麻醉蘇醒期躁動(dòng)的影響。方法擇期行短小手術(shù)的患兒100例，年齡1～3歲，隨機(jī)分為地佐辛0.03 mg/kg組(D1組)、0.05 mg/kg組(D2組)、0.10 mg/kg組(D3組)和對(duì)照組，每組25例。患兒面罩吸入6%的七氟醚，睫毛反射消失后靜脈給予瑞芬太尼1 μg/kg置入喉罩，術(shù)中吸入1.5%～2.5%七氟醚，并持續(xù)靜脈輸注瑞芬太尼維持麻醉。在手術(shù)開始前D1組、D2組、D3組分別給予地佐辛0.03、0.05和0.10 mg/kg，對(duì)照組給予等容量生理鹽水。記錄拔除喉罩時(shí)間、麻醉恢復(fù)室(PACU)停留時(shí)間；PACU期間躁動(dòng)發(fā)生情況，采用患兒麻醉蘇醒期躁動(dòng)量化評(píng)分表(PAED)評(píng)價(jià)躁動(dòng)程度?；純喝隤ACU即刻(T0)及15 min(T1)、30 min(T2)行FLACC評(píng)分和Ramsey評(píng)分。記錄術(shù)后24 h患兒不良反應(yīng)的發(fā)生情況。結(jié)果與對(duì)照組比較，D2組和D3組躁動(dòng)發(fā)生率、PAED評(píng)分均明顯降低(P<0.05)；D2組和D3組各時(shí)點(diǎn)FLACC評(píng)分均明顯降低(P<0.05)，Ramsey評(píng)分均明顯升高(P<0.05)。與D2組比較，D3組Ramsey評(píng)分明顯升高(P<0.05)。D3組PACU停留時(shí)間較其他3組均明顯延長(zhǎng)(P<0.05)。結(jié)論0.05 mg/kg及0.10 mg/kg地佐辛都可以有效減少小兒七氟醚復(fù)合麻醉蘇醒期躁動(dòng)的發(fā)生，但0.05 mg/kg地佐辛可減少七氟醚麻醉后蘇醒期躁動(dòng)且鎮(zhèn)靜強(qiáng)度適當(dāng)，不延長(zhǎng)PACU停留時(shí)間。

[關(guān)鍵詞]地佐辛；七氟醚；麻醉恢復(fù)期；情緒障礙；兒童

蘇醒期躁動(dòng)是小兒七氟醚麻醉非常常見的一個(gè)術(shù)后問題。盡管這種蘇醒期躁動(dòng)是自限性的，但是其危害性較大，躁動(dòng)過度甚至?xí)?duì)患兒的生理和心理造成繼發(fā)性傷害[1]。其機(jī)制目前還不明確，有研究發(fā)現(xiàn)小兒使用鎮(zhèn)靜類藥物、α2受體激動(dòng)劑或阿片類藥物均可在一定程度上減少小兒術(shù)后躁動(dòng)的發(fā)生[2-5]。地佐辛是混合型阿片受體激動(dòng)拮抗劑，具有較強(qiáng)的鎮(zhèn)痛效應(yīng)和一定的鎮(zhèn)靜作用，目前關(guān)于地佐辛降低小兒七氟醚麻醉引起的蘇醒期躁動(dòng)的文獻(xiàn)報(bào)道很少。本研究旨在觀察不同劑量地佐辛對(duì)小兒七氟醚復(fù)合麻醉恢復(fù)期躁動(dòng)的影響，以探討地佐辛的最佳給藥劑量。

1資料與方法

1.1一般資料本研究已獲醫(yī)院倫理委員會(huì)批準(zhǔn)，所有受試患兒家長(zhǎng)及法定監(jiān)護(hù)人均簽署知情同意書。擇期行短小手術(shù)(如疝囊高位結(jié)扎或疝修補(bǔ)術(shù)、鞘狀突高位結(jié)扎術(shù))的患兒100例，美國(guó)麻醉醫(yī)師協(xié)會(huì)(ASA)分級(jí)Ⅰ級(jí)，年齡1～3歲，體質(zhì)量11～18 kg。排除標(biāo)準(zhǔn)：有神經(jīng)、精神系統(tǒng)疾病病史；術(shù)前24 h內(nèi)應(yīng)用鎮(zhèn)靜或鎮(zhèn)痛藥物；有惡性高熱家族史。本研究采用前瞻性、隨機(jī)、對(duì)照、雙盲研究，按照隨機(jī)數(shù)字表法將患兒分為地佐辛0.03 mg/kg組(D1組)、0.05 mg/kg組(D2組)、0.10 mg/kg組(D3組)和對(duì)照組，每組25例。

1.2方法患兒入手術(shù)室后靜脈給予阿托品0.01 mg/kg，常規(guī)監(jiān)測(cè)心電圖(ECG)、血壓(BP)和血氧飽和度(SpO2)。面罩吸入100%的氧氣3 min，使SpO2≥99%，然后吸入6%的七氟醚(批號(hào)1X12，Maruishi Pharmaceutical 公司，日本)，睫毛反射消失后靜脈緩慢推注瑞芬太尼1 μg/kg，當(dāng)擠壓斜方肌無反應(yīng)后插入合適大小的喉罩，喉罩氣囊充氣并檢查有無口腔漏氣和氣道梗阻，連接麻醉機(jī)行呼吸控制，潮氣量(VT)8～10 mL/kg，呼吸頻率(RR)20～25次/min，吸呼比1∶2，維持呼氣末二氧化碳分壓(PETCO2)30～40 mm Hg。術(shù)中吸入1.5%～2.5%七氟醚，并持續(xù)靜脈輸注瑞芬太尼0.1～1.0 μg·kg-1·min-1維持麻醉。手術(shù)結(jié)束后停止七氟醚吸入和瑞芬太尼輸注，將氧流量調(diào)至6 L/min，新鮮氣流快速?zèng)_洗麻醉管路，手控通氣清除殘余七氟醚，待患兒自主呼吸平穩(wěn)SpO2>95%、PETCO2<50 mm Hg拔除喉罩送至麻醉恢復(fù)室(PACU)。D1組、D2組和對(duì)照組在手術(shù)開始前由專門人員分別從靜脈通路給予地佐辛(批號(hào)12060421)0.03、0.05、0.10 mg/kg和等容量生理鹽水。

1.3監(jiān)測(cè)指標(biāo)記錄手術(shù)時(shí)間、麻醉時(shí)間、拔除喉罩時(shí)間(術(shù)畢停藥到拔除喉罩的時(shí)間)和患兒在PACU停留時(shí)間。PACU期間參照文獻(xiàn)[6]采用的方法進(jìn)行躁動(dòng)評(píng)分(1分，入睡；2分，清醒、安靜；3分，急躁、哭鬧；4分，無法安撫的哭鬧；5分，驚恐不安、譫妄)，若患兒躁動(dòng)評(píng)分大于或等于4分為發(fā)生躁動(dòng)，記錄術(shù)后躁動(dòng)發(fā)生情況。采用患兒麻醉蘇醒期躁動(dòng)量化評(píng)分表(PAED)對(duì)躁動(dòng)程度進(jìn)行評(píng)估[7]：(1)患兒的眼睛注視護(hù)理人員；(2)患兒的行動(dòng)帶有目的性；(3)患兒能知道自己所處的環(huán)境；(4)患兒不安寧；(5)患兒無法被安撫。第1、2和3項(xiàng)評(píng)分為4～0分，4=沒有；3=較少；2=較多；1=非常多；0=一直是；第4、5項(xiàng)評(píng)分為0～4分，0=沒有；1=較少；2=較多；3=非常多；4=一直是。各項(xiàng)評(píng)分總和為PAED評(píng)分，分?jǐn)?shù)越高蘇醒期躁動(dòng)的程度越重。患兒入PACU即刻(T0)及15 min(T1)、30 min(T2)時(shí)采用FLACC(表1)疼痛評(píng)分表評(píng)價(jià)疼痛程度，0分為無痛,10分為最痛。采用Ramsey鎮(zhèn)靜評(píng)分表對(duì)鎮(zhèn)靜程度進(jìn)行評(píng)分。1分：患兒焦慮、躁動(dòng)不安；2分：患兒配合，有定向力，安靜；3分：患兒對(duì)指令有反應(yīng)；4分：嗜睡，對(duì)輕叩眉間或大聲聽覺刺激反應(yīng)敏捷；5分：嗜睡，對(duì)輕叩眉間或大聲聽覺刺激反應(yīng)遲鈍；6分：嗜睡，無任何反應(yīng)。待患兒改良Aldrete麻醉恢復(fù)評(píng)分(表2)為9～10分后轉(zhuǎn)至普通病房。術(shù)后24 h隨訪，記錄惡心嘔吐、頭暈頭痛、心悸、呼吸抑制等不良反應(yīng)的發(fā)生情況。

2結(jié)果

4組患兒性別構(gòu)成、年齡、體質(zhì)量、手術(shù)時(shí)間和麻醉時(shí)間差異均無統(tǒng)計(jì)學(xué)意義(P>0.05)，見表3。與對(duì)照組比較，D2組和D3組躁動(dòng)發(fā)生率、PAED評(píng)分均明顯降低(P<0.05)，D2組與D3組躁動(dòng)發(fā)生率及PAED評(píng)分無統(tǒng)計(jì)學(xué)差異(P>0.05)；D1組、D2組和對(duì)照組患兒拔除喉罩時(shí)間及PACU停留時(shí)間相比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，D3組PACU停留時(shí)間較其他3組均延長(zhǎng)(P<0.05)，見表4。與對(duì)照組比較，D2組、D3組各時(shí)點(diǎn)FLACC評(píng)分明顯降低(P<0.05)；D2組與D3組比較，F(xiàn)LACC評(píng)分無統(tǒng)計(jì)學(xué)差異(P>0.05)，見表5。與對(duì)照組比較，D2組和D3組各時(shí)點(diǎn)Ramsey評(píng)分均明顯升高(P<0.05)；與D2組比較，D3組各時(shí)點(diǎn)Ramsey評(píng)分明顯升高(P<0.05)，見表5。術(shù)后24 h隨訪，4組患兒均無明顯不良反應(yīng)發(fā)生。

表1　　FLACC疼痛評(píng)分標(biāo)準(zhǔn)

表2　　Aldrete改良評(píng)分標(biāo)準(zhǔn)

表3　　4組患兒一般情況和術(shù)中情況比較±s，n=25)

表4　　4組患兒拔除喉罩時(shí)間、PACU停留時(shí)間和躁動(dòng)發(fā)生情況的比較

a:P<0.05，與對(duì)照組比較；b：P<0.05，與D1組比較；c：P<0.05，與D2組比較。

表5　　4組患兒術(shù)后各時(shí)點(diǎn)FLACC評(píng)分和Ramsey評(píng)分比較,分)

a:P<0.05,與對(duì)照組比較；b:P<0.05,與D1組比較；c:P<0.05,與D2組比較。

3討論

七氟醚由于血?dú)夥峙湎禂?shù)低、誘導(dǎo)蘇醒快、過程平穩(wěn)，無呼吸道刺激，易于被患兒接受，對(duì)呼吸循環(huán)系統(tǒng)影響小，因而廣泛應(yīng)用于小兒全身麻醉。但臨床觀察發(fā)現(xiàn)小兒七氟醚麻醉易發(fā)生蘇醒期躁動(dòng)，且發(fā)生率較高[8-9]，其發(fā)生與疼痛、蘇醒時(shí)間、環(huán)境、年齡、手術(shù)類別、藥物影響等多種因素有關(guān)[10-12]。本研究4組患兒均為擇期行短小手術(shù)的患兒；且患兒年齡均在1～3歲，可排除年齡及手術(shù)類別對(duì)于各組間麻醉恢復(fù)期躁動(dòng)發(fā)生的影響。成人術(shù)中單次靜脈注射地佐辛用于預(yù)防全身麻醉蘇醒期不良反應(yīng)的常用劑量為0.10 mg/kg[13-14]，目前，還沒有文獻(xiàn)報(bào)道地佐辛用于預(yù)防小兒全身麻醉蘇醒期躁動(dòng)的最佳有效劑量，因此本研究選擇0.03 mg/kg、0.05 mg/kg和 0.10 mg/kg 3個(gè)不同劑量觀察地佐辛用于預(yù)防小兒七氟醚麻醉術(shù)后躁動(dòng)的最佳劑量。

本研究結(jié)果顯示，術(shù)前給予0.05 mg/kg及0.10 mg/kg劑量的地佐辛，兩組患兒的FLACC評(píng)分均降低，Ramsey評(píng)分升高，提示0.05 mg/kg及0.10 mg/kg劑量的地佐辛都可以提供良好的術(shù)后鎮(zhèn)痛和鎮(zhèn)靜效果；本研究結(jié)果同時(shí)顯示兩組患兒麻醉恢復(fù)期躁動(dòng)發(fā)生率及躁動(dòng)程度均明顯降低，提示良好的術(shù)后鎮(zhèn)痛和鎮(zhèn)靜有助于降低麻醉恢復(fù)期躁動(dòng)的發(fā)生，與之前的研究結(jié)果一致[15-17]。而術(shù)前給予0.03 mg/kg地佐辛則不能提供有效的術(shù)后鎮(zhèn)痛和鎮(zhèn)靜，對(duì)于減少小兒蘇醒期躁動(dòng)的發(fā)生沒有明顯的作用。相對(duì)于0.05 mg/kg地佐辛組的患兒，0.10 mg/kg地佐辛組患兒術(shù)后鎮(zhèn)靜程度增強(qiáng)，嗜睡情況增加，同時(shí)PACU停留時(shí)間延長(zhǎng)，提示術(shù)中給予0.05 mg/kg地佐辛對(duì)于預(yù)防患兒七氟醚麻醉蘇醒期躁動(dòng)的效果更佳。

綜上所述，0.05 mg/kg及0.10 mg/kg地佐辛都可以有效減少小兒七氟醚復(fù)合麻醉蘇醒期躁動(dòng)的發(fā)生，但0.05 mg/kg地佐辛可減少七氟醚麻醉后蘇醒期躁動(dòng)且鎮(zhèn)靜強(qiáng)度適當(dāng),不延長(zhǎng)PACU停留時(shí)間。

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The effect of various doses of dezocine on children emergence agitation after combined sevoflurane general anesthesia

ZhangYanjun,LiRong,LiuJinzhu

(DepartmentofAnesthesiology,Children′sHospitalofTianjincity,Tianjin300700,China)

[Abstract]ObjectiveTo investigate the effect of various doses of dezocine on the prevention of emergence agitation after sevoflurane anesthesia in children.Methods100 children aged from 1 to 3 years old were randomly divided into 4 groups with 25 cases each:the 0.03 mg/kg dezocine group (group D1),the 0.05 mg/kg dezocine group (group D2),the 0.10 mg/kg dezocine group (group D3) and the control group.Anaesthesia was induced with 6% sevoflurane and 1 μg/kg remifentanil.Anaesthesia was maintained with 1.5%-2.5% sevoflurane and remifentanil.Different doses of dezocine 0.03 mg/kg,0.05 mg/kg,0.10 mg/kg,and the same volume saline were administered before surgery.The incidence of emergence agitation was assessed with 5 points scale and the severity of emergence agitation was assessed with Pediatric Anesthesia Emergence Delirium (PAED) scale.The time to remove the laryngeal mask airway,the time to be discharged from the post-anesthesia care unit (PACU),FLACC and Ramsey scores,postoperative nausea and vomiting were recorded and considered.ResultsCompared with the control group,the incidence of emergence agitation and PAED scales of D2 and D3 group were significantly lower than it(P<0.05).Compared with the control group,FLACC scores of D2 and D3 group were lower than it(P<0.05).At the same time,Ramsey scores of D2 and D3 were higher than that of the control group(P<0.05).Moreover,Ramsey score of D3 was higher than D2(P<0.05).The time span of being discharged from the PACU of D3 was significantly longer than that of the other groups(P<0.05).ConclusionDezocine of 0.05 mg/kg and 0.10 mg/kg both can reduce the incidence of emergence agitation effectively,and there is no significant difference between the effect of the two doses.However,the dose of 0.05 mg/kg has a better performance in the time span for being discharged from the PACU.

[Key words]dezocine;sevoflurane;anesthesia recovery period;mood disorders;child

作者簡(jiǎn)介：章艷君(1980-)，主治醫(yī)師，碩士，主要從事小兒臨床麻醉研究。

doi:10.3969/j.issn.1671-8348.2016.01.025

[中圖分類號(hào)]R614.2

[文獻(xiàn)標(biāo)識(shí)碼]A

[文章編號(hào)]1671-8348(2016)01-0074-03

(收稿日期：2015-08-18修回日期：2015-09-24)