崔 濤,吳思思(1.湖北省第三人民醫(yī)院麻醉科,武漢 430033;.武漢市東西湖區(qū)婦幼保健院B超室,武漢430040)
七氟烷吸入麻醉與異丙酚靜脈麻醉對(duì)疝氣手術(shù)患兒血流動(dòng)力學(xué)、應(yīng)激反應(yīng)及麻醉效果的影響
崔 濤1*,吳思思2(1.湖北省第三人民醫(yī)院麻醉科,武漢 430033;2.武漢市東西湖區(qū)婦幼保健院B超室,武漢430040)
目的:探討七氟烷吸入麻醉與異丙酚靜脈麻醉對(duì)疝氣手術(shù)患兒血流動(dòng)力學(xué)、應(yīng)激反應(yīng)及麻醉效果的影響。方法:選取2011年5月-2015年9月于湖北省第三人民醫(yī)院接受疝氣手術(shù)的86例患兒為研究對(duì)象,采用隨機(jī)數(shù)字表法分為試驗(yàn)組和對(duì)照組,各43例。試驗(yàn)組患兒給予注射用鹽酸替羅非班0.4 μg/(kg·min),ivgtt,注射用苯磺順阿曲庫(kù)銨0.1 mg/kg+枸櫞酸芬太尼注射液1.0 μg/kg,iv,進(jìn)行麻醉誘導(dǎo);吸入用七氟烷2%~3%進(jìn)行麻醉維持,必要時(shí)追加枸櫞酸芬太尼注射液0.5 μg/kg,iv。對(duì)照組患兒給予異丙酚乳狀注射液3 mg/kg+注射用苯磺酸阿曲庫(kù)銨0.1 mg/kg+枸櫞酸芬太尼注射液1.0 μg/kg,iv,進(jìn)行麻醉誘導(dǎo);丙泊酚注射液3 mg/(kg·h)微泵注入進(jìn)行麻醉維持,必要時(shí)追加枸櫞酸芬太尼注射液0.5 μg/kg,iv。觀察兩組患兒麻醉起效時(shí)間、血流動(dòng)力學(xué)指標(biāo)[收縮壓(SBP)、舒張壓(DBP)和心率(HR)]、應(yīng)激反應(yīng)指標(biāo)[去甲腎上腺素(NE)、腎上腺素(E)和腎素(R)]、蘇醒情況,并記錄不良反應(yīng)發(fā)生情況。結(jié)果:試驗(yàn)組患兒麻醉起效時(shí)間為(3.82±0.45)min,明顯短于對(duì)照組的(5.13±0.74)min,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。麻醉誘導(dǎo)前,兩組患兒SBP、DBP、HR和血清NE、E、R水平比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05)。切皮即刻、切皮后5 min、切皮后10 min時(shí),兩組患兒SBP、DBP、HR水平均明顯高于麻醉誘導(dǎo)前,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);切皮即刻、切皮后5 min時(shí),試驗(yàn)組上述指標(biāo)明顯低于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。切皮即刻時(shí),兩組患兒血清NE、E、R水平均較麻醉誘導(dǎo)前明顯升高,但試驗(yàn)組明顯低于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。試驗(yàn)組患兒術(shù)后的睜眼時(shí)間、清醒時(shí)間、定向力恢復(fù)時(shí)間均明顯短于對(duì)照組,蘇醒期躁動(dòng)量化評(píng)分明顯低于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。試驗(yàn)組患兒不良反應(yīng)發(fā)生率(0)明顯低于對(duì)照組(11.6%),差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論:七氟烷吸入麻醉較異丙酚靜脈麻醉對(duì)疝氣手術(shù)患兒的血流動(dòng)力學(xué)指標(biāo)影響小,有助于緩解應(yīng)激反應(yīng)、促進(jìn)術(shù)后蘇醒,且安全性較好。
疝氣;七氟烷;異丙酚;血流動(dòng)力學(xué);麻醉
疝氣是小兒普外科的常見疾病,主要的治療方式是手術(shù)修補(bǔ),時(shí)間較短且創(chuàng)傷較小,雖需在全身麻醉下進(jìn)行,但不需深度麻醉,選擇合適的麻醉方案有利于手術(shù)的順利進(jìn)行和術(shù)后恢復(fù)[1]。全身麻醉的常用方法為靜脈麻醉和吸入麻醉。靜脈麻醉的藥物劑量相對(duì)較大,麻醉程度較深,術(shù)后蘇醒時(shí)間較長(zhǎng);吸入麻醉則具有麻醉誘導(dǎo)迅速、麻醉程度可控性強(qiáng)、停藥后蘇醒迅速等優(yōu)勢(shì)[2]。本研究探討了七氟烷吸入麻醉和異丙酚靜脈麻醉對(duì)疝氣手術(shù)患兒血流動(dòng)力學(xué)、應(yīng)激反應(yīng)及麻醉效果的影響,現(xiàn)報(bào)道如下。
1.1 納入與排除標(biāo)準(zhǔn)
納入標(biāo)準(zhǔn):(1)確診為腹外疝的患兒;(2)符合無張力疝修補(bǔ)手術(shù)指征;(3)年齡≤8歲;(4)患兒家長(zhǎng)均知情同意并簽署知情同意書。
排除標(biāo)準(zhǔn):(1)存在藥物過敏史者;(2)嚴(yán)重心肺功能不全者;(3)合并腎、肺和造血系統(tǒng)等嚴(yán)重的原發(fā)性疾病者;(4)合并精神疾病者;(5)存在智力障礙或聽力障礙者。
1.2 研究對(duì)象
本研究方案經(jīng)醫(yī)院醫(yī)學(xué)倫理委員會(huì)審核通過后,選取2011年5月-2015年9月于湖北省第三人民醫(yī)院接受疝氣手術(shù)的86例患兒為研究對(duì)象,采用隨機(jī)數(shù)字表法分為試驗(yàn)組和對(duì)照組,各43例。試驗(yàn)組男性28例,女性15例;年齡1~8歲,平均年齡(4.62±0.55)歲;體質(zhì)量6~30 kg,平均體質(zhì)量(14.38±1.35)kg;手術(shù)時(shí)間20~ 30 min,平均手術(shù)時(shí)間(24.32±3.24)min。對(duì)照組男性30例,女性13例;年齡1~8歲,平均年齡(4.72±0.61)歲;體質(zhì)量7~30 kg,平均體質(zhì)量(14.41±1.42)kg;手術(shù)時(shí)間20~30 min,平均手術(shù)時(shí)間(24.36±3.16)min。兩組患兒的性別、年齡、體質(zhì)量和手術(shù)時(shí)間等一般資料比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。
1.3 麻醉方法
兩組患兒進(jìn)入手術(shù)室后均進(jìn)行心電監(jiān)護(hù),建立靜脈通道。試驗(yàn)組患兒給予注射用鹽酸替羅非班[杭州中美華東制藥有限公司,批準(zhǔn)文號(hào):國(guó)藥準(zhǔn)字H20060265,規(guī)格:5 mg(以替羅非班計(jì))]0.4 μg/(kg·min),ivgtt(30 min),注射用苯磺順阿曲庫(kù)銨[上藥東英(江蘇)藥業(yè)有限公司,批準(zhǔn)文號(hào):國(guó)藥準(zhǔn)字H20060927,規(guī)格:5 mg]0.1 mg/kg+枸櫞酸芬太尼注射液[國(guó)藥集團(tuán)工業(yè)有限公司廊坊分公司,批準(zhǔn)文號(hào):國(guó)藥準(zhǔn)字H20123298,規(guī)格:10 mL∶0.5 mg(以芬太尼計(jì))]1.0 μg/kg,iv,進(jìn)行麻醉誘導(dǎo);吸入用七氟烷(日本Maruishi Pharmaceutical Co.Ltd.,注冊(cè)證號(hào):H20150020,規(guī)格:250 mL/瓶)2%~3%吸入(4 L/min),進(jìn)行麻醉維持,必要時(shí)追加枸櫞酸芬太尼注射液0.5 μg/kg,iv。對(duì)照組患兒給予異丙酚乳狀注射液(四川國(guó)瑞藥業(yè)有限責(zé)任公司,批準(zhǔn)文號(hào):國(guó)藥準(zhǔn)字H20030115,規(guī)格:20 mL∶0.2 g)3 mg/kg+注射用苯磺酸阿曲庫(kù)銨(上海恒瑞醫(yī)藥有限公司,批準(zhǔn)文號(hào):國(guó)藥準(zhǔn)字H20061298,規(guī)格:25 mg)0.1 mg/kg+枸櫞酸芬太尼注射液1.0 μg/kg,iv,進(jìn)行麻醉誘導(dǎo);給予丙泊酚注射液(西安力邦制藥有限公司,批準(zhǔn)文號(hào):國(guó)藥準(zhǔn)字H20123318,規(guī)格:50 mL∶1.0 g)3 mg/(kg·h)微泵注入進(jìn)行麻醉維持,必要時(shí)追加枸櫞酸芬太尼注射液0.5 μg/kg,iv。
1.4 觀察指標(biāo)
(1)觀察兩組患兒麻醉起效時(shí)間。(2)觀察兩組患兒麻醉誘導(dǎo)前(T1)、切皮即刻(T2)、切皮后5 min(T3)、切皮后10 min(T4)、術(shù)畢(T5)即刻的收縮壓(SBP)、舒張壓(DBP)和心率(HR)等血流動(dòng)力學(xué)指標(biāo)。(3)觀察兩組患兒應(yīng)激反應(yīng)指標(biāo)。于麻醉誘導(dǎo)前、切皮即刻采集兩組患兒的外周靜脈血4 mL,以3 000 r/min離心10 min(離心半徑為3 cm),取上層血清,采用酶聯(lián)免疫吸附法測(cè)定去甲腎上腺素(NE)、腎上腺素(E)和腎素(R)水平,儀器為HITACHI 7600型全自動(dòng)生化分析儀(日本日立公司),試劑均購(gòu)自深圳晶美生物工程有限公司。(4)觀察兩組患兒麻醉蘇醒情況,包括術(shù)后蘇醒時(shí)間(睜眼時(shí)間、清醒時(shí)間、定向力恢復(fù)時(shí)間)和小兒麻醉蘇醒期躁動(dòng)量化評(píng)分表(PAED)評(píng)分。PAED評(píng)分包括患兒服從指令并可交流、行為具有目的性、關(guān)注周圍環(huán)境、不安靜和哭鬧等項(xiàng)目,每項(xiàng)分為5個(gè)評(píng)分等級(jí)(0~5分),癥狀越嚴(yán)重分?jǐn)?shù)越高。(5)記錄兩組患兒不良反應(yīng)發(fā)生情況。
1.5 統(tǒng)計(jì)學(xué)方法
采用SPSS 20.0軟件對(duì)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料以±s表示,采用t檢驗(yàn);計(jì)數(shù)資料以例數(shù)或率表示,采用χ2檢驗(yàn)。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2.1 兩組患兒麻醉起效時(shí)間比較
試驗(yàn)組患兒麻醉起效時(shí)間為(3.82±0.45)min,明顯短于對(duì)照組的(5.13±0.74)min,差異有統(tǒng)計(jì)學(xué)意義(t=9.918,P<0.05)。
2.2 兩組患兒血流動(dòng)力學(xué)指標(biāo)比較
麻醉誘導(dǎo)前,兩組患兒SBP、DBP和HR比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05);T2、T3、T4時(shí),兩組患兒上述指標(biāo)均明顯高于麻醉誘導(dǎo)前,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);T2、T3時(shí),試驗(yàn)組上述指標(biāo)明顯低于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。兩組患兒不同時(shí)間點(diǎn)血流動(dòng)力學(xué)指標(biāo)比較見表1(1 mmHg=0.133 kPa)。
表1 兩組患兒不同時(shí)間點(diǎn)血流動(dòng)力學(xué)指標(biāo)比較(±s,n=43)Tab 1 Comparison of hemodynamic indexes between 2 groups at different time points(±s,n=43)
注:與T1比較,*P<0.05;與對(duì)照組比較,#P<0.05Note:;vs.at T1,*P<0.05;vs.control group,#P<0.05
T1T2T3T4T5指標(biāo)SBP,mmHg DBP,mmHg HR,次/min 114.13±9.32 115.36±8.65 78.06±7.68 80.14±8.13 104.12±7.55 108.65±8.32組別試驗(yàn)組對(duì)照組試驗(yàn)組對(duì)照組試驗(yàn)組對(duì)照組112.34±12.61 113.08±10.26 77.43±8.56 78.13±8.72 102.32±9.71 104.64±10.23 122.12±8.45*#128.32±9.06*85.31±6.35*#90.68±7.58*115.65±6.24*#123.12±7.21*119.48±7.68*#130.24±8.68*83.52±7.54*#92.27±9.54*108.52±8.54*#128.72±6.45*116.36±10.12*118.65±9.68*80.06±7.45*82.14±8.32*107.85±10.12*110.25±10.25*
2.3 兩組患兒不同時(shí)間點(diǎn)血清NE、E、R水平比較
麻醉誘導(dǎo)前,兩組患兒的血清NE、E、R水平比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05);T2時(shí),兩組患兒上述指標(biāo)均較麻醉誘導(dǎo)前明顯升高,但試驗(yàn)組明顯低于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。兩組患兒不同時(shí)間點(diǎn)血清NE、E、R水平比較見表2。
表2 兩組患兒不同時(shí)間點(diǎn)血清NE、E、R水平比較(x± s,n=43,ng/mL)Tab 2 Comparison of serum levels of NE,E and R between 2 groups at different time points(±s,n=43,ng/mL)
表2 兩組患兒不同時(shí)間點(diǎn)血清NE、E、R水平比較(x± s,n=43,ng/mL)Tab 2 Comparison of serum levels of NE,E and R between 2 groups at different time points(±s,n=43,ng/mL)
注:與T1比較,*P<0.05;與對(duì)照組比較,#P<0.05Note:vs.at T1,*P<0.05;vs.control group,#P<0.05
E時(shí)點(diǎn)R組別試驗(yàn)組對(duì)照組1.92±0.28 2.61±0.35*#2.10±0.32 4.14±0.56*T1 T2 T1 T2 NE 66.55±5.65 89.33±9.14*#66.74±6.14 124.24±12.15*77.42±8.73 101.61±11.21*#78.13±9.12 138.92±14.21*
2.4 兩組患兒麻醉蘇醒情況比較
試驗(yàn)組患兒術(shù)后的睜眼時(shí)間、清醒時(shí)間、定向力恢復(fù)時(shí)間均明顯短于對(duì)照組,蘇醒期PAED評(píng)分明顯低于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。兩組患兒麻醉蘇醒情況比較見表3。
表3 兩組患兒麻醉蘇醒情況比較(±s,n=43)Tab 3 Comparison of anesthesia revival between 2 groups(±s,n=43)
表3 兩組患兒麻醉蘇醒情況比較(±s,n=43)Tab 3 Comparison of anesthesia revival between 2 groups(±s,n=43)
注:與對(duì)照組比較,#P<0.05Note:vs.control group,#P<0.05
組別試驗(yàn)組對(duì)照組PAED,分1.32±0.27#2.56±0.38蘇醒時(shí)間,min睜眼時(shí)間11.43±1.32#16.26±1.74清醒時(shí)間18.65±2.12#25.14±3.28定向力恢復(fù)時(shí)間20.62±2.43#29.12±3.35
2.5 不良反應(yīng)
對(duì)照組患兒術(shù)后有5例(11.6%)出現(xiàn)嘔吐等不良反應(yīng),試驗(yàn)組患兒術(shù)后未見明顯的不良反應(yīng)發(fā)生(0)。試驗(yàn)組患兒不良反應(yīng)發(fā)生率明顯低于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。
腹外疝是小兒疝氣最常見類型,約占90%以上。突出的疝囊會(huì)引起腹部墜脹、疼痛等癥狀,不及時(shí)處理會(huì)引起疝囊嵌頓并增加腸梗阻、腸管壞死和腸穿孔等的發(fā)生概率。臨床常用的治療方式為全身麻醉下疝囊高位結(jié)扎和無張力修補(bǔ)手術(shù)[3]。兒童身體機(jī)能處于發(fā)育的關(guān)鍵階段,對(duì)手術(shù)麻醉的要求為安全、簡(jiǎn)單和適度。傳統(tǒng)的靜脈麻醉藥物麻醉效果確切,但用量大、麻醉程度深、蘇醒慢、蘇醒后躁動(dòng)和惡心嘔吐等并發(fā)癥較多,限制了靜脈麻醉在小兒外科中的應(yīng)用[4]。理想的麻醉方案應(yīng)具有麻醉誘導(dǎo)起效迅速、術(shù)中生命體征穩(wěn)定、麻醉可控性強(qiáng)和術(shù)后蘇醒快的特點(diǎn)[5]。吸入麻醉是一種新興的麻醉方法,通過給予吸入型麻醉藥物進(jìn)行麻醉誘導(dǎo)和維持[6]。七氟烷是最常用的吸入型麻醉藥物,其血?dú)夥峙湎禂?shù)為0.63,可控性好[7],用于小兒麻醉誘導(dǎo)時(shí)無需進(jìn)行有創(chuàng)穿刺,且能使患兒迅速進(jìn)入無意識(shí)狀態(tài)[8-9]。
本研究結(jié)果顯示,試驗(yàn)組患兒麻醉起效時(shí)間明顯短于對(duì)照組;T2、T3時(shí),試驗(yàn)組患兒SBP、DBP和HR等血流動(dòng)力學(xué)指標(biāo)水平明顯低于對(duì)照組,顯示出試驗(yàn)組麻醉方案的明顯優(yōu)勢(shì)。與文獻(xiàn)[10-11]報(bào)道的七氟烷吸入麻醉有助于縮短麻醉起效時(shí)間和穩(wěn)定術(shù)中生命體征的結(jié)論一致。麻醉誘導(dǎo)時(shí)的刺激和手術(shù)操作的創(chuàng)傷均會(huì)激活機(jī)體的應(yīng)激反應(yīng),激活交感神經(jīng)系統(tǒng)并導(dǎo)致兒茶酚胺類激素大量合成和釋放[12-13]。NE、E、R是常見的兒茶酚胺類神經(jīng)物質(zhì),能影響血管舒縮狀態(tài)并造成血流動(dòng)力學(xué)指標(biāo)波動(dòng)。本研究顯示,T2時(shí),試驗(yàn)組患兒血清NE、E、R水平明顯低于對(duì)照組;術(shù)后,試驗(yàn)組患兒的睜眼時(shí)間、清醒時(shí)間、定向力恢復(fù)時(shí)間均明顯短于對(duì)照組,且蘇醒期躁動(dòng)程度更輕,與文獻(xiàn)[14-15]報(bào)道的七氟烷吸入麻醉有助于緩解術(shù)中應(yīng)激、可控性較強(qiáng)、術(shù)后蘇醒過程順利的結(jié)論一致。試驗(yàn)組患兒術(shù)后未見明顯的不良反應(yīng)發(fā)生,可見七氟烷吸入麻醉安全性較好。
綜上所述,七氟烷吸入麻醉較異丙酚靜脈麻醉對(duì)疝氣手術(shù)患兒的血流動(dòng)力學(xué)指標(biāo)影響小,有助于緩解應(yīng)激反應(yīng),促進(jìn)術(shù)后蘇醒,且安全性較好。但是,本研究納入樣本量較小,有待大樣本、多中心研究進(jìn)一步驗(yàn)證。
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(編輯:陶婷婷)
Influence of Sevoflurane Inhalation Anesthesia and Propofol Intravenous Anesthesia on Hemodynamics,Stress Reaction and Anesthesia Effects of Pediatric Hernia Surgery
CUI Tao1,WU Sisi2(1.Dept.of Anesthesia,Hubei Provincial Third People’s Hospital,Wuhan 430033,China;2. B Ultrasonic Room,Wuhan Dongxihu District Maternal and Child Care Service Centre,Wuhan 430040,China)
OBJECTIVE:To investigate the influence of sevoflurane inhalation anesthesia and propofol intravenous anesthesia on hemodynamics,stress reaction and anesthesia effects of pediatric hernia surgery.METHODS:Eight-six children underwent her-nia surgery in Hubei Provincial Third People’s Hospital from May 2011 to Sept.2015 were selected as subjects and divided into trial group and control group according to random number table,with 43 cases in each group.Trial group was given Tirofiban hydrochloride for injection 0.4 μg/(kg·min),ivgtt,Cisatracurium besilate for injection 0.1 mg/kg+Fentanyl citrate injection 1.0 μg/kg,iv,for anesthesia induction;given 2%-3%sevoflurane inhalation for anesthesia maintenance,and additionally given fentanyl citrate 0.5 μg/kg,iv if necessary.Control group was given Propofol emulsion injection 3 mg/kg+atracurium 0.1 mg/kg+fentanyl citrate 1.0 μg/kg,iv for anesthesia induction;given micro pump injection of propofol 3 mg/(kg·h)for anesthesia maintenance,and additionally given fentanyl citrate 0.5 μg/kg,iv if necessary.The onset time of anesthesia,hemodynamic parameters(SBP,DBP,HR),stress reaction indexes(NE,E,R),recovery situation and the occurrence of ADR were observed in 2 groups.RESULTS:The onset time of anesthesia in trial group was(3.82±0.45)min,significantly shorter than control group(5.13±0.74)min,with statistical significance(P<0.05).Before anesthesia induction,there was no statistical significance in SBP,DBP,HR,the serum levels of NE,E and R between 2 groups(P>0.05).The levels of SBP,DBP,HR of 2 groups at incision,5 min after incision,10 min after incision were significantly higher than before anesthesia,with statistical significance(P<0.05).Above indexes of trial group at incision,5 min after incision were significantly lower than control group,with statistical significance(P<0.05).At incision,the serum levels of NE,E and R in 2 groups were increased significantly compared to before anesthesia induction,but the trial group was significantly lower than the control group,with statistical significance(P<0.05).The postoperative eye opening time,awake time and orientation recovery time of trial group were significantly shorter than control group,while the PAED score was significantly lower than control group,with statistical significance(P<0.05).The incidence of ADR in trial group(0)was significantly lower than control group(11.6%),with statistical significance(P<0.05).CONCLUSIONS:Sevoflurane inhalation anesthesia has less effect than propofol intravenous anesthesia on hemodynamic indexes and is helpful to relieve stress reaction and promote postoperative revival with good safety.
Hernia;Sevoflurane;Propofol;Hemodynamics;Anesthesia
R614
A
1001-0408(2017)11-1544-04
2017-02-04
2017-03-03)
*主治醫(yī)師。研究方向:臨床麻醉。電話:027-83745674。E-mail:29146607@qq.com
DOI10.6039/j.issn.1001-0408.2017.11.31