Feng Jumian,Wang Huaizhen,Peng Liangming,et al.Application of dexmedetomidine combined with sufentanil in ultra-fast track cardiac anesthesia for infants and young children[J].Journal of Clinical Pediatric Surgery,2020,19(11):1032-1037.[doi:10.3969/j.issn.1671-6353.2020.11.014]
右美托咪定复合舒芬太尼在婴幼儿超快通道心脏麻醉中的应用
- Title:
- Application of dexmedetomidine combined with sufentanil in ultra-fast track cardiac anesthesia for infants and young children
- 分类号:
- R729;R614
- 摘要:
- 目的 观察右美托咪定复合舒芬太尼在婴幼儿围术期超快通道心脏麻醉（ultra-fast track cardiac anesthesia，UFTCA）中的临床应用效果。方法 纳入广州市妇女儿童医疗中心麻醉科择期行体外循环（cardiopulmonary bypass，CPB）下心内直视房间隔缺损（atrial septal defect，ASD）修补术和（或）室间隔缺损（ventricular septal defect，VSD）修补术婴幼儿130例为研究对象。采用随机数字表法将患儿分为右美托咪定UFTCA组和传统麻醉组，每组65例。UFTCA组诱导完成后持续静脉泵注右美托咪定每小时1 mcg/kg至主动脉开放，后改为每小时0.3 mcg/kg维持至术毕，术后镇痛采用右美托咪定复合舒芬太尼；传统麻醉组诱导完成后泵注相同容量的生理盐水，术后镇痛仅采用舒芬太尼。记录并比较两组患儿术中舒芬太尼用量、血流动力学指标、术后住院情况、术后FLACC疼痛评分和Ramsay镇静评分、术后2小时动脉血乳酸值（lactic acid，Lac）、氧分压（arterial partial arterial of oxygen，PaO2）和二氧化碳分压（arterial partial pressure of carbon dioxide，PaCO2）。结果 UFTCA组患儿术中舒芬太尼用量明显低于传统麻醉组（P<0.05）。两组患儿在麻醉诱导前（T1）、诱导后（T2）、切皮时（T3）、CPB运行中（T4）、CPB停机后（T5）、手术结束（T6）的心率（heart rate，HR）及平均动脉压（mean arterial pressure，MAP）比较差异均无统计学意义（P>0.05）。UFTCA组患儿术后拔管时间、心脏监护室（cardiac intensive care unit，CICU）住院时间、总住院时间和住院费用均明显低于传统麻醉组（P<0.05）。两组患儿术后第1~2天FLACC疼痛评分均无显著差异（P>0.05），UFTCA组患儿术后第1~2天Ramsay镇静评分均明显高于传统麻醉组（P<0.05）。UFTCA组患儿术后2小时动脉血Lac值明显低于传统麻醉组（P<0.05）。结论 右美托咪定复合舒芬太尼在婴幼儿围术期UFTCA中的应用临床效果明显，可减少围术期阿片类药物的用量，维持血流动力学平稳，缩短拔管时间，提供良好的术后镇静镇痛效果，改善术后氧合平衡，且无明显不良反应。
- Abstract:
- Objective To observe the clinical effects of dexmedetomidnie combined with sufentanil in ultra-fast track cardiac anesthesia for infants and young children.Methods A total of 130 infants and young children patients undergoing opening atrial septal defect (ASD) repair and (or) ventricular septal defect (VSD) repair by cardiopulmonary bypass (CPB),were randomized into a dexmedetomidnie UFTCA group and a conventional anesthesia group according to the random number table method (65 patients in each group).Patients in UFTCA group were received a continuous infusion dose of 1 mcg/kg/h dexmedetomidine following induction until cross clamp releasing,then decreased the dose of dexmedetomidine to 0.3 mcg/kg/h until the end of the operation;the post operation analgesia was dexmedetomidine combined with sufentanil.Patients in conventional anesthesia group were received a comtinuous infusion of the same volume of normal saline until the end of the operation,the drug of analgesia was sufentanil.The doses of sufentanil,hemodynamic indexes,postoperative hospitalization conditions,scores of FLACC,scores of Ramsay and the lactic acid (Lac),arterial partial arterial of oxygen (PaO2),arterial partial pressure of carbon dioxide (PaCO2) 2 hours post-operation were recorded and compared between the two groups.Results The dose of sufentanil in UFTCA group was significantly lower than that in conventional anesthesia group (P<0.05).There were no significant differences in the heart rate (HR)and mean arterial pressure (MAP) between the two groups at the time of before induction(T1),after induction(T2),skin incision(T3),during CPB(T4),end of CPB(T5),end of operation(T6)(P>0.05).The length of extubation post-operation,cardiac intensive care unit (CICU) stay,hospital stay and hospitalization expenses in UFTCA group were all significantly less than those in conventional anesthesia group (P<0.05).There were no significant differences in the scores of FLACC at the first and second day post-operation between the two groups(P>0.05).The scores of Ramsay in UFTCA group were significantly higher than those in conventional anesthesia group at the first and second day post-operation respectively(P<0.05).The Lac 2 hours post-operation in UFTCA group was significantly lower than that in conventional anesthesia group (P<0.05).Conclusion The application of dexmedetomidine combined with sufentanil in UFTCA for infants and young children is effective,and can decrease the perioperative dose of opioids,ensure stable hemodynamics,shorten extubation time,provide good postoperative sedation and analgesia effect,improve postoperative oxygenation balance and internal environment,with no obvious adverse reactions.
参考文献/References:
1 Hemmerling TM,Prieto I,Choiniere JL,et al.Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting:a prospective audit comparing opioid-based anesthesia vs thoracic epidural-based anesthesia[J].Can J Anaesth,2004,51(2):163-168.DOI:10.1007/BF03018777.
2 Mahmoud M,Mason KP.Dexmedetomidine:review,update,and future considerations of paediatric perioperative and periprocedural applications and limitations[J].Br J Anaesth,2015,115(2):171-182.DOI:10.1093/bja/aev226.
3 杨勇,周静,拾翠翠,等.右美托咪定和咪达唑仑对小儿静脉吸入复合麻醉苏醒期躁动的影响研究[J].临床小儿外科杂志,2018,17(7):547-551.DOI:10.3969/j.issn.1671-6353.2018.07.016. Yang Y,Zhou J,Shi CC,et al.Comparing inhibitory effects between dexmedetomidine and midazolam on emergence agitation induced by intravenous-inhalation combined anesthesia in children[J].J Clin Ped Sur,2018,17(7):547-551.DOI:10.3969/j.issn.1671-6353.2018.07.016.
4 Tobias JD,Gupta P,Naguib A,et al.Dexmedetomidine:Applications for the Pediatric Patient With Congenital Heart Disease[J].Pediatric Cardiology,2011,32(8):1075-1087.DOI:10.1007/s00246-011-0092-8.
5 Verrier ED,Wright IH,Cochran RP,et al.Changes in cardiovascular surgical approaches to achieve early extubation[J].J Cardiothorac Vasc Anesth,1995,9(5 Suppl 1):10-15.
6 Davis S,Worley S,Mee RB,et al.Factors associated with early extubation after cardiac surgery in young children[J].Pediatr Crit Care Med,2004,5(1):63-68.DOI:10.1097/01.PCC.0000102386.96434.46.
7 Yuki K,Matsunami E,Tazawa K,et al.Pediatric Perioperative Stress Responses and Anesthesia[J].Transl Perioper Pain Med,2017,2(1):1-12.
8 Duncan HP,Cloote A,Weir PM,et al.Reducing stress responses in the pre-bypass phase of open heart surgery in infants and young children:a comparison of different fentanyl doses[J].Br J Anaesth,2000,84(5):556-564.DOI:10.1093/bja/84.5.556.
9 Roth-Isigkeit A,Brechmann J,Dibbelt L,et al.Persistent endocrine stress response in patients undergoing cardiac surgery[J].J Endocrinol Invest,1998,21(1):12-19.DOI:10.1007/BF03347280.
10 Reismann M,von Kampen M,Laupichler B,et al.Fast-track surgery in infants and children[J].J Pediatr Surg,2007,42(1):234-238.DOI:10.1016/j.jpedsurg.2006.09.022.
11 Rozet I,Metzner J,Brown M,et al.Dexmedetomidine Does Not Affect Evoked Potentials During Spine Surgery[J].Anesth Analg,2015,121(2):492-501.DOI:10.1213/ANE.0000000000000840.
12 Zhang Y,Jia S,Gao T,et al.Dexmedetomidine mitigate acute lung injury by inhibiting IL-17-induced inflammatory reaction[J].Immunobiology,2018,223(1):32-37.DOI:10.1016/j.imbio.2017.10.017.
13 Su F,Nicolson SC,Zuppa AF.A dose-response study of dexmedetomidine administered as the primary sedative in infants following open heart surgery[J].Pediatr crit care Med,2013,14(5):499-507.DOI:10.1097/PCC.0b013e31828a8800.
14 Chrysostomou C,Komarlu R,Lichtenstein S,et al.Electrocardiographic effects of dexmedetomidine in patients with congenital heart disease[J].Intensive Care Med,2010,36(5):836-842.DOI:10.1007/s00134-010-1782-z.
15 Sarma J,Narayana PS,Ganapathi P,et al.A comparative study of intrathecal clonidine and dexmedetomidine on characteristics of bupivacaine spinal block for lower limb surgeries[J].Anesth Essays Res,2015,9(2):195-207.DOI:10.4103/0259-1162.153763.
16 Naguib AN,Tobias JD,Hall MW,et al.The role of different anesthetic techniques in altering the stress response during cardiac surgery in children:a prospective,double-blinded,and randomized study[J].Pediatr Crit Care Med,2013,14(5):481-490.DOI:10.1097/PCC.0b013e31828a742c.
17 Kumar P,Thepra M,Bhagol A,et al.The newer aspect of dexmedetomidine use in dentistry:As an additive to local anesthesia,initial experience,and review of literature[J].Natl J Maxillofac Surg,2016,7(1):76-79.DOI:10.4103/0975-5950.196137.
18 Pasin L,Febres D,Testa V,et al.Dexmedetomidine vs midazolam as preanesthetic medication in children:a meta-analysis of randomized controlled trials[J].Paediatr Anaesth,2015,25(5):468-476.DOI:10.1111/pan.12587.
相似文献/References:
[1]刘涌王正坤叶玉萍谢威武建.舒芬太尼和芬太尼用于小儿腹腔镜手术麻醉的比较[J].临床小儿外科杂志,2010,9(03):0.
[2]李京生 田肇隆. 右美托咪定用于小儿脑瘫选择性脊神经后根切断术麻醉的研究[J].临床小儿外科杂志,2014,13(03):246.
[3]刘晶晶,安频,朱诗利,等. 舒芬太尼减轻小儿全麻苏醒期躁动的临床观察[J].临床小儿外科杂志,2016,15(02):196.
[4]赵新民,方芳,岳书玉,等.右美托咪定在小儿腹腔镜疝囊高位结扎手术麻醉中的应用[J].临床小儿外科杂志,2017,16(05):487.
[5]杨勇,周静,拾翠翠,等.右美托咪定和咪达唑仑对小儿静脉吸入复合麻醉苏醒期躁动的影响研究[J].临床小儿外科杂志,2018,17(07):547.
Yang Yong,Zhou Jing,Shi Cuicui,et al.Comparing inhibitory effects between dexmedetomidine and midazolam on emergence agitation induced by intravenousinhalation combined anesthesia in children.[J].Journal of Clinical Pediatric Surgery,2018,17(11):547.
[6]杜真,向珍,危思维,等.右美托咪定提高儿童日间手术舒适度的临床研究[J].临床小儿外科杂志,2020,19(07):622.[doi:10.3969/j.issn.1671-6353.2020.07.012]
Du Zhen,Xiang Zhen,Wei Siwei,et al.Clinical study of dexmedetomidine in enhancing perioperative comfort during daytime pediatric surgery[J].Journal of Clinical Pediatric Surgery,2020,19(11):622.[doi:10.3969/j.issn.1671-6353.2020.07.012]
备注/Memo
收稿日期:2019-09-01。
基金项目:广州市科技计划项目（编号：201803010025）
通讯作者:宋兴荣,Email:songxingrong@gwcmc.org