| 谢阳,姜文强,周蓦,等.不同剂量右美托咪定滴鼻对小儿气管插管拔除七氟烷半数有效浓度的影响[J].安徽医药,2019,23(12):2510-2516. |
| 不同剂量右美托咪定滴鼻对小儿气管插管拔除七氟烷半数有效浓度的影响 |
| Effects of different doses of dexmedetomidine nasal dropping on smooth extubation of sevoflurane ED50 in children |
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| DOI：10.3969/j.issn.1009?6469.2019.12.045 |
| 中文关键词: 气管插管拔除 /方法 右美托咪定 投药，鼻内 围手术期 儿童，学龄前 七氟烷 半数有效浓度(ED50) |
| 英文关键词: Airway extubation/methods Dexmedetomidine Administration,intranasal Perioperative period Child,pre? school Sevoflurane 50% effective dose(ED50) |
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| 中文摘要: |
| 目的探讨在小儿扁桃体或腺样体手术中，不同剂量右美托咪定术前滴鼻对七氟烷麻醉下平稳拔管的半数有效浓度(ED50)的影响。方法选取 2018年1—10月南京医科大学附属苏州市立医院择期行扁桃体和腺样体切除术的小儿 113例，采用随机数字表法将病儿分为四组: D1.0组 28例、 D1.5组 30例、 D2.0组 27例及对照组(D0组) 28例。在麻醉准备间各组病儿在术前 30 min由麻醉医师配置好的滴鼻液，总量均为 1 mL，分别为右美托咪定 1.0、1.5和 2.0 μg/kg，D0组为 0.9%氯化钠溶液，用滴鼻器经鼻滴入滴鼻液 1 mL。30 min后，采取全凭七氟烷吸入麻醉进行诱导，插管成功后连接麻醉机机械通气；术中吸入七氟烷、瑞芬太尼持续泵注维持麻醉，维持 Narcotrend指数(NI)值在 40～60。手术结束前 5 min时停止输注瑞芬太尼；术毕吸痰，维持七氟烷呼气末浓度稳定在目标浓度至少 10 min，行气管拔管。各组病儿气管拔管的呼末七氟烷预设最低肺泡有效浓度(MAC)值根据 Dixon?Massey序贯法确定。若平稳拔管，则下一例病儿的呼末七氟烷目标 MAC值降低 0.1，若失败拔管，则下一例病儿目标 MAC值升高 0.1。重复该过程直到出现第 7个转折点(平稳拔管)时停止试验。用 Probit概率单位回归法计算各组病儿平稳拔管的七氟烷 ED50。采用 4分评分法评估拔管后的呛咳严重程度，判断拔管质量；并记录拔管前后的屏气、喉痉挛或支气管痉挛、气道梗阻等呼吸道不良事件。苏醒期躁动评分法(emergence agitation scale，EA评分法)评估术后躁动程度，记录瑞芬太尼补救量和恢复室停留时间。同时观察并记录滴鼻前(T0)、滴鼻后 30 min(T1)、拔管前(T2)、拔管后 1 min(T3)、拔管后 5 min(T4)、入恢复室后 5 min(T5)、出恢复室(T6)和术后 1h(T7)的血流动力学和呼吸功能变化。结果四组病儿的一般情况如年龄、体质量、性别构成 比，手术麻醉时间及右美托咪定给药至拔管时间的比较差异无统计学意义(P＞0.05)。 D0组及各右美托咪定组病儿在全凭七氟烷吸入麻醉下平稳拔管的 ED50依次为 1.39 vol%、1.28 vol%、0.83 vol%、0.52 vol%，D1.5、D2.0组的 ED50明显低于 D0、D1.0组(P＜ 0.05)。拔管后， D1.5、D2.0组轻微呛咳的发生率分别为 30%和 40.7%，高于 D0组(3.7%)和 D1.0组(7.2%)(P＜0.05)； D1.5、D2.0组无一例发生剧烈呛咳，优于 D0组(25%)和 D1.0组(21.5%)(P＜0.05)。D1.5、D2.0组术后躁动的发生率分别为 10.0%和7.4%，明显低于 D0组(82.1%)和D1.0组(78.6%)(P＜0.05)； D1.5、D2.0组的清醒病儿多于 D0、D1.0组，差异有统计学意义(P＜0.05)。 D2.0组病儿镇静过度的发生率为 30%，明显高于 D0、D1.0组(P＜0.05)； D2.0组的恢复室停留时间为(38.9±5.2)min明显超过其它三组(P＜0.05)。在 T1、T2时点， D1.5、D2.0组的 HR和 MAP较 T0时点明显下降(P＜0.05)；在 T3、T4时点， D0、D1.0组的 HR和 MAP较 T2时点明显升高(P＜0.05)； D1.5、D2.0组的 HR和 MAP较T2时点虽有升高，但差异无统计学意义(P＞0.05)。结论右美托咪定滴鼻对扁桃体或腺样体切除术病儿平稳拔管七氟烷 ED50的影响具有剂量依赖性。术前右美托咪定滴鼻 1.5 μg/kg优于 1.0 μg/kg和2.0 μg/kg。 |
| 英文摘要: |
| Objective:This study was to explore the effects of preoperative nasal drops different dose of dexmedetomidine on the ef? fective dose(ED50)of sevoflurane anesthesia on smooth extubation in children with tonsillectomy or adenoidectomy.Methods One hundred and thirteen patients undergoing selective tonsillectomy and adenoidectomy in Suzhou Hospital Affiliated to Nanjing Medi?cal University from January to October 2018 were randomly divided into four groups:dexmedetomidine 1.0 μg/kg(D1.0 group，28 patients)，dexmedetomidine 1.5μg/kg(D1.5 group，30 patients)，dexmedetomidine 2.0μg/kg(D2.0 group，27 patients)，and control group(D0 group，28 patients).Thirty min pre?operation，patients received intranasal naristillae，the volume is 1 mL..Then patientswere transported to operation room.Inhalation induction were performed with sevoflurane under spontaneous ventilation.Anesthesiais maintained with sevoflurane and remifentanil with continued perfusion until the operation finished.Maintain Narcotrend Index in40?60，Remifentanil infusion was stopped at 5 min before the end of surgery.After the operation，adjust the concentration of sevoflu? rane to the default MAC(minimum alveolar concentration).The end tidal of sevoflurane concentration for each group was main?tained for at least 10 minutes before the deep tracheal extubation was performed.ED50 of each group were estimated from the up?and ?down method of Dixon?Massey.If smooth extubation，then the next patient’s sevoflurane target MAC was decreased by 0.1，if extu? bation fails，the end tidal of sevoflurane target MAC for the next patient was increased by 0.1.Repeat the process until the seventhturning point(smooth extubation)is stopped.The median effective dose(ED50)of sevoflurane was calculated by Probit regression.The severity of coughing after extubation was assessed by 4 point rating scale.The quality of tracheal extubation was evaluated.Theadverse events such as breath?holding，laryngeal spasm or bronchospasm and airway obstruction were recorded during tracheal extu? bation.The Emergence Agitation Scale(EA scores)assesses the degree of agitation，records the remifentanyl administration and therecovery time.Hemodynamic and respiratory profiles were recorded at the following times:before administration(T0)，after adminis? tration(T1)before extubation(T2)，1 min after extubation(T3)，5 min after extubation(T4)，5 min after enter recovery room(T5)， beforeleavere，covery room(T6)and postoperative 1 h(T7).Results The demographic data(age，sex and weight)，the durations of surgery and anesthesia were similar in four groups(P＞0.05).The ED50 of group D0 and each dexmedetomidine group were 1.39 vol%，1.28 vol%，0.83 vol% and 0.52 vol%，respectively.The ED50 of group D1.5 and D2.0 was significantly lower than that of group D0 and D1.0(P＜0.05)..The incidence of mild cough in group D1.5，D2.0 was 30% and 40.7%，respectively，which was higher than that in group D0(3.7%)and group D1.0(7.2%)(P＜0.05).There was no severe cough in group D1.5 and D2.0 which was superior to group D0(25%)and group D1.0(21.5%)(P＜0.05).The incidence of agitation in group D1.5 and D2.0 was 10% and 7.4%，respective? ly，which was significantly lower than that in group D0 and D1.0(82.1%，78.6%)(P＜0.05).Awake patients in group D1.5 and D2.0 were more than that in group D0 and D1.0，and the difference was statistically significant(P＜0.05).Comparing with group D0 and D1.0，the incidence of deep sedation was 30% in group D2.0，and the difference was statistically significant(P＜0.05).The time of PACU discharge in group D2.0 was significantly higher than that in the other three groups(P＜0.05).In group D1.5 and D2.0，the HR and MAP of T1 and T2 were significantly lower than those of T0(P＜0.05).In group D0 and D1.0，the HR and MAP of T3 and T4 were significantly higher than those of T2(P＜0.05).In group D1.5 and D2.0，HR and MAP of T3 and T4 were also higher than those in T2， but the difference was not statistically significant(P＞0.05).Conclusion The effect of dexmedetomidine on sevoflurane ED50 was dose?dependent.In short，Preoperative dexmedetomidine nasal drops of 1.5 μg/kg was superior to those of 1.0 μg/kg and 2.0 μg/kg. |
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