瑞芬太尼用于婴幼儿快通道心脏手术麻醉

Remifentanil for Fast Track Cardiac Anesthesia in Children

目的通过观察心内直视手术中，瑞芬太尼对婴幼儿血流动力学和应激激素水平，及术后对拔管时间和ICU逗留时间的影响，以评价瑞芬太尼在心脏快通道麻醉中的应用。方法20例患儿，ASAⅠ～Ⅱ级，择期行房间隔缺损（ASD）或单纯室间隔缺损（VSD）修补术。所有患儿诱导前30min口服咪达唑仑糖浆，入室后予咪达唑仑、瑞芬太尼、维库溴铵静注诱导插管。术中机械通气应用PCV模式，O2-N2O—ISO吸入，瑞芬太尼及维库溴铵持续输注，根据患儿或手术调节瑞芬太尼用量。分别记录各时点患儿的心率、收缩压、舒张压和平均动脉压，以及其他用药和不良事件的发生。其中10例患儿，分别于其中5个时点抽取静脉血，测定血浆肾上腺素和去甲肾上腺素浓度。结果本组患儿瑞芬太尼平均诱导剂量为（2．83±0．62）μg／kg，体外转流前维持剂量为（2．02±0．41）μg·kg^-1·min^-1，体外转流后维持剂量（1．56±0．34）μg·kg^-1·min^-1。与基础值比较，诱导后患儿心率、收缩压、舒张压和平均动脉压均有明显下降（P〈0．01）。与诱导后比较，气管插管后1、3、5min患儿的心率、收缩压、舒张压和平均动脉压无显著变化（P〉0．05）。麻醉维持过程中，患儿的心率、收缩压、舒张压和平均动脉压均低于基础值。与诱导后比较。插管后5min、锯胸骨后5min、体外转流开始前及术毕的血浆肾上腺素和去甲肾上腺素浓度无显著升高（P〉0．05）。术后拔管时间（53±57）min，重插管率0％，术后ICU逗留时间（15±8）h。结论瑞芬太尼用于婴幼儿ASD或单纯VSD心内直视手术具有血流动力学稳定，能有效抑制应激反应，术后能早期拔管等特点，适用于婴幼儿心脏快通道麻醉。

Objective To evaluate intraoperative haemodynamics and postoperative outcomes associated with remifentanil-based fast track anesthesia in infants and children undergoing open heart surgery. Methods Twenty infants and children with atrial septal defect or simple ventricular septal defect who were deemed suitable for fast track anesthetic management were included in this study. All patients were premedicated with midazolam. Anesthesia was induced with remifentanil, midazolam and vecuronium. Remifentanil infusion,isoflurane and N20 inhalation were administered to maintain anesthesia after intubation. BP and HR were recorded at baseline,pre- and postinduction, intubation,skin incision, sternotomy, pre- and post-cardiopulmonary bypass and the end of operation. Blood samples were obtained after induction, 5 min after incision and sternotomy, shortly before CPB and at the end of surgery. Other parameters measured included the time from the end of surgery to extubation, reintubation rate and the time of discharge from the cardiac intensive care unit. Results After induction, there was a significant decrease in SBP, DBP, MAP and HR. Haemodynamic responses to intubation were well tolerated. The plasma level of epinephrine and norepinephrine was stable during surgery. Time intervals from the end of the surgery to extubation and discharge from the ICU was （53±57） min and （15±8） h, respectively. Conclusion The results of this study demonstrate that remifentanil-based anesthesia can be successfully used for fast track anesthesia in elected infants and children with atrial and simple ventricular septal defects.