开腹手术新生儿不同剂量舒芬太尼术后镇痛的效果

Efficacy of postoperative analgesia with different doses of sufentanil in neonates undergoing abdominal operations

目的 评价不同剂量舒芬太尼用于开腹手术新生儿术后镇痛的效果。方法选择拟在全麻下行开腹手术的足月新生儿60例，日龄7～28d，ASAⅡ或Ⅲ级，体重2．4～4．2k，均于术毕拔除气管导管后连接舒芬太尼术后静脉镇痛泵，随机分为3组（n=20），镇痛泵配方：Ⅰ组舒芬太尼0．6μg／kg（输注速率0．3μg·kg^-1·d^-1），Ⅱ组舒芬太尼1．2μg／kg（输注速率0．6μg·kg^-1·d^-1），Ⅲ组舒芬太尼2．4μg／kg（输注速率1．2μg·kg^-1·d^-1），均溶于100ml生理盐水中，于术后24h时停用舒芬太尼。于术毕即刻、术后4、8、12、24h时记录呼吸频率、HR、SpO2、MAP及疼痛评分。于术毕即刻和术后24b时抽取桡动脉血样行动脉血气分析，取外周静脉血样测定血浆白细胞介素6（IL-6）浓度。记录术后24h内镇痛满意情况和不良反应发生情况。结果与术毕即刻比较，Ⅰ组术后8—24h时HR、MAP和疼痛评分升高，术后24h时血浆IL-6浓度升高，Ⅲ组术后8h时HR降低，术后24h时动脉血氧分压、血浆IL-6浓度降低；与Ⅰ组比较，Ⅱ组和Ⅲ组术后8～24h时HR、MAP及疼痛评分降低，术后24h时血浆IL-6浓度降低，Ⅲ组术后24h时动脉血氧分压降低（P〈0．05）；与Ⅱ组比较，Ⅲ组术后8h时HR降低、术后24h时血浆IL-6浓度降低（P〈0．05）。Ⅱ组和Ⅲ组镇痛满意率高于Ⅰ组（P〈0．05）。三组呼吸频率、恶心、呕吐和呼吸抑制发生率比较差异无统计学意义（P〉0．05）。结论新生儿开腹手术后静脉输注舒芬太尼0．6μg·kg^-1·d^-1行术后镇痛效果好，有利于免疫功能的调节。

Objective To investigate the efficacy of postoperative analgesia with different doses of sufentanil in neonates undergoing abdominal operations. Methods Sixty ASA Ⅱ or m full-term neonates undergoing different abdominal operations under general anesthesia were randomly divided into 3 dose groups of twenty patients each. The patients received sufentanil 0.3 μg· kg^-1· d^-1 （ group i ）, 0.6 μg· kg^-1· d^-1 （ group Ⅱ ） and 1.2 μg· kg^-1· d^-1 （ group Ⅲ ） respectively after operation. Anesthesia was induced with ketamine 2 mg/kg and vecuronium 0.1 mg/kg and maintained with 2.0%-4.5% sevoflurane. No opioid was used during operation. The patients were mechanically ventilated after tracheal intubation. ECG, HR, MAP, RR and SpO2 were monitored during operation. The patients were extubated after operation and placed in incubator in NICU. Postoperative pain was assessed and scored at the end of operation and at 4, 8, 12 and 24 h after operation. CRIES neonatal postoperative pain scoring system was used, based on 5 criteria： crying （0-2） ; O2 inhalation needed to maintain SaO2〉 95% （0-2） ; increase in MAP and HR （0-2）, expression （0-2） and sleeplessness （0-2）. The total score is 10 （0 = no pain, 10 = worst pain） （0-3 satisfactory analgesia, 4-6 moderate pain, 7-10 severe pain）. Arterial blood samples were taken at the end of operation and 24 h after operation for blood gas analysis and venous blood samples for IL-6 concentration measurement. Results The 3 groups were comparable with respect to age, body weight, ASA physical status and duration of operation. Pain scores were significantly higher in group Ⅰ （low dose） than in group Ⅱ （moderate dose） and Ⅲ （high dose） starting from 8 h after operation. The rate of satisfactory analgesia （0-3） was significantly higher in groupⅡ （90%） and Ⅲ（95%） than in group Ⅰ （60%）. HR and BP were significantly increased starting from 8 h after operation in group Ⅰ while HR was decreased starting from 8 h after operation in group m as compared with the baseline at the end of operation. PaO2 was significantly lower at 24 h after operation in group m than in group Ⅰ . As compared with the baseline at the end of operation, IL-6 concentration was significantly increased at 24 h after operation in group Ⅰ but decreased in group m Conclusion Sufentanil 0.6 μg· kg^-1· d^-1 is the optimal dose which provides satisfactory analgesia.