气体吹入法在无插管麻醉小儿上气道手术中的应用

Insufflate anesthesia for up-airway surgery without intubation in children

目的观察麻醉气体吹入法实施保留自主呼吸的无插管麻醉在小儿气道手术中的应用效果。方法 2008年3月至2009年12月,15例上气道特殊要求手术患儿行无插管麻醉,采用麻醉气体吹入法,术中全程保留自主呼吸。七氟醚吸入浓度8%,氧流量8 L/min以上诱导,调节七氟醚吸入浓度和氧流量,气体吹入维持。吹入途径:经鼻腔置入气管导管于声门上方或经患儿口角置入导管于声门上方。记录患儿年龄、性别、体重、疾病类型、喉阻塞程度、麻醉诱导和维持用药、吸入麻醉药浓度及氧流量、手术时间、苏醒时间,术中及术后并发症等。术中观察声门活动度、生命指征、体动或其他不良反应。结果 15例患儿喉阻塞程度:Ⅰ度4例,Ⅱ度10例,Ⅲ度1例。诱导至意识消失平均时间为(16±3)s,七氟醚诱导平均浓度为(6.36±1.21)%,诱导达到外科手术条件平均时间为(4.17±0.96)min,七氟醚平均维持浓度/氧流量为5.7%/4 L.min-1。术中5例于呼吸频率、心率加快时静脉追加芬太尼0.5μg/kg和异丙酚1 mg/kg。平均手术时间(27.6±3.67)min,平均苏醒时间(6.2±2.23)min。无1例发生心律失常、喉或支气管痉挛、体动、苏醒延迟等并发症。结论小儿上气道手术采用麻醉气体吹入法维持无插管麻醉可提供不受干扰的手术条件,值得在30个月龄以下婴幼儿气道手术中被推荐,成功的关键在于维持自主呼吸与麻醉深度之间的平衡。

Objective To evaluate the effect of insufflate anesthesia for up-airway surgery without intubation during spontaneous respiration in children. Methods From May 2008 to Dec 2009,15 children scheduled for up-airway surgery were performed anesthesia without intubation and insufflation anesthesia,spontaneously breathing during procedure.Induction of anaesthesia commenced with inhalation of 8% sevoflurance and insufflation of oxygen flow at 8 L/min,to maintain the depth of anaesthasia by adjusting up-down concentration of sevoflurance and oxygen flow.Pathways of insufflating anesthetic agent： to intubate into supraglottis via nasal cavity or angulus oris of subjects.Each procedure was scored with respect to patient age,weight,gender,categories of disease,degree of laryngostasis,anaesthetic drugs,oxygen flow,the duration of operation and wake,intraoperative and postoperative complications.Routine monitoring included ECG,pulse oximetry（SpO2）,heart rate,breathing rate and noninvasive blood pressure（NIBP）.Glottis and body movement during procedure and other adverse effect were also obsered. Results Patients were classified according to the degree of laryngostasis,which were 4 of Ⅰ degree,10 of Ⅱ degree and 1 of Ⅲ degree.Mean time of consciousness disappear was（16±3）s,induction mean concentration of sevoflurance was（6.36±1.21）%,and 8 L/min oxygen flow oxygen.Induction time to satisfied surgery qualification was（4.17±0.96）min.Concentration of sevoflurance and oxygen flow to maintain anaesthesia were 5.7% and 4 L/min.1 mg/kg propofol and 0.5 μg/kg fentanil were delivered intravenously each time in 5 patients more than 30 months on account of accelerate of heart and breathing rate.None of bronchiospasm and laryngospasm occurred,no arhythmia and palinesthesia emergenced,and other critical complications were not observed. Conclusions Insufflate anesthesia for up-airway surgery without intubation during spontaneous respiration in children can give good condition for laryngology,which is deserved to be spread in young children under 30 months.The key point of succeed anaesthesia is to maintain the balance between spontaneous respiration and anaesthetic depth.