普鲁泊福复合瑞芬太尼控制性降压在小儿鼻内镜手术中的应用

Controlled hypotension with remifentanil and propofol in children during endoscopic sinus surgery

目的 观察普鲁泊福复合瑞芬太尼控制性降压在小儿鼻内镜手术中的效果.方法 择期行鼻内镜下腺样体切除术患儿40例,ASA分级Ⅰ级,按随机数字表法分为对照组和降压组,每组20例.两组均采用静脉注射普鲁泊福和瑞芬太尼.对照组不施行控制性降压,降压组瑞芬太尼由初始0.2μg/（kg·min）,每隔2 min增加0.1 μg/（kg·min）,直到无创平均动脉压（MAP）降为55～60 mm Hg（1 mm Hg=0.133 kPa）,并调节输注速度维持MAP于此水平.全麻诱导后放置激光多普勒血流仪探头,开始（To）监测鼻咽部黏膜血流量,15 min后（T1）开始手术,在手术开始后15 min（T2）进行术野质量评分.结果 降压组从控制性降压开始至达目标血压所需时间（2.5±0.3）min,术中控制性降压时瑞芬太尼输注速度（0.43±0.16）μ g/（kg·min）.降压组T1和T2时心率、MAP均低于本组T0和对照组同一时点（P＜0.05）.降压组T1时的鼻咽部黏膜血流量[（68.3±8.3）%]明显少于对照组[（99.8±7.9）%]（P＜0.05）,手术时间[（21±4）min]明显短于对照组[（32±6）min]（P＜0.05）,术野质量评分[（1.8±0.1）分]明显低于对照组[（3.5±0.5）分]（P＜0.05）.术后两组患儿均在10 min内清醒拔管,均未出现麻醉相关并发症.结论 普鲁泊福复合瑞芬太尼用于小儿鼻内镜下腺样体切除术控制性降压时,能显著减少鼻咽部黏膜血流量,为手术提供满意的术野质量.

Objective To observe the effect of remifentanil combined with propofol to induce and sustain controlled hypotension in children during endoscopic sinus surgery（ESS）. Methods Forty ASA Ⅰ children undergoing adenoidectomy in ESS were divided into control group and controlled hypotension group by random digits table with 20 cases in each group. No controlled hypotension in control group. Anesthesia was induced with propofol,remifentanil and atracurium, and maintained with continuous infusion of propofol 2 min until the target mean arterial pressure （MAP）（55 - 60 mm Hg, 1 mm Hg = 0.133 kPa） was reached,and MAP was maintained at this level during operation in controlled hypotension group. During 15 min before surgical procedure pharynx nasalis blood flow was measured and recorded with laser Dopper flowmetry continuously. The quality of the surgical field in term of blood loss and dryness was established at 15 min after operation starting. Results Controlled hypotension was induced within （2.5 ± 0.3 ） min, the infusion rate ofMAP and heart rate at 15 min after controlled hypotension and 15 min after operation starting were significantly lower than those at controlled hypotension instantly in controlled hypotension group and control group （P 〈 0.05 ）. The pharynx nasalis blood flow decreased at 15 min after controlled hypotension from baseline [（68.3 ± 8.3 ）% vs. （99.8 ± 7.9 ）%] （P 〈 0.05 ）. The operation time and the quality of the surgical field in term of blood loss and dryness in controlled hypotension group were better than those in control group [（21 ± 4） min vs. （32 ± 6） min and （ 1.8 ± 0.1 ） scores vs. （3.5 ± 0.5） scores] （P 〈 0.05 ）. The awakeextubate time was within 10 min in two groups, and there were no anesthesia related complications.Conclusion Remifentanil combined with propefol can induce and sustain controlled hypotension,reduce pharynx nasal is blood flow and provide good surgical conditions in children for ESS.