瑞芬太尼静脉连续输注在儿童和成人保留自主呼吸的剂量

Proper doses of remifentanil to maintain spontaneous ventilation in children and adults during total intraveneous anesthesia

目的观察瑞芬太尼复合丙泊酚全凭静脉麻醉在儿童和成人保留自主呼吸的剂量。方法 41例行眼科手术的患者,根据年龄分为儿童组(1～14岁,18例)和成人组(≥14岁,23例)。采用静脉吸入复合麻醉诱导,吸入体积分数为0.08的七氟烷5L/min,静脉注射丙泊酚3mg/kg、瑞芬太尼1.5μg/kg,置入喉罩,停止吸入七氟烷。持续静脉滴注丙泊酚200μg·kg-1·min-1,瑞芬太尼起始速度为0.2μg·kg-1·min-1,然后每5min减少瑞芬太尼滴注速度0.05μg·kg-1·min-1直至患者呼吸频率>10次/min,此即瑞芬太尼呼吸恢复剂量。再上调瑞芬太尼滴注速度至患者呼吸频率≤10次/min或呼气末二氧化碳分压(petCO2)>65mmHg(1mmHg=0.133kPa),此即瑞芬太尼呼吸抑制剂量。取瑞芬太尼呼吸恢复剂量和呼吸抑制剂量的算术均数为保留自主呼吸的瑞芬太尼平均剂量。记录并比较患者呼吸抑制即刻和呼吸恢复即刻的心率、血压和petCO2。结果儿童组保留自主呼吸的瑞芬太尼平均剂量显著高于成人组(P<0.05)。儿童组在呼吸抑制即刻、呼吸恢复即刻的心率均显著高于成人组(P值均<0.05),两组间petCO2和平均动脉压的差异均无统计学意义(P值均>0.05)。两组患者呼吸抑制即刻的petCO2均显著高于同组呼吸恢复即刻(P值均<0.05),而同组呼吸抑制即刻与呼吸恢复即刻间的心率和平均动脉压的差异均无统计学意义(P值均>0.05)。所有患者麻醉效果均满意,顺利完成手术。其中儿童组2例和成人组1例患者因手术时间限制未能及时滴定出瑞芬太尼呼吸恢复剂量。儿童组3例和成人组4例患者在麻醉诱导时出现心动过缓(心率<60次/min),予阿托品0.01mg/kg静脉注射后缓解。所有患者均未发生低氧血症(脉搏血氧饱和度<95%)。结论 0.13和0.08μg·kg-1·min-1可分别作为儿童和成人保留自主呼吸的瑞芬太尼的参考剂量。儿童耐受瑞芬太尼的剂量显著高于成人。

Objective To examine the tolerable doses of remifentanil（combined with propofol）during spontaneous ventilation under total intravenous anesthesia in children and adults.Methods Forty-one patients scheduled for ophthalmologic operation were divided into child group（1to 14years,n=18）and adult group（≥14years,n=23）according to their ages.Anesthesia was induced by intravenous injection of 3mg/kg propofol and 1.5μg/kg remifentanil in combination with 8% sevoflurane inhalation.Then a laryngeal mask airway was inserted and sevoflurane was discontinued.Propofol（200μg.kg^-1.min^-1）was continuously infused during maintenance of anesthesia.The infusion of remifentanil started at 0.2μg.kg^-1.min^-1 and was adjusted until the patient was breathing spontaneously at a rate just greater than 10br/min.Once this endpoint was achieved,the infusion rate was recorded and regarded as the respiratory recovery dose.Then the infusion rate was increased until patient＇s respiratory rate decreased to 10br/min or less,or petCO2increased to 65mmHg or more,and this infusion rate was defined as the respiratory depression dose.The mean value of the two infusion rates was defined as the dose of remifentanil to maintain spontaneous ventilation.Heart rate,blood pressure and petCO2 were recorded at respiratory recovery and respiratory depression.Results The mean dose of remifentanil to maintainspontaneous ventilation in child group was significantly higher than that in adult group（P0.05）.Heart rate at the time of respiratory depression and recovery in child group was significantly higher than that in adult group（P 0.05）,while there were no significant differences of petCO2or mean arterial pressure between two groups（P 0.05）.The level of petCO2at the time of respiratory depression was significantly higher than that at respiratory recovery in both two groups（P0.05）,while both the heart rate and the mean blood pressure showed no significant difference between respiratory depression and respiratory recovery（P0.05）.The operation was successfully performed in the patients with satisfactory anesthesia.The titrated rate of remifentanil for respiratory recovery can not be detected in 3patients（2in child group and 1in adult group）because of operation time limit.Bradycardia（heart rate less than 60times per min）occurred in 7patients（3in child group and 4in adult group） and released after intravenous injection of 0.01mg/kg atropine.No hyoxemia（saturation pulse oxygen95%） happened in all patients.Conclusion 0.13and 0.08μg.kg^-1.min^-1 remifentanil can be regarded as the reference doses to maintain spontaneous ventilation for children and adults,respectively.Children can tolerate a higher dose of remifentanil during spontaneous anesthesia than adults.（Shanghai Med J,2012,35：833-836）