先天性喉软化症患儿手术的麻醉管理

Anesthetic management for pediatric congenital laryngomalacia

目的探讨先天性喉软化症手术的麻醉管理。方法回顾性分析浙江大学医学院附属儿童医院2010年12月至2012年11月拟诊断为先天性喉软化症患儿27例，经鼻插入相应大小的气管导管至声门上方给氧，连续静脉输注丙泊酚和瑞芬太尼维持麻醉，保留患儿自主呼吸。记录麻醉时间、手术时间、瑞芬太尼最大输注速度；术中监测心电图、心率、平均动脉压（MAP）、脉搏血氧饱和度（SpO2）、呼吸频率；观察术中并发症的发生情况。结果与麻醉诱导时比较，手术开始、手术开始后20min、手术结束时的心率、RR明显降低，差异有统计学意义（P〈0．05）；各时间点MAP、SpO2差异无统计学意义（P〉0．05）。诱导达到外科手术条件时间9-12min，瑞芬太尼最大输注速度为（0．18±0．03）μg·kg^-1·min^-1。3例（11％）患儿出现肢体运动，单次缓慢给予丙泊酚1mg／kg后消失；2例（7％）患儿术中短暂出现SpO2〈95％，予降低瑞芬太尼输注速度后缓解。术中无咳嗽、低氧血症、喉痉挛、恶心、呕吐、心率失常并发症发生。结论先天性喉软化症患儿麻醉管理的关键是术前仔细评估患儿合并的其他疾病，使用保留自主呼吸的全凭静脉麻醉技术，加强术中监测，合理调整麻醉深度。

Objective To explore our experience of anesthetic management for pediatric congenital laryngomalacia operation. Methods A total of 27 pediatric patients with congenital laryngomalacia were treated at our hospital between December 2010 and November 2012. All patients were anesthetized by intravenous anesthesia of propofol-remifentanil and spontaneous breathing. Oxygen was insufflated at a rate of 4 L/min through an endotracheal tube near glottis. Propofol was set at a constant rate of 100 μg·kg^-1·min^-1 The initial dose of remifentanil at 0. 05 μg·kg^-1·min^-1 was adjusted in 0.05 μg·kg^-1·min^-1increments to titrate a 50% reduction in baseline respiratory rate. Heart rate （HR） , mean arterial pressure, pulse oxygen saturation （ SpO2 ） , respiratory rate （ RR）, operation time, anesthesia time and remifentanil rate were recorded. Adverse events and interventions were also examined. Results Comparison with induction of anesthesia, HR and RR changed significantly intraoperatively （ P 〈 0. 05 ）. MAP, SpO2 were no significantly change during operation （ P 〉 0. 05 ） . The induction time was 9--12 min and the highest remifentanil rate stood at （0. 18±0.03）μg·kg^-1·min^-1. Body movements occurred in 3 （ 11% ） patients and a bolus of propofol was administered. Desaturation below 95% occurred in 2 （7%） patients in which interventions were offered by decreasing the remifentanil infusion rate. No complications such as cough, hypoxemia, laryngospasm or bronehospasm, nausea or vomiting, arrhythmia were observed. Conclusion Key points of anesthetic management for pediatric congenital laryngomalacia include sufficient preoperative evaluation, spontaneous respiration anesthesia technique with total intravenous anesthesia, suitable anesthesia depth and intensive intraoperative monitoring.