法洛四联症小儿心脏手术不同麻醉诱导方案可行性比较

Comparison of the feasibility of different anesthetic induction regimens in cardiac surgery in children with tetralogy of fallot

目的比较法洛四联症（TOF）小儿心脏手术时采用不同麻醉诱导方案的效果和安全性。方法将92例TOF患儿完全随机分成A、B、c组。A组患儿（31例）肌内注射氯胺酮5mg／kg，B组患儿（31例）吸人8％七氟烷，待患儿入睡后分别静脉注射舒芬太尼1μg/kg、顺式阿曲库铵0．15mg／kg。C组患儿（30例）静脉注射咪达唑仑0．1mg／kg、舒芬太尼2μg/kg、顺式阿曲库铵0．15mg／kg。行动脉穿刺置管和气管插管，术中麻醉维持采用吸人七氟烷一空氧混合（1：1）气体复合舒芬太尼2．5μg／（kg·h）、顺式阿曲库铵100μg／（kg·h）、丙泊酚4mg／（kg·h）连续输注。记录患儿麻醉前（T，）、静脉给药后（1r2）和气管插管后（T，）3个时间点的生命体征。在动脉穿刺后即刻（T4）和机械通气30min后（T5）各进行1次动脉血气分析。结果A、B、C组患儿T2、L时点HR、SBP和DBP均明显低于T，时点（P〈0．05），而脉搏血氧饱和度均明显高于T1时点（P〈0．05）。C组患儿T2、T]时点HR、SBP和DBP明显低于A、B组[T2：（128±18）／min比（1434-17）、（142．4-21）／min，（90-1-19）mmHg（1mmHg=0．133kPa）比（95±18）、（97±14）mmHg，（52-4-14）mmHg比（55±22）、（54±18）mmHg；T：（118±23）次／min比（137±20）、（133±24）／min，（85±17）mmHg比（94±17）、（94±19）mmHg，（47±15）mmHg比（53±18）、（51±16）mmHg；均P〈0．05]。3组患儿T，时点动脉血氧饱和度明显高于T4时点[A组：（94±15）％比（88±14）％；B组：（92±12）％比（88±16）％；C组（91±15）％比（86±14）％；P〈0．05]。结论TOF患儿采用氯胺酮肌内注射、七氟烷吸入或大剂量舒芬太尼麻醉不会对血流动力学和血氧饱和度造成不良影响，因此均适用于心脏手术时的麻醉诱导。

Objective To evaluate the effect and safety of different anesthetic induction regimens in chil- dren with tetralogy of fallot （TOF） during cardiac surgery. Methods Ninety-two TOF patients [ American society of anesthesiologists（ASA） II-llI, aged 6 months-3 old years, weighing 5.8-14 kg], were randomly assigned to three groups. Following patients received ketamine 5 mg/kg intramuscular injection in group A （ n = 31 ）, patients inhaled 8% sevollurane in group B （n = 31 ）, both groups were given intravenously sufentanil 1 ±g/kg and cis-atra- curium 0.15 mg/kg when patients had fallen asleep. Individually, patients in group C （n = 30） received midazolam 0.1 mg/kg, sufentanil 2 ug/kg and cis-atracurium 0.15 mg/kg intravenously. After arterial cannulation and intuba- tion, sevoflurane-air-oxygen inhalation combinated with sufentanil 1 ug/（kg ± h）, cis-atracurium 100 ±（ kg ± h）, propofol 4 mg/kg continously intravenous injection were used to anesthetic maintenance. Vital signs of patients were recorded before anesthesia （T1 ）, after intravenous administration （T2）, after intubation （T3）. Respectively, arte- rial blood gas was analyzed after arterial cannulation （T4 ）, 30 minutes after mechanical ventilation （T±）. Results Heart rate, systolic pressure, dystolic pressure of all patients at T2 and T3 were significantly lower than those at T1 （P 〈 0.05 ）, pulse oxygen saturation （ SpO2 ） incresed conversely （ P 〈 0.05 ）. Heart, systolic blood pressure, diastolic blood pressure of patients in group C at T2, T3 were lower than those of patients in group A and group B IT2 ：（128 ± 18）times/min vs （143 ＋ 17）, （142 ±21）times/min, （90 ＋ 19）mm Hg（1 mm Hg =0. 133 kPa） vs （95 ± 18）, （97 ± 14）mm Hg, （52 ± 14）mm Hg vs （55 ±22）, （54 ± 18）ram Hg; T3：（118 ±23）times/rain vs （137 ±20）, （133 ±24）times/min, （85 ±17）mm Hg vs （94 ± 17）, （94 ± 19）mm Hg, （47±15）mm Hg vs （53 ± 18）, （51 ± 16）mm Hg; all P 〈0.05], but there was no Sp02 difference among three groups（P 〉0.05）. Arterial oxygen saturation at T5 got more significant improvement than at T4 in 3 groups [ group A： （94 ± 15 ）% vs （88±14）%; group B： （92212）% vs （88 ±16）%; group C（91 215）% vs （86±14）%; P 〈0.05]. Conclusions It seems that induction with ketamine and sevoflurane and large dose of sufentanil have no significant adverse effects on hemodynamics and oxygen saturation in TOF patients. Therefore, these three programs are able to apply to anesthetic induction in TOF cardiac surgery.