儿童拔除气管导管时呼气末七氟烷体积分数与拔除气管导管后躁动的相关性

Association of post-extubation delirium with pre-extubation end-tidal sevoflurane concentration in children

目的采用前瞻性观察研究设计评估儿童拔除气管导管(以下简称拔管)时呼气末七氟烷体积分数与拔管后躁动的相关性。方法选择107例美国麻醉医师协会(ASA)分级Ⅰ或Ⅱ级、年龄2～7岁的外科手术患儿。采用七氟烷诱导和维持的吸入麻醉,利多卡因声门喷雾或静脉注射1mg/kg氯化琥珀胆碱注射液后进行气管插管,并给予有效的骶管阻滞或臂丛神经阻滞。术中维持呼气末七氟烷体积分数为0.025,保留自主呼吸。手术结束后,停止吸入七氟烷,当患儿呛咳或体动时拔管。在麻醉后监测治疗室由一名经过培训的护士用小儿麻醉苏醒期躁动量表(PAEDs)进行评分,PAEDs评分≥10分定义为躁动。观察躁动发生情况,记录并比较发生躁动与未发生躁动患儿在面罩诱导时的焦虑评分、拔管时呼气末七氟烷体积分数、拔管时间、麻醉时间,以及术后恶心呕吐、低氧饱和度、拔管后呼吸道不良事件等发生情况。采用单因素logistic回归分析拔管后躁动与拔管时呼气末七氟烷体积分数、拔管时呼气末七氟烷体积分数与使用利多卡因喷雾的相关性。采用Pearson相关分析拔管时间与拔管时呼气末七氟烷体积分数的相关性。采用多因素logistic回归分析与拔管后躁动相关的影响因素。结果 107例患儿中,发生躁动28例(躁动组)、未发生躁动79例(非躁动组)。躁动组患儿的拔管时呼气末七氟烷体积分数为0.005 0±0.001 3,显著高于非躁动组的0.004 2±0.001 7(P<0.05);拔管时间为(5.7±2.3)min,显著短于非躁动组的(8.2±4.2)min(P<0.05);使用利多卡因喷雾的患儿比例为32.1%(9/28),显著低于非躁动组的58.2%(46/79,P<0.05)。两组间的性别构成、年龄、体重、麻醉时间、面罩诱导时焦虑评分,发生低氧饱和度、术后恶心恶吐和其他呼吸道不良事件的患儿比例,以及手术类型构成的差异均无统计学意义(P值均>0.05)。单因素logistic回归分析显示,拔管后躁动与拔管时呼气末七氟烷体积分数呈正相关(OR=18.365,P=0.03),拔管时呼气末七氟烷体积分数与使用利多卡因呈正相关(OR=165.164,P<0.001)。Pearson相关分析显示,拔管时间与拔管时呼气末七氟烷体积分数呈负相关(r=-0.864,P<0.001)。对可能影响拔管躁动的各因素进行多因素logistic回归分析,结果显示,拔管时呼气末七氟烷体积分数(OR=60.849,95%CI为2.224～1 664.525)、体重(OR=1.359,95%CI为1.105～1.672)、年龄(OR=0.468,95%CI为0.232～0.946)均为拔管后躁动的影响因素(P值均<0.05),而性别、麻醉时间和诱导时焦虑评分均与拔管后躁动无关(P值均>0.05)。结论儿童患者中拔管后躁动与拔管时呼气末七氟烷体积分数具有相关性,拔管时呼气末七氟烷体积分数越高,拔管后躁动发生率越高。

Objective To explore the association of post-extubation delirium with pre-extubation end-tidal sevoflurane concentration in children.Methods A total of 107children(aged 2-7years old,American Society of Anesthesiologists Ⅰ or Ⅱ)undergoing elective surgery under sevoflurane anesthesia were enrolled in this prospective study.Intubation was performed after lidocaine spray on vocal cord or succinylcholine 1 mg/kg intravenous injection.After that,an effective caudal or brachial plexus block was performed.End-tidal sevoflurane concentration maintained at 0.025 and patients had spontaneous respiration during the procedure.Sevoflurane was stopped at the end of surgeries.Extubation was performed after cough or purposeful movement.A trained nurse recorded pediatric anesthesia emergence delirium scale(PAEDs)scores in post-anesthesia care unit(PACU).Post-extubation delirium was defined as PAEDs score ≥10.Modified Yale preoperative anxiety scale(m-YPAS)scores on induction,extubation time,anesthesia time and end-tidal sevoflurane concentration at extubation were recorded.Postoperative nausea and vomiting(PONV),hypoxemia and respiratory adverse events were also recorded.The association of post-extubation delirium with end-tidal sevoflurane concentration at extubation and the association of end-tidal sevoflurane concentration at extubation with usage of lidocaine spray were analysed using univariable logistic regression analysis.The association of extubation time with end-tidal sevoflurane concentration at extubation was analysed using Pearson’s correlation analysis.Multivariable logistic regression analysis was performed to determine predictors of post-extubation delirium.Results Among the children,28 out of 107 developed post-extubation delirium.There were significant differences in terms of end-tidal sevoflurane concentration at extubation(0.005 0±0.001 3 vs.0.004 2±0.001 7),extubation time(\[5.7±2.3\]min vs.\[8.2±4.2\]min)and percentage of patients who used lidocaine spray(32.1% vs.58.2%)between patients with and without delirium(all P<0.05).Sex,age,weight,anesthesia time,m-YPAS scores,incidences of hypoxemia,PONV and respiratory adverse events,and surgery types were comparable between patients with and without delirium(all P>0.05).Post-extubation delirium was positively associated with end-tidal sevoflurane concentration at extubation(OR=18.365,P=0.03).End-tidal sevoflurane concentration at extubation was positively associated with usage of lidocaine spray(OR=165.164,P<0.001).Extubation time was negatively associated with end-tidal sevoflurane concentration at extubation(r=-0.864,P<0.001).End-tidal sevoflurane concentration at extubation(OR=60.849,95%CI:2.224-1 664.525,P<0.05),weight(OR=1.359,95%CI:1.105-1.627,P<0.05)and age(OR=0.468,95%CI:0.232-0.946,P<0.05)had significantly higher odds of post-extubation delirium.However,sex,anesthesia time and m-YPAS did not significantly impact post-extubation delirium(all P >0.05).Conclusion Post-extubation delirium is associated with end-tidal sevoflurane concentration at extubation.Children with higher end-tidal sevoflurane concentration at extubation have agreater incidence of post-extubation delirium.