靶控输注瑞芬太尼与恒速输注右美托咪定用于小儿全凭静脉麻醉苏醒期的临床研究

The clinical study of target controlled infusion of remifentanil and constant infusion of dexmedetomidine during emergence from total intravenous anesthesia for pediatric patients

目的：观察靶控输注瑞芬太尼与恒速输注右美托咪定对小儿全凭静脉麻醉苏醒期拔管反应及躁动的影响。方法将90例择期全凭静脉麻醉下行扁桃体腺样体切除术患儿，随机分为对照组（C组）、瑞芬太尼组（R组）和右美托咪定（D组）。麻醉诱导后D组静脉持续输注右美托咪定0.3μg·k g-1·h-1直至气管导管拔出。手术结束前2 min，C组和D组停用异丙酚和瑞芬太尼；R组停用异丙酚，将瑞芬太尼的T CI浓度调整为1.5 ng/ml直至气管导管拔出。记录泵注右美托咪定前（T 0）、手术结束时（T1）、拔管前1 min（T2）、拔管时（T3）和拔管后1 min（T4）、5 min（T5）、10 min （T6）的平均动脉压（M AP）、心率（HR）；记录停用异丙酚至拔管时间、睁眼时间、拔管时呛咳反应评分；根据儿童麻醉后躁动评分（ PA ED ）和改良加拿大东安大略儿童医院疼痛评分量表（m-CH EOP S），拔管后每5 min对患儿进行躁动和疼痛评分，记录所得最高值作为监测有效值。结果与T0时比较，C组T2～T6时、R组T5～T6时MAP和HR均显著升高（P＜0.05），D组各时点MAP与HR差异无统计学意义；与C组比较，R组T2～T4时、D组T2～T6时MAP与HR均较低（P＜0.05）；与R组比较，D组T5～T6时MAP与HR较低（P＜0.05）。三组患儿拔管时间、睁眼时间比较差异无统计学意义（P＞0.05）；拔管时呛咳反应评分R组与D组显著低于C组（P＜0.05），PAED评分和疼痛评分D组显著低于C组（P＜0.05）与R组（P＜0.05）。结论靶控输注瑞芬太尼（1.5 ng/ml）与恒速输注右美托咪定（0.3μg·k g-1·h-1），均能有效抑制小儿扁桃体腺样体切除术全凭静脉麻醉苏醒期的拔管反应，且不延长麻醉苏醒时间。恒速输注右美托咪定还能减少患儿术后躁动的发生，更适用于小儿全麻苏醒期。

Objective To observe the effects of target controlled infusion of remifentanil and constant infusion of dexmedetomidine on extubation response and emergence delirium during emergence from total intravenous anesthesia （TIVA） for pediatric patients. Methods 90 children undergoing adenotonsillectomy under TIVA were randomly divided into control group （group C） , remifentanil （group R） and dexmedetomidine group （group D）. Dexmedetomidine was infused at the rate of 0.3μg·kg-1·h-1 in group D until extubation after anesthesia induction. At 2 minutes before the end of the surgery, propofol was ceased and infusion of remifentanil was stopped in group C and group D and maintained in group R at target organ concentration of 1.5 ng/ml until extubation. Mean artery pressure （MAP） and heart rate （HR） were recorded before Dex delivery （T0）, the end of the surgery （T1）, 1 min （T2） before extubation, during extubation （T3） and 1 （T4）, 5 （T5）, 10 min （T6） after extubation. Time from stopping propofol to extubation and opening eyes and cough reflex score during extubation were recorded. According to the Pediatric Anesthesia Emergence Delirium to mark the delirium of the patient per 5 minutes after extubation, the highest score was used to effective value, and at the same time, mark the degree of pain according to the modified Children’s Hospital of Eastern Ontario Pain Scale. Results Compared with T0, MAP and HR at T2-T6 in group C and at T5-T6 in group R were significantly higher （P〈0.05）, at each time point in group D were no significant difference （P〉0.05）. Compared with group C , MAP and HR at T2-T4 in group R and T2-T6 in group D were significantly lower （P〈0.05）. Compared with group R, MAP and HR at T5-T6 in group D were significantly lower （P〈0.05）. There was no significant difference in extubation time and opening eyes time between the three groups （P〉0.05）. Cough reflex score of group R and group D was significantly lower than group C （P〈0.05）, PAED and pain score of group D was significantly lower than group C （P〈0.05） and group R （P〈0.05）. Conclusion Target controlled infusion of remifentanil （1.5 ng/ml） and continuous infusion of dexmedetomidine （0.3 μg·kg-1·h-1） can effectively inhibit extubation response and don’t increase the postoperative recovery time in pediatric adenotonsillectomy under TIVA. While continuous infusion of dexmedetomidine can decrease the incidence rate of emergence delirium, more applicable to infusion during emergence from TIVA for pediatric patients.