盐酸右美托咪定对胸腔镜下治疗先天性心脏病的快通道麻醉患儿苏醒质量的影响

Effect of Dexmedetomidine Hydrochloride Injection on Awakening Quality in Children with Congenital Heart Disease Undergoing Fast-track Anesthesia and Video-assisted Thoracoscopic Surgery

目的探讨盐酸右美托咪定注射液(Dex)对全电视胸腔镜下小儿先天性心脏病手术快通道麻醉患儿围拔管期苏醒质量的影响。方法随机选择采取股动静脉插管,建立体外循环,右胸胸壁打3个小孔后施行全电视胸腔镜房间隔缺损或单纯室间隔缺损修补术的心脏病患儿120例,美国麻醉医师协会(ASA)Ⅰ或Ⅱ级。按随机数字表法分Dex快通道麻醉组(D组,n=60)和常规快通道麻醉组(C组,n=60)。D组患儿Dex负荷剂量1μg·kg-1术中Dex以0.5μg·kg-1·h-1维持输注,C组患儿给予相同方法相同剂量0.9%氯化钠注射液维持输注。记录两组患儿麻醉前(t0)、拔管即刻(t1)、拔管后5 min(t2)、拔管后10 min(t3)、拔管后15 min(t4)及拔管后30 min(t5)及出心脏重症监护室(CICU)时(t6)各时点血流动力学变化,记录躁动程度及发生率、呼唤睁眼时间、完全清醒时间、拔管时间、出CICU时间及视觉模拟评分(VAS)评分。结果与t0时点相比,D组患儿t2~t5时点收缩压(SBP)从(114.2±10.5)mm Hg逐渐下降至(107.2±10.3)^(105.3±11.3)mm Hg、舒张压(DBP)从(61.3±9.2)mm Hg下降至(58.8±7.8)^(57.3±6.3)mm Hg,而t1~t5时点心率(HR)从(95.2±15.7)次·min-1逐渐下降至(85.7±13.7)^(83.3±12.6)次·min-1,差异有统计学意义(P<0.05);与C组相比,t2~t5时点SBP、DBP显著下降(P<0.01),t1~t5时点HR显著下降(P<0.01);C组患儿躁动总发生率明显高于D组(48.3%vs.16.7%,P<0.01),且C组中、重度躁动发生率明显高于D组(18.3%vs.6.7%和20.0%vs.1.7%,均P<0.01);D组患儿呼唤睁眼时间、完全清醒时间、拔管时间、出CICU时间有所延长,但与C组比较差异无统计学意义(P>0.05);C组患儿拔管后30 min VAS[(4.7±0.7)分]明显高于D组[(2.4±0.6)分],差异有统计学意义(P<0.05)。结论 Dex负荷剂量1μg·kg-1,术中以0.5μg·kg-1·h-1维持能提高全电视胸腔镜下小儿先天性心脏病手术快通道麻醉患儿围拔管期血流动力学的稳定性,降低苏醒期躁动的发生,减轻术后疼痛,提高患儿苏醒期的安全性。

Objective To study the effect of dexmedetomidine hydrochloride injection（ Dex） on awakening quality in pediatric patients with congenital heart disease undergoing fast-track anesthesia and whole video-assisted thoracoscopic surgery.Methods One hundred and twenty pediatric patients（ ASA Ⅰ or Ⅱ level） with congenital heart diseases were randomly chosen for this study. They received femoral artery and vein cannulation to establish cardiopulmonary bypass and three small holes were obtained in the right chest for the purpose of undergoing the whole video-assisted thoracoscopic surgery on repairmen of atrial septal defect or simple ventricular septal defect. They were randomly divided into two groups： Dex-assisted fast-track anesthesia group（ D group,n = 60） and general fast-track anesthesia group（ C group,n = 60）. Each one in group D was injected with loading dose of Dex（ 1 μg·kg-1）,then was intraoperatively infused with maintenance dose of 0. 5 μg·kg-1·h-1. Children in group C were given the same dose of saline in the same way. Hemodynamic changes in the two groups at each time point： before anesthesia（ t0）,at the time of extubation（ t1）,5 min post-extubation（ t2）,10 min post-extubation（ t3）,15 min post-extubation（ t4）,30 min post-extubation（ t5） and at the time of transferring out of CICU（ t6）,respectively,were observed. Restlessness extent,incidence,time of eye opening after calling,fully awaking time,extubation time,the time of transferring out of CICU and VAS scores,were also recorded. Results From t0 to t2- t5,SBP in D group was decreased from（ 114. 2±10. 5） mm Hg to（ 107. 2±10. 3）-（ 105. 3±11. 3） mm Hg,DBP decreased from（ 61. 3±9. 2） mm Hg to（ 58. 8±7. 8）-（ 57. 3±6. 3） mm Hg,and HR gradually decreased from（ 95. 2 ± 15. 7） time · min-1to（ 85. 7 ± 13. 7）-（ 83. 3 ± 12. 6） time · min-1,with significant differences（ P〈0. 05）. Compared with C group,SBP and DBP at t2-t5 were decreased significantly（ P〈0. 01）,and HR at t1-t5 decreased significantly（ P〈0. 01）. Overall incidence of agitation was significantly higher in group C than in group D（ 48. 3% vs.16. 7%,P〈0. 01）. Incidence of moderate and severe agitation were significantly higher in group C than in group D（ 18. 3% vs. 6.7%,and 20% vs. 1. 7%,respectively,P〈0. 01）. In group D,time of eye opening after calling,fully awaking time,extubation time,and the time of transferring out of CICU were prolonged,without significant difference as compared with group C（ P〈0. 05）. VAS at 30 min after extubation was significantly higher in group C than in group D（ 4. 7±0. 7 vs. 2. 4±0. 6,P〈0. 05）. Conclusion Injection of Dex with loading dose（ 1 μg·kg-1） and intraoperative infusion of maintenance dose of 0. 5 μg·kg-1·h-1in children with congenital heart disease undergoing fast-track anesthesia and whole video-assisted thoracoscopic surgery could be conducive to maintain hemodynamic stability,reduce restlessness occurrence,enhance security during awakening process,and alleviate post-operative pain.