氯胺酮与七氟醚麻醉诱导对先天性心脏病患儿血流动力学的影响

Comparison of the effects of sevoflurane and ketamine on systemic hemodynamic changes during induction of anesthesia in children with congenital heart disease

目的 采用压力记录分析法（PRAM）比较氯胺酮与七氟醚麻醉诱导对先天性心脏病患儿血流动力学的影响。方法 选择1～5岁行室间隔缺损修补术的患儿32例,年龄1～5岁,随机均分为两组：氯胺酮（K组）和七氟醚组（S组）,行基础麻醉后均给予哌库溴铵0.2mg/kg、咪达唑仑0.2mg/kg、舒芬太尼1μg/kg及气管插管。用压力记录分析法记录基础麻醉时（T0）、静脉复合麻醉用药后1min（T1）、2min（T2）、5min（T3）和插管后1min（T4）、2min（T5）、5min（T6）、10min（T7）的HR、SBP、DBP、每搏量指数（SVI）、CI、体循环阻力指数（SVRI）、反映左心室收缩力的压力升支最大速率（dp/dt）,计算心率-血压乘积（RPP）。结果 与K组比较,S组T0～T7时HR明显减慢、RPP明显降低（P〈0.01）、T1～T7时SVI明显升高（P〈0.05）,T0、T1时SBP、T0～T2、T4、T5时SVRI、T0～T3时dp/dt明显降低（P〈0.05或P〈0.01）。两组各时点CI差异无统计学意义。无一例患儿发生低血压、心动过速、心律失常不良反应。结论 与七氟醚比较,氯胺酮产生了明显负性肌力作用及血流动力学波动,七氟醚可能更适合于以低心排为主的先天性心脏病患儿的基础麻醉。

Objective To compare the effects of sevoflurane and ketamine on systemic hemody- namic changes during anesthetic induction in children with congenital heart disease by using pressure record analytical method （PRAM）. Methods Thirty two children, aged 1-5 years, with ventricular septal defect undergoing CPB were randomized to sevoflurane group （group S） or ketamine group （group K）. Following basal anesthesia, all children were given pipecuronium-midazolam-sufentanil and endotracheal intubation was performed. Hemodynamic data including HR, SBP, DBP, SVI, CI, SVRI, dp/dt were recorded by PRAM and rate-pressure product （RPP） was calculated after basal an- esthesia, 1, 2 and 5 rain after combined intravenous anesthesia and 1, 2, 5 and 10 min after endotra- cheal intubation. Results Compared with group K, HR was significantly slowed and RPP was signif- icantly decreased at T0-T7 （P〈0.01）, SVI was significantly increased at T1-T7 （P〈0. 05）, SBP at To, T1 and SVRI at T0-T2, T4, T5, dp/dt at T0-Ta were decreased significantly in group S （P〈 0.05 or P〈0. 01）. There was no significant difference in CI between the two groups at each time point. There was no adverse reaction of hypotension, tachycardia, arrhythmia in all children. Conclusion Ketamine, as compared to sevoflurane, exerts highly unstable and adverse effects on sys- temic hemodynamies. Sevoflurane might be suitable for basal anesthesia in children with congenital heart disease with low CO.