右美托咪定复合芬太尼在小儿鼾症术后静脉自控镇痛中的应用

Effect observation of dexmedetomidine combined with fentanil on patient-controlled intravenous analgesia after the operation of children's snoring

目的观察右美托咪定复合芬太尼患者静脉自控镇痛（PCIA）应用于小儿鼾症术后镇痛的安全性和有效性。方法行鼾症手术的患儿120例，美国麻醉医师协会（ASA）分级Ⅰ或Ⅱ级，随机分入芬太尼小剂量组、芬太尼大剂量组、右美托咪定＋芬太尼小剂量组和右美托咪定＋芬太尼大剂量组，每组30例。术后均给予PCIA：芬太尼小剂量组为芬太尼6μg／kg＋恩丹西酮50μg／kg，芬太尼大剂量组为芬太尼8μg／kg＋恩丹西酮50μg／kg，右美托咪定＋芬太尼小剂量组为右美托咪定1．25μg／kg＋芬太尼6μg／kg＋恩丹西酮50μg／kg，右美托咪定＋芬太尼大剂量组为右美托咪定1．25μg／kg＋芬太尼8μg／kg＋恩丹西酮50μg／kg，各组均加0．9％氯化钠溶液稀释至100mL；负荷量均为芬太尼1μg／kg；背景剂量为4mL／h，单次给药1mL，锁定时间为15min。观察4组患儿术后的心率（HR）、收缩压（SBP）、舒张压（DBP）、呼吸频率（RR）、脉搏血氧饱和度（SpO2）、疼痛视觉模拟评分（VAS评分）、Ramsay镇静评分，以及不良反应的发生情况。结果各组间在术后2、4、6h的HR、SBP、DBP、RR的差异均无统计学意义（P值均〉0．05），SpO2均〉95％。芬太尼大剂量组、右美托咪定＋芬太尼小剂量组、右美托咪定＋芬太尼大剂量组在术后4、8h的疼痛VAS评分均显著低于芬太尼小剂量组，Ramsay镇静评分均显著高于芬太尼小剂量组（P值均〈0．05）；右美托咪定＋芬太尼小剂量组、右美托咪定＋芬太尼大剂量组在术后4、8h的疼痛VAs评分均显著低于芬太尼大剂量组，Ramsay镇静评分均显著高于芬太尼大剂量组（P值均〈0．05）；右美托咪定＋芬太尼大剂量组在术后4、8h的疼痛VAS评分均显著低于右美托咪定＋芬太尼小剂量组（P值均〈0．05），Ramsay镇静评分均显著高于右美托咪定＋芬太尼小剂量组（P值均〈0．05）；4组间在术后12、24h的疼痛VAS评分和Ramsay镇静评分的差异均无统计学意义（P值均〉0．05）。芬太尼大剂量组、右美托咪定＋芬太尼小剂量组、右美托咪定＋芬太尼大剂量组术后12h内的PCIA按压次数均显著少于芬太尼小剂量组（P值均〈0．05），右美托咪定＋芬太尼小剂量组、右美托咪定＋芬太尼大剂量组均显著少于芬太尼大剂量组（P值均〈0．05），右美托咪定＋芬太尼大剂量组显著少于右美托咪定＋芬太尼小剂量组（P〈0．05），4组间术后12～24h的PCIA按压次数的差异均无统计学意义（P值均〉0．05）。4组均未发生心动过缓、呼吸抑制和皮肤瘙痒，但右美托咪定＋芬太尼大剂量组出现过度镇静现象，芬太尼小剂量组发生恶心呕吐3例，芬太尼大剂量组发生恶心呕吐6例，右美托咪定＋芬太尼小剂量组和右美托咪定＋芬太尼大剂量组均无恶心呕吐发生。结论右美托咪定复合小剂量芬太尼用于小儿鼾症术后PCIA的效果确切，安全可靠，且不良反应少，值得临床推广。

Objective To observe the safety and efficacy of dexmedetomidine combined with fentanyl in patient-controlled intravenous analgesia （PCIA） after surgery for children＇s snoring. Methods A total of 120 American Society of Anesthesiologists （ASA） grade Ⅰ or Ⅱ patients with children＇s snoring treated by surgery were randomly divided into 4 groups （n = 30）, PCIA was performed immediately after surgery. Fentanyl 6 μg/kg and ondansetron 50 μg/kg were given in group A, Fentanyl 8 μg/kg and ondansetron 50 μg/kg were given in groupB. Dexmedetomidine 1. 25 pg/kg, fentanil 6 μg/kg and ondansetron 50μg/kg were given in group C. Dexmedetomidine 1.25 μg/kg, fentanil 8 μg/kg and ondansetron 50 μg/kg were given in group D. The medicines in the four groups were diluted with 100 ml normal saline （background infusion at 4 mL/h with a bolus dose of 1 mL and a 15 min lockout interval）. Heart rate （HR）, systolic blood pressure （SBP）, diastolic blood pressure （DBP）, respiratory rate （RR）, pulse blood oxygen saturation （SpO2）, visual analogue scale （VAS） pain scores, Ramsay sedation scores and adverse reaction were recorded. Results No significant difference was found in HR, SBP, DBP or RR between groups at 2, 4 and 6 h after surgery （all P〉0.05）. SpO2 was more than 95% in all patients. Group A had higher VAS scores and lower Ramsay scores than the other three groups at 4 and 8 h after surgery （all P〈0.05）. Group B had higher VAS scores and lower Ramsay scores than group C and D at 4 and 8 h after surgery （all P〈0.05）. Group D had lower VAS scores and higher Ramsay scores than group C at 4 and 8 h after surgery （all P〈0.05）. There were no significant differences in VAS scores or Ramsay scores between groups at 12 and 24 h after surgery （all P〉0. 05）. In 12 h after surgery, the frequency of PCIA in group B, C and D were significantly less than that in group A （all P〈0.05） ; the frequency of PCIA in group C and D were significantly less than that in group B （both P〈0.05） ; the frequency of PCIA in group D was significantly less than that in group C （P〈0.05）. No significant difference was found in the frequency of PCIA between groups in 12- 24 h after surgery （all P〉0.05）. No bradycardia, respiratory depression or itching occurred. Over-sedation was found in group D. Postoperative nausea and vomiting occurred in 3 patients of group A and 6 patients of group B. Conclusion Dexmedetomidine combined with low dose of fentanyl is safe and effective in PCIA after surgery for children＇ s snoring.