芬太尼对机械通气早产儿脑功能的保护作用

Effect of Fentanyl infusion on protection of neuro - function in prematurity during mechanical ventilation

目的探讨持续静脉滴注芬太尼对机械通气早产儿脑功能的影响。方法选择2012年11月至2014年11月人住南京医科大学附属南京儿童医院新生儿重症监护室需要机械通气的早产儿共53例，随机信封法分为2组：A组为非镇痛（对照）组，26例；B组为镇痛（试验）组，27例。试验组于气管插管后即予芬太尼1μg／（kg·h），持续静脉滴注，当呼吸机参数平均呼吸道压（MAP）〈7cmH20（1cmH2O=0．098kPa），吸入氧体积分数（FiO2）〈0．25，呼吸频率〈25次／min（同步间歇指令通气）或者MAP〈10cmH2O（高频振荡通气），芬太尼剂量减半，30min后完全停药，停药后撤机；对照组以相同滴注速度静脉滴注50g/L葡萄糖。比较2组用药前、用药后呼吸机参数[MAP、FiO2、动脉血氧饱和度、动脉血二氧化碳分压、动脉血氧分压]，患儿平均血压、心率、呼吸总频率、机械通气时间、不良反应发生情况；采用早产儿疼痛量表（PIPP）与COMFORT双疼痛评分量表评估2组患儿各时段的疼痛行为反应评分；比较2组患儿纠正胎龄37周振幅整合脑电图（aEEG），纠正胎龄40周新生儿神经行为评分（NBNA）。结果1．试验组各时段呼吸机参数、平均血压、机械通气持续时间、不良反应发生率与对照组比较差异均无统计学意义，试验组心率在12、24、48h低于对照组（t=6．36、7．01、6．28，P均〈0．05）；试验组呼吸总频率在24、48h时要低于对照组，差异均有统计学意义（t=12．48、10．34，P均〈0．05）。2．试验组在给药2h后各时段的PIPP评分及COMFORT评分均低于对照组（P均〈0．05），特别是在给药12h后降低更明显（P〈0．01）。3．试验组纠正胎龄37周aEEG评分及纠正胎龄40周NBNA评分均高于对照组（t=4．85、3．27，P均〈0．05）。结论持续静脉滴注芬太尼能较好减轻机械通气新生儿的疼痛，改善NBNA评分及脑电图，对机械通气早产儿脑功能有保护作用。

Objective To discuss the short - and long - term outcome of neuro - function with continuous Fentanyl infusion in ventilated prematurity. Methods Fifty - three ventilated preterm infants in the NICU of Nanjing Children＇s Hospital Affiliated to Nanjing Medical University from November 2012 to November 2014 were randomized into 2 groups of which 26 patients were in control group without receiving Fentanyl infusion, and 27 patients in study group. Study group received Fentanyl infusion at 1 μg/（kg · h） immediately after the intubation,and Fentanyl was re- duced to half dose when ventilation settings were as below： mean airway pressure （MAP） 〈 7 cmH20（ 1 cmH20 = O. 098 kPa）, fraction of inspired oxygen （ FiO2 ） 〈 0. 25, breathing rate 〈 25 beats/min （ synchronized intermittent man- datory ventilation）, or MAP 〈 10 cmH20（ high frequency oscillation）. If patients were stable Fentanyl was weaned off in 30 minutes then the baby was extubated. Control group received 50 g/L glucose infusion at a same rate. Same stan- dard care was provided to all patients. （ 1 ） Ventilation settings including MAP, FiO2, arterial oxygen saturation, partial pressure of carbon dioxide in artery, partial pressure of oxygen in artery, respiratory rate, mean blood pressure, heart rate, duration of ventilation, side effects before and after intubation （2,12,24,48 h） were compared. （2）Behavior re- sponses to pain were assessed and compared by using premature infant pain profile （PIPP） and COMFORT scores. （3） Amplitude integrated electro - encephalogram （aEEG） in 37 weeks of corrected gestational age and neonatal behavioral neurological assessment （NBNA） scores in 40 weeks of corrected gestational age were compared. Results （ 1 ） There was no significant difference in ventilation settings, mean blood pressure, duration of ventilation, and side effects. Heart rates in control group were lower than those in study group in 12, 24 and 48 hours after intubation with significant difference（ t = 6.36,7.01,6.28, all P 〈0. 05 ） ;respiratory rates in control group were lower than those in study group in 24 and 48 hours after intubation with significant difference （ t = 12.48,10.34, all P 〈 0.05 ）. （2） Two hours after in- tubation PIPP and COMFORT scores in control group were lower than those in study group with significant difference （all P 〈 0.05 ）, especially in 12 hours after intubation （P 〈 0.01 ）. （3） NBNA and aEEG scores in control group were higher than those in study group （t = 4.85,3.27, all P 〈 0.05）. Conclusions Fentanyl infusion has potential protec- tion for developing brain of ventilated prematurity by relieving pain during mechanic ventilation period, and improving NBNA scores and aEEG.