右美托咪定、氯胺酮、舒芬太尼联用预防儿童包皮环切术后疼痛的效果

The effects of combination of Dexmedetomidine-Ketamine-Sufentanil on postoperative analgesia in children undergoing circumcision

目的观察比较右美托咪定、氯胺酮与舒芬太尼三种药物不同组合方式的麻醉方法对儿童包皮环切术后疼痛的影响,明确右美托咪定滴鼻与氯胺酮+舒芬太尼静脉麻醉联用对儿童包皮环切术后疼痛的预防效果。方法接受包皮环切术的儿童118例,年龄2~14岁。按麻醉药物组合方式分为4组,DK组(n=30)采用右美托咪定滴鼻复合氯胺酮、丙泊酚静脉麻醉,DS组(n=28)采用右美托咪定滴鼻复合舒芬太尼、丙泊酚静脉麻醉,KS组(n=30)采用氯胺酮、舒芬太尼、丙泊酚静脉麻醉,DKS组(n=30)采用右美托咪定滴鼻复合氯胺酮-舒芬太尼-丙泊酚静脉麻醉,4组均采用静脉缓慢推注丙泊酚3 mg/kg诱导,入睡后,DK组氯胺酮2 mg/kg静脉注射麻醉,DS组舒芬太尼0.3μg/kg(总量不超过10μg)静脉注射,KS组氯胺酮2 mg/kg+舒芬太尼0.3μg/kg静脉注射,DKS组氯胺酮2 mg/kg+舒芬太尼0.3μg/kg静脉注射,其中DK组、DS组与DKS组于麻醉诱导入睡后经鼻滴入右美托咪定1μg/kg,KS组滴入等体积生理盐水。术后疼痛达中、重度者给予镇痛治疗。记录4组患儿苏醒后疼痛评分、术后12 h内镇痛治疗情况及术中氯胺酮、舒芬太尼、丙泊酚的使用剂量、术中包皮环扎时体动现象、术中血压、心率、麻醉苏醒时间、苏醒期肢体扭动、苏醒期呼吸抑制、苏醒后镇静评分、恶心呕吐、眩晕的发生情况。结果 DKS组术后疼痛评分及术后12 h内镇痛需求率较DK组、DS组及KS组低(P<0.05);与DS组比较,DKS组、KS组术中丙泊酚和舒芬太尼使用剂量低(P<0.05),与DK组比较,DKS组、KS组术中丙泊酚和氯胺酮使用剂量低(P<0.05);DKS组、KS组术中体动发生率低于DK组、DS组(P<0.05);DKS组、DS组术后眩晕发生率低于DK组、KS组(P<0.05);DKS组苏醒时间、苏醒后镇静评分较KS组、DK组、DS组长和高(P<0.05);DS组苏醒期肢体扭动发生率高于其他3组(P<0.05),4组患儿术中循环平稳,苏醒期无呼吸抑制,术后无恶心呕吐发生。结论右美托咪定滴鼻与氯胺酮+舒芬太尼静脉麻醉联用能有效、安全地预防儿童包皮环切术后疼痛。

Objective To investigate the effects of intranasal dexmedetomidine in combination with intravenous ketamine plus sufentanil on postoperative analgesia in children undergoing circumcision. Methods A total of 118 boys undergoing circumcision surgery were included in the study. The patients were divided into 4 groups. After induction of propofol, the participants in Group DK (n =30) received dexmedetomidine (1 μg/kg) plus intravenous ketamine ( 2 mg/ kg);in Group DS ( n = 28) received intranasal dexmedetomidine (1 μg/kg) pus intravenous sufentanil (0. 3 μg/kg);in Group KS (n = 30) received intranasal saline, intravenous ketamine ( 2 mg/kg) and sufentanil (0. 3μg/kg);and in Group DKS (n=30) received intranasal dexmedetomidine ( 1μg/kg), intravenous Ketamine (2 mg/kg) and Sufentanil (0. 3 μg/kg). Patients with moderate or severe postoperative pain received analgesic treatment. Scores of pain after recovery and incidence of analgesic requirement were evaluated. Total doses of Ketamine, Sufentanil and propofol consumed during the procedure were calculated. Hemodynamic parameters, body -movement during surgical procedure, time to awake and body writhing during recovery period were assessed, the number of episodes of respiratory depression, nausea, vomiting and vertigo were recorded. Results The score of postoperative pain and incidence of requirement for analgesic treatment were significantly lower in Group DKS as compared to Group DK, Group DS and Group KS ( 3. 3% vs. 66. 67%, 78.57% and 73. 33%, P < 0. 05 ). The doses of propofol and Ketamine consumed in Group DKS and Group KS were significantly lower than that in Group DK (P <0. 05). The doses of propofol and Sufentanil consumed in Group KS and Group DKS were significantly lower than that in Group DS ( P < 0. 05 ). The frequency of body - movement during surgical procedure in Group DKS and Group KS was significantly lower than Group DS and Group DK ( P < 0. 05 ). The time for recovery was significantly longer and the score was significantly higher in Group DKS as compared to Group DK, Group DS and Group KS ( P < 0. 05 ). The body writhing during recovery period was significantly higher in Group DS as compared to Group DK, Group KS and Group DKS (P < 0. 05 ). The frequency of vertigo was significantly lower in Group DS and Group DKS as compared to Group DK and Group KS ( P < 0. 05). No respiratory depression, bradycardia, hypotension ,nausea or vomiting in all of the four groups during study were observed. Conclusion Intranasal dexmedetomidine in combination with intravenous ketamine plus sufentanil is effective on postoperative analgesia in children undergoing circumcision.