儿童白血病侵袭性操作镇静镇痛方案比较研究

Comparison of Invasive Operative Sedation and Analgesia Regimens in Children with Leukemia

目的:优选儿童白血病侵袭性操作镇静镇痛方案。方法:选取2011年11月至2016年11月在我院进行侵袭性操作的白血病患儿,根据选用的镇静镇痛方案分为A(咪达唑仑+局部麻醉)、B(咪达唑仑+氯胺酮+局部麻醉)、C(咪达唑仑+芬太尼+局部麻醉)、D(芬太尼+丙泊酚+局部麻醉)四组各210例。镇静效果评价参照Ramesay评分法:1分-不安静,烦燥,哭闹;2分-安静合作;3分-嗜睡能听从指令;4分-睡眠状态,可唤醒;5分-呼吸反应迟钝;6分-深睡状态,呼唤不醒。术后疼痛评估采用面部表情评估法,包括脸谱疼痛评分法(适用于婴幼儿)和改良面部表情评分法(适用于学龄儿童和青少年)。采用χ^2检验比较四组方案的镇静镇痛效果及不良反应发生情况。结果:B、D组镇静效果优于A、C组(P<0.01),D组优于B组(P<0.05),A、C组比较差异无统计学意义(P>0.05)。B、D组镇痛效果优于A、C组(P<0.01),B、D组比较差异无统计学意义(P>0.05)。B、C组幻觉发生率高于A、D组(P<0.01),B组恢复清醒时间比其他各组长(P<0.01)。结论:在充分做好辅助呼吸准备和严密监测的情况下,丙泊酚联用小剂量芬太尼(D组方案)应用于儿童白血病侵袭性操作,是一种较好的镇静镇痛方法,疗效较好、清醒时间短、安全易行。

Objective:To optimize invasive operative sedation and analgesia regimens in children with leukemia.Methods:From Nov.2011 to Nov.2016,children with leukemia undergoing invasive operative sedation in our hospital were extracted to be divided into group A(midazolam+local anesthesia)and B(midazolam+ketamine+local anesthesia),C(midazolam+fentanyl+local anesthesia)and D(fentanyl+propofol+local anesthesia)according to different invasive operative sedation and analgesia regimens,with 210 cases in each group.Sedative effect was evaluated according to Ramesay scale:1-anxious,agitated and restless;2-cooperative,oriented and tranquil;3-responsive to commands only;4-brisk response to light glabellar tap or loud auditory stimulus;5-sluggish response to light glabellar tap or loud auditory stimulus;6-no response to light glabellar tap or loud auditory stimulus.Postoperative pain was assessed by using facial expression assessment,including facial pain rating(for infants and young children)and modified facial expression rating(for school-age children and adolescents).χ^2 test was used to compare the operative sedation and analgesia effect and adverse drug reactions of four groups.Results:The sedative effect of group B and D was better than that of group A and C(P<0.01),and that of group D was better than that of group B(P<0.05),there was no significant difference between group A and C(P>0.05).The analgesic effect of group B and D was better than that of group A and C(P<0.01),but there was no significant difference between group B and D(P>0.05).The incidence of hallucination in group B and C was higher than that in group A and D(P<0.01),and the recovery time of group B was longer than that of other groups(P<0.01).Conclusion:In the case of adequate preparation for assisted breathing and close monitoring,propofol combined with low-dose fentanyl is a good invasive operative sedation and analgesia regimen in children with leukemia,with more significant efficacy,shorter wakening time and higher safety.