艾司氯胺酮联合超声引导下阴茎背神经阻滞对全麻包皮环切术患儿术后不良行为改变的影响

Effect of esketamine combined with ultrasound-guided dorsal penile nerve block on negative postoperative behavioral changes in pediatric patients undergoing circumcision under general anesthesia

目的评价艾司氯胺酮联合超声引导下阴茎背神经阻滞(DPNB)对全麻包皮环切术患儿术后不良行为改变(NPOBCs)的影响。方法选择择期在全麻下行包皮环切术患儿195例, 年龄4~8岁, 体质量10~35 kg, ASA分级Ⅰ或Ⅱ级, 采用随机数字表法分为3组(n=65):艾司氯胺酮组(E组)、DPNB组(D组)和艾司氯胺酮联合DPNB组(ED组)。3组患儿静脉注射丙泊酚1.5 mg/kg, 待意识消失后入室。E组和ED组静脉注射艾司氯胺酮0.5 mg/kg, D组静脉注射等容量生理盐水;然后D组和ED组在超声引导下采用0.25%罗哌卡因0.15 ml/kg行双侧DPNB, 最大药物总量不超过10 ml。3组于切皮前静脉注射芬太尼1.0 μg/kg和丙泊酚2.0 mg/kg。如术中出现体动反应, 则追加丙泊酚10 mg, 可重复追加。记录术中体动、呼吸抑制发生情况和丙泊酚追加量。发生术后疼痛(FLACC评分>4分)时静脉注射氟比洛芬酯1 mg/kg镇痛, 记录氟比洛芬酯使用情况。发生苏醒期躁动(PEAD评分>10分)时静脉注射丙泊酚1 mg/kg镇静, 记录苏醒期躁动发生情况。分别于术后1、7和30 d时对患儿父母进行电话随访, 采用PHBQ量表评估NPOBCs的发生情况。结果最终E组有56例, D和ED组各59例患儿完成研究。与E组比较, D组和ED组术中体动发生率降低, 丙泊酚追加量减少, 苏醒期躁动评分、苏醒期躁动和严重躁动发生率、术后氟比洛芬酯使用率降低, 术后7和30 d时分离焦虑发生率降低, ED组术中呼吸抑制发生率降低, 术后7和30 d时NPOBCs发生率降低(P<0.05);与D组比较, ED组术中呼吸抑制发生率降低, 丙泊酚追加量减少, 术后氟比洛芬酯使用率和术后1 d时睡眠焦虑发生率降低(P<0.05), 术后各时点NPOBCs发生率差异无统计学意义(P>0.05)。结论艾司氯胺酮联合超声引导下DPNB可减少全麻包皮环切术患儿NPOBCs的发生。

Objective To evaluate the effect of esketamine combined with ultrasound-guided dorsal penile nerve block(DPNB)on negative postoperative behavioral changes(NPOBCs)in pediatric patients undergoing circumcision under general anesthesia.Methods One-hundred and ninety-five pediatric patients,aged 4-8 yr,with body mass index of 10-35 kg,of American Society of Anesthesiologists Physical Status classificationⅠorⅡ,undergoing elective circumcision under general anesthesia,were selected and divided into 3 groups(n=65 each)using a random number table method:esketamine group(group E),DPNB group(group D)and esketamine combined with DPNB group(group ED).Propofol 1.5 mg/kg was intravenously injected,and the patients were admitted to the operating room after consciousness disappeared in the 3 groups.Esketamine 0.5 mg/kg was intravenously injected in E and ED groups,and the equal volume of normal saline was given in group D.D and ED groups underwent bilateral DPNB with 0.25%ropivacaine 0.15 ml/kg under ultrasound guidance,with the maximum total amount of the drug not exceeding 10 ml.Fentanyl 1.0μg/kg and propofol 2.0 mg/kg were intravenously injected prior to the skin incision in the three groups.If intraoperative body movement occurred,propofol 10 mg was added,which could be repeated.The occurrence of intraoperative body movement,respiratory depression and amount of propofol added was recorded.When postoperative pain(FLACC score>4)occurred,flurbiprofen 1 mg/kg was intravenously injected for analgesia,and the usage of flurbiprofen was recorded.When emergence agitation(PEAD score>10)occurred,propofol 1 mg/kg was intravenously injected for sedation,and the occurrence of emergence agitation was recorded.Parents were followed up by telephone at 1,7 and 30 days postoperatively to assess the occurrence of NPOBCs using the PHBQ scale.Results Fifty-six patients in group E and 59 patients in D and ED groups finally completed the study.Compared with group E,the incidence of intraoperative body movement was significantly decreased,the amount of additional propofol was reduced,the emergence agitation score,incidence of emergence agitation and severe agitation and usage rate of postoperative flurbiprofen were decreased,and the incidence of separation anxiety at 7 and 30 days postoperatively was decreased in D and ED groups,and the incidence of intraoperative respiratory depression was significantly decreased,and the incidence of NPOBCs at 7 and 30 days postoperatively was decreased in group ED(P<0.05).Compared with group D,the incidence of intraoperative respiratory depression was significantly decreased,the amount of additional propofol was decreased,the usage rate of postoperative flurbiprofen and incidence of sleep anxiety at 1 day postoperatively were decreased(P<0.05),and no significant change was found in the incidence of NPOBCs at each time point after operation in group ED(P>0.05).Conclusions Esketamine combined with ultrasound-guided DPNB can reduce the occurrence of NPOBCs in pediatric patients undergoing circumcision under general anesthesia.