儿童在全凭静脉麻醉下行直接喉镜和支气管镜检查中的麻醉管理

Anesthesia management in children undergoing direct laryngoscopy and bronchoscopy under total intravenous anesthesia

目的探讨不同年龄儿童在保留自主呼吸的全凭静脉麻醉下行直接喉镜和支气管镜检查的麻醉管理。方法选取2022年5月至2023年1月上海交通大学医学院附属上海儿童医学中心收治的气道畸形患儿71例,美国麻醉医师协会(ASA)分级Ⅱ~Ⅲ级,年龄1个月至10岁,按年龄将患儿分成<1岁组(A组)25例,≥1岁且<4岁组(B组)23例,≥4岁且≤10岁组(C组)23例。静脉注射利多卡因、舒芬太尼和右美托咪定结合滴定式静脉注射丙泊酚行麻醉诱导,并以泵注丙泊酚10~12 mg/(kg·h)维持麻醉。采用2.4%利多卡因气雾剂行声带表面麻醉。比较三组患儿麻醉后呼吸暂停、喉痉挛、呛咳和低氧血症等发生率,并记录患儿清醒状态时(T_(0))、置入硬质喉镜时(T_(1))、直接喉镜和支气管镜检查时(T_(2))的生命体征指标。结果三组患儿麻醉后呼吸暂停、喉痉挛和呛咳发生率比较差异无统计学意义(P>0.05)。A组患儿丙泊酚诱导用量较B组和C组显著减少,而低氧血症的发生率较C组显著升高(P<0.05)。A组患儿T_(1)和T_(2)时间点心率(HR)较T_(0)时间点显著降低,B组患儿T_(2)时间点HR较T_(0)时间点显著降低(P<0.05)。三组患儿T_(1)和T_(2)时间点收缩压(SBP)和舒张压(DBP)较T_(0)时间点显著降低(P<0.05)。结论保留自主呼吸的全凭静脉麻醉技术可用于儿童直接喉镜和支气管镜检查,但需注意1岁以下婴儿低氧血症的发生率较年长儿高。

Objective To explore the anesthesia management in children of different ages with spontaneous breathing and undergoing direct laryngoscopy and bronchoscopy under total intravenous anesthesia.Methods A total of 71 pediatric patients with airway malformation who were admitted to Shanghai Children′s Medical Center,Shanghai Jiao Tong University School of Medicine from May 2022 to January 2023 were selected.The pediatric patients were classified by the American Society of Anesthesiologists(ASA)as gradeⅡ-Ⅲ,with ages ranging from 1 month to 10 years old.According to the ages,the pediatric patients were divided into younger than 1 year group(group A,25 cases),older than or equal to 1 year and younger than 4 years group(group B,23 cases)and older than or equal to 4 years group(group C,23 cases).Anesthesia was induced by intravenous infusion of lidocaine,sufentanil and dexmedetomidine combined with intravenous drip of propofol,and maintained by pump infusion of propofol at 10-12 mg/(kg·h).Vocal cord surface anesthesia was performed with 2.4%lidocaine aerosol.The pediatric patients′incidence rates of apnea,laryngeal spasm,choking cough and hypoxemia after anesthesia were compared among the three groups.The pediatric patients′indicators of vital signs were recorded at awake state(T_(0)),rigid laryngoscope insertion(T_(1))and direct laryngoscopy and bronchoscopy(T_(2)).Results After anesthesia,there were no significant differences in the pediatric patients′incidence rates of apnea,laryngeal spasm and choking cough among the three groups(P>0.05).The dose of propofol used for inducing anesthesia in the pediatric patients of group A was significantly reduced compared with that in the pediatric patients of group B and the pediatric patients of group C,while the incidence rate of hypoxemia in the pediatric patients of group A was significantly higher than that in the pediatric patients of group C(P<0.05).In the pediatric patients of group A,heart rate(HR)at T_(1)and T_(2)time points was significantly lower than that at T_(0)time point,and in the pediatric patients of group B,HR at T_(2)time point was significantly lower than that at T_(0)time point(P<0.05).Systolic blood pressure(SBP)and diastolic blood pressure(DBP)at T_(1)and T_(2)time points were significantly lower than those at T_(0)time point in the three groups(P<0.05).Conclusion The technique of total intravenous anesthesia with the patients′spontaneous breathing preserved can be used for direct laryngoscopy and bronchoscopy in children,but it should be noted that the incidence rate of hypoxemia in infants under 1 year of age is higher than that in children aged 1 year and above.