艾司氯胺酮预处理对小儿隐匿阴茎矫治术后早期不良行为发生的影响

Effect of Esketamine on Early Negative Postoperative Behavioural Occurrence After Pediatric Concealed Penis Correction

【目的】探讨艾司氯胺酮预处理对小儿隐匿阴茎矫治术后早期不良行为发生的影响。【方法】选择隐匿性阴茎矫治术患儿88例,手术时间小于1 h,年龄4~10岁,ASA分级I~Ⅱ级;采用数字表法随机分为艾司氯胺酮组(E组,n=44)和对照组(C组,n=44),E组麻醉诱导前20 min予以艾司氯胺酮0.5 mg/kg预处理,C组予以等量生理盐水静注,两组均采用喉罩静吸复合全身麻醉。在术前一天和入手术室时采用m-YPAS评估焦虑状态,记录诱导期ICC评分。分别记录诱导前(T0)、诱导后即刻(T1)、手术开始(T2)、入PACU(T3)、入PACU后10 min(T4)、出PACU前(T5)患儿的HR和MAP。记录苏醒期间PAED、FLACC评分。留取术前1天和术后第1天外周静脉血3 mL,检测MCP-1、Cortisol、Epinephrine水平。术后第3天、第7天对所有患儿行PHBQ问卷评分。【结果】E组术后第3天、第7天术后出现不良行为改变(NPOBCs)发生率明显低于C组(31.8%vs.63.6%,P<0.05;18.2%vs.40.9%,P<0.05)。E组术后第3天PHBQ中分离焦虑、睡眠焦虑、饮食障碍发生率明显低于C组,差异有统计学意义(P<0.05);两组整体焦虑、攻击性、冷漠退缩发生率相比较差异无统计学意义(P>0.05)。术后第7天,2组PHBQ中各项指标发生率差异均无统计学差异(P>0.05)。E组术后MCP-1明显降低,差异有统计学意义(P<0.05);而肾上腺素和皮质醇水平,2组比较差异无统计学意义(P>0.05)。多因素Logistic回归分析发现艾司氯胺酮和入手术室的m-YPAS是患儿术后早期NPOBCs的影响因素,且二者作为预测NPOBCs发生的ROC曲线下面积AUC(95%CI)分别为0.659(0.544,0.774)和0.918(0.849,0.988),敏感性分别为66.70%和92.90%,特异性分别为65.20%和84.80%,差异有统计学意义(P<0.05)。两组PACU中PAED评分和FLACC评分差异无统计学意义(P>0.05)。【结论】艾司氯胺酮预处理可以降低接受隐匿性阴茎矫治术儿童的术后早期NPOBCs的发生,且可能与降低术后MCP-1有关,同时不增加围术期不良事件,安全性较高。

【Objective】To investigate the effect of esketamine pretreatment on early negative postoperative behavioural occurrence after pediatric concealed penis correction.【Methods】A total of 88 children,aged 4-10 years old,of American Society of Anesthesiologists physical statusⅠ-Ⅱ,undergoing pediatric cryptorchid penis correction operation within 1 hour,were randomly divided into the esketamine group(Group E,n=44)and the control group(Group C,n=44)according to the computer-generated random numeral order.Esketamine was infused intravenously at a dose of 0.5 mg/kg 20 minutes before entering the operating room in Group E,while equal volume of normal saline was given instead of esketamine in group C.General anesthesia with laryngeal mask and inhalation anesthesia was used in both groups.The anxiety level of children was evaluated by modified Yale Preoperative Anxiety Scale(m-YPAS)on the day before surgery and before entering operating room on the day of the operation.The induction compliance level of children was evaluated by the Induction Compliance Checklist(ICC).Heart rate(HR)and mean arterial pressure(MAP)were recorded before the induction of anesthesia(T 0),immediately after the induction(T 1),the beginning of the operation(T 2),the time of admission to the PACU(T 3),10 min after the PACU(T 4),and before discharge from PACU(T 5).Paediatric Anaesthesia Awakening Delirium Scale(PAED)and Pain Behavioural Assessment Scale(FLACC)scores were performed during awakening.A volume of 3 mL of peripheral venous blood was collected on the first preoperative day as well as the first postoperative day,and the levels of monocyte chemotactic protein 1(MCP-1),cortisol and epinephrine were measured.The Postoperative Behavioural Questionnaire(PHBQ)questionnaire was recorded on postoperative days 3 and 7 for all children.【Results】The incidence of NPOBCs on postoperative days 3 and 7 was significantly lower in Group E compared with that of Group C(31.8%vs.63.6%,P<0.05;18.2%vs.40.9%,P<0.05).The incidence of separation anxiety,sleep anxiety,and eating disorders in the PHBQ on postoperative day 3 was significantly lower in Group E than in Group C.The difference was statistically significant(P<0.05);there was no statistically significant difference between the two groups when comparing the incidence of overall anxiety,aggression,and apathetic withdrawal(P>0.05).On postoperative day 7,the incidence of all indicators in the PHBQ was not statistically different between the 2 groups(P>0.05).Compared with Group C,postoperative MCP-1 was significantly lower in Group E,and the difference was statistically significant(P<0.05);whereas for epinephrine and cortisol levels,there was no statistically significant difference between the 2 groups(P>0.05).Multivariable logistic regression analysis suggested that the possible risk factors for NPOBCs after pediatric concealed penis correction included the m-YPAS score[OR=1.152,95%CI(1.083,1.226);P=0.000],and the use of esketamine[OR=0.223,95%CI(0.062,0.803);P=0.022].The AUC under the ROC curve of m-YPAS and the use of esketamine as two predictors of the occurrence of NPOBCs were 0.918[P<0.001,95%CI(0.849,0.988)]and 0.659[P=0.010,95%CI(0.544,0.774)],respectively.There was no statistically significant difference in PAED scores and FLACC scores between the two groups in the PACU(P>0.05).【Conclusion】Esketamine pretreatment can reduce the incidence of NPOBCs in children undergoing concealed penis correction,which may be associated with a reduction in postoperative MCP-1,without an increase in perioperative adverse events and with a high safety profile.