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【摘要】 目的:研究右美托咪定聯合复方利多卡因乳膏对小儿包皮环切术术后苏醒期安全性及躁动的影响。方法:选择2017年9月-2018年9月择期全麻下行小儿包皮环切术的患儿200例,按照随机数字表法分为右美托咪定联合复方利多卡因乳膏组(DL组)、右美托咪定组(D组)、复方利多卡因乳膏组(L组)、对照组(C组),每组50例。记录四组患儿术后进入复苏室30 min内心率(HR)、呼吸频率(RR)、血氧饱和度(SpO2)、躁动发生率和回到病房后6 h内的疼痛评分、镇静评分。结果:DL组、D组与L组组内比较,患儿30 min内HR均较平稳,差异均无统计学意义(P>0.05),但DL、D组各时间点的HR均低于C组,差异均有统计学意义(P<0.05)。DL组躁动发生率为8%,D组为14%,L组为12%,均明显低于C组的44%,差异均有统计学意义(P<0.05)。返回病房2、6 h时,C组的疼痛评分均明显高于其他三组,差异均有统计学意义(P<0.05)。返回病房1、2 h时,DL组、D组与L组患儿的镇静评分均高于C组,差异均有统计学意义(P<0.05)。结论:在小儿包皮环切术围术期,右美托咪定静脉泵注联合复方利多卡因乳膏局部应用是一种安全可靠的方案,具有术后良好的镇静和镇痛效果,使患儿复苏期躁动发生率降低,明显提高了麻醉恢复室的复苏质量。
【关键词】 右美托咪定; 复方利多卡因乳膏; 小儿; 包皮环切术; 躁动
【Abstract】 Objective:To study the effect of Dexmedetomidine combined with Compound Lidocaine Ointment on the safety and agitation of waking period after pediatric circumcision.Method:200 children with elective general anesthesia underwent pediatric circumcision from September 2017 to September 2018 were selected,and they were randomly divided into Dexmedetomidine combined with Compound Lidocaine Ointment group(group DL),Dexmedetomidine group(group D),Compound Lidocaine Ointment group(group L),control group(group C),50 patients in each group.Heart rate(HR),respiration rate(RR),oxygen saturation(SpO2)and incidence of agitation were recorded within 30 min after resuscitation in the recovery room,pain scores and sedation scores were recorded within 6 h after returning to the ward.Result:HR of the children in group DL,group D and group L were all stable within 30 min,the differences were not statistically significant(P>0.05),however,HR of group DL and D at each time point were lower than those of group C,the differences were statistically significant(P<0.05).The incidence of agitation was 8% in group DL,14% in group D,and 12% in group L,all significantly lower than 44% in group C,the differences were statistically significant(P<0.05).After returning to the ward for 2 and 6 hours,the pain scores of group C were significantly higher than those of the other three groups,with statistically significant differences(P<0.05).After returning to ward 1 and 2 hours,sedation scores of children in group DL,D and L were higher than that in group C,with statistically significant differences(P<0.05).Conclusion:In the perioperative period of pediatric circumcision,the local application of Dexmedetomidine intravenous infusion combined with Compound Lidocaine Cream is a safe and reliable scheme with good postoperative sedative and analgesic effects,which reduces the incidence of restlessness in the recovery period of children and significantly improves the quality of recovery in the anesthesia recovery room. 【Key words】 Dexmedetomidine; Compound Lidocaine Ointment; Pediatric; Circumcision; RestlessnessFirst-author’s address:Maternal and Child Health Hospital of Pingshan District in Shenzhen,Shenzhen 518122,China
doi:10.3969/j.issn.1674-4985.2019.17.012
包皮環切术能有效解决小儿包皮过长、包茎这类常见疾病,但是包皮环切术引起强烈的疼痛可造成患儿术后躁动发生,影响病情的预后。因此,有效的术后镇痛能在一定程度上降低躁动的发生。右美托咪定是一种高选择性α2肾上腺素能受体激动剂,张忠其等[1]研究发现术前单次给予0.5 μg/kg的右美托咪定能明显降低包皮环切术小儿术后烦躁,然而右美托咪定并无明显的镇痛作用。复方利多卡因乳膏其主要成分为丙胺卡因和利多卡因,术后局部应用能增加术后镇痛的作用,从而减少术后躁动发生[2]。然而两种药物结合应用是否能进一步降低小儿术后躁动的发生率还值得研究探讨。本研究主要采用右美托咪定联合复方利多卡因乳膏,观察其对小儿包皮环切术术后苏醒期安全性及躁动的影响,为临床小儿术后康复提供参考,现报道如下。
1 资料与方法
1.1 一般资料 选择病例为2017年9月-2018年9月行择期小儿包皮环切术的患儿200例,入选标准:在本院泌尿外科因包皮过长或包茎就诊的患儿,年龄1~10岁,体重10~30 kg,ASA Ⅰ级。排除标准:相关药物过敏史、近24 h使用镇静镇痛药物史等。按照随机数字表法分为右美托咪定联合复方利多卡因乳膏组(DL组)、右美托咪定组(D组)、复方利多卡因乳膏组(L组)、对照组(C组),每组50例。本研究经过本院伦理委员会批准,且与患儿家属签署麻醉知情同意书。
1.2 麻醉方法 所有患儿入手术室前常规肌注硫酸阿托品注射液[生产厂家:上海锦帝九州药业(安阳)有限公司,批准文号:国药准字H41023675,规格:1 mL∶0.5 mg]0.4 mg。手术室门口静脉注射盐酸氯胺酮注射液(生产厂家:山东方明药业集团股份有限公司,批准文号:国药准字H37022831,规格:
2 mL︰0.1 g)2 mg/kg后推进手术室。鼻导管吸氧并常规心电监测,麻醉诱导使用静脉注射丙泊酚注射液(生产厂家:北京费森尤斯卡比医药有限公司,批准文号:国药准字J20040122,规格:50 mL∶1 g)1~2 mg/kg,咪达唑仑注射液(生产厂家:江苏恩华药业股份有限公司,批准文号:国药准字H20031071,规格:5 mL∶5 mg)0.05 mg/kg,枸橼酸芬太尼注射液(生产厂家:宜昌人福药业有限责任公司,批准文号:国药准字H42022076,规格:2 mL∶0.1 mg)0.5~1 μg /kg,术中心率<60次/min或低于基础心率的30%给予阿托品0.2 mg静脉滴注,围术期对四组处理情况,见表1。盐酸右美托咪定注射液(生产厂家:辰欣药业股份有限公司,批准文号:国药准字H20163388,规格:1 mL∶0.1 mg);复方利多卡因乳膏(生产厂家:同方药业集团有限公司,批准文号:国药准字H20063466,规格:10 g),术后送入麻醉恢复室(PACU)观察,待患儿苏醒后生命体征平稳送回病房。
1.3 观察指标与评价标准 记录进入麻醉恢复室(PACU)0、5、10、15、20、25、30 min各个时间点心率(HR)、呼吸(RR)、血氧饱和度(SpO2)及患儿躁动情况。记录患儿回到病房后1、2、6 h的疼痛和镇静情况。具体评分标准:(1)躁动评分(SAS方法):平静睡眠为1分;清醒、平静为2分;易怒、易激惹、哭喊为3分;难以安慰、无法控制的哭喊4分;无法安静、谵妄为5分;术后患儿未苏醒记为1分,3分以上判定为躁动[1]。(2)疼痛评分(脸谱疼痛评分法):无痛为0分,有点痛为2分,疼痛轻微为4分,疼痛明显为6分,疼痛严重为8分,疼痛剧烈为10分。(3)镇静评分(Ramsay方法):焦虑、烦躁为1分;安静为2分;对指令有反应为3分;睡眠状态但可唤醒为4分;大声刺激反应表现迟钝为5分;无反应为6分。
1.4 统计学处理 采用Graphpad Prism 6.01统计软件,计量资料以(x±s)表示,组间比较采用多因素的方差分析,计数资料以率(%)表示,比较采用字2检验,不同时间段所得HR、RR及SpO2数据采用重复测量的方差分析,P<0.05为差异有统计学意义。
2 结果
2.1 四组患儿一般资料比较 四组患儿的年龄、身高、体重和手术时间比较,差异均无统计学意义(P>0.05),具有可比性,见表2。
2.2 四组患儿进入PACU 30 min内HR、RR及SpO2比较 DL组、D组与L组组内比较,患儿30 min内HR均较平稳,差异均无统计学意义(P>0.05),但DL与D组各时间点的HR均低于C组,差异均有统计学意义(P<0.05);L组进入PACU后20、25、30 min的HR均低于C组,差异均有统计学意义(P<0.05);C组进入PACU后20、25、30 min的HR均较0 min时出现较大幅度上升,差异均有统计学意义(P<0.05)。C组进入PACU后15、20、25、30 min的RR均明显高于0 min,差异均有统计学意义(P<0.05),其他三组的RR均较平稳,但DL组30 min的RR低于C组,差异有统计学意义(P<0.05)。四组SpO2各时间点均无明显变化,差异均无统计学意义(P>0.05)。见表3。
【关键词】 右美托咪定; 复方利多卡因乳膏; 小儿; 包皮环切术; 躁动
【Abstract】 Objective:To study the effect of Dexmedetomidine combined with Compound Lidocaine Ointment on the safety and agitation of waking period after pediatric circumcision.Method:200 children with elective general anesthesia underwent pediatric circumcision from September 2017 to September 2018 were selected,and they were randomly divided into Dexmedetomidine combined with Compound Lidocaine Ointment group(group DL),Dexmedetomidine group(group D),Compound Lidocaine Ointment group(group L),control group(group C),50 patients in each group.Heart rate(HR),respiration rate(RR),oxygen saturation(SpO2)and incidence of agitation were recorded within 30 min after resuscitation in the recovery room,pain scores and sedation scores were recorded within 6 h after returning to the ward.Result:HR of the children in group DL,group D and group L were all stable within 30 min,the differences were not statistically significant(P>0.05),however,HR of group DL and D at each time point were lower than those of group C,the differences were statistically significant(P<0.05).The incidence of agitation was 8% in group DL,14% in group D,and 12% in group L,all significantly lower than 44% in group C,the differences were statistically significant(P<0.05).After returning to the ward for 2 and 6 hours,the pain scores of group C were significantly higher than those of the other three groups,with statistically significant differences(P<0.05).After returning to ward 1 and 2 hours,sedation scores of children in group DL,D and L were higher than that in group C,with statistically significant differences(P<0.05).Conclusion:In the perioperative period of pediatric circumcision,the local application of Dexmedetomidine intravenous infusion combined with Compound Lidocaine Cream is a safe and reliable scheme with good postoperative sedative and analgesic effects,which reduces the incidence of restlessness in the recovery period of children and significantly improves the quality of recovery in the anesthesia recovery room. 【Key words】 Dexmedetomidine; Compound Lidocaine Ointment; Pediatric; Circumcision; RestlessnessFirst-author’s address:Maternal and Child Health Hospital of Pingshan District in Shenzhen,Shenzhen 518122,China
doi:10.3969/j.issn.1674-4985.2019.17.012
包皮環切术能有效解决小儿包皮过长、包茎这类常见疾病,但是包皮环切术引起强烈的疼痛可造成患儿术后躁动发生,影响病情的预后。因此,有效的术后镇痛能在一定程度上降低躁动的发生。右美托咪定是一种高选择性α2肾上腺素能受体激动剂,张忠其等[1]研究发现术前单次给予0.5 μg/kg的右美托咪定能明显降低包皮环切术小儿术后烦躁,然而右美托咪定并无明显的镇痛作用。复方利多卡因乳膏其主要成分为丙胺卡因和利多卡因,术后局部应用能增加术后镇痛的作用,从而减少术后躁动发生[2]。然而两种药物结合应用是否能进一步降低小儿术后躁动的发生率还值得研究探讨。本研究主要采用右美托咪定联合复方利多卡因乳膏,观察其对小儿包皮环切术术后苏醒期安全性及躁动的影响,为临床小儿术后康复提供参考,现报道如下。
1 资料与方法
1.1 一般资料 选择病例为2017年9月-2018年9月行择期小儿包皮环切术的患儿200例,入选标准:在本院泌尿外科因包皮过长或包茎就诊的患儿,年龄1~10岁,体重10~30 kg,ASA Ⅰ级。排除标准:相关药物过敏史、近24 h使用镇静镇痛药物史等。按照随机数字表法分为右美托咪定联合复方利多卡因乳膏组(DL组)、右美托咪定组(D组)、复方利多卡因乳膏组(L组)、对照组(C组),每组50例。本研究经过本院伦理委员会批准,且与患儿家属签署麻醉知情同意书。
1.2 麻醉方法 所有患儿入手术室前常规肌注硫酸阿托品注射液[生产厂家:上海锦帝九州药业(安阳)有限公司,批准文号:国药准字H41023675,规格:1 mL∶0.5 mg]0.4 mg。手术室门口静脉注射盐酸氯胺酮注射液(生产厂家:山东方明药业集团股份有限公司,批准文号:国药准字H37022831,规格:
2 mL︰0.1 g)2 mg/kg后推进手术室。鼻导管吸氧并常规心电监测,麻醉诱导使用静脉注射丙泊酚注射液(生产厂家:北京费森尤斯卡比医药有限公司,批准文号:国药准字J20040122,规格:50 mL∶1 g)1~2 mg/kg,咪达唑仑注射液(生产厂家:江苏恩华药业股份有限公司,批准文号:国药准字H20031071,规格:5 mL∶5 mg)0.05 mg/kg,枸橼酸芬太尼注射液(生产厂家:宜昌人福药业有限责任公司,批准文号:国药准字H42022076,规格:2 mL∶0.1 mg)0.5~1 μg /kg,术中心率<60次/min或低于基础心率的30%给予阿托品0.2 mg静脉滴注,围术期对四组处理情况,见表1。盐酸右美托咪定注射液(生产厂家:辰欣药业股份有限公司,批准文号:国药准字H20163388,规格:1 mL∶0.1 mg);复方利多卡因乳膏(生产厂家:同方药业集团有限公司,批准文号:国药准字H20063466,规格:10 g),术后送入麻醉恢复室(PACU)观察,待患儿苏醒后生命体征平稳送回病房。
1.3 观察指标与评价标准 记录进入麻醉恢复室(PACU)0、5、10、15、20、25、30 min各个时间点心率(HR)、呼吸(RR)、血氧饱和度(SpO2)及患儿躁动情况。记录患儿回到病房后1、2、6 h的疼痛和镇静情况。具体评分标准:(1)躁动评分(SAS方法):平静睡眠为1分;清醒、平静为2分;易怒、易激惹、哭喊为3分;难以安慰、无法控制的哭喊4分;无法安静、谵妄为5分;术后患儿未苏醒记为1分,3分以上判定为躁动[1]。(2)疼痛评分(脸谱疼痛评分法):无痛为0分,有点痛为2分,疼痛轻微为4分,疼痛明显为6分,疼痛严重为8分,疼痛剧烈为10分。(3)镇静评分(Ramsay方法):焦虑、烦躁为1分;安静为2分;对指令有反应为3分;睡眠状态但可唤醒为4分;大声刺激反应表现迟钝为5分;无反应为6分。
1.4 统计学处理 采用Graphpad Prism 6.01统计软件,计量资料以(x±s)表示,组间比较采用多因素的方差分析,计数资料以率(%)表示,比较采用字2检验,不同时间段所得HR、RR及SpO2数据采用重复测量的方差分析,P<0.05为差异有统计学意义。
2 结果
2.1 四组患儿一般资料比较 四组患儿的年龄、身高、体重和手术时间比较,差异均无统计学意义(P>0.05),具有可比性,见表2。
2.2 四组患儿进入PACU 30 min内HR、RR及SpO2比较 DL组、D组与L组组内比较,患儿30 min内HR均较平稳,差异均无统计学意义(P>0.05),但DL与D组各时间点的HR均低于C组,差异均有统计学意义(P<0.05);L组进入PACU后20、25、30 min的HR均低于C组,差异均有统计学意义(P<0.05);C组进入PACU后20、25、30 min的HR均较0 min时出现较大幅度上升,差异均有统计学意义(P<0.05)。C组进入PACU后15、20、25、30 min的RR均明显高于0 min,差异均有统计学意义(P<0.05),其他三组的RR均较平稳,但DL组30 min的RR低于C组,差异有统计学意义(P<0.05)。四组SpO2各时间点均无明显变化,差异均无统计学意义(P>0.05)。见表3。