七氟烷、氯胺酮静吸复合麻醉用于小儿腹股沟斜疝修补术的临床观察

时间: 2017-10-18 19:00:05 来源:未知 作者:admin 点击:51 次
  

                        作者:郭继龙,张联义,王光磊,齐敦益,刘功俭

【摘要】    目的 观察七氟烷、氯胺酮静吸复合用于小儿腹股沟斜疝修补术的效果及不良反应,评价静吸复合全麻在小儿术中的临床应用。方法 选择ASAⅠ~Ⅱ级择期行腹股沟斜疝修补术住院患儿120例,随机分为七氟烷组(S组)、七氟烷复合氯胺酮组(KS组)和氯胺酮组(K组),每组40例。患儿入室后开放上肢静脉,S组术中吸入3%~5%七氟烷,维持在1.3~1.5肺泡气最低有效浓度(minimal alveolar concentration,MAC);KS组术中吸入1%~3%七氟烷,维持在0.6~1.0 MAC,同时静脉输注0.5 mg?kg-1?h-1氯胺酮;K组手术开始时静脉注射2 mg?kg-1氯胺酮,术中持续静脉输注0.5 mg?kg-1?h-1氯胺酮。术中患儿始终保持自主呼吸,常规监测平均动脉压(MAP)、心率(HR)、脉搏血氧饱和度(SpO2)、呼吸频率(RR)、苏醒时间、清醒时间和不良反应。结果 ①与术前相比,KS组患儿围术中呼吸、循环变化不明显(P>0.05),而S组和K组RR术中较低,HR及MAP较术前高(P<0.05)。②K组患儿苏醒时间和清醒时间较S组及KS组明显延长(P<0.05)。③S组及K组患儿呛咳、恶心、呕吐、躁动、呼吸抑制等不良反应发生率明显高于KS组(P<0.05或P<0.01)。结论 七氟烷复合氯胺酮可安全用于小儿全身麻醉,不良反应发生率低。 
【关键词】  七氟烷 氯胺酮 复合麻醉 腹股沟斜疝 小儿
   Abstract: Objective  To observe the clinical effect and adverse reactions of sevoflurane combined with ketamine in pediatric oblique inguinal hernia neoplasty and evaluate the clinical application of general anesthesia combined with vein-inhalation in pediatric surgery. Methods  120 inpatients with ASA Ⅰ-Ⅱ undergoing hernia neoplasty operation were randomly divided into 3 groups (n=40 each): sevoflurane group (S group), sevoflurane / ketamine group (KS group) and ketamine group (K group). All patients had a vein of upper extremity opened. Patients in S group were assigned to receive sevoflurane (3%~5%) and anesthesia was maintained at 1.3~1.5 MAC (minimum alveolar concentration). In KS group, patients received sevoflurane (1%~3%)combined with intravenous drip of 0.5 mg?kg-1?h-1 ketamine. In group K, 2 mg?kg-1 ketamine was given intravenously at the onset of operation, followed by continuous intravenous drip 0.5 mg?kg-1?h-1 during operation. Throughout the operation, all the patients had autonomous respiration voluntary respiration. The heart rate (HR), mean arterial blood pressure (MAP), respiratory rate (RR), saturation of pulse oxygen (SpO2) and adverse reactions were monitored during and after operation. The time of palinesthesia and consciousness were recorded. Results  The HR and MAP were significantly lower in group KS than in groups K and S during operation (P<0.05). But the RR was significantly lower in group K and S than those in group KS (P<0.05) .The time of palinesthesia and consciousness in group K were significantly longer than that in groups S and KS after operation (P<0.05). The incidence of agitation, nausea-vomiting, dyspnea, etc. were significantly lower in group KS than those in groups K and S (P<0.05 or P<0.01). Conclusion  It is safe and feasible to give sevoflurane combined with ketamine anesthesia in pediatric operations, with an incidence of adverse reactions reduced.
  Key words:sevoflurane; ketamine; combined anesthesia; oblique inguinal hernia; pediatric patient
  腹股沟斜疝修补术是儿外科常见手术。麻醉期间患儿生理功能变化快,麻醉用药及术中管理都比较困难,麻醉风险性较大,这就要求术毕尽快清醒。复合应用麻醉药具有用药量少,术后苏醒快及不良反应发生率低等优点,临床上日益受到重视[1]。七氟烷、氯胺酮静吸复合能否安全用于小儿全身麻醉,临床上少见报道。本研究旨在观察七氟烷、氯胺酮静吸复合用于小儿腹股沟斜疝修补术全麻的效果及不良反应,现将结果报道如下。
  1  资料和方法
  1.1  一般资料  120例腹股沟斜疝修补术住院患儿,ASAⅠ~Ⅱ级,年龄1~3岁,体重10~16 kg,手术时间(46.6±7.9)min。随机分为3组,七氟烷组(S组)、七氟烷复合氯胺酮组(KS组)和氯胺酮组(K组),每组40例。患儿术前无心肺疾病,肝、肾功能无明显异常。3组患儿的年龄、体重、手术时间均无显著性差异。
  1.2  方法  患儿术前30 min均肌注0.01 mg?kg-1东莨菪碱,入室后开放上肢静脉,维持输液。S组术中吸入3%~5%七氟烷,采用麻醉气体监测仪(Ulti-ma,芬兰)监测七氟烷浓度,维持在1.3~1.5肺泡气最低有效浓度(minimal alveolar concentration,MAC);KS组吸入1%~3%七氟烷,维持在0.6~1.0 MAC,同时持续静脉输注0.5 mg?kg-1?h-1氯胺酮;K组手术开始时静脉注射2 mg?kg-1氯胺酮,术中持续静脉输注0.5 mg?kg-1?h-1氯胺酮。术中患儿均保持自主呼吸,面罩持续吸氧,氧流量2.0~4.0 L?min-1。采用Datex心电监测仪常规监测呼吸、循环功能。手术结束后停止所有麻醉用药,术毕待患儿清醒后送回病房。
  1.3  观察指标  ①记录用药前(T0)、用药后5 min(T1)、手术开始(T2)、手术结束时(T3)、术后5 min(T4)及术后30 min(T5)的心率(HR)、平均动脉压(MAP)、呼吸频率(RR)、脉搏血氧饱和度(SpO2)。②观察患儿术后苏醒时间和清醒时间。苏醒时间指停药后至患儿开始哭闹时的时间;清醒时间为停药后至对语音有反应时的时间。③观察记录术中及术后不良反应。不良反应包括恶心、呕吐、躁动,呼吸抑制等。
  1.4  统计学处理  所有数据采用SSPS 13.0软件进行分析,定量资料以±s表示,组间比较采用方差分析及t检验,定性资料采用χ2检验,P<0.05认为差异有显著性,检验水准:α=0.05。
  2  结  果
  2.1  呼吸、循环功能的变化  与术前相比,术中和术后KS组患儿HR、MAP、RR变化不明显(P>0.05)。S组和K组患儿RR明显低于术前,K组和S组HR、MAP较术前明显升高(P<0.05),而KS组呼吸、循环较平稳。见表1。
  2.2  苏醒时间、清醒时间的比较  K组患儿苏醒时间和清醒时间较KS组和S组明显延长(P<0.05),KS组患儿清醒时间和苏醒时间较S组延迟,但差异不显著(P>0.05)。见表2。

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