【作者】 王嵘；

【导师】 李立环；

【作者基本信息】 中国协和医科大学 ， 心血管麻醉， 2008， 博士

【摘要】 背景:随着先心病诊疗技术的发展,如何为患儿提供效价比最高的治疗成为大家关心的重点,术后尽早拔管是实施心脏外科快通道的最重要的环节,在实施早拔管的同时如何能保证足够的麻醉深度值得探讨。目的:探讨应用小剂量芬太尼和不同输注速度瑞芬太尼实施先心病患儿术后手术室内拔管的可行性及安全性,比较术中血流动力学、应激反应因子变化及术后转归。方法:37例择期行房、室间隔缺损修补术患儿,随机分为3组:Ⅰ组（n=13）芬太尼总量10μg·kg^-;Ⅱ组（n=12）、Ⅲ组（n=12）分别持续输入瑞芬太尼0.25μg·kg^-1·min^-1、0.50μg·kg^-1·min^-1。记录患儿入睡（基础值T0）、气管插管后（T1）、切皮（T2）、劈胸骨（T3）、开始转机（T4）、转机10min（T5）、复温5min（T6）、停机（T7）、停机10min（T8）、穿钢丝（T9）、手术结束（T10）、拔除气管插管（T11）、拔管后0.5h（T12）,拔管后2h（T13）的心率、血压、BIS值、呼出七氟烷浓度。患儿入睡（T0基础值）、劈胸骨后（T3）、复温后（T6）、拔除气管插管后0.5h（T12）、2h120min（T13）检测动脉去甲肾上腺素（Noradrenaline NE）、皮质醇（Cortisol COR）、血糖（BloodGlucose）、乳酸（Lactate acid LAC）浓度。术后随访有无早拔管相关并发症,比较住院时间和住院费用。结果:三组患儿均成功地在手术室内拔除气管插管,Ⅲ组拔管时间显著长于其他两组,无早拔管相关的并发症。三组拔管后心率均显著增快,Ⅱ组伴有血压升高,术后需要更多降压及镇静药物。NE浓度仅Ⅰ组T6点显著高于基础值。Ⅱ组T13NE、COR、Lac浓度显著高于其他两组,Ⅲ组T3BG,T6COR、BG、及Lac浓度显著低于其他两组。三组患儿各时间点BIS变化趋势一致,与呼出七氟烷浓度呈显著负相关,手术结束和拔管时的均值均为73、80。结论:简单先心病患儿术中应用10μg·kg^-1芬太尼,持续输注0.25μg·kg^-1·min^-1或0.50μg·kg^-1·min^-1瑞芬太尼均可实现手术室内拔管。0.5μg·kg^-1·min^-1瑞芬太尼可更有效的阻断术中各个时期,尤其是体外循环过程中的儿茶酚胺类物质的释放,并能抑制机体分解代谢,内环境更为稳定。BIS监测可反应镇静深度为选择拔管时机提供指导。更多还原

【Abstract】 Background:With the improvements of perioperative strategies for children with congenital heart disease,the focus in now has directed towards provision of cost-effective patient care.Early extubation is necessary element of fast tracking cardiac anaesthesia.How to achieve early extubation without compromising the patients’ anaesthesia depth is gaining anesthesiologists’ attention.Objective:To evaluate the efficacy and safety of anesthetic technique based on either fentanyl or remifentanil for early extubation after paediatric cardiac surgery.The circulation stability,stress responses,complications were compared.Methods:37 patients with atrial septal defect（ASD） or simple ventricular septal defect（VSD） were randomly assigned to groupⅠwith bolus infusion of 5,2.5,2.5μg·kg^-1 fentanyl,groupⅡand groupⅢwith continuous remifentanil infusion of 0.25μg·kg^-1·min^-1 and 0.50μg·kg^-1·min^-1.Arterial pressure,heart rate,Bispectral index（BIS）,endtidal concentration of sevoflurane were recorded at conscious loss as baseline（T0）,post intubation（T1）, skin incision（T2）,sternotomy（T3）,establish of CPB（T4）,10min of CPB（T5）,5 min after rewarmed（T6）,end of CPB（T7）,10min after CPB（T8）,sternal wires（T9）,end of operation（T10）,extubation（T11）,0.5 and 2 hours after extubation（T12 and T13）. Serum norepinephrine（NE）,cortisol（COR）,glucose（BG）,lactate acid（LAC） levels were measured at T0,T3,T6,T12,T13.Results:All the patients were successfully extubated in the OR.Heart rate increased significantly in three groups after extubation while blood pressure only increased in groupⅡwith more vasodilator and sedative treatments.Serum NE level in three groups was constant except groupⅠat T6.Serum level of NE,COR,and LAC in groupⅡat T13 were significantly higher than the other two groups.The level of COR,BG and LAC in groupⅢat T6 were significantly lower than the other two groups.No significant differences were observed in BIS over time,and there was significant negative correlation between BIS and endtidal concentration of sevoflurane in all three groups.The mean BIS at the end of surgery and extubation was 73 and 80 for all groups.Conclusion:All the patients can be successfully extubated in the OR with 10μg·kg^-1 fentanyl,0.25μg·kg^-1·min^-1 and 0.50μg·kg^-1·min^-1 remifentanil while 0.50μg·kg^-1·min^-1 remifentanil may attenuate the stress responses better and maintained stabler internal environment.BIS monitor can evaluate the anesthetic level and guide extubation.更多还原