【作者】 金梅花；

【导师】 李少岩；

【作者基本信息】 延边大学 ， 麻醉学， 2007， 硕士

【摘要】 【目的】：探讨七氟醚复合瑞芬太尼麻醉在小儿扁桃体切除术中的麻醉效果及其可行性。【方法】：选择40例ASAⅠ～Ⅱ级拟行扁桃体切除腺样体刮除术的小儿，年龄6～12岁，随机分为七氟醚组（S组，n=20）、异丙酚组（P组，n=20）。麻醉诱导：S组面罩法吸入8％七氟醚，待患儿意识消失后静注瑞芬太尼2μg／kg，罗库溴铵0.6mg／kg，地塞米松0.1 mg／kg，吸入七氟醚浓度减为3％～4％控制呼吸行气管插管。P组静注异丙酚2.5 mg／kg，瑞芬太尼2μg／kg，罗库溴铵0.6mg／kg，地塞米松0.1 mg／kg，行气管插管。麻醉维持：S组吸入2～3％七氟醚复合瑞芬太尼0.25μg／kg.min。P组异丙酚7～9 mg／kg.h，瑞芬太尼0.25μg／kg.min泵入。两组在诱导过程及麻醉维持中，BIS值控制在45～55范围内，MAP控制在（60～90mmHg）、HR控制在（80～120次／min）范围内，P_ETCO₂维持在35～45 mmHg。观察指标：麻醉诱导时意识消失时间、行静脉穿刺时配合程度、有无咳嗽、呕吐，暴露声门时有无喉痉孪、躲闪、肢体运动的发生、分泌物情况及插管时声门暴露情况，并记录麻醉诱导时间，患儿麻醉诱导前5min（T₁）、气管插管前即刻（T₂）、气管插管后即刻（T₃）、1min（T₄）、3min（T₅）、5min（T₆）、腺样体刮除时（T₇）、术毕拿出开口器（T₈）、八个时点的MAP、HR、SpO₂变化，并且分别在T₁、T₂、T₆、T₇、T₈五个时间段监测ACTH和ANP。术后记录呼吸恢复时间，呼之睁眼时间、拔管时间、完全清醒时间，以及拔管后5min的意识状态OAAS评分及对患儿进行术后访视，观察有无术中知晓、术后疼痛程度，以及恶心、呕吐、分泌物情况、躁动、等不良反应发生率。【结果】：在麻醉诱导过程中，40例患儿均配合，诱导中均无呕吐、喉痉挛、体动、呛咳、屏气等不良反应，声门暴露40例均优，P组插管时分泌物明显多于S组（P＜0.05），P组大多数患儿静脉及输注异丙酚时明显感到疼痛（P＜0.05）。两组内T₂、T₃、T₄、T₅、T₆与T₁比较血压明显降低（P＜0.05），两组内T₂与T₁比较HR降低（P＜0.05），两组内T₂、T₆、T₇、T₈与T₁比较ACTH无统计学差异（P＞0.05），两组内T₂与T₁比较ANP有统计学差异（P＜0.05）。两组间MAP、HR、ACTH、ANP均无统计学差异（P＞0.05）。S组患儿术后呼吸恢复时间、睁眼睛时间、拔管时间均比P组短，有统计学差异（P＜0.05），P组术后分泌物明显多于S组有统计学差异（P＜0.05），两组术后随访皆无术中知晓，但大多数患儿感到术区中度疼痛，两组VAS评分无统计学差异（P＞0.05）。【结论】：1通过面罩法七氟醚吸入诱导应用方便、具有无创伤、不增加分泌物、无疼痛等特点，比静脉穿刺更易被小儿接受。2七氟醚复合瑞芬太尼麻醉术后苏醒迅速，无术后不良反应，不增加气道分泌物，有助于术后呼吸道通畅，便于咽喉部术后呼吸道管理。更多还原

【Abstract】 Objective To evaluate the effect and feasibility of sevoflurane inhalation anesthesia combined with remifentanil intravenous anesthesia inchildren undergoing tonsillectomy. Methods Forty patients（aged 6-12 yr）, ASA statusⅠ-Ⅱ, undergoing tonsillectomy were randomly divided into two groups:the sevoflurane group（S group, n=20）and the propofol group（P group, n=20）.In the S group, anesthesia induction was with 8% sevoflurane before remifentanil 2μg/kg, rocuronium 0.6mg/kg and Dexamethasone 0.1 mg/kg infusion, whereas in the P group propofol 2.5 mg/kg,remifentanil 2μg/kg, rocuronium 0.6mg/kg and Dexamethasone 0.1 mg/kgwas administered. After tracheal intubation, the patients received 2～3% sevoflurane with remifentanil 0.25μg/kg. min or propofol 7～9 mg/kg.h with remifentanil 0.25μg/kg. min for anesthesia maintenance. During anesthesia induction and maintenance, the range of BIS was from 45 to 55, MAP was from 60mmHg to 90mmHg, HR was from 80 to 120and P_ETCO₂ wasfrom 35mmHg to 45mmHg. At the same time, Extinction time of lash reflex and status of cough, vomit, larynx spasm, escape, extremity movement, secretion and glottis exposure were observed. The variations of MAP, HR and SpO₂ were recorded at eight time points:five minutes before anesthesia induction（T1）,the moment just before intubation（T2）,the moment just after intubation（T3）,one minute after intubation（T4）,three minutes after intubation（T5）,five minutes after intubation（T6）,the moment when resecting the tonsil（T7） and the moment just after the operation（T8）.The levels of ACTH and ANP were also recorded at T1, T2, T6, T7 andT8. After the operation, we evaluated all kinds Of parameters of postoperative recovery. Results During the tracheal intubation, there was more secretions in the R group than in the P group（P＜0.05）.Most of patients in the R group felt painful obviously when propofol was administered（P＜0.05）.In the R group and P group, the blood pressure at T2, T3, T4, T5 and T6 was lower than at T1 （P＜0.05）,the HR at T2 was less thanat T1（P＜0.05）,the levels of ACTH at T2, T6, T7, T8 and T1 were similar（P＞0.05） and the ANP at T2 and T1 had statistical differences（P＜0.05）.There were no statistical differences in MAP, HR, ACTH and ANP between the R group and P group（P＞0.05）. The time of postoperative recovery ofthe S group was shorter than the P group （P＜0.05） and postoperative secretions was less than the P group （P＜0.05）.Conclusions 1. anesthesia induction by sevoflurane combined with remifentanil is convenient, painless and does not augment secretion. It is easy to be accepted by children. 2. sevoflurane-remifentanil anesthesia is convenient in the respiratory tract administration after tonsillectomy.更多还原