【Keywords】 dexmedetomidine nasal drops; Midazolam; Ketamine; Pediatric surgery
With the development of medical anesthesia technology, to reduce the dysphoria of pediatric anesthesia patients before operation and to maintain the stability of hemodynamics during operation, to shorten the residence time of anesthesia and resuscitation room as far as possible, and to speed up the recovery of children Attract great attention from anesthesiologists [1]. Dexmedetomidine is a highly selective α2- adrenoceptor agonist with sedative, analgesic, anti-sympathetic, and hemodynamic stabilizing effects. Its conscious sedation during anesthesia is similar to natural sleep and has no respiratory depression. Midazolam belongs to benzodiazepines and can produce anxiolytic, sedative, hypnotic, anticonvulsant and muscle relaxation effects. Intravenous injection of Midazolam may cause respiratory depression and blood pressure reduction in some patients. Ketamine, as a traditional pediatric intravenous anesthetic, is a non-barbiturate sedative and analgesic drug that acts on the central nervous system. Ketamine can increase sympathetic activity, plasma catecholamine, heart rate, blood pressure, peripheral vascular resistance, pulmonary artery pressure and pulmonary vascular resistance. Ketamine can also increase the secretion of mucus in oral cavity and trachea and other side effects such as respiratory depression. This study provides reference for clinical medication by comparing effect of the dexmedetomidine nasal drops, midazolam and ketamine applied to preoperative sedation in children.
Data and Methods
General information The general data were approved by the Ethics Committee of Wuzhou Red Cross Hospital and informed consent by the patient's family members. From May 2016 to May 2019, 150 children with 86 males and 64 females, 3-7 years old, 15-30kg weight and I-II grade ASA were randomly selected for surgical treatment under general anesthesia in our hospital. Exclusion criteria: the patients with a history of opioid anesthesia allergy or hypersensitivity;the patients with a history of cold and fever one week before the operation. the patients Suffering from congenital diseases; the patients with Obese and stunted children.The patients were randomly divided into 3 groups (50 cases in each group). Sedation before anesthesia, 50 cases in group D received dexmedetomidine nasal drops (1.0ug/kg), 50 cases in group M received midazolam intravenous injection (0.08mg/kg), and 50 cases in group K received ketamine intravenous injection (1mg/kg).
Anesthesia methods Routine fasting for 6 hours and no drinking for 4 hours were performed before anesthesia. Atropine (0.01 mg/kg) was injected intramuscularly at 30min before anesthesia. Intravenous access was established before entering the room. 5% glucose was injected intravenously at a rate of 10～20ml·kg-1·h-1. Sedation was performed before entering the room. 50 patients in group D received dexmedetomidine nasal drops (1.0ug/kg), 50 patients in group M received midazolam intravenous injection (0.08mg/kg), and 50 patients in group K received ketamine intravenous injection (1mg/kg). Under of the condition of Room temperature 24～26℃, BP, ECG, SpO2, PETCO2, BIS, body temperature and urine volume were monitored. Anesthesia induction: Propofol (3mg/kg) and remifentanil (1.5ug/kg) were injected intravenously in the three groups. Cisatracurium (0.1 mg/kg) was injected intravenously after the eyelash reflex disappeared. 3 minutes later, tracheal intubation was performed for mechanical ventilation. Anesthesia maintenance: propofol 4～6mg·kg-1·h-1, remifentanil 9～12ug·kg-1·h-1, intravenous administration of cisatracurium were performed intermittently according to the intraoperative situation. Inhaled oxygen concentration is 60%, oxygen flow rate is 1.5～2.0L/min, respiratory frequency is R 20～22 times/min, and tidal volume is 6～10ml/kg, I: E1: 2. The end-of-breath carbon dioxide partial pressure is maintained at 35～45 mmHg, BIS value is 40～60, anesthetic rate is adjusted according to intraoperative BIS value, and respiratory parameters are adjusted according to arterial blood gas analysis. All narcotic drugs were stopped at the end of the operation.
Observation index The records were used to compare the recovery time T1, recovery time T2, extubation time T3, recovery room residence time, incidence rate of adverse reactions (drowsiness, nausea and vomiting, postoperative restlessness). MAP and HR of the three groups patients were also compared at T1, T2 and T3 time.
Statistical analysis Statistical analysis was performed using SPSS16.0 statistical software.Measurement data are expressed by mean standard deviation （x±s）, and t test is compared between groups. Chi-square test was used to compare the counting data. P <0.05 shows statistically significant.
Result
A total of 150 patients were included in this study, 50 cases in each group. no significant difference was observed in gender, age, height, weight, ASA grade and operation time among the three groups (Table 1). The recovery time, recovery time, extubation time and recovery chamber residence time in group D were shorter than those in group M and group K, and the difference was statistically significant (P <0.05) (Table 2). The incidence of adverse reactions in group D was lower than that in group M and group K, and the difference was statistically significant (P <0.05) (Table 3). MAP and HR in group D patients were lower at times T1, T2 and T3 than those in group M and group K, and the difference was statistically significant (P <0.05) (Table 4).
Table 1 Comparison of General Data of Three Groups of Patients
Table 2 comparison of recovery time of spontaneous respiration, awakening time, extubation time and residence time in resuscitation room among the three groups of patients
Table 3 Comparison of Postoperative Sleepiness, Nausea and Vomiting and Postoperative Agitation among Three Groups of Patients
Table 4 Comparison of MAP and HR of Three Groups of Patients at T1, T2 and T3
Discuss
With the continuous improvement of people's health awareness and medical level, people's requirements for preoperative anesthesia have risen from the reduction of initial pain to the Reduction of side effects and adverse reactions and the length of patients' waking time, extubation time and recovery room residence time during the operation. Especially the children patients with small age, show emotional fluctuations during treatment because of their fear, anxiety, etc. Furthermore, they show dysphoria, crying, fidgeting, which is not easy to cooperate with medical staff. The occurrence of agitation will also affect the process of surgery. Therefore, in the selection of anesthetic drugs for children, the side effects of anesthetic drugs should also be avoided from harming children[2], except the sedative and analgesic effects of anesthesia time need to ensure.
Clinical workers tried their best for Children's sedation and analgesia, and the domestic pharmaceutical enterprises can provide more choices for children's comfortable medical treatment[3]. Dexmedetomidine, midazolam and ketamine can be almost used in all sedation and analgesia ways,which provided better combination of children's sedation and analgesia for clinical use. However, the midazolam and ketamine has some inevitable adverse reactions, such as hypotension, lethargy, delirium, hallucination, palpitation, rash,hyperventilation, respiratory depression, etc.Therefore, how to select a comfortable and safer drug is very significant for the anesthesiologists.
Dexmedetomidine with anti-sympathetic, sedative and analgesic effects shows stronger electivity for central α2- adrenoceptor excitation, which is 8 times higher than clonidine for α2- adrenoceptor. Alpha 2a receptor subtypes play an important role in mediating pharmacological and therapeutic effects of Dexmedetomidine. Alpha 2a receptor exists in presynaptic and postsynaptic areas, which mainly inhibits the release of norepinephrine and holds back the transmission of pain signals by exciting α2 receptor in presynaptic membrane. Dexmedetomidine inhibits sympathetic nerve activity by activating postsynaptic membrane receptors, thus causing a decrease in blood pressure and heart rate[4]; When combined with α2 receptor in spinal cord to produce analgesic effect, it can cause sedation and anxiety relief. Dexmedetomidine can also reduce the dosage of other anesthetics, improve the stability of hemodynamics during surgery and reduce the incidence of myocardial ischemia[5-6]. Some experts at home and abroad in the study of dexmedetomidine nasal drops found that, 1.5～2 ug/kg of dexmedetomidine were given for 5～10kg of children and 2.5-3 ug/kg were given for above 11kg children. This dosage range has little effect on the heart rate and blood pressure of children, and can achieve better sedative effect.
Dexmedetomidine can also show good effects on shivering inhibition, heat production and hypothermia risks. In a prospective study, 24 children with 7 years old shivered after general anesthesia. Dexmedetomidine was injected intravenously at 0.5 ug/kg. All children stopped shaking within 5 minutes without relapse[7-8]. At the same time, dexmedetomidine is also a better anesthetic which can not only maintain good spontaneous breathing, but also give sedation and analgesia, inhibit strong stress response, leaving anesthesiologists more time and space to complete tracheal intubation of difficult airway[9].
In this study, we found that the recovery time, extubation time, recovery chamber residence time, and the average arterial pressure and heart rate changes of the children who used dexmedetomidine as sedation and analgesia before anesthesia were significantly lower than those of the children who were given midazolam and ketamine before anesthesia. These indicated that the effect of dexmedetomidine anesthesia on hemodynamics of the children was relatively small and statistically significant (P <0.05). The incidence rate of adverse reactions such as lethargy, restlessness, nausea and vomiting after operation was also significantly lower than that of children using midazolam and ketamine, which was statistically significant (P <0.05). This further illustrates the advantages of dexmedetomidine in pediatric anesthesia.
Dexmedetomidine has good sedative and analgesic effects, without respiratory depression and addiction. Meanwhile, it has little adverse effect on the hemodynamics of patients and is safe and reliable. This anesthetic can be widely used in clinic.
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论文作者:WANG Yun-jie, HUANG Sheng, FU
论文发表刊物:《中国结合医学》2019年10期
论文发表时间:2019/12/10
标签：小儿论文; 外科论文; 中国论文; 杂用论文; 学杂志论文; 全麻论文; 杂志论文; 《中国结合医学》2019年10期论文;