异丙酚靶控输注联合气管表面麻醉在婴幼儿气管支气管异物取出术中

【摘要】 目的:探讨异丙酚靶控输注联合咽喉、气管内表面麻醉应用于小儿气管支气管异物取出术的疗效，并与氯胺酮复合γ—羟基丁酸钠麻醉效果比较。方法:40例婴幼儿气管、支气管异物患儿，年龄8～36个月，体重7.5～18 kg，随机分为A组和B组。A组为异丙酚效应室靶控输注联合1%丁卡因咽喉、气管表面麻醉，B组为氯胺酮复合γ—羟基丁酸钠麻醉，观察麻醉效果、并发症和苏醒时间。结果:两组患儿均麻醉成功，全部一次顺利插入硬式支气管镜。B组患儿术中最低SpO2低于A组；支气管镜置入后发生较严重屏气、呛咳需处理的病例A组为1例，B组为5例。B组术毕全部病例发生下颌松弛和舌后坠，显著多于A组（1例）（P0.01）。术毕发生喉鸣、托下颌仍吸气困难B组12例，显著多于A组（0例）。B组患儿术毕在手术室滞留时间、苏醒时间长于A组（P0.01）。结论:异丙酚靶控输注联合气管表面麻醉是一种可控性强、安全、实用的婴幼儿气管支气管异物取出术的麻醉方法。

【关键词】 异丙酚 药物释放系统 表面麻醉 婴幼儿 气管 异物。

Abstract: Objective:To investigate the effect of propofol target controlled infusion(TCI) com—bined throat and trachea topical anaesthesia for the removal of tracheobronchial foreign body in children and compare it to ketamine combined sodium γ—hydroxybutrate anaesthesia. Methods: Forty patients, aged 8～36 months, weighted 7.5～18 kg and scheduled to be undergone removal of tracheobronchial foreign body were randomly enrolled into two groups: group A and group B. Propofol TCI combined throat and trachea topical anaesthesia with 1% decicaine was used in group A. Ketamine combined sodium γ—hydroxybutrate anaesthesia was applied in group B. Effect of anaesthesia, complication and palinesthesia time were observed. Results: Anaesthesia was successful and rigid bronchoscope was inserted smoothly at one time in all patients. The minimum SpO2 in group B was lower than that in group A（P0.01）; The severe breathholding and bucking after inserting bronchoscope were 1 case in group A and 5 in group B. Occurrence of mandibular relax and glossocoma was observed in all patients in group B, while it was only 1 in group A. It was significantly more in group B than that in group A（P0.01）. Laryngeal stridor and dyspnea in inspiration when holding mandibular were observed in 12 patients in group B and none occurred in group A. It was notablely more in group B than that in group A（P0.01）. Comparing with group A. stayed time after surgery in operating room and palinesthesia time were significantly longer in group B（P0.01）. Conclusion: Propofol TCI combined trachea topical anaesthesia is safe, practical and can be controlled for removal of tracheobronchial foreign body in children.

Key words: propofol; drug delivery systems; topical anaesthesia; infant; trachea; foreign body。

婴幼儿气管异物取出术是临床常见的急症手术，麻醉不当是引起严重并发症的原因之一[1]。气管内操作所需麻醉深度与产生明显呼吸抑制的麻醉深度接近，目前临床常用的保留自主呼吸的方法因麻醉深浅难以控制，均存在一定的缺点。本研究拟观察采用异丙酚靶控输注联合气管表面麻醉应用于婴幼儿气管支气管异物取出术的麻醉效果和安全性，并与氯胺酮复合γ—羟基丁酸钠麻醉比较。

1 资料和方法。

1.1 一般资料 经确诊为气道、支气管异物的患儿40例，随机分为A组和B组，每组20例。A组为异丙酚靶控输注＋气管表面麻醉，B组为传统静脉组，即传统氯胺酮+γ—羟基丁酸钠麻醉。排除患儿年龄36个月、异物误吸时间2 w病例和伴三凹征等严重呼吸困难病人和紫绀病人。本研究经本院伦理委员会批准，患儿家属在术前均签署知情同意书。

1.2 麻醉方法 A组合作患儿抱入手术室后开放上肢静脉，不合作患儿给予面罩吸入七氟烷麻醉，无挣扎后开发上肢静脉，静脉注射阿托品0.01 mg/kg和地塞米松5 mg。经三通在静脉输液的前端连接异丙酚靶控输注泵（北京思路高公司生产，MARSH模型），采用效应室靶控。停吸入麻醉，面罩持续给纯氧，异丙酚靶控浓度从3μg/ml开始诱导，待升到3μg/ml后依次逐步调高效应室浓度，分别为4μg/ml和5μg/ml。喉镜置入观察患儿反应，如出现挣扎等明显的对抗反应，则退喉镜，升高异丙酚效应室浓度至6μg/ml，达该浓度后再试。如果置入喉镜仍然挣扎，再升高异丙酚效应室浓度至7μg/ml，反复调整浓度，每次升高1μg/ml，一直到喉镜置入时无明显反应为合适浓度。暴露会厌、声门等结构，采用2 ml注射器按0.1 ml/kg量抽取1%丁卡因，注射器前端接16 G静脉穿刺针外套伸入口腔局麻，将半量涂抹在会厌和声门周围后，外套伸入声门下气管内注射剩余的半量行气管—支气管表面麻醉。3 min后开始手术，当外科医师将支气管镜置入气管，氧气接口与气管镜侧孔相接，调节氧流量在3～6 L/min。调整异丙酚效应室浓度至5.0 μg/ml，术中观察患儿的反应，当异丙酚效应室浓度至5μg/ml时患儿无明显挣扎反应，再次调低异丙酚浓度至3μg/ml维持。如在降低异丙酚的过程中出现反应，可在该浓度的基础上每次上调1μg/ml维持。B组合作患儿抱入手术室，不合作患儿肌注氯胺酮3 mg/kg后无挣扎抱入手术室。开放静脉后, 静脉注射阿托品0.01 mg/kg和地塞米松5 mg。静脉缓慢注射γ—羟基丁酸钠80～100 mg/kg，15 min后γ—羟基丁酸钠作用较完善时，静脉注射氯胺酮1～2 mg/kg，开始手术，置入支气管镜，氧气接口与气管镜侧孔相接，调节氧流量在3～6 L/min，术中麻醉浅，出现体动、呛咳等反应较明显时，每次给于氯胺酮1 mg/kg。

1.3 观察项目 ①记录麻醉前心率（HR）、麻醉期间的最高HR和发生心动过缓事件，记录入手术室时的经皮血氧饱和度（SpO2）、术中最低的SpO2和苏醒时的SpO2。②麻醉期间发生屏气、呛咳、发绀、喉鸣、完全性喉痉挛例数和次数。③记录两组术毕发生下颌松弛和舌后坠，需托下颌或放置口咽通气道例数，托下颌仍发生喉鸣、吸气困难例数。④记录手术时间、术毕患儿在手术室的滞留时间和苏醒时间(术毕到清醒)。

1.4 统计学处理方法 组间比较采用独立样本t检验,计数资料比较采用x2检验。