本文選題：右美托咪定 + 蘇醒期譫妄　； 參考：《安徽醫(yī)科大學》2015年博士論文

【摘要】：目的：通過觀察不同負荷劑量右美托咪定對腹腔鏡疝修補術(shù)患兒麻醉蘇醒期躁動和譫妄的影響,確定右美托咪定預防國人兒童全麻蘇醒期譫妄的安全有效劑量；觀察右美托咪定在兒童心內(nèi)直視手術(shù)中的臨床應用,探討其減少蘇醒期譫妄的可能機制。為國人兒童臨床麻醉中使用右美托咪定提供理論依據(jù)。方法：第一部分：擇期全麻下行腹腔鏡疝修補術(shù)的100例患兒,美國麻醉醫(yī)師協(xié)會(ASA)分級Ⅰ～Ⅱ級,年齡1-5歲,按計算機隨機數(shù)字表隨機分為4組(n=25)：C組(對照組,生理鹽水)和D1、D2、D3組(右美托咪定總劑量分別為0.25、0.5、1.0μg/kg).麻醉誘導后10min內(nèi)靜脈泵注右美托咪定或生理鹽水后開始手術(shù)。記錄麻醉誘導后泵注右美托咪定前(T1)、手術(shù)開始即刻(T2)、氣腹即刻(T3)、手術(shù)結(jié)束(T4)、拔喉罩時(T5)、入PACU (T6)、出PACU (T7)各時間點的心率(HR)、平均動脈壓(MAP)、脈搏血氧飽和度(Sp02),從置入喉罩接麻醉機控制通氣至手術(shù)結(jié)束間每5分鐘為一節(jié)點,記錄呼氣末七氟烷濃度/MAC(SEVET/MAC)。記錄并統(tǒng)計各組間手術(shù)時間(TS)、麻醉停藥至拔喉罩時間(TE)、自主睜眼時間(TA)、在PACU的時間(TP)及術(shù)中七氟烷的用量有無差異。術(shù)后2小時內(nèi)每5分鐘分別使用5-point scale量表評估蘇醒期躁動及譫妄,CHIPPS量表評估術(shù)后疼痛程度,統(tǒng)計蘇醒期躁動(EA,emergency agitation)和蘇醒期譫妄(ED, emergency delirium)的評分。計算兩組患者EA和ED的發(fā)生率。比較兩組間EA和ED的發(fā)生率有無差異；兩組間術(shù)后疼痛評分有無差異；并比較兩組間七氟烷的用量有無統(tǒng)計學差異。第二部分：擇期全麻下行房、室間隔缺損心內(nèi)直視修補術(shù)的50例患兒(ASAⅡ),1-6歲,體重10-25公斤,按計算機隨機數(shù)字表隨機分為C組和D組。麻醉誘導后分別靜脈持續(xù)泵注生理鹽水(C組)和右美托咪定(D組)。在術(shù)前一天8點(T0)、麻醉誘導后即刻(T1)、輸注右美托咪定負荷量10分鐘即刻(T2)、劈胸骨后3分鐘(T3)、CPB開始即刻(T4)、心臟超濾結(jié)束即刻(T5)、術(shù)后3小時(T6)和手術(shù)后第一天8點(T7)采集患兒血液樣本測定血清褪黑素(MT)、皮質(zhì)醇(COR)、去甲腎上腺素(NE)、腫瘤壞死(Factor-a)、白介素-6(IL-6)、血糖(GLU)。手術(shù)后24小時內(nèi)每兩個小時分別采用5-point scale量表和小兒蘇醒期譫妄量表(Pediatric Anesthesia Emergence Delirium scale, PAED)評估患兒譫妄的發(fā)生率和嚴重程度。比較兩組間譫妄的發(fā)生率有無差異,并比較兩組間血清褪黑素、應激反應和炎癥反應指標有無差異,探討Dex減少譫妄的發(fā)生率的機制。結(jié)果第一部分： C、D1、D2、D3組術(shù)后2小時內(nèi)躁動評分分別為(3分、3分、2分、1分),躁動的發(fā)生率為45.8%、30.4%、12%、4%,蘇醒期譫妄的發(fā)生率分別為29.1%、13%、4%、4%,術(shù)后CHIPPS評分分別為(8分、6分、3分、3分),與C組比較差異有統(tǒng)計學意義(P0.05)。C、D1、D2、D3組七氟烷的用量分別為13.21±3.36ml、 12.23±3.58ml、9.47±4.12ml(vs C組,P0.05)、9.43±3.48ml(vs C組,P0.05)。D2組TE、TA延長,D3組TE、TA、TP延長,與C組比較差異有統(tǒng)計學意義(P0.05)。組間比較,D1與C組各指標比較差異無統(tǒng)計學意義,D3與D2組比較,TE、TA延長(P0.05),TP差異無統(tǒng)計學意義(P0.05)。其他各觀察指標組間比較差異無統(tǒng)計學意義(P0.05)。第二部分：與C組相比,D組的ED發(fā)病率和嚴重程度較低[12% vs 44%, X2=4.861, P=0.028 and 3(6～10) vs 9(8-12), Z=-2.597, P=0.009],且血清褪黑素的波動幅度顯著降低；血清NE、IL-6、TNF-a和GS水平在兩組均明顯增加,但D組的增加幅度顯著降低；D組的七氟烷用量顯著減少(15.5±3.4 vs19.8±4.2ml,P=0.00020.01)；兩組的術(shù)后鎮(zhèn)痛評分無差異[3(3～4)vs 3(3～4),P=0.502],但D組的術(shù)后芬太尼的用量較少[1.7±0.8 vs 2.1±0.5 μg/kg,p=0.04],術(shù)后D組的拔管時間略有延長(*t=2.215,P=0.0320.05),但CICU停留時間和住院時間無統(tǒng)計學意義。結(jié)論：一：腹腔鏡疝修補術(shù)中應用右美托咪定,能夠有效降低患兒手術(shù)后躁動及蘇醒期譫妄的發(fā)生率,改善術(shù)后疼痛評分并減少術(shù)中七氟烷的用量,且以0.5μg/kg Dex劑量組安全有效,對血流動力學影響小。二：在小兒心內(nèi)直視修補術(shù)中持續(xù)輸注右美托咪定可以減少小兒心內(nèi)直視修補術(shù)后蘇醒期譫妄的發(fā)生,其機制包括減少血清褪黑激素水平的波動,減少應激反應和炎癥反應。
[Abstract]:Objective: to determine the safe and effective dose of right metomomidin in the prevention of waking delirium in children of Chinese children by observing the effects of dexmedetomidin on the restlessness and delirium during the anaesthesia of children with laparoscopic herniorrhaphy, and to observe the clinical application of right metomomidin in children's open heart surgery and to explore the reduction of the awakening period. The possible mechanism of delirium provides a theoretical basis for the use of dexmedetomidine in clinical anesthesia for Chinese children. Methods: Part 1: 100 cases of laparoscopic herniorrhaphy under general anesthesia under general anesthesia, the American anesthesiologist Association (ASA) grade I to class II, age 1-5 years, randomly divided into 4 groups (n=25):C group according to the computer random number table (control group, Physiological saline) and D1, D2, D3 group (total dose of right metomomidin was 0.25,0.5,1.0 mu g/kg respectively). After anesthesia induction, 10min internal intravenous infusion of right metomomidin or saline was started. Before anesthesia induction, right metodetonidine (T1) was recorded, operation began immediately (T2), pneumoperitoneum immediate (T3), operation end (T4), laryngeal mask (T5), into PACU (T5), The heart rate (HR) at each time point of PACU (T7), mean arterial pressure (MAP), pulse oxygen saturation (Sp02), a node from insertion of the laryngeal mask anesthesia machine to the end of the operation to the end of the operation, and the concentration of /MAC (SEVET/MAC) at the end of the exhalation at the end of the expiratory, recorded and unified the operation time of each group (TS), the anesthetic stopped to the laryngeal mask time (TE) and independent opening. Eye time (TA), the time (TP) and the dosage of seven fluorane during the operation were not different. 2 hours after the operation, the 5-point scale scale was used to evaluate the restlessness and delirium in the awakening period. The CHIPPS scale was used to assess the degree of postoperative pain, and the score of the awakening stage agitation (EA, emergency agitation) and the awakening delirium (ED, emergency delirium) were counted. The incidence of EA and ED in the two groups was compared. There were no differences in the incidence of EA and ED among the two groups; there was no difference in postoperative pain scores between the two groups; and there was no statistical difference in the dosage of seven fluorane among the two groups. The second part: 50 cases of ventricular septal defect (ASA II), 1-6 years of age, and weight 10-25 Kilograms, randomly divided into C group and D group according to the computer random number table. After anesthesia induction, the intravenous infusion of normal saline (group C) and right metomomidine (group D). 8 points (T0) a day before the operation, immediately after anesthesia induction (T1), right metodetonidine load for 10 minutes (T2), 3 minutes after splitting the sternum (T3), CPB begin immediately (T4), cardiac ultrafiltration junction Serum melatonin (MT), cortisol (COR), norepinephrine (NE), tumor necrosis (Factor-a), leukin -6 (IL-6), and blood glucose (GLU) were measured at 3 hours (T6) and 8 (T7) after the first day after the operation (T7). The 5-point scale scale and the awakening delirium scale were used every two hours within 24 hours after the operation. Ediatric Anesthesia Emergence Delirium scale, PAED) assessment of the incidence and severity of delirium in children. Compare the incidence of delirium among the two groups, and compare the differences in the serum melatonin, stress response and inflammatory response between the two groups, and explore the mechanism of Dex reduction of delirium. Results the first part: C, D1, D2, D3. The agitation scores in 2 hours after 2 hours were respectively (3, 3, 2, 1). The incidence of agitation was 45.8%, 30.4%, 12%, 4%. The incidence of delirium in the awakening period was 29.1%, 13%, 4%, 4%, respectively, and the CHIPPS scores were statistically significant (P0.05).C, D1, D2, and D3 group, respectively. Ml, 12.23 + 3.58ml, 9.47 + 4.12ml (vs C group, P0.05), 9.43 + 3.48ml (vs C group, P0.05).D2 group TE. There was no significant difference between the observation groups (P0.05). Second: compared with the C group, the incidence and severity of ED in group D were lower than [12% vs 44%, X2=4.861, P=0.028 and 3 (6~10) vs 9 (8-12), Z=-2.597, P=0.009], and the level of serum melatonin significantly decreased in two groups. Addition, the increase of D group was significantly reduced, and the dosage of seven fluorane in group D decreased significantly (15.5 + 3.4 vs19.8 + 4.2ml, P=0.00020.01), and there was no difference between [3 (3~4) vs 3 (3~4), P=0.502] in the two group, but the dosage of fentanyl in group D was less [1.7 + 0.8 vs 2.1 + 0.5 mu g/kg. =2.215, P=0.0320.05), but there is no statistical significance in CICU stay time and time of hospitalization. Conclusion: first, the application of dexmedetomidin in laparoscopic herniorrhaphy can effectively reduce the incidence of postoperative agitation and waking delirium in children, improve postoperative pain score and reduce the dosage of seven Fluoroalkane in the operation, and it is safe to be in the 0.5 g/kg Dex dose group. The effect on hemodynamics is small. Two: continuous infusion of right metoamidin in pediatric open heart repair can reduce the occurrence of waking delirium in children after open heart repair. The mechanism includes reducing the fluctuation of serum melatonin level, reducing stress response and inflammatory response.
【學位授予單位】：安徽醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R726.1

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