右美托咪定对小儿术后谵妄的影响及其机制研究

发布时间：2018-06-12 17:46

本文选题：右美托咪定 + 苏醒期谵妄　；参考：《安徽医科大学》2015年博士论文

【摘要】：目的：通过观察不同负荷剂量右美托咪定对腹腔镜疝修补术患儿麻醉苏醒期躁动和谵妄的影响,确定右美托咪定预防国人儿童全麻苏醒期谵妄的安全有效剂量；观察右美托咪定在儿童心内直视手术中的临床应用,探讨其减少苏醒期谵妄的可能机制。为国人儿童临床麻醉中使用右美托咪定提供理论依据。方法：第一部分：择期全麻下行腹腔镜疝修补术的100例患儿,美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级,年龄1-5岁,按计算机随机数字表随机分为4组(n=25)：C组(对照组,生理盐水)和D1、D2、D3组(右美托咪定总剂量分别为0.25、0.5、1.0μg/kg).麻醉诱导后10min内静脉泵注右美托咪定或生理盐水后开始手术。记录麻醉诱导后泵注右美托咪定前(T1)、手术开始即刻(T2)、气腹即刻(T3)、手术结束(T4)、拔喉罩时(T5)、入PACU (T6)、出PACU (T7)各时间点的心率(HR)、平均动脉压(MAP)、脉搏血氧饱和度(Sp02),从置入喉罩接麻醉机控制通气至手术结束间每5分钟为一节点,记录呼气末七氟烷浓度/MAC(SEVET/MAC)。记录并统计各组间手术时间(TS)、麻醉停药至拔喉罩时间(TE)、自主睁眼时间(TA)、在PACU的时间(TP)及术中七氟烷的用量有无差异。术后2小时内每5分钟分别使用5-point scale量表评估苏醒期躁动及谵妄,CHIPPS量表评估术后疼痛程度,统计苏醒期躁动(EA,emergency agitation)和苏醒期谵妄(ED, emergency delirium)的评分。计算两组患者EA和ED的发生率。比较两组间EA和ED的发生率有无差异；两组间术后疼痛评分有无差异；并比较两组间七氟烷的用量有无统计学差异。第二部分：择期全麻下行房、室间隔缺损心内直视修补术的50例患儿(ASAⅡ),1-6岁,体重10-25公斤,按计算机随机数字表随机分为C组和D组。麻醉诱导后分别静脉持续泵注生理盐水(C组)和右美托咪定(D组)。在术前一天8点(T0)、麻醉诱导后即刻(T1)、输注右美托咪定负荷量10分钟即刻(T2)、劈胸骨后3分钟(T3)、CPB开始即刻(T4)、心脏超滤结束即刻(T5)、术后3小时(T6)和手术后第一天8点(T7)采集患儿血液样本测定血清褪黑素(MT)、皮质醇(COR)、去甲肾上腺素(NE)、肿瘤坏死(Factor-a)、白介素-6(IL-6)、血糖(GLU)。手术后24小时内每两个小时分别采用5-point scale量表和小儿苏醒期谵妄量表(Pediatric Anesthesia Emergence Delirium scale, PAED)评估患儿谵妄的发生率和严重程度。比较两组间谵妄的发生率有无差异,并比较两组间血清褪黑素、应激反应和炎症反应指标有无差异,探讨Dex减少谵妄的发生率的机制。结果第一部分： C、D1、D2、D3组术后2小时内躁动评分分别为(3分、3分、2分、1分),躁动的发生率为45.8%、30.4%、12%、4%,苏醒期谵妄的发生率分别为29.1%、13%、4%、4%,术后CHIPPS评分分别为(8分、6分、3分、3分),与C组比较差异有统计学意义(P0.05)。C、D1、D2、D3组七氟烷的用量分别为13.21±3.36ml、 12.23±3.58ml、9.47±4.12ml(vs C组,P0.05)、9.43±3.48ml(vs C组,P0.05)。D2组TE、TA延长,D3组TE、TA、TP延长,与C组比较差异有统计学意义(P0.05)。组间比较,D1与C组各指标比较差异无统计学意义,D3与D2组比较,TE、TA延长(P0.05),TP差异无统计学意义(P0.05)。其他各观察指标组间比较差异无统计学意义(P0.05)。第二部分：与C组相比,D组的ED发病率和严重程度较低[12% vs 44%, X2=4.861, P=0.028 and 3(6～10) vs 9(8-12), Z=-2.597, P=0.009],且血清褪黑素的波动幅度显著降低；血清NE、IL-6、TNF-a和GS水平在两组均明显增加,但D组的增加幅度显著降低；D组的七氟烷用量显著减少(15.5±3.4 vs19.8±4.2ml,P=0.00020.01)；两组的术后镇痛评分无差异[3(3～4)vs 3(3～4),P=0.502],但D组的术后芬太尼的用量较少[1.7±0.8 vs 2.1±0.5 μg/kg,p=0.04],术后D组的拔管时间略有延长(*t=2.215,P=0.0320.05),但CICU停留时间和住院时间无统计学意义。结论：一：腹腔镜疝修补术中应用右美托咪定,能够有效降低患儿手术后躁动及苏醒期谵妄的发生率,改善术后疼痛评分并减少术中七氟烷的用量,且以0.5μg/kg Dex剂量组安全有效,对血流动力学影响小。二：在小儿心内直视修补术中持续输注右美托咪定可以减少小儿心内直视修补术后苏醒期谵妄的发生,其机制包括减少血清褪黑激素水平的波动,减少应激反应和炎症反应。
[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.
【学位授予单位】：安徽医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R726.1

【参考文献】