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【摘要】 目的 对比短时效阿片类药物-瑞芬太尼与芬太尼对小儿斜视术后呕吐和疼痛的作用的差别。方法 60名ASA I～II级,2～12岁择期在全麻下行斜视纠正术的小儿,随机分为两组,R组(瑞芬太尼)与F组(芬太尼)。术后记录25 h呕吐事件。苏醒后60 min记录疼痛评分。结果 两组术后呕吐发生率没有统计学差异(49% vs 48%)。但是R组术后呕吐频率较F组低(0.95 vs 2.2)。苏醒后头30 min,F组术后疼痛评分较低。结论 平衡全麻下小儿斜视术后,瑞芬太尼组术后呕吐发生频率较少,但芬太尼组对术后早期镇痛效果较好。
【关键词】 瑞芬太尼;芬太尼;术后恶心呕吐;疼痛;斜视手术
A comparison of remifentanil and fentanyl for postoperative vomiting and pain after strabismus surgery
CHEN Ying,LIAO Zhijie,CHEN Qianru,et al.Department of Anesthesiology,Zhongshan Ophthalmology Ceater of Zhongsshan University Guangzhou 510600,China
【Abstract】 Objective To compare the effect of remifentanil with fentanyl on postoperative vomiting and pain in children undergoing strabismus surgery. Methods 60 ASA status I or II children from 2~12 years undergoing elective strabismus surgery under general anesthesia. Children were randomized to receive either remifentanil (Group R) or fentanyl (Group F). POV episodes were recorded for 25 hour. pain scores were obtained by using an objective pain scale for 60 min during recovery. Results The number of patients who experienced POV did not differ significantly between groups(49% vs 48%). However, in the group R, POV episodes were significantly less frequent(0.95 vs 2.2). In contrast, fentanyl was associated with lower pain scores during the first 30 min of recovery. ConclusionChild undergoing strabismus surgery under balanced anesthesia with remifentanil, compared with fentanyl, shows less frequent POV. However, early postoperative analgesia is better with fentanyl.
【Key words】 Remifentanil;Fentanyl;PONV;Pain;Strabismus surgery
小儿行斜视术后常出现呕吐。由于不同麻醉技术、抗呕吐治疗及手术时间和类型、患者个体差异的差别,发生率为15%～75% [1]。术后恶心呕吐增加患者痛苦,增加住院率[2]。
围术期阿片类药物的应用显著增加了术后呕吐的发生,且与剂量有关[3]。小儿斜视纠正术,静脉应用吗啡诱导较酮络酸术后呕吐发生率明显增加(71% vs 9%)[4]。瑞芬太尼具有酯键,因而结构独特。酯键易被血和组织中的非特异性酯酶消解,导致其代谢迅速,时-量相关半衰期3～4 min。与长效阿片类药物相比,瑞芬太尼超短半衰期的特点对小儿斜视术后呕吐发生率的影响尚未明确。本研究旨在对比瑞芬太尼与芬太尼对术后呕吐及疼痛的影响,以寻找小儿斜视手术的最佳麻醉药物。
1 资料与方法
1.1 一般资料 60例ASA I～II级择期行斜视纠正术小儿,年龄2～12岁(男42例,女39例),随机分为两组:R组(瑞芬太尼)和F组(芬太尼)。有术后呕吐病史、运动疾病或恶性高热高危人群排除在外。
1.2 治疗方法 患儿术前口服咪唑安定0.4 mg/kg(最大剂量10 mg)。建立静脉通道后,监测ECG、NIBP、SO2,静脉注射阿托品10 μg/kg。根据Song等[5]和Guy等[6]的研究确定瑞芬太尼和芬太尼的用量。瑞芬太尼诱导量1 μg/kg,静脉注射时间2 min,以0.2 μg/kg/min维持,切皮后降为0.1 μg/kg/min,缝合结膜时停药。芬太尼组诱导量2 μg/kg,术中每45 min追加1 μg/kg。两组患儿除阿片类药物区别外,均采用6%七氟烷面罩吸入诱导,至意识消失后给予罗库溴铵0.6 mg/kg,行气管插管。吸入七氟烷维持麻醉,保持呼气末浓度2.5%。缝合结膜时,停止吸入麻醉药。未使用抗呕吐药。术后,给予肌松拮抗剂。待自主呼吸满意,气管反射恢复,拔除气管导管,患者转入PACU。
1.3 术后25 h记录呕吐事件。呕吐定义为胃内容物从口腔的溢出。间隔超过10 min以上视为下一次呕吐。若发生呕吐,根据患者体质量不同,静脉给予0.1 mg/kg托烷司琼,2 h后若无改善,可重复用药。术后15、30、45、60 min进行疼痛评估(VAS)。术后疼痛评分若>3分,用爱尔卡因滴眼。记录者不知道给药方案。
1.4 统计学方法 应用SPSS 11.0统计软件进行分析,计量资料以均数±标准差(x±s)表示,计量资料不同时点间比较采用单因素方差分析,POV组间比较采用t检验。P 本研究中,瑞芬太尼组术后呕吐发生率明显减少。虽然两组小儿术后25 h内呕吐例数接近,但瑞芬太尼组患儿呕吐次数较芬太尼明显减少(20:47)。本研究中未涉及出院时间或收入院例数等相关临床指标,因为所有患儿离开复苏室后均留院观察至少24 h。
有趣的是两组患儿夜间几乎均无呕吐发生。可能是因为睡眠中,没有一些增加呕吐发生的因素如体动引起的前庭刺激、疼痛、进食等。而且斜视术后引起呕吐的一大原因是视轴的变化,而睡眠中这一因素也不存在。本研究显示了一种术后呕吐发生的昼夜节律,夜间几乎没有呕吐发生。
拔管后即时瑞芬太尼组疼痛评分较高,但是30 min后两组患儿疼痛评分无统计学差异,因为当患儿疼痛评分较高时,则给予爱尔卡因滴眼。
综上所述,R组患者较F组患者术后呕吐发生率明显减少,但术后30 min内疼痛较明显。如果采用疼痛的补救药物,术后30 min后疼痛明显减轻。瑞芬太尼麻醉是一种较适合用于小儿眼科的阿片类药物。
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