脑电双频指数在先天性心脏病患儿镇静程度评估中的运用

目的 评价和分析脑电双频指数(bispectral index,BIS)与舒适行为最表(COMFORT behavior scale,COMFORT B)相关性,探讨运用BIS评估6个月～2岁先天性心脏病患儿术后镇静程度的意义.方法 采用前瞻性研究方法选择50例先天性心脏病术后接受镇静治疗的患儿.两位研究者在预定的监测时间点同步、独立记录BIS值和使用COMFORTB量表评估患儿镇静程度,共获得375例次观察数据.运用Spearman等级相关和预测概率分析BIS与COMFORT B量表之间的相关性,判断BIS预测不同镇静程度的准确性.结果 COMFORT B量表评分各等级(镇静过度、镇静适度和镇静不足)对应的BIS值分别为57.0±11.0、69.9±7.6和84.4±9.0.BIS值与COMFORT B量表等级评分呈中度相关(rs =0.63,P＜0.0001).其中6个月～1岁组rs为0.66,1～2岁组rs为0.59(P均＜0.0001).反映BIS能够正确预测不同镇静程度的预测概率值为0.85(P ＜0.0001).结论 BIS是一项能准确、有效监测6个月～2岁先天性心脏病患儿术后镇静程度的客观指标.     

简化COMFORT量表评估机械通气患儿镇静水平的信度和效度

目的探索采用简化COMFORT量表评估机械通气患儿镇静水平时,不同评价者之间以及与脑电双频指数(BIS)的一致性,从而确定其信度、效度和临床应用前景。方法以重症监护病房3~16岁接受机械通气和镇静治疗的患儿为研究对象,以简化COMFORT量表(不包括心率和血压)进行镇静分层评估,同时记录BIS监测数值。由4名专业医师独立完成评估,计算评估者相互之间Kappa值,分析简化COMFORT量表与BIS结果之间相关性。结果共纳入20例患儿,进行了70次评估。4名评分者相互之间的Kappa值为0.62~0.77(P0.001);简化COMFORT量表与BIS结果之间成正相关(r=0.53~0.61,P均0.01)。结论简化COMFORT量表在不同的评价者以及与BIS之间均显示出较高的一致性,具有较好的信度和效度,可用于机械通气患儿镇静水平评估。     

动态监测血乳酸与小儿危重病例评分的相关性

目的 探讨动态监测PICU患儿血乳酸与小儿危重病例评分(PCIS)的相关性.方法 对77例入住南通大学附属常州儿童医院儿科重症监护病房的患儿立即进行PCIS,根据评分结果分为极危重组(23例)、危重组(32例)、非危重组(22例).并检测患儿动脉血乳酸水平,每6 h监测1次,并测出乳酸峰值.比较各组间乳酸监测指标(入PICU乳酸水平、乳酸峰值)和PCIS,进行相关性分析,探讨其与患儿预后的相关性.结果 极危重组血乳酸水平:入PICU时乳酸[(5.28±3.69) mmol·L-1]、乳酸峰值[(8.54±4.32) mmol·L-1]明显高于危重组和非危重组(F=3.98,3.12,Pa<0.01),而PCIS[(65.79±2.34) 分]明显低于其他2组(F=4.23,P<0.01);死亡组 PCIS[(62.35±4.22) 分]低于存活组[(89.21±5.36) 分](t=3.15,P<0.01),而血乳酸水平[(5.31±4.05) mmol·L-1]高于存活组[(3.22±2.13) mmol·L-1](t=2.32,P<0.05);PCIS与血乳酸水平呈负相关(r=-0.889,P<0.01).结论 血乳酸升高的PICU危重患儿病情更重、预后更差,PCIS评分可有效评估患儿的病情和预后,并与乳酸水平存在显著负相关.动态监测血乳酸水平是反映危重病患儿病情严重程度和预测患儿转归的较好指标.     

儿科机械通气时咪唑安定血药浓度与镇静效应的研究

目的探讨机械通气患儿应用咪唑安定(MDZ)的理想血药浓度及与镇静深度间的相关关系。方法28例需机械通气患儿,首先予MDZ负荷量0.1mg/kg静脉注射,后以0.1mg/(kg·h)持续静脉输入,每1h进行1次Ramsay评分,使其保持3～5级。否则即调整MDZ剂量至0.15～0.25mg/(kg·h)。于持续静脉用药≥24h时,取血检测MDZ血药浓度。结果随着镇静深度增加,MDZ血药浓度由(83.2±7.5)ng/ml上升至(244.6±56.5)ng/ml,与Ramsay评分相关性良好(r=0.8523,P<0.05)。结论机械通气时维持理想的适度镇静,为Ramsay评分保持3～4级,此时MDZ血药浓度应维持80～160ng/ml。监测血药浓度可作为临床调整剂量的基础。     

重症监护室儿童镇静评估的研究进展

镇静治疗是危重症患儿安全、舒适管理中的重要一环,镇静评估工具的准确选择能够帮助护理人员有效评估患儿的镇静水平,指导临床护理。本文就现存的Ramsay镇静评分、Richmond躁动-镇静量表、舒适量表等6种较常用的重症监护室儿童镇静评估量表和相关的镇静护理理念进行综述,旨在为选择一种适合危重症患儿的镇静评估量表以及规范镇...     

重症肺炎合并脓毒症患儿炎症因子及凝血指标与危重症评分相关性分析

目的 探讨重症肺炎合并脓毒症患儿炎症因子和凝血指标与危重症评分的相关性。方法 选择2010年1月至2012年11月在福建省妇幼保健院PICU入住24 h以上,符合重症肺炎合并脓毒症诊断的患儿为研究对象。根据小儿危重病例评分法分为极危重组（<70分）、危重组（~80分）和非危重组（>80分）。检测炎症因子（血WBC、PLT和CRP、IL-6）和凝血指标（D-二聚体和可溶性P-选择素）水平,采用多元线性逐步回归分析炎症因子、凝血指标与危重症评分的相关性。结果 101例患儿进入分析,男47例,女54例。非危重组53例,危重组42例,极危重组6例。①随着危重症评分分值降低,IL-6、D-二聚体和可溶性P-选择素水平逐渐增高,组间两两比较差异均有统计学意义(P均<0.05);CRP水平亦随危重症评分降低而逐渐增高,在非危重组和危重组间差异有统计学意义（P<0.05）;PLT计数则随危重症评分降低呈降低趋势,组间两两比较差异均有统计学意义(P均<0.05);血WBC在各组间差异均无统计学意义(P均﹥0.05)。②IL-6、可溶性P-选择素和D-二聚体水平与危重症评分呈正相关,PLT计数与危重症评分呈负相关,血WBC和CRP与危重症评分无相关性。结论 IL-6、可溶性P-选择素、D-二聚体和PLT水平与儿童重症肺炎合并脓毒症的严重程度相关。     

危重症患儿血清上皮来源中性粒细胞活化肽-78的变化及意义

目的 探讨危重症患儿血清上皮来源中性粒细胞活化肽-78(ENA-78)的变化,及其与儿童危重症病情严重程度和预后的关系.方法 采用前瞻性病例对照研究,选取2013年9月至11月上海交通大学附属儿童医院重症医学科收治的42例危重症患儿(危重症组),入院后24h内(急性期)和第7天(恢复期)留取血标本;选取本院同期42例儿童体检残血样本作为对照.采用儿童危重病例评分标准(PCIS)和儿童死亡危险因素评分(PRISMⅢ)评估病情的危重程度;双抗体夹心酶联免疫法测定血清中ENA-78水平.结果 1.对照组血液ENA-78水平为(0.44 ±0.28) ng/L;危重症组急性期ENA-78为(2.85±0.89) ng/L,恢复期为(1.00±0.64) ng/L,危重症组与对照组、急性期与恢复期ENA-78水平比较差异均有统计学意义(P均=0.000).2.ENA-78水平与PCIS评分呈负相关(r=-0.724,P=0.000);PRISMⅢ≥10分组血清ENA-78水平明显高于PRISMⅢ＜10分组(P =0.000).危重症患儿中,存活组ENA-78水平与死亡组比较差异有统计学意义(P=0.000).3.严重感染患儿血清ENA-78水平与非感染性疾病组比较差异有统计学意义(P =0.000).4.随着器官功能障碍损伤范围扩大ENA-78水平相应上升,差异有统计学意义(P =0.000).结论 危重症患儿存在血液ENA-78水平的变化,测定血液中ENA-78水平,能对评估疾病严重程度及判断预后提供参考.     

芬太尼持续静脉泵入在PICU中的镇静作用

目的 探索芬太尼在PICU中的镇静效果.方法 对PICU患儿用芬太尼1～4 μg/(kg·h)持续静脉泵入,定期评价镇静程度,并根据需要调整用量,用药期间监测呼吸、心率、血压、经皮血氧饱和度等.结果 38例危重患儿中36例于用药2 h内达到理想的镇静程度,有效率94.7%;用药后患儿的血气分析各项指标及心率、呼吸、经皮血氧饱和度均明显改善;只有5例患儿出现一过性轻微不良反应,均于减量或停药后恢复正常.结论 芬太尼的镇静、镇痛作用可减轻危重患儿的应激反应,利于安全有效实施各种操作、治疗,而且不良反应较小,有利于提高危重患儿的抢救存活率.     

1920例危重患儿血淀粉酶水平分析

目的探讨危重患儿血淀粉酶升高对病情评估的意义及影响因素。方法回顾性分析2009年11月至2014年6月入住儿童重症监护病房(PICU)危重患儿临床资料,根据入PICU时的血淀粉酶水平,分为血淀粉酶正常组(≤103IU/L)、血淀粉酶升高组(103 IU/L),比较两组间的差异。结果共1 920例危重患儿入选,初发疾病以呼吸系统疾病、神经系统疾病为主;血淀粉酶正常1 470例(76.6%)、升高450例(23.4%)。血淀粉酶正常组与升高组之间器官衰竭个数和小儿危重病例评分(PCIS)分布,以及有创机械通气率和病死率的差异均有统计学意义(P均0.001),血淀粉酶升高组中器官衰竭个数≥4、有创机械通气、PCIS评分70以及死亡的比例均较高。血淀粉酶与血脂肪酶、尿淀粉酶、尿素氮和肌酐水平相关性较大(r=0.246~0.683,P均0.001)。血淀粉酶与休克指数呈正相关(r=0.111,P=0.002),与呼吸衰竭指数呈负相关(r=-0.133,P0.001)。结论血淀粉酶水平可评估危重患儿病情,血淀粉酶升高与胰腺外分泌功能、肾功能、缺血缺氧密切相关,对危重患儿血淀粉酶升高需警惕。     

生长分化因子-15在心肌损伤危重病患儿中的临床价值

目的 探讨生长分化因子-15(GDF-15)在心肌损伤危重病患儿中的应用价值.方法 对入住南通大学附属常州儿童医院PICU的无原发性心脏病患儿立即进行小儿危重病例评分(PCIS),标准按太原会议方案,以PCIS≤80分或出现单器官危重者为危重标准,入选病例50例.同期体检健康儿童20例为健康对照组.用ELISA法检测外周血血清GDF-15水平,并记录肌钙蛋白I(cTnI)、CK-MB及CK等生化指标,统计心肌损伤发生率;以cTnI＞0.2μg/L作为判断心肌损伤的标准,将50例患儿分为心肌损伤组(n=23)和无心肌损伤组(n=27).观察GDF-15与危重病患儿心肌损伤的关系,并行GDF-15与cTnI的相关性分析.结果 1.危重病患儿心肌损伤发生率为46％(23/50例);2.心肌损伤组患儿GDF-15阳性率[60.87％(14/23例)]显著高于无心肌损伤组[25.93％(7/27例)]及健康对照组[5.00％(1/20例)](P =0.027,0.000),无心肌损伤组与健康对照组比较差异无统计学意义(P=0.056);3.心肌损伤组GDF-15水平高于无心肌损伤组,差异有统计学意义(P=0.000);4.GDF-15水平与cTnI水平呈正相关(r=0.9704,P＜0.05).结论 危重症患儿心肌损伤的血清GDF-15水平高于非心肌损伤患儿,联合检测GDF-15与cTnI对危重症患儿心肌损伤程度的判断有重要价值.     

Correlation of the Bispectral Index Monitor with the COMFORT scale in the pediatric intensive care unit.

OBJECTIVE: The COMFORT scale is a commonly used observational scoring system to assess the level of sedation in ventilated children in pediatric intensive care units (PICUs). The bispectral index (BIS) monitor is a processed electroencephalographic parameter that noninvasively measures the hypnotic effect of anesthetic and sedative drugs on the brain. The objective of this study was to assess the degree of correlation between the COMFORT scale and the BIS monitor. DESIGN: A prospective study in a tertiary level PICU. RESULTS: A total of 75 children were enrolled in the study, resulting in 869 valid paired observations of BIS values and COMFORT scores. The median age was 10 months, with a range of 1 month to 12 yrs. The median COMFORT score was 11 (range, 8-40). The median BIS value was 52 (range, 0-98). In a repeated-measures analysis, the correlation coefficient between COMFORT scores and BIS values averaged over time was 0.61 (p < .0001). CONCLUSIONS: The BIS monitor may be a valid and useful monitor of the level of sedation of children in the PICU. We cannot expect perfect correlation between BIS values and observational scales because they measure different variables. The BIS monitor may be the best objective monitor currently available for children receiving neuromuscular blockade because it does not rely on subjective measures such as those used in the COMFORT scale. The ability of the BIS monitor to distinguish between very deep levels of sedation may be useful to prevent over-sedation of children in PICUs and to help clarify the appropriate target level of sedation for each child.     

Valoración de la sedación en el niño crítico con ventilación mecánica durante la aspiración endotraqueal

ObjectivesTo compare the changes in clinical sedation scales, bispectral index (BIS) and physiological variables occurring during tracheal suction in critically ill children.DesignProspective, observational study in critically ill children on mechanical ventilation. BIS value, heart rate (HR), systolic blood pressure (SPB), diastolic blood pressure (DBP), modified Ramsay sedation scale score and the dose of sedative drugs were recorded before and 3 minutes after every tracheal suction.ResultsA total of 83 tracheal suctions were analyzed from 46 children, 1 month to 15 years of age. Most of the children (92%) were receiving continuous infusions of fentanyl and midazolam, and 45.7% of them were receiving vecuronium. The increase in BIS, SPB and DBP values were small but statistically significant (BIS, from 51.8 to 57.3; SBP, from 92.9 to 103.1 mmHg; DBP, from 51.8 to 58.9 mmHg). There was poor correlation between the BIS, HR, SBP and DBP values before and after suction. A total of 87% of patients maintained the same Ramsay score values.ConclusionsTracheal suction produces a slight increase in the BIS and the BP in critically ill children who are receiving sedation by continuous infusion. Most children with adequate sedation do not need any other drugs before the tracheal suction. Physiological variables have no correlation with sedation scales or BIS values during the tracheal suction.     

Clinical utility of the bispectral index score when compared to the University of Michigan Sedation Scale in assessing the depth of outpatient pediatric sedation

This single blinded observational study compared the bispectral index (BIS) monitor with a validated pediatric sedation scale, the University of Michigan Sedation Scale (UMSS), to evaluate whether the BIS score can be used to judge the depth of sedation in pediatric outpatients. Thirty-eight children, with a mean age of 5.8 years, undergoing routine sedation for both noninvasive and gastrointestinal procedures, had simultaneous BIS and UMSS scores recorded. Sedation categories were defined as light, moderate, and deep for both UMSS and BIS. There was a moderate correlation between BIS and the UMSS, Spearman's r < -0.499. The correlation was poor for children receiving chloral hydrate, r < -0.213. The BIS score was not predictive of any specific UMSS score. The UMSS and BIS categories of sedation matched only 36% of the time. BIS underestimated the clinical level of sedation.     

东北及内蒙古地区儿科重症监护病房护士镇痛镇静护理行为现状调查及影响因素分析

目的通过横断面调查,了解东北及内蒙古地区儿科重症监护病房(pediatric intesive care unit,PICU)护士镇痛镇静护理行为现状并对其影响因素进行分析,为进一步构建规范化培训方案及研发标准化镇痛镇静护理流程提供参考依据。方法采用自行设计的PICU护士镇痛镇静护理知信行现状调查问卷对东北及内蒙古地区18家医院的435名PICU护士进行问卷调查。结果东北及内蒙古地区PICU护士镇痛镇静护理行为问卷平均得分为(70.54±13.63)分。不同年龄、护龄、PICU护龄、学历、职称,以及是否是重症专科护士、是否接受过镇痛镇静培训、有无护理镇痛镇静患儿经历,各组间护士的行为得分比较,差异均有统计学意义(均P<0.05)。护士是否接受过镇痛镇静相关培训、有无护理镇痛镇静患儿经历及对镇痛镇静的态度是影响PICU护士镇痛镇静行为的主要因素。结论东北及内蒙古地区PICU护士镇痛镇静护理行为尚有很大提升空间,PICU护士参加镇痛镇静相关培训次数越多、护理镇痛镇静患儿经历越丰富、镇痛镇静态度越积极,其临床护理实践能力越强。     

山东省多中心儿童重症监护室镇静镇痛治疗及管理状况调查

目的了解山东省三级甲等医院儿童重症监护室(PICU)镇静镇痛治疗及管理状况,为镇静镇痛治疗方案的改进提供依据。方法本研究为一项多中心回顾性研究,山东省6家三级甲等医院的PICU参与了本研究。收集2016年1月至2018年12月入住这6家PICU的1340例患儿,调阅病历资料,统计患儿的年龄、性别、入院24 h小儿死亡风险评分Ⅲ、是否接受机械通气、是否接受镇静和(或)镇痛治疗、是否监测镇静和(或)镇痛情况、住院病死率等。依据是否接受镇静治疗和(或)镇痛治疗,将患儿分为单纯镇静组(798例)、镇静+镇痛组(120例)及非镇静镇痛组(422例),比较各组的病种、机械通气比例、低血压发生率、平均住PICU天数及院内病死率。结果1340例患儿的平均年龄为(13.3±6.4)个月,其中男786例(58.7%)。6家PICU均已开展镇静治疗,其中5家PICU进行常规镇静评估;已开展镇痛治疗的PICU有4家,其中仅有2家进行常规疼痛评估。共有918例(68.5%)患儿接受了镇静治疗和(或)镇痛治疗,咪达唑仑是最常用的镇静药物,其次是右美托咪定。526例(57.3%)患儿进行了镇静评估监测,最常用的评估方法是Richmond躁动镇静量表。120例(9.0%)患儿接受了镇静联合镇痛治疗,芬太尼是最常用的镇痛药物,38例(31.7%)患儿接受了常规疼痛评估。3组患儿年龄和性别差异无统计学意义。镇静+镇痛组外科疾病的比例最高,该组机械通气患儿的比例也最高(100.0%,120/120),非镇静镇痛组机械通气患儿的比例最低(11.4%,48/422),两组比较差异有统计学意义(P<0.01)。镇静+镇痛组的平均机械通气时间略短于单纯镇静组,但组间比较差异无统计学意义(P>0.05)。镇静+镇痛组低血压发生率最高,非镇静镇痛组低血压发生率最低[21.7%(26/120)比2.1%(9/422),P<0.01]。院内病死率和平均住PICU天数3组间比较差异无统计学意义。结论苯二氮类药物仍是目前山东省PICU中主要使用的镇静药物,右美托咪定的应用逐渐增加,但镇痛剂应用的比例很低。目前镇痛镇静治疗主要用于外科术后及接受机械通气治疗的患儿,镇痛镇静治疗虽未增加患儿的院内病死率及平均住PICU天数,但增加了低血压的发生率。山东省PICU的镇静镇痛治疗和监测仍欠规范,主要体现在镇痛治疗以及对镇静和疼痛水平的评估未受到重视。     

镇痛镇静策略在PICU机械通气患儿中的应用

目的探讨不同镇静、镇痛策略对机械通气患儿的辅助治疗效果及不良反应。方法将80例进行机械通气且需镇静镇痛治疗的危重患儿随机分为咪达唑仑组(40例)和瑞芬太尼+咪达唑仑组(40例),采用Ramsay及FLACC量表评估镇静、镇痛效果,记录治疗期间生命体征、呼吸机参数动态变化、脏器功能指标、瑞芬太尼及咪达唑仑应用总量、机械通气时间、PICU住院时间及费用、不良反应发生情况等。结果 2组患儿均能达到满意镇痛镇静效果。与咪达唑仑组比较,瑞芬太尼+咪达唑仑组达到镇静镇痛效果所需时间更短,Ramsay评估3~4级所占百分比增高,咪达唑仑用量降低,差异均有统计学意义(P0.05)。2组患儿治疗后心率、平均动脉压及自主呼吸频率均降低,但瑞芬太尼+咪达唑仑组在用药后3~24 h的心率、3~12 h的平均动脉压和自主呼吸频率下降更明显(P0.05)。与咪达唑仑组比较,瑞芬太尼+咪达唑仑组患儿用药后的6 h和12 h呼吸机潮气量及经皮氧饱和度均明显增高,呼气末二氧化碳水平明显降低,差异有统计学意义(P0.05)。瑞芬太尼+咪达唑仑组停药至苏醒的时间、拔管时间、机械通气以及PICU住院时间均明显低于咪达唑仑组(P0.05)。2组患儿PICU住院费用、不良反应发生率以及用药前后肝肾功能差异均无统计学意义(P0.05),但空腹血糖比镇静前明显降低(P0.05)。结论 PICU机械通气患儿采用瑞芬太尼+咪达唑仑治疗方案能迅速达到镇痛、镇静目标,改善通气效果,减少镇静剂用量,耐受性良好。     

小儿死亡危险评分的临床应用

目的观察小儿死亡危险评分(PRISM评分)与PICU急性危重症患儿预后的关系。方法对2003年2-10月PICU收治急性危重症45例,回顾性评定PRISM评分,并依据评分分组,记录患儿临床资料和住院时间、预后。结果PRISM 评分<15分24例,>15分21例。两组年龄、体质量和院内感染率均无显著差异(P均>0.05)。两组死亡率分别为8.1%(2/ 24例)和38.1%(8/21例),PRISM评分<15分组死亡率明显低于>15分组(x2=4.14 P<0.05)。PRISM>15分组存活病例住院天数(13.2±6.1)d显著长于PRISM<15分组(9.7±8.5)d(t=1.74.P<0.05)。结论PRISM评分越高,死亡率随之增加。PRISM评分增高,患儿住院时间越长。PRISM评分能够准确评估急性危重症病人的严重程度和预后。     

Validez y fiabilidad de la escala de sedación para procedimientos del Hospital Niño Jesús bajo sedoanalgesia profunda

IntroductionThe procedural sedation scale of the Niño Jesús Hospital (Madrid) (SSPNJH) has not been validated.Patients and methodsA prospective analytical study was conducted in 2 hospitals on patients ≥ 6 months undergoing invasive procedures using sedation-analgesia with propofol or midazolam and fentanyl. All were monitored using the bispectral index (BIS). Videos were made of each procedure, which were then edited and randomised. A total of 150 videos were rated by four observers using the SSPNJH, the sedation scale of the University of Michigan (UMSS), and the Ramsay Scale (SR). These observers were blinded to the BIS, and at the time of drug administration. To assess test-retest reliability, 50 of the initial 150 randomly selected videos were re-assessed.ResultsThe study included a total of 65 patients. The within-observer agreement was high (ρ = 0.793). The SSPNJH gave a good interobserver reliability when compared with the UMSS (ICC = 0.88) and the SR (ICC = 0.86), and there was none with the BIS. Internal consistency was moderate (α = 0.68). Construct validity was demonstrated by changes in scores after administering sedatives (p < 0.0001). The SSPNJH had a very low correlation with the BIS (r = -0.166), and a moderate correlation with the UMSS (r = 0.497) and the SR (r = 0.405). As regards the applicability, this scale has been used in two hospitals in five different areas by four professionals of different categories.ConclusionsThe SSPNJH is valid, reliable and applicable for sedation monitoring in invasive procedures under deep sedation-analgesia in paediatric patients. The SSPNJH has worse properties than the UMSS and the SR.     

Pharmacokinetics of dexmedetomidine in postsurgical pediatric intensive care unit patients: preliminary study.

OBJECTIVE: To characterize the pharmacokinetics of dexmedetomidine and monitor any dexmedetomidine-related adverse events in postoperative pediatric patients requiring short-term mechanical ventilation, analgesia, and sedation in the pediatric intensive care unit (PICU). DESIGN: Prospective, case series. SETTING: Operating room and PICU in a large, urban children's hospital. Enrollment from February 14 to November 25, 2002. PATIENTS: Ten children (4 months to 7.9 yrs of age) who received postoperative infusions of dexmedetomidine. INTERVENTIONS: Toward the end of the operation, patients received dexmedetomidine at 1 microg/kg per hr for 10 mins. The anesthesiologist then titrated the infusion, as clinically indicated, to a rate of 0.2-0.7 microg/kg per hr. In the PICU, the infusion was titrated by the nursing staff based on assessment with a modified Ramsey Sedation Scale, while maintaining heart rate and blood pressure within normal limits for age. Dexmedetomidine was continued until the intensivist felt the patient no longer benefited, but for no longer than 24 hrs. MEASUREMENTS AND MAIN RESULTS: At specified times during the infusion and after discontinuation, dexmedetomidine plasma concentrations were determined. Pharmacokinetic parameters were calculated using a two-compartment model. Vital signs, sedation scores, adjunct sedative or analgesic medications, and adverse events were recorded. Average duration of infusion was 18.8 hrs (range, 8-24 hrs). Means (+/-sd) were calculated for the following: clearance, 0.57 (+/-0.14) L/hr per kg; volume of distribution at steady state, 1.53 (+/-0.37) L/kg; and terminal elimination half-life, 2.65 (+/-0.88 hrs)-all similar to published values in adults. There were no serious adverse events related to dexmedetomidine. CONCLUSIONS: Dexmedetomidine, administered as a continuous infusion, produces consistent, predictable concentrations in children and infants. Further evaluations of the safety, efficacy, and pharmacodynamics of dexmedetomidine are warranted.     

地佐辛用于儿童术后镇痛有效性和安全性的随机对照试验

背景：新型阿片受体激动 拮抗剂地佐辛用于儿童术后镇痛的研究报道甚少,且没有公认的儿童用药参考剂量。 目的：探讨地佐辛应用于儿童术后镇痛的有效性和安全性,为其用于儿童术后镇痛提供合适的参考剂量。 设计单中心RCT。 方法：纳入在重庆医科大学附属儿童医院行先天性心脏病（CHD）手术后直接转入PICU的患儿,手术时年龄>28 d,术前美国麻醉医师协会（ASA）分级Ⅲ～Ⅳ级。按随机数字表法生成随机分组方案,装入密闭信封保存;由当班的PICU医生负责入组,由管床护士执行干预。随机分为5组,试验组患儿在术后持续静脉泵入低剂量（D1组）、中剂量（D2组）或高剂量（D3组）地佐辛,对照组泵入舒芬太尼（SF组）或吗啡（M组）,观察术后疼痛评分和镇静评分。未对结局指标观察人员和数据分析人员施盲。共同干预措施：入PICU后使用有创呼吸机辅助通气,予对症处理和咪达唑仑镇静。D1、D2、D3组分别予地佐辛20、30、40 μg·kg-1·h-1,SF组予舒芬太尼0.08 μg·kg-1·h-1,M组予吗啡20 μg·kg-1·h-1,均为静脉泵注。疼痛评分包括脸谱疼痛评分法（FPS）和CRIES评分法,镇静评分包括Ramsay评分法和舒适行为量表（Comfort B评分）,均由PICU专科护士完成。 主要结局指标:术后1 h、4 h、8 h、12 h和24 h的镇痛/镇静满意度百分比。 结果:共152例CHD患儿入组,D1、D2、D3、SF和M组分别为30、30、31、31和30例,均完成设计的干预和观察。5组患儿年龄、体重、性别、体外循环时间、危重症评分（PCIS）和术前ASA分级差异均无统计学意义。①FPS评分：D2组术后24 h,D3组术后4 h、24 h镇痛满意度高于M组;CRIES评分：D1、D2组术后1 h、4 h,D3组术后4 h、24 h镇痛满意度高于M组;Ramsay评分： D2、D3组术后1 h、4 h镇静满意度高于M组;Comfort B评分： D1组术后4 h、12 h,D2组术后1 h、4 h,D3组术后1 h、4 h、12 h镇静满意度高于M组;差异均有统计学意义。4种评分D组和SF组的镇痛/镇静满意度差异均无统计学意义。②5组术后各时间点生命体征及相关指标差异均无统计学意义;D1、D2组追加镇静/镇痛药物的比例低于M组和SF组,差异均有统计学意义。M组观察到2例低血压及1例呼吸抑制。 结论:地佐辛应用于儿童CHD术后的镇痛效果优于吗啡,与舒芬太尼效果相当,且不良反应少。