Bispectral Index System (BIS) monitoring reduces time to discharge in children requiring intramuscular sedation and general anesthesia for outpatient dental rehabilitation

PURPOSE: Pediatric patients who receive both intramuscular (i.m.) sedation and general anesthesia (GA) for oral rehabilitation occasionally experience prolonged sedation and delayed discharge. The Bispectral Index System (BIS) is an EEG monitor that measures the level of sedation. The authors compared discharge times of patients who had BIS monitoring to those who did not to determine if the use of BIS speeded discharge. METHODS: After IRB approval, 20 children were enrolled. BIS was monitored continuously from admission until discharge. Each child received ketamine, midazolam, and glycopyrrolate i.m. Once sedated, the patient was transferred to the operating room, monitored, and i.v. access was established. GA proceeded with sevoflurane, rocuronium, and fentanyl. Randomly, in half the patients, the anesthesiologist knew and maintained the BIS at GA level of sedation by adjusting sevoflurane. In the rest, the anesthesiologist did not know BIS. Time from turning of sevoflurane to discharge was noted and compared. RESULTS: Patients where the BIS was known and used were discharged 60+/-13 minutes after the end of GA. Patients where BIS was unknown were discharged 90+/-11 minutes after the end of GA (P<.001). CONCLUSIONS: Based on the data, the authors recommend the use of BIS to facilitate faster discharge of pediatric patients who require i.m. sedation and GA for oral rehabilitation.     

瑞芬太尼对七氟烷诱导小儿口腔颌面部术后烦躁的影响

目的：探讨瑞芬太尼对口腔颌面部手术患儿七氟烷诱导术后苏醒烦躁的影响。方法：择期口腔颌面部手术患儿30例,ASAⅠ级,3～8岁,体质量15～26kg。实验随机分为2组,每组15例,A组为实验组,B组为对照组。2组患儿入手术室前根据改良耶鲁术前焦虑分级表评分,肌内注射盐酸氯胺酮后入室诱导,调节七氟烷浓度,静脉注射罗库溴铵后行气管插管。术中瑞芬太尼血浆靶浓度4～6ng/ml,调节七氟烷浓度维持BIS于40～60,2组术毕前10min调节瑞芬太尼至1ng/mL,七氟烷浓度0.8%（结束时关闭）。对照组手术结束时停用瑞芬太尼,实验组入苏醒室5min后停用。根据小儿麻醉苏醒烦躁量表及改良CHEOPS表,对小儿烦躁及疼痛情况评分。采用SPSS12.0软件包对数据进行统计学分析。结果：2组小儿术前焦虑及术后疼痛评分差异无统计学意义（P〉0.05）,实验组小儿术后烦躁评分显著低于对照组（P〈0.05）。结论：瑞芬太尼能有效减少小儿七氟醚诱导口腔颌面部手术术后烦躁。     

右美托咪定复合七氟烷在儿童口腔全麻治疗中的效果评价

目的: 观察右美托咪定复合七氟烷用于儿童口腔全麻治疗的疗效及其影响因素。方法: 将120例拟行口腔全麻治疗（>90 min）的患儿随机分为右美托咪定复合七氟烷组（D组）和七氟烷组(S组),每组60例。D组经面罩吸入4%~6%七氟烷,静脉推注芬太尼1 μg/kg,咪唑安定0.1 mg,丙泊酚2 mg/kg,罗库溴铵0.3 mg/kg。待患儿睫毛反射消失后,进行气管插管,以2%~3%七氟烷吸入维持。手术开始时,泵注丙泊酚,速度为9~12 mg/(kg·h);同时先以1 μg/kg速度泵注右美托咪定15 min后,减为0.5 μg/（kg·h）维持直至手术结束。S组未泵注右美托咪定。监测患儿入室（T1）、睫毛反射消失（T2）、泵注右美托咪定10 min（T3）、手术开始（T4）、手术结束（T5）时的心率（HR）、平均动脉压（MAP）及Ramsay镇静评分,记录手术完成时间、手术后患儿苏醒时间、拔管时间、麻醉后恢复室（PACU）内小儿苏醒期躁动评分（PAED）。采用 SPSS 20.0软件包对数据进行统计学分析。结果: 2组手术完成时间比较差异无统计学意义;术中T3-T5时D组MAP、HR显著低于S组（P<0.05）, Ramsay镇静评分显著高于S组（P<0.05）;D组苏醒时间、拔管时间显著高于S组;在PACU内,D组小儿苏醒期PAED评分显著低于S组。结论: 右美托咪定复合七氟烷用于儿童口腔全麻手术,患儿循环指标稳定,对呼吸影响小。虽然苏醒时间有所延长,但可提高苏醒质量。     

Hypotensive anesthesia and recovery of cognitive function in long-term craniofacial surgery

The aim of our study was to compare three different anesthesiological techniques with regard to hemodynamics, recovery, and postoperative morbidity, for craniofacial surgery. One hundred twenty patients with American Society of Anesthesiologists (ASA) classification of I or II patients, 18 to 32 years old, and undergoing maxillary and mandibular osteotomies were randomly assigned to receive anesthesia with propofol-remifentanil (group P), desflurane-remifentanil (group D), or sevoflurane-remifentanil (group S). All patients were given premedication: midazolam 0.03 mg/kg, atropine 0.007 mg/kg, desametasone 0.1 mg/kg, NaCl 0.9% 100 mL + 2 mg/kg ketoprofene + 1.5 mg/kg ranitidine + 1 microg/kg clonidine. Anesthesia was induced by O2/air (FiO2 0.5), remifentanil 0.5 microg/kg/min, propofol 2 mg/kg, rocuronium 0.6 mg/kg. Maintenance group P received O2/air (FiO2 0.5), remifentanil 0.25 to 1.5 microg/kg/min, propofol 6 to 10 mg/kg/h; groups D and S received O2/air (FiO2 0.5), remifentanil 0.25 to 1.5 microg/kg/min, and respectively, sevoflurane or desflurane 0.5 minimum alveolar anesthetic concentration. The dosage of propofol, desflurane, and sevoflurane, obtained with a value of bispectral index (BIS) 40, was kept unchanged throughout the course, and remifentanil was titrated to maintain controlled hypotension: systolic arterial blood pressure 70 to 90 mmHg and mean arterial blood pressure 50 to 65 mmHg. A 24-hour elastomeric infusion system (ketoprofene 320 mg) was started 60 minutes before induction and cloridrat ondansetron 0.1 mg/kg was administered 30 minutes before the end of surgery. Hypotension was successfully obtained in all three groups with a bloodless surgical field, and there was no need for additional use of a potent hypotensive agent. Early and late recovery were faster and more complete in the D group; P < 0.05. Postoperative morbidity (nausea, vomiting, shivering, pain, and edema) was slight and did not significantly differ among the groups.     

布洛芬超前镇痛对婴幼儿腭裂术后苏醒质量的影响

目的:评价布洛芬注射液对婴幼儿腭裂手术后麻醉苏醒质量的影响.方法:将46例拟行腭裂修补术治疗的患儿,按照是否接受布洛芬注射液随机分为试验组(A组)和对照组(B组),每组23例.采用8％七氟醚合并8 L/min氧气吸入麻醉诱导,待患儿意识消失后开放静脉,静脉注射阿托品0.01 mg/kg、芬太尼2μg/kg、异丙酚2 m...     

BIS monitoring during midazolam and midazolam-ketamine conscious intravenous sedation for oral surgery

OBJECTIVE: The purpose of this study was to determine whether the bispectral index scale (BIS) would provide added benefit to established methods of monitoring conscious sedation with midazolam (M group) or midazolam supplemented with ketamine (MK group). STUDY DESIGN: BIS was prospectively and blindly examined in 22 patients receiving outpatient oral surgery with conscious sedation supplemented with local anesthesia. RESULTS: The average midazolam dose in the midazolam group over the treatment period was 0.01 mg/kg/h, and the average midazolam plus ketamine dose was 0.01 and 0.05 mg/kg/h, respectively. Mean BIS values throughout the sedation study period were 90 for the midazolam group and 94 for the midazolam plus ketamine group. The addition of ketamine did not lower BIS. BIS values did not alter significantly over time except for an expected transient drop after the midazolam bolus induction. CONCLUSION: BIS levels remained close to baseline levels, suggesting that BIS would not provided any additional benefit to currently established methods of monitoring patient consciousness during conscious sedation for oral surgery.     

Continuous infusion of methohexital and alfentanil hydrochloride for general anesthesia in outpatient third molar surgery

Three anesthetic techniques were compared in this study: 1) Intermittent Brevital boluses supplemented with fentanyl and midazolam all titrated to patient movement, 2) constant infusion of Brevital supplemented with fentanyl and midazolam all delivered in calculated mg/kg doses based on total body weight, and 3) constant infusion of methohexital (Brevital) and alfentanil (Alfenta) supplemented by midazolam (Versed), droperidol, and glycopyrolate (Robinul) delivered in calculated mg/kg doses based on lean body mass. Nitrous oxide was delivered in all cases via nasal mask in a 30% to 50% concentration. The mean total dose of Brevital in group 1 (intermittent Brevital bolus) was 0.17 mg/kg/min (SD = 0.07), group 2 (Brevital infusion) was 0.23 mg/kg/min (SD = 0.06), and group 3 (alfentanil/Brevital infusion) was 0.12 mg/kg/min (SD = 0.07). Mean total dose of alfentanil in group 3 equaled 1.58 mcg/kg/min (SD = 0.73). In group 1, 94% of the patients experienced moderate to severe movement intraoperatively. Twenty-three percent of the patients in group 2, and only 7% of group 3 exhibited moderate to severe movement. Emergence in group 3 averaged 4.5 minutes (SD = 1.6). Three patients (7%) in group 3 had postoperative nausea. Additional subjective findings in group 3 included easier airway maintenance during administration of the anesthetic, lack of unpleasant emergence phenomena such as crying, and prompt readiness for discharge. It was concluded that continuous alfentanil and Brevital infusion satisfied the objectives of safety, stability, predictability, and rapid recovery, while improving operating conditions (less patient movement) when compared with more traditional anesthetic techniques.     

丙泊酚与氢吗啡酮联合用于口腔颌面外科术后留置气管导管患者的临床研究

目的:探讨丙泊酚与氢吗啡酮联合用于口腔颌面外科术后留置气管导管患者镇静及镇痛的作用。方法:将口腔颌面外科术后留置气管导管患者40例患者按照随机原则分为丙泊酚-氢吗啡酮组(P-H组,20例)、丙泊酚-右美托咪定(P-D组,20例)。P-H组以异丙酚0.5～1mg/Kg·h^-1持续泵注复合氢吗啡酮4～8μg/kg·h^-1持续泵注;P-D组以异丙酚0.5～1mg/Kg·h^-1持续泵注复合右美托咪定0.2～0.6μg/kg·h^-1持续泵注。比较2组患者的Ramsay评分、心率、血压、呼吸等变化。采用SPSS16.0软件包对数据进行统计学处理。结果:在拔管前2组的动脉血pH值、氧分压、二氧化碳分压无显著差异;2组间各时点SPO2、MAP、RR、RAMSAY比较无显著差异,2组间HR在T2、T5、T6时点比较有显著差异(P<0.05)。结论:静脉泵注丙泊酚-氢吗啡酮可以取得静脉泵注丙泊酚-右美托咪定类似的临床疗效,且无减慢心率的作用。     

右美托咪啶对口腔颌面手术苏醒期躁动的作用评价

目的：评价右美托咪啶(简称右美)对口腔颌面手术苏醒期躁动的作用。方法：全麻下行口腔手术患者55例,术后入苏醒室,随机分为右美组28例,使用右美托咪啶0.3μg/kg静脉推注。对照组27例,使用等量生理盐水静脉推注。评估苏醒期发生躁动情况,记录2组入室后拔除气管导管的时间,记录入苏醒室即刻、入室后5、15、30、60、120min时平均动脉压、心率、血氧饱和度、镇静评分。采用SAS9.1软件包对数据进行统计学分析。结果：苏醒期躁动的发生率,右美组(18%)较对照组(70%)显著降低(P<0.05)。入苏醒室后5、15、30、60min,右美组的Ramsay镇静评分显著高于对照组(P<0.05)。入苏醒室后5、15、30、60、120min,右美组患者心率较对照组显著下降(P<0.05),入苏醒室后15、30min,右美组患者平均动脉压较对照组显著下降(P<0.05)。2组患者术后拔管时间无显著差异,术后均无呼吸抑制发生。结论：右美托咪啶0.3 μg/kg一次静脉推注能安全有效地降低口腔手术苏醒期躁动。     

不同麻醉方式在腮腺肿瘤切除术时面神经监测中的应用比较

目的 比较静吸复合麻醉与全凭静脉麻醉用于腮腺肿瘤切除术时面神经监测的临床效果及安全性。方法 70例接受腮腺肿瘤切除手术的患者,随机分为静吸复合组（S组）和全凭静脉组（V组）（n=35）。麻醉诱导时静脉给予顺式阿曲库铵0.15 mg/kg,气管插管后S组吸入七氟醚复合泵注丙泊酚+瑞芬太尼维持,V组则仅泵注丙泊酚+瑞芬太尼维持。使用肌松监测仪测定拇指内收肌的4个成串刺激（TOF）反应,记录阻滞起效时间、深度阻滞恢复时间（T₁的出现时间）、T₁ 50%及TOF 90%恢复时间。术中采用面神经电生理监测,记录2组患者在T₁ 50%时监测的成功率,比较2组患者术中发生体动与心血管药物使用情况及术后拔管时间。采用SPSS 20.0软件包对数据进行统计学分析。结果 2组患者肌松起效时间无显著差异(P>0.05),S组T1的出现时间晚于V组,但组间差异无统计学意义(P>0.05),S组的T₁ 50%及TOF 90%恢复时间显著延长（P<0.05）。2组患者在T₁ 50%时均能成功获得面神经监测信号。2组均无使用血管活性药物的患者;V组有2例患者术中发生轻微体动。2组患者拔管时间无显著差异（P>0.05）。结论 静吸复合麻醉和全凭静脉麻醉均能满足术中面神经监测的手术要求,全凭静脉麻醉有利于更早地获得面神经电生理信号,而静吸复合麻醉有利于预防术中体动发生。     

咪达唑仑术前喷鼻对儿童在七氟烷诱导期间癫痫样脑电图的影响

目的 评估咪达唑仑术前喷鼻对儿童在七氟烷诱导麻醉期间癫痫样放电的影响。方法 将择期行全身麻醉下口腔颌面外科手术的86例患者（ASA分级Ⅰ~Ⅱ级,年龄0.5~6岁）,随机分为咪达唑仑组和生理盐水组2组。患儿在等候区予以术前药物喷鼻,入室后以相同步骤行8%七氟烷面罩诱导,持续监测麻醉诱导期间脑电图改变。采用SPSS 25.0软件包对数据进行统计学分析。结果 咪达唑仑组23例（53%,包括DSP30%、PSR37%、PED9%）、生理盐水组29例（67%,包括DSP37%、PSR35%、PED19%）患儿发生癫痫样脑电图改变,2组癫痫样脑电图发生率无统计学差异（P=0.186）。咪达唑仑组意识丧失时间早于生理盐水组,但差异无显著性[（41.6±11.0）s ∶（44.1±16.1）s,P=0.409]。结论 0.4 mg/kg咪达唑仑术前喷鼻并不能减少儿童在七氟烷诱导期间的癫痫样脑电图发生。     

咪达唑仑作为口腔颌面外科麻醉前用药的探讨

目的研究咪达唑仑用于口腔颌面外科麻醉前用药的效果。方法60例患者随机等分为Ⅰ、Ⅱ、Ⅲ组,麻醉前30min分别肌肉注射咪达唑仑0.06mg/kg、地西泮0.12mg/kg、苯巴比妥钠3mg/kg,观察镇静和抗焦虑作用、对循环和呼吸的影响以及不良反应。结果Ⅰ组用药后5min始出现BIS明显下降、Ramsay镇静评分明显增大,用药后30min时AVAT和SAI数值明显降低(P<0.05),Ⅱ组和Ⅲ组无明显改变;3组的循环和呼吸功能无明显变化,也未见明显不良反应。结论咪达唑仑作为麻醉前用药,镇静和抗焦虑作用确切,无明显不良反应,值得推广应用。     

Assessment of recovery in patients undergoing intravenous conscious sedation using bispectral analysis.

PURPOSE: The Bispectral Index (BIS) has been recently shown to objectively predict the level of sedation in patients undergoing conscious sedation. It was the goal of this study to directly compare the recovery profile of patients where the BIS was used to monitor sedation with a control group where the monitor was not used. PATIENTS AND METHODS: Forty patients undergoing third molar extractions under intravenous conscious sedation were randomly assigned to 2 groups. In both groups, induction of sedation was performed using a standard dose of fentanyl (1.5 microg/kg) and midazolam (0.05 mg/kg). Propofol was then given in 10 to 20 mg boluses until a clinically desirable sedation level was achieved. In 1 group, the BIS was then monitored continually during surgery using a microcomputer (Aspect-1050 Monitor, Aspect Co, Natick, MA) and recorded at 5-minute intervals. The anesthetist (N.A.S.) provided additional propofol boluses to maintain a BIS level of 70 to 80. In the other group, the BIS sensor was applied, but the monitor was not used. In this group, the sedation was modified, and additional propofol was given based solely on the anesthetist's subjective assessment of the desired level of sedation (Observer's Assessment of Alertness/Sedation [OAA/S] scale level 2 to 3). Additional boluses of 1 mg of midazolam were given during the procedure if patients required repeated boluses of propofol at less than 5-minute intervals to maintain the desired sedation level (BIS level of 70 to 80 or OAA/S level of 2 to 3). These additional midazolam boluses, as well as the time of the last sedative dose (propofol or midazolam) were recorded to study the effect of these factors on recovery. RESULTS: Of the 40 patients initially included in the study, 1 subject in the BIS-monitored group was excluded due to the loss of intravenous access at initiation of the case. For the remaining 39 subjects, 19 were assessed objectively using the BIS monitor, whereas 20 were assessed subjectively using the OAA/S scale. The BIS cases were slightly longer in duration than the OAA/S cases, lasting an average of 26 minutes versus 22 minutes. This difference was statistically nonsignificant (P =.19). Less propofol was used in the BIS cases, with an average of 98 mg for BIS cases versus 106 mg for OAA/S cases (P =.59). The total dose in mg/kg/min was significantly less in the BIS group (0.054 mg/kg/min) than in the OAA/S group (0.074 mg/kg/min; P =.0082). There was no significant difference in the amount of midazolam administered after induction between the 2 groups (P =.60). The surgeon, who was blinded to whether the monitor was used, ranked the third molar extractions more difficult in the BIS group (P =.05). However, patients in the BIS group were on average more cooperative, with better maintenance of muscle tone. The difference in these parameters were nonsignificant (P =.15 and .092, respectively). A positive Romberg test was obtained earlier in BIS patients, although this difference was nonsignificant (P =.097). The straight-line test was completed significantly sooner in BIS patients (P =.013). There was no significant difference between the BIS and OAA/S groups in perceptual speed (P =.55) or computation (P =.32). There was essentially no difference between groups in patient-assessed comfort or recall of the procedure. There were also no notable differences in anesthesia complications, return to activities of daily life, or pain medication use between the 2 groups. CONCLUSIONS: The BIS provides additional information for standard monitoring techniques that helps guide the administration of sedative-hypnotic agents. It appears that use of the BIS monitor can help to titrate the level of sedation so that less drugs are used to maintain the desired level. The trend toward an earlier return of motor function in BIS-monitored patients warrants further investigation.     

The effect of midazolam premedication on discharge time in pediatric patients undergoing general anesthesia for dental restorations.

PURPOSE: The purpose of this study was to evaluate the effect of oral premedication with midazolam on recovery times of children undergoing dental restorations under general anesthesia. METHODS: The records of 106 children (1.2-11.3 years, ASA I or II) undergoing ambulatory dental restorations were randomly selected and retrospectively reviewed: 50 subjects received midazolam (M) 0.5 mg/kg orally approximately 30 minutes prior to their procedure and 56 control subjects received no premedication (C). General anesthesia consisted primarily of inhalational anesthesia. Time in the operating room (OR), post-anesthesia care unit (PACU) and same day surgery (SDS) were determined and compared between groups. RESULTS: Both groups were similar with respect to age and weight. There were no significant differences between groups in time spent in the OR, PACU or SDS (p>0.05). In a subset of children having shorter dental procedures (OR time < or =75 minutes, n=29), there remained no significant difference in discharge times between groups. CONCLUSIONS: Preoperative administration of oral midazolam does not delay discharge of children undergoing general anesthesia for dental rehabilitation.     

Complications of sevoflurane–fentanyl versus midazolam–fentanyl anesthesia in pediatric cleft lip and palate surgery: a randomized comparison study

Careful choice of anesthetic agents in pediatric patients reduces the frequency of anesthesia-related complications. The frequency and type of intraoperative and postoperative complications of sevoflurane–fentanyl versus midazolam–fentanyl anesthesia were compared in 140 consecutive children (aged 3 months to 10 years) undergoing cleft lip and palate repair. Midazolam–fentanyl anesthesia was induced with midazolam (0.05 mg/kg), fentanyl (0.005 mg/kg) and vecuronium (0.1 mg/kg), and maintained with the same agents according to the defined parametars. Sevoflurane–fentanyl anesthesia was induced and maintained with sevoflurane (5–8 vol% and 0.8–1 vol%, respectively) in an oxygen/air mixture and supplemented with fentanyl (0.005 mg/kg). Both groups were comparable in basic demographic data, hemodynamic and respiratory parameters. Difficult intubation occurred in 6 of 76 children (midazolam–fentanyl group) and 4 of 64 children (sevoflurane–fentanyl group) (P = 0.754). Ventricular extrasystole and bronchospasm occurred in one patient each in the sevoflurane–fentanyl group. Postoperatively, emergence agitation was observed in the sevoflurane–fentanyl group (17 cases; P < 0.001); postoperative nausea and vomiting occurred in 2 children (midazolam–fentanyl group) and 3 children (sevoflurane–fentanyl group) (P = 0.660). Midazolam-based anesthesia in children is safer than sevoflurane-based anesthesia regarding occurrence of emergence agitation.     

���������������������г�������������ά��Ч���۲�

目的评价依托咪酯用于腮腺肿物切除手术麻醉维持的效果和不良反应。方法选择2011年8月至2012年2月在中国医科大学附属口腔医院择期全麻下行腮腺肿物切除手术患者40例,ASA分级Ⅰ-Ⅱ级,随机分为依托咪酯组（E组）和丙泊酚组（P组）,每组20例。常规诱导,给予长托宁0．5mg、咪达唑仑0．1mg／kg、罗库溴铵0．6mg／kg、芬太尼4μg/kg,依托咪酯0．3mg／kg;麻醉维持：持续静脉泵注瑞芬太尼O．1～0．4μg／（kg·min）,E组采用微量输液泵以10～15μg／（kg·min）连续输注依托咪酯,P组采用微量输液泵以6-10mg／（kg·h）连续输注丙泊酚,酌情追加顺苯磺酸阿曲库铵0．03mg／kg。分别记录诱导前、诱导后1min、插管后1min、手术切皮时、手术开始后30min及手术结束时的收缩压（SBP）、舒张压（DBP）、心率（HR）并记录停药后患者苏醒时间、拔管时间和术后不良反应。结果两组诱导后1minSBP、DBP明显下降（P〈0．05）。切皮时P组SBP、DBP、HR较E组低（P〈0．05）。E组与P组停药后苏醒时间和拔管时间差异均无统计学意义（P〉0．05）。两组患者均无术中知晓及术后恶心、呕吐;E组发生术后躁动2例,P组1例;E组术中有1例肌颤,P组有2例注射痛。结论在腮腺肿物切除手术过程中,应用依托咪酯复合瑞芬太尼麻醉维持,术中血流动力学平稳,苏醒迅速,麻醉效果满意,短时间内临床应用是安全可行的。     

Bispectral analysis during deep sedation of pediatric oral surgery patients.

PURPOSE: Bispectral (BIS) analysis uses electroencephalogram information from a forehead electrode to calculate an index score (0 to 100; 0 = coma; 90 to 100 = awake). This index score correlates with the level of alertness in anesthetized patients. Classically, sedation has been monitored with clinical sedation scales such as the Observers Assessment of Alertness Sedation Scale (OAA/S), Modified Ramsey Scale, or a Visual Analog Scale (VAS). Our objective was to determine the correlation between clinical sedation scales and BIS index in pediatric patients undergoing sedation in an outpatient oral surgery setting. MATERIALS AND METHODS: Prospective cohort study of patients aged 2 to 17 years undergoing sedation in an outpatient oral surgery office. Sedation was performed in the customary manner with the addition of BIS monitoring. Three clinical sedation scores (OAA/S: 5 to 1; 5 = awake, 1 = unresponsive; Modified Ramsey: 1 to 6; 1-2 = awake, 6 = unresponsive; VAS: 0 to 10; 0 = awake, 10 = unresponsive) were assigned every 5 minutes by an investigator blinded to the BIS index. Data were analyzed using a repeated measures linear regression model. RESULTS: Sixteen subjects undergoing oral surgery, ages 4.5 years to 17 years, were enrolled, mean age 12.6 years +/- 4.3 years (standard deviation). Patients received methohexital in addition to 1 or more of the following: nitrous oxide, fentanyl, or midazolam. The results of the longitudinal regression analysis showed a highly significant association between the sedation scales and the BIS index. CONCLUSION: The BIS monitor may be a useful adjunct in monitoring pediatric patients receiving sedation in the outpatient setting.     

用氯胺酮抑制颌面外科手术瑞芬太尼麻醉后痛觉过敏的临床研究

目的评价应用小剂量氯胺酮缓解颌面部手术瑞芬太尼麻醉后痛觉过敏的有效性和安全性。方法择期全麻下颌面部手术患者80例,随机分为氯胺酮组（n=40）和对照组（n=40）,均采用静吸复合全身麻醉。静脉注射咪唑安定、丙泊酚、芬太尼和罗库溴铵麻醉诱导后,气管插管行机械通气。麻醉维持采用瑞芬太尼0.1-0.2ug/kg/min泵注,吸入七氟醚2%~3%,间断给予罗库溴铵维持麻醉。分别于缝皮时静脉给予0.5mg/kg氯胺酮（氯胺酮组）和相同剂量的生理盐水（对照组）。记录两组患者拔管时间、苏醒时间及再次要求镇痛的患者例数、曲马多用量和不良事件的发生情况。分别于苏醒后15min（T1）、30min（T2）、60min（T3）、120min（T4）进行VAS、Ramsay评分。结果两组患者拔管时间、苏醒时间比较差异无统计学意义（P〉0.05）。氯胺酮组要求镇痛人数（17/40）和曲马多用量（40.5mg）均低于对照组（25/40,70.6mg）（P〈0.05）。患者苏醒后15min Ramsay评分氯胺酮组显著大于对照组（P〈0.01）,30min VAS评分对照组显著高于氯胺酮组（P〈0.05）。两组患者不良反应无显著差异。结论颌面部手术瑞芬太尼麻醉后使用小剂量氯胺酮,可以有效缓解瑞芬太尼所致的痛觉过敏,无不良反应,临床应用安全可靠。     

Clinical outcome of perioperative airway and ventilatory management in children undergoing craniofacial surgery

Data on the management of perioperative airway and ventilatory support in children undergoing craniofacial surgery are limited. The purpose of this study was to review the authors' experience with airway management and ventilatory support during the perioperative period in children undergoing craniofacial surgery. Ninety-five consecutive children underwent 99 craniofacial procedures from July 1, 1999, through June 30, 2002. Direct laryngoscopy was successfully used to establish an airway in 86 (86.8%) cases, whereas 13 (13.1%) cases required the use of fiberoptic bronchoscopy to establish an airway before surgery. The oral route was used in 82 (83%) cases, and the nasal route was used in 17 (17%) cases. Length of anesthesia was 330 +/- 160 minutes, and the actual surgical time was 246 +/- 151 minutes. The volume of crystalloids infused during surgery was 87 +/- 78 mL/kg body weight (BW), and the volume of packed red blood cells infused during surgery was 10 +/- 14 mL/kg BW (range, 0-60 mL/kg BW). Tracheal extubation was successfully accomplished in the postanesthesia recovery unit (PACU) in 57 (58%) patients, whereas 42 patients were admitted to the pediatric intensive care unit (PICU) and received mechanical ventilation for 10 +/- 9 hours (range, 1-60 hours). Of these, 37 (37%) were extubated in the PICU, whereas 5 patients were extubated in the operating room with the craniofacial surgeon in attendance in the event an emergency tracheostomy was needed. However, none of these patients required tracheostomy to maintain a secure airway. Three patients required reintubation after the first attempt at tracheal extubation in the PICU. All three of those patients subsequently were extubated without the need for tracheostomy. The length of tracheal intubation and mechanical ventilation was longer (24 +/- 13 hours versus 8.6 +/- 7 hours, P < 0.001) in patients who required bronchoscopic intubation than in those who were intubated using direct laryngoscopy. The length of hospital stay, although clinically relevant, did not reach statistical significance between the two groups (5 +/- 7 days versus 3.7 +/- 2.7 days, P = 0.5). A positive correlation was observed between the duration of tracheal intubation and mechanical ventilation and the following perioperative factors: anesthesia time (rho = 0.6, P < 0.01), surgical time (rho = 0.55, P < 0.01), volume of crystalloids (rho = 0.5, P < 0.01), and the volume of packed red blood cells infused (rho = 0.55, P < 0.01) during surgery. No episodes of cardiorespiratory arrest or death occurred in any of the patients. This study demonstrates that when performing complex craniofacial procedures in children, a thorough evaluation of the airway before surgery and continuous communication between specialists during the perioperative period is imperative for a successful outcome. Furthermore, most pediatric patients who require mechanical ventilation during the postoperative period do so for a short period of time following surgery.