术前医学心理治疗对全麻病人苏醒的影响

全麻病人苏醒期因恐惧和焦虑的心理状态,多有躁动发生;而且气管拔管可刺激交感神经使病人血压急剧升高,易导致心脑血管意外。为了防止上述情况的发生,临床上多使用镇静催眠药和镇痛药及降压药物如乌拉地尔等治疗[1-3],这样不仅延长麻醉恢复期,还会增加病人的治疗费用。本研究旨在评价术前医学心理治疗对全麻病人苏醒期     

术前压力管理对全麻苏醒期躁动的影响

目的观察术前压力管理对全身麻醉患者苏醒期躁动发生率的影响。方法选择80例成年全身麻醉下行择期腹腔镜胆囊切除或子宫切除患者,无精神病、麻醉和手术史。随机分为压力管理组(P组)和对照组(C组),各40例。P组利用术前访视掌握患者心理情况,施行压力管理,向患者提供全身麻醉的客观存在和主观感受信息,帮助患者建立正确的心理防御机制。C组仅做常规访视。记录诱导前(T0)、术毕(T1)、拔管时(T2)、拔管后5 min(T3)、拔管后l0 min(T4)各时段HR、MAP、Sp O2,躁动评分,Ramsay镇静评分及苏醒时躁动发生率及程度。结果 2组术后清醒时间、拔管时间和Sp O2均无差异。麻醉苏醒期患者的HR、MAP升高幅度P组比C组低(P0.05)。P组躁动发生率低于C组,醒期躁动评分低于C组,2组相比有差异有统计学意义(P0.05)。结论手术前施行压力管理有助于降低全身麻醉患者苏醒期躁动的发生率。     

单次静注曲马多预防小儿斜视矫正术后全麻苏醒期躁动的观察

目的:小儿行斜视矫正术前单次静脉注射曲马多,观察其对小儿全麻苏醒期躁动的预防作用.方法:选择60例择期在全麻下行单侧眼斜视矫正术的小儿,ASA分级为Ⅰ-Ⅱ级,年龄3～9岁,随机分为曲马多组和对照组,曲马多组在全麻插入喉罩后静脉注射曲马多1.5mg/kg,对照组在全麻插喉罩后静脉注射相同容量的生理盐水.术中连续监测无创血压、心电图、心率、血氧饱和度.记录手术时间、麻醉时间、拔除喉罩时间并由另一位不知分组情况的医师评估拔管前两组患儿的Comfort评分(包括警惕度、平和/易怒、对呼吸机反应、生理运动、平均动脉压、心率、肌张力、面部表情共8个项目,每个项目1-5分,共40分.8-16分为深度镇静;17-26分为轻度镇静;27-40分为镇静不足.其中,Comfort评分17-26分为镇静满意,及苏醒期间的躁动评分(无躁动:0分、轻度躁动:1分、中度躁动:2分、重度躁动:3分),观察有无恶心呕吐、术后低氧血症、反流误吸等不良反应.结果:两组在手术时间、麻醉时间,拔管时间、术后低氧血症、恶心呕吐发生率均没有显著差异(P>0.05).Comfort评分:曲马多组和对照组的镇静满意率分刺为80%和60%,两组比较有显著性差异(P<0.05),曲马多组和对照组镇静不足的比率分别为10%和33%,曲马多组因为镇静不足引起的躁动发生机会要低于对照组,两组比较有显著性差异(P<0.05),在曲马多组迭到深度镇静的患乙比率为10%,对照组为6%,两组比较没有显著性差异(P>0.05).躁动评分:曲马多组与对照组中无或轻度躁动的比率分别为87%、33%,两组比较有显著性差异(P<0.05),曲马多组与对照组中度躁动的比率分别为10%、43%,两组比较无显著性差异,曲马多组与对照组重度躁动的比率分别为3%、23%,两组比较有显著性差异(P<0.05).结论:在小儿斜视矫正术前静注曲马多1.5mg/kg,可获得苏醒期良好的镇静镇痛效果,减少了拔除喉罩期的躁动.同时,不影响拔喉罩时同,不增加术后低氧血症、忍心呕吐、反流误吸等不良反应发生率.     

心理干预对全麻苏醒的影响

随着医疗技术的发展，外科手术领域的不断扩大，气管插管全身麻醉越来越被广泛应用。大部分手术病人术后需尽快苏醒，以便于观察手术疗效及进行术后护理。国内有关心理干预与医疗有关的文章已有不少，但与麻醉有关的文章尚未见报道。本文目的是研究心理干预对全麻病人苏醒的影响。     

右美托咪定持续输注对小儿全麻术后躁动的影响

目的探讨在小儿全麻手术中使用右美托咪定（dexmedetomidine,Dex）持续输注对术后躁动的影响。方法选取美国麻醉医师协会（ASA）分级Ⅰ-Ⅱ级、72名4岁．10岁在全麻下行骨折切开复位内固定手术的患儿,采用完全随机分组法随机分为4组（每组18例）,分别采用丙泊酚复合Dex（0．5μg·kg-1·h-1）（PD组）及七氟醚复合Dex（SD组）,丙泊酚复合生理盐水（PN组）及七氟醚复合生理盐水（SN组）。分别记录患儿泵注Dex前（T1）、泵注后10（T2）、20（T3）、30min（T4）及拔管时（L）的心率（heartrate,HR）、平均动脉压（mean artery pressure,MAP）、脑电双频指数（bispectralindex,BIS）;测定停止麻醉药物至拔管时间、睁眼时间;对术后患儿躁动及疼痛程度进行评分;计算患儿苏醒期躁动的发生率。结果①PD组与PN组比较、SD组与SN组比较,拔管时间[（7．1±2．6）min vs（4．4±2．1）min、（7．3±2．1）minvs（4．9±2．0）mini及睁眼时间[（16±6）minvs（10±3）min、（13±6）min vs（9±5）min]显著延长（P〈O．05）,但PD组与SD组比较差异无统计学意义（P〉0．05）。②PD组与PN组、SD组与SN组比较,术后躁动评分（1分vs2分、3分vs4分）及术后患儿疼痛程度评分（cHIPPS评分）（2_5分VS3分、4分vs7分）下降（P〈0．01）。SD组术后躁动发生率显著下降[SD组（5．6％）vsSN组（33．3％）]（P〈0．05）。PD组的躁动评分低于sD组（P〈0．05）。结论Dex虽会造成术后苏醒时间延长,但可以降低小儿麻醉术后躁动评分及术后即刻疼痛评分,并且显著降低七氟醚麻醉术后躁动发生率,使患儿苏醒期更加平稳。     

多感官唤醒方案在全身麻醉胸科手术患者中的应用

目的 探讨多感官唤醒方案在全身麻醉胸科手术患者中的应用效果。方法 将2021年1~8月的胸科手术患者按住院时间分为对照组与干预组各51例,对照组采用传统语音唤醒方案,干预组采用多感官唤醒方案,比较两组自主呼吸恢复时间、苏醒室停留时间,咽喉痛、躁动发生程度以及平均动脉压波动发生率。结果 干预组自主呼吸恢复时间、苏醒室停留时间显著短于对照组（均P＜0.05）;干预组咽痛、躁动发生程度显著低于对照组,平均动脉压波动发生率显著低于对照组（均P＜0.05）。结论 多感官唤醒方案扩展了原有单一感官的唤醒模式,能缩短胸科手术患者的苏醒时间及苏醒室停留时间,提高苏醒质量。     

脑状态指数预测龋齿手术患儿全麻苏醒期躁动的可行性

目的分析围术期脑状态指数(CSI)与患儿全麻苏醒期躁动(EA)的相关性,并探讨CSI预测EA的可行性。方法选取择期行口腔龋齿治疗手术的患儿100例,男58例,女42例,年龄2～7岁,ASAⅠ或Ⅱ级,根据全麻苏醒期患儿有无躁动分为两组:躁动组(A组)和无躁动组(NA组)。所有患儿静脉麻醉诱导气管插管后使用多功能组合式监护仪(HXD-I)监测CSI,分别记录插管后(T_1)、手术开始20 min(T_2)、停麻醉药时(T_3)、拔管后(T_4)及唤醒时(T_5)的CSI,包括镇静指数(WLi)、镇痛指数(PTi)、皮层下兴奋指数(SCEi)、皮层兴奋指数(CEi)、谵妄指数(DELi)、遗忘指数(AMi)、焦虑指数(ANXi)和舒适指数(CFi)。绘制相关指数的ROC曲线,计算各指数ROC曲线下面积(AUC)。结果患儿发生EA 21例(21%)。T_1—T_5时两组WLi、PTi、DELi和AMi差异均无统计学意义。T_5时A组SCEi、CEi、ANXi和CFi明显大于NA组(P0.05)。SCEi、CEi、ANXi和CFi预测EA的AUC分别为0.765、0.768、0.712和0.717,敏感性分别为81%、100%、85.7%和61.9%,特异性分别为70.9%、44.3%、49.4%和77.2%。结论 SCEi、CEi、ANXi和CFi均可有效预测龋齿手术患儿全麻EA的发生,但SCEi的预测效能最高。     

奥布卡因滴眼联合苏醒后术眼覆盖对斜视患儿全麻术后躁动的影响

目的 探讨不同护理措施对斜视患儿全麻术后躁动的作用.方法 选择3～12岁全身麻醉下行斜视矫正术的患儿696例,随机分为观察组和对照1、2组各232例,观察组在手术结束时于患儿结膜囊内滴入0.4％盐酸奥布卡因滴眼液1滴,手术眼无敷料覆盖送入麻醉恢复室,待患儿苏醒后与其沟通将敷料粘贴于眼部上方;对照1组手术结束时于患儿结膜囊内滴入0.4％盐酸奥布卡因滴眼液1滴,手术眼覆盖送入麻醉恢复室;对照2组在手术结束时直接将手术眼覆盖送入麻醉恢复室.观察并记录患儿苏醒期躁动的发生情况,评估发生躁动的程度.结果 观察组躁动发生率8.6％,对照1组躁动发生率13.8％,对照2组躁动发生率为35.8％,三组比较差异有统计学意义(P＜0.01).结论 手术眼滴0.4％盐酸奥布卡因联合苏醒后覆盖术眼对斜视患儿术后躁动有较好的预防作用.     

自制眼罩敷料在斜视手术患儿全麻苏醒期伤口护理中的应用

目的探讨自制眼罩敷料在斜视患儿矫正术后全麻苏醒期伤口护理中的应用效果。方法将100例斜视矫正全麻苏醒期患儿按入院时间分为对照组和观察组各50例。对照组采用常规双眼敷料包盖,观察组使用自制眼罩敷料护理伤口。比较两组患儿苏醒期临床表现、评分及苏醒期前后心率、呼吸变化。结果观察组苏醒期揉眼、哭闹、抓敷料发生率,评分及苏醒后心率、呼吸显著低于对照组(均P<0.01)。结论斜视患儿矫正术后使用自制眼罩敷料代替传统敷料包盖,可降低术后揉眼、哭闹、抓敷料的发生率,帮助患儿安全、平稳渡过全麻苏醒期。     

丙泊酚联合七氟烷麻醉对全麻下扁桃体切除术患儿苏醒期躁动的影响

目的观察丙泊酚联合七氟烷麻醉对全麻下扁桃体切除术患儿苏醒期躁动的影响。方法随机将行扁桃体切除术的94例患儿分为2组,各47例。对照组实施七氟烷麻醉,观察组采取丙泊酚联合七氟烷麻醉。观察2组麻醉苏醒时间、手术时间、不良反应、苏醒期躁动发生情况等。结果 (1)观察组Watcha评分、苏醒期躁动发生率低于对照组,差异有统计学意义(P0.05)。(2)2组麻醉苏醒时间、手术时间、不良反应发生率差异无统计学意义(P0.05)。结论丙泊酚联合七氟烷麻醉有助于提升全麻下扁桃体切除术患儿镇静效果,减少苏醒期躁动发生率,安全性较高。     

Effect of propofol on emergence behavior in children after sevoflurane general anesthesia

BACKGROUND: Emergence agitation (EA) is a postoperative behavior that may occur in children undergoing general anesthesia with inhaled agents. OBJECTIVES: The aim of the present study was to assess the effect of propofol administered at the end of sevoflurane anesthesia on the incidence and severity of EA in children undergoing magnetic resonance imaging (MRI). METHODS: Eighty-four children, 2-7 years old, undergoing MRI were enrolled in this randomized double-blind study. No sedative premedication was administered prior to anesthesia induction. Anesthesia was induced and maintained with sevoflurane in N(2)O/O(2). Group P received propofol 1 mg.kg(-1) and group S received saline. Pediatric Anesthesia Emergence Delirium scale (PAEDs) was used to evaluate recovery characteristics upon awakening and during the first 30 min after emergence from anesthesia. Children with PAEDs >16 were considered agitated. EA was analyzed using the Mann-Whitney U-test. Demographic data and other side effects were analyzed using the Student's t-test. RESULTS: Eighty-three children completed the study. There were 42 children in group P. EA was diagnosed in two children in the propofol group (4.8%) and in 11 children in the placebo group (26.8%, P < 0.05). Time to achieving postanesthesia care unit discharge criteria was not different between the two groups. CONCLUSIONS: The addition of propofol 1 mg.kg(-1) can significantly decrease the incidence of EA after sevoflurane general anesthesia in children undergoing nonpainful procedures.     

Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia

BACKGROUND: Emergence agitation or delirium is a known phenomenon that may occur in children undergoing general anesthesia with inhaled agents. Our aim was to test the hypothesis that the addition of a small dose of ketamine at the end of sevoflurane anesthesia will result in a decrease in the incidence and severity of such phenomenon. METHODS: We performed a randomized double blind study involving 85 premedicated children 4-7 years old undergoing dental repair. Children were premedicated with acetaminophen and midazolam. Anesthesia was induced and maintained with sevoflurane in N2O/O2. Group K received ketamine 0.25 mg.kg (-1) and Group S received saline. We evaluated recovery characteristics upon awakening and during the first 30 min using the Pediatric Anesthesia Emergence Delirium scale. RESULTS: Eighty of the 85 enrolled children completed the study. There were 42 children in Group I. Emergence agitation was diagnosed in seven children in the ketamine group (16.6%) and in 13 children in the placebo group (34.2%). There was no difference in time to meet recovery room discharge criteria between the two groups. CONCLUSIONS: We conclude that the addition of ketamine 0.25 mg.kg(-1) can decrease the incidence of emergence agitation in children after sevoflurane general anesthesia.     

全麻苏醒期患儿躁动风险预测模型的建立与验证

目的 建立与验证全麻苏醒期患儿躁动风险列线图预测模型,为识别躁动高风险患儿提供评估工具。方法 收集全麻手术的1～6岁患儿651例,随机分为建模组(n=459)和验证组(n=192),利用多因素logistic回归分析确定建模组全麻苏醒期患儿躁动的危险因素,构建列线图预测模型,分别使用建模组和验证组数据集对模型进行验证。结果 苏醒期发生躁动160例(建模组113例,验证组47例),躁动发生率24.58%。多因素logistic回归显示,年龄、手术科室、身体约束、麻醉方式、镇痛治疗、留置尿管是全麻苏醒期患儿躁动的影响因素(均P<0.05)。基于6个危险因素构建列线图预测模型,模型验证的校正曲线显示模型准确度良好,建模组ROC曲线下面积为0.767,验证组为0.827。结论 全麻苏醒期患儿躁动风险列线图预测模型具有良好的准确度和区分度,可为临床筛查术后躁动高危患儿提供评估工具。     

A comparison of emergence delirium scales following general anesthesia in children

Background: Emergence delirium (ED) is of increasing interest since the introduction of short‐acting volatiles such as sevoflurane. Methods: We compared the Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales for assessing the presence of ED in 117 of 118 consecutive children <18 years recovering from general anesthesia. The primary measure was the worst score for ED as assessed on each scale and for each patient during their PACU stay. An experienced anesthetist observer also made a subjective assessment of the presence of ED. Results: A PAED score of ≥10 detected ED in 37 children (32%), while the Watcha detected 30 (26%) and Cravero 41 (35%). Twenty‐five patients (21%) fulfilled criteria for ED in all three scales as did all eight patients assessed by the experienced pediatric anesthetist observer. Median PAED scores (interquartile ranges) for patients assessed as having ED or not respectively were for Watcha, 12 (11,14), 7 (4,8); for Cravero, 11 (9,13), 7 (4,8); and for the experienced anesthetist observer, 14.5 (13.5,16.5), 7 (6,10). Conclusions: All three scales correlated reasonably well with each other but have individual limitations in their potential to assess whether ED is present. In the absence of developing an improved research tool to assess ED, a PAED score >12 appears to provide greater sensitivity and specificity than a PAED score ≥10. However, the Watcha scale is a simpler tool to use in clinical practice and may have a higher overall sensitivity and specificity than the other scales.     

Midazolam does not reduce emergence delirium after sevoflurane anesthesia in children

Background: Behavioral disturbance in children following sevoflurane anesthesia is a relatively frequent event. The aim of this study was to evaluate whether a higher dose of preoperatively administered rectal midazolam compared with a lower would alleviate this phenomenon. Furthermore the impact of these two doses of midazolam on sedation at induction of anesthesia was compared. Methods: A total of 115 children presenting for minor surgery under anesthesia were included in the study. The children were randomized to receive rectally either 1 mg·kg⁻¹ midazolam (group H) or 0.5 mg·kg⁻¹ midazolam (group L). General anesthesia was induced with propofol or sevoflurane and maintained with 1.5% sevoflurane in the inspiratory limb. Prior to the start of surgery a regional block was performed to ensure adequate pain relief. Behavior on emergence was assessed using a three point scale. In case of severe agitation propofol was administered IV. Results: The children in group H were significantly better sedated preoperatively (P < 0.01). There was no significant difference in emergence behavior: 42.1% of children in group H compared with 36.2% of children in group L exhibited severe agitation requiring sedation with propofol (P = 0.37). However, regardless of the preoperative dose of midazolam more children under the age of 36 months (61.4%) were severely distressed at emergence compared with older children (16.7%) (P < 0.01). Conclusions: A higher dose of 1 mg·kg⁻¹ rectal midazolam results in much better sedated children on induction of anesthesia than 0.5 mg·kg⁻¹. This, however, does not result in a reduced incidence of emergence delirium after sevoflurane anesthesia. Regardless of the premedication negative behavioral changes occur more frequently in children younger than 3 years of age.     

缩短全麻下咽喉部手术患儿术后禁食禁饮时间研究

目的探讨咽喉部患儿全身麻醉术后适宜的禁食时间,促进患儿术后恢复。方法将102例择期咽喉部全麻手术患儿(3～14岁)随机分为观察组(53例)和对照组(49例)。观察组在患儿意识清醒且吞咽功能恢复的前提下2h后开始进食,先饮少量凉开水,如无误吸现象可进纯奶油冰淇淋或流质;对照组按照常规护理,即患儿麻醉清醒6h后开始进食。比较两组患儿术后6h、24h疼痛、恶心、呕吐、口渴、饥饿等不适发生率。结果观察组患儿术后6h疼痛、恶心、口渴、饥饿不适症状发生率显著低于对照组(均P<0.01)。结论早期进食能有效缓解咽喉部患儿全麻术后的不适症状,有利于患儿尽快恢复。     

Characterizing the behavior of children emerging with delirium from general anesthesia

Background: Emergence delirium (ED) frequently occurs in young children awakening from general anesthesia (GA). To date, research is limited by scales that are unable to discriminate the condition from other forms of agitation. Aim: The primary aim of this study was to determine the core behaviors of ED that discriminate the condition from pain and tantrum in young children and to cluster these behaviors according to the DSM‐IV/V core diagnostic criteria and associated behaviors of delirium. Method: Children aged 18 months to 6 years (n = 198) were observed upon awakening from GA following surgical or nonsurgical procedures to determine which behaviors categorize ED. Behaviors were recorded via a structured behavioral observation. Clinical opinion was sought to determine whether the child presented ED, pain, or tantrum. Results: A chi‐square analysis revealed children with ED were significantly more likely to display activity, nonpurposefulness, eyes averted, stared or closed, no language, and nonresponsivity. These behaviors were not significantly associated with pain or tantrum. A logistic regression showed eyes averted or stared and nonpurposefulness were significant predictors of ED, while no language and activity were not significant predictors of ED. Conclusions: Children with ED are significantly more likely to display nonpurposefulness, eyes averted, stared or closed, and nonresponsivity. These behaviors were not significantly associated with pain or tantrum and are believed to reflect the DSM‐IV/V diagnostic criteria for delirium. Associated behaviors of ED identified by this research are irrelevant language, activity, and vocalization.