Répercussions psychocomportementales en périopératoire chez l’enfant

The relevant literature since the 1940s has been collected from the Medline database, using the keywords: child, operation, anxiety, distress, postoperative complications, preparation, premedication, parental presence, prevention. Preoperative anxiety, emergence delirium, and postoperative behavior changes are all manifestations of psychological distress in children undergoing surgery. Preoperative anxiety is most prominent during anaesthesia induction. Emergence delirium is frequent and somewhat independent of pain levels. Postoperative behavior changes most often include separation anxiety, tantrums, fear of strangers, eating problems, nightmares, night terrors and bedwetting. These difficulties tend to resolve themselves with time but can last up to one year in some children. The major risk factors for postoperative behavior problems are young age, prior negative experience with hospitals or medical care, certain kinds of hospitalization, postoperative pain, parental anxiety, and certain personality traits of the child. Currently, tools exist for quantifying anxiety (m-YPAS) and postoperative behavior (PHBQ). It is possible to identify those children who are at risk for postoperative complications during the preanaesthesia consultation by paying close attention to children under six years with higher levels of emotionality and impulsivity and poorer socialization skills with anxious parents. Suggested strategies for reducing child distress include preoperative preparation, premedication, parental presence during anaesthesia induction, and interventions affecting the child's environment, such as hypnosis. There are numerous ways to provide preoperative preparation (information, modeling, role playing, encouraging effective coping) and their effectiveness is proven in the preoperative setting but not during anaesthesia induction or in the operating room. Midazolam has been shown to be an effective preoperative sedative for reducing anxiety. Parental presence during induction has been shown to effectively reduce preoperative anxiety in children in certain contexts (when the parent is calm and the child is anxious). It is worthwhile if it is integrated into a family-centered anxiety management program and remains one of several options offered to families. Overall, taking into account the child's psychological needs should be considered an essential part of paediatric anaesthesia. Tools and techniques are available for assessing and managing the perioperative distress experienced by children.     

右美托咪定对腺样体切除小儿患者苏醒期间的影响

目的:观察右美托咪定对小儿腺样体切除术后苏醒期间疼痛和躁动的影响。方法:选择择期行腺样体切除术,年龄4~12岁,ASA分级Ⅰ~Ⅱ级小儿患者88例。随机分为对照组(C组)和右美托咪定组(D组),每组44例。两组均采用8%七氟烷进行吸入麻醉诱导,C组诱导期间静脉给予芬尼2μg/kg,而D组则缓慢静注右美托咪定1μg/kg(给药时间大于10 min)随后0.5μg.kg-1.h泵注维持,手术结束前10 min停止。两组心率或收缩压较切皮前上升30%且持续3 min以上时静注1μg/kg。记录术中相关数据,在患者进入麻醉恢复时(0 min)、入室后5、10 min、15 min,以后每隔15 min测定疼痛评分、苏醒期躁动评分;疼痛评分大于4分或严重躁动持续3 min以上给予芬太尼0.5μg/kg。结果:两组术中均未使用阿托品和麻黄素控制心率和血压,D组术中心率较C组对应时间点低而收缩压比较无明显差别。D组患者睁眼时间和拔管时间明显短于C组(P<0.05,P<0.01);D组术中和复苏室追加芬太尼剂量分别为(22±8)μg和(15±7)g,与C组比较有统计学差异(P<0.05)。拔管后苏醒期间低氧发生率D组(5%)低于C组(12%),严重躁动发生率(观察时间为15 min内)D组(27%)显著低于C组(54%),两组比较有统计学差异(P<0.01)。D组在0、5和15 min重度疼痛评分比例较C组低(P<0.01)。结论:小儿患者腺样体切除术右美托咪定1μg/kg负荷剂量,随后0.5μg.kg-1.h泵注可以降低术后躁动的发生,减轻疼痛,降低镇痛药物(芬太尼)用量,减少麻醉恢复期间呼吸抑制的发生。     

不同剂量的芬太尼和曲马朵对预防全麻后苏醒期躁动的比较研究

目的探讨不同剂量芬太尼和曲马朵对预防全麻后苏醒期躁动的临床效果、不良反应和安全性。方法择期腹腔镜手术患者120例,随机分为曲马朵组（Q组）1、2、3mg／kg剂量组,芬太尼组（F组）0．1、0．2、0．3μg／kg剂量组,每组各20例。术毕前30min,Q组分别缓慢静脉输入曲马朵1、2、3mg／kg,F组分别缓慢静脉输入芬太尼0．1、0．2、0．3μg／kg。观察拔管前、拔管时、拔管后10min各组的躁动评分（RS）、镇静评分（RSS）和意识状态评分（0AAs）。结果Q组3mg剂量组RS评分低于1mg剂量组、2mg剂量组,差异有统计学意义（P〈0．05）。F组0．3μg／kg组RS评分低于0．1μg／kg组、0．2μg／kg组,差异有统计学意义（P〈0．05）。F组0．1μg／kg剂量组、0．2μg／kg剂量组、0．3μg／kg剂量组RS评分低于Q组1mg剂量组、2mg剂量组、3mg剂量组,差异有统计学意义（P〈0．05）。两组RSS评分差异无统计学意义（P〉0．05）。Q组1mg剂量组、2mg剂量组、3mg剂量组OAAS评分低于F组0．1μg／kg剂量组、0．2μg／kg剂量组、0．3μg／kg剂量组,差异有统计学意义（P〈0．05）。Q组3mg剂量组有3例拔管后SpO2〈95％需面罩加压给氧,F组0．2μg／kg剂量组有3例拔管后SpO2〈95％需面罩加压给氧,0．3μg／kg剂量组有10例拔管后SpO2〈95％需面罩加压给氧,0．3μg／kg剂量组有8例血压下降明显。结论芬太尼用于预防全麻后苏醒期躁动,效果明显优于曲马朵。芬太尼0．2μg／kg对呼吸、循环影响较小,较适合用于预防全麻后苏醒期躁动。     

右美托咪定对高血压患者全身麻醉苏醒期躁动及血流动力学的影响

目的 观察右美托咪定对高血压患者全身麻醉苏醒期躁动和血流动力学的影响。方法 选择既往有高血压病史,血压控制稳定,择期行胃癌根治手术的患者40例。随机分成右美托咪定组(D组)和生理盐水组(C组),均采用静吸复合全身麻醉,手术结束前60minD组静脉微泵注射右美托咪定0.5μg/kg(用生理盐水20ml稀释);C组静脉微泵注射生理盐水20ml。结果 D组躁动明显低于C组(P<0.01);D组患者术后1h的视觉模拟镇痛(VAS)评分明显低于C组(P<0.01);而C组围拔管期各时点的平均动脉压(MAP)、心率(HR)明显高于D组相应时点值(P<0.01或P<0.05)。结论 右美托咪定能有效减少高血压患者全身麻醉术后躁动发生率及血流动力学的变化。     

右美托咪啶预防全麻患者术后躁动和咽喉疼痛的临床观察

目的探讨右美托咪啶(DEX)对全麻患者术后躁动和咽喉疼痛的预防作用。方法选择在广西钦州市第二人民医院行择期腹腔镜妇科手术患者200例,按随机数字表法将其分为A组和B组,每组100例,两组均以咪唑安定、维库溴铵、舒芬太尼、丙泊酚诱导,丙泊酚、瑞芬太尼和七氟醚维持麻醉。手术结束前30min A组DEX 0.6μg/kg10min泵入,B组相同量生理盐水10min泵入。观察记录两组患者的自主呼吸恢复时间、呼之睁眼时间、拔管时间及苏醒期患者的躁动评级、身体舒适度评分(BCS)、术后24h咽喉疼痛评级。结果两组患者手术结束后,自主呼吸恢复时间、呼之睁眼时间及拔管时间差异无显著性(P<0.05),而躁动和咽喉痛发生率A组比B组明显降低(P<0.05),身体舒适度评分(BCS)A组明显高于B组(P<0.05)。结论 DEX可有效预防全麻术后躁动和咽喉疼痛的发生。     

A protocol for the cessation of sedation in brain-injured patients

Objectives

The cessation of sedation in brain-injured patients may result in severe agitation and/or acute withdrawal syndrome related to the prolonged administration of large doses of benzodiazepines and/or opioids. The aim of the present study was to assess the clinical efficacy of a written protocol to withdraw sedation for these patients.

Study design

Observational prospective study.

Patients and methods

After approval by the Institutional Review Board, 40 severely brain-injured patients were included. They had received continuous administration of midazolam and sufentanil or fentanyl for median 15 days. On cessation of midazolam infusion, patients were given clorazepate for 3 days. On cessation of opioid infusion and clorazepate, clinical data were collected for 48 hours: heart rate, systolic blood pressure, respiratory rate, agitation, and pupil diameter. If an opioid withdrawal syndrome occurred, patients received a 48-hour continuous infusion of buprenorphine.

Results

Of 40 patients, there were 10 who did not require buprenorphine. An agitation occurred 5 hours (1–21) after cessation of opioid, associated with tachycardia, arterial hypertension, and tachypnea. After 6 hours buprenorphine treatment, these parameters were normalized. No patient needed the reintroduction of the initial sedation.

Conclusion

The cessation of sedation in severely brain-injured patients can be successfully managed with the use of clorazepate, associated with buprenorphine in the presence of agitation.     

The patient and their family’s perspectives on agitation and its management in adult critical care: A qualitative study

BackgroundAgitation is frequently experienced by patients during critical illness, this is distressing for both the patient and their family. In addition, an acute episode of agitation can create management dilemmas for clinical teams. What is not understood is the patient and family’s perspective of agitation and any subsequent management strategies employed.ObjectiveTo understand the perspectives of patients and family members on the experience of agitation in adult critical care.MethodAn interpretive qualitative study using semi-structured interviews was undertaken with 13 participants, patient participants (n = 7) with the mean critical care length of stay 59 days (±70.88 days). Family members (n = 6) all opted to be interviewed with the patient present.FindingsThree themes generated from the data: 1) The recollection of sensations and delusions. 2) Communication and its impact. 3) Managing agitation, what helped and what did not.ConclusionThe presence of family members has a positive effect on the patient during episodes of agitation. Their involvement in care requires promotion.     

Implementation of a protocol for integrated management of pain,agitation, and delirium can improve clinical outcomes in the intensive care unit: A randomized clinical trial

Background

Inappropriate diagnosis and treatment of pain, agitation, and delirium (PAD) in intensive care settings results in poor patient outcomes. We designed and used a protocol for systematic assessment and management of PAD by the nurses to improve clinical intensive care unit (ICU) outcomes.

Materials and Methods

A total of 201 patients admitted to 2 mixed medical-surgical ICUs were randomly allocated to protocol and control groups. A multidisciplinary team approved the protocol. Pain was assessed by Numerical Rating Scale and Behavioural Pain Scale, agitation by Richmond Agitation Sedation Scale, and delirium by Confusion Assessment Method in ICU. The Persian version of the scales was prepared and tested for validity, reliability, and feasibility in a preliminary study. The patients in the protocol group were managed pharmacologically according to the protocol, whereas those in the control group were managed according to the ICU routine.

Results

The median (interquartile range) for the duration of mechanical ventilation in the protocol and control groups was 19 (9.3-67.8) and 40 (0-217) hours, respectively (P = .038). The median (interquartile range) length of ICU stay was 97 (54.5-189) hours in the protocol group vs 170 (80-408) hours in the control group (P < .001). The mortality rate in the protocol group was significantly reduced from 23.8% to 12.5% (P = .046).

Conclusion

The current randomized trial provided evidence for a substantial reduction in the duration of need to ventilatory support, length of ICU stay, and mortality rates in ICU-admitted patients through protocol-directed management of PAD.