小儿颞下颌关节强直手术的麻醉处理

目的: 探讨小儿颞下颌关节强直手术的麻醉和困难气道管理。方法: 回顾性分析43例小儿颞下颌关节强直开口受限,困难气道病例资料,在保留自主呼吸的情况下,分为氯胺酮组（K1组）和氯胺酮复合右美托咪定组（K2组）。K1组和K2组均静脉给予氯胺酮1~2 mg/kg,K2组则追加静注右美托咪定1 μg/kg。患者意识消失后,辅以气管内和咽喉区表面麻醉。采用纤维支气管镜经鼻腔气管插管。插管过程中,根据患者反应小剂量滴定氯胺酮,维持麻醉深度。采用GraphPad Prism 6.0软件对数据进行统计学分析。结果: 所有患儿均在纤维支气管镜下经鼻腔成功气管插管。插管过程中,氧饱和度<95%发生率K2组略低于K1组,差异无统计学意义（P>0.05）。插管过程中追加氯胺酮次数和氯胺酮总剂量K2组显著低于K1组（P<0.05）,插管时心率变化和插管用时K2组显著低于K1组（P<0.05）。结论: 氯胺酮麻醉辅以良好的气管内和咽喉区表面麻醉,可完成小儿颞下颌关节强直开口受限的困难气道纤维支气管镜插管,氯胺酮复合右美托咪定可使小儿困难气道的插管过程更短、更平稳。

Anesthetic management of children with temporomandibular joint ankylosis and restricted mouth opening

PURPOSE: To investigate anesthetic and difficult airway management in children with temporomandibular joint (TMJ) ankylosis. METHODS: Forty-three children with TMJ ankylosis and difficult airway were analyzed retrospectively . In case of spontaneous breathing, they were divided into ketamine group (K1 group) and Ketamine combined with dexmedetomidine group (K2 group). The dose of ketamine administration was 1~2 mg/kg intravenously in K1 group. In K2 group, 1 μg/kg dexmedetomidine was intravenously injected after ketamine administration.After the patients' consciousness disappearing, they were treated with intratracheal and laryngopharyngeal surface anesthesia, and intubated with fibrobronchoscopic nasal intubation. During intubation, the depth of anesthesia was maintained by adding titration of small dose of ketamine. GraphPad Prism 6.0 software was used to analyze the data. RESULTS: The children in both groups were successfully intubated through fibrobronchoscopic nasal intubation. During intubation, respiratory incidence (oxygen saturation<95%) rates in K2 group was a little lower than that in K1 group, but the difference was not significant (P>0.05). During intubation, the times of ketamine supplement in K2 group was significantly lower than that in K1 group, total ketamine dosage in K2 group was significantly lower than that in K1 group, and heart rate variation in K2 group was significantly lower than that in K1 group during intubation (P<0.05). CONCLUSIONS: Ketamine anesthesia combined with sufficient intratracheal and laryngopharyngeal surface anesthesia can accomplish the difficult airway fibrobronchoscope intubation in children with TMJ ankylosis, and ketamine combined with dexmedetomidine can make the intubation process of children's difficult airway shorter and more stable.