超前镇痛联合适度镇静对患儿髋部手术围手术期镇痛疗效的影响

目的：通过前瞻性随机对照临床试验，探索小儿髋关节手术围手术期超前镇痛联合适度镇静的有效性和安全性。方法2012年4月至2013年11月，对本组进行髋部手术的66例患儿，随机分为A、B1、B2三组。术前A组不行超前镇痛处理，B1组和B2组均予以超前镇痛（术前乙酰氨基酚混悬滴剂口服＋术中“鸡尾酒”注射）；术后A组采用常规镇痛（镇痛泵＋曲马多）， B1组采用常规剂量复合镇痛（镇痛泵＋咪达唑仑＋曲马多），B2组采用半量复合镇痛模式。术后72 h后，三组均拔除镇痛泵；在术后第7天出院并停用曲马多注射液，院外改用口服对乙酰氨基酚混悬液维持1周。在患儿麻醉苏醒时进行躁动评分，出麻醉后监测治疗室（PACU）时进行镇静及躁动评分（SAS），术后2、4、8、12、24、48、72 h进行Ramsay镇静深度评估和CRIES疼痛评估。并记录各组患儿治疗过程中发生的不良反应。结果麻醉苏醒时躁动评分A组和B1组（2.7±0.7 vs．2.3±0.3，P＜0.05）， A组和B2组（2.7±0.7 vs.2.2±0.6，P＜0.05）相比差异具有统计学意义；PACU出室时SAS评分A组和B1组（5.3±1.2 vs.4.1±0.9，P＜0.01），A组和B2组（5.3±1.2 vs.4.4±1.2，P＜0.05）相比差异有统计学意义。术后各时间点镇静程度和疼痛控制效果，B1组与A组比较，在大部分时间点上B1组数据指标较A组有优势；B2组与A组比较，在12 h内各项指标较A组具有统计学差异，12 h后各项指标与A组比较无统计学差异；B1和B2组比较，12 h内各项指标无统计学差异，12 h后有统计学差异。结论通过采用超前镇痛联合术后适度镇静的模式，具有相互增强作用，可以使得镇痛效应最大化，可以有效减少小儿髋关节手术围术期疼痛，取得良好的镇痛效果。镇痛药物减量联合镇静的方法可以作为儿童临床镇痛选择之一。

Effects of preemptive analgesia and moderate sedation on perioperative analgesia of children＇s hip surgery

Objective To evaluate the efficacy and safety of the preemptive analgesia combined with the moderate sedation for the hip surgeries in children .Methods From 2012.4 ~2013.11, 66 children were randomly divided into three groups （ A、B1、B2 ） .The preemptive analgesia was applied in group B1 and B2 （ perioperative acetaminophen and Cocktail during the procedure ） .After the procedure , the traditional analgesia of the patient controlled analgesia （ PCA） and tramadol was applied in group A . The traditional analgesia combined with midazolam was applied in group B 1, while half of the traditional dosage was applide in group B 2.PCA was removed from all the children 3 days after the procedure . Tramadol was stopped 7 days after the procedure , when the children were discharged from the hospital .The next week the children were given acetaminophen .The restlessness was evaluated when awaking from anesthesia, and SAS assessment was performed when leaving the postanesthesia care unit （PACU）.At 2, 4, 8, 12, 24, 48 and 72 hours after the procedure , Ramsay scale for sedation and CRIES scale for pain were performed .Results Compared with group A , the degree of restlessness of group B 1 （ 2.7 ±0.7 vs.2.3 ±0.3,P〈0.05） and group B2 were lower （2.7 ±0.7 vs.2.2 ±0.6,P〈0.05）.When leaving the PACU, group A had higher SAS score than either group B 1 （5.3 ±1.2 vs.4.1 ±0.9,P〈0.01） or group B2 （5.3 ±1.2 vs.4.4 ±1.2,P〈0.05）.As for the analgsia and sedation assessment , group B1 was better than group A at most of the time points; group B2 was better than group A within 12 hours after the procedure;group B1 became better than group B 2 since 12 hours after the procedure .Conclusion The combination of the preemptive analgesia and the postoperative moderate sedation would lead to a synergistic effect , which could significantly relieve the perioperative pain of the children .