右美托咪定在儿童脊髓栓系综合征手术麻醉维持的应用分析
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摘要
目的探讨右美托咪定在儿童脊髓栓系综合征(TCS)手术全身麻醉维持中,对机体正常呼吸及循环功能的维持作用。方法选择2018年9月25日,因"发现骶尾部包块3~+个月",于四川大学华西医院进行手术治疗时,采取右美托咪定进行麻醉维持的1例TCS患儿为研究对象。采用回顾性分析方法,收集该例患儿的临床病例资料,对其手术麻醉维持方案及其效果进行总结。对儿童TCS手术麻醉维持相关文献进行复习时,设定检索策略为:分别以"脊髓栓系综合征""儿童""麻醉""tethered cord syndrome""pediatric"及"anesthesia"为中、英文关键词,在PubMed数据库、EMBASE数据库、中国生物医学文献服务系统(SinoMed)、中国知网(CNKI)、万方数据知识服务平台、维普中文科技期刊数据库中,检索儿童TCS手术麻醉维持相关文献,检索时间设定为2007年1月1日至2018年10月1日。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求。结果①病史采集及辅助检查结果:本例患儿为男性,3~+个月龄,发现骶尾部包块3~+个月,其他发育正常。MRI检查结果显示,骶管增粗,L4至S3平面骶管后部可见梭形脂肪信号影(4.0 cm×1.2 cm×1.3 cm)。②手术治疗方案:对本例TCS患儿进行脊髓黏连松解术+椎管内外巨大占位切除术,采用术中神经电生理监测(IONM)技术,对患儿运动诱发电位(MEP)、肌电图进行监测。③手术麻醉诱导及维持方案:对本例患儿TCS手术采取8%七氟烷潮气量法,并静脉注射舒芬太尼5μg、顺阿曲库铵2 mg进行麻醉诱导。同时,采用静脉注射右美托咪定0.5～1.0μg/(kg·min)联合瑞芬太尼0.15～0.20μg/(kg·min)进行麻醉维持,麻醉维持时间为5.1 h。患儿术后未发生低血压、心率降低等不良反应,拔管顺利,术后第4天顺利出院。④文献复习结果:按照本研究设定的文献检索策略,共计检索出5篇文献报道儿童TCS手术麻醉维持方案,涉及277例TCS患儿。这277例TCS患儿接受手术治疗时,手术麻醉维持方案为静脉注射丙泊酚或吸入异氟烷或二者联合使用;手术过程中,除1篇文献报道27例患儿应用IONM技术外,其余均未应用IONM技术;其麻醉维持时间均较短,为50～260 min。结论对于术中需持续使用IONM、手术时间长的儿童TCS手术,可采用右美托咪定进行麻醉维持,但是需联合使用舒芬太尼、瑞芬太尼等。对于右美托咪定用于儿童TCS手术麻醉维持的剂量选择,仍然需要大样本、患儿长期预后随访进一步研究、证实。
Objective To explore the effects of dexmedetomidine on maintaining the normal breathing and circulatory functions during pediatric tethered cord syndrome(TCS) surgery with general anesthesia maintenance. Methods On September 25, 2018, a child with TCS and discovery of sacrococcygeal mass for 3~+ months who underwent surgical treatment with dexmedetomidine for anesthesia maintenance in West China Hospital of Sichuan University was selected as research subject. A retrospective analysis was conducted to collect the clinical data of the patient, summarize the anesthesia maintenance plan during operation and its effects. When reviewing literatures related to anesthesia maintenance in pediatric TCS surgery, the strategies of literature retrieval were set as follows. With the keywords of "tethered cord syndrome" "pediatric" and "anesthesia" both in Chinese and English, literatures related to anesthesia maintenance of pediatric TCS surgery were searched from PubMed database, EMBASE database, SinoMed, China National Knowledge Infrastructure(CNKI), Wanfang Data Knowledge Service Platform and VIP database. The retrieval time was set from January 1, 2007 to October 1, 2018. The procedure followed in this study met the requirements of the World Medical Association Declaration of Helsinki revised in 2013. Results ①Medical history collection and auxiliary examination results: this child was male, 3~+ months old, with discovery of sacrococcygeal mass 3~+ months and without other abnormal development. The results of MRI showed that his sacral canal was enlarged and spindle fat signal was found in the posterior part of the sacral canal from L4 to S3 planes, which was about 4.0 cm × 1.2 cm × 1.3 cm. ②Surgical treatment: this child with TCS received the treatment of spinal cord adhesiolysis and resection of giant space occupying both inside and outside the spinal canal. Intraoperative neurophysiological monitoring(IONM) technique was used during the operation to monitor the motor evoked potential(MEP) and electromyogram of the child. ③Anesthesia induction and maintenance methods: inhalation of 8% sevoflurane by tidal volume method and intravenous injection of 5 μg sufentanil and 2 mg cisatracurium was used as anesthesia induction plan. Intravenous injection of dexmedetomidine 0.5-1.0 μg/(kg·min) combined with remifentanil 0.15-0.20 μg/(kg·min) was used as anesthesia maintenance plan for pediatric TCS operation. The duration of anesthesia maintenance was 5.1 h. No symptoms such as hypotension and heart rate decrease occurred after operation. Tracheas were successfully extubated, and the child discharged from hospital on the fourth day after operation. ④The results of literatures review were as follows. A total of 5 articles related to anesthesia maintenance for pediatric TCS operation were retrieved, involving 277 children with TCS. During the operation, intravenous injection of propofol, or inhalation of isoflurane, or the combination of these two were used as anesthesia maintenance plans for pediatric TCS operation. During the operation, except for one literature reported that 27 children were monitored by IONM technology, the rest were not monitored by IONM technology, and the duration of anesthesia maintenance was short, ranging from 50 to 260 min. Conclusions For pediatric TCS operation with the need of continuous use of IONM and long operation duration, dexmedetomidine can be used for anesthesia maintenance, but sufentanil and remifentanil should be combined to achieve ideal state of anesthesia maintenance. However, the dose of dexmedetomidine for anesthesia maintenance of pediatric TCS surgery still needs to be further confirmed by large-sample and long-term prognostic follow-up clinical studies.
Objective To explore the effects of dexmedetomidine on maintaining the normal breathing and circulatory functions during pediatric tethered cord syndrome(TCS) surgery with general anesthesia maintenance. Methods On September 25, 2018, a child with TCS and discovery of sacrococcygeal mass for 3~+ months who underwent surgical treatment with dexmedetomidine for anesthesia maintenance in West China Hospital of Sichuan University was selected as research subject. A retrospective analysis was conducted to collect the clinical data of the patient, summarize the anesthesia maintenance plan during operation and its effects. When reviewing literatures related to anesthesia maintenance in pediatric TCS surgery, the strategies of literature retrieval were set as follows. With the keywords of "tethered cord syndrome" "pediatric" and "anesthesia" both in Chinese and English, literatures related to anesthesia maintenance of pediatric TCS surgery were searched from PubMed database, EMBASE database, SinoMed, China National Knowledge Infrastructure(CNKI), Wanfang Data Knowledge Service Platform and VIP database. The retrieval time was set from January 1, 2007 to October 1, 2018. The procedure followed in this study met the requirements of the World Medical Association Declaration of Helsinki revised in 2013. Results ①Medical history collection and auxiliary examination results: this child was male, 3~+ months old, with discovery of sacrococcygeal mass 3~+ months and without other abnormal development. The results of MRI showed that his sacral canal was enlarged and spindle fat signal was found in the posterior part of the sacral canal from L4 to S3 planes, which was about 4.0 cm × 1.2 cm × 1.3 cm. ②Surgical treatment: this child with TCS received the treatment of spinal cord adhesiolysis and resection of giant space occupying both inside and outside the spinal canal. Intraoperative neurophysiological monitoring(IONM) technique was used during the operation to monitor the motor evoked potential(MEP) and electromyogram of the child. ③Anesthesia induction and maintenance methods: inhalation of 8% sevoflurane by tidal volume method and intravenous injection of 5 μg sufentanil and 2 mg cisatracurium was used as anesthesia induction plan. Intravenous injection of dexmedetomidine 0.5-1.0 μg/(kg·min) combined with remifentanil 0.15-0.20 μg/(kg·min) was used as anesthesia maintenance plan for pediatric TCS operation. The duration of anesthesia maintenance was 5.1 h. No symptoms such as hypotension and heart rate decrease occurred after operation. Tracheas were successfully extubated, and the child discharged from hospital on the fourth day after operation. ④The results of literatures review were as follows. A total of 5 articles related to anesthesia maintenance for pediatric TCS operation were retrieved, involving 277 children with TCS. During the operation, intravenous injection of propofol, or inhalation of isoflurane, or the combination of these two were used as anesthesia maintenance plans for pediatric TCS operation. During the operation, except for one literature reported that 27 children were monitored by IONM technology, the rest were not monitored by IONM technology, and the duration of anesthesia maintenance was short, ranging from 50 to 260 min. Conclusions For pediatric TCS operation with the need of continuous use of IONM and long operation duration, dexmedetomidine can be used for anesthesia maintenance, but sufentanil and remifentanil should be combined to achieve ideal state of anesthesia maintenance. However, the dose of dexmedetomidine for anesthesia maintenance of pediatric TCS surgery still needs to be further confirmed by large-sample and long-term prognostic follow-up clinical studies.
引文
[1] 陈可夫, 贾连顺, 史建刚. 脊髓栓系综合征病因的研究进展[J]. 中国矫形外科杂志, 2016, 24(1): 55-57.
[2] 林坚. 儿童脊髓栓系综合征的治疗分析[C]//浙江省医学会神经外科学分会. 2014浙江省神经外科学学术年会论文汇编, 湖州, 2014. 杭州: 浙江省医学会神经外科学分会, 浙江省科学技术协会, 2014: 1.
[3] 杨雄. 儿童脊髓栓系综合征的手术疗效及预后分析[D]. 武汉: 华中科技大学, 2016.
[4] 荆俊杰, 赵清爽, 王守森, 等. 术中神经电生理监测下显微手术治疗儿童脊髓栓系综合征27例[J/CD]. 中华临床医师杂志(电子版), 2013, 7(21): 9553-9554.
[5] 刘福云. 脊髓栓系综合征的诊断与治疗[J]. 实用儿科临床杂志, 2008, 23(11): 812-814.
[6] 秦洪猛, 韩志刚. 婴幼儿脊髓栓系松解术的麻醉处理[J]. 河南外科学杂志, 2007, 13(1): 21-22.
[7] 蓝雨雁, 黄艺文, 覃怡, 等. 婴幼儿脊髓栓系松解术麻醉方法的探讨(附46例报告)[J]. 广西医学, 2007, 29(8): 1273-1274.
[8] 徐亚莉, 吕志瑞, 沈霞. 小儿脊髓栓系综合症的麻醉配合[J]. 医学信息(上旬刊), 2010, 23(18): 3484.
[9] 姬乐婷, 姜丽华. 瑞芬太尼复合丙泊酚全凭静脉麻醉用于小儿脊髓栓系综合征手术的临床观察[J]. 中国实用医刊, 2010, 37(2): 85.
[10] 张玉龙, 角述兰. 运动诱发电位与麻醉的研究进展[J]. 临床麻醉学杂志, 2013, 29(7): 718-720.
[11] Shida Y, Shida C, Hiratsuka N, et al. High-frequency stimulation restored motor-evoked potentials to the baseline level in the upper extremities but not in the lower extremities under sevoflurane anesthesia in spine surgery[J]. J Neurosurg Anesthesiol, 2012, 24(2): 113-120.
[12] 汪露, 角述兰, 杨娟, 等. 地氟醚和七氟醚对术中运动诱发电位监测的影响[J]. 临床麻醉学杂志, 2015, 31(3): 253-256.
[13] Parris-Piper T. Recent advances in intravenous anaesthesia[J]. Br J Anaesth, 2005, 94(3): 393.
[14] Withington DE, Decell MK, Al Ayed T. A case of propofol toxicity: further evidence for a causal mechanism[J]. Pediatr Anesth, 2004, 14(6): 505-508.
[15] Gottschling S, Meyer S, Krenn T, et al. Effects of short-term propofol administration on pancreatic enzymes and triglyceride levels in children[J]. Anaesthesia, 2005, 60(7): 660-663.
[16] 王猛, 古妙宁. 丙泊酚在婴幼儿的临床应用[J]. 临床麻醉学杂志, 2007, 23(3): 260-261.
[17] 陈明华, 张西京. 右美托咪定的小儿临床应用研究新进展[J]. 医学综述, 2014, 20(1): 112-115.
[18] Mason KP, Lerman J. Review article: dexmedetomidine in children: current knowledge and future applications[J]. Anesth Analg, 2011, 113(5): 1129-1142.
[19] 任海洋, 高建华. 右美托咪定预防小儿全麻苏醒期躁动的研究进展[J]. 医学综述, 2015, 21(11): 2019-2021.
[2] 林坚. 儿童脊髓栓系综合征的治疗分析[C]//浙江省医学会神经外科学分会. 2014浙江省神经外科学学术年会论文汇编, 湖州, 2014. 杭州: 浙江省医学会神经外科学分会, 浙江省科学技术协会, 2014: 1.
[3] 杨雄. 儿童脊髓栓系综合征的手术疗效及预后分析[D]. 武汉: 华中科技大学, 2016.
[4] 荆俊杰, 赵清爽, 王守森, 等. 术中神经电生理监测下显微手术治疗儿童脊髓栓系综合征27例[J/CD]. 中华临床医师杂志(电子版), 2013, 7(21): 9553-9554.
[5] 刘福云. 脊髓栓系综合征的诊断与治疗[J]. 实用儿科临床杂志, 2008, 23(11): 812-814.
[6] 秦洪猛, 韩志刚. 婴幼儿脊髓栓系松解术的麻醉处理[J]. 河南外科学杂志, 2007, 13(1): 21-22.
[7] 蓝雨雁, 黄艺文, 覃怡, 等. 婴幼儿脊髓栓系松解术麻醉方法的探讨(附46例报告)[J]. 广西医学, 2007, 29(8): 1273-1274.
[8] 徐亚莉, 吕志瑞, 沈霞. 小儿脊髓栓系综合症的麻醉配合[J]. 医学信息(上旬刊), 2010, 23(18): 3484.
[9] 姬乐婷, 姜丽华. 瑞芬太尼复合丙泊酚全凭静脉麻醉用于小儿脊髓栓系综合征手术的临床观察[J]. 中国实用医刊, 2010, 37(2): 85.
[10] 张玉龙, 角述兰. 运动诱发电位与麻醉的研究进展[J]. 临床麻醉学杂志, 2013, 29(7): 718-720.
[11] Shida Y, Shida C, Hiratsuka N, et al. High-frequency stimulation restored motor-evoked potentials to the baseline level in the upper extremities but not in the lower extremities under sevoflurane anesthesia in spine surgery[J]. J Neurosurg Anesthesiol, 2012, 24(2): 113-120.
[12] 汪露, 角述兰, 杨娟, 等. 地氟醚和七氟醚对术中运动诱发电位监测的影响[J]. 临床麻醉学杂志, 2015, 31(3): 253-256.
[13] Parris-Piper T. Recent advances in intravenous anaesthesia[J]. Br J Anaesth, 2005, 94(3): 393.
[14] Withington DE, Decell MK, Al Ayed T. A case of propofol toxicity: further evidence for a causal mechanism[J]. Pediatr Anesth, 2004, 14(6): 505-508.
[15] Gottschling S, Meyer S, Krenn T, et al. Effects of short-term propofol administration on pancreatic enzymes and triglyceride levels in children[J]. Anaesthesia, 2005, 60(7): 660-663.
[16] 王猛, 古妙宁. 丙泊酚在婴幼儿的临床应用[J]. 临床麻醉学杂志, 2007, 23(3): 260-261.
[17] 陈明华, 张西京. 右美托咪定的小儿临床应用研究新进展[J]. 医学综述, 2014, 20(1): 112-115.
[18] Mason KP, Lerman J. Review article: dexmedetomidine in children: current knowledge and future applications[J]. Anesth Analg, 2011, 113(5): 1129-1142.
[19] 任海洋, 高建华. 右美托咪定预防小儿全麻苏醒期躁动的研究进展[J]. 医学综述, 2015, 21(11): 2019-2021.