小剂量吗啡在重症手足口病患儿机械通气中的应用研究

目的 观察小剂量吗啡对重症手足口病机械通气患儿镇静的有效性和安全性。 方法 2010年1月—2014年12月期间，收住儿科重症监护病房(PICU)且需行机械通气的重症手足口病患儿78例，随机均分为对照组和观察组。对照组患儿静脉给予咪达唑仑0.1 mg/kg后，以0.05～0.15 mg/(kg·h)维持；给予舒芬太尼0.1 μg/kg后，以0.03～0.06 μg/(kg·h)维持；观察组患儿静脉给予吗啡40 μg/kg后，以10～30 μg/(kg·h)静脉维持。首要观察指标是Ramsay评分、吸气峰压(PIP)、氧合指数、肌酸激酶(CK-MB)、机械通气时间。次要观察指标为血气、PICU入住时间、住院费用等。 结果 2组患儿均达到完善的镇静状态。机械通气后，PIP逐渐降至正常，但在插管后12 h(T_12h)和插管后1 d(D₁)，观察组PIP明显低于对照组(P=0.04；P=0.03)；患儿的氧合指数也逐渐改善，观察组在T_12h、D₁时间点明显优于对照组(P=0.01；P=0.04);肌酸激酶也在机械通气后逐渐降低,但对照组患儿肌酸激酶在T_12h、D₁和拔管前均明显高于观察组(P=0.05；P=0.05；P=0.03)。此外，观察组机械通气时间较对照组明显减少(P=0.02)；观察组PICU入住时间明显短于对照组(P=0.02)，住院费用也明显减少(P＜0.01)。 结论 机械通气期间给予小剂量吗啡和咪达唑仑联合舒芬太尼，均能使重症手足口病患儿达到满意的镇静程度。小剂量吗啡能较快地改善患儿的缺血缺氧症状和心肺功能，明显减少患儿机械通气时间、PICU的入住时间及住院费用。 

Efficacy and safety of low dose morphine on the sedation of children suffering from severe hand foot mouth during mechanical ventilation

Objective To observe the efficacy and safety of low dose morphine in the patients with severe hand foot mouth disease during the mechanical ventilation of. Methods From January 2010 to December 2014,78 patients with severe hand foot and mouth disease were randomly divided into control group(Con) and low dose morphine group(Mor).The ptients in Con group were given midazolam 0.1 mg/kg,and 0.05-0.15 mg/(kg·h) infusion continuously;sufentanil 0.1 μg/kg,and 0.03-0.06 μg/(kg·h) infusion continuously;while the patients in Mor group were given morphine 40 μg/kg,to 10-30 μg/(kg·h) infusion continuously.The primary outcomes included Ramsay scores,inspiratory peak pressure(PIP),oxygenation index(OI),creatine kinase (CK-MB),mechanical ventilation time;andthe secondary outcomes included blood gas,PICU time,hospital costs,etc. Results All patients achieved the perfect calm state.The inspiratory peak pressure decreased gradually to normal duration of the mechanical ventilation,but the PIP in Mor group was significantly lower than that in Con group at T_12h,D₁ point(P=0.04;P=0.03).With the mechanical ventilation time prolonged,the OI of patients turned gradually to normal,and the OI in Mor group was better than that in Con group at T_12h,D₁ point(P=0.01;P=0.04).The creatine kinase decreased gradually with the mechanical ventilation time prolonged too,but the CK-MB in Con group was still significantly higher than that in Mor group at T_12h,D₁ and before the extubation(P=0.05;P=0.05;P=0.03).The mechanical ventilation time in Mor group was less than that in Con group(P=0.02).The duration of PICU in Mor group was less than that in Con group(P=0.02).The charge of Mor group was less too(P<0.01). Conclusion Low dose of morphine and midazolam combined with sufentanil both can achieve satisfactory sedation state to the children with severe hand,foot and mouth disease during mechanical ventilation.The low dose of morphine can improve rapidly the hypoxia and ischemia symptoms,improve heart and lung function,and reduce significantly the mechanical ventilation time,the duration of PICU and hospital costs.