艾司氯胺酮复合麻醉在小儿瘢痕非插管全身麻醉患者超脉冲点阵二氧化碳激光治疗术中的应用及效果观察

目的探讨艾司氯胺酮+七氟烷+小儿布洛芬肛栓在小儿烧伤后增生性瘢痕非插管全身麻醉患者超脉冲二氧化碳点阵激光(UFCL)治疗术中的应用及效果观察。 方法选取2020年1月至2021年4月就诊于空军军医大学第一附属医院烧伤与皮肤外科门诊89例烧伤后增生性瘢痕患儿纳入本随机对照临床试验。将患儿采用随机数字表法分为氯胺酮+丙泊酚组共42例，其中男22例，女20例，平均年龄为(44.33±14.87)个月]和复合麻醉镇痛组(艾司氯胺酮+七氟烷+小儿布洛芬肛栓)共47例，男24例，女23例，平均年龄(44.47±14.65)个月]；在麻醉前和术中监测患儿血流动力学指标以及警觉/镇静(OAA/S)量表评分；在麻醉清醒时(T0)、麻醉清醒后1 h(T1)、麻醉清醒后2 h(T2)应用儿童疼痛行为量表(FLACC)对患儿疼痛程度进行评估；分别于术前和术后6个月应用温哥华瘢痕量表(VSS)对瘢痕进行评分。对数据行独立样本t检验和χ²检验。 结果(1)麻醉前氯胺酮+丙泊酚组血流动力学及OAA/S量表评分平均动脉压(63.71±3.40)mmHg、心率(107.21±9.45)次/min、呼吸(25.29±2.34)次/min、血氧饱和度(99.00±0.80)%、OAA/S量表评分(4.64±0.49)分]与复合麻醉镇痛组平均动脉压(63.87±3.57)mmHg、心率(109.34±12.21)次/min、呼吸(26.473.53)次/min、血氧饱和度(98.77±0.91)%、OAA/S量表评分(4.57±0.50)分]比较差异均无统计学意义(t＝-0.213、0.490、-1.840、1.280、0.204，P>0.05)；麻醉后手术中氯胺酮+丙泊酚组平均动脉压(56.29±2.43)mmHg、心率(94.48±7.01)次/min、呼吸(21.07±3.03)次/min、血氧饱和度(96.12±1.64)%、OAA/S量表评分(2.07±0.71)分]与复合麻醉镇痛组平均动脉压(62.87±3.56)mmHg、心率(108.791±1.93)次/min、呼吸(26.52±3.48)次/min、血氧饱和度(99.23±0.67)%、OAA/S量表评分(1.45±0.50)分]比较差异有统计学意义(t＝-10.068、-6.794、-7.824、-11.960、4.820，P<0.05)。(2)氯胺酮+丙泊酚组患儿麻醉清醒时T0：(4.40±1.17)分]麻醉清醒后1 hT1：(2.05±0.88)分]、麻醉清醒后2 hT2：(0.43±0.63)分]FLACC评分比复合麻醉镇痛组(1.32±0.96)、(0.43±0.62)、(0.13±0.34)分]评分高，说明患儿疼痛度高，且数据比较差异均有统计学意义(t＝10.139、13.669、2.794，P<0.05)。(3)术前及术后6个月瘢痕评分：氯胺酮+丙泊酚组(9.33±1.60)、(4.48±1.11)分]与复合麻醉镇痛组(8.43±2.04)、(4.26±1.04)分]相比差异均无统计学意义(t＝2.320、0.940, P>0.05)。 结论复合麻醉镇痛措施在小儿烧伤后增生性瘢痕非插管全身麻醉患者(UFCL)治疗术中应用效果较好，可使患儿术中血流动力学平稳，术中镇静良好，术后疼痛度较低，对于激光治疗效果无影响。

Application and effect of esketamine combined anesthesia in the treatment of pediatric scar patients with non-intubation general anesthesia by ultra-pulsed fractional carbon dioxide laser

ObjectiveTo investigate the application and effect of esmketamine combined with sevoflurane and pediatric ibuprofen suppository in the treatment of hypertrophic scar after burns in children under non intubation general anesthesia with ultra pulsed fractional carbon dioxide laser (UFCL). MethodsFrom January 2020 to April 2021, 89 children with hypertrophic scar after burns in the outpatient Department of Burns and skin surgery, First Affiliated Hospital of Air Force Military Medical University were included in this randomized controlled clinical trial. The children were randomly divided into ketamine + propofol group 42 cases, 22 males and 20 females, age (44.33±14.87) months] and compound anesthesia and analgesia group (esmketamine + sevoflurane + pediatric ibuprofen anal suppository) 47 cases, 24 males and 23 females, age (44.47±14.65) months]. Hemodynamic indexes and OAA/S scores were monitored before anesthesia and during operation. The pain degree of children was evaluated by children′s pain assessment scale (the face, legs, activity, cry, consolability behavioral tool, FLACC) during awake anesthesia (T0), 1 h after awake anesthesia (T1) and 2 h after awake anesthesia (T2). Vancouver scar scale (VSS) was used to score scars before operation and 6 months after operation. Data were statistically analyzed with independent sample t test and chi-square test. ResultsPre anesthesia hemodynamics and OAA /S score in ketamine + propofol group mean arterial pressure (63.71±3.40) mmHg, heart rate (107.21±9.45) times / min, respiration (25.29±2.34) times / min, oxygen saturation (99.00±0.80)%, OAA/S (4.64±0.49) points] and compound anesthesia analgesia group mean arterial pressure (63.87±3.57) mmHg, heart rate (109.34±12.21) times / min, respiration (26.47±3.53) times/min, oxygen saturation (98.77±0.91)%, OAA/S (4.57±0.50) points], there were no significant differences(t=-0.213, 0.490, -1.840, 1.280, 0.204; P>0.05). Ketamine + propofol group mean arterial pressure (56.29±2.43) mmHg, heart rate (94.48±7.01) times / min, respiration (21.07±3.03) times/min, oxygen saturation (96.12±1.64)%, OAA/S (2.07±0.71) points] and compound anesthesia analgesia group mean arterial pressure (62.87±3.56) mmHg, heart rate (108.79±11.93) times/min, respiration (26.52 ± 3.48) times / min, oxygen saturation (99.23±0.67)%, OAA/S (1.45±0.50) points], there were significant statistical differences (t=-10.068, -6.794, -7.824, -11.960, 4.820; P<0.05). (2) The FLACC score of the ketamine + propofol group was higher than that of the compound anesthesia analgesia group (1.32±0.96), (0.43±0.62), (0.13±0.34)], indicating the high degree of pain, the differences of data were statistically significant (t=10.139, 3.669, 2.794; P< 0.05). (3) Scar score before and 12 months after operation: there were no significant differences between ketamine + propofol group (9.33 ± 1.60), (4.48±1.11) points] and compound analgesia group (8.43±2.04), (4.26±1.04) points] (t=2.320, 0.940; P>0.05). ConclusionsThe application of compound anesthesia and analgesic measures in the treatment of hypertrophic scar aftern burns in children under non intubation general anesthesia with UFCL has a good effect. It can make the children have stable hemodynamics, good intraoperative sedation, low postoperative pain, and has no effect on the effect of laser treatment.