A comparative study in children undergoing ophthalmologic surgery during general anesthesia:systemic fentanyl vs. retrobulbar block combined with remifentanyl

目的：对比小儿眼底手术中，采用芬太尼镇痛的全麻管理方案和球后神经阻滞联合瑞芬太尼术中镇痛的全麻方案在术中心率及血压波动、应激及炎性反应、术后镇痛及围手术期不良事件上的优劣。方法选取2013年6月至2014年3月于北京大学人民医院拟择期行全身麻醉下眼底手术的患儿28例，年龄1～6岁，随机分为球后神经阻滞联合瑞芬太尼组（N 组，n=13）和芬太尼组（F 组，n=15）。两组均采用丙泊酚诱导及维持，予爱可松后置入喉罩，压力控制通气。N 组术中持续泵入瑞芬太尼，手术开始前行球后神经阻滞；F 组间断静脉给予芬太尼。分别测量术前和术后外周血中皮质醇、血糖、及炎性因子浓度。记录两组患儿诱导前（T0）、喉罩置入时（T1）、手术开始时（T2）、手术结束时（T3）、拔出喉罩时（T4）、出手术室时（T5）的平均动脉压、心率，观察停药后患者苏醒时间、拔管时间。记录患儿术后即刻、术后2 h 及24 h 的疼痛评分。随访围手术期不良事件。结果 N 组 T0、T2及 T3时的心率低于 F 组，差异有统计学意义[（100.5±17.6）次/min vs.（123.4±26.5）次/min，t=－2.656，P=0.013；（85.2±14.9）次/min vs.（119.3±26.0）次/min，t=－4.179， P＜0.001；（86.8±19.1）次/min vs.（112.7±26.8）次/min，t=－2.891，P=0.008]。N 组 T2时的平均动脉压低于 F 组，差异有统计学意义[（66.2±9.5）mmHg vs.（78.0±10.6）mmHg，t=－3.073，P=0.005]。N 组术后的 TNF-α浓度低于 F 组，差异有统计学意义[（51.8±7.8）pg/ml vs.（60.0±11.8）pg/ml， t=－2.137，P=0.042]。两组术后即刻、术后2 h 及术后24 h 的镇痛评分，组间比较差异无统计学意义（P＞0.05）。两组均无术中及术后不良事件发生。结论在小儿全麻眼科手术中，增加球后神经阻滞的应用，可以有效抑制手术应激引起的血流动力学反应，可能具有抑制炎性反应的潜在优势。Objective To evaluate the influence of retrobulbar block combined with remifentanyl vs. systemic fentanyl on the hemodynamic response, stress response, inflammatory response, postoperative analgesia and perioperative adverse events in pediatric ophthalmologic surgeries during general anesthesia. Methods A total of 28 children undergoing vitreoretinal surgeries in Peking university people's hospital from Jun. 2013 to Mar. 2014 were enrolled in the study, whose age were 1-6 years. They were randomly assigned into 2 groups: retrobulbar nerve block combined with remifentanyl group (group N, n=13) and systemic fentanyl group (group F, n=15). Anesthesia was induced and maintained with propofol, and laryngeal mask airway was placed after rocuronium bromide given intravenously, following pressure control ventilation. In group N, remifentanyl was pumped continuously, and satisfying retrobulbar nerve block was achieved before surgical procedure. In group F, intravenous fentanyl was administrated intermittently. Two blood samples were collected before and after surgery to measure plasma cortisol, glucose and cytokines concentrations. The mean arterial pressure and heart rate were recorded at the time of before the induction of anesthesia (T0), after laryngeal mask airway placement (T1), beginning of surgery (T2), ending of surgery (T3), laryngeal mask airway removal (T4), leaving operating room (T5). The emergence time and time interval from cease of surgery to the laryngeal mask removal were recorded. The Pain Scales were assessed immediately after emergence from anesthesia, 2 h later and 24 h later, respectively. The adverse events during and after surgery were also recorded. Results The heart rate (per minute) in group N was significantly lower than in group F at T0, T2 and T3, respectively, (100.5±17.6)times/beat vs. (123.4±26.5)times/beat, t=-2.656, P=0.013; (85.2±14.9)times/beat vs. (119.3±26.0)times/beat, t=-4.179, P<0.001; (86.8±19.1)times/beat vs. (112.7±26.8)times/beat, t=-2.891, P=0.008. The mean arterial pressure in group N was significantly lower than in group F at T2 (66.2±9.5)mmHg vs. (78.0±10.6)mmHg, t=-3.073, P=0.005. The concentration of TNF-α after surgery in group N was significantly lower than in group F (51.8±7.8)pg/ml vs. (60.0±11.8)pg/ml, t=-2.137, P=0.042. There was no significant difference in Pain Scales immediately, 2 h and 24 h after emergence from anesthesia between groups. There was no severe adverse events during and after surgery in either group. Conclusion In pediatric ophthalmologic surgeries during general anesthesia, the application of retrobulbar block can profoundly suppress the hemodynamic response to surgery, may have potential benefit for suppression of the inflammatory response.北京大学人民医院研究与发展基金91287-12911