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Comparison of Fentanyl，Sufentanil and Remifentanil for Fast－track Pediatric Cardiac Anesthesia

¹黄悦  ²杭燕南

1上海交通大学医学院附属上海儿童医学中心麻醉科，上海 200127

2上海交通大学医学院附属仁济医院麻醉科，上海 200001

¹Yue Huang  ²Yan－nan Hang

1Department of Anesthesiology，Shanghai Children’s Medical Centre Affiliated to Shanghai Jiaotong University，Shanghai 200127，China

2Department of Anesthesiology，<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />Renji Hospital Affiliated to Shanghai Second Medical University，Shanghai 200001，China

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ABSTRACT

　　Objective：To compare the effects of fentanyl，sufentanil and remifentanil on hemodynamics，stress and emergence characteristics undergoing fast－track cardiac surgery in children.

　　Methods：Sixty pediatric patients with atrial septal defect or simple ventricular septal defect who were deemed suitable for fast track anesthetic management were randomly allocated into fentanyl－based（Group F），sufentanil－based（Group S），or remifentanil－based（Group R）groups. All patients were premedicated with midazolam，and induced with fentanyl，sufentanil or remifentanil，respectively，added with midazolam and vecuronium. Following intubation，isoflurane and N₂O was inhaled in all patients. Anesthesia was maintained with fentanyl or sufentanil interval injection and remifentanil infusion，respectively. Blood samples were obtained after induction，5 min after intubation and sternotomy，immediately before cardiopulmonary bypass（CPB）and at the end of surgery. The time of extubation，duration of cardiac intensive care unit（ICU）stay and complications were recorded.

　　Results：There were no demographic differences among groups. After induction，HR，SBP and DBP decreased similarly from baseline in all groups. Hemodynamic response to intubation，incision and sternotomy was stable and similar in all groups. Catecholamines were low in all groups during surgery. Extubation in Group S（56±48 min）and Group R（53±57 min）were earlier than that in Group F（116±34 min）. The reintubation incidence and stays in ICU were similar among groups.

　　Conclusion：We conclude that moderate dose of fentanyl，sufentanil and remifentanil can provide stable hemodynamics for fast－track cardiac surgery in elected pediatric patients. Remifentanil and sufentanil can provide earlier extubation than fentanyl.

　　Key words：fentanyl；sufentanil；remifentanil；children；fast－track cardiac anesthesia

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　　心脏快通道麻醉（Fast－track cardiac anesthesia，FTCA）是为了达到术后早期拔管，减少重症监护室（Intensive care unit，ICU）逗留天数以及住院天数，最终降低治疗费用的目的^[1]。传统的大剂量芬太尼心脏麻醉技术具有对心肌抑制作用轻，镇痛效能强，对血液动力学影响小，能显著降低气管插管和手术刺激的心血管反应，又无组胺释放作用等特点，一度被称为“无应激麻醉”（Stress－free anesthesia）。随着外科、体外循环（Cardiopulmonary bypass，CPB）以及临床麻醉技术的发展，大剂量芬太尼麻醉造成的肌肉强直，术后呼吸抑制时间延长、苏醒延迟，以及呼吸机支持时间和ICU逗留时间延长等缺点日益突出，最终导致医疗资源的占用和医疗支出增加。FTCA摒弃了传统心脏麻醉所使用的大剂量芬太尼麻醉技术，而将中等剂量甚至小剂量芬太尼或一些新型的阿片类药物－－舒芬太尼和瑞芬太尼辅以强效的吸入麻醉药用于心脏麻醉。本研究目的在于比较芬太尼、舒芬太尼及瑞芬太尼用于先心病小儿心内直视手术快通道麻醉对患儿血流动力学、血浆应激激素水平及术后拔管时间等的影响，为小儿先心病快通道手术提供良好的麻醉方法。

　　一、资料与方法

　　1. 研究资料

　　（1）病例选择

　　60例患儿，ASAⅠ－Ⅱ级，择期行房间隔缺损（atrial septal defects，ASD）或单纯室间隔缺损（ventricular septal defects，VSD）修补术。入组患儿术前心功能Ⅰ－Ⅱ级，无心血管手术史或者麻醉史，无贫血，无肝、肾、内分泌、神经系统以及代谢性疾病。

　　（2）分组情况

　　根据所选择的芬太尼类药，随机分为3组：芬太尼组（F组，n＝20）、舒芬太尼组（S组，n＝20）及瑞芬太尼组（R组，n＝20），表1。

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