儿童和青少年在局部麻醉联合静脉注射丙泊酚麻醉下进行的门诊关节镜膝关节手术。

Maldini Branka, Miskulin Mladen

Department of Anesthesia, Sveti Duh General Hospital, Zagreb, Croatia.

Paediatr Anaesth. 2006 Nov;16(11):1125-32. doi: 10.1111/j.1460-9592.2006.01959.x.

BACKGROUND

This prospective observational study included a case series of children and adolescents receiving light intravenous propofol anesthesia combined with local anesthesia (LA) for arthroscopic knee procedures. The aim was to examine the merits of anesthesia, to discuss the indications for the procedure and to analyze recovery/discharge times from the postanesthesia care unit (PACU).

METHODS

A cohort of 147 children and adolescents (ASA 1 and 2) aged 12-18 years admitted for outpatient arthroscopic knee procedures between January 2004 and May 2005 were studied. After IV access in the operating theater, the patients received propofol (10 mg.ml(-1)). Arthroscopy was performed approximately 15 min after injecting local anesthetic (15 ml 2% lidocaine with epinephrine 1:200,000) partly at the site of insertion of the arthroscope and other instruments (5 ml), and the rest intra-articular. The following parameters were assessed: airway patency, propofol requirement, vital signs, procedure time, surgical operating conditions, patient satisfaction score, time to discharge, postoperative analgesia and adverse events.

RESULTS

Of 147 patients, 133 patients (90.5%) underwent arthroscopic knee surgery, whereas knee arthroscopy alone was performed in 14 patients (9.5%) without indication for operative treatment. The arthroscopy was well tolerated in 96.6% patients (no pain, movement or discomfort during the procedure) and only five patients required conversion to general anesthesia. Pain experienced during the injection of lidocaine was more severe than pain experienced during the surgical procedure itself (P < 0.001). The surgical evaluation of operative conditions (visualization and access to intra-articular structures) was generally satisfactory and completely acceptable. Almost 94% (138/147) of patients said they would have the same procedure again under the same type of anesthesia. The mean propfol induction dose was 1.4 mg.kg(-1) (range: 0.9-3.8) and mean propofol infusion rate 167 microg.kg(-1).min(-1) (range: 130-250). Movement was more likely at lower infusion rates (mean: 151 microg.kg(-1).min(-1)). The maximal decrease in respiratory rate was 5.9 +/- 5.1 br.min(-1) (27.2 +/- 21%) and no patient became hypoxic. Patients recovered to preoperative values at 9.8 +/- 7.5 min following infusion discontinuation. There were no respiratory or cardiovascular complications. The mean stay in PACU was 47 min (range: 32-150). As many as 71% (105/147) of patients required no analgesics during the first two postoperative hours.

CONCLUSIONS

The combination of light intravenous propofol anesthesia combined with local anesthesia for arthroscopic knee procedures provided effective sedation, good preservation of upper airway patency, rapid recovery and pain relief without major side effects and offers a good alternative to the methods already available. The majority of patients did not require postoperative analgesia.

背景

这项前瞻性观察性研究纳入了一系列接受轻度静脉注射丙泊酚麻醉联合局部麻醉（LA）进行膝关节镜手术的儿童和青少年病例。目的是探讨麻醉的优点，讨论该手术的适应症，并分析麻醉后护理单元（PACU）的恢复/出院时间。

方法

研究了2004年1月至2005年5月期间因门诊膝关节镜手术入院的147名12 - 18岁儿童和青少年（ASA 1和2级）。在手术室建立静脉通路后，患者接受丙泊酚（10 mg.ml⁻¹）。在注射局部麻醉剂（15 ml 2%利多卡因加1:200,000肾上腺素）约15分钟后进行关节镜检查，部分局部麻醉剂注射于关节镜和其他器械插入部位（5 ml），其余注入关节腔内。评估以下参数：气道通畅性、丙泊酚需求量、生命体征、手术时间、手术操作条件、患者满意度评分、出院时间、术后镇痛及不良事件。

结果

147例患者中，133例（90.5%）接受了膝关节镜手术，而14例（9.5%）仅进行了膝关节镜检查，无手术治疗指征。96.6%的患者对关节镜检查耐受良好（手术过程中无疼痛、活动或不适），仅5例患者需要转为全身麻醉。注射利多卡因时的疼痛比手术过程本身的疼痛更严重（P < 0.001）。手术操作条件（关节内结构的可视化和进入）的外科评估总体令人满意且完全可接受。几乎94%（138/147）的患者表示他们愿意在相同类型的麻醉下再次接受相同的手术。丙泊酚诱导剂量平均为1.4 mg.kg⁻¹（范围：0.9 - 3.8），丙泊酚输注速率平均为167 μg.kg⁻¹.min⁻¹（范围：130 - 250）。输注速率较低时（平均：151 μg.kg⁻¹.min⁻¹）更易出现活动。呼吸频率最大下降为5.9 ± 5.1次/分钟（27.2 ± 21%），无患者出现低氧血症。输注停止后9.8 ± 7.5分钟患者恢复到术前值。无呼吸或心血管并发症。在PACU的平均停留时间为47分钟（范围：3 to 150）。多达71%（105/147）的患者在术后前两小时不需要镇痛。