Mester Robert, Easley R Blaine, Brady Kenneth M, Chilson Kelly, Tobias Joseph D
University of Missouri School of Medicine, Columbia, Missiouri 65212, USA.
Am J Ther. 2008 Jan-Feb;15(1):24-30. doi: 10.1097/MJT.0b013e3180a72255.
No specific regimen has been universally accepted as ideal for sedation during cardiac catheterization in infants and children. We evaluated a combination of ketamine and dexmedetomidine for sedation during cardiac catheterization in children with congenital heart disease. The study design included a retrospective analysis of data sheets and hospital records. The protocol for sedation was standardized and data collected prospectively for an ongoing quality assurance project. Heart rate, blood pressure, and oxygen saturation were recorded every 1 minute for the first 5 minutes and then at 5-minute intervals. The efficacy of sedation was judged by the need for supplemental ketamine doses. The study cohort included 16 infants and children undergoing either diagnostic or therapeutic cardiac catheterization. Sedation was initiated with a bolus dose of ketamine (2 mg/kg) and dexmedetomidine (1 microg/kg) administered over 3 minutes followed by a continuous infusion of dexmedetomidine (2 microg/kg per hour for the initial 30 minutes followed by 1 microg/kg per hour for the duration of the case). Supplemental analgesia/sedation was provided by ketamine (1 mg/kg) as needed. The baseline heart rate was 103 +/- 21 beats/minute. After the bolus dose of ketamine and dexmedetomidine, the heart rate increased by 7 +/- 5 beats/minute. The greatest increase was 15 beats/minute. The low heart rate after the bolus dose of ketamine/dexmedetomidine or during the subsequent dexmedetomidine infusion was 91 +/- 20 beats/minute (P < 0.001 compared with baseline) and the high heart rate was 110 +/- 25 beats/minute (P < 0.01 compared with baseline). In two patients, the dexmedetomidine infusion was decreased from 2 to 1 microg/kg per hour at 12 to 15 minutes instead of 30 minutes as a result of a decreased heart rate. No clinically significant changes in blood pressure or respiratory rate were noted. Two patients developed upper airway obstruction, which responded to repositioning of the airway. No apnea was noted. During the procedure, the PaCO2 varied from 37.5 to 48 mm Hg and was > or =45 mm Hg in seven patients. No patient responded to local infiltration of the groin and placement of the arterial and venous cannulae. Three patients required a supplemental dose of ketamine (1 mg/kg) during the procedure. In two of these patients, this was required before changing the cannulae. Our preliminary data suggest that a combination of ketamine and dexmedetomidine provides effective sedation for cardiac catheterization in infants and children without significant effects on cardiovascular or ventilatory function.
目前尚无一种特定的方案被普遍认为是婴儿和儿童心导管插入术期间理想的镇静方法。我们评估了氯胺酮和右美托咪定联合用于先天性心脏病儿童心导管插入术期间的镇静效果。研究设计包括对数据表和医院记录的回顾性分析。镇静方案标准化，并为一个正在进行的质量保证项目前瞻性收集数据。在前5分钟每分钟记录心率、血压和血氧饱和度，然后每隔5分钟记录一次。根据是否需要补充氯胺酮剂量来判断镇静效果。研究队列包括16例接受诊断性或治疗性心导管插入术的婴儿和儿童。镇静开始时静脉推注氯胺酮（2mg/kg）和右美托咪定（1μg/kg），持续3分钟，随后持续输注右美托咪定（最初30分钟为2μg/kg每小时，之后病例全程为1μg/kg每小时）。根据需要给予氯胺酮（1mg/kg）补充镇痛/镇静。基线心率为103±21次/分钟。静脉推注氯胺酮和右美托咪定后，心率增加7±5次/分钟。最大增加为15次/分钟。静脉推注氯胺酮/右美托咪定后或随后右美托咪定输注期间的最低心率为91±20次/分钟（与基线相比P<0.001），最高心率为110±25次/分钟（与基线相比P<0.01）。在两名患者中，由于心率下降，右美托咪定输注在12至15分钟时从2μg/kg每小时降至1μg/kg每小时，而不是30分钟时。未观察到血压或呼吸频率有临床显著变化。两名患者出现上呼吸道梗阻，经气道重新定位后缓解。未观察到呼吸暂停。在手术过程中，动脉血二氧化碳分压在37.5至48mmHg之间变化，7名患者的动脉血二氧化碳分压≥45mmHg。没有患者对腹股沟局部浸润和动脉及静脉套管置入有反应。3名患者在手术过程中需要补充氯胺酮剂量（1mg/kg）。其中两名患者在更换套管前需要补充。我们的初步数据表明，氯胺酮和右美托咪定联合可为婴儿和儿童心导管插入术提供有效的镇静，且对心血管或呼吸功能无显著影响。
