Dalal Priti G, Taylor Dan, Somerville Nicola, Seth Neena
Department of Anesthesia, Penn State Milton Hershey Medical Center College of Medicine, Hershey, PA 17033, USA.
Paediatr Anaesth. 2008 Mar;18(3):260-7. doi: 10.1111/j.1460-9592.2008.02410.x.
Pediatric patients undergoing anorectal manometry require ketamine anesthesia as other anesthetic agents affect the anorectal sphincter tone. The aim of this prospective observational audit was to evaluate our practice and report the occurrence of adverse events and behavioral reactions related to the use of ketamine, propofol, and midazolam combinations.
Eighty-two consecutive pediatric patients (mean age 8.06 +/- 3.43 years) undergoing anorectal manometry were audited over a 1-year period. After a routine ketamine anesthetic some children were administered midazolam 0.1 mg.kg(-1), at the discretion of the attending anesthetist. Children requiring anal stretch following manometry studies also received propofol 3-5 mg.kg(-1). Intra- and postoperative adverse events, times to spontaneous awakening and discharge from the PACU were noted. Postoperative behavioral reactions were noted in the PACU and at follow-up interviews on the first postoperative day and after a period of 1 month.
Following completion of the audit, all patients fell into one of the four groups depending on the anesthetic agents they received: K (ketamine only, n = 16), KM (ketamine and midazolam, n = 10), KP (ketamine and propofol, n = 27), and KPM (ketamine, propofol, and midazolam, n = 29). There was no difference in the occurrence of behavioral reactions between the four groups at the three stages of follow-up. Overall, five patients reported 'new onset' nightmares that had resolved completely at the 3-month follow-up. The time to spontaneous awakening was shorter for K group (17.8 min +/- 20.2) vs KPM group (61.7 min +/- 24.4; P < 0.001). The times to discharge in minutes was also shorter in the K group (54.5 min, IQR 30-75 vs 90 min IQR 78-120; P < 0.001). Administration of propofol appeared to have an antiemetic effect [odds ratio (OR) 0.1, 95% confidence intervals (CI) 0.02-0.58, P < 0.009] in the recovery unit.
Our study findings suggest that, besides significantly prolonging time to spontaneous awakening and PACU discharge, neither the use of midazolam, propofol, or combinations is beneficial in preventing the occurrence of behavioral reactions following ketamine anesthesia. Behavioral reactions were common but did not appear to be long-term. Drug combinations with ketamine may have other benefits such as antiemesis.
接受肛门直肠测压的儿科患者需要氯胺酮麻醉，因为其他麻醉剂会影响肛门直肠括约肌张力。这项前瞻性观察性审计的目的是评估我们的做法，并报告与氯胺酮、丙泊酚和咪达唑仑联合使用相关的不良事件和行为反应的发生情况。
在1年的时间里，对82例连续接受肛门直肠测压的儿科患者（平均年龄8.06±3.43岁）进行了审计。在常规氯胺酮麻醉后，根据主治麻醉师的判断，一些儿童给予0.1mg/kg的咪达唑仑。在测压研究后需要进行肛门扩张的儿童还接受了3-5mg/kg的丙泊酚。记录术中及术后不良事件、自主苏醒时间和从麻醉后恢复室出院的时间。在麻醉后恢复室以及术后第1天和1个月后的随访访谈中记录术后行为反应。
审计完成后，所有患者根据所接受的麻醉剂分为四组之一：K组（仅氯胺酮，n=16）、KM组（氯胺酮和咪达唑仑，n=10）、KP组（氯胺酮和丙泊酚，n=27）和KPM组（氯胺酮、丙泊酚和咪达唑仑，n=29）。在三个随访阶段，四组之间行为反应的发生率没有差异。总体而言，五名患者报告有“新发”噩梦，在3个月的随访时已完全缓解。K组的自主苏醒时间（17.8分钟±20.2）比KPM组（61.7分钟±24.4；P<0.001）短。K组的出院时间（分钟）也更短（54.5分钟，四分位数间距30-75，而90分钟，四分位数间距78-120；P<0.001）。在恢复室，丙泊酚的使用似乎有止吐作用[优势比（OR）0.1，95%置信区间（CI）0.02-0.58，P<0.009]。
我们的研究结果表明，除了显著延长自主苏醒时间和从麻醉后恢复室出院的时间外，咪达唑仑、丙泊酚或联合使用在预防氯胺酮麻醉后行为反应的发生方面并无益处。行为反应很常见，但似乎不是长期存在。氯胺酮的联合用药可能有其他益处，如止吐。
