Janda Matthias, Bajorat Jörn, Kudlik Christiana, Pohl Birgit, Schubert Agnes, Nöldge-Schomburg Gabriele, Hofmockel Rainer
Department of Anesthesiology and Intensive Care Medicine, University of Rostock, Rostock, Germany.
Paediatr Anaesth. 2013 Dec;23(12):1153-9. doi: 10.1111/pan.12236. Epub 2013 Aug 1.
The routine use of neuromuscular blocking drugs (NMBD) for endotracheal intubation in children is the subject of much controversy. The analysis of heart rate variability (HRV) can reveal information about the functional state of the autonomic nervous system (ANS).
The purpose of this study was to determine if HRV elucidates differences in the sympathovagal balance of children undergoing elective endo-tracheal intubation with and without neuromuscular blockade (NMB).
In this prospective study, 38 children (2-6 years) scheduled for adenotonsillectomy were randomized into two groups to receive fentanyl 2 μg·kg(-1) and propofol 4 mg·kg(-1) , with either mivacurium 0.25 mg·kg(-1) (NMB group) or saline solution (NoNMB group) for anesthesia induction. The same experienced, blinded anesthesiologist performed endotracheal intubation. Heart rate variability, RR intervals, ECG as well as an electroencephalogram were recorded with HRV and BIS XP monitors, respectively. Heart rate variability was analyzed in the frequency domain.
There was no significant difference in HRV changes immediately after mivacurium administration compared with an administration of saline. The groups were comparable for the bispectral index value (NMB 35 [33-41] vs NoNMB 34 [32-42]) during endotracheal intubation. Changes in both the low-frequency power and the low-/high-frequency ratio immediately after endotracheal intubation compared with the unstimulated state before laryngoscopy were significantly higher without NMB (P = 0.015 and P = 0.006, respectively), whereas there was no significant difference with respect to the high-frequency power.
The stress response during endotracheal intubation in pediatric patients represented by the frequency domain analysis of HRV was found to be higher without NMB. When mivacurium was added to a propofol-fentanyl induction regimen, the ANS alterations during endotracheal intubation decreased significantly.
儿童气管插管时常规使用神经肌肉阻滞药物（NMBD）存在诸多争议。心率变异性（HRV）分析可揭示自主神经系统（ANS）功能状态的信息。
本研究旨在确定HRV是否能阐明接受择期气管插管且使用或未使用神经肌肉阻滞（NMB）的儿童交感迷走神经平衡的差异。
在这项前瞻性研究中，38例计划行腺样体扁桃体切除术的儿童（2至6岁）被随机分为两组，分别接受2μg·kg⁻¹芬太尼和4mg·kg⁻¹丙泊酚，麻醉诱导时一组给予0.25mg·kg⁻¹米库氯铵（NMB组），另一组给予生理盐水（非NMB组）。由同一位经验丰富的、不知情的麻醉医生进行气管插管。分别使用HRV和BIS XP监测仪记录心率变异性、RR间期、心电图以及脑电图。在频域分析心率变异性。
与给予生理盐水相比，给予米库氯铵后立即出现的HRV变化无显著差异。气管插管期间，两组的双谱指数值相当（NMB组为35[33 - 41]，非NMB组为34[32 - 42]）。与喉镜检查前未受刺激状态相比，气管插管后立即出现的低频功率和低频/高频比值变化在未使用NMB时显著更高（分别为P = 0.015和P = 0.006），而高频功率方面无显著差异。
通过HRV频域分析发现，小儿患者气管插管期间未使用NMB时以应激反应更高。当在丙泊酚 - 芬太尼诱导方案中加入米库氯铵时，气管插管期间的ANS改变显著减少。
