Broadman L M, Patel R I, Feldman B A, Sellman G L, Milmoe G, Camilon F
Department of Anesthesiology, Children's Hospital National Medical Center, Washington, DC 20010.
Laryngoscope. 1989 Jun;99(6 Pt 1):578-81. doi: 10.1288/00005537-198906000-00002.
Improved hemostasis and reduction of postoperative pain are desired goals when performing tonsillectomy. This is especially true in children, who may be reluctant to receive intramuscular injections for pain relief and who may lose a higher percentage of total blood volume during surgery than adults. This study evaluated the effects of peritonsillar infiltration upon operative blood loss and postoperative pain in 42 children. For the purpose of infiltration, patients were randomly assigned to one of four groups. Children in groups I, II, and III had their peritonsillar infiltrations performed with the contents of a coded vial which contained bupivacaine 0.25% with epinephrine (1:200,000), normal saline with epinephrine (1:200,000), and normal saline, respectively. Group IV children (controls) received no infiltration. All solutions were prepared in the hospital pharmacy to assure binding of the operator and observer. All infiltrations were performed following the induction of general anesthesia and 5 minutes prior to the onset of surgery. Anesthetic agents, end-tidal carbon dioxide levels, and the administration of intravenous fluids were carefully regulated. Surgery was performed by one of two attending otolaryngologists or a senior otolaryngology fellow using the same dissection and snare technique. Hemostasis was managed by suction-electrocautery and packs. Patients in group IV, the control group, lost twice as much blood as did those who had infiltrations performed with normal saline, group III (p less than 0.001). However, patients in group III lost 1.5 times more blood than did those children in either of the two groups whose infiltrations were performed with an epinephrine solution, groups I and II (p less than 0.001). No postoperative bleeding was noted in any patient. Infiltration of the peritonsillar space with epinephrine (1:200,000) was shown to be more effective in reducing blood loss than infiltration with normal saline. Because of the small sample size we were unable to evaluate the beneficial effects of peritonsillar infiltration performed with bupivacaine upon the reduction of the severity of pain and the requirement for narcotic analgesics following tonsillectomy. Therefore, until further studies demonstrate such efficacy, all peritonsillar infiltrations should be performed solely for the purpose of reducing operative blood loss. As such, infiltrations should be performed with either normal saline containing epinephrine (1:200,000) or lidocaine containing epinephrine (1:200,000).
在进行扁桃体切除术时，改善止血效果并减轻术后疼痛是理想的目标。对于儿童而言尤其如此，他们可能不愿接受肌肉注射来缓解疼痛，而且在手术过程中可能比成年人流失更高比例的总血容量。本研究评估了扁桃体周围浸润对42名儿童手术失血和术后疼痛的影响。为了进行浸润，患者被随机分为四组。第一组、第二组和第三组的儿童分别用含有0.25%布比卡因加肾上腺素（1:200,000）、含肾上腺素（1:200,000）的生理盐水以及生理盐水的编码瓶内容物进行扁桃体周围浸润。第四组儿童（对照组）未接受浸润。所有溶液均在医院药房配制，以确保操作者和观察者不知情。所有浸润均在全身麻醉诱导后且手术开始前5分钟进行。仔细调节麻醉剂、呼气末二氧化碳水平以及静脉输液的给药。手术由两名主治耳鼻喉科医生或一名资深耳鼻喉科住院医师之一采用相同的解剖和圈套技术进行。通过吸引电灼和纱布进行止血。对照组第四组患者的失血量是用生理盐水进行浸润的第三组患者的两倍（p<0.001）。然而，第三组患者的失血量比用肾上腺素溶液进行浸润的第一组和第二组这两组儿童中的任何一组多1.5倍（p<0.001）。所有患者均未出现术后出血。结果显示，用肾上腺素（1:200,000）浸润扁桃体周围间隙在减少失血方面比用生理盐水浸润更有效。由于样本量小，我们无法评估用布比卡因进行扁桃体周围浸润对减轻扁桃体切除术后疼痛严重程度和减少麻醉性镇痛药需求的有益效果。因此，在进一步研究证明这种疗效之前，所有扁桃体周围浸润仅应出于减少手术失血的目的进行。因此，浸润应使用含肾上腺素（1:200,000）的生理盐水或含肾上腺素（1:200,000）的利多卡因进行。
