Zhang Yingjun, Ou Chaopeng, Bai Xiaohui, Lai Jielan, Huang Wan, Ouyang Handong
State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China.
Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
Front Pediatr. 2022 Aug 17;10:974917. doi: 10.3389/fped.2022.974917. eCollection 2022.
Totally implantable venous access port (TIVAP) implantation is usually performed under general anesthesia with endotracheal intubation in children. Procedural sedation without endotracheal intubation has been applied to minor pediatric surgeries like central venous catheter insertion. To explore a more efficient and less invasive anesthesia mode to implant TIVAPs for children, we aimed to evaluate the efficacy and safety of procedural sedation using propofol and S(+)-ketamine compared with general anesthesia.
Sixty-six patients aged 6 months to 10 years undergoing TIVAP implantation were randomly allocated to two groups. Patients under procedural sedation [S(+)-ketamine-propofol (sketofol) group] were given target-controlled infusion of propofol 4 μg/ml using the Paedfusor model and S(+)-ketamine 0.5 mg/kg as induction, and had target-controlled infusion of propofol 3-4 μg/ml as maintenance. Patients in sketofol group received medium-flow oxygen inhalation through facemasks during surgery. Patients under general anesthesia (control group) were given propofol 2 mg/kg, cisatracurium 0.2 mg/kg, fentanyl 3 μg/kg as induction, and sevoflurane 0.8 minimum alveolar concentration as maintenance after endotracheal intubation. Primary outcome was the postoperative emergence agitation evaluated 5 min after awakening.
Postoperative emergence agitation evaluated 5 min after awakening was lower in sketofol group versus control group [1.0 (0.5, 1.0) vs. 3.0 (2.0, 4.0); median difference (95% CI): 2.0 (1.0, 2.0); < 0.001]. Time to awakening was significantly lower in sketofol group versus control group [15.0 (5.0, 23.0) vs. 26.0 (20.5, 37.5); median difference (95% CI): 11.0 (7.0, 19.0); < 0.001], as well as time to discharge from post anesthesia care unit [35.0 (24.0, 45.0) vs. 45.0 (37.5, 59.5); median difference (95% CI): 10.0 (10.0, 23.0); < 0.001]. Postoperative complications or adverse events were not reported in sketofol group.
Compared to general anesthesia with endotracheal intubation, procedural sedation using propofol and S(+)-ketamine improves the postoperative emergence agitation right after the recovery of consciousness, and has advantage in shortening anesthetic recovery time for pediatric patients undergoing TIVAP implantation.
儿童完全植入式静脉通路端口（TIVAP）植入术通常在全身麻醉下行气管插管进行。非气管插管的程序镇静已应用于小儿中心静脉导管插入等小型手术。为探索一种更高效、侵入性更小的儿童TIVAP植入麻醉方式，我们旨在评估丙泊酚和S(+)-氯胺酮程序镇静与全身麻醉相比的有效性和安全性。
66例年龄6个月至10岁行TIVAP植入术的患者被随机分为两组。程序镇静组[S(+)-氯胺酮-丙泊酚（sketofol）组]采用Paedfusor模型以4 μg/ml的靶控输注丙泊酚，并给予0.5 mg/kg的S(+)-氯胺酮诱导，维持时丙泊酚靶控输注3 - 4 μg/ml。sketofol组患者在手术期间通过面罩接受中等流量吸氧。全身麻醉组（对照组）诱导时给予2 mg/kg丙泊酚、0.2 mg/kg顺式阿曲库铵、3 μg/kg芬太尼，气管插管后以0.8最低肺泡浓度的七氟醚维持。主要结局是苏醒后5分钟评估的术后苏醒期躁动。
sketofol组苏醒后5分钟评估的术后苏醒期躁动低于对照组[1.0（0.5，1.0）对3.0（2.0，4.0）；中位数差异（95%CI）：2.0（1.0，2.0）；P<0.001]。sketofol组的苏醒时间显著低于对照组[15.0（5.0，23.0）对26.0（20.5，37.5）；中位数差异（95%CI）：11.0（7.0，19.0）；P<0.001]，麻醉后监护病房出院时间也低于对照组[35.0（24.0，45.0）对45.0（37.5，59.5）；中位数差异（95%CI）：10.0（10.0，23.0）；P<0.001]。sketofol组未报告术后并发症或不良事件。
与气管插管全身麻醉相比，丙泊酚和S(+)-氯胺酮程序镇静可改善小儿TIVAP植入术后意识恢复后的苏醒期躁动，并在缩短麻醉恢复时间方面具有优势。
