Application Of Dexmedetomidine In Children Undergoing Laparoscopic Transfixion Of Internal Ring

Research BackgroundLaparoscopic transfixion of internal ring,which has the advantages of safety,less trauma and shorter operation time is one of the most commonsurgical methods for inguinal hernia and hydrocele in children.For surgeons,it has the advantages of being fully exposed and easily graspable.The anesthetic mode was general anesthesia with tracheal intubation.However,intraoperative hemodynamic instability and frequent postoperative agitation in pediatric patients have become a major challenge for pediatric surgical anesthesiologists.Dexmedetomidine(Dex)is a highly selective alpha 2 receptor agonist,which has sedative and analgesic effects,and is commonly used as an adjunct drug for general anesthesia and regional anesthesia.It has obvious effects on reducing stress reaction and preventing postoperative agitation.Studies have shown that different doses of Dex have different effects on stabilizing perioperative hemodynamics,reducing surgical stress and improving the quality of recovery in children.However,the optimal dosage of Dex for Laparoscopic transfixion of internal ring has not yet been reported and defined clearly at home and abroad.Research ObjectiveIn this study,Single dose of Dex was injected intravenously before induction of anesthesia.and This study was designed to investigate the optimal dose of Dex for reducing the stress reaction,maintaining stable vital signs and improving the quality of recovery in children undergoing Laparoscopic transfixion of internal ring.Materials and Methods1 Case selection and SubgroupA randomized,double-blind,controlled trial was conducted in this study.A total of 150 children undergoing Laparoscopic transfixion of internal ring were enrolled from September 2015 to September 2016 in the Department of Pediatric Surgery,Affiliated Boai Hospital of Zhongshan,Southern Medical University.The children were treated with inhalation combined general anesthesia,aged 4-8 years,ASA grade I,gender,height was not limited.Using random number table method,The patients were divided into 5 groups(A(0.4 ?g/kg),B(0.6 ?g/kg),C(0.8 ?g/kg),D(1.0 ?g/kg),group E Of the saline)),30 cases in each group.The inclusion criteria were as follows:preoperative cardiac function class I-II,EF>55%;liver,lung and kidney function is normal;Exclusion criteria:(1)weight greater than 30 kg;(2)associated with congenital heart disease,asthma and other diseases;(3)mental retardation;(4)family of inhaled anesthetic allergy;(5)abnormal coagulation function;(6)systemic disease.2 methods of anesthesiaFive groups of children were fasted from solid foods for 4?6 h prior to the procedure;clear liquids were permitted until 2 h prior to admission to the operating room(OR).Preoperative drugs were not used for patients of five groups.The upper extremity venous access has been opened in the ward,The dosage of propofol with 1 to 2 mg/kg was slowly injected intravenously.The aim was to make the children get a state of sedation.After shifting patients to the operating room,Ringer's Solution was connected to the vein,and the liquid velocity was controlled with 8 mL/(kg.h).Vital data as mean arterial pressure(MAP),Electrocardiogram(ECG)?Heart Rate(HR)and pulse oxygen saturation(SpO2)were recorded.Intravenous induction of anesthesia using fentanyl 2 ?g/kg,propofol 1.5-2.5 mg/kg and cisatracurium 0.05 mg/kg was performed.Tracheal intubation was performed after preoxygenation 3 min.After successful intubation,the anesthesia machine was connected with the endotracheal tube.At the same time,the respiratory parameters were adjusted,Pressure control ventilation mode was used to maintain breathing,and the inspiratory pressure was set according to the tidal volume to make the tidal volume reaching 10 ml/kg?12 ml/kg,The positive end expiratory pressure(PEEP)was 0 cmH2O,oxygen flow(1?1.5 L/min),respiratory ratio(1:2),respiratory rate(18-26 times/min)and the partial pressure of end-tidal carbon dioxide(PETCO2;35-45 mmHg),Fraction of inspiration O2(FiO2)ranged from 50%to 60%.Anaesthesia was maintained by inhalation concentation of sevoflurane from 2%to 3%combined with remifentanil from 0.2 to 0.3 ?g/kg.min,And the depth of sedation was monitored using the Narcotrend monitor and maintaining at D1?D2 level.Sevoflurane was discontinued 8 minutes before the end of the operation And stop pumping remifentanil when the surgical skin was suture.When the children's heart rate was less than 80 beats/min,the patients would be injected with atropine 0.2 mg/times.Five groups of children were pulled out tracheal catheter in the operating room,then were observed in the post-anesthesia care unit(PACU).3 The mode of administration and dosage of dexmedetomidineDex(O.lmg/1mL)and 0.9%sodium chloride were mixed into a mixture(Dex dilution concentration?4?g/mL).A,B,C and D groups were given intravenous injection of Dex(0.4,0.6,0.8,1 ?g/kg)before the induction of anesthesia,and the total volume of each group was 10 mL.Besides,In group E,the same volume of saline(10 mL)was injected intravenously at the same time point.Before the induction of anesthesia,five groups with dexmedetomidine constant injection time was 15 min.4 Blood sample processing and testingAll the venous blood were taken at 3 time points(TO),at the end of the operation(T2)and at the time of leaving the recovery room(PACU)(T3).1h sent to the laboratory,3000 r/min,centrifugal 5 minutes,2h on the machine to complete the test.Chemiluminescence method was used to detect the plasma concentration of adrenaline,cortisol and glucagon.The plasma glucose concentration was measured by hexokinase method.5 Observed Parameters5.1 Main outcome parameters5.1.1 Stress parametersBlood samples were collected from all children at the time of admission(TO),at the end of the operation(T2)and at the time of leaving the recovery room(PACU)(T3).The concentrations of epinephrine,glucagon,glucose and cortisol were recorded.5.1.2 Agitation scoreThe agitation scores(Sedation-Agitation Scale,SAS)were recorded at 5,10,15,20,25,30 min after admission to PACU for children of five groups.1 score,calm sleep;2 scores,sober,calm;3 scores,Easily angered,Irritableness,crying;4 scores,hard to comfort,can not control the cry;5 scores,can not be quiet,delirium,More than 3 scores were diagnosed as agitation,and postoperative children were not awake for 1 score.5.2 secondary outcome parameters5.2.1Basic characteristic of five groupsThe transfusion volume,amount of bleeding,operation time,ratio of sexual distinction,age,height and weight were recorded in the five groups.5.2.2 Hemodynamic parametersThe mean arterial pressure(MAP),heart rate(HR)and pulse oxygen saturation(SpO2)of the five groups were recorded at the time of admission(TO),at the beginning of the operation(T1)and at the end of the operation(T2).5.2.3 Time of extubationThe time of tracheal extubation was recorded in the five groups(at the end of the operation to the tracheal tube removal).5.2.4 Adverse reactions during recovery periodIn the Post Anaesthetic Care Unit(PACU),the incidence of emergence agitation,nausea,vomiting and shivering were recorded in five groups of children.Besides,the remedial rate of fentanyl 1.0ug/kg was recorded.When the children face pain score(FPS-R)was more than 6 scores,intravenous fentanyl(1.0ug/kg)will be given for the rescue analgesia treatment.5.2.5 Analgesic score and Sedation scoreThe analgesic score(Revised Faces Pain Scale,FPS-R)and sedation score(RSS)were recorded after 1 h(T4),2 h(T5)and 3 h(T6)of postoperation.FPS-R:0 score,painless,2 scores,a little pain;4 scores,slight pain;6 scores,obvious pain;8 scores,serious pain;10 points,severe pain.RSS:1 score,anxiety,irritability;2 scores,quiet;3 scores,response to the instructions;4 scores,for sleep state,but can wake;5 scores,loud stimulation unresponsive performance;6 scores,no response.6 Statistics AnalysisThe measurement data were represented by mean standard deviation,and the two groups were compared by independent sample t test.The variance analysis of the repeated samples was used to compare the number of samples.Data were analyzed by SPSS 19.0(Statistical Package for the Social Science 19.0)software package,P<0.05,the difference was statistically significant.Research results1 Main research results1.1 Comparison of perioperative stress parameters in five groups of children at different time pointsAt the same time point,the concentrations of adrenaline,glucagon and cortisol in B,C and D groups were significantly lower than those in group E at T2 and T3(P<0.05).The concentration of glucose in group C and D was significantly lower than that of group E at T2(P<0.05);Comparison of different time points,The concentrations of adrenaline,glucagon and glucose in group C and group D were significantly lower than those in TO at T2 and T3(P>0.05),while cortisol concentration increased significantly at T2(P<0.05).The stress parameters of the other groups at these two time points were different from that of T0.1.2 Comparison of SAS agitation score at different time after operation in five groupsAt the same time point,compared with the E group,the SAS agitation scores of the four groups of A,B,C and D at 5?25 min after entering PACU were significantly lower than those in the E group(P<0.05).2 Secondary research results2.1 Comparison of the preoperative basic characteristics of the patients in five groupsThere was no significant difference between the five groups in general information such as the transfusion volume,amount of bleeding,operation time,ratio of sexual distinction,age,height and weight(P>0.05).2.2 Comparison of hemodynamic parameters at different time between the five groupsAt the same time point,MAP and HR were significantly decreased in group B,C and D at T1 and T2 Compared with the E group(P<0.05);Comparison of different time points,The MAP and HR of group C and group D were significantly lower than those of TO at T1 and T2(P<0.05),while MAP and HR in group E were significantly higher than those in TO at T1 and T2(P<0.05).2.3 Comparison of extubation time between the five groupsThe extubation time of A,B,C,D and E groups were(7±1.5)min,(8± 2.1)min,(7±1.8)min,(20±3.2)min and(6± 1.7)min,respectively.The extubation time of group D was significantly longer than that of other groups(P<0.05).2.4 Comparison of adverse reactions in five groups of children during recovery periodCompared with group E,the incidence of remedial fentanyl 1.Oug/kg,nausea,vomiting and shiver was significantly decreased in patients with A,B,C and D(P<0.05);Between Dex groups:Compared with group C,the incidence of remedial fentanyl 1.0ug/kg,nausea,vomiting and shiver was significantly higher than in group A and B(P<0.05).2.5 Comparison of analgesic score(FPS-R)and sedation score(RSS)at different time points in five groupsCompared with group E,the analgesic scores of T4,T5 and T6 were significantly decreased in group B,C and D(P<0.05).Compared with group E,The analgesic scores were higher than those of the other two time points(P<0.05).Compared with group E,the sedation scores of T4,T5 and T6 were significantly increased in group B,C and D(P<0.05).Research Conclusions(1)Dex(0.8 ug/kg?1.0ug/kg)could not reduce the stress response of the patients significantly,make more stable hemodynamics,but also reduce the incidence of Emergence agitation,nausea,vomiting,shivering and fentanyl remediation effectively,which had good sedative and analgesic effect.However,when the dose of Dex was 1.0 ug/kg,the time of recovery and endotracheal extubation of the children was prolonged obviously.(2)The optimal dose of Dex was 0.8 ug/kg before induction of anesthesiain for children undergoing Laparoscopic transfixion of internal ring.