Russian Journal of Pediatric Surgery, Anesthesia and Intensive CareRussian Journal of Pediatric Surgery, Anesthesia and Intensive CareРоссийский вестник детской хирургии, анестезиологии и реаниматологии2219-40612587-6554Eco-Vector151410.17816/psaic1514Original Study ArticlesОригинальные исследованияResearch ArticlePostoperative analgosedation with dexmedetomidine in combination with paracetamol in pediatric cardiac surgeryПослеоперационная аналгоседация дексмедетомидином в комбинации с парацетамолом в детской кардиохирургии小儿心脏外科学中右美托咪定与对乙酰氨基酚联合使用的术后止痛方法https://orcid.org/0000-0002-8448-26709896-8364SatvaldievaElmira A.СатвалдиеваЭльмира АбдусаматовнаSatvaldievaElmira A.
Uzbekistan

MD, Dr. Sci. (Med.), Professor

д-р мед. наук, профессор

sshoraxmedovs@gmail.comhttps://e.mail.ru/inbox/0:16494102140588612644:0https://orcid.org/0000-0003-2638-0796TuychievDilmurod B.ТуйчиевДилмурод БахтиёровичTuychievDilmurod B.
Uzbekistan

anesthesiologist

врач – анестезиолог-реаниматолог

dtuychiev37@gmail.comAshurovDoston R.АшуровДостон РустамовичAshurovDoston R.
Uzbekistan

anesthesiologist-resuscitator

врач – анестезиолог-реаниматолог

elsatanest@mail.ruSayramovIkbol Kh.СайрамовИкбол ХасановичSayramovIkbol Kh.
Uzbekistan

anesthesiologist-resuscitator

врач – анестезиолог-реаниматолог

elsatanest@mail.ruTashkent Pediatric Medical InstituteТашкентский педиатрический медицинский институтTashkent Pediatric Medical InstituteNational Children’s Medical CenterНациональный детский медицинский центрNational Children’s Medical CenterRegional Children’s Multidisciplinary Medical CenterФерганский областной детский многопрофильный медицинский центрRegional Children’s Multidisciplinary Medical Center12062023150720231321611742703202303062023Copyright ©; 2023, Eco-VectorCopyright ©; 2023, Эко-ВекторCopyright ©; 2023,2023Eco-VectorЭко-Векторhttps://creativecommons.org/licenses/by-nc-nd/4.0https://rps-journal.ru/jour/article/view/1514

BACKGROUND: Although the principles of postoperative multimodal analgesia have been discussed in several articles, this issue remains insufficiently studied in pediatric cardiac surgery.

AIM: To increase the effectiveness of postoperative analgosedation in children after heart surgery by combining intravenous dexmedetomidine and paracetamol.

MATERIALS AND METHODS: Prospective, nonrandomized, controlled study (n = 65, 2–4 yr). Elective heart surgeries were performed in children with congenital heart defects, such as ventricular and/or interatrial septal defect and tetralogy of Fallot, under cardiopulmonary bypass and general anesthesia. Patients were divided into two groups according to the type of postoperative analgesia: group 1, main (n = 35): 30 min after surgery, infusion of dexmedetomidine with a loading dose of 1.0 μg/kg/h or 10 min, then infusion of 0.8 μg/kg/h during the day against the background of planned analgesia with paracetamol (15 mg/kg, intravenously) 2 h after surgery and then every 8 h during the day; group 2, comparisons (n = 30), 0.3 mg/kg — morphine, intramuscularly. The effectiveness of postoperative analgosedation in children was analyzed using the Richmond scale and FLACC + hemodynamics, acid-base balance, blood gases, cortisol, glucose, and blood lactate.

RESULTS: Sufficient stabilization of the main hemodynamics and respiratory indicators confirmed the adequacy of postoperative analgosedation in group 1 patients. There was a −14% drop in heart rate, specific peripheral resistance, and mean arterial pressure. There was no respiratory depression observed, and the decrease in blood pressure and heart rate was hemodynamically modest. Postoperative stability of blood lactate, glucose, and cortisol levels demonstrated the absence of major metabolic diseases and emotional and physical stress in the main group of children. The transfer of 74.3% of the first group's patients to the specialized department 42.3 ± 5.5 h after the procedure decreased costs and strain on the intensive care unit staff.

CONCLUSIONS: Dexmedetomidine combined with paracetamol provides an adequate level of sedation, suppresses extubation irritations, prevents psychomotor agitation, and provides sufficient analgesia.

Актуальность. Принципы послеоперационной мультимодальной аналгезии отражены в многочисленных публикациях, однако в детской кардиохирургии этот вопрос остается недостаточно изученным.

Цель — повысить эффективность послеоперационной аналгоседации комбинированным внутривенным применением дексмедетомидина и парацетамола у детей после кардиохирургических операций.

Материалы и методы. Исследование проспективное контролируемое нерандомизированное (n = 65, от 2 до 4 лет). Плановые операции на сердце проведены детям с врожденными пороками сердца: дефектом межжелудочковой и/или межпредсердной перегородки, тетрадой Фалло, в условиях искусственного кровообращения и общей анестезии. Пациенты были разделены на 2 группы по виду послеоперационного обезболивания: 1-я группа, основная (n = 35) — через 30 мин после операции инфузия дексмедетомидина с нагрузочной дозой 1,0 мкг/(кг · ч) в течение 10 мин, затем инфузия в дозе 0,8 мкг/(кг · ч) в течение суток на фоне плановой аналгезии парацетамолом (15 мг/кг, внутривенно) через 2 ч после операции и последующие каждые 8 ч в течение суток; 2-я группа, сравнения (n = 30) — морфин в дозе 0,3 мг/кг, внутримышечно. Проведен анализ эффективности послеоперационной аналгоседации у детей по шкале Ричмонда и FLACC + системная гемодинамика, кислотно-щелочное состояние и газы крови, кортизол, глюкоза и лактат крови.

Результаты. Достаточная стабилизация основных параметров гемодинамики и дыхания подтверждала адекватность послеоперационной аналгоседации у пациентов 1-й группы. Зафиксировано снижение частоты сердечных сокращений, удельного периферического сопротивления и среднего артериального давления до –14 %. Депрессии дыхания не отмечено ни в одном случае, снижение артериального давления и частоты сердечных сокращений гемодинамически незначимы. Послеоперационная стабильность уровней лактата, глюкозы и кортизола крови фиксировала отсутствие грубых нарушений метаболизма и эмоционально-болевых напряжений у детей основной группы. После перевода 74,3 % пациентов 1-й группы через 42,3 ± 5,5 ч после операции в профильное отделение уменьшились расходы и нагрузка на медперсонал отделения реанимации и интерсивной терапии.

Заключение. Мультимодальная аналгезия дексмедетомидином в сочетании с парацетамолом обеспечивает адекватный уровень седации, подавляет раздражения на экстубацию, предупреждает психомоторное возбуждение и обеспечивает эффективную аналгезию.

现实性。术后多模式镇痛的原则已经发表在许多出版物上。但在小儿心脏外科学中，这一问题仍然未得到充分研究。

该研究的目的是通过联合静脉注射右美托咪定和对乙酰氨基酚来提高儿童心脏手术后的镇 痛疗效。

材料和方法。该研究是前瞻性、对照、非随机的（n = 65，2至4岁）。对患有先心病的儿童进行了择期心脏手术，研究的先心病包括：室间隔和/或房间隔缺损、法洛氏四联症。手术是在人工循环和全麻下进行的。根据术后镇痛的类型，患者被分为2组。第1组是主组（n = 35）。术后30分钟， 1.0微克/千克/小时负荷剂量输注右美托咪定，持续10分钟。然后在手术后2小时用对乙酰氨基 酚（15毫克/千克，静脉注射）择期镇痛，此后一天每8小时一次的背景下，0.8微克/千克/小时剂量输注 24小时。第2组是对照组（n = 30）。吗啡的剂量为0.3毫克/千克，肌肉注射。使用Richmond和FLACC量表+系统血液动力学、酸碱状态和血液气体、皮质醇、血葡萄糖和血乳酸盐对儿童的术后镇通疗效进行分析。

结果。血液动力学和呼吸的基本参数充分稳定证实了第一组患者术后镇痛的充分性。心率、比外周阻力和平均动脉压下降了14%。在所有的病例中都没有观察到呼吸抑制，动脉压和心率的下降在血液动力学上是不明显的。术后血乳酸盐、血葡萄糖和血皮质醇水平是稳定的，所以记录了主组儿童没有严重的代谢紊乱和情绪疼痛紧张。74.3%的第一组患者在术后42.3±5.5小时被转移到专用病房。转院后，重症监护室的费用和护理人员的负担得到了减轻。

结论。右美托咪定联合对乙酰氨基酚的多模式镇痛提供了足够的镇静水平，抑制拔管刺激，防止精神运动性兴奋并提供有效的镇痛。

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