【摘要】：【目的】本研究擬通過動(dòng)態(tài)測(cè)定正常兒童、圍手術(shù)期兒童唾液皮質(zhì)醇分泌規(guī)律以及靜脈全麻誘導(dǎo)使用依托咪酯、丙泊酚對(duì)兒童圍手術(shù)期唾液皮質(zhì)醇分泌規(guī)律影響的比較研究,探討國(guó)內(nèi)兒童皮質(zhì)醇分泌規(guī)律和特征,明確臨床常規(guī)誘導(dǎo)劑量的依托咪酯是否影響兒童皮質(zhì)醇的分泌規(guī)律。【方法】招募健康兒童和新華醫(yī)院住院擬行選擇性中小型泌尿外科手術(shù)兒童共20例,在排除應(yīng)激刺激下于日間每隔1小時(shí)收集唾液,使用ELISA檢測(cè)唾液皮質(zhì)醇濃度,觀察健康兒童日間皮質(zhì)醇分泌規(guī)律,并比較健康兒童和擬行手術(shù)兒童皮質(zhì)醇晝夜節(jié)律的差異;招募健康兒童和新華醫(yī)院住院擬行手術(shù)兒童共20例,于晨間清醒時(shí)、清醒后30min、以及清醒后60min分別收集唾液,比較健康兒童和擬行手術(shù)兒童晨起皮質(zhì)醇覺醒反應(yīng)差異;招募新華醫(yī)院擬行選擇性尿道成形術(shù)和腎盂成形術(shù)患兒,隨機(jī)分為麻醉誘導(dǎo)依托咪酯組(38例)和丙泊酚組(39例),麻醉誘導(dǎo)分別使用依托咪酯(0.3mg/kg)和丙泊酚(2mg/kg),于手術(shù)日以及術(shù)后兩日連續(xù)多時(shí)點(diǎn)采集唾液測(cè)定唾液皮質(zhì)醇濃度,比較兩組的皮質(zhì)醇濃度差異,并比較術(shù)后非預(yù)防性抗生素使用、住院天數(shù)、尿道瘺形成、傷口愈合情況的差異。【結(jié)果】健康兒童和擬行手術(shù)兒童術(shù)前日間皮質(zhì)醇分泌具有晨高晚低的晝夜節(jié)律,二者唾液皮質(zhì)醇水平比較沒有顯著差異(P0.05);健康兒童和擬行手術(shù)兒童術(shù)前均表現(xiàn)出晨起后的皮質(zhì)醇覺醒反應(yīng),二者唾液皮質(zhì)醇水平比較也沒有顯著差異(P0.05);與丙泊酚組相比較,依托咪酯組兒童皮質(zhì)醇水平從手術(shù)日離開蘇醒室(約14:00)起顯著降低直至術(shù)后第1日晨8:00(F=14.703,P0.01),與術(shù)前相應(yīng)時(shí)間點(diǎn)相比也顯著降低(F=55.496,P0.01)。丙泊酚組兒童皮質(zhì)醇水平與術(shù)前相比沒有顯著差異(F=13.176,P0.01).依托咪酯組和丙泊酚組兒童在非預(yù)防性抗生素使用、術(shù)后住院天數(shù)、傷口愈合和尿道瘺的發(fā)生率等方面沒有顯著差異(P0.01).【結(jié)論】健康兒童和擬行泌尿外科中小手術(shù)患兒的皮質(zhì)醇分泌具有晨高晚低的晝夜節(jié)律和晨起皮質(zhì)醇覺醒反應(yīng),兩組兒童皮質(zhì)醇分泌的節(jié)律和HPA軸功能沒有顯著差異;使用動(dòng)態(tài)連續(xù)監(jiān)測(cè)皮質(zhì)醇變化的方法研究發(fā)現(xiàn),誘導(dǎo)時(shí)單次使用依托咪酯可顯著降低患兒術(shù)后皮質(zhì)醇水平,但皮質(zhì)醇水平的降低是短時(shí)現(xiàn)象,持續(xù)不超過24h,且對(duì)患兒術(shù)后感染、傷口愈合和住院時(shí)間等臨床表現(xiàn)沒有顯著影響,可以安全使用于行中小型泌尿外科手術(shù)兒童。
[Abstract]:[objective] to study the effect of intravenous general anesthesia induced by etomidate and propofol on salivary cortisol secretion in normal children and perioperative children by means of dynamic determination of salivary cortisol secretion in normal children and perioperative children, and to compare the effects of etomidate and propofol on salivary cortisol secretion in children during perioperative period. To explore the rules and characteristics of cortisol secretion in children in China. To determine whether the routine dose of etomidate affects the secretion of cortisol in children. [methods] A total of 20 children with selective small and medium-sized urological surgery were recruited from healthy children and hospitalized in Xinhua Hospital. Saliva was collected every 1 hour every day after excluding stress stimulation. The concentration of cortisol in saliva was measured by ELISA, and the rules of cortisol secretion in healthy children were observed, and the circadian rhythm of cortisol was compared between healthy children and children scheduled for operation. A total of 20 healthy children and 20 hospitalized children were recruited. Saliva was collected 30 minutes after waking and 30 minutes after waking, and 60min was collected after waking to compare the morning cortisol arousal reaction between healthy children and children who planned to undergo surgery. To recruit children with selective urethroplasty and pyeloplasty in Xinhua Hospital. Etomidate group (n = 38) and propofol group (n = 39) were randomly divided into two groups. 0.3mg/kg and 2mg/kg were used to determine salivary cortisol concentration in saliva on the day of operation and two days after operation. The difference of cortisol concentration between the two groups was compared, and the use of non-prophylactic antibiotics, the length of stay in hospital and the formation of urethral fistula were compared. The difference of wound healing. [results] the circadian rhythm of cortisol secretion before operation in healthy children and operative children was high, late and low. There was no significant difference in salivary cortisol levels between the two groups (P0.05); healthy children and children who planned to undergo surgery showed cortisol arousal reaction before operation, and there was no significant difference in salivary cortisol levels between them (P0.05); compared with propofol group, there was no significant difference in salivary cortisol level between them. The level of cortisol in etomidate group decreased significantly from the day of operation to 8:00 (F _ (14.703) P _ (0.01) from the day of operation to 8:00 (F _ (14.703) P _ (0.01), and also significantly decreased compared with the corresponding time point before operation (F _ (55.496) P _ (0.01). There was no significant difference in cortisol level between propofol group and preoperation group (F = 13.176, P 0.01). Children in etomidate group and propofol group were treated with non-prophylactic antibiotics and hospitalized days after operation. There was no significant difference in wound healing and the incidence of urethral fistula (P0.01). [conclusion] cortisol secretion in healthy children and children undergoing minor surgery in urology has a circadian rhythm of high and late morning and early morning cortisol arousal. There was no significant difference between the rhythm of cortisol secretion and the function of HPA axis in the two groups. However, the decrease of cortisol level is a short-term phenomenon, lasting no more than 24 hours, and has no significant effect on the postoperative infection, wound healing and hospital stay in children, so it can be safely used in children undergoing small and medium-sized urological surgery.
【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R726.1

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