对行胸壁超声心动图的婴儿和学步幼儿使用鼻内右美托咪定和口服戊巴比妥后的镇静作用进行比较：一项前瞻性随机双盲试验
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Comparison of Intranasal Dexmedetomidine and Oral Pentobarbital Sedation for Transthoracic Echocardiography in Infants and Toddlers: A Prospective, Randomized, Double-Blind Trial
背景
儿童要得到经胸超声心动图（TTEcho）图像通常需要镇静。TTEcho的最佳镇定剂还没有确定。患有先天性心脏病的儿童反复接触镇静剂和麻醉剂可能影响大脑发育。在动物体内，右美托咪定会不同程度改变大脑结构，这可能会对体弱的人群有影响。
方 法
一项前瞻性、随机、双盲试验的研究纳入了280名儿童，年龄为3-24个月，别接受门诊TTEcho，分别使用2.5g/kg鼻内右美托咪定和口服5mg/kg戊巴比妥镇静，比较两者的效果。对两组来说，追加镇静都使用1g/kg的右美托咪定。主要指标是30分钟内充分有效的镇静，并且不追加镇静剂，由不知情的人员进行评估。次要指标包括超声医师的暂停次数，关于运动伪影的图像质量与父母的满意度。
结 果
单次剂量的成功率在镇静技术上并没有什么不同;戊巴比妥组中为85%，右美托咪定组为84%（P=.8697）。充分镇静开始时间的中位数戊巴比妥比右美托咪定组更快（四分位间距为16.5，（ 13 -21）比18 （16 -23）分钟P=.0095）。从给药到出院的时间并没有什么不同（P=.8238），戊巴比妥组为70.5（64- 83）分钟内服用戊巴比妥，70（63 82）分钟和右美托咪定组为70（63-82）分钟。戊巴比妥组镇静有95%失败了，右美托咪定组100%失败，之后用鼻内右美托咪定来进行追加镇静都成功了。
结 论
鼻内右美托咪定和口服戊巴比妥对婴儿TTEcho镇静作用可以相提并论，并且没有增加临床重要不良事件的风险。鼻内右美托咪定看来是一种有效追加镇静的方法，可用于戊巴比妥和右美托咪定镇静失败。右美托咪定对于儿童反复镇静是一种更安全的选择，但是需要进一步的研究来评估在这个高危人群中反复镇静的长期后果。
原始文献摘要
BACKGROUND: Acquisition of transthoracic echocardiographic (TTEcho) images in children often requires sedation. The optimal sedative for TTEcho has not been determined. Children with congenital heart disease are repeatedly exposed to sedatives and anesthetics that may affect brain development. Dexmedetomidine, which in animals alters brain structure to a lesser degree, may offer advantages in this vulnerable population.
METHODS: A prospective, randomized, double-blind trial enrolled 280 children 3 24 months of age undergoing outpatient TTEcho, comparing 2.5 g·kg 1 intranasal dexmedetomidine to 5 mg·kg 1 oral pentobarbital. Rescue sedation, for both groups, was intranasal dexmedetomidine 1 g·kg 1. The primary outcome was adequate sedation within 30 minutes without rescue sedation, assessed by blinded personnel. Secondary outcomes included number of sonographer pauses, image quality in relation to motion artifacts, and parental satisfaction.
RESULTS: Success rates with a single dose were not different between sedation techniques; 85% in the pentobarbital group and 84% in the dexmedetomidine group (P = .8697). Median onset of adequate sedation was marginally faster with pentobarbital (16.5 [interquartile range, 13 21] vs 18 [16 23] minutes for dexmedetomidine [P = .0095]). Time from drug administration to discharge was not different (P = .8238) at 70.5 (64 83) minutes with pentobarbital and 70 (63 82) minutes with dexmedetomidine. Ninety-five percent of sedation failures with pentobarbital and 100% of dexmedetomidine failures had successful rescue sedation with intranasal dexmedetomidine.
CONCLUSIONS: Intranasal dexmedetomidine was comparable to oral pentobarbital sedation for TTEcho sedation in infants and did not increase the risk of clinically important adverse events. Intranasal dexmedetomidine appears to be an effective rescue sedative for both failed pentobarbital and dexmedetomidine sedation. Dexmedetomidine could be a safer option for repeated sedation in children, but further studies are needed to assess long-term consequence of repeated sedation in this high-risk population.
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