儿童牙科门诊镇静麻醉的作业流程——术前准备

2018-07-05 范国栋 等 中国医学论坛报今日口腔

1.儿童牙科门诊镇静麻醉技术主要用于有牙科焦虑恐惧症患儿的口腔疾病治疗,途径和方法非常多,但也有其风险和注意事项; 2.术前、书中、术后系统、完善的诊治和操作流程有助减少镇静麻醉过程中的风险; 3.门诊镇静麻醉技术只是儿童牙科治疗的辅助手段,口腔医生、麻醉医生和助手还需通力合作,密切配合,完成儿童镇静麻醉下口腔疾病治疗。


童口腔门诊镇静麻醉的台湾经验

门诊镇静麻醉的作业流程

作者:

范国栋      中国台湾Abc牙医集团镇静麻醉教培中心
苏百川      欣辰麻醉舒眠团队
纪乃智      杭州儿童口腔医院
陈启中       “卫生福利部”旗山医院牙科
廖桂君      品味/品御/品悦牙医诊所儿童牙科
关  明      北京大学第一人民医院麻醉科

本文重要观点提炼:

1.儿童牙科门诊镇静麻醉技术主要用于有牙科焦虑恐惧症患儿的口腔疾病治疗,途径和方法非常多,但也有其风险和注意事项;

2.术前、书中、术后系统、完善的诊治和操作流程有助减少镇静麻醉过程中的风险;

3.门诊镇静麻醉技术只是儿童牙科治疗的辅助手段,口腔医生、麻醉医生和助手还需通力合作,密切配合,完成儿童镇静麻醉下口腔疾病治疗。

儿童牙科门诊镇静麻醉的途径非常多,有应用较为普遍的插管全麻和鼻吸笑气,也有近几年才开始出现的靶控泵注输丙泊酚(propofol)的(非插管)静脉全麻、深度镇静或意识镇静。欧、美、日等地区和国家的牙科门诊镇静麻醉技术还包括口服、鼻喷、栓塞等多种用药方式。

门诊镇静麻醉技术主要用于有牙科焦虑恐惧症患儿的龋洞充填、根管治疗、戴冠、舌系带切开、多生或阻生牙拔除等。但门诊镇静麻醉技术只是儿童牙科治疗的辅助手段,比如考虑鼻吸笑气/氧气进行门诊镇静时,“牙、麻、护”团队必须考虑患儿对鼻罩吸气的承受压力和口腔医师手术治疗时间是否过长;通过口服药物来完成意识镇静时,术中也要重视患儿对口服药物的抗拒和口腔医师团队沟通安抚的能力;实行鼻喷药剂以达成意识镇静时,则要注意患儿鼻道的感染不适和口腔医师手术刺激的强度;有时候,团队成员还得结合行为管理,以制定出适合患儿的多元整合镇静麻醉方案(表1)。总之,儿童牙科门诊镇静麻醉有其风险和注意事项,下面主要介绍其关键操作流程。

表1  个性化制定多元整合镇静麻醉

(Abc牙医集团镇静麻醉教培中心  范国栋主任提供)

术前确认清单

在约诊镇静麻醉当日,当患儿与家属按约定时间到达医院或科室后,镇静麻醉团队宜有专人与之确认术前的相关事宜,例如手术麻醉的同意书签署、术前是否遵守医嘱、是否发生需要推迟手术的突发事件等。在门诊诊疗椅或手术室的医护团队,则需要确认相关系统是否正常运转,手术镇静麻醉需要的器械、药物和材料是否齐全,如急救设备与任务编组系统、中央(或移动式)气水供应与吸引系统、(适合儿童体形)诊疗椅/手术床的动力系统和辅助用品、生理监护系统、插管全麻呼吸器系统和静脉全麻的靶控泵/注输系统等。

对于在较小型的门诊部进行儿童口腔镇静麻醉,或以多点执业方式提供照护的个别医师、团队或医生集团公司,更需要一套安全的作业流程,以便掌控患儿术前评估准备到镇静麻醉当日的治疗流程(图1),最后还要确认急救设备与任务编组系统是否已配置齐全,且已启动待命。

当上述软硬件均准备妥当,团队就可准备迎接患儿和家属,根据镇静麻醉计划依次按“稳定情绪”、“安全诱导”、“麻醉调控”、“畅通气道”和“平顺苏醒”完成治疗流程。与此同时,医护团队还要有完整的镇静麻醉记录。

“麻醉调控”和“畅通气道”是手术期间的两项重点,镇静不足、止痛不足、气道阻塞和呛咳反射能否处理得当关系着手术麻醉的平顺和风险。特别是未施予肌肉松弛剂,完全靠患儿自呼换气的喉罩全麻和静脉深度镇静/全麻,更须借由跨专业的团队协作才能顺利完成。

图 1  多点执业麻醉团队儿牙门诊镇静流程

(台湾欣辰麻醉舒眠团队  苏百川执行长提供)

稳定情绪

稳定患儿情绪的首要任务就是尽可能避免患儿带着恐惧或哭闹情绪进入镇静麻醉的诱导室、门诊诊疗椅或手术室。虽然诊疗手术期间的哭闹,未必会成为患儿以后成长的永恒记忆,但仍有发展成为牙科恐惧的风险。而且哭闹有可能影响患儿呼吸道的畅通,可能让家属对镇静团队的能力产生质疑,也会影响其他候诊或诊疗中的患者。所以,如何稳定患儿情绪将是团队要面对的第一个挑战。医护团队可与家属配合,以利诱奖赏和正面行为诱导方式,或调整移动路线,避免路过容易引发小儿恐慌的场景来缓解患儿焦虑。

当然,如果儿童可通过行为诱导,配合坐上治疗椅或躺在手术台上,并通过鼻罩呼吸笑气,或对静脉针扎注射无明显抗拒,则可直接进入诱导/麻醉(包括笑气镇静、意识镇静或插管全麻),然后麻醉团队再依不同镇静麻醉途径的操作规范,完成生理监测并畅通气道,随着手术刺激调控麻醉剂量至诊疗手术结束,患儿苏醒恢复。但是,如果麻醉团队决定采取药效作用较慢的口服镇静,就要注意药物动力学和药物效力学对治疗流程的作用程度。以口服咪达唑仑0.2~0.5 mg/kg 为例,患儿口服后约须再等 15~30 分钟,才会出现注意力不集中、步态不稳、表情放松或失忆等现象。但是,若通过术中追加口服药剂来延长意识镇静时间的方式则容易导致深度镇静,反而不好控制患儿对周遭刺激的行为反射,故多为单次给药。这也意味着,口服镇静不容易采取滴定调控(titration adjustment)镇静深度方式,而应按照当次短时间治疗刺激的大小。这时团队便要考虑到患者的安全监测、运转效率和手术期的镇静成效等问题;不然本来应该是药物成本最低的口服镇静药剂,却将之使用在重度牙科恐惧症患儿,且长时间、刺激大的口腔治疗内容反而会增加营运的人力成本或给手术操作带来干扰。

对于无法接受行为诱导稳定情绪的患儿,可考虑采取①口服/鼻喷镇静剂,待患儿情绪缓和、反应迟钝,再带至诱导室/诊间或手术室;②缩短移动路线,迅速抱至诱导室执行镇静麻醉的快速诱导。但这两种方式都考验团队的耐心与配合程度。

安全诱导

安全平稳地为门诊儿童施予镇静麻醉,有助于提升患儿和家属对医疗团队照护的信赖,也是进入到安全手术的第一道关卡。为了有效管理门诊手术的运转,我们仍应迅速对情绪稳定的患儿执行原定意识镇静或全麻计划。

有些儿童原来评估可以接受鼻吸笑气或其他意识镇静,但给药后反而出现无法配合的现象,甚至对手术准备与刺激产生轻微躁动或哭闹,此时,镇静麻醉团队要有应对策略,比如稍加束敷或加重镇静深度(如追加笑气浓度或是静脉注射剂量),甚至进行全麻。因为变更镇静麻醉计划,麻醉医师必须适时地告知家属原委,并让手术团队知晓接下来的配套计划和相关作为(前文表 1)。

对于在医院/门诊门口就开始哭闹的幼儿,医师在镇静前评估时,宜增加给予口服/鼻喷镇静剂(如:咪达唑仑或氯胺酮)的医嘱,以便安全快速地诱导患儿接受后续的麻醉和治疗计划。有关口服/鼻喷诱导剂量的(一次性)给予,应考虑患儿体重、药效与治疗时间的关系,避免因剂量不足而未能有效缓解患儿恐惧,无法达到快速诱导效果,推迟后续疗程。相反,如果剂量过大,也会造成术中镇静调控的困难,或术后苏醒缓慢、引发视力模糊和呕吐等并发症,并造成家属返家照护的不便。

接着若是选择经鼻/口气管内插管或喉罩全麻,麻醉医师可依诊疗需求和全麻操作指南完成镇静麻醉诱导──从选好适合患儿大小的气管内管和喉罩到固定适当深度,以完成插管工作。

团队成员还需依次确认相关连接管线(如气道、呼吸器和输液等)和相关生理监视设备(如心电图、呼吸、心跳、血氧、血压、呼末二氧化碳,或脑电双频监测仪)是否装置妥当。最后,再请口腔团队进行后续的消毒和诊疗作业(部份用水量多的治疗,还可能需要咽腔填塞纱布,以免过多水/血进入患儿胃肠,增加术后苏醒过程发生恶心呕吐风险)。

倘若决定采取辅助患儿自主呼吸的静脉深度镇静或不插管全麻,那么在建立静脉路径、注射初始镇静麻醉剂后,团队成员必须协同合作维持患儿自主呼吸,并迅速装置生理监护仪和持续给氧设备。若是使用代谢快速的丙泊酚进行静脉深度镇静或全麻,则需尽快将静脉导管与靶控泵/传统泵注输系统连接,同时有专人注意和评估儿童自主呼吸状况、血氧变化和注输浓度(速率)三者间的关系,适时介入辅助患儿通气或调控丙泊酚输注标靶浓度/速率,以利诊疗手术。在此要特别提醒一事,接受这类深度镇静或不插管全麻的患儿,其口腔数字照或治疗牙位的根尖X线片等影像学信息或证据大多不齐全,因此,团队成员宜在诱导稳定后加拍足够的影像学信息以修正原拟定的口腔治疗计划。

当然,团队若经评估有把握在门诊手术室或是诊间快速设置静脉路径,也可跳过口服/鼻喷诱导的程序,接着注射初始镇静剂(如短效的硫喷妥钠、丙泊酚或咪达唑仑等),和配合治疗时间长短的肌松剂(种类和剂量);或是经面罩给予七氟醚,再建立静脉路径,让患儿从躁动进入嗜睡/全麻状态。再视状况吸引口/鼻内唾液,给予患儿辅助通气提升血氧饱和度,以利后续的经口/经鼻气管内插管或喉罩全麻与口腔诊疗。

总之,在安全诱导阶段,口腔门诊镇静麻醉团队必须各司其职。特别是采取静脉深度镇静/全麻时,口腔医师和助理护士也须加入镇静麻醉作业。

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    太棒了#学习#

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  3. [GetPortalCommentsPageByObjectIdResponse(id=966926, encodeId=e04a966926cc, content=太棒了<a href='/topic/show?id=23e3454e353' target=_blank style='color:#2F92EE;'>#学习#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=55, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=45473, encryptionId=23e3454e353, topicName=学习)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6f865475954, createdName=ms3000001627599051, createdTime=Wed May 19 16:28:31 CST 2021, time=2021-05-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2041121, encodeId=4c5c2041121ed, content=<a href='/topic/show?id=1e1296819e7' target=_blank style='color:#2F92EE;'>#镇静麻醉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96819, encryptionId=1e1296819e7, topicName=镇静麻醉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=21015, createdName=heli0118, createdTime=Tue Aug 21 03:10:00 CST 2018, time=2018-08-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=330335, encodeId=2ca2330335d7, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=989f1678108, createdName=傻妮, createdTime=Mon Jul 09 08:14:40 CST 2018, time=2018-07-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1461335, encodeId=09fd14613355a, content=<a href='/topic/show?id=67356e62003' target=_blank style='color:#2F92EE;'>#牙科#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=67620, encryptionId=67356e62003, topicName=牙科)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d786418402, createdName=xzw115, createdTime=Sat Jul 07 14:10:00 CST 2018, time=2018-07-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329696, encodeId=b44532969674, content=厉害了我的哥, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Fri Jul 06 08:28:21 CST 2018, time=2018-07-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329632, encodeId=dcab32963214, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1bb241978, createdName=phoebeyan520, createdTime=Fri Jul 06 05:31:37 CST 2018, time=2018-07-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=329625, encodeId=a48f32962512, content=学习了.谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Fri Jul 06 00:30:44 CST 2018, time=2018-07-06, status=1, ipAttribution=)]
    2018-07-09 傻妮

    学习了.谢谢分享

    0

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    2018-07-07 xzw115
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    2018-07-06 飛歌

    厉害了我的哥

    0

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    2018-07-06 phoebeyan520

    学习了.谢谢分享

    0

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    2018-07-06 1209e435m98(暂无昵称)

    学习了.谢谢分享

    0