探讨不同剂量艾司氯胺酮复合骶管阻滞(CB)在小儿尿道下裂术(PHS)中的临床疗效及艾司氯胺酮适宜剂量。

选择2023年4月至2024年9月在徐州医科大学附属徐州儿童医院进行尿道板背侧纵切卷管尿道成形术治疗的先天性尿道下裂(CH)患儿120例为研究对象，年龄为2~6岁，美国麻醉医师协会(ASA)分级为Ⅰ~Ⅱ级。采用随机数字表法，将CH患儿平均分为S1组、S2组和S3组，每组CH患儿均为40例，艾司氯胺酮给药方式均为静脉注射，给药剂量分别为0.81、0.97及1.13 mg/kg。3组CH患儿进入手术室后，均采取连续面罩吸氧，氧流量为5 L/min，对3组分别静脉注射对应剂量艾司氯胺酮，待患儿《改良警觉/镇静量表》评分≤1分时，让其取左侧卧位，由同1名高年资副主任麻醉医师对其进行超声引导下CB。记录3组CH患儿手术时间、麻醉后恢复正常的时间及艾司氯胺酮复合CB的体动抑制率；进入手术室平静时、静脉注射艾司氯胺酮1 min、CB即刻、手术结束即刻、入苏醒室即刻、出苏醒室即刻(T′0~T′5)各时间点的心率及平均动脉压(MAP)、脉搏血氧饱和度(SpO₂)；术中和术后不良反应(视物模糊、流涎、呼吸抑制等)发生情况；评估入苏醒室即刻与入苏醒室后10、20、30 min及出苏醒室即刻(T1~T5)的《儿童麻醉苏醒期躁动量表(PAED)》评分。采用χ²检验、单因素方差分析、重复测量资料方差分析，对3组CH患儿上述指标进行统计学分析。本研究遵循的程序通过徐州医科大学附属徐州儿童医院医学伦理委员会批准(批准文号：2023-05-71-H71)，并且与所有患儿监护人签署临床研究知情同意书。3组CH患儿年龄和体重分别比较，差异均无统计学意义(P>0.05)。

①3组CH患儿骶管穿刺时体动抑制率及手术时间分别整体比较，差异均无统计学意义(P>0.05)。S1、S2、S3组患儿麻醉后恢复正常的时间分别为(40.9±0.6)、(41.3±0.7)、(41.7±0.5) min，3组整体比较，差异有统计学意义(P<0.05)；进一步两两比较结果显示，与S1、S2组相比较，S3组患儿麻醉后恢复正常的时间明显延长(F＝33.23、21.98，P<0.001)，S1组与S2组比较，差异无统计学意义(P>0.05)。②对3组CH患儿T1~T5时间点的PAED评分，T′0~T′5时间点的MAP、心率、SpO₂进行重复测量资料方差分析结果显示，不同处理措施和时间因素的交互效应比较，差异均无统计学意义(P_{处理×时间}>0.05)。进一步分析艾司氯胺酮不同剂量组CH患儿T1~T5时间点PAED评分主效应比较结果显示，差异均有统计学意义(P_处理＝0.036)，采用Bonferroni法校正检验水准(校正α＝0.017)，对3组患儿T1~T5时间点PAED评分两两比较结果显示，S3组患儿T1~T5时间点的PAED评分与S1、S2组比较，虽然差异均无统计学意义(P＝0.033、0.316)，但是S3组患儿各时间点的PAED评分平均值均高于其他2组；艾司氯胺酮不同剂量组CH患儿T′0~T′5时间点MAP、心率、SpO₂的主效应比较，差异均无统计学意义(P_处理＝0.941、0.844、0.275)。③3组患儿视物模糊、谵妄、流涎等不良反应发生率分别比较，差异均无统计学意义(P>0.05)。

0.81、0.97、1.13 mg/kg艾司氯胺酮复合CB对于PHS患儿骶管穿刺操作时制动效果，以及对患儿的PAED评分、MAP、心率、SpO₂、不良反应等影响相当，但是0.81 mg/kg艾司氯胺酮复合CB患儿的麻醉后恢复正常的时间最短，为艾司氯胺酮复合CB的艾司氯胺酮适宜剂量。

To investigate the clinical efficacy of different doses of esketamine combined with caudal block (CB) in pediatric hypospadias surgery (PHS), and the optimal dose of esketamine.

A total of 120 pediatric patients aged 2 to 6 years with congenital hypospadias (CH) who underwent tubuloplasty with longitudinal incision of the urethral plate at Xuzhou Medical University Affiliated Xuzhou Children′s Hospital from April 2023 to September 2024 were selected. All children were classified as American Society of Anesthesiologists (ASA) physical status Ⅰ or Ⅱ. They were randomly assigned to group S1, S2 and S3 by a random number table, with 40 children in each group. Esketamine was administered via intravenous injection at doses of 0.81, 0.97, and 1.13 mg/kg, respectively. The CH children in 3 groups received continuous oxygen via face mask at a flow rate of 5 L/min after entering the operating room. Each group received the corresponding dose of esketamine via intravenous injection. Once the children′s Modified Observer′s Assessment of Alertness and Sedation score ≤1 point, they were positioned in the left lateral decubitus position. A senior deputy chief anesthesiologist then performed an ultrasound-guided CB. The operation time, time to recover after anesthesia, and movement inhibition rate of esketamine combined with CB were recorded in the three groups. The heart rate, mean arterial pressure (MAP), and pulse oxygen saturation (SpO₂) were recorded at the time of entering the operating room, 1 minute after intravenous injection of esketamine, immediately after CB, immediately after the end of the operation, immediately after entering the recovery room, and immediately after leaving the recovery room (T′0-T′5). The incidence of adverse reactions (blurred vision, drooling, respiratory depression, etc.) during and after the operation was also recorded. The Pediatric Anesthesia Emergence Delirium Scale (PAED) scores were recorded immediately after entering the recovery room, and 10, 20, 30 minutes after entering the recovery room, and immediately after leaving the recovery room (T1-T5). The chi-square test, one-way analysis of variance and analysis of variance for repeated measures were used to compare the above indicators among three groups of CH children. The procedures followed in this study were approved by the Medical Ethics Committee of Xuzhou Medical University Affiliated Xuzhou Children′s Hospital (Approval No. 2023-05-71-H71). All guardians of the pediatric patients signed informed consent forms for clinical study. There were no statistically significant differences in age and weight among the pediatric patients in three groups (P>0.05).

①There were no statistically significant differences in the rates of movement inhibition during caudal puncture and the operation time among three groups (P>0.05). The time to recover after anesthesia of children in groups S1, S2, and S3 was (40.9±0.6), (41.3±0.7), and (41.7±0.5) min, respectively. The overall comparison among the three groups showed statistically significant difference (P<0.05). Further pairwise comparisons showed that compared with groups S1 and S2, the time to recover after anesthesia of children in group S3 was significantly prolonged (F=33.23, 21.98; P<0.001). There was no statistically significant difference in time to recover after anesthesia between groups S1 and S2 (P>0.05). ②The results of analysis of variance of repeated measurement data of PAED scores at T1-T5, and mean arterial pressure, heart rate, and SpO₂ at T′0-T′5 in the three groups of children showed that the interaction effects of different treatment measures and time factors were not statistically significant (P_{treatment×time}>0.05). Further analysis of the main effect of treatment measures (different esketamine doses) showed that the main effect of different esketamine doses on the PAED scores of children at T1-T5 was statistically significant (P_treatment=0.036). After Bonferroni correction for pairwise comparisons (adjusted α=0.017), pairwise comparisons of PAED scores of three groups at T1-T5 showed that there were no statistically significant differences in PAED scores of S3 group compared with those of S1 and S2 groups at T1-T5 (P=0.033, 0.316). However, the average PAED scores of S3 group at each time were higher than those of the other two groups. There was no statistically significant main effect of different esketamine doses on the MAP, heart rate, and SpO₂ of the children at T′0-T′5 (P_treatment=0.941, 0.844, 0.275). ③There were no statistically significant differences in the incidence rates of adverse reactions such as blurred vision, delirium, and drooling among the three groups (P>0.05).

The effects of 0.81, 0.97, and 1.13 mg/kg esketamine combined with CB on suppressing motor responses during caudal puncture in children undergoing PHS, as well as on the children′s PAED score, MAP, heart rate, SpO₂, and adverse reactions, are comparable. However, the time to recover after anesthesia of 0.81 mg/kg esketamine combined with CB was the shortest, which was the appropriate dose of esketamine.