日本臨床麻酔学会 vol.34

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1 739 日本臨床麻酔学会第 33 回大会専門医が伝えるプロの技日臨麻会誌 Vol.34 No.5, , 2014 小児麻酔 覚醒時興奮 金谷明浩 亀山良亘 山内正憲 *2 蔵谷紀文 [ 要旨 ] 小児の覚醒時興奮は自傷行為のリスク, 看護スタッフの負担, 両親の満足度を低下させるなど, 術後の大きな問題の一つである. リスク因子には年齢, 術前不安, 性格, 痛み, 麻酔方法, 術式がある. 麻酔方法は重要で, 血液 / ガス分配係数の小さいセボフルランやデスフルランは広く使用されているが, 小児の覚醒時興奮の原因として注目されている. 予防 治療にはオピオイド, ミダゾラム, ケタミン,α 2 受容体作動性鎮静薬, 非ステロイド性抗炎症薬などの周術期投与が有効とされている. プロポフォールによる麻酔維持も予防に有効である. 小児では覚醒時興奮が生じにくい麻酔方法を選択するべきで, 発生した場合は適切に治療を行わなければならない. キーワード : 覚醒時興奮, 小児, プロポフォール, セボフルラン, デスフルラン はじめに / Ⅰ 背 emergence agitation/delirium/excitation Sikich and Lerman 1 a disturbance in a child s awareness of and attention to his or her environment with disorientation and perceptual alterations including hypersensitivity to stimuli and hyperactive 景

2 740 Vol.34 No.5/Sep motor behavior in the immediate postanesthesia period. 2 14, Ⅱ 原因とリスク因子 1 Aono MRI 7 5 / Kuratani 8 Cohen

3 741 図 1 覚醒時興奮の治療フローチャート 3 Ⅲ 予防法および治療法 NSAIDs NSAIDs Dahmani 3 図 1

4 742 Vol.34 No.5/Sep 表 1 The Pediatric Anesthesia Emergence Delirium Scale 1. 患児は視線を合わせることができる 2. 患児は意味のある行動をとる 3. 患児は周囲の環境を理解できている 4. 患児は落ち着いていられる 5. 患児は慰められない PAED 1 The Pediatric Anesthesia Emergence Delirium Scale PAED Scale 表 g/kg 1mg/kg 0.1mg/kg Ⅳ プロポフォールによる小児全身麻酔 16 Steur 18 表 2 2,271 表 2 7.5ng/ ml mg/kg/ hr まとめ

5 743 表 2 プロポフォールのステップダウン投与法 麻酔経過時間 0 10 分 分 分 分 分 その後 月齢 年齢 3 ヵ月未満 ヵ月 a a ヵ月 a a 歳 12 9 a a a 6 mg/kg/h 3-5mg/kg a a 18 参考文献 1) Sikich N, Lerman J:Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology 100: , ) Eckenhoff JE, Kneale DH, Dripps RD:The incidence and etiology of postanesthetic excitment. A clinical survey. Anesthesiology 22: , ) Dahmani S, Mantz J, Veyckemans F:Case scenario: severe emergence agitation after myringotomy in a 3-yr-old child. Anesthesiology 117: , ) Aono J, Ueda W, Mamiya K, et al.:greater incidence of delirium during recovery from sevoflurane anesthesia in preschool boys. Anesthesiology 87: , ) Kain ZN, Caldwell-Andrews AA, Maranets I, et al.: Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg 99: , ) Aouad MT, Kanazi GE, Siddik-Sayyid SM, et al.:preoperative caudal block prevents emergence agitation in children following sevoflurane anesthesia. Acta Anaesthesiol Scand 49: , ) Uezono S, Goto T, Terui K, et al.:emergence agitation after sevoflurane versus propofol in pediatric patients. Anesth Analg 91: , ) Kuratani N, Oi Y:Greater incidence of emergence agitation in children after sevoflurane anesthesia as compared with halothane:a meta-analysis of randomized controlled trials. Anesthesiology 109: , ) Cohen IT, Finkel JC, Hannallah RS, et al.:rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children:a comparison with propofol. Paediatr Anaesth 13:63-67, )Komatsu H, Taie S, Endo S, et al.:electrical seizures during sevoflurane anesthesia in two pediatric patients with epilepsy. Anesthesiology 81: , )Vakkuri AP, Seitsonen ER, Jäntti VH, et al.:a rapid increase in the inspired concentration of desflurane is not associated with epileptiform encephalogram. Anesth Analg 101: , )Jacob Z, Li H, Makaryus R, et al.:metabolomic profiling of children s brains undergoing general anesthesia with sevoflurane and propofol. Anesthesiology 117: , )Lapin SL, Auden SM, Goldsmith LJ, et al.:effects of sevoflurane anaesthesia on recovery in children:a comparison with halothane. Paediatr Anaesth 9: , )Akin A, Bayram A, Esmaoglu A, et al.:dexmedetomidine vs midazolam for premedication of pediatric patients undergoing anesthesia. Paediatr Anaesth 22: , )Chen JY, Jia JE, Liu TJ, et al.:comparison of the effects of dexmedetomidine, ketamine, and placebo on emergence agitation after strabismus surgery in children. Can J Anaesth 60: , )Kanaya A, Kuratani N, Satoh D, et al.:lower incidence of emergence agitation in children after propofol anesthesia compared with sevoflurane:a meta-analysis of randomized controlled trials. J Anesth 28:4-11, )Davis PJ, Greenberg JA, Gendelman M, et al.:recovery characteristics of sevoflurane and halothane in preschool-aged children undergoing bilateral myringotomy and pressure equalization tube insertion. Anesth Analg 88:34-38, )Steur RJ, Perez RS, De Lange JJ:Dosage scheme for propofol in children under 3 years of age. Paediatr Anaesth 14: , )Park HJ, Lee JR, Kim CS, et al.:remifentanil halves the EC50 of propofol for successful insertion of the la-

6 744 Vol.34 No.5/Sep ryngeal mask airway and laryngeal tube in pediatric patients. Anesth Analg 105:57-61, )Bray RJ:The propofol infusion syndrome in infants and children:can we predict the risk? Curr Opin Anaesthesiol 15: , )Bray RJ:Propofol infusion syndrome in children. Paediatr Anaesth 8: , 1998 Emergence Agitation in Children after General Anesthesia Akihiro KANAYA, Yoshinobu KAMEYAMA, Masanori YAMAUCHI, Norifumi KURATANI *2 Department of Anesthesiology and Perioperative Medicine, Tohoku University Postgraduate Medical School *2 Department of Anesthesiology, Saitama Children s Medical Center Emergence agitation(ea)following general anesthesia in children is an evolving problem because it can injure both the patient and the caregiver and decrease the parent s satisfaction. Risk factors for emergence agitation include age, preoperative anxiety, the character of the patient, pain, the operative procedure, and the anesthetics used. Maintenance of anesthesia with sevoflurane is a major risk factor for EA, whereas propofol maintenance allows for calm wake-up, smooth and rapid recovery profile, and few postoperative side effects. Perioperative medications including opioids, midazolam, alpha-2 agonists, ketamine, and non-steroidal anti-inflammatory drugs are effective for avoiding EA. Anesthesiologists should prevent EA following pediatric anesthesia by considering the risk factors and appropriate selection of anesthetics. Key Words : Emergence agitation, Children, Propofol, Sevoflurane, Desflurane The Journal of Japan Society for Clinical Anesthesia Vol.34 No.5, 2014

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