Clinical application of transesophageal echocardiography under sedation and analgesia
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摘要: 随着患者对舒适化医疗要求的增加，镇痛、镇静技术在经食管超声心动图中的应用逐渐广泛。在无气管插管镇静、镇痛下完成经食管超声心动图检查，能够在改善患者体验的同时，更加清楚地显示心内异常结构。本文就经食管超声心动图中镇静、镇痛技术的使用进行综述。Abstract: Under the increase of patients' requirements for comfortable medical treatment, Analgesic and sedative techniques have been widely used in transesophageal echocardiography. Transesophageal echocardiography under sedation and analgesia without endotracheal intubation can improve the patient experience and show the cardiac abnormalities more clearly. This article reviews the use of sedative and analgesic techniques in transesophageal echocardiography.
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Key words:
- transesophageal echocardiography /
- sedation /
- analgesia
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表 1 镇静程度分级
Table 1. Classification of sedation degree
项目 轻度镇静 中度镇静 深度镇静 全身麻醉 反应水平 对言语刺激正常应答 言语和触觉刺激可有目的性应答 重复或疼痛刺激后可有目的性应答 对疼痛刺激无反应 气道 不受影响 不需要气道支持 可能需要气道支持 通常需要气道支持 自主通气 不受影响 充足 可能不足 通常不足 心血管功能 不受影响 通常能保持 通常能保持 可能受影响 
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表 2 常见的镇静镇痛药物用法及优缺点
Table 2. Common sedative and analgesic drugs and their advantages and disadvantages
药物 适用人群 初始用量/续接用量 优点 缺点 镇静 咪达唑仑 成人[4, 19] 1~2 min内静脉给药1~2 mg(或 < 0.03 mg/kg)；追加剂量：每2 min，重复给药1 mg(或0.02~0.03 mg/kg) 抗焦虑，肌松，顺行遗忘，起效迅速，代谢快 无镇痛作用，呼吸抑制，低血压，60岁以上者减量，最大量为3.5 mg 小儿[20] < 5岁：0.05~0.1 mg/kg(最大剂量0.6 mg/kg)；6~12岁：0.025~0.05 mg/kg(最大剂量0.4 mg/kg)；>12岁：2~2.5 mg(为总量) 丙泊酚 成人[6, 19, 21-23] 1.5~2.5 mg/kg根据患者体征，每次静脉追加0.2~0.5 mg/kg 抑制咽喉反射，起效快，作用时间短 循环抑制，呼吸抑制，注射部位疼痛，无拮抗剂 小儿[20] 静脉用药，婴幼儿：2 mg/kg；>3岁：1 mg/kg；追加剂量： < 3岁：1 mg/kg；≥3岁：0.5 mg/kg 依托咪酯 成人[19] 0.2~0.3 mg/kg；根据患者体征，每次静脉追加0.1 mg/kg 对心率影响小，轻微扩冠效果，不增加心肌耗氧量，血流动力学稳定，起效快 恢复期恶心、呕吐发生率高，抑制肾上腺皮质激素合成，局部刺激强，肌痉挛 右美托咪定 成人[12, 24] 1 μg/kg，10~15 min推注；以0.1~0.5 μg/kg/h维持 抗交感、镇痛，对于异常升高的血压、心率有助于稳定循环，对呼吸抑制小 给药15 min左右起效，剂量依赖的血压、心率降低 镇痛 芬太尼 成人[9] 1 μg/kg，30~60 s缓推，老年人减量1/3 起效快，代谢快，对循环影响小 呼吸抑制，禁用于哮喘、慢阻肺患者，高龄或一般情况欠佳者起始剂量减半 小儿[20] 静脉用药1~2 μg/kg(最大剂量达50 μg) 氯胺酮 成人[23] 0.25 mg/kg 减轻咽反射，咽喉痛，起效快，维持时间短，麻醉过程中痛觉消失，意识部分存在，血压、心率轻度升高 呼吸抑制、口咽部分泌物增多、喉痉挛 小儿[20] 缓慢静推>1 min，1~1.5 mg/kg 布托啡诺 成人[9] 20 μg/kg 呼吸抑制、恶心呕吐的不良反应发病率稍低 哌替啶[15] 成人 1 mg 短效，镇痛作用强 体位性低血压，心动过速，呼吸抑制，与抗抑郁药物相互作用
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