导致术后苏醒期发生躁动的因素很多,如低氧血症,膀胱膨胀,代谢紊乱,麻醉药物代谢不全,疼痛等,然而,除以上因素以外,Dvis在他的试验中发现,在骶管麻醉无痛患儿中发生苏醒期躁动容仍可高达50%,说明其心理因素所起的作用是不容忽视的[8],我们的实验也证实了这一观点。在本试验中,以异丙酚、瑞芬太尼二者结合笑气维持麻醉,术后恢复快速、平稳且清醒完全[9] ,局部阻滞复合静脉镇痛,镇痛完善,基本可以排除生理因素的干扰。但仍有部分患儿出现术后躁动倾向,评分达到17分,说明其发生与儿童的心理性格有关。有研究表明,情绪性(神经质)的稳定性与否,虽不影响人对于不良刺激的感觉记忆,但能影响人的认知表达过程[10];情绪性不稳定的患儿认知表达相对较差,这类患儿在快速苏醒以后,对陌生环境和陌生人的刺激具有高度敏感性,易产生冲动情绪,引起焦虑不安,这类儿童适应能力差,运动神经活动亢进,从而易发生苏醒期躁动倾向[11]。
已经证实,术前焦虑程度越高,越易发生术后不良现象[12]。对处在较高焦虑紧张情绪中的患儿来说,他们在术后不能很快摆脱住院期间所带来的心理不良影响,术后很容易出现整体焦虑,噩梦,梦哭,遗尿,分离焦虑等术后适应不良行为[13]。在这两组患儿中术后或多或少不同程度的出现了怕提到医院、医生,食欲不佳,害怕天黑,不愿自己单独睡觉,害怕离开父母,尿床,易发脾气等不良行为,相对来说,C组发生几率较大,是与其术前状态密切相关的。
总之,患儿术前情绪的稳定性可以影响术前焦虑水平、苏醒期躁动发生和行为适应性。本研究中只是针对一种术式和全麻来探讨的,同时使用小样本,所以有一定不足之处,但仍希望可以为临床提供一定参考。做儿童麻醉时,不可忽略心理因素给患儿带来不良反应,期待在今后工作中取得更多临床经验,对小儿心理与麻醉手术的关系做进一步探讨。
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