Application effects of nitrous oxide and oxygen mixed inhalation technology on analgesia and sedation during debridement and dressing change in children with moderate or severe burns
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摘要:
目的 探讨氧化亚氮与氧气混合吸入技术在中重度烧伤患儿清创换药镇痛镇静中的应用效果。 方法 采用回顾性非随机同期对照研究方法。2019年12月—2021年11月，山东第一医科大学附属中心医院收治符合入选标准的1~3岁中重度烧伤患儿140例。将在伤后3~14 d于清创换药过程中采用以护士为中心的疼痛管理模式、使用氧化亚氮与氧气混合吸入技术行镇痛镇静的42例患儿纳入氧化亚氮组（选择首次使用前述技术的换药过程进行后续研究），其中男23例、女19例；将从换药过程中未进行镇痛镇静处理的98例患儿中分层随机抽样后得到的42例患儿纳入非氧化亚氮组（任选1次换药过程进行后续研究），其中男24例、女18例。分别采用面部表情、腿部动作、活动度、哭闹和可安慰性量表和Ramsay镇静量表评估患儿换药前30 min（以下简称换药前）、清创后即刻、换药结束后30 min（以下简称换药后）的疼痛强度和镇静程度。换药后，采用自制满意度量表评估换药医师及患儿监护人对患儿换药过程中镇痛效果的满意度。分别记录换药时长和深Ⅱ度创面愈合时间。记录换药前、中、后患儿心率、经皮动脉血氧饱和度（SpO 2）和换药过程中恶心、呕吐等不良事件发生情况。对数据行Mann-Whitney U检验、 χ 2检验、重复测量方差分析、独立样本 t检验及Bonferroni校正。 结果 2组患儿换药前、后疼痛强度评分及镇静程度评分均无明显差异（ P>0.05）。氧化亚氮组患儿清创后即刻疼痛强度评分为（2.5±0.7）分，明显低于非氧化亚氮组的（7.6±1.0）分（ t=-26.69， P<0.05）；氧化亚氮组患儿清创后即刻镇静程度评分为（1.83±0.38）分，明显高于非氧化亚氮组的（1.21±0.42）分（ t=7.15， P<0.05）。换药后，氧化亚氮组换药医师和患儿监护人对患儿换药过程中的镇痛效果满意度评分均明显高于非氧化亚氮组（ t值分别为10.53、2.24， P<0.05）。氧化亚氮组患儿换药时长明显短于非氧化亚氮组（ t=-5.33， P<0.05），2组患儿深Ⅱ度创面愈合时间无明显差异（ P>0.05）。氧化亚氮组患儿换药中心率明显低于非氧化亚氮组（ t=-12.40， P<0.05），SpO 2明显高于非氧化亚氮组（ t=5.98， P<0.05）。换药过程中，氧化亚氮组2例患儿出现恶心，1例患儿出现欣快表现；非氧化亚氮组所有患儿心率持续高于正常范围。 结论 在中重度烧伤患儿清创换药过程中，采用以护士为中心的疼痛管理模式，规范使用氧化亚氮与氧气混合吸入技术能安全、有效地控制疼痛和镇静。 Abstract:Objective To investigate the application effects of nitrous oxide and oxygen mixed inhalation technology on analgesia and sedation during debridement and dressing change in children with moderate or severe burns. Methods A retrospective non-randomized contemporary controlled study was conducted. From December 2019 to November 2021, 140 burn children with moderate or severe burns, aged 1 to 3 years, who met the inclusion criteria were admitted to Central Hospital Affiliated to Shandong First Medical University. During debridement and dressing change 3 to 14 days after injury, 42 children, including 23 males and 19 females, who received nurse-centered pain management mode and analgesia and sedation with nitrous oxide and oxygen mixed inhalation technology were included in nitrous oxide group (the dressing change process using the above-mentioned technology for the first time was selected for the follow-up study). Another 42 children, including 24 males and 18 females, were included in non-nitrous oxide group from 98 children who did not apply analgesia or sedation treatment during dressing change with stratified random sampling (one dressing change process was randomly selected for the follow-up study). The face, legs, activity, cry, and consolability scale and Ramsay sedation scale were used to evaluate the pain intensity and degree of sedation, respectively, at 30 minutes before dressing change (hereinafter referred to as before dressing change), immediately after debridement, and at 30 minutes after finishing dressing change (hereinafter referred to as after dressing change). After dressing change, the self-made satisfaction scale was used to evaluate the satisfaction degree of dressing change surgeons and guardians of children for analgesic effects during dressing change. The duration of dressing change and the healing time of deep partial-thickness burn wounds were recorded. The heart rate and percutaneous arterial oxygen saturation (SpO 2) before, during, and after dressing change and the occurrence of adverse events such as nausea and vomiting during dressing change were recorded. Data were statistically analyzed with Mann-Whitney U test, chi-square test, analysis of variance for repeated measurement, independent sample t test, and Bonferroni correction. Results There were no significant differences in the score of pain intensity and score of sedation degree between children in two groups before and after dressing change ( P>0.05). Immediately after debridement, the score of pain intensity of children in nitrous oxide group was 2.5±0.7, which was significantly lower than 7.6±1.0 in non-nitrous oxide group ( t=-26.69, P<0.05); the score of sedation degree of children in nitrous oxide group was 1.83±0.38, which was significantly higher than 1.21±0.42 in non-nitrous oxide group ( t=7.15, P<0.05). After dressing change, the satisfaction degree scores of dressing change surgeons and guardians of children for analgesic effects during dressing change of children in nitrous oxide group were significantly higher than those in non-nitrous oxide group (with tvalues of 10.53 and 2.24, respectively, P<0.05). The dressing change duration of children in nitrous oxide group was significantly shorter than that in non-nitrous oxide group ( t=-5.33, P<0.05). The healing time of deep partial-thickness burn wounds in children between the two groups had no significant difference ( P>0.05). The heart rate of children in nitrous oxide group was significantly lower than that in non-nitrous oxide group during dressing change ( t=-12.40, P<0.05), while the SpO 2 was significantly higher than that in non-nitrous oxide group ( t=5.98, P<0.05). During dressing change, 2 children had nausea and 1 child had euphoria in nitrous oxide group, while heart rate of all children in non-nitrous oxide group continued to be higher than the normal range. Conclusions In the process of debridement and dressing change in children with moderate or severe burns, the use of nurse-centered pain management mode and the standardized use of nitrous oxide and oxygen mixed inhalation technology can safely and effectively control pain and sedation. -
Key words:
- Burns /
- Child /
- Pain /
- Nitrous oxide /
- Analgesia /
- Sedation /
- Dressing change
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参考文献
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表1 非氧化亚氮组分层随机抽样前后组内及2组间中重度烧伤患儿临床资料比较
组别与时间点 例数 性别（例） 年龄［岁， M（ Q 1， Q 3）］ 体重［kg， M（ Q 1， Q 3）］ 烧伤总面积［%TBSA， M（ Q 1， Q 3）］ Ⅲ度烧伤面积［%TBSA， M（ Q 1， Q 3）］ 换药部位（例） 伤后换药时间［d， M（ Q 1， Q 3）］ 手术例数 男 女 躯干 上肢 下肢 非氧化亚氮组 抽样前 98 59 39 1（1，2） 12.0（10.5，14.0） 10.0（8.0，15.0） 0（0，2） 52 16 30 6（3，10） 19 抽样后 42 24 18 1（1，2） 11.5（10.0，12.6） 12.0（9.5，18.0） 1（0，2） 26 4 12 6（4，9） 13 氧化亚氮组 42 23 19 1（1，2） 12.0（10.9，13.1） 12.0（8.8，18.0） 1（0，2） 21 7 14 6（4，9） 16 统计量值1 χ 2=0.11 Z=-0.75 Z=-0.96 Z=-1.90 Z=-1.28 χ 2=1.41 Z=-0.41 χ 2=2.23 P 1值 0.851 0.456 0.338 0.058 0.202 0.486 0.679 0.187 统计量值2 χ 2=0.36 Z=-0.97 Z=-0.60 Z=-1.98 Z=-1.28 χ 2=0.12 Z=-0.27 χ 2=5.49 P 2值 0.549 0.333 0.551 0.047 0.199 0.940 0.786 0.019 统计量值3 χ 2=0.05 Z=-0.20 Z=-0.38 Z=-0.14 Z=-0.33 χ 2=0.84 Z=-0.12 χ 2=0.47 P 3值 0.826 0.841 0.706 0.885 0.742 0.659 0.903 0.491 注：氧化亚氮组采用氧化亚氮与氧气混合吸入技术镇痛镇静，非氧化亚氮组不进行镇痛镇静处理；统计量值1、 P 1值为非氧化亚氮组抽样前与抽样后比较所得，统计量值2、 P 2值，统计量值3、 P 3值分别为非氧化亚氮组抽样前、后与氧化亚氮组比较所得；TBSA为体表总面积；手术例数指换药时已行手术治疗的例数 
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表2 分层随机抽样后2组中重度烧伤患儿各时间点疼痛强度评分和镇静程度评分比较（分，
组别 例数 疼痛强度评分 镇静程度评分 换药前 清创后即刻 换药后 换药前 清创后即刻 换药后 氧化亚氮组 42 1.9±0.4 2.5±0.7 1.8±0.7 1.93±0.26 1.83±0.38 2.12±0.59 非氧化亚氮组 42 1.9±1.0 7.6±1.0 1.9±1.1 1.90±0.48 1.21±0.42 2.14±0.75 t值 0.15 -26.69 -0.36 0.28 7.15 -0.16 P值 0.886 <0.001 0.719 0.780 <0.001 0.872 注：氧化亚氮组采用氧化亚氮与氧气混合吸入技术镇痛镇静，非氧化亚氮组不进行镇痛镇静处理；换药前指换药开始前30 min，换药后指换药结束后30 min；疼痛强度评分处理因素主效应， F=12.56， P<0.001；时间因素主效应， F=28.80， P<0.001；两者交互作用， F=9.74， P<0.001；镇静程度评分处理因素主效应， F=284.23， P<0.001；时间因素主效应， F=361.89， P<0.001；两者交互作用， F=239.15， P<0.001
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表3 换药结束后30 min分层随机抽样后2组换药医师和患儿监护人对中重度烧伤患儿换药过程中的镇痛效果满意度评分比较（分，
组别 例数 换药医师 患儿监护人 氧化亚氮组 42 8.5±0.8 8.4±0.9 非氧化亚氮组 42 6.3±1.1 7.9±1.0 t值 10.53 2.24 P值 <0.001 0.028 注：氧化亚氮组采用氧化亚氮与氧气混合吸入技术镇痛镇静，非氧化亚氮组不进行镇痛镇静处理
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表4 分层随机抽样后2组中重度烧伤患儿清创换药各时间点心率及SpO 2比较（
组别 例数 心率（次/min） SpO 2 换药前 换药中 换药后 换药前 换药中 换药后 氧化亚氮组 42 115±8 120±15 112±8 0.991±0.005 0.990±0.008 0.990±0.005 非氧化亚氮组 42 114±8 151±7 111±7 0.991±0.005 0.973±0.017 0.989±0.005 t值 0.75 -12.40 0.76 -0.48 5.98 0.42 P值 0.455 <0.001 0.449 0.635 <0.001 0.674 注：氧化亚氮组采用氧化亚氮与氧气混合吸入技术镇痛镇静，非氧化亚氮组不进行镇痛镇静处理；SpO 2为经皮动脉血氧饱和度；换药前指换药开始前30 min，换药中指贴附内敷料结束后、包扎外敷料开始前，换药后指换药结束后30 min；心率处理因素主效应， F=26.52， P<0.001；时间因素主效应， F=586.78， P<0.001；两者交互作用， F=293.05， P<0.001；SpO 2处理因素主效应， F=23.73， P<0.001；时间因素主效应， F=32.38， P<0.001；两者交互作用， F=31.16， P<0.001
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