手术麻醉对不同个性特征儿童心理行为的影响
【关键词】 手术麻醉； 性格特征； 学龄儿童； 心理行为
Anesthetic effects on childrens’ psycho-behavior of different personality characteristics
【Abstract】 Objective To investigate the effect on psycho-behavior of children in different personality characteristics.Methods 53 ASAⅠ～Ⅱcases of children undergoing tonsillectomy or adenoidectom were randomly selected and divided into two groups according to Eysenck Personal Questionnaire(children): children with N>50, which means unstable emotion, as C group, while those with N<50, which means stable emotion, as S group. All children were induced with propofol, norcuron and fentanyl, after tracheal intubation, anesthesia were maintained with isoflurane-N2O-O2. Items tested: modified Yale Anxiety Score(mYALE) were tested at three time points: the day before surgery, entering the operating room and the day after surgery; Induction Compliance Checklist(ICC) were tested during induction period; Pediatric anesthesia emergence delirium (PAED) were tested after surgery and post hospital behavior questionnaire(PHBQ) were tested one week and one month after surgery.Results There were no significant difference on mYALE between the two groups before surgery, but during induction period and after surgery mYALE were much higher on C group; The Induction Compliance Checklist showed high score in C group, and also the PAED score after surgery; The incidence of behavior change were higher in C group one week after surgery, but no significant different between two groups after one month.Conclusion Unlike the children with stable emotion, children in unstable emotion showed high level of anxiety before surgery especially during induction period. These kind of children also showed bad cooperation, tendency of restlessness after surgery and more incidence of behavior change, especially during the first week after surgery.
【Key words】 operative anesthesia;personality characteristics;children;psycho-behavior
对儿童患者来说，围术期是他们要经历的一个特殊时期；由于自身疾病造成的痛苦，加之认知能力有限，自控能力差，在紧张的医疗氛围中，约有65%的孩子可能发生术前焦虑［1］，12%～18%的孩子可能会出现苏醒期躁动现象［2］，同时50％的孩子可能会发生术后行为适应不良［1］。有报道证实，过分紧张、焦虑不但影响患儿的身心健康，还阻碍患儿在治疗过程中的配合，对术后恢复及心身恢复极为不利。目前，这些临床现象的发生程度是否和患儿本身不同的个性特性有关，国内外尚无报道，就此我们进行了一系列探讨研究，以便为临床工作提供参考依据。
1 资料与方法
1.1 一般资料
选择择期腺样体或扁桃体切除术患儿53例，年龄5～12岁，ASAⅠ～Ⅱ级，精神及智力发育正常。
1.2 方法
术前对所有患儿进行艾森克人格测试（幼儿版），据N维度将患儿分为情绪稳定组（S组）25例，和情绪不稳定组（C组）28例。术前30min肌注阿托品0.02mg/kg，以咪唑安定0.05mg/kg，芬太尼2μg/kg，万可松0.1mg/kg及异丙酚2mg/kg静脉诱导，行气管内插管，氧气－笑气－异氟醚吸入维持。手术结束后清醒拔管，以芬太尼行术后止痛。于术后1周及1个月进行随访。
1.3 心理测试指标
(1)两组患儿均于手术前日(T1)、入室时（T2）及术后1日（T3）以改良耶鲁焦虑评分（mYALE）测定儿童的焦虑水平［3］。(2)在麻醉诱导期采用“诱导期合作度量表”（ICC）［4］评定患儿合作程度。 (3)手术结束后进行苏醒期躁动评分（PAED）［5］。(4)于术后1周及1个月分别进行随访，以术后行为量表（PHBQ）［6］测评儿童术后行为改变情况。
1.3.1 艾森克个性问卷（幼儿版）（Eysenck Personality Questionaire, EPQ）
为一信度及效度均较高的个性测试量表［3］，是由内外倾向性（E）、情绪稳定性（N）和精神质（P，又称倔强性）、掩饰倾向（L，不真实性）四个维度组成，操作简便，已被广泛使用。
1.3.2 mYPAS(modified Yale preoperative anxiety scale)
常用于评定1岁以上儿童的围术期焦虑状态。包括儿童的精神状态、语言、情感表达能力、觉醒状态、对父母的依赖等五方面，共22项。每项对应的分值不同，其综合分值范围是21～100。评分越高，表明焦虑越明显。
1.3.3 诱导期合作度量表ICC（Induction Compliance Checklist） 将患儿在诱导期的各种负面表现分别量化。如患儿在静脉穿刺给药时无任何负面行为表现、恐惧或焦虑即为一个完善的诱导，记为0分。患儿在诱导期出现的任一项负性行为均记为1分。累加起来得出ICC的总分，最高分为10分。分值越高，表明患儿的合作程度越差。
1.3.4 苏醒期躁动评分PAED(Pediatric Anesthesia Emergence Delirium)
共由五项构成，每一项评分范围由0～4分，总分为最后得分，其信度和效度都很高，其包含了意识紊乱、认知改变等方面的情况，比较全面评估了苏醒期的状况。得分越高，苏醒期躁动倾向性越大。
1.3.5 术后行为量表PHBQ(Post Hospital Behavior Questionaire)
包含6个范畴，共27项。是目前测量儿童术后行为的标准方法，同时具有很好的信度和效度,自从编制后一直被广泛使用。
1.4 统计和数字分析
采用SPSS11.0统计软件包进行统计学处理，计量资料包括mYALE、ICC、PAED以t检验进行统计学处理，计数资料PHBQ采用卡方检验进行数字分析，P＜0.05为差异有显著性，P＜0.01为差异有非常显著性。
2 结果
2.1 两组患儿一般情况
见表1。两组年龄、文化程度、手术时间长短无统计学差异（P＞0.05）。表1 患儿一般情况（略）注：两组病人一般情况比较差异无统计学意义，P＞0.05
