不同气道管理方式下行胸腔镜肺大疱切除术的系统性回顾

发布时间：2018-05-24 07:30

本文选题：非气管插管 + 胸腔镜　；参考：《大连医科大学》2017年硕士论文

【摘要】：目的:探讨不同气道管理方式下行胸腔镜肺大疱切除术的临床应用效果。方法:回顾性分析2016年1月至2017年2月就诊于大连医科大学附属第二医院胸外科行肺大疱切除术的患者共计87例,根据本研究纳入标准:ASA分级Ⅰ-Ⅱ级,BMI25kg/m2,单纯原发性自发性气胸,单孔胸腔镜下手术;排除标准:年龄60岁,ASA分级≥Ⅲ级,BMI≥25kg/m2,中转开胸手术,合并呼吸系统、循环系统疾病、血液系统疾病,精神异常不能合作者。最后共有60例患者纳入本次回顾性研究,其中气管插管组(A组)患者30例,非气管插管组(B组)患者30例。所有患者术前禁食、禁饮6小时,入室后常规开放上肢静脉通路,连接监护仪,选择健侧桡动脉穿刺,监测收缩压(SBP)、舒张压(DBP)、心率(HR)、脉搏血氧饱和度(SpO_2)、心电图(ECG)、脑电双频指数(BIS)、血气分析。术前用药盐酸戊乙奎醚注射液0.5mg静脉注射。麻醉诱导前所有患者均选择胸段椎旁神经阻滞,摆侧卧位,手术侧向上,弓背、低头,手术侧切口对应肋间隙(T4~T5或T5~T6)距脊柱正中线旁开2.5 cm,常规皮肤消毒,超声引导下行椎旁神经阻滞,回抽无血后,推注0.33%罗哌卡因30ml。气管插管组常规麻醉诱导后置入双腔气管插管,纤维支气管镜调整导管位置,插管成功后给予纯氧机械通气;非气管插管组不使用肌松药物,采用保留自主呼吸、麻醉机面罩给氧完成手术。比较两组患者生理指标:术中收缩压(SBP),舒张压(DBP),心率(HR),脉搏血氧饱和度(SPO_2);PH,动脉血氧分压(PaO_2),动脉血二氧化碳分压(PaCO_2),钾离子(K+);术中评估指标:手术时间,视野暴露情况,麻醉效果,苏醒时间;术后恢复评估指标:术后进食时间,术后下地时间,胸腔引流管拔除时间,住院时间;术后并发症评估指标:术后咽痛发生率,术后恶心、呕吐发生率,肺部并发症,循环系统系统并发症。其他指标还包括:麻醉药物费用,手术费用及住院费用。结果:两种通气方式下均顺利完成手术,所有患者均生命体征平稳,术野及麻醉效果满意。两组患者年龄、身高及体重差异无统计学意义(P0.05)。两组患者T0时刻收缩压(SBP)、舒张压(DBP)、心率(HR)及脉搏血氧饱和度(SPO_2)比较差异无统计学意义(P0.05)。A组和B组SBP及DBP在T1、T2、T3、T4、T5时刻较T0时刻有所下降,差异具有统计学意义(P0.05);A组vs B组仅有T5时刻SBP及DBP比较略高,差异具有统计学意义(P0.05)。T1、T5时刻脉搏血氧饱和度(SP02)A组vs B组差异具有统计学意义(P0.05)。T1时刻脑电双频指数(BIS)A组vs B组[(43.5±4.4)vs(50.5±8.3)],差异具有统计学意义(P0.05)。动脉血二氧化碳分压(Pa CO2)B组在T2时刻、T3时刻、T4时刻、T5时刻明显高于A组[(37.7±2.3)mm Hg vs(59.1±9.9)mm Hg、(37.2±2.5)mm Hg vs(66.7±8.4)mm Hg、(39.0±2.3)mm Hg vs(62.1±6.6)mm Hg、(40.7±4.0)mm Hg vs(56.6±6.7)mm Hg],且差异具有统计学意义(P0.05)。T2、T3、T4、T5时刻A组PaO_2与B组相比较差异具有统计学意义;术中评估指标:视野暴露情况及麻醉满意度无明显差异;B组vs A组在手术时间[(43.6±8.4)min vs(63.6±22.2)min]、苏醒时间[(9.3±4.2)min vs(19.8±15.2)min]明显缩短,且差异具有统计学意义(P0.05);术后恢复评估指标:A组vs B组术后进食时间[(0.51±0.1)天vs(0.26±0.04)天]、术后下地时间[(1.00±0.18)天vs(0.67±0.11)天]明显缩短,差异具有统计学意义(P0.05);胸腔引流管拔出时间、住院时间比较无统计学差异(P0.05);术后并发症评估指标:术后咽痛发生率B组vs A组[(0/30)vs(18/30),P0.05],差异有统计学意义(P0.05);术后恶心、呕吐发生率B组vs A组[(0/30)vs(2/30)]。仅A组1例患者出现肺部并发症,所有患者均无循环系统并发症发生。其他指标:A组vs B组在麻醉药物费用[(1724.23±296.52)元vs(1128.53±395.28)元,P0.05]、住院费用[(35678.95±9632.88)元vs(31483.78±5666.00)元]有所减少,差异具有统计学意义(P0.05),手术费用[(5565.23±806.27)元vs(5181.70±680.52)元,P0.05],未见明显差异。结论:青中年患者在不同气道管理方式下均能安全顺利完成胸腔镜肺大疱切除术。非气管插管行胸腔镜肺大疱切除术手术时间缩短,术后苏醒迅速,麻醉药物费用及住院费用减少,值得临床进一步推广。
[Abstract]:Objective: To investigate the clinical effect of VATS pulmonary bullectomy under different airway management methods. Methods: a retrospective analysis of 87 cases of pulmonary bullectomy in Department of thoracic surgery, Second Affiliated Hospital of Dalian Medical University from January 2016 to February 2017 was retrospectively analyzed. According to the study, ASA grade I - II, BMI25kg/m2, single Primary spontaneous pneumothorax, single hole thoracoscopic surgery, exclusion criteria: age 60 years old, ASA grade more than grade III, BMI > 25kg/m2, transthoracic surgery, respiratory system, circulatory system disease, blood system disease, abnormal psychosis. Finally, 60 patients were included in this retrospective study, in which the tracheal intubation group (Group A) patients 30 cases, non tracheal intubation group (group B), 30 cases. All patients were fasting before operation and no drink for 6 hours. After admission, routine open upper limb vein access, connecting monitor, selective radial artery puncture, monitoring systolic pressure (SBP), diastolic pressure (DBP), heart rate (HR), pulse blood oxygen saturation (SpO_2), electrocardiogram (ECG), electroencephalogram double frequency index (BIS), blood gas analysis. Intravenous injection of Penehyclidine Hydrochloride Injection 0.5mg. All patients before induction of anesthesia were treated with thoracic paravertebral block, lateral position, lateral, dorsal, low head, 2.5 cm adjacent to the midline of the spine (T4~T5 or T5~T6), routine skin disinfection, ultrasound guided paravertebral block, and blood withdrawal. After the 0.33% ropivacaine 30ml. tracheal intubation group was injected into the double lumen tracheal intubation after routine anesthesia induction, the position of the catheter was adjusted by fiberoptic bronchoscope and the catheterization was performed after the intubation was successful. The non tracheal intubation group did not use muscle relaxant drugs, and the autonomic breathing was retained and the anesthesia machine mask was used to complete the operation. The physiological indexes of the two groups were compared. : intraoperative systolic pressure (SBP), diastolic pressure (DBP), heart rate (HR), pulse oxygen saturation (SPO_2); PH, arterial oxygen partial pressure (PaO_2), arterial blood carbon dioxide partial pressure (PaCO_2), potassium ion (K+); operation time, visual field exposure, anesthesia effect, revival time; postoperative recovery evaluation index: postoperative feeding time, postoperative down time, chest The extraction time, hospitalization time, postoperative complications assessment index: postoperative sore pain, postoperative nausea, vomiting, pulmonary complications, circulatory system complications. The other indicators include the cost of narcotic drugs, surgical costs and hospitalization costs. Results: the operation was completed successfully under the two types of ventilation. All patients were born There was no significant difference in age, height and weight between the two groups (P0.05). There was no significant difference in T0 systolic pressure (SBP), diastolic pressure (DBP), heart rate (HR) and pulse oxygen saturation (SPO_2) in the two groups (P0.05) and SBP and DBP in group.A and B. The difference was statistically significant (P0.05), and in group A vs B only T5 time SBP and DBP were slightly higher, the difference was statistically significant (P0.05).T1, T5 time pulse oxygen saturation (SP02) A group differences had statistical significance (43.5 + 4.4) (50.5 + 8.3), and the difference was statistically significant P0.05 (Pa CO2) B group at T2 moment, T3 moment, T4 moment, T5 moment obviously higher than group A [(37.7 + 2.3) mm Hg vs (59.1 + 9.9), 66.7 + 8.4), and (39 + 2.3) The difference between group A PaO_2 and group B at T5 time was statistically significant, and there was no significant difference in the evaluation index in the operation, and in group vs A in group B (((((43.6 + 8.4) min vs (63.6 + 22.2) min], and (9.3 + 4.2) min vs (19.8 + 15.2)) in group B, and the difference was statistically significant. Re evaluation index: the time of postoperative feeding in group A vs B [(0.51 + 0.1) days vs (0.26 + 0.04) days], postoperative lower ground time [(1 + 0.18) days vs (0.67 + 0.11) days] significantly shortened, the difference was statistically significant (P0.05); thoracic drainage tube extraction time and hospitalization time were not statistically different (P0.05); postoperative complications assessment index: postoperative sore throat B group vs A Group [(0/30) vs (18/30), P0.05], the difference was statistically significant (P0.05); postoperative nausea and vomiting occurred in the B group vs A Group [(0/30)]. Only 1 patients had pulmonary complications, all patients had no circulatory complications. P0.05], hospitalization expenses [(35678.95 + 9632.88) yuan vs (31483.78 + 5666) yuan] decreased, the difference was statistically significant (P0.05), operation cost [(5565.23 + 806.27) yuan vs (5181.70 + 680.52) yuan, P0.05], no obvious difference. Conclusion: middle-aged patients with different airway management can successfully complete thoracoscopic bullous resection. The operation time of the thoracoscopic bullectomy with non tracheal intubation is shortened, the postoperative recovery is rapid, the cost of narcotic drugs and the cost of hospitalization are reduced. It is worthy of further clinical promotion.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614

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