喉罩与气管插管全麻用于非小细胞肺癌根治术的对比研究

发布时间：2018-06-16 13:36

本文选题：喉罩 + 气管插管　；参考：《南方医科大学》2017年硕士论文

【摘要】：开胸手术是现代胸外科所面临的一项常规手术方式。但对于开胸手术,目前仍存在诸如术中切口大、并发症较多以及对待患者机体创伤较大导致的患者康复难度大等弊端。然而随着现代医学的发展,成像技术的清晰化,光学设备的细致化,相关手术器械的专业化,使得胸腔镜手术在胸外科这一领域得到快速发展。胸腔镜技术在过往只是一种诊断技术,而现如今已成为了主要的新型外科治疗手段,应用范围之广已覆盖了胸外科医疗领域的多个方面,对于诊断评估以及治疗具有重要帮助价值,其显著的手术优点在于手术时间无明显限制。现代胸腔镜手术优点甚多,其中存在诸多明显优势,保证了术中患者生命体征的平稳,同时患者生理指标影响较小以及短时间内能够恢复。虽然许多胸腔镜手术(VATS)肺叶切除术已经进行了 12年,但第一次VATS肺叶切除术,该程序没有得到广泛接受。在美国每年进行的4万例肺叶切除术中,约5%使用VATS进行。来自世界各地的各种作者已经出版了多份病例报告,报告了该手术的安全性及其巨大优势。然而,一些胸外科医生更加关注该手术的安全性和相关的发病率和死亡率。在迄今为止最大的系列报告中,介绍了这一系列病例来评估这些问题。近年来,有不少临床实践显示了气管插管可引起诸多相关风险,为了规避这些风险,国内外相关领域学者报道了在患者硬膜外麻醉的有意识状态下,行胸外科手术的一些经验。这些研究结果最终表面:在患者的非单肺通气下行硬膜外麻醉,同时可完整保留患者自主呼吸功能,此时可以行小型胸外科手术操作。国外学者Ambrogi,曾报道了八例采用新型胸腔镜手术治疗气胸的患者,均采用侧卧位喉罩通气,保持自主呼吸,最终患者预后良好。但这种新型的胸腔镜手术方法未完全证实其安全性,迄今缺乏关于术后生存质量的研究。因此,有必要对其术后相关效应与气管插管麻醉对照组行相关临床研究,阐明患者术后获益。目的和意义由于之前文献报道了许多非气管插管条件下,患者行胸腔镜手术的经验,我们进行了这项临床随机对照实验,主要将患者置于全麻条件下,行小型胸腔镜手术,来治疗患者非小细胞肺癌,通过患者预后等数据,评估其手术方式的可行性及安全性。同时,为将来可进行喉罩与气管插管全麻用于非小细胞肺癌根治术的临床研究,提供一些相关经验和相关临床数据指导。另外,本次临床研究创新性地使用了 FACT-L生存质量量表对患者术后生存质量进行评价,提高了实验研究的可信度并且这一量表现已国际通用。研究方法回顾性分析我院2016年03月09日至2016年08月25日间40例非小细胞肺癌根治术患者的临床资料,其中喉罩组20例,气管插管组20例,比较两组患者术后恢复情况、全身炎症反应和术后生存质量等指标。1.患者麻醉1.1通过喉罩采用全麻组麻醉方式所有患者在知情同意后,采取30°半卧位进行麻醉,麻醉前,通过纤支镜和支堵塞器等相关器械进行,目的是必要时可快速行气管插管。麻醉前30分钟雾化吸入2%利多卡因10毫升。进入手术室后持续监测心电图(ECG)、心率(HR)、血压(Bp)、脉搏氧饱和度(Sp02)、呼吸频率(RR)、脑电双频谱指数和尿量。麻醉诱导方式采用了:患者提前量泵入右旋美托咪啶(0.3微克/公斤),然后泵入异丙酚(维持维持血浆目标浓度为于2.5微克/毫升),以及瑞芬太尼(维持血浆目标浓度为于3纳克/毫升)。麻醉维持处理:监测患者的脑电双频指数(脑电双频谱指数),将其维持在40到60左右。患者静脉内泵注:异丙酚药剂(维持血浆1.5到3微克/毫升)以及瑞芬太尼(维持血浆目标浓度为2到4.5纳克/毫升),切皮操作前,静脉内给予舒芬太尼(0.15微.克/公斤)。胸腔镜术中关闭胸腔前,再次给予舒芬太尼(0.1微克/公斤)。术后,判断清醒时间,以呼唤患者可睁眼为标准,最终麻醉技师决定拔除喉罩的时机,并在复苏室内拔除患者喉罩后,入住ICU进行维持处理。1.2气管插管全麻组麻醉方式所有纳入研究的患者,均取健侧卧位行麻醉处理。麻醉监测方法同喉罩组一致。麻醉诱导方法,采用了右旋美托咪啶(0.6微克/公斤)处理,然后再次分别泵入异丙酚药剂(维持血浆目标浓度为3-3.5微克/毫升)以及瑞芬太尼药剂(维持血浆目标浓度为4-6纳克/毫升),顺阿曲库铵药剂(0.2毫克/公斤)。患者气管插管后将呼吸机设置为:潮气量8到10毫升/公斤,呼吸频率为15次/分钟,吸呼比率为1:2,吸氧浓度50%,维持PetCO2在28到35毫米汞柱,手术后即立刻开始后行单肺通气。麻醉维持时,脑电双频谱指数为40到60,患者静脉泵注异丙酚(维持血浆目标浓度为2到4微克/毫升),瑞芬太尼(维持血浆目标浓度为4-6纳克/毫升),切皮前追加舒芬太尼0.15-0.2微克/公斤。根据手术需要追加顺阿曲库铵0.05毫克/公斤,胸腔镜术中关闭胸腔前,追加舒芬太尼0.1微克/公斤。手术期间,保持患者氧饱和度≥90%。术后,判断清醒时间,以呼唤患者可睁眼为标准,最终麻醉技师决定拔除喉罩的时机,并在复苏室内拔除患者喉罩后,入住ICU进行维持处理。2.胸腔镜手术手术中设置胸腔镜的观察孔,主要位于患者腋前线的第7肋间,而常用的手术切口在3-4肋间,手术的辅助操作孔常位于腋后线的第9肋间。术侧胸壁切口使肺萎陷并造成医源性气胸后,于肺表面喷洒2%利多卡因5-10毫升,术者在胸腔镜直视下,迷走神经胸部干(右侧位于奇静脉弓上方气管表面;左侧位于肺根上方升主动脉表面纵隔胸膜下)、膈神经(左右两侧膈神经从纵膈胸膜与心包之间下行到达膈,最终于中心腱附近穿入膈)、切口肋间神经注射2%利多卡因2-3毫升;当考虑行肺叶切除或预计手术时间超过2小时,可使用0.5%罗哌卡因,且术中每2小时间中给药。肺叶切除程序与常规胸腔镜手术无异。手术关闭胸膜腔并缝合切口后,面罩辅助加压通气,并且辅助吸引器吸引胸管帮助肺组织膨胀。同时停止静脉输注药物,转送麻醉恢复室,待患者苏醒后,即可安返病房。气管插管全麻组手术过程按照普通双腔气管插管麻醉过程进行。3.术后止痛及护理对照组和实验组的术后管理基本保持一致,其共同的施行方法为:术后止痛处理采用留置患者自控镇痛泵以及非甾体类止痛药处理。在患者术后当天,或者第一天清晨时摄X线胸正位片。对照组和实验组患者全部允许在拔除喉罩或者气管导管后,2到4小时内恢复进食及饮水。此外,胸腔的闭式引流顺畅时,提示无漏气,同时24小时内的引流量≤100毫升,便可拔除患者胸导管。研究内容及过程1.研究内容1.1术中部分记录手术时间、术中失血情况以及血气分析实时结果,术野暴露效果和麻醉效果评分均给予记录。1.2术后部分返回病房后,记录患者术后开始进食和下地活动的时间,术后使用抗生素时间(以无肺部感染症状、体征以及术后白细胞将至正常为标准,停用抗生素),胸管留置时间,术后住院时间,术后患者生存质量评分。手术前后72小时抽血检测白细胞、中性粒细胞百分比、超敏C反应蛋白水平。麻醉满意度评分:1分:麻醉非常完善:患者无痛感、表现安静,手术过程良好,血流动力学一直保持相对稳定;2分:麻醉欠完善,患者有轻度疼痛表现,需术中用镇静剂处理,血流动力学有非病理改变引起的波动;3分:麻醉不完善,患者有疼痛明显,呻吟躁动,在手术中辅助用药处理后,情况才有所改善,但整体不够理想,勉强完成操作;4分:需改用另外的麻醉方式,才能完成手术。手术视野满意度评分:1分:术中野暴露充分满意,便于完成手术;2分:手术视野比较充分且清晰,同时肺塌陷一般,但无需中断手术另行处理;3分:手术视野暴露较差,患者肺塌陷不满意,大部分时间需要中断手术操作来处理手术视野:4分:手术视野暴露较差,以致无法进行相关手术,改行插管手术。本研究首次使用了评估肺癌患者的生存质量的FACT-L量表,FACT-L量表能对患者进行完整的术前、术后的生活质量进行可靠地评估[4,5]。患者首先要接受医师和护士的指导,随后使用FACT-L量表,采取自填和问询结合的方式,完整评估患者生存质量,包括情绪改变、角色类型、躯体功能和社会交往活动等情况进行相应的评分。得分与生活质量正相关,两组患者在术后1周均全部进行问卷调查。2.研究过程2.1 一般资料本研究选取2016年03月09日至2016年08月25日于南方医科大学南方医院(以下简称“我院”)行肺癌根治术(肺叶切除+系统淋巴结清扫术)的患者共40例为研究对象,所有纳入研究的患者麻醉评分(美国ASA评分标准)≥3分,BMI25,且无凝血障碍、心肺功能异常等。排除标准:患者有精神疾并、协作性差,血容量不足难以手术、血液系统疾病等难以手术的血液病患者。肺叶切除术入选标准按照陈进兴报道标准[3]:术前或术中冰冻确诊为非小细胞肺癌患者,肿瘤最大直径小于6cm,并且无侵犯胸壁、隔肌、心包、主气管等组织。按不同麻醉方式将患者分为使用喉罩全麻的研究组(20例)和使用气管插管全麻的对照组(20例)。研究组男11例,女9例,平均年龄(54.6±15.2)。对照组男12例,女8例,平均年龄(51.6±12.0)。两组患者的性别比、平均年龄、吸烟史、BMI值、ASA评分等的差异,无统计学意义(P值0.05),未显示其明显的患者个体差异性。2.2患者分组与手术进行采用Excel软件进行患者随时的分组,实验组,行喉罩条件下(采用小潮气量高频双肺通气)全麻下行胸腔镜手术,对照组,在双腔气管插管(全麻单肺通气下),行胸腔镜手术治疗。记录术中评估指标及术后恢复情况。2.3数据分析本次实验所得的计量资料,均采用均数(Mean)±标准差(SEM)进行描述,两组间的差异在方差齐性检验通过后,采用t检验的方法进行。计数资料用百分率表示,组间差异比较采用卡方检验。所有数据,均采用SPSS软件分析,a设置为0.05认为其差异有统计学意义。结果所以患者均手术顺利无明显事故出现,无手术死亡患者,对照组和实验组的手术时间、最低氧饱和度、最高呼气末的二氧化碳分压、手术视野和麻醉满意度、失血量方面,无明显的统计学差异。喉罩组患者术后进食时间、抗生素使用时间、术后住院时间均短于气管插管组;喉罩组手术前后白细胞数量(计数)、中性粒细胞百分比(%)和超敏C反应蛋白升高数值(计数)均低于气管插管组;喉罩组患者在术后生理状况、附加状况及生活质量总分等方面高于气管插管组,两组对比有统计学差异。结论:喉罩全麻胸腔镜手术治疗非小细胞肺癌具有良好的可操作性和安全性,同时在降低全身炎症反应、加快术后康复、提高患者术后生存质量方面具有一定的优越性。
[Abstract]:Thoracotomy is a routine surgical approach in the modern department of thoracic surgery. However, there are still disadvantages such as large incision, more complications and more difficulty in treating patients with greater trauma. However, with the development of modern medicine, the clarity of imaging technology and the meticulous of optical equipment With the specialization of related surgical instruments, thoracoscopic surgery has developed rapidly in this field in the Department of thoracic surgery. Thoracoscopy is a diagnostic technique in the past, and now it has become a major new surgical treatment. The wide range of applications has covered many aspects of the medical field in the Department of thoracic surgery, for diagnostic evaluation and The advantage of the treatment is that the operative advantage is that there is no obvious limitation on the operation time. There are many advantages of modern thoracoscopic surgery. There are many obvious advantages, which guarantee the stability of the vital signs of the patients during the operation, and the effect of the patient's physiological index is small and the short time can be restored. Although many thoracoscopic surgery (VATS) Lobectomy has been carried out for 12 years, but the first VATS lobectomy has not been widely accepted. In the United States, about 5% of the 40 thousand cases of lobectomy per year in the United States use VATS. Various authors from all over the world have published a number of case reports on the safety and great advantages of the operation. However, however, Some thoracic surgeons have paid more attention to the safety and associated morbidity and mortality of the operation. In the largest series of reports to date, this series of cases have been introduced to assess these problems. In recent years, many clinical practices have shown that tracheal intubation can cause many related risks to avoid these risks, related to these risks at home and abroad. The field scholars reported some experience in the Department of thoracic surgery operation in the conscious state of epidural anesthesia in patients. These findings finally surface: the patient's epidural anesthesia in the patient's non single lung ventilation and the complete retention of the patient's autonomic breathing function can be performed at this time in a small department of thoracic surgery operation. Foreign scholar Ambrogi, once reported Eight cases of pneumothorax treated by new thoracoscopic surgery were used in the lateral position of laryngeal mask ventilation to maintain self breathing and the patient had a good prognosis. However, this new method of thoracoscopic surgery did not completely confirm its safety. So far, there is no study on the quality of life after the operation. Therefore, it is necessary for the postoperative related effects and trachea intercalation. The clinical study of the anesthesia control group was conducted to clarify the postoperative benefit of the patients. Objective and significance, because of the previous literature on many non tracheal intubation conditions, patients underwent thoracoscopic surgery. We conducted this clinical randomized controlled trial mainly to put patients under general anesthesia and perform small thoracoscopic surgery to treat patients. For small cell lung cancer, the feasibility and safety of the surgical methods are evaluated through the patient's prognosis. At the same time, some relevant experience and related clinical data can be provided for the clinical study of laryngeal mask and tracheal intubation general anesthesia for non small cell lung cancer in the future. Moreover, this clinical study uses FACT-L students innovatively. The quality of life of the patients was evaluated by the memory quality scale, and the reliability of the experimental study was improved and the performance of this measurement was international. The clinical data of 40 patients with non small cell lung cancer from 09 to 08 month 2016 2016 were analyzed retrospectively, including 20 cases in the laryngeal mask group and 20 cases in the tracheal intubation group. The postoperative recovery, systemic inflammatory response and postoperative quality of life of the two groups of patients in the two groups were anaesthetized 1.1 through the general anesthesia of the laryngeal mask and all the patients in the general anesthesia group. After the informed consent, the anesthesia was taken in the 30 degree semi decubitus position, before anesthesia, through the fiberoptic bronchoscope and the branch blocker and other related instruments. Tube intubation. 30 minutes before anesthesia inhalation of 2% lidocaine 10 ml. After entering the operation room, continuous monitoring of electrocardiogram (ECG), heart rate (HR), blood pressure (Bp), pulse oxygen saturation (Sp02), respiratory frequency (RR), EEG bispectral index and urine volume. Anesthesia induction method was used: patients were pumped into dexmedetomidine (0.3 microgram / kilogram), and then pump Propofol (maintaining a plasma target concentration of 2.5 micrograms per milliliter) and remifentanil (maintaining a plasma target concentration of 3 ng / ml). Anesthesia maintenance treatment: monitoring patients' EEG bispectral index (EEG bispectrum index) and maintaining it at about 40 to 60. Intravenous infusion of propofol (maintaining plasma 1.5 to 3 micrograms) G / ml) and remifentanil (maintaining a plasma target concentration of 2 to 4.5 ng / ml) and sufentanil (0.15 microgram / kg) before the skin cutting operation. Before the thoracoscopy closed the thoracic cavity, sufentanil was given again (0.1 micrograms per kilogram). After the operation, the waking time was judged in order to call the patient to open the eyes as the standard, and eventually the anesthetist decision was made. The time to remove the larynx was determined, and after the laryngeal mask was removed in the resuscitation chamber, all the patients who were in the ICU and the.1.2 tracheal intubation group were all anaesthetized. The anesthetic monitoring method was the same as that of the laryngeal mask group. The anesthesia induction method was treated with dexamethodine (0.6 microgram / kg). Then pump the propofol (3-3.5 microgram / milliliter) and remifentanil (4-6 ng / ml) and CIS atracurium (0.2 mg / kg). After tracheal intubation, the ventilator was set up to 8 to 10 ml / kg, and the respiratory rate was 15 times per minute. The respiratory rate was 1:2, the oxygen concentration was 50%, and the PetCO2 was maintained at 28 to 35 mm Hg. After the operation, the single lung ventilation was immediately started. The EEG bispectral index was 40 to 60 when the anesthesia was maintained. The patient was injected with propofol (2 to 4 micrograms per milliliter in plasma target concentration), and rifentanil (maintenance of the plasma target concentration of 4-6 ng / ml) and the skin cut. 0.15-0.2 microgram / kg of sufentanil was added before the operation. According to the operation, 0.05 mg / kg of CIS atracurium was added, and 0.1 micrograms / kg of sufentanil before the thoracoscopy was closed, and 0.1 micrograms per kilogram were added to the sufentanil. During the operation, the patient's awake time was judged by keeping the patient's oxygen saturation more than 90%., so that the patient could open the eyes as the standard, and finally the anesthetist decided to pull out the anesthesia. In addition to the timing of the laryngeal mask, and after the removal of the laryngeal mask in the resuscitation chamber, the observation hole in the ICU for the maintenance treatment of.2. thoracoscopic surgery is located mainly in the seventh ribs of the frontline of the patient, while the common operative incision is in the 3-4 intercostal space, and the operative holes are often located in the ninth intercostal intercostal line of the posterior axillary line. The thoracic wall incision makes the lung After collapsing and causing iatrogenic pneumothorax, 2% lidocaine was sprayed on the lung surface, and 5-10 ml of lidocaine was sprayed on the lung surface. The pericardial nerve (the right was located on the surface of the trachea above the arch of the odd vein, and the left is located under the mediastinal pleural surface of ascending aorta above the root of the lung), and the phrenic nerve (the right and left phrenic nerve descended from the mediastinal pleura to the pericardium to the pericardium to the right. 2% lidocaine was injected into the intercostal nerve and 2-3 ml of lidocaine was injected into the intercostal tendon. 0.5% ropivacaine was allowed to be treated with 0.5% ropivacaine and was given every 2 small time during the operation. The lobectomy procedure was not the same as that of the conventional thoracoscopic surgery. The pleural cavity was closed and the incision was sutured after the operation. The cover assisted pressure ventilation, and the auxiliary suction apparatus attracted the chest tube to help the lung tissue expansion. At the same time, the intravenous drug was stopped and the anesthesia recovery room was transferred. After the patients woke up, the operation process of the tracheal intubation general anesthesia group was treated with the common double lumen tracheal intubation process for the pain relief and the nursing control group and the experimental group after.3.. Postoperative management was basically consistent, and the common method was: postoperative analgesic treatment was treated with a self controlled analgesia pump and a non steroidal painkiller. The X-ray chest radiographs were taken on the day after the operation, or at the morning of the first day. All patients in the control group and the experimental group were allowed to remove the laryngeal mask or trachea, 2 to 4 hours after the removal of the laryngeal mask or tracheal tube. In addition, when the closed drainage of the thoracic cavity was smooth, there was no air leakage, while the amount of drainage within 24 hours was less than 100 milliliters, the thoracic duct could be removed. The content and process of study and process 1. were studied in part 1.1, the operation time, the blood loss and the blood gas analysis in real time, the effect of the operation and the anesthetic effect of the operation field, the operation field and the anesthetic effect. The score of the fruit score was recorded after a partial return of the ward to the ward after.1.2, and the time for the patients to start eating and going down after the operation, the time of antibiotic use (with no pulmonary infection symptoms, signs and the standard of postoperative leukocytes to normal, the discontinuation of antibiotics), the retention time of the thoracic duct, the postoperative hospital stay, and the quality of life score of the postoperative patients. 72 hours before and after the operation to detect white blood cells, neutrophils percentage, hypersensitivity C reaction protein level. Anesthesia satisfaction score: 1 points: the anesthesia is very perfect: the patient has no pain, is quiet, the operation process is good, the hemodynamics remains relatively stable; 2: the intoxication is not perfect, the patient has mild pain performance, it needs the tranquilizer in the operation. Treatment, hemodynamics have non pathological changes caused by the 3 points: incomplete anesthesia, patients with obvious pain, moaning and restlessness, in the operation of adjuvant treatment, the situation is improved, but the whole is not ideal, barely complete the operation; 4 points: the need to use another way of anesthesia, to complete the operation. Visual field satisfaction score: 1 points: 1: In the operation, the operation was satisfactory, and the operation was easy to complete. 2 points: the operation field was full and clear, and the lung collapse was common, but there was no need to break the operation. 3 points: the operation field of vision was poor, the patients were dissatisfied with the lung collapse, and most of the time needed to break the operation to deal with the operation field of vision: 4 points: the operation field of vision was poor, so that there was no The first use of the FACT-L scale to assess the quality of life of the patients with lung cancer was first used in this study. The FACT-L scale was able to complete the patient's pre operation, and the quality of life after the operation was evaluated reliably for the [4,5]. patients first to receive the guidance of the doctors and nurses, and then the FACT-L scale was used to fill in and ask questions. A complete assessment of the quality of life of the patients, including emotional changes, role types, physical function and social interaction, was assessed. The score was positively related to the quality of life. The two groups were all surveyed in the 1 week after the operation in the.2. study process 2.1 general data from 09 to 2016 from 03 months of 2016. A total of 40 patients underwent radical resection of lung cancer (lobectomy + systematic lymphadenectomy) at the Southern Hospital of Southern Medical University (hereinafter referred to as "our hospital") on 25 days of 08 January. All the patients enrolled in the study (American ASA score standard) were more than 3, BMI25, without coagulation disorders, and abnormal cardiopulmonary function. The exclusion criteria: Patients There are mental disorders, poor cooperation, lack of blood volume and difficult operation, hematological diseases, and other Unoperable blood diseases. The standard of lobectomy for lobectomy is according to Chen Jinxing's standard [3]: Patients with non-small cell lung cancer diagnosed before or during the operation, the maximum diameter of the tumor is smaller than 6cm, and there is no invasion of the chest wall, septum, pericardium, and main trachea. The patients were divided into the study group (20 cases) using laryngeal mask general anesthesia (20 cases) and the control group using tracheal intubation general anesthesia (20 cases). The study group was 11 men and 9 women, with the average age (54.6 + 15.2). The control group was 12 men, 8 women, the average age (51.6 + 12). The average age, smoking history, BMI value, ASA score, and so on. The difference was not statistically significant (P value 0.05). The patients who had no distinct individual difference in.2.2 were divided into groups and operated by Excel software at any time, in the experimental group, under the laryngeal mask condition (using the high frequency and high frequency double lung ventilation) under general anesthesia under general anesthesia, the control group, and the double lumen tracheal intubation (the single lung ventilation with general anesthesia). Video-assisted thoracoscopic surgery. Intraoperative evaluation and postoperative recovery were recorded..2.3 data analysis.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614;R734.2

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