保留自主呼吸的喉罩全麻在胸腔镜肺叶切除术中的应用

发布时间：2018-09-12 07:16

【摘要】：目的受到近年来喉罩全麻应用于胸腔镜下肺大泡切除、自发性气胸等手术的启发,我们设计了这项临床实验来探索保留自主呼吸的喉罩全麻应用于胸腔镜下肺叶切除术的临床可操作性及安全性,以便获取实践经验及实验数据,进一步指导喉罩全麻在胸外科手术中的推广应用。方法1喉罩组麻醉方法:所有患者术前肌注东莨菪碱0.3mg,鲁米那钠0.1mg。麻醉前配备纤维支气管镜、气管插管设备、双腔支气管导管等,必要时可即刻行气管插管。患者入室后建立外周静脉通路,输注乳酸林格氏液(37-38℃),检测Ⅱ导联心电图、脉搏血氧饱和度、体温、呼吸频率,检测脑电双频谱指数(BIS),术中检测呼气末CO2分压。诱导前给予右美托咪定0.6mg/kg并在20分钟内泵入,然后局部麻醉下行桡动脉穿刺置管检测有创动脉血压。麻醉诱导采用丙泊酚2mg/kg,舒芬太尼0.3μg/kg,喉罩置入操作均由同一位熟练的麻醉副主任医师完成。喉罩放置不满意时采用喉镜辅助。喉罩放置后丙泊酚输入泵持续泵注、吸入1%七氟烷维持麻醉。术中维持BIS值40~60。诱导后如有呼吸抑制,可手控呼吸囊辅助呼吸,待自主呼吸恢复。根据手术需要分次静注小剂量舒芬太尼。术中患者置腋下垫,采用侧卧体位,开始前外科医师用0.375%罗哌卡因注射液行手术操作孔所在肋间神经阻滞。手术取腋前线第4(或第5)肋间4cm为操作孔及观察孔。操作孔建立后患侧由于与大气相通,造成医源性气胸,从而使得患侧肺逐渐萎陷,如肺叶萎陷不佳可器械辅助挤压肺叶以促使气体排出。手术期间保持氧饱和度≥90%。使用切割吻合器处理动脉、静脉、支气管时,加用小剂量舒芬太尼以减慢呼吸频率,维持呼吸频率3~5次/分钟,便于手术操作。当呼气末CO2分压大于70mm Hg时,手控小潮气量呼吸以促使CO2排出。关胸前追加舒芬太尼0.1μg/kg,并停止吸入七氟烷,丙维持泊酚持续泵入直至手术结束。带喉罩入麻醉后恢复室监护观察,待清醒后拔出喉罩。观察至Steward评分达6分时,送回病房。2双腔支气管插管组麻醉方法:患者术前肌注东莨菪碱0.3mg,鲁米那钠0.1mg。麻醉前配备纤维支气管镜、气管插管设备、双腔支气管导管等,必要时可即刻行气管插管。入室后建立外周静脉通路,输注乳酸林格氏液(37-38℃),监测同喉罩组。诱导前给予右美托咪定0.6mg/kg 20分钟内泵入。麻醉诱导采用丙泊酚2.5mg/kg、舒芬太尼0.4μg/kg、顺苯磺酸阿曲库铵0.2 mg/kg静脉缓慢推注,喉镜暴露声门行双腔支气管插管,采用听诊法结合纤支镜定位,以上操作均由同一位熟练的麻醉副主任医师完成。而后丙泊酚输入泵持续泵入、1%七氟烷吸入、顺苯磺酸阿曲库铵间断注射维持麻醉。根据手术需要分次追加小剂量舒芬太尼。手术置腋下垫,采用侧卧体位,手术开始前外科医师用0.375%罗哌卡因注射液行手术操作孔所在肋间神经阻滞。手术取腋前线第4(或第5)肋间4cm为操作孔及观察孔。手术开始前改为单肺通气,潮气量设置6ml/kg,呼吸频率为14次/分钟。手术期间保持氧饱和度≥90%。肌松药手术结束前30分钟不再使用。关胸前追加舒芬太尼0.1μg/kg,并停止吸入七氟烷,丙泊酚维持继续泵入直至手术结束。带双腔管入麻醉后恢复室,清醒后拔出导管。观察至Steward评分达6分时,送回病房。结果喉罩组与双腔管组手术均顺利完成,无中转开胸等病例。两组手术在手术时间、术中最低血氧饱和度、术前、术后1小时Pa CO2方面无明显差异(P0.05)。喉罩/双腔管放置满意用时、拔管时间、恢复室停留时间、喉罩组均短于双腔管组(P0.05)。插管/喉罩前后,△MAP、△HR(放置喉罩/双腔管前后平均动脉压差值、心率差值)喉罩组低于双腔管组(P0.001)。术中每千克体重舒芬太尼、丙泊酚用量喉罩组显著少于双腔管组(P0.05)。肺叶切除后血气Pa CO2、术中最高呼气末CO2,喉罩组显著高于双腔管组(P0.001)。术后咽喉痛发生率、住院总费用喉罩组低于双腔管组(P0.05)。结论1.喉罩应用于胸腔镜肺叶切除术手术,具有操作简单、刺激小、损伤小,麻醉相关并发症少的优点。保留自主呼吸有利于保持患者肺功能的生理状态。应用喉罩使术后咽喉疼痛的发生率明显降低。2.喉罩应用于胸腔镜肺叶切除术,可减少住院天数,节省住院总费用,使患者术后快速康复。
[Abstract]:Objective Inspired by the application of laryngeal mask general anesthesia in thoracoscopic bullae resection and spontaneous pneumothorax in recent years, we designed this clinical experiment to explore the feasibility and safety of laryngeal mask general anesthesia with self-breathing in thoracoscopic lobectomy, so as to obtain practical experience and experimental data for further study. Methods 1. Anesthesia method of laryngeal mask group: All patients were injected scopolamine 0.3 mg and rumina 0.1 mg intramuscularly before anesthesia. Fiberoptic bronchoscope, tracheal intubation equipment, double lumen bronchial catheter were equipped before anesthesia, and tracheal intubation was performed immediately if necessary. Ringer's solution lactate was injected (37-38 C), ECG, pulse oxygen saturation, body temperature, respiratory rate, bispectral index of EEG (BIS) and end-expiratory CO2 partial pressure were measured during operation. Right metoprolidine was given 0.6 mg/kg before induction and pumped in 20 minutes. Then the invasive arterial blood pressure was detected by radial artery puncture and catheterization under local anesthesia. Drunk induction was performed with propofol 2 mg/kg, sufentanil 0.3 ug/kg, and the laryngeal mask placement was performed by the same skilled assistant anesthesiologist. The laryngeal mask placement was not satisfactory with laryngoscope assistance. After the laryngeal mask placement, propofol was continuously pumped into the pump, and sevoflurane was inhaled to maintain anesthesia. BIS value was maintained between 40 and 60 during the operation. Intraoperative small doses of sufentanil were injected into the patient's axillary pad. The surgeon used 0.375% ropivacaine injection to block the intercostal nerve at the operating hole before operation. The fourth (or fifth) intercostal space of the anterior axillary line was taken as the operating hole and the view. After the operation hole is established, the affected side will cause iatrogenic pneumothorax due to its connection with the atmosphere, so that the affected side will gradually collapse, such as lobar atrophy can be assisted by instruments to squeeze the lobe of the lung to facilitate the discharge of gas. The oxygen saturation should be maintained (>90%) during the operation period. When the end-expiratory CO2 partial pressure is greater than 70 mm Hg, hand-controlled low tidal volume breathing is used to promote CO2 excretion. Sufentanil 0.1 ug/kg is added before chest closure and sevoflurane inhalation is stopped. Propofol is continuously pumped into the operation until the end of the operation. The patients were given intramuscular injection of scopolamine 0.3 mg and luminal sodium 0.1 mg before anesthesia. Fiberoptic bronchoscope, tracheal intubation equipment, double-lumen bronchial catheter were equipped before anesthesia. Tracheal intubation was performed immediately when necessary. Peripheral venous access, infusion of Ringer's solution lactate (37-38 C), monitoring of the same laryngeal mask group. Before induction, dexmedetomidine was given 0.6 mg/kg within 20 minutes. Anesthesia induction was induced by propofol 2.5 mg/kg, sufentanil 0.4 ug/kg, cisplatin atracurium 0.2 mg/kg intravenous injection, laryngoscope exposure glottis by double-lumen bronchial intubation, auscultation method was used. Combined with fiberoptic bronchoscopic localization, the above operations were performed by the same skilled deputy director of anesthesia physician. Then propofol pump was continuously pumped in, sevoflurane inhaled, and atracurium cis-benzosulfonate was intermittently injected to maintain anesthesia. Small doses of sufentanil were added according to the operation needs. Intercostal nerve block was performed with 0.375% ropivacaine injection. Operative foramen and observation foramen were taken from the 4cm intercostal space at the anterior axillary line. One lung ventilation was used before the operation, tidal volume was set at 6ml/kg and respiratory rate was set at 14 times/min. Oxygen saturation was maintained at least 90% during the operation. Sufentanil 0.1 ug/kg was added before thoracic closure and sevoflurane inhalation was stopped. Propofol continued to be pumped until the end of the operation. After anesthesia, the catheter was put into the recovery room with a double-lumen catheter and pulled out after awakening. The catheter was returned to the ward when the Steward score reached 6. There was no significant difference in Pa CO2 between the two groups (P 0.05). The mean arterial pressure (MAP, HR) was shorter in the laryngeal mask group than in the double-lumen tube group (P 0.05) before and after intubation. After lobectomy, the blood gas Pa CO 2, the highest end expiratory CO 2, and the total hospitalization cost in the laryngeal mask group were significantly lower than those in the double lumen tube group (P 0.001). Conclusion 1. Laryngeal mask used in thoracoscopic lobectomy has the advantages of simple operation, less stimulation, less injury, and less anesthesia-related complications. Retaining spontaneous breathing is helpful to maintain the physiological state of the patients'lung function. Resection can reduce hospitalization days, save total hospitalization expenses, and make patients recover quickly after operation.
【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614.2

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