保留自主呼吸的喉罩全麻在胸腔鏡肺葉切除術(shù)中的應(yīng)用
發(fā)布時間：2018-09-12 07:16
【摘要】：目的受到近年來喉罩全麻應(yīng)用于胸腔鏡下肺大泡切除、自發(fā)性氣胸等手術(shù)的啟發(fā),我們設(shè)計了這項臨床實驗來探索保留自主呼吸的喉罩全麻應(yīng)用于胸腔鏡下肺葉切除術(shù)的臨床可操作性及安全性,以便獲取實踐經(jīng)驗及實驗數(shù)據(jù),進一步指導(dǎo)喉罩全麻在胸外科手術(shù)中的推廣應(yīng)用。方法1喉罩組麻醉方法:所有患者術(shù)前肌注東莨菪堿0.3mg,魯米那鈉0.1mg。麻醉前配備纖維支氣管鏡、氣管插管設(shè)備、雙腔支氣管導(dǎo)管等,必要時可即刻行氣管插管。患者入室后建立外周靜脈通路,輸注乳酸林格氏液(37-38℃),檢測Ⅱ?qū)?lián)心電圖、脈搏血氧飽和度、體溫、呼吸頻率,檢測腦電雙頻譜指數(shù)(BIS),術(shù)中檢測呼氣末CO2分壓。誘導(dǎo)前給予右美托咪定0.6mg/kg并在20分鐘內(nèi)泵入,然后局部麻醉下行橈動脈穿刺置管檢測有創(chuàng)動脈血壓。麻醉誘導(dǎo)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練的麻醉副主任醫(yī)師完成。喉罩放置不滿意時采用喉鏡輔助。喉罩放置后丙泊酚輸入泵持續(xù)泵注、吸入1%七氟烷維持麻醉。術(shù)中維持BIS值40~60。誘導(dǎo)后如有呼吸抑制,可手控呼吸囊輔助呼吸,待自主呼吸恢復(fù)。根據(jù)手術(shù)需要分次靜注小劑量舒芬太尼。術(shù)中患者置腋下墊,采用側(cè)臥體位,開始前外科醫(yī)師用0.375%羅哌卡因注射液行手術(shù)操作孔所在肋間神經(jīng)阻滯。手術(shù)取腋前線第4(或第5)肋間4cm為操作孔及觀察孔。操作孔建立后患側(cè)由于與大氣相通,造成醫(yī)源性氣胸,從而使得患側(cè)肺逐漸萎陷,如肺葉萎陷不佳可器械輔助擠壓肺葉以促使氣體排出。手術(shù)期間保持氧飽和度≥90%。使用切割吻合器處理動脈、靜脈、支氣管時,加用小劑量舒芬太尼以減慢呼吸頻率,維持呼吸頻率3~5次/分鐘,便于手術(shù)操作。當呼氣末CO2分壓大于70mm Hg時,手控小潮氣量呼吸以促使CO2排出。關(guān)胸前追加舒芬太尼0.1μg/kg,并停止吸入七氟烷,丙維持泊酚持續(xù)泵入直至手術(shù)結(jié)束。帶喉罩入麻醉后恢復(fù)室監(jiān)護觀察,待清醒后拔出喉罩。觀察至Steward評分達6分時,送回病房。2雙腔支氣管插管組麻醉方法:患者術(shù)前肌注東莨菪堿0.3mg,魯米那鈉0.1mg。麻醉前配備纖維支氣管鏡、氣管插管設(shè)備、雙腔支氣管導(dǎo)管等,必要時可即刻行氣管插管。入室后建立外周靜脈通路,輸注乳酸林格氏液(37-38℃),監(jiān)測同喉罩組。誘導(dǎo)前給予右美托咪定0.6mg/kg 20分鐘內(nèi)泵入。麻醉誘導(dǎo)采用丙泊酚2.5mg/kg、舒芬太尼0.4μg/kg、順苯磺酸阿曲庫銨0.2 mg/kg靜脈緩慢推注,喉鏡暴露聲門行雙腔支氣管插管,采用聽診法結(jié)合纖支鏡定位,以上操作均由同一位熟練的麻醉副主任醫(yī)師完成。而后丙泊酚輸入泵持續(xù)泵入、1%七氟烷吸入、順苯磺酸阿曲庫銨間斷注射維持麻醉。根據(jù)手術(shù)需要分次追加小劑量舒芬太尼。手術(shù)置腋下墊,采用側(cè)臥體位,手術(shù)開始前外科醫(yī)師用0.375%羅哌卡因注射液行手術(shù)操作孔所在肋間神經(jīng)阻滯。手術(shù)取腋前線第4(或第5)肋間4cm為操作孔及觀察孔。手術(shù)開始前改為單肺通氣,潮氣量設(shè)置6ml/kg,呼吸頻率為14次/分鐘。手術(shù)期間保持氧飽和度≥90%。肌松藥手術(shù)結(jié)束前30分鐘不再使用。關(guān)胸前追加舒芬太尼0.1μg/kg,并停止吸入七氟烷,丙泊酚維持繼續(xù)泵入直至手術(shù)結(jié)束。帶雙腔管入麻醉后恢復(fù)室,清醒后拔出導(dǎo)管。觀察至Steward評分達6分時,送回病房。結(jié)果喉罩組與雙腔管組手術(shù)均順利完成,無中轉(zhuǎn)開胸等病例。兩組手術(shù)在手術(shù)時間、術(shù)中最低血氧飽和度、術(shù)前、術(shù)后1小時Pa CO2方面無明顯差異(P0.05)。喉罩/雙腔管放置滿意用時、拔管時間、恢復(fù)室停留時間、喉罩組均短于雙腔管組(P0.05)。插管/喉罩前后,△MAP、△HR(放置喉罩/雙腔管前后平均動脈壓差值、心率差值)喉罩組低于雙腔管組(P0.001)。術(shù)中每千克體重舒芬太尼、丙泊酚用量喉罩組顯著少于雙腔管組(P0.05)。肺葉切除后血氣Pa CO2、術(shù)中最高呼氣末CO2,喉罩組顯著高于雙腔管組(P0.001)。術(shù)后咽喉痛發(fā)生率、住院總費用喉罩組低于雙腔管組(P0.05)。結(jié)論1.喉罩應(yīng)用于胸腔鏡肺葉切除術(shù)手術(shù),具有操作簡單、刺激小、損傷小,麻醉相關(guān)并發(fā)癥少的優(yōu)點。保留自主呼吸有利于保持患者肺功能的生理狀態(tài)。應(yīng)用喉罩使術(shù)后咽喉疼痛的發(fā)生率明顯降低。2.喉罩應(yīng)用于胸腔鏡肺葉切除術(shù),可減少住院天數(shù),節(jié)省住院總費用,使患者術(shù)后快速康復(fù)。
[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.
【學(xué)位授予單位】：青島大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R614.2
本文編號：2238292
[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.
【學(xué)位授予單位】：青島大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R614.2
【參考文獻】
相關(guān)期刊論文 前10條
1 李樹本;劉君;陳漢章;殷偉強;徐鑫;崔飛;彭桂林;董慶龍;梁麗霞;何建行;;自主呼吸麻醉單孔非置管胸腔鏡技術(shù)診治肺小結(jié)節(jié)的24小時解決方案[J];中華外科雜志;2015年10期
2 蔡開燦;王向東;葉靖;刁定偉;何建行;劉君;黃志勇;吳華;;喉罩全麻與氣管插管全麻胸腔鏡手術(shù)治療肺大皰的臨床對照研究[J];南方醫(yī)科大學(xué)學(xué)報;2013年05期
3 Wenlong Shao;Wei Wang;Weiqiang Yin;Zhihua Guo;Guilin Peng;Ying Chen;Jianxing He;;Nonintubated thoracoscopic lobectomy plus lymph node dissection following segmentectomy for central type pulmonary masses[J];Chinese Journal of Cancer Research;2013年01期
4 徐馳;曾志勇;劉道明;楊勝生;葉仕新;楊鯨蓉;;胸腔鏡與常規(guī)開胸肺葉切除術(shù)治療非小細胞肺癌的臨床比較[J];中國內(nèi)鏡雜志;2011年10期
5 阮駱陽;曹金良;許曉夢;;SLIPA喉罩用于腹腔鏡手術(shù)的可行性和安全性[J];臨床麻醉學(xué)雜志;2011年05期
6 李仁虎;李家寬;李元海;;喉罩與氣管插管對腹腔鏡膽囊切除術(shù)患者術(shù)后躁動影響觀察[J];國際麻醉學(xué)與復(fù)蘇雜志;2011年02期
7 葛明建;吳慶琛;向小勇;汪斌;陳煥文;范盛浩;;電視胸腔鏡輔助肺葉切除及系統(tǒng)性淋巴結(jié)清掃術(shù)治療肺癌的臨床分析[J];中國胸心血管外科臨床雜志;2010年03期
8 姚東旭;徐娜;王天龍;張建華;;一次性喉罩在功能神經(jīng)外科手術(shù)麻醉中的應(yīng)用[J];神經(jīng)疾病與精神衛(wèi)生;2010年02期
9 盧麗雅;葉靖;歐陽葆怡;;單肺通氣模式對阻塞性通氣障礙患者氣道峰壓、氧合作用及肺內(nèi)分流的影響[J];河北醫(yī)藥;2009年09期
10 楊旭東;董穩(wěn);劉克英;劉瑞昌;;ProSeal喉罩在頭頸部手術(shù)中的應(yīng)用[J];臨床麻醉學(xué)雜志;2008年12期
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