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肌松程度对腹腔镜胆囊切除术中患者肺功能的影响

Effects of neuromuscular blockade on pulmonary function in patients undergoing laparoscopic cholecystectomy

    摘要
  • 摘要:
    目的 探讨肌松程度对腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中患者肺功能的影响。
    方法 选取2018年9月到2020年1月复旦大学附属上海市第五人民医院收治的择期LC患者90例，采用随机数字表法分为3组（n=30）：浅度肌松组（S组）、中度肌松组（M组）和深度肌松组（D组），3组均在肌松监测下采用罗库溴铵维持目标肌松程度，S组、M组和D组目标肌松程度分别为TOF计数4、TOF计数1~3、PTC计数≤2，分别于插管后（T1）、气腹10 min（T2）、气腹结束后（T3）和术毕（T4）时记录气道峰压（Ppeak）、气道平台压（Pplat）和肺顺应性（lung compliance，CL），在T1、T2、T4时采集桡动脉血样行血气分析，计算氧合指数（oxygenation index，OI）、呼吸指数（respiratory index，RI）和肺内分流率（Qs/Qt），术后进行手术条件满意度评级，并记录拔管时间和罗库溴铵用量。
    结果 与S组相比，M组和D组T2时CL和OI较高、RI和Qs/Qt较低（P < 0.01），T4时各指标差异无统计学意义，M组和D组手术条件满意度较高，但拔管时间明显延长（P < 0.01），罗库溴铵用量增加（M组P < 0.05，D组P < 0.01）。D组与M组相比，拔管时间延长11 min，罗库溴铵用量增加（P < 0.01），其余指标无统计学意义。3组各时间点Ppeak和Pplat差异均无统计学意义。
    结论 中度肌松能够提供与深度肌松相似的手术条件，在改善气腹期间肺功能的同时，拔管时间较短，是腹腔镜胆囊切除术中较为适宜的肌松程度。

     

    Abstract:
    Objective To explore the effect of different degrees of neuromuscular blockade on pulmonary function in patients undergoing laparoscopic cholecystectomy.
    Methods Ninety patients were selected from Shanghai Fifth People's Hospital, Fudan University from September 2018 to January 2020, scheduled for elective laparoscopic cholecystectomy were randomly arranged into 3 groups (n=30 in each group) using a random number table: shallow neuromuscular blockade group (Group S), moderate neuromuscular blockade group (Group M), and deep neuromuscular blockade group (Group D). Rocuronium was infused to maintain the degree of neuromuscular blockade in three groups to achieve the target degrees: train-of-four count (TOF) of 4 in group S, TOF 1-3 in group M, and post-tetanic count (PTC) ≤2 in group D. Peak airway pressure (Ppeak), airway plateau pressure (Pplat), and lung dynamic compliance (CL) were recorded at following time points: just after tracheal intubation (T1), 10 min after pneumoperitoneum (T2), immediately at the end of pneumoperjtoneum (T3) and end of surgery (T4). Artefial blood samples were collected for blood gas analysis at T1, T2, and T4, oxygenation index (OI), respiratory index (RI), and intrapulmonary shunt (Qs/Qt) were calculated derivatively. Extubation time and dosages of rocuronium were recorded, while surgical condition scores were assessed by surgeons.
    Results Compared with group S, CL and OI were significantly higher, while RI and Qs/Qt were lower at T2 in groups M and D (P < 0.01), but there was no difference at T4. Surgery condition scores were higher and extubation time was longer in group M and D than those in Group S (P < 0.01), the dosages of rocuronium in group M and D were higher than that in group S (P < 0.05, P < 0.01). Furthermore, extubation time in group D was 11 min longer and the dosage of rocuronium was higher than that in group M (P < 0.01), but other parameters did not show any significant differences between the two groups. Ppeak and Pplat did not show statistical differences among the three groups.
    Conclusions Moderate neuromuscular blockade can provide similar surgical conditions as deep neuromuscular blockade, and improve pulmonary function during pneumoperitoneum for laparoscopic cholecystectomy, and require shorter extubation time. It may be a more appropriate neuromuscular blockade approach for laparoscopic cholecystectomy.

     

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