Search

妇科腹腔镜手术通气策略的研究进展

腹腔镜在妇科手术中已被广泛应用，于妇科腹腔镜手术的麻醉研究也相应增多，而二氧化碳气腹引起的相关不良反应（高碳酸血症、低氧血症、呼吸机相关性肺损伤、术后认知功能障碍等）并未引起麻醉医生的高度重视。该文通过综述近年来妇科腹腔镜手术中不同通气策略（不同吸入氧浓度、适当增加分钟通气量、针对肥胖患者的几种通气模式以及喉罩通气策略）对患者的影响，旨在为妇科腹腔镜手术乃至其他科室的腹腔镜手术麻醉管理提供参考依据。

Two Ways of Airway Management in Video-assisted Thoracoscopy Surgery for Sympathectomy

目的评价喉罩或单腔气管内插管在胸腔镜下胸交感神经链切断术的应用效果。 方法选择80例行胸腔镜下胸交感神经链切断术的手汗症患者，采用计算机随机法将患者分为A、B两组，每组各40例。其中A组男20例、女20例，平均年龄24岁；B组男21例、女19例，平均年龄23岁。A组使用喉罩通气，B组使用单腔气管内导管，均应用小潮气量较快频率正压通气及间歇人工气胸。观察两组麻醉期间各时点心率（HR）、平均动脉压（MAP）、呼气末二氧化碳分压（PetCO2）、动脉血氧饱和度（SpO2）、心电图（ECG）的变化。同时记录喉罩/单腔导管置入时间、CO2充气时间、手术时间、术中术后不良反应和并发症。 结果两组患者手术顺利，无并发症。A组喉罩/插管置入时间和喉罩/单腔管呛咳、术后咽喉疼痛发生率低于B组，差异有统计学意义（P<0.05）。B组MAP、HR水平在T2（喉罩/单腔管置入后）和T7（苏醒后拨喉罩/单腔管时）明显高于T1（麻醉诱导完成），差异有统计学意义（P<0.05）；A组MAP、HR水平在T2和T7时亦明显低于B组，差异有统计学意义（P<0.05）。所有患者术中ECG、SpO2和PetCO2无明显变化。 结论喉罩或单腔气管内插管结合间歇的人工气胸都能满足胸交感神经切断术的操作需要，喉罩具有更稳定的血流动力学状态和更高的安全性。

Comparison of Laryngeal Tube Suction II and LMAProseal for Airway Management in Elective Surgery: Asystematic Review

摘要:目的:评价II代引流型喉管(LTS II)和Proseal喉罩(PLMA)在择期手术中应用效果。方法:检索了Cochrane图书馆(2009年第3期)、Pubmed(1950～2009)、EMBase(1989～2009)、CNKI(1979～2009)、VIP(1989～2009)、CBM(1978～2009)中相关II代引流型喉管(LTS II)和Proseal喉罩在择期手术中应用的随机对照试验(RCT),同时筛检纳入文献的参考文献。由2名研究者对文献质量进行严格评价和资料提取,根据指标相应异质性进行描述性分析或Meta分析(RevMan 5.0)。结果:共纳入3个RCT,共244例研究对象,文献质量均为B级。3个RCT的结果显示与PLMA相比,LTS II具有相似的首次置入成功率(P=0.45)、术毕即刻上呼吸道损伤发生率(P=1.00)、术后24 h咽痛发生率(P=0.81)、术后24 h吞咽困难发生率(P=0.12)。2个RCT的结果显示两组引流管置入均较容易。1个RCT的结果显示两组的操作者主观评价相近(OR=1.86,95%CI 0.39～ 8.99)。气道封闭效果由于采用方法学差异性较大,指标也不尽相同,尚不能得出准确结果。结论:LTS II在择期手术中用于气道管理具有较好的前景。但是现时仍不宜用于需在择期术中进行控制通气的病人。关于气道封闭效果,尚需采用更合理规范的指标、更高质量的研究设计进一步研究。Abstract: Objective: To assess the efficacy of laryngeal tube suction II (LTS II) and LMAProseal (PLMA) for airway management in elective surgery. Methods:We searched Cochrane Library (2009),Pubmed (19502009)、EMBase (19892009),CNKI (19792009),VIP (19892009),CBM (19782009). The quality of the trials was assessed by two reviewers independently. RevMan 5.0 software provided by the Cochrane Collaboration was used for statistical analysis. Results:Three studies involving 244 participants were included. Same rates of fist successful attempt (P=0.45),upper airway trauma (P=1.00),sore throat (P=0.81) and dysphagia (P=0.12) were observed in LTS II and PLMA in all studies. Two studies indicated that the insertion of gastric tube was easy in both groups. The similarity of subjective maneuverability in two groups was reported in one study (OR=1.86, 95%CI 0.39 to 8.99). The correct result of effectiveness of airway seal could not be made because of various methods and measurements. Conclusion:LTS II have a good perspective in the airway management. Otherwise, it is not safe for patient required control ventilation because of lack of evidence on the effectiveness of airway seal. More RCTs of high quality need to be undertaken in the future.

Determination of effective dose of remimazolam benzenesulfonate to suppress cardiovascular responses to laryngeal mask placement in elderly patients

Objective To investigate the effective dose of remimazolam benzenesulfonate to suppress cardiovascular responses to laryngeal mask placement in elderly patients. Methods Elderly patients undergoing laryngeal mask anesthesia between March and June 2023 were selected. Combined with sulfentanil 0.2 μg/kg, remimazolam was used as induction hypnotic. The first patient was given remizolam benzenesulfonate 0.16 mg/kg infused by pump for 1 min. The dose of remimazolam for the next patient was determined by the biased coin up-and-down method based on the patient’s response to the laryngeal mask placement. The score of Modified Observer’s Assessment of Alert/Sedation, vital signs and anesthesia depth index (AI) were recorded during induction. Probit analysis was used to calculate the half effective dose (ED50), 95% effective dose (ED95) and half effective AI (AI50). According to the statistical requirements, at least 45 negative patients were required. Results A total of 53 elderly patients were enrolled in the study until the end of the trial. The ED50 and ED95 of remimazolam benzenesulfonate for inhibiting cardiovascular responses to laryngeal mask insertion were 0.154 mg/kg [95% confidence interval (CI) (0.034, 0.170) mg/kg] and 0.207 mg/kg [95%CI (0.190, 0.614) mg/kg], respectively. AI decreased during induction, with an AI50 of 64.119 [95%CI (60.609, 69.984)]. Conclusion When combined with 0.2 μg/kg sufentanil, infusing 0.2 mg/kg remimazolam benzenesulfonate for 1 min is effective and safe for laryngeal mask anesthesia induction in elderly patients.

改良弯接头连接喉罩全身麻醉在小儿纤维支气管镜检查中的应用

目的探讨改良螺纹管弯接头连接普通喉罩用于全身麻醉下小儿纤维支气管镜检查的有效性及安全性。 方法2012年11月－2013年8月行小儿纤维支气管镜检查的患儿36例，采用改良弯接头连接喉罩行七氟醚吸入全身麻醉下小儿纤维支气管镜检查。 结果36例患儿检查均顺利结束，检查中无检查中断发生，无组织损伤，无喉痉挛及支气管痉挛，无喉头水肿，无血氧饱和度降低至90%以下。 结论改良螺纹管弯接头连接喉罩用于小儿纤维支气管镜检查简单价廉，能有效保证氧供，尤其适用于基层医院开展。

应用经气管镜冷冻活检诊断弥漫性肺疾病

目的 探讨经气管镜进行冷冻肺组织活检于弥漫性肺疾病诊断的应用价值。 方法 选择河南省人民医院呼吸与危重症医学科自 2016 年 5 月至 2017 年 4 月收治的弥漫性肺疾病患者 53 例行经支气管镜肺活检，其中采用冷冻活检者 17 例（冷冻组），采用常规活检钳活检者 36 例（常规组）。全身麻醉后置入喉罩，常规检查气管镜后，术前据胸部影像选定支气管，冷冻组患者经支气管镜活检孔道送入冷冻探头至肺部病变，冷冻 3～5 s 后冷冻探头随支气管镜一同取出。比较冷冻活检标本与常规活检标本的组织面积、人工伪差、临床诊断率及出血和气胸并发症等的发生率。 结果 经气管镜冷冻活检标本的组织面积［（44.2±17.2）mm2 比（7.5±6.1）mm2］、临床诊断率（88.2% 比 36.1%）明显高于常规活检标本（均 P<0.05），而人工伪差（11.8% 比 52.8%）明显降低（P<0.05），患者出血和气胸发生率却未明显增多。 结论 在弥漫性肺疾病经气管镜进行冷冻活检是一个安全有效的诊断方法。

SLIPATM 喉罩全身麻醉期间误吸致肺不张一例

A comparative study of laryngeal mask and tracheal intubation anesthesia for "three-port" thymectomy without myasthenia

ObjectiveTo investigate the safety and feasibility of laryngeal mask general anesthesia as a replacement of tracheal intubation general anesthesia in the "three-port" thoracoscopic thymectomy via subxiphoid and subcostal arch for thymoma patients without myasthenia.MethodsFrom January 2018 to June 2019, clinical data of patients with thymoma who underwent the novel "three-port" operation in our institution were analyzed retrospectively. The patients were divided into two groups according to the anesthesia methods, including a tracheal intubation general anesthesia group and a laryngeal mask general anesthesia group. There were 70 patients in the tracheal intubation general anesthesia group, including 42 males and 28 females, with an average age of 45.83±15.89 years. There were 39 patients in the laryngeal mask general anesthesia group, including 26 males and 13 females, with an average age of 43.31±15.64 years. The clinical data of the two groups were compared.ResultsThe baseline characteristics of the patients in the two groups were well balanced (P>0.05). No massive bleeding, conversion to thoracotomy, postoperative myasthenia or death occurred in those patients. No patient with laryngeal mask anesthesia had a conversion to tracheal intubation anesthesia during the operation. There was no significant difference in the operation time, intraoperative bleeding, intraoperative maximum partial pressure of CO2, lowest partial pressure of oxygen and anesthesia effect score between the two groups (P>0.05). There was also no statistical difference in postoperative aspiration, gastrointestinal discomfort, length of hospital stay, pain score and patient satisfaction degree between the two groups (P>0.05). However, the anesthesia time before operation and the time of awake after anesthesia in the laryngeal mask anesthesia group were significantly shorter than those in the tracheal intubation general anesthesia group (P<0.05), and the incidence of transient arrhythmia, laryngeal discomfort and hoarseness in the laryngeal mask general anesthesia group was significantly lower than that in the tracheal intubation general anesthesia group (P<0.05).ConclusionThe "three-port" thoracoscopic thymectomy via subxiphoid and subcostal arch under laryngeal mask general anesthesia is safe and feasible in the treatment of thymoma without myasthenia, and can be recommended routinely.

喉罩-超短效麻醉药在小儿短小手术中的应用

【摘要】　目的　比较喉罩-七氟醚、雷米芬太尼与喉罩-丙泊酚、雷米芬太尼两种麻醉方法在小儿短小手术应用中的优缺点。　方法　2009年3-9月，将40例择期行斜疝手术或隐睾下降固定术的患儿，随机分为A、B组，各20例。A组施喉罩+七氟醚+雷米芬太尼，B组施喉罩+丙泊酚+雷米芬太尼。观察诱导时间、术中生命体征、苏醒时间、麻醉后恢复室（PACU）停留时间、围术期并发症。　结果　麻醉前两组患儿血压及心率无统计学差异，麻醉后B组各时点血压及心率明显低于麻醉前水平，且B组各时点血压及心率明显低于A组，A组血压及心率在麻醉前后比较无统计学差异。B组麻醉诱导时间明显短于A组。A组术后躁动发生率明显高于B组。　结论　与喉罩+丙泊酚+雷米芬太尼相比，喉罩+七氟醚+雷米芬太尼具有对全身影响小、麻醉平稳等特点，但麻醉诱导时间长，术后躁动发生率高。

Laryngeal Mask Airway versus Endotracheal Tubes for Airway Management during General Anesthesia in Children: A Meta-analysis

Objective　To assess the effectiveness and safety of laryngeal mask airway (LMA) and endotracheal tube (ETT) for airway management in pediatric general anesthesia. Methods　Randomized controlled trials were collected through electronic searches of the PubMed, The Cochrane Library, EMbase, CBM, WanFang Data, VIP, CNKI from the date of establishment to November 2010. All the related data that matched the standards were abstracted by two reviewers independently. The quality of the included trials was evaluated according to the Cochrane Handbook 5.0. RevMan 5.0 software was used for meta-analysis of the complications, success of insertion on the first attempt and hemodynamic changes. Results　A total of 39 trials involving 2 612 patients were included. The results of meta-analyses showed that LMA was superior to ETT in terms of less cough (RR=0.21, 95%CI 0.15 to 0.28, Plt;0.000 01), laryngospasm or bronchospasm (RR=0.37, 95%CI 0.18 to 0.77, P=0.008) and agitation (RR=0.14, 95%CI 0.09 to 0.22, Plt;0.000 01) during emergency. The incidence of postoperative sore throat (RR=0.32, 95%CI 0.19 to 0.55, Plt;0.000 1), hoarse voice (RR=0.09, 95%CI 0.03 to 0.27, Plt;0.000 1), nausea and vomiting (RR=0.46, 95%CI 0.26 to 0.80, P=0.006) was significantly lower in the LMA group. The hemodynamic changes during insertion and extraction of LMA were more stable than ETT, such as the heart rate changes in insertion, extraction and post-extraction period (SMD= –1.18, 95%CI –1.59 to –0.77, Plt;0.000 01; SMD= –1.29 95%CI –1.72 to –0.86, Plt;0.000 01; and SMD= –1.51 95%CI –2.15 to –0.87, Plt;0.000 01, respectively) and the MAP changes in insertion, extraction and post-extraction period (SMD= –1.21, 95%CI –1.39 to –1.02, Plt;0.000 01; SMD= –1.31, 95%CI –1.77 to –0.85, Plt;0.000 01; and SMD= –0.85, 95%CI –1.24 to –0.46, Plt;0.000 1, respectively); but no significant differences in postoperative regurgitation and aspiration (RR=3.00, 95%CI 0.62 to 14.61, P=0.17) and successful insertion on the first attempt (RR=0.99, 95%CI 0.94 to 1.05, P=0.84) were found between the LMA and ETT groups. Conclusion　Current evidence indicates that the laryngeal mask airway is superior to endotracheal tube in terms of fewer complications during emergency and after operation as well as stable hemodynamic changes. So, it is a selective, safe and effective airway management for children.