双腔Supreme喉罩在高龄患者腹腔镜下胆囊切除术中的应用

Efficacy of Supreme laryngeal mask in senile patients undergoing laparoscopic cholecystectomy

目的评价双腔Supreme喉罩(SLAM)应用于高龄(≥80岁)患者腹腔镜下胆囊切除术时的通气效果。方法选择择期于全身麻醉下行腹腔镜下胆囊切除术的高龄患者50例,美国麻醉医师学会(ASA)分级Ⅰ至Ⅲ级。随机分入SLAM组和气管插管组,每组25例。两组患者均予静脉注射咪达唑仑0.04mg/kg、丙泊酚1.0mg/kg、芬太尼0.1mg、维库溴铵0.1mg/kg行麻醉诱导。SLAM组置入SLAM,气管插管组于喉镜直视下置入气管导管。记录两组手术时间、麻醉时间、置管时间(移去面罩至建立肺通气的时间)、气管拔管时间(手术完毕至拔除气管导管或SLAM的时间)、苏醒时间(手术完毕至呼之能睁眼的时间)、置入SLAM或气管导管的成功率(置入成功率),以及经SLAM引流管置入胃管的成功率;分别于置入SLAM和气管导管前5min(T0)、置管后1min(T1)、置管后5min(T2)、气腹后10min(T3)、气腹后30min(T4)和拔除气管导管后10min(T5)各时间点,记录两组患者的平均动脉压(MAP)、心率(HR)、脉搏血氧饱和度(Sp O2)、呼气末二氧化碳分压(petCO2)、气道峰压(ppeak),观察拔除SLAM和气管导管后有无低氧血症(Sp O2<90%)、呛咳、恶心呕吐、声音嘶哑、咽喉痛、反流误吸等不良反应发生。评价SLAM头中位、屈曲位、过伸位和侧位时的气道密封效果。将纤维支气管镜置入SLAM通气管检查其对位情况。结果 SLAM组的置管时间、拔管时间和苏醒时间均显著短于气管插管组(P值均<0.05)。SLAM组置入成功率为100%(25/25),与气管插管组96%(24/25)的差异无统计学意义(P>0.05)。两组T1至T5时间点的MAP、HR、Sp O2、petCO2、ppeak与同组T0时间点间的差异均无统计学意义(P值均>0.05);SLAM组T1和T2时间点的MAP、HR均显著低于气管插管组同时间点(P值均<0.01)。SLAM组的喉罩对位评分为4分22例,3分2例,2分1例;对位准确率为96%(24/25)。当ppeak为20cmH2O(1cmH2O=0.098kPa)时,SLAM 4种头位时无1例患者发生口咽部和引流管漏气;当ppeak为30cmH2O时,SLAM头中位、屈曲位各有1例(4%)患者,过伸位、侧位各有2例(8%)患者发生口咽部和引流管漏气,4种头位间气道密封效果的差异无统计学意义(P值均>0.05)。SLAM组低氧血症、呛咳、咽喉痛的发生率均显著低于气管插管组(P值均<0.05)。结论 SLAM气道密封性可靠,可行正压通气且通气效果佳,拔除后苏醒迅速且不良反应少,对高龄患者呼吸、循环功能的影响较小,可安全有效地应用于高龄患者腹腔镜下胆囊切除术的气道管理。

Objective To assess the efficacy of Supreme laryngeal mask （SLAM） airway used in senile patients （ 80 years old） undergoing laparoscopic cholecystectomy. Methods Fifty American Society of Anesthesiologists（ASA） Ⅰ -Ⅲ patients, and scheduled for laparoscopic cholecystectomy were randomized into SLAM group （group S） and tracheal intubation group （group T）. There were 25 patients in each group. Midazolam 0.04 mg/kg, propofol 1 mg/kg, fentanyl 0. 1 mg and vecuronium 0. 1 mg/kg were intravenously injected for induction of anesthesia in all patients. Then SLAM and endotracheal tube were inserted in group S and group T, respectively. SLAM placement/intubation time, operation time, anesthesia time, extubation time, postoperative recovery time, and the success rate of SLAM placement/intubation and gastric tube placement were recorded. Mean arterial pressure （MAP）, heart rate （HR）, pulse oxygen saturation （SpO2）, partial pressure of carbon dioxide in endexpiratory gas （pet CO2 ）, peak airway pressure （peat） were measured at 5 min before SLAM placement/intubation （To）, 1 min after SLAM placement/intubation （T1）, 5 min after SLAM placement/intubation （T2）, 10 min after abdominal 002 insufflation （T3）, 30 min after abdominal 002 insufflation （T4）, and 10 after extubation （Ts）. Complications such as hypoxemia, bucking, nausea and vomiting, hoarseness, sore throat and regurgitation of gastric contents,were observed. The airway sealing of SLMA was examined in 4 head and neck positions （neutral, flexed, extended and turned to side）. Fiberoptic bronchoscope was inserted into the airway tube of SLMA to check its position. Results SLAM placement/intubation time, extubation time and postoperative recovery time in group S were significantly shorter than those in group T （all P〈O. 05）. There was no significant difference in the success rate of SLAM placement/intubation between the two groups （100% in group S, 96% in group T, P〉0. 05）. Compared with the values at To, MAP, HR, SpO2, petCO2 and Ppe were not significantly changed from T1 to T5 in both groups （all P〉0. 05）. MAP and HR at T1 and T2 in group S were significantly lower than those in group T （all P〈0. 01 ）. The success rate of airway sealing was 96% in group S （according to airway sealing scoring.. 4 points in 22 cases, 3 points in 2 cases and 2 points in one case）. No air leaking occurred in group S when Ppek was 20 cmH20（ 1 cmH20= 0. 098 kPa）. Air leaked in 6 patients （one in neutral position, one in flexed position, two in extended position and two in turned-to-side position） when p~ was 30 cmH20. But there was no significant difference in the results of SLAM airway sealing between four head and neck positions （P〉 0.05）. The incidences of postoperative hypoxemia, choking and sore throat in group S were significantly lower than those in group T （all P〈0. 05）. Conclusion SLAM can provide adequate ventilation during operation with less complications, tight sealing of airway and quick operative recovery. It can be used effectively for laparoscopic cholecystectomy in senile patients.