插管型喉罩在高龄合并高血压患者腹腔镜手术麻醉中的应用

Application of Intubation Laryngeal Mask in Laparoscopic Anesthesia for Elderly Patients with Hypertension

目的探讨插管型喉罩（intubating laryngeal mask airway,ILMA）在合并高血压的高龄患者腹腔镜手术麻醉中的应用价值。方法选择2014年3月～2015年2月厦门大学附属第一医院80例70岁以上择期行腹腔镜胃肠和胆囊胆道手术的患者,ASAⅡ或Ⅲ级,按随机数字表法分为插管型喉罩组（ILMA组）和气管插管组（ET组）,每组40例。诱导插管后均采用靶控输注（target-controlled infusion,TCI）瑞芬太尼、七氟烷静吸复合麻醉。ILMA组诱导后先插入配套喉罩行控制呼吸通气并适当加深麻醉,5 min后经插管型喉罩内置入气管导管,并经气管导管行控制呼吸维持麻醉。ET组诱导后行气管插管,术中控制呼吸直至手术结束,术后待各项拔管指征恢复后拔除气管导管。记录ILMA组和ET组诱导前（T0）,诱导用药后插入喉罩或气管导管前（T1）,气管导管插入时（T2）,切皮时（T3）,开始游离组织或进腔镜时（T4）,脏器或组织切除时（T5）,拔除气管导管时（T6）等7个时段的心率（HR）、收缩压（SBP）、舒张压（DBP）和脑电双频指数（bispectral index,BIS）。观察苏醒期间的苏醒时间、自主呼吸恢复时间,苏醒期间的并发症如躁动、恶心呕吐等。结果 HR、SBP、DBP、BIS组间及不同时点间均有显著性差异（P=0.000）。2组术前（T0～T2）和术中麻醉维持阶段（T3～T6）的HR、SBP、DBP和BIS均较平稳,插入气管导管时（T2）和拔除气管导管时（T6）ET组的HR、SBP、DBP明显升高且高于ILMA组（P〈0.05）;T6时ET组BIS值明显升高且高于ILMA组（P〈0.05）。术后苏醒质量方面,ET组麻醉用药后至自主呼吸恢复的时间和术毕至呼之能睁眼的时间明显长于LIMA组[（130.1±26.1）min vs.（96.4±24.5）min,t=5.94,P=0.000;（16.1±2.7）min vs.（5.5±2.2）min,t=19.07,P=0.000]。结论高龄患者腹腔镜手术麻醉时采用插管型喉罩全麻的血流动力学更稳定,心血管不良反应更小,麻醉苏醒效果更优。

Objective To investigate the application of intubation laryngeal mask in laparoscopic anesthesia for elderly patients with hypertension. Methods A total of 80 patients（ ASA Ⅱ- Ⅲ） over 70 years old undergoing laparoscopic gastrointestinal and gallbladder surgery from March 2014 to February 2015 were selected. They were randomly divided into the intubating laryngeal mask group（ ILMA group） or endotracheal tube group（ ET group）,with 40 patients in each group. After the intubation,the two groups were anesthetized with remifentanil by target-controlled infusion（ TCI） and sevoflurane inhalation. The ILMA group was inserted matching laryngeal mask to control respiratory ventilation and deepened to the proper depth of anesthesia. An endotracheal tube were inserted through the mask 5 min later,and then the breath was controlled via transtracheal catheter to maintain anesthesia. The ET group was inserted tracheal intubation after induction,and then the breath was controlled until extubation after the recovery of the tracheal extubation after surgery. The heart rate（ HR）,blood pressure（ SBP and DBP） and bispectral index（ BIS）were recorded at time points of before induction（ T0）,laryngeal mask or endotracheal tube insertion（ T1）,after endotracheal tube insertion（ T2）,skin incision（ T3）,beginning tissue dissection or entry of laparoscope（ T4）,resection of organs or tissues（ T5）,and tracheal extubation（ T6）,respectively. In addition,the recovery time,the recovery of spontaneous breathing,complications during the recovery time,such as restlessness,nausea and vomiting,were observed and compared. Results There were significant differences in HR,SBP,DBP,BIS between the two groups and among different time points（ P = 0. 000）. At time points of before operation（ T0- T2） and anesthesia maintaining stage（ T3- T6）,the HR,SBP,DBP and BIS were stable in both groups. At the time points of after endotracheal intubation（ T2） and extubation（ T6）,the ET group had significantly increased HR,SBP,and DBP,which were higher than the ILMA group（ P〈0. 05）. At the time point of T6,the BIS values were significantly increased in the ET group than the ILMA group（ P〈0. 05）. On postoperative recovery quality,the time from anesthesia to spontaneous breathing recovery and from end of surgery to call to open eyes was significantly longer in the ET group than the LIMA group [（ 130. 1 ± 26. 1） min vs.（ 96. 4 ± 24. 5） min,t = 5. 94,P = 0. 000;（ 16. 1 ± 2. 7） min vs.（ 5. 5 ± 2. 2） min,t = 19. 07,P = 0. 000]. Conclusion For elderly patients with hypertension undergoing laparoscopic surgery,use of intubation laryngeal mask for anesthesia is more stable and has less adverse cardiovascular reactions,with good outcomes of anesthesia recovery.