经FOB联合硬膜外导管注药对颈椎手术患者清醒气管插管术表面麻醉的改良效果

Efficacy of injecting drugs through fiberoptic bronchoscope and epidural catheter in improving topical anesthesia for awake tracheal intubation in patients undergoing cervical surgery

目的评价经纤维支气管镜(FOB)联合硬膜外导管注药对颈椎手术患者清醒气管插管术表面麻醉的改良效果。方法选择颈椎损伤需行手术治疗的患者50例,年龄18~64岁,ASA分级Ⅰ或Ⅱ级,采用随机数字表法分为2组(n=25):FOB注药孔组(Ⅰ组)及FOB联合硬膜外导管组(Ⅱ组)。Ⅰ组经FOB注药孔于后联合(2ml)、声门口声带上方(3ml)及越过声门于声门下5cm处(2ml)各喷洒2%利多卡因。Ⅱ组将硬膜外导管经FOB注药孔置入,于后联合(1ml)、声带上方(3ml)、越过声门即刻(1ml)、声门下5cm(1ml)喷洒2%利多卡因,声门下5cm至隆突上经硬膜外导管边前进边缓慢注射2%利多卡因1ml。2组给药后5min采用FOB引导行经鼻清醒气管插管术。若操作时患者剧烈呛咳无法耐受需重复上一步骤操作,进行补救。如实施补救措施后未能明显改善,予以环甲膜穿刺下行气管插管术。记录麻醉及气管插管期间高血压、心动过速和低氧血症的发生情况;记录操作时间、气管插管时间、气管插管一次成功情况、补救和环甲膜穿刺情况;记录麻醉和气管插管期间呛咳、体动和喉痉挛的发生情况。气管插管完成后采用JOA评分评价脊髓损伤是否加重。术后第2天随访患者对气管插管术的满意度评分。结果与Ⅰ组比较,Ⅱ组高血压及心动过速发生率降低,操作时间延长,补救率和环甲膜穿刺率降低,体动和呛咳发生率降低,患者满意度评分升高(P<0.05),气管插管时间、气管插管一次成功率和低氧血症发生率差异无统计学意义(P>0.05)。2组均未见脊髓损伤进一步加重和喉痉挛发生。结论对于颈椎手术患者清醒气管插管术,经FOB联合硬膜外导管注药可达到较为完善的气管表面麻醉效果,减少不良反应发生,优于经FOB注药孔注药的效果。

Objective To evaluate the efficacy of injecting drugs through fiberoptic bronchoscope(FOB)and epidural catheter in improving topical anesthesia for awake tracheal intubation in patients undergoing cervical surgery.Methods Fifty patients with cervical spine injury that requiring surgical treatment,aged 18-64 yr,of American Society of Anesthesiologists physical statusⅠor Ⅱ,were divided into 2 groups(n=25 each)using a random number table method:FOB injection hole group(groupⅠ)and FOB combined with epidural catheter group(group Ⅱ).In groupⅠ,2% lidocaine was sprayed through the FOB injection hole on the oropharynx posterior(2 ml),glottis above vocal cords(3 ml)and the site 5 cm below the glottis(2 ml).In group Ⅱ,2% lidocaine was sprayed via the epidural catheter implanted through FOB injection hole on the oropharynx posterior(1 ml),the site above vocal cords(3 ml),the site immediately after crossing the glottis(1 ml),the site 5 cm below the glottis(1 ml),and 2% lidocaine 1 ml was slowly injected into the site 5 cm below the glottis to protuberance via the epidural catheter.Awake nasotracheal intubation was then performed under FOB guidance at 5 min after administration in both groups.When patients presented with severe bucking during operation and did not tolerate severe bucking,the previous procedure was repeated for rescue.When severe bucking was not significantly improved after carrying out rescue measures,thyrocricocentesis was performed and the patients were tracheally intubated.The development of hypertension,tachycardia and hyoxemia was recorded during anesthesia and intubation.The operation time,intubation time,success of intubation at first attempt,requirement for rescue measures and thyrocricocentesis were recorded.The development of bucking,body movement and laryngeal spasm were record during anesthesia and tracheal intubation.JOA score was used to evaluate the occurrence of accentuated spinal cord injury after intubation.Parents'satisfaction with intubation was recorded and scored on 2nd day after operation.Results Compared with group Ⅰ,the incidence of hypertension and tachycardia was significantly decreased,the operation time was prolonged,the requirement for rescue measures and incidence of thyrocricocentesis were decreased,the incidence of body movement and bucking was decreased,and the parents'satisfaction scores were increased(P<0.05),and no significant change was found in intubation time,success rate of intubation at first attempt or incidence of hyoxemia in group Ⅱ(P>0.05).Accentuated spinal cord injury or laryngeal spasm was not found in either group.Conclusion Injecting drugs through FOB and epidural catheter can achieve better efficacy of topical anesthesia for awake tracheal intubation with reduced adverse reactions than injecting drugs through FOB injection hole in patients undergoing cervical surgery.