深度肌松联合低气腹压用于肥胖患者妇科腹腔镜手术的效果

Efficacy of deep neuromuscular blockade combined with low-pressure pneumoperitoneum for gyne-cological laparoscopic surgery in obese patients

目的评价深度肌松联合低气腹压用于肥胖患者腹腔镜手术的效果.方法择期腹腔镜下行全子宫切除术患者60例,年龄34~64岁,体重指数28.7~32.0 kg/m2,ASA分级Ⅰ或Ⅱ级,采用随机数字表法分为2组(n=30):深度肌松+低气腹压组(A组)和中度肌松+高气腹压组(B组).2组在肌松监测下静脉输注苯磺酸顺阿曲库铵维持肌松,A组维持四个成串刺激肌颤搐(TOF)计数0,强直刺激后单刺激肌颤搐计数(PTC)1或2,气腹压10 mmHg;B组维持TOF计数1或2,气腹压14 mmHg.评价术野满意度;记录恢复指数、TOF比值恢复至0.7和0.9的时间;分别于气腹前5 min(T0)、气腹平卧位5 min(T1)、气腹手术位5 min(T2)和术毕放气后5 min(T3)时记录气道峰压.记录术后48 h内低氧血症、肩部疼痛、腹部疼痛的发生情况.结果 2组患者术野满意度比较差异无统计学意义(P>0.05).与B组比较,A组恢复指数、TOF比值恢复至0.7和0.9的时间延长,T1和T2时气道峰压降低,术后肩部疼痛和腹部疼痛发生率降低(P<0.05).结论与中度肌松联合高气腹压相比,深度肌松联合低气腹压同样能提供满意的手术操作空间,还能降低术后疼痛的发生,然而会延长肌松恢复时间.

Objective To evaluate the efficacy of deep neuromuscular blockade (NMB) combined with low-pressure pneumoperitoneum for gynecological laparoscopic surgery in the obese patients. Methods Sixty obese patients, aged 34-64 yr, with body mass index 28. 7-32. 0 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective laparoscopic hysterectomy, were allocated into 2 groups (n =30 each) using a random number table method: deep NMB plus low-pressure pneumoperitoneum group (group A) and moderate NMB plus high-pressure pneumoperitoneum group (group B). Cis-atracurium sulfamate was intravenously infused to maintain NMB under monitoring in both group. Group A was to maintain train-of-four (TOF) count of 0, post-tetanic count of 1 or 2, and pneumoperitoneum pressure of 10 mmHg. Group B was to maintain TOF count of 1 or 2 and pneumoperitoneum pressure of 14 mmHg. Satisfaction with surgical field was evaluated. The recovery index and time for TOF ratio returning to 0. 7 and 0. 9 were recorded. Peak airway pressure was recorded at 5 min before pneumoperitoneum (T0), 5 min of pneumoperitoneum-supine position (T1), 5 min of pneumoperitoneum-surgical position (T2 ), and 5 min after deflation at the end of surgery (T3 ). The development of hypoxemia, shoulder pain, and abdominal pain was recorded within 48 h after surgery. Results There was no significant difference in the satisfaction with surgical field between the two groups (P>0. 05). Compared with group B, the recovery index and time for TOF ratio returning to 0. 7 and 0. 9 were significantly prolonged, peak airway pressure was decreased at T1 and T2, and the incidence of postoperative shoulder pain and abdominal pain was decreased in group A (P<0. 05). Conclusion Compared with moderate NMB combined with high-pressure pneumoperitoneum, deep NMB combined with low-pressure pneumoperitoneum can provide a satisfactory surgical field and reduce postoperative pain, however, it prolongs the recovery time of NMB for gynecological laparoscopic surgery in the obese patients.