不同全身麻醉管理方式与早产儿眼底手术临床结局

Different anesthesia management in preterm infants undergoing surgeries for retinopathy of prematurity:A retrospective study

目的:探讨在矫正胎龄<60周的早产儿眼底手术中,不同全身麻醉管理方式对临床结局的影响。方法:选择2016年11月至2018年10月于北京大学人民医院行全身麻醉下眼底手术、出生孕周<37周、矫正胎龄<60周的早产儿病例资料进行回顾性分析。所有患儿实施七氟醚吸入诱导与维持,气道管理工具为喉罩(laryngeal mask airway,LMA)或气管内导管(endotracheal tube,ETT)。根据麻醉管理方法分为LMA组(置入喉罩,压力支持通气)和ETT组(肌松剂+气管插管,压力控制通气)两组,主要观察指标包括围术期并发症及不良事件,次要观察指标包括术毕拔管时间和住院时间。结果:168例早产儿纳入本研究,LMA组68例,ETT组100例。术中不良事件(包括更换气道管理工具、更换通气模式和低氧血症)LMA组3例(4.4%),ETT组1例(1.0%),组间差异无统计学意义(P=0.364)。术毕拔管时间中位数(四分位数)LMA组和ETT组分别为6(5,10)min和10(6,19)min(P<0.001);术毕拔管困难(拔管时间>30 min)的比例LMA组显著低于ETT组(4.4%vs.15.0%,RR=0.262,95%CI:0.073~0.942,P=0.029)。LMA组呼吸系统并发症14例(20.6%),ETT组27例(27.0%),组间差异无统计学意义(P=0.342);其中LMA组呼吸暂停发生率较ETT组显著降低(4.4%vs.15.0%,RR=0.266,95%CI:0.086~0.822,P=0.015)。两组心血管系统并发症(0%vs.1.0%,P=1.000)及意外转新生儿重症监护室发生率(5.9%vs.7.0%,P=0.774)差异均无统计学意义。所有患儿均未出现气道痉挛、二次插管/喉罩、反流误吸并发症。患儿返病房后,不良事件发生率组间差异无统计学意义(0%vs.2.0%,P=0.241)。LMA组住院时间中位数为20(17,22)h,较ETT组22(17,68)h显著缩短(P=0.002)。结论:与使用肌松剂行气管插管的全麻管理模式相比,无肌松剂置入喉罩的管理模式用于早产儿眼底手术可缩短术后拔管时间,降低术后苏醒期呼吸暂停的风险。

Objective:To evaluate the effect of different anesthesia management on clinical outcomes in former prematurely born infants undergoing surgeries for retinopathy of prematurity(ROP).Methods:In this retrospective study,electronic medical record database was searched for all former prematurely born infants(gestational age<37 weeks and post conceptual age<60 weeks)who received ROP surgery under inhalational general anesthesia between November 2016 and October 2018.The patients were divided into two groups based on anesthesia management:laryngeal mask airway(LMA)insertion without intravenous muscle relaxant injection and with pressure support ventilation(LMA group)or airway secured with endotracheal tube(ETT)with intravenous muscle relaxant injection and pressure controlled ventilation(ETT group).Primary outcomes included perioperative adverse events and complications.Extubation time and length of stay after surgery were also recorded.Results:Sixty eight preterm infants in the LMA group and 100 preterm infants in the ETT group were included.The incidence of adverse events during surgery(including airway management change and desaturation)was similar in LMA group and ETT group(4.4%vs.1.0%,P=0.364).During the early recovery period after surgery,the incidence of difficult extubation(extubation time>30 min)was significantly lower in LMA group compared with ETT group(4.4%vs.15.0%,RR=0.262,95%CI:0.073-0.942,P=0.029).The incidence of respiratory events was similar between the two groups(20.6%vs.27.0%,P=0.342).However,the incidence of apnea was significantly lower in the LMA group than in the ETT group(5.9%vs.19.0%,RR=0.266,95%CI:0.086-0.822,P=0.015).No significant difference was observed between the LMA group and ETT group in incidences of cardiovascular events(0%vs.1.0%,P=1.000)and unplanned admission to neonatal intensive care unit(5.9%vs.7.0%,P=0.774).No airway spasm,re-intubation,aspiration or regurgitation was observed during early recovery.During late recovery after returning to ward,the incidence of adverse events was also similar between the two groups(0%vs.2.0%,P=0.241).The median(IQR)extubation time was 6(5,10)min in LMA group and 10(6,19)min in ETT group(P<0.001).The median length of stay after surgery was significantly shortened in LMA group compared with ETT group[20(17,22)hours vs.22(17,68)hours,P=0.002].Conclusion:Compared with endotracheal intubation with intravenous muscle relaxant injection,laryngeal mask airway insertion without muscle relaxant could achieve an early extubation,and reduce the incidence of apnea during early recovery period in former prematurely born infants undergoing ROP surgery.