浅肌松用于腹腔镜胆囊切除术的可行性

Feasibility of shallow neuromuscular blockade in laparoscopic cholecystectomy

目的探讨浅肌松用于腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的可行性。方法择期LC术患者64例,ASAⅠ~Ⅱ级,年龄20~60岁,体重指数18~30 kg/m^(2)。采用随机数字表法分为浅度肌松组(S组,n=32)和中度肌松组(M组,n=32),两组均在肌松监测下采用罗库溴铵维持目标肌松程度,S组和M组的目标肌松程度分别为四个成串刺激(train-of-four stimulation,TOF)计数4和TOF计数1~3。于插管后(T_(1))、气腹10 min(T_(2))、气腹结束后(T_(3))和术毕(T_(4))时记录气道峰压、气道平台压和肺顺应性,在诱导前(T_(0))、T_(1)、T_(2)、T_(4)时采集桡动脉血样行血气分析,T_(1)、T_(2)、T_(4)时计算肺泡-动脉血氧分压差[P(A-a)O_(2)]、氧合指数(oxygenation index,OI)、肺内分流率(intrapulmonary shunt,Qs/Qt)和死腔率(dead space fraction,VD/VT),术后进行手术满意度评级并记录手术时间、拔管时间、罗库溴铵用量、肌松拮抗情况和苏醒期不良反应。结果最终60例患者纳入统计学分析,两组各30例,与M组相比,S组T_(2)时肺顺应性下降近5 mL/cm H_(2)O,OI降低40 mm Hg且Qs/Qt增加至12.4%(P<0.01),T_(4)时两组间各指标差异均无统计学意义。S组手术条件满意度评级较低(P<0.01),但满足手术条件的患者(83.3%,25/30)与M组(96.7%,29/30)相比差异无统计学意义,拔管时间缩短(P<0.01),罗库溴铵用量减少(P<0.01)。两组患者使用肌松拮抗情况的差异有统计学意义(P<0.05),两组间其他指标差异均无统计学意义。结论LC术中浅肌松的应用具有临床可行性。

Objective To explore the feasibility of shallow neuromuscular blockade in laparoscopic cholecystectomy.Methods Sixty-four patients(ASAⅠ-Ⅱ),aged 20-60 y,with body mass index of18-30 kg/m^(2),scheduled for elective laparoscopic cholecystectomy,were randomly divided into shallow neuromuscular blockade group(group S,n=32)and moderate neuromuscular blockade group(group M,n=32)by a random number table.Rocuronium was infused to maintain the degree of neuromuscular blockade in both groups to achieve the target degrees:train-of-four stimulation(TOF)count of 4 in group S and 1~3 in group M.Peak airway pressure,airway plateau pressure and compliance of lung(CL)were recorded at following time points:just after tracheal intubation.(T_(1)),10 min after pneumoperitoneum(T_(2)),just end of pneumoperjtoneum(T_(3))and end of surgery(T_(4)).Artefial blood samples were collected for blood gas analysis at before induction(T0),T_(1),T_(2)and T_(4).Alveolar-arterial oxygen gradient[P(A-a)O2],oxygenation index(OI),intrapulmonary shunt(Qs/Qt)and dead space fraction(VD/VT)were calculated derivatively at T_(1),T_(2)and T_(4).Surgical condition scores were assessed by surgeons,while operation times,extubation times,dosages of rocuronium,usage of muscle relaxant antagonists and adverse reactions during recovery in the two groups were recorded.Results Sixty patients were available for the final statistical analysis,with 30 cases in each group.Compared with group M,CL decreased by nearly 5 mL/cm H_(2)O at T_(2)in group S,while OI decreased by 40 mm Hg and Qs/Qt increased to 12.4%(P<0.01),but there were no significant difference between the two groups at T_(4).Surgery condition score was lower(P<0.01),however acceptable surgical conditions of group S(83.3%,25/30)has no statistical difference compared with group M(96.7%,29/30),meanwhile extubation time was shorter(P<0.01)and the dosage of rocuronium was less than that of group M(P<0.01),neuromuscular blockade reverse in two groups was statistically significant(P<0.05),There were no significant difference in the other parameters between the two groups.Conclusion Use of shallow neuromuscular blockade in LC has clinical feasibility.