肺超声评估拔管前肺复张对胆囊切除日间手术患者肺部含气量的影响

Effects of recruitment maneuver before extubation on postoperative lung air content by lung ultrasonography in patients un⁃dergoing ambulatory laparoscopic cholecystectomy

目的通过肺部超声技术评估全身麻醉拔管前肺复张对行腹腔镜胆囊切除日间手术患者肺部含气量的影响。方法进行腹腔镜胆囊切除日间手术的患者80例,年龄18~64岁,ASA分级Ⅰ、Ⅱ级,采用随机数字表法将患者分为2组(每组40例):观察组、对照组。所有患者均采用全凭静脉全身麻醉,观察组在术毕拔管前采用潮气量递增法肺复张,对照组不进行肺复张。分别在术前1 h(T_(1))、拔除气管导管后30 min(T_(2))及术后20~30 h(T_(3))对两组患者进行肺部超声检查评分(lung ultrasound score,LUS),记录两组患者肺各分区的LUS及各时点患者的SpO_(2),同时记录两组患者性别比、年龄、体重、BMI、ASA分级、机械通气时间、手术时间、T_(2)和T_(3)时数字分级评分法(Numerical Rating Scale,NRS)疼痛评分。结果两组患者性别比、年龄、体重、BMI、ASA分级、机械通气时间、手术时间、T_(2)和T_(3)时NRS疼痛评分差异均无统计学意义(P>0.05)。与T_(1)比较,两组患者T_(2)、T_(3)时LUS升高(P<0.05);与T_(2)比较,两组患者T_(3)时LUS降低(P<0.05)。与对照组比较:观察组LUS在T_(2)、T_(3)时降低(P<0.05),SpO_(2)在T_(3)时增加(P<0.05)。与同侧上前区比较:两组患者T_(2)、T_(3)时两上、下后区LUS增高(P<0.05);对照组左上侧区、左下侧区、右下侧区在T_(2)时增高,右下前区在T_(3)时增高(P<0.05)。观察组左上侧区、左下侧区、左上后区、左下后区、右下侧区、右上后区、右下后区LUS在T_(2)时较对照组降低(P<0.05)。观察组右上侧区、右上后区在T_(3)时较对照组较低(P<0.05)。结论腹腔镜胆囊切除日间手术后,患者会出现一定程度的肺含气量减少,且至少持续至术后1 d;拔除气管导管前给予潮气量递增法的肺复张可在一定程度上改善该症状,并在术后维持较好的氧合。肺部超声能较好地评估肺含气量减少的情况。

Objective To evaluate the effect of recruitment maneuvers by lung ultrasound before extubation under general an⁃esthesia on patients undergoing ambulatory laparoscopic cholecystectomy.Methods A total of 80 patients,aged 18‒64 years,Amer⁃ican Society of Anesthesiologists(ASA)gradeⅠorⅡ,who underwent ambulatory laparoscopic cholecystectomy were enrolled.Accord⁃ing to the random number table method,they were divided into two groups(n=40):an observation group and a control group.All pa⁃tients were under general anesthesia.Before extubation,the lungs were resuscitated using the tidal volume increment method in the ob⁃servation group,the control group was not resuscitated.Lung ultrasound score(LUS)were recorded for patients in the two groups 1 h be⁃fore surgery(T_(1)),30 min after removal of tracheal catheter(T_(2)),and 20‒30 h after surgery(T_(3)).The LUS of each division and the pulmo⁃nary oxygen concentration(SpO_(2))were recorded at each time point.Meanwhile,their sex ratio,age,body weight,body mass index(BMI),ASA grade,mechanical ventilation time,operation time,and the Numerical Rating Scale(NRS)scores at T_(2) and T_(3) were record⁃ed.Results There was no significant difference in sex ratio,age,body weight,BMI,ASA grade,mechanical ventilation time,opera⁃tion time,and NRS scores at T_(2) and T_(3) between the two groups(P>0.05).Compared with those at T_(1),the LUS at T_(2) and T_(3) increased in the two groups(P<0.05).Compared with those at T_(2),the LUS at T_(3) decreases in the two groups(P<0.05).Compared with the control group,the LUS of the observation group decreased at T_(2) and T_(3)(P<0.05),and SpO_(2) increased at T_(3)(P<0.05).Compared with those in the ipsilateral superior anterior area,the LUS of both upper and lower posterior areas significantly increased in the two groups at T_(2) and T_(3)(P<0.05).In the control group,the LUS increased in the left upper area,left lower area and right lower area at T_(2) and in the right low⁃er anterior area at T_(3)(P<0.05).The LUS of the left upper area,left lower area,left upper posterior area,left lower posterior area,right lower area,right upper posterior area and right lower posterior area in the observation group were significantly lower than those in the control group at T_(2)(P<0.05).The LUS of the right upper area and right upper posterior area in the observation group were lower than those in the control group at T_(3)(P<0.05).Conclusions After ambulatory laparoscopic cholecystectomy,lung air content may de⁃crease to some extent,which persists until at least one day after surgery;recruitment maneuvers with increasing tidal volume before tra⁃cheal tube removal can improve the symptom to some extent and maintain good oxygenation after operation.Lung ultrasonography pro⁃vides good assessment of reduced lung air content.