深度肌松和中度肌松在单孔腹腔镜全子宫切除术中的比较

Comparison of deep versus moderate neuromuscular blockade during laparoendoscopic single-site surgery for total hysterectomy

目的比较术中维持深度肌松和中度肌松在单孔腹腔镜全子宫切除术中的应用效果。方法选择2020年6—10月择期在全凭静脉麻醉下行单孔腹腔镜全子宫切除术的患者61例,年龄45~62岁,BMI 17~28 kg/m^(2),ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组:深度肌松组(n=31)和中度肌松组(n=30)。深度肌松组麻醉诱导使用顺式阿曲库铵0.15 mg/kg,术中持续泵注顺式阿曲库铵0.06~0.15 mg·kg^(-1)·h^(-1),维持强直刺激后单刺激肌颤搐计数(PTC)1~2。中度肌松组麻醉诱导使用顺式阿曲库铵0.1 mg/kg,术中持续泵注顺式阿曲库铵0.06~0.15 mg·kg^(-1)·h^(-1),维持四个成串刺激(TOF)1~2。两组术中麻醉深度维持Narcotrend 25~35。记录术中手术条件评分、平均气腹压、自主呼吸次数、额外肌松药物使用例数、停药至四个成串刺激比值(TOFr)0.25、TOFr 0.9时间和拔管时间、恢复指数、PACU停留时间、拔管后10 min的pH值、PaO_(2)、PaCO_(2)。记录术后1、6、24、48、72 h活动时VAS疼痛评分、镇痛泵总按压次数、镇痛泵有效按压次数、补救镇痛例数、术后住院时间。记录术中血管和器官损伤、术后呼吸抑制、切口疝、出血、恶心呕吐等不良反应发生情况和术后14 d内肩痛发生情况。结果与中度肌松组比较,深度肌松组术中平均气腹压明显降低(P<0.05),自主呼吸次数明显减少(P<0.05),停药至TOFr 0.25、TOFr 0.9时间和拔管时间明显延长(P<0.05),术后6、24、48 h活动时VAS疼痛评分明显降低(P<0.05),镇痛泵总按压次数、镇痛泵有效按压次数明显减少(P<0.05),补救镇痛发生率明显降低(P<0.05),术后14 d内肩痛发生率明显降低(P<0.05)。两组术中手术条件评分、额外肌松药物使用率、恢复指数、PACU停留时间、血气分析、术后住院时间、术中血管和器官损伤、术后其余不良反应发生率差异无统计学意义。结论与中度肌松比较,深度肌松在单孔腹腔镜全子宫切除术中可明显降低术后疼痛,但拔管时间延长,且不改善手术条件。

Objective To compare the effect of maintaining deep neuromuscular blockade and moderate neuromuscular blockade during laparoendoscopic single-site(LESS)surgery undergoing total hysterectomy.Methods Sixty-one female patients between June 2020 and October 2020 scheduled for LESS surgery undergoing total hysterectomy under total intravenous anesthesia,aged 45-62 years,BMI 17-28 kg/m^(2),ASA physical statusⅡorⅢ,were randomly divided into two groups using random number table method:deep neuromuscular blockade(NMB)group(n=31)and moderate NMB group(n=30).Deep NMB group was induced by administration of cisatracurium 0.15 mg/kg followed by continuous infusion 0.06-0.15 mg·kg^(-1)·h^(-1) to maintain intraoperative post-tetanic count of 1-2,while moderate NMB group was induced by administration of cisatracurium 0.1 mg/kg followed by continuous infusion 0.06-0.15 mg·kg^(-1)·h^(-1) to maintain intraoperative train-of-four of 1-2.Depth of anesthesia was controlled at a Narcotrend rating of 25-35 in both groups.The surgical conditions scores,mean intra-abdominal pressure,numbers of autonomous breathing,additional NMB requirements,time from agents withdrawal to TOF ratio 0.25,to TOF ratio 0.9 and to extubation,recovery index,postanesthesia care unit stay time,and pH value,PaO_(2),PaCO_(2)10 minutes after extubation were recorded.VAS scores at 1,6,24,48,and 72 hours during exercise after surgery,the total number of analgesic pump compressions,the number of effective analgesic pump compressions,the number of rescue analgesia,and postoperative length of stay were also recorded.The occurrence of intraoperative vascular and organ injuries,postoperative respiratory depression,incisional hernia,bleeding,nausea and vomiting and shoulder pain within 14 days postoperatively were recorded.Results Compared with moderate NMB group,the mean intra-abdominal pressure was significantly decreased(P<0.05),numbers of autonomous breathing were significantly less(P<0.05),the time from agents withdrawal to TOF ratio 0.25,to TOF ratio 0.9 and to extubation were significantly longer(P<0.05),VAS scores 6,24,and 48 hours during exercise after surgery were significantly decreased(P<0.05),the total number of analgesic pump compressions and the number of effective analgesic pump compressions were significantly reduced(P<0.05),the incidence of rescue analgesia was significantly decreased(P<0.05),the incidence of postoperative shoulder pain within 14 days were significantly decreased in deep NMB group(P<0.05).There were no significant differences in surgical conditions scores,additional NMB requirements,recovery index,postanesthesia care unit stay time,blood gas analysis,postoperative length of stay,intraoperative vascular and organ injuries,and other adverse events between the two groups.Conclusion Compared with moderate NMB,deep NMB can significantly reduce postoperative pain scores after LESS surgery for total hysterectomy.However,it does not improve surgical conditions and prolong the time to extubation.