肺部电阻抗断层成像技术评估不同肌松拮抗剂对术后肺局部通气恢复的影响

Effects of different muscle relaxation antagonists on postoperative local lung ventilation recovery evaluated by pulmonary electrical impedance tomography

目的 利用肺部电阻抗断层成像(electrical impedance tomography,EIT)技术比较腹腔镜下根治性前列腺切除术患者术后使用肌松拮抗药舒更葡糖钠和新斯的明后肺局部通气的恢复情况。方法 选择2020年9月—2021年9月在复旦大学附属肿瘤医院全麻下行腹腔镜下根治性前列腺切除术的患者75例,采用随机数字表法将患者分为舒更葡糖钠组(S组)和新斯的明组(X组)。使用EIT监测肺局部通气,四个成串刺激(train-of-four stimulation,TOF)监测肌松。术毕TOF恢复至2个计数时,S组静脉给予舒更葡糖钠2 mg/kg,X组静脉给予新斯的明40μg/kg联合阿托品20μg/kg,比较两组患者术前及拔管后10、20、30 min的EIT潮气阻抗差值(tidal impedance variation,TIV)、呼气末肺阻抗差值(changes of end-expiratory lung impedance,ΔEELI),感兴趣区域(region of interest,ROI)阻抗比例,并记录两组患者的肌松恢复时间(TOF恢复至90%)和术前及拔管后10、20、30 min的心率、血压、动脉氧分压(PaO_(2))、动脉二氧化碳分压(PaCO_(2))、动脉氧饱和度(SaO_(2))、肺泡动脉氧分压差(PA-aO_(2))和氧合指数(PaO_(2)/FiO_(2))。结果 两组患者拔管后30 min的TIV(P=0.932)、ΔEELI(P=0.822)、ROI 1比例(P=0.529)、ROI 2比例(P=0.693)、ROI 3比例(P=0.868)和ROI 4比例(P=0.185)的差异均无统计学意义;S组的肌松恢复时间(3.4 min)明显短于X组(11.3 min,P<0.001)。与术前相比,S组拔管后30 min的PaO_(2)(P=0.007)、SaO_(2)(P<0.001)和PaO_(2)/FiO_(2)(P=0.007)均显著降低。与术前相比,X组拔管后30 min的PaO_(2)(P=0.018)、SaO_(2)(P=0.002)和PaO_(2)/FiO_(2)(P=0.018)均显著降低。结论使用新斯的明或舒更葡糖钠术毕拮抗肌松,对腹腔镜下根治性前列腺切除术患者术后肺局部通气分布可能无影响,即使肌松完全恢复,肺呼吸功能在术后30 min也不能完全恢复至术前基础水平。

Objective To investigate postoperative local lung ventilation recovery with different neuromuscular blockade antagonists, sugammadex or neostigmine,in patients undergoing laparoscopic radical prostatectomy using electrical impedance tomography(EIT). Methods Seventy-five patients with general anesthesia undergoing laparoscopic radical prostate cancer surgery in Fudan University Shanghai Cancer Center were selected during Sep 2020 to Sep 2021. These patients were randomly divided into sugammadex group(S group) and neostigmine group(X group) by a random digital table. EIT was utilized to monitor local lung ventilation, and train-of-four stimulation(TOF) was employed to monitor muscle relaxation. When T_(2) of TOF appeared at the end of surgery,S group received intravenous sugammadex(2 mg/kg), and X group received intravenous neostigmine(40 μg/kg) combined with atropine(20 μg/kg). The EIT parameters such as tidal impedance variation(TIV), changes of endexpiratory lung impedance(ΔEELI)and the ratio of region of interest(ROI) were recorded and compared before surgery and 10, 20, and 30 minutes after extubation between the two groups The time from administration of neuromuscular blockade antagonists to the recovery of TOF ratio(TOFr) to 0.9 were recorded, and the heart rate, blood pressure, PaO_(2), PaCO_(2), SaO_(2), PA-aO_(2)and PaO_(2)/FiO_(2)were also recorded before surgery and 10, 20 and 30 minutes after extubation. Results There were no significant differences in TIV(P=0.932), ΔEELI(P=0.822), the ratio of ROI 1(P=0.529), the ratio of ROI 2(P=0.693), the ratio of ROI 3(P=0.868) and the ratio of ROI 4(P=0.185) between the two groups 30minutes after extubation. The time from the administration of neuromuscular blockade antagonists to the recovery of TOFr to 0.9 of S group was significantly shorter than that of X group(3.4 minutes vs. 11.3minutes, P<0.001). Compared with baseline values, PaO_(2)(P=0.007),SaO_(2)(P<0.001),PaO_(2)/FiO_(2)(P=0.007) 30 minutes after extubation were significantly decreased in S group. Compared with baseline values, PaO_(2)(P=0.018), SaO_(2)(P=0.002) and PaO_(2)/FiO_(2)(P=0.018) 30 minutes after extubation were significantly decreased in X group. Conclusion Postoperative local lung ventilation distribution dose not differ after neostigmine or sugammadex antagonizing neuromuscular blockade in patients undergoing laparoscopic radical prostatectomy. However, even recovery of muscle relaxation is complete, pulmonary ventilation function can not completely restored to the preoperative baseline level at 30 minutes after surgery.