不同肌肉松弛药给药方案联合ERAS技术对妇科腹腔镜子宫全切术患者麻醉管理及术后疼痛的影响

Effects of different muscle relaxant administration regimens combined with ERAS technology on anesthesia management and postoperative pain in patients with gynecological laparoscopic hysterectomy

目的探讨不同肌肉松弛药给药方案联合ERAS技术对妇科腹腔镜子宫全切术患者麻醉管理及术后疼痛的影响。方法前瞻性选取2021年6月至2022年6月于甘肃省妇幼保健院就诊的135例需进行腹腔镜子宫全切术患者,按照随机数字表法分为3组,各45例。3组患者采取不同肌肉松弛药给药方案,包括无肌松(NM)组、肌松药诱导(MI)组和肌松药诱导维持(MIC)组,在围术期均联合快速外科康复技术(ERAS)。比较3组患者气管插管条件,诱导前(t0)、气管插管前(t1)、气管插管后1 min(t2)、气管插管后3 min(t3)的血流动力学情况[心率和平均动脉压(MAP)],术后拔管时间、肌松药用量、TOF≥0.9时间,不同时间双肩、切口疼痛评分,术前、术后24 h应激反应指标[血清白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)、血糖]。结果NM组气管插管条件优秀率为75.56%,低于MI组(91.11%)、MIC组(93.33%),差异有统计学意义(P<0.05),但MI组和MIC组气管插管优秀率比较,差异无统计学意义(P>0.05)。t0~t3时刻,与NM组相比,MI组、MIC组心率、MAP均更低,3组心率、MAP组间比较,差异均有统计学意义(P<0.05)。与NM组相比,MI组术后拔管时间更短,MIC组术后拔管时间更长,MIC组术后拔管时间长于MI组,MIC组肌松药用量多于MI组,TOF≥0.9时间长于MI组,差异均有统计学意义(P<0.05)。术后2、4、8、12、24 h,与NM组相比,MI组、MIC组双肩、切口VAS评分均更低,MIC组双肩、切口VAS评分均低于MI组,差异均有统计学意义(P<0.05)。术后24 h,与NM组相比,MI组、MIC组血清IL-6、TNF-α和血糖水平均更低,MIC组血清IL-6、TNF-α和血糖水平均低于MI组,差异均有统计学意义(P<0.05)。结论腹腔镜子宫全切术患者麻醉诱导和麻醉诱导维持时使用肌松药联合ERAS技术能有效提高气管插管条件,维持血流动力学稳定,有效缓解术后疼痛和应激反应,但会延长术后拔管时间。而麻醉维持过程中使用肌松药会使拔管时间进一步延长,肌松药用量增加。

Objective To investigate the effect of different muscle relaxant dosage regimens combined with ERAS technology on anesthesia management and postoperative pain in patients with gynecological laparoscopic total hysterectomy.Methods A total of 135 patients requiring laparoscopic hysterectomy who were treated in Gansu Provincial Maternity and Child-Care Hospital from June 2021 to June 2022 were prospectively selected and divided into three groups according to the random number table method,45 cases in each.The three groups of patients were given different dosage regimens of muscle relaxants,including the non-muscle relaxant(NM)group,the muscle relaxant induction(MI)group and the muscle relaxant induction maintenance(MIC)group,all combined with Fast-track Surgery or Enhanced Recovery After Surgery(ERAS)in the perioperative period,the trachea of the three groups of patients were compared.Intubation conditions,hemodynamics[heart rate and mean arterial pressure(MAP)]before induction(t0),before endotracheal intubation(t1),1 min after endotracheal intubation(t2),3 min after endotracheal intubation(t3),postoperative extubation time,muscle relaxant dosage,TOF≥0.9 Time,shoulder and incision pain scores at different times,and stress response indexes[serum interleukin-6(IL-6),tumor necrosis factor-α(TNF-α),blood sugar]before and after surgery.Results The excellent rate of tracheal intubation in NM group was 75.56%,which was lower than that in MI group(91.11%)and in MIC group(93.33%),the difference was statistically significant(P<0.05);however,there was no statistically significant difference in the excellent rate of endotracheal intubation between MI group and MIC group(P>0.05).Compared with the NM group,the heart rate and MAP of the MI group and the MIC group were all lower at t0~t3,and the heart rate and MAP of the three groups at t0~t3 were compared,the differences were statistically significant(P<0.05).Compared with the NM group,the postoperative extubation time in the MI group was shorter,the postoperative extubation time in the MIC group was longer,and the postoperative extubation time in the MIC group was longer than that in the MI group,the dosage of muscle relaxants in the MIC group was more than that in the MI group,and the TOF≥0.9 time was longer than that in the MI group,the differences were statistically significant(P<0.05).Compared with NM group,MI group and MIC group had lower shoulder and incision VAS scores at 2,4,8,12,and 24 hours after operation,incision VAS scores were lower than those in the MI group,the differences were statistically significant(P<0.05).Compared with the NM group,the serum IL-6,TNF-αand blood sugar levels in the MI group and MIC group were lower at 24 h after surgery,the serum levels of IL-6,TNF-αand blood glucose in the MIC group were lower than those in the MI group,the differences were statistically significant(P<0.05).Conclusion The use of muscle relaxants combined with ERAS technology in patients with laparoscopic total hysterectomy during anesthesia induction and maintenance of anesthesia induction can effectively improve the conditions of tracheal intubation,maintain hemodynamic stability,and effectively relieve postoperative pain and stress response.Extend postoperative extubation time.The use of muscle relaxants during anesthesia maintenance will further prolong the extubation time and increase the amount of muscle relaxants.