不同全身麻醉维持方式对双胎输血综合征SLPCV术后妊娠结局的影响

Effect of different maintenance methods of general anesthesia on pregnancy outcomes after selective laser photocoagulation of communicating vessels for twin-to-twin transfusion syndrome

目的分析不同全身麻醉维持方式对双胎输血综合征(twin-to-twin transfusion syndrome, TTTS)选择性胎盘血管交通支激光凝固术(selective laser photocoagulation of communicating vessels, SLPCV)术后妊娠结局的影响。方法回顾性选取空军军医大学第一附属医院2016年10月至2022年10月诊断为TTTS并于全身麻醉下行SLPCV的患者143例。根据术中全身麻醉维持药物不同分为全凭静脉麻醉(total intravenous anesthesia, TIVA)组和吸入麻醉(volatile induction and maintenance anesthesia, VIMA)组。经纳入排除标准筛选后, 最终纳入104例, TIVA组(术中维持采用丙泊酚+瑞芬太尼)59例, VIMA组(术中维持采用七氟醚+瑞芬太尼)45例。收集并记录患者一般信息(身高、体重、BMI、孕次、产次、ASA分级、手术时妊娠周数、Quintero分期等)、实验室检查信息(术前和术后Hb、Hct)、手术和麻醉信息(心率、术中SBP和DBP基础值及最低值、SpO_(2)、急诊手术发生率、手术时长、麻醉时长、麻醉-手术开始时长、术中液体入量、术中尿量、术中羊水减量、麻黄碱和去甲肾上腺素使用情况及用量、肺水肿例数等)、妊娠结局(胎膜早破发生率、自然流产/引产/死产发生率、术后48 h内一胎死亡率、一胎存活率、双胎存活率、新生儿出生时孕周等)。结果两组患者年龄、身高、体重、BMI、ASA分级、孕次、产次、Quintero分期、手术时妊娠周数等差异无统计学意义(P>0.05)。两组患者术前、术后Hb和Hct, 心率, SBP、DBP基础值, SpO_(2), 手术时长, 麻醉时长, 麻醉-手术开始时长, 术中液体入量, 术中尿量, 术中麻黄碱、去甲肾上腺素使用率及麻黄碱用量等差异无统计学意义(P>0.05)。VIMA组术中SBP、DBP最低值低于TIVA组(P<0.05);VIMA组术中羊水减量少于TIVA组(P<0.05);VIMA组去甲肾上腺素用量高于TIVA组(P<0.05)。两组患者胎膜早破发生率、自然流产/引产/死产发生率、术后48 h内一胎死亡率、一胎存活率、双胎存活率、新生儿出生时孕周等差异无统计学意义(P>0.05)。结论尽管VIMA组术中SBP和DBP最低值显著低于TIVA组, 但两组患者在妊娠结局方面无差异, 因此, 两种麻醉维持方式均可用于TTTS时的SLPCV。

Objective To analyze the effect of different maintenance methods for general anesthesia on pregnancy outcomes after selective laser photocoagulation of communicating vessels(SLPCV)for twin-to-twin transfusion syndrome(TTTS).Methods A total of 143 patients who were diagnosed with TTTS and underwent general anesthesia for SLPCV in the First Affiliated Hospital of Air Force Military Medical University from October 2016 to October 2022 were selected.According to the different anesthetics used for intraoperative anesthesia maintenance,they were divided into two groups:a total intravenous anesthesia(TIVA)group(group TIVA)and a volatile induction and maintenance anesthesia(VIMA)group(group VIMA).The patients were screened based on inclusion and exclusion criteria,and 104 cases were finally included,with 59 cases in the TIVA group(receiving propofol plus remifentanil during the operation)and 45 cases in the VIMA group(receiving sevoflurane plus remifentanil during the operation).Their general information were recorded,namely height,weight,body mass index(BMI),gravidity and parity,American Society of Anesthesiologists(ASA)grade,gestational weeks at the time of operation and Quintero stage.Furthermore,laboratory information,such as pre-and post-operative hemoglobin(Hb)and hematocrit(Hct),as well as operative and anesthetic information,such as heart rate,baseline and minimum values of intraoperative systolic blood pressure(SBP)and diastolic blood pressure(DBP),SpO_(2),the incidence of emergency surgery,the duration of operation,the duration of anesthesia,the duration of anesthesia to onset of the operation,intraoperative fluid intake,intraoperative urine volume,reduction of intraoperative amniotic fluid volume,the use and dosage of ephedrine and epinephrine,and the number of cases of pulmonary edema were recorded.Moreover,their pregnancy outcomes,such as the incidence of premature rupture of membranes and spontaneous abortion/induced labor/stillbirth,one child survival/mortality rate within 48 h after operation,twin survival rate,and gestational weeks at birth were recorded.Results There was no difference between the two groups in age,height,weight,BMI,ASA grade,gravidity and parity,Quintero stage and gestational weeks at the time of surgery(P>0.05).There was no difference in Hct,Hb,heart rate,baseline SBP and DBP,baseline SpO_(2),the duration of operation,the duration of anesthesia,the duration of anesthesia to onset of the operation,intraoperative fluid intake,intraoperative urine volume,the use and dosage of ephedrine and the use of epinephrine before and after the operation(P>0.05).However,compared with the TIVA group,the VIMA group showed decreases in the minimum SBP and DBP(P<0.05),reduction of intraoperative amniotic fluid volume(P<0.05),but increases in the dosage of epinephrine(P<0.05).There was no difference between the two groups in the incidence of premature rupture of membranes and spontaneous abortion/induced labor/stillbirth,one child survival/mortality rate within 48 h after operation,twin survival rate,and gestational weeks at birth(P>0.05).Conclusions Although the minimum SBP and DBP in group VIMA are remarkably lower than those in group TIVA,no difference is found in pregnancy outcomes between the two groups.Therefore,each of the anesthesia maintenance methods can be used for SLPCV for TTTS.