经鼻微旁流式监测PETCO_(2)在门诊无痛胃镜诊疗中对呼吸抑制的预警作用观察

Observation on early warning effect of nasal microflow monitoring PETCO_(2) on respiratory depression in outpatient painless gastroscopy

目的无痛舒适化的诊疗给麻醉医生提供多样化的麻醉机遇同时也是挑战,如何更安全的做好手术室外麻醉工作是广大麻醉医生最为关注的问题。本研究就门诊无痛胃镜诊疗中的呼吸管理提供一些新的思路,探讨更为安全的进行患者呼吸管理的方法。方法选择2022年8月—2023年11月在本院经麻醉门诊评估后选择做无痛胃镜下诊疗的1630例患者作为研究对象,随机数表法分为经鼻微旁流式监测PETCO_(2)组(观察组,818例)和对照组(812例)两组。两组患者入室均经鼻导管吸氧,对照组在推注静脉麻醉药物丙泊酚过程中常规监测BP、SPO_(2)、HR,出现麻醉医生经验范围内认为的呼吸抑制情况如不能观察到呼吸运动幅度或呼吸运动幅度明显减弱时麻醉医生给予辅助托下颌处理;观察组除进行常规BP、SPO_(2)、HR的监测外,还进行经鼻导管微旁流式PETCO_(2),推注静脉麻醉药物丙泊酚过程中PETCO_(2)数值较前出现明显升高变化(PETCO_(2)>50 mmHg)或出现波形中断10 s以上时,即认为有一定程度的呼吸抑制或呼吸暂停,麻醉医师即给予同样的托下颌等处理。记录两组患者在入室经鼻导管吸氧5 min推注药物时(t0)、内镜进入时(t1)、分别被认为发生呼吸抑制时(t2)以及术毕(t3)四个时间点的生命体征包括:MAP、HR、SPO_(2);观察组的术中连续PETCO_(2)监测情况;对比两组患者术中认为发生呼吸抑制情况;两组患者术中药物用量、术中心率下降至50次/min以下情况、术后不适主诉情况;恶心呕吐情况;门诊复苏室留观时间以及其他异常情况等。结果观察发现,两组患者在入室吸氧5 min推注药物时(t0)、内镜进入时(t1)和手术结束时(t3)的MAP、HR和SPO_(2)均无明显差异(P>0.05)。观察到两组患者分别被麻醉医生认为发生呼吸抑制时(t2)的MAP和HR均无明显差异(P>0.05),然而对照组在此时间点的SPO_(2)较观察组明显降低(P<0.05);对照组通过观察认为321例发生呼吸抑制或呼吸暂停,观察组通过经鼻监测PETCO_(2)认为554例发生呼吸抑制或呼吸暂停,两组差异具有统计学意义(P<0.05);两组患者在术中均静脉推注使用舒芬太尼和丙泊酚,两组患者使用舒芬太尼的剂量差异无统计学意义(P>0.05);对照组的丙泊酚使用剂量均数较观察组增加,组间差异具有统计学意义(P<0.05);两组患者留观时间比较,差异具有统计学意义(P<0.05);两组患者围术期其他不良反应比较,差异无统计学意义(P>0.05)。结论经鼻监测PETCO_(2)在无痛内镜诊疗中更早更直接地发现患者的呼吸抑制,麻醉医生可以更及时给予患者呼吸干预,更好地进行无痛内镜诊疗中呼吸的管理,提高手术室外非插管麻醉的安全性,并且有效的节约静脉麻醉药物。

Objective Painless and comfortable diagnosis and treatment provide diversified opportunities and challenges for anesthesiologists.How to perform anesthesia outside the operating room more safely is the most concerned issue for anesthesiologists.This study provides some new ideas for respiratory management in outpatient painless gastroscopy diagnosis and treatment,and discusses much safer methods for respiratory management of patients.Methods A total of 1,630 patients underwent painless gastroscopic diagnosis and treatment during August 2022 and Novenmber 2023 after anesthesia outpatient evaluation were selected as the study subjects.According to random number table method,they were divided into the nasal microflow monitoring PETCO_(2) group(the observation group,n=818)and the control group(n=812).Patients in both groups received oxygen through nasal catheter.BP,SPO_(2) and HR were routinely monitored during intravenous injection of anesthetic drug propofol in the control group.If the respiratory depression was considered to occur within the scope of anesthesiologist's experience,such as the respiratory motion range could not be observed or the respiratory motion range was significantly weakened,anesthesiologist gave the mandibular support treatment.In addition to routine BP,SPO_(2) and HR monitoring,the observation group was also carried out nasal microflow monitoring PETCO_(2).When the value of PETCO_(2) increased significantly(over 50 mmHg)or when the waveform was interrupted for more than 10s during intravenous injection of anesthetic drug propofol,a certain degree of respiratory depression or apnea was considered,then the anesthesiologist gave the same mandibular support.Vital signs of patients including MAP,HR and SPO_(2) in the two groups were recorded at four time points:inhalation of oxygen through nasal catheter for 5 min and drug infusion(t0),endoscopic entry(t1),when respiratory depression was considered to occur(t2)and after operation(t3).Intraoperative continuous PETCO_(2) monitoring of the observation group was recorded.The occurrence of respiratory depression during surgery in both groups were compared.The intraoperative drug dosage,situation that the intraoperative heart rate of patients in the two groups decreased to below 50 times/min,and the complaints of postoperative discomfort were recorded.Nausea and vomiting,observation time in the outpatient resuscitation room and other abnormal conditions were recorded.Results It was found that there were no significant differences in MAP,HR and SPO_(2) between the two groups at t0,t1,t2,and t3(P>0.05).It was observed that there were no significant differences in MAP and HR at t2 between the two groups(P>0.05),while SPO_(2) in the control group was significantly lower than that in the observation group,and the difference at this time point was statistically significant(P<0.05).In the control group,321 patients were considered to have respiratory depression or apnea by observing the changes of respiratory motion amplitude;there were 554 patients considered to have respiratory depression or apnea in the observation group according to nasal microflow monitoring PETCO_(2),the difference between the two groups was statistically significant(P<0.05).Intraoperative intravenous infusion of sufentanil and propofol was used in 2 groups,there was no significant difference in intraoperative use of sufentanil(P>0.05).The mean dose of propofol in control group increased compared with observation group,and the difference between the two groups was statistically significant(P<0.05).The difference in observation time between the two groups was statistically significant(P<0.05);there was no significant difference in other perioperative adverse effects between the two groups(P>0.05).Conclusions Nasal PETCO_(2) monitoring can detect respiratory depression in patients earlier and more directly in painless endoscopic diagnosis and treatment.Anesthesiologist can give respiratory intervention to patients in a more timely manner,better manage respiration in painless endoscopic diagnosis and treatment,improve the safety of non-intubation anesthesia outside the operating room,and effectively save intravenous anesthesia drugs.