经鼻湿化快速充气交换通气对创伤性颅脑损伤急诊手术患者全麻诱导期脑氧饱和度的影响

Effect of transnasal humidified rapid insufflation ventilatory exchange on cerebral oxygen saturation during induction of general anesthesia in patients undergoing traumatic brain injury emergency surgery

目的评估经鼻湿化快速充气交换通气(THRIVE)对创伤性颅脑损伤(TBI)急诊手术患者全麻诱导期局部脑氧饱和度(rScO_(2))的影响。方法采用前瞻性随机对照研究方法,选择2023年1月至7月在江苏省苏北人民医院接受颅内血肿清除术的TBI急诊全麻手术患者作为研究对象。采用随机数字表法将患者分为常规面罩通气组和THRIVE组。常规面罩通气组患者麻醉诱导前面罩无正压通气预充氧10 min,氧流量8 L/min,吸入氧浓度(FiO_(2))1.00,麻醉诱导约90 s,待患者下颌肌肉松弛后进行气管插管;THRIVE组患者使用THRIVE预充氧10 min,氧流量30 L/min,FiO_(2)1.00,麻醉诱导时将氧流量提升至50 L/min,麻醉诱导用药,双手托起患者下颌保持呼吸道通畅,整个过程保持患者口腔闭合,待患者下颌肌肉松弛后进行气管插管。分别于患者入手术室时、预充氧10 min、插管成功即刻监测术侧和非术侧rScO_(2),同时采用超声测量胃窦部横截面积(CSA),并进行动脉血气分析;记录气管插管成功后首次机械通气时呼气末二氧化碳分压(P_(ET)CO_(2))、气管插管期间低氧血症〔脉搏血氧饱和度(SpO_(2))<0.95〕发生情况及重症监护病房(ICU)住院时间、总住院时间、出院时格拉斯哥预后评分(GOS)等预后指标。结果研究期间共70例TBI患者接受急诊全麻手术,其中2例患者术后死亡,2例患者不能配合闭口呼吸,3例患者胃窦部超声图像采集不佳,均予以剔除;最终共纳入63例患者,常规面罩通气组32例,THRIVE组31例。两组患者性别、年龄、体质量指数(BMI)、美国麻醉医师协会(ASA)分级、格拉斯哥昏迷评分(GCS)、视神经鞘直径(ONSD)、基线生命体征、禁食情况、麻醉时间、手术时间及术中失血量差异均无统计学意义,说明具有可比性。入手术室时,两组患者术侧和非术侧rScO_(2)及动脉血气分析指标动脉血氧分压(PaO_(2))、动脉血二氧化碳分压(PaCO_(2))差异均无统计学意义。预充氧10 min时,THRIVE组患者术侧和非术侧rScO_(2)均较常规面罩通气组明显升高(术侧:0.709±0.036比0.636±0.028,非术侧:0.791±0.016比0.712±0.027,均P<0.01),PaO_(2)亦明显升高〔mmHg(1 mmHg≈0.133 kPa):450.23±60.99比264.88±49.33,P<0.01〕,PaCO_(2)明显降低(mmHg:37.81±3.65比43.59±3.76,P<0.01),且该优势一直持续至插管成功即刻;两组各时间点超声检查CSA差异均无统计学意义。与常规面罩通气组比较,THRIVE组患者气管插管成功后首次机械通气时P_(ET)CO_(2)明显降低(mmHg:43.10±2.66比49.22±3.31,P<0.01),且气管插管期间低氧血症发生率亦明显降低〔0%(0/31)比28.12%(9/32),P<0.01〕。在预后指标方面,常规面罩通气组与THRIVE组患者ICU住院时间和总住院时间差异均无统计学意义〔ICU住院时间(d):10(9,10)比10(9,11),总住院时间(d):28.00(26.00,28.75)比28.00(27.00,29.00),均P>0.05〕;但THRIVE组患者出院时预后良好(GOS评分>3分)比例明显高于常规面罩通气组〔35.5%(11/31)比12.5%(4/32),P<0.05〕。结论THRIVE可明显提升TBI急诊全麻手术患者麻醉诱导期间rScO_(2),并且改善患者神经功能预后。

Objective To evaluate the effect of transnasal humidified rapid insufflation ventilatory exchange(THRIVE)on regional cerebral oxygen saturation(rScO_(2))during induction of general anesthesia in patients undergoing traumatic brain injury(TBI)emergency surgery.Methods A prospective randomized controlled trial was conducted.The TBI emergency general anesthesia patients who underwent intracranial hematoma removal surgery at the Northern Jiangsu People's Hospital from January to July in 2023 were enrolled.The patients were divided into a conventional mask ventilation group and a THRIVE group using a random number table method.The patients in the conventional mask ventilation group were anesthetized and induced to pre oxygenate without positive pressure ventilation in the front mask for 10 minutes,with an oxygen flow rate of 8 L/min and an fraction of inspired oxygen(FiO_(2))of 1.00.After anesthesia induction for about 90 s,tracheal intubation was performed after the muscle relaxant took effect(patient's jaw muscle was relaxed).The patients in the THRIVE group were pre oxygenated with THRIVE for 10 minutes,with an oxygen flow rate of 30 L/min and a FiO_(2)of 1.00.During anesthesia induction,the oxygen flow rate was increased to 50 L/min,and anesthesia induction medication was used.The lower jaw of patient was supported with both hands to maintain airway patency,and the patient's mouth was kept closed throughout the process.After the muscle relaxant took effect(the patient's jaw muscle was relaxed),tracheal intubation was performed.At the time of patient entering the operating room,10 minutes of pre oxygenation,and immediately after successful intubation,rScO_(2)was measured on the surgical and non-surgical sides.At the same time,ultrasound was used to measure the cross-sectional area(CSA)of the gastric antrum and arterial blood gas analysis was performed.The partial pressure of end-tidal carbon dioxide(P_(ET)CO_(2))during the first mechanical ventilation after successful tracheal intubation,the incidence of hypoxemia[pulse oxygen saturation(SpO_(2))<0.95]during tracheal intubation,as well as prognostic indicators such as the length of intensive care unit(ICU)stay,total length of hospital stay,and Glasgow outcome scale(GOS)score at discharge were recorded.Results During the study period,a total of 70 TBI patients underwent emergency general anesthesia surgery,of which 2 patients died postoperatively,2 patients were unable to cooperate with closed mouth breathing,and 3 patients had poor ultrasound image acquisition in the gastric antrum,all of whom were excluded.A total of 63 patients were ultimately enrolled,including 32 in the conventional mask ventilation group and 31 in the THRIVE group.There were no statistically significant differences in gender,age,body mass index(BMI),American Society of Anesthesiologists(ASA)classification,Glasgow coma scale(GCS)score,optic nerve sheath diameter(ONSD),baseline vital signs,fasting situation,anesthesia time,surgical time,and intraoperative blood loss between the patients in the two groups,indicating comparability.When entering the operating room,there was no statistically significant difference in rScO_(2)on the surgical and non-surgical sides,and blood gas analysis indexes arterial partial pressure of oxygen(PaO_(2))and arterial partial pressure of carbon dioxide(PaCO_(2))between the patients in the two groups.When pre oxygenated for 10 minutes,both the surgical and non-surgical sides rScO_(2)levels in the THRIVE group were significantly higher than those in the conventional mask ventilation group(surgical side:0.709±0.036 vs.0.636±0.028,non-surgical side:0.791±0.016 vs.0.712±0.027,both P<0.01),and the PaO_(2)was significantly increased[mmHg(1 mmHg≈0.133 kPa):450.23±60.99 vs.264.88±49.33,P<0.01],PaCO_(2)was significantly reduced(mmHg:37.81±3.65 vs.43.59±3.76,P<0.01),and the advantage continues tilled immediately after successful intubation.There was no statistically significant difference in CSA at each time point of ultrasound examination between the two groups.Compared with the conventional mask ventilation group,the patients in the THRIVE group showed a significant decrease in P_(ET)CO_(2)during the first mechanical ventilation after successful tracheal intubation(mmHg:43.10±2.66 vs.49.22±3.31,P<0.01),and the incidence of hypoxemia during tracheal intubation was also significantly reduced[0%(0/31)vs.28.12%(9/32),P<0.01].In terms of prognostic indicators,there was no statistically significant difference in the length of ICU stay and total length of hospital stay between the patients in the conventional mask ventilation group and the THRIVE group[length of ICU stay(days):10(9,10)vs.10(9,11),total length of hospital stay(days):28.00(26.00,28.75)vs.28.00(27.00,29.00),both P>0.05].However,the proportion of patients in the THRIVE group with a good prognosis at discharge(GOS score>3)was significantly higher than that in the conventional mask ventilation group[35.5%(11/31)vs.12.5%(4/32),P<0.05].Conclusion THRIVE can significantly increase rScO_(2)during anesthesia induction in TBI emergency surgery patients and improve their neurological function prognosis.