不同肌松程度对腹腔镜胃切除术患者术后早期恢复的影响_李烨华.pdf

临床研究不同肌松程度对腹腔镜胃切除术患者术后早期恢复的影响李烨华曹晖周兴根万智钢DOI:1012089/jca202303010基金项目:苏州市“科技兴卫”青年科技项目(kjxw2018073);苏州市科技计划项目(SYS2019012)作者单位:215200苏州大学附属苏州九院麻醉科通信作者:万智钢，Email:15962558877 163com【摘要】目的评估深度肌松和中度肌松对腹腔镜胃切除术患者术后早期恢复的影响。方法选择 2021年 1 月至 2022 年 1 月行腹腔镜胃切除术的患者 79 例，男 53 例，女 26 例，年龄 4564 岁，BMI 1828 kg/m2，ASA 或级。患者随机分为两组:深度肌松组(D 组)和中度肌松组(M 组)，每组 40 例。D 组术中静脉泵注罗库溴铵 0.50.6 mgkg1h1，维持强直刺激后单次刺激肌颤搐计数(PTC)在 12 次之间。M 组术中静脉泵注罗库溴铵 0.20.3 mgkg1h1，维持四个成串刺激(TOF)保持出现 12 个肌颤搐。记录术中丙泊酚、瑞芬太尼用量，拔管时间、PACU 停留时间、首次排气时间、首次排便时间、术后住院时间。于入室即刻、术后 24、48 h 抽取外周静脉血，检测二胺氧化酶(DAO)和 D-乳酸。记录术后恶心呕吐(PONV)、苏醒期躁动、苏醒延迟、术后寒战发生情况。使用手术状态评分评价术者对肌松效果的满意度。结果两组术中丙泊酚、瑞芬太尼用量差异无统计学意义。与 M 组比较，D 组拔管时间明显延长(P0.05)，首次排气时间明显缩短(P0.05)，术后 24、48 h 的 DAO 和 D-乳酸明显降低(P0.05)。两组 PACU 停留时间、首次排便时间、术后住院时间，PONV、苏醒期躁动、苏醒延迟、术后寒战发生率差异无统计学意义。D 组手术状态评分明显高于 M组(P0.05)。结论与中度肌松比较，深度肌松能够保护肠黏膜屏障，促进腹腔镜胃切除术患者术后肠道功能的恢复。【关键词】神经肌肉阻滞;腹腔镜胃切除术;肠黏膜屏障;肠道功能;罗库溴铵Effect of different muscle relaxations on early postoperative recovery in patients undergoing laparo-scopic gastrectomyLI Yehua，CAO Hui，ZHOU Xinggen，WAN Zhigang Department of Anesthesiolo-gy，Suzhou Ninth Hospital Affiliated to Soochow University，Suzhou 215200，ChinaCorresponding author:WAN Zhigang，Email:15962558877 163com【Abstract】ObjectiveTo evaluate the effect of deep or moderate muscle relaxation on early postop-erative recovery in patients undergoing laparoscopic gastrectomy MethodsSeventy-nine patients，53 malesand 26 females，aged 4564 years，BMI 1828 kg/m2，ASA physical status or，who were scheduledto undergo laparoscopic gastrectomy from January 2021 to January 2022 were selected Patients were ran-domly assigned to deep muscle relaxation group(group D)or moderate muscle relaxation group(group M)Each group had 40 patients Patients in group D were given rocuronium 0.50.6 mgkg1h1intrave-nously during operation，and post-tetanic count(PTC)was maintained between 1 and 2 times after stimula-tion Patients in group M were given rocuronium 0.20.3 mgkg1h1intravenously during operation，and 1 2 muscle twitching was maintained by maintaining four train of four stimulation(TOF)Intraoperative propofol and remifentanil dosage，extubation time，PACU stay time，first exhaust time，firstdefecation time，and postoperative hospital stay were recorded Venous blood was extracted immediately afterentry operating room，24 hours after operation and 48 hours after operation to detect diamine oxidase(DAO)and D-lactic acid Postoperative nausea and vomiting(PONV)，emergence agitation，delayed re-covery and postoperative shivering were recorded Surgical condition score was used to evaluate the satisfac-tion with muscle relaxation esultsThere was no statistical significance in the intraoperative dosage ofpropofol and remifentanil between the two groups First exhaust time in group M was significantly longer thanthat in group D(P 0.05)Extubation time in group M was significantly shorter than that in group D(P 0.05)DAO and D-lactate in group M were significantly higher than those in group D 24 and 48 hours afteroperation，with a statistical significance(P 0.05)There were no significant differences in duration ofPACU stay，first defecation time，hospital stays after surgery，the incidence of PONV，emergence agitation，572临床麻醉学杂志 2023 年 3 月第 39 卷第 3 期J Clin Anesthesiol，March 2023，Vol39，No3delayed recovery，and postoperative shivering between the two groups The surgical condition score of groupD was significantly higher than that of group M(P 0.05)ConclusionCompared with moderate musclerelaxation，deep muscle relaxation can protect the intestinal mucosal barrier and promote the recovery of in-testinal function after laparoscopic gastrectomy【Key words】Neuromuscular block;Laparoscopic gastrectomy;Intestinal mucosal barrier;Intestinalfunction;ocuronium肠黏膜屏障由机械屏障、化学屏障、微生物屏障和免疫屏障组成，对肠道的正常功能至关重要1。腹腔镜手术中持续气腹会减少胃肠道血流灌注，对肠黏膜屏障造成不良影响，进而延缓术后肠道功能恢复2。神经肌肉阻滞是保证腹腔镜手术实施的重要环节，深度肌松能够改善腹腔镜手术的手术条件，但不同肌松对腹腔镜手术患者术后肠道功能的影响仍不清楚3。因此，本研究旨在评估深度或中度肌松对腹腔镜胃切除术患者术后早期恢复的影响，为临床提供参考。资料与方法一般资料本研究经医院伦理委员会审核(KY2021-092-01)，患者或家属签署知情同意书。选择 2021 年 1 月至 2022 年 1 月行腹腔镜胃切除术患者，性别不限，年龄 4564 岁，BMI 1828 kg/m2，ASA 或级。排除标准:炎症性肠病，严重心肺功能异常，严重肝肾功能不全，重症肌无力等神经肌肉疾病，对罗库溴铵过敏。采用随机数字表将患者分为两组:深度肌松组(D 组)和中度肌松组(M 组)。麻醉方法患者术前禁食禁饮 8 h。患者入室后建立一侧上肢静脉通路。常规监测 H、BP、SpO2、ECG。连接肌松监测仪监测肌松状态。麻醉诱导:依次静脉注射咪达唑仑 0.1 mg/kg、丙泊酚1.52.5 mg/kg、罗库溴铵 0.6 mg/kg，缓慢注射舒芬太尼 0.61.0 g/kg。待睫毛反射消失后行经口明视气管内插管，确认导管位置及深度后转为机械通气。呼吸机参数:VT6 8 ml/kg、12 18次/分、I E 1 1.5、呼气末正压(positive end-expir-atory pressure，PEEP)5 cmH2O，维持 PETCO23545mmHg。麻 醉 维 持:静 脉 泵 注 丙 泊 酚 4 12mgkg1h1、瑞芬太尼 0.052 gkg1min1。D 组术中静脉泵注罗库溴铵 0.50.6 mg kg1 h1，维持强直刺激后单次刺激肌颤搐计数(post-tetaniccount，PTC)12 次4，维持 BIS 4060。M 组术中静脉泵注罗库溴铵 0.20.3 mgkg1h1，维持四个成串刺激(train of four stimulation，TOF)保持出现12 个肌颤搐4，维持 BIS 在 4060。维持术中气腹压力1012 mmHg。若术中 SBP 升高幅度大于基础值的 20%则静脉注射乌拉地尔 12.525.0 mg;若术中 SBP 降低幅度大于基础值的 20%则静脉注射麻黄碱 6 mg;若术中 H100 次/分时，给予艾司洛尔 0.5 mg/kg;若术中 H50 次/分时，给予阿托品0.5 mg。手术结束后待 TOF 维持 2 个肌颤搐时静脉注射舒更葡糖钠 2 mg/kg。手术结束拔除气管导管后 送 麻 醉 后 复 苏 室(postanesthesia care unit，PACU)，患者均于手术后 24 h 下床活动。所有患者均由同组外科医师完成手术，患者和外科医师均不清楚分组情况。为保证患者术中安全性，分组和用药情况并未对麻醉科医师设盲。观察指标记录