第三代喉罩和气管插管用于腹腔镜胆囊手术的比较研究

来源： 2010-08-23 17:14:32

Comparison of ProSeal laryngeal mask airway and intratracheal tube for ventilation under General Anesthesia during Laparoscopic Cholecystectomy<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

史东平　封卫征　闻大翔　杭燕南

Dong-ping SHI,Wei-zheng FENG，Da-xiang WENG, Yan-nan HANG.

Department of Anesthesiology, Jiading Branch of Affiliated Renji Hospital, Shanghai Second Medical University,Shanghai 201800, China

Abstract

Objective：To compare ProSeal laryngeal mask airway with intratracheal tube for ventilation and investigate respiratory mechanics and hemodynamics during laparoscopic cholecystectomy.

Methods：80 ASA Ⅰ-Ⅱ adult patients undergoing elective Laparoscopic Cholecystectomy were randomly divided into two groups: ProSeal laryngeal mask airway group (PLMA, n=40) and intratracheal intubation group (TT n=40). In group PLMA, the patients were used the size 4 PLMA and in group TT the patients were used the size 7.5 tracheal tube. Anesthesia was induced with midazolam 0.05mg/kg, fentanyl 2-5ug/kg, propofol 1-1.5mg/kg and vecuronium 0.1-0.2mg/kg, maintained with inhalation of low concentration of isoflurane and intravenous fentanyl and vecuronium. ECG, SpO₂ , SBP, DBP , HR and PTEC0₂ were routinely monitored by PhillipsA₃ monitor. PIP, R, CL were measured by Bicore CP-100 respiratory monitor. Measurements were done at 5　distinct phases: before induction of anesthesia，1 min after insertion of PLMA or TT, 10 min after pneumoperitoneum, 5 min after the peritoneal deflation and extubation．

Results：Two groups were inserted successfully and gas leak did not occur in all patients. The time required for insertion of PLMA and TT were 24.2 sec and 22.7 sec average. In ProSeal laryngeal mask airway group the first time success rate was 87.5%, gastric tube was placed successfully, the airway seal pressure was 24.5±6.81 cmH₂O, hemodynamic had no change significantly during PLMA insertion or extubation. In intratacheal intubation group the first time success rate was 90% , hemodynamic had changed significantly during TT insertion or extubation. During pneumoperitoneum PETCO₂、PIP、R increased and CL decreased significantly　in two groups.

Conclusion：It is safety and convenient to use Proseal laryngeal mask airway with the result of effective ventilation, stable anesthesia and Less complication . So ProSeal laryngeal mask airway ventilation is suitable for laparoscopic cholecystectomy.

第一、二代喉罩没有食管引流管，使用中可能发生误吸。第三代喉罩(Proseal laryngeal maskairway, 简称PLMA)可经食管引流管放置胃管，在外型设计上更适合于咽部解剖，使通气效果更好^[1-3]。本文报告在腹腔镜胆囊切除手术中PLMA的临床应用,观察气腹病人血液动力学及呼吸力学变化，为临床安全有效的使用提供参考。
资料和方法<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

选择腹腔镜胆囊切除手术病人80例，年龄32-56岁,体重45-80kg, ASAⅠ～Ⅱ级, 无张口困难和特殊咽喉部病史。随机分为两组，第三代喉罩组（PLMA）40例，气管插管（TT）组40例。PLMA组应用TOKIBO第三代4号喉罩，TT组应用7.5号气管导管。
　　麻醉方法病人入室后常规开放静脉。PhillipsA3监护仪连续监测血压、心率和氧饱和度；BicoreCP100多功能呼吸监护仪连续监测呼吸参数。面罩给氧三分钟，麻醉诱导：咪唑安定0.05mg/kg、丙泊酚 1-1.5mg/kg、芬太尼2-5ug/kg及维库嗅铵0.1-0.2mg/kg，麻醉维持:吸入0.5%-1%异氟醚, 维库嗅铵0.04mg/kg和芬太尼0.05-0.1mg间断静注,持续输注丙泊酚60-120mg/h。插入喉罩和气管导管后接麻醉机（DRAGER JULIANS），常规行机械通气。
　　插入方法 PLMA组，所有患者均应用TOKIBO 4号PLMA，专用排气装置排空通气罩内气体，表面涂抹液体润滑剂，首先直接插入，困难者借助于引导器或喉镜（喉镜撑开口裂，喉镜片不触及舌根和会咽）。所有操作均由熟练的麻醉医生实施。插入后人工通气，观察：胸廓起伏良好，PETCO2波形显示正常，两肺呼吸音均匀，认为试插成功;若3次不成功,则改气管插管；插入喉罩后，在不予PLMA充气的情况下，人工挤压贮气囊，观察喉罩的漏气情况：不漏气，向通气罩内充气5-6 ml；如漏气则向通气罩内充气至不漏气后，继续充气5-6 ml，记录充气量、漏气部位以及操作时间（结束面罩给氧到PLMA充气后人工挤压贮气囊胸廓起伏良好的时间）。 TT组按常规方法操作。
　　放置胃管 PLMA组所有病人均使用１４号胃管；首先将胃管表面涂抹润滑剂，再向PLMA的食管引流管中注入液体润滑剂，使其充分润滑。放置胃管时采取两种方式：1首先置入PLMA，再沿食管引流管放入胃管；2 预先将胃管放入食管引流管，然后放置PLMA时连同胃管一起置入，再将胃管沿食管引流管插入胃内。胃管位置判断：听诊器置于剑突下3－5cm，沿胃管注入10ml气体，听诊有气过水声，并能抽出胃液，则胃管放置成功，同时进一步确定PLMA位置正确。病人清醒后胃管随喉罩一同拔除。TT组不放置胃管。

调节通气确定位置准确后，连接麻醉机进行间歇正压通气，设置潮气量8-10ml/kg,呼吸频率12次/min，I:E为1:1.5，气腹充气压力15-18 mmHg。气腹后，根据情况首先调整RR, 其次调整Vt，使PETCO₂维持在32-38mmHg之间。
　　呼吸道密封压测定先停止机械通气，通气环路内的呼气活瓣关闭，将新鲜气流量调至5L/ min，气道压力开始上升，当气道压力达到最高而形成平台时，此时的平台气道压力即为呼吸道密封压。记录呼吸道密封压数值。若呼吸道密封压超过40cmH₂O，或SPO₂≤95%，或HR≤60次/min，则停止呼吸道密封压测定。
　　监测指标记录诱导前，诱导后，插入喉罩或气管导管后1分钟，气腹后1分钟,清醒后拔除喉罩或气管导管后1分钟的SBP，DBP，HR，SPO₂值；以及记录气腹前，气腹中(充气后10分钟)，放气腹后5分钟的ＰETCO₂，气道峰压（PIP），吸气潮气量（VT_I），呼气潮气量（VT_E），气道阻力（R），胸肺顺应性（CL）。
　　拔除喉罩或气管导管手术结束，病人Ramsay评分2分，潮气量300～400ml,频率12～18次/min;脱机后吸氧条件下，SPO₂保持98%～100%，拔除PLMA，送PACU。
　　统计学处理计量资料以均数±标准差(<?xml:namespace prefix = v ns = "urn:schemas-microsoft-com:vml" />±s)表示，采用SPSS11.5统计软件进行处理。组间比较采用单因素方差分析，P<0.05为差异有统计学意义。

结　果<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

两组病人平均年龄、身高、体重、手术时间无显著差异。PLMA插入一次成功率87.5%(34例)，二次成功率10%(4例) ，三次成功率2.5%(2例)； TT组一次成功率90%（36例），二次成功率10%（4例），两组均无失败病例。操作时间：PLMA组最短7.1s，最长41.3s，平均24.2s；TT组最短6.1s，最长39.3s，平均22.7s。 PLMA充气量平均15.17±8.59ml，最大充气量30 ml；呼吸道密封压：<20cmH₂O, 2例；>20cmH₂O，38例；其中5例>40cmH₂O，平均24.5±6.81cmH₂O；在测量呼吸道密封压的过程中，无一例病人出现SPO₂ 降低和HR减慢；所有病人均成功放置胃管，平均放置长度51±4.70cm，手术结束时3例病人胃管内有引流液。术中无胃胀气，无返流、误吸的发生。；TT 组常规套囊充气，术中16例病人胃胀气。

插入和拔除PLMA和气管导管时血流动力学变化见表1，TT组血液动力学变化较PLMA组明显,有显著性差异( P<0.05)；气腹后较气腹前相比，血压明显升高，两组相比无显著差异。呼吸力：学变化详见表2；气腹以后变化： ① ＰETCO₂、PIP、R明显升高，有显著性差异（P<0.05）；PLMA组分别平均增加7.15mmHg，6.70cmH₂O和2.91cmH₂O/L/s，TT组分别平均增加7.87mmHg，6.91 cmH₂O和2.30cmH₂O/L/s；两组间比较无显著性差异；② CL明显下降，有显著性差异（P<0.01），两组分别下降16.60 ml/cm/H₂O和17.55 ml/cm/H₂O。气腹10分钟后，PLMA组有3例病人,TT组有1例病人需调整呼吸频率至14次/分，使ＰETCO₂维持在设定范围内。 PLMA组和TT组术后各有1例病人述咽喉部不适，6小时后均消失。

参考文献<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

1.Brain AI, Verghese C Strube PJ. The LMA ‘Proseal’- a laryngeal mask with an oesophageal vent. Br J Anaesth 2000; 84: 650-654.

2.Brimacombe J,Keller C.The ProSeal laryngeal mask airway: a randomized,crossover study with the standard laryngeal mask airway in paralyzed, anesthetized patients. Anaesthesiology 2000; 93: 104-109.

3.Brimacombe J, Keler C. Stability of the LMA ProSeal and standard laryngeal mask airway in different head and neck positions: a randomized crossover study. Eur J Anaesthesiol 2003; 20 : 65-69.

4.杭燕南, 庄心良, 蒋豪，主编. 当代麻醉学. 第一版. 上海: 上海科学技术出版社,2002. 648-656.

5.Verghese C, Brimacombe JR.Survey of laryngeal mask airway usage in 11910 patients: safety and efficacy for conventional and nonconventional usage.Anaesth Anaglg 1996; 82: 129-133.

6.宛泉龙卢平徐春明 2683例喉罩通气在LC中的应用.中华现代临床医药杂志.2004,5:7-8.

7.孙海燕，薛富善译. 食管引流型喉罩及其临床应用.<< 国外医学>> 麻醉学与复苏分册, 2004,25: 102—104.

8.Evans NR, Gardner SV, James mf,et al. The ProSeal laryngeal mask: results of a descriptive trail with experience of 300 cases. Br J Anaesth, 2002; 88:534-539.

9.孙海燕，薛富善. 食管引流型喉罩在全身麻醉中的应用和临床观察. 临床与实验研究,2003;10:419-422.

10.Brimacombe JR,Berry A. The incidence of aspiration associated with the laryngeal mask airway: a meta-analysis of published literature. J Clin Anaesth 1995; 7: 297-305.

11.David A Protection from aspiration with the LMA-ProSeal^TMafter vomiting: a case report. Can J Anesth 2003;50: 78-80.

12.王放呜译. Wood MLB.放置喉罩通气道的血流动力学反应. 国外医学麻醉学与复苏分册，1995，16：124-125.

13.Harris MN, Plantevin OM,Crowther A. Cardiac arrhythmias during anaesthesia for laparoscopy. Br J Anaesth,1984,56: 1213-1217.

14.Mattioli G, Montobbio G, Pini Prato A, et al. Anesthesiologic aspects of laparoscopic fundoplication for gastroesophageal reflux in children with chronic respiratory and gastroenterological symptoms. Surg Endosc,2003,17: 559-566.

15.王永光，张利东，徐建国，等.全麻下腹腔镜手术对循环和呼吸功能的影响.中国腹腔镜杂志,2005,11:15-18.16.张锦，李莉，邵娟.腹腔镜胆囊切除手术气腹对呼吸力学的影响及其参数的调整. 中国腹腔镜杂志,2005,11:22-24.

17.Kraut JK, Anderson JT, Safw AA. In patient of cardiac performance by laparoscopy in patient receiving positive endexpiratory pressure[J]. Arch Surg,1999,134: 76-80.

18.Obeid FO. Increases in intra-abdominal pressure affect pulmonary compliance[J]. Arch Surg,1995,130:544-547.

19.Enzwuerker A, Rothhaas T, et al. The ProSeal laryngeal mask airway and the laryngeal tube suction for ventilation in gynaecological patients undergoing laparoscopic surgery. Eur J Anaesthesiology 2005;22: 117-122.

上一篇 :核转录因子κB研究进展

下一篇 : 脑缺血再灌注损伤机制及治疗进展

分享到

相关信息