洪甲庚 劉曉芳 馮宇峰 梁小玲 韓明杰 高海鷹 張慶洪 陳曲敏 王慶祥

Supreme喉罩用于全身麻醉患者的價(jià)值與地位

洪甲庚 劉曉芳 馮宇峰 梁小玲 韓明杰 高海鷹 張慶洪 陳曲敏 王慶祥

目的 評(píng)價(jià)Supreme喉罩(LMAS)在全身麻醉中的應(yīng)用價(jià)值與地位。方法 ASAⅠ～Ⅲ級(jí)的820例全身麻醉手術(shù)患者, 隨機(jī)分為Ⅰ組(n=410, LMAS全身麻醉)和Ⅱ組(n=410, 氣管插管全身麻醉)。記錄兩組患者HR、SBP、DBP的基礎(chǔ)值、插罩/管后即刻、拔罩/管前后等時(shí)點(diǎn)的變化；記錄兩組的手術(shù)時(shí)間、麻醉時(shí)間及患者蘇醒時(shí)間；記錄第一次插罩/管的成功率、術(shù)中氣道峰壓(Ppeak)、呼氣末二氧化碳分壓(PETCO2)、通氣效果以及不良反應(yīng)包括返流、誤吸、嗆咳、體動(dòng)及術(shù)后咽喉痛。結(jié)果 Ⅱ組在插管和拔管期間HR, SBP、DBP比基礎(chǔ)值增高, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05), Ⅰ組在插管和拔管期間HR, SBP、DBP比Ⅱ組明顯降低, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.01)；Ⅰ組蘇醒時(shí)間顯著短于Ⅱ組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)；兩組第一次插罩/管的成功率(分別是92.68%和90.73%)、Ppeak、PETCO2和通氣效果組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。兩組插罩/管時(shí)患者均無(wú)嗆咳、體動(dòng)、返流、誤吸, 差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)；拔罩/管期間, Ⅰ組嗆咳、體動(dòng)及術(shù)后咽喉痛的發(fā)生明顯少于Ⅱ組, 差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。結(jié)論 LMAS用于全身麻醉具有血流動(dòng)力學(xué)定穩(wěn)、心血管不良反應(yīng)少、操作簡(jiǎn)單、并發(fā)癥少、適用范圍廣等優(yōu)點(diǎn), 與氣管插管的通氣效果相同, 可安全有效地用于腹腔鏡手術(shù)、乳腺外科等手術(shù), 尤其適用于合并有高血壓、心電圖(ECG)異常的老年患者。

Supreme喉罩；全身麻醉；氣管插管

聲門(mén)上通氣裝置作為一種氣管插管選項(xiàng)越來(lái)越多地用于各種復(fù)雜的擇期手術(shù)［1］。Supreme喉罩(Laryngeal mask airway supreme, LMAS)是一種最新引進(jìn)的一次性聲門(mén)上通氣裝置, 具有Pro-Seal喉罩和插管型喉罩二者的共同特點(diǎn)［2］。2009年12月～2013年12月, 本院成功應(yīng)用LMAS全身麻醉患者9000余例。作者對(duì)LMAS全身麻醉和傳統(tǒng)的氣管插管全身麻醉用于腹腔鏡、乳腺外科等手術(shù)的效果進(jìn)行了前瞻性隨機(jī)對(duì)比研究, 現(xiàn)報(bào)告如下。

1 資料與方法

1.1 一般資料 選擇2013年1～12月ASAⅠ～Ⅲ級(jí)的820例患者, 年齡21～78歲, 體重47～89 kg, 全身麻醉下行婦科、肝膽外科、乳腺外科、骨科、腫瘤外科、普外科和燒傷科手術(shù), 按隨機(jī)數(shù)字表法隨機(jī)分為Ⅰ組(n=410, LMAS全身麻醉)和Ⅱ組(n=410, 氣管插管全身麻醉)；兩組腹腔鏡手術(shù)患者分別為308例和310例。所有患者術(shù)前常規(guī)檢查無(wú)嚴(yán)重心肺功能異常, 術(shù)前合并高血壓者275例, ECG輕度異常者161例,糖尿病92例, 貧血77例；患者存在口咽喉部疾患、困難氣道及張口度≤3 cm, 不在本研究范圍。

1.2 麻醉方法 本研究經(jīng)本院倫理委員會(huì)批準(zhǔn), 患者及家屬簽署麻醉知情同意書(shū)。患者入室后開(kāi)放靜脈, 靜脈滴注長(zhǎng)托寧0.01 mg/kg、地塞米松10 mg。術(shù)中常規(guī)監(jiān)測(cè)SBP、DBP、HR、SpO2、ECG和PETCO2。麻醉誘導(dǎo)：靜脈滴注咪達(dá)唑侖0.1 mg/kg、芬太尼4 μg/kg、順式阿曲庫(kù)銨0.1 mg/kg及依托咪酯0.2 mg/kg, 肌肉松弛后, Ⅰ組：根據(jù)患者體重插入對(duì)應(yīng)型號(hào)LMAS, 經(jīng)喉罩引流通道插入12 F吸痰管(4 mm×550 mm)引流胃內(nèi)容物；判定置入喉罩位置正確的標(biāo)準(zhǔn)［3］：置入喉罩及插入吸痰管順暢；PETCO2波形正常, Ppeak(氣道峰壓)<20 cm H2O(1 cm H2O=0.098 kPa)；IPPV胸廓起伏良好, 口咽部無(wú)異常氣流聲；Ⅱ組：選擇ID7.0氣管導(dǎo)管行氣管插管全身麻醉；固定罩/管后接麻醉機(jī)IPPV, 設(shè)定參數(shù)：TV 6～8 ml/kg, RR 8～12次/min。采用微量泵泵注丙泊酚2～4 mg/(kg·h)、瑞芬太尼2～4 μg/(kg·h)、間斷靜脈滴注順式阿曲庫(kù)銨維持麻醉與肌松。術(shù)畢送患者至PACU觀察, 待患者蘇醒后拔除罩/管。

1.3 觀察指標(biāo) ①監(jiān)測(cè)術(shù)中患者BP、HR、SpO2、ECG、PETCO2波形和Ppeak值。②記錄患者麻醉前(基礎(chǔ)值)、插罩/管后即刻、拔罩/管前后等時(shí)點(diǎn)的HR、SBP、DBP數(shù)值；麻醉時(shí)間、手術(shù)時(shí)間及蘇醒時(shí)間。③記錄第一次置入喉罩/氣管插管的成功率。④記錄腹腔鏡手術(shù)患者氣腹后胃脹氣情況。⑤記錄拔罩/氣管前后是否出現(xiàn)嗆咳、體動(dòng)、胃內(nèi)容物返流、誤吸等情況。⑥術(shù)后24 h內(nèi)隨訪患者有無(wú)咽喉部疼痛不適等情況。

1.4 統(tǒng)計(jì)學(xué)方法 采用SPSS16.0統(tǒng)計(jì)軟件。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差( x-±s)表示, 采用t檢驗(yàn)；計(jì)數(shù)資料采用χ2檢驗(yàn)。P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 兩組患者年齡、體重、麻醉時(shí)間、手術(shù)時(shí)間差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05), 而蘇醒時(shí)間差異有統(tǒng)計(jì)學(xué)意義(P＜0.05)。見(jiàn)表1。

2.2 兩組插罩/管及拔罩/管期間HR、BP比較 在插管/罩和拔管/罩期間, Ⅱ組HR、SBP、DBP比基礎(chǔ)值增高(P＜0.05)、比Ⅰ組明顯增高(P＜0.01)；Ⅰ組與基礎(chǔ)值比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)。見(jiàn)表2。

表1 兩組患者年齡、體重、麻醉、手術(shù)和蘇醒時(shí)間比較( x-±s)

表2 兩組患者HR、BP的變化比較( x-±s)

2.3 Ⅰ組、Ⅱ組第一次插罩/管成功率分別為92.68%(380例/410例)和90.73%(372例/410例), 差異無(wú)統(tǒng)計(jì)學(xué)意義(P＞0.05)；Ⅰ組28例氣囊充氣后IPPV時(shí)口咽部有異常氣流聲、PETCO2波形異?；騊peak>25 cm H2O等情況, 經(jīng)調(diào)整第二次重新置入LMAS后正常, 2例反復(fù)調(diào)整無(wú)效改氣管插管；Ⅱ組36例2次氣管插管成功, 2例3次以上插管失敗改用插管型喉罩氣管插管成功。

2.4 兩組Ppeak和PETCO2均在正常范圍內(nèi), 腹腔鏡手術(shù)的患者通氣效果、Ppeak和PETCO2隨CO2氣腹的影響一致(P＞0.05), 無(wú)一例發(fā)生胃脹氣。兩組插罩/管時(shí)患者均無(wú)嗆咳、體動(dòng)、返流、誤吸(P＞0.05)；在PACU拔罩/管期間, Ⅰ組嗆咳、體動(dòng)及術(shù)后24 h隨訪咽喉痛的發(fā)生明顯少于Ⅱ組(P＜0.05)。

3 討論

LMAS是一種依照解剖學(xué)彎曲設(shè)計(jì)的一次性的新型聲門(mén)上通氣裝置, 它有第二個(gè)管道用于插入胃管［4］。由于喉罩置入口咽腔未接觸患者聲帶和氣管, 對(duì)聲門(mén)氣管無(wú)刺激, 循環(huán)相對(duì)穩(wěn)定。本研究Ⅰ組置入喉罩后和拔除喉罩時(shí)HR、BP與基礎(chǔ)值比較變化不大, 蘇醒迅速, 故合并高血壓、ECG異常老年患者手術(shù)可首選喉罩全身麻醉, 避免氣管插管操作對(duì)循環(huán)的明顯影響, 降低心血管意外的風(fēng)險(xiǎn)。而氣管插管或拔管須經(jīng)過(guò)聲門(mén), 可刺激呼吸道, 對(duì)聲帶與氣管造成機(jī)械損傷,使機(jī)體心血管應(yīng)激反應(yīng)增強(qiáng), HR增快、BP升高, 心肌耗氧量增加, 心臟負(fù)荷加重, 增加了麻醉意外的風(fēng)險(xiǎn)。

腹腔鏡手術(shù)CO2氣腹時(shí)腹壓增加, 膈肌上移, 返流誤吸的風(fēng)險(xiǎn)加大； LMAS是一種帶有引流胃內(nèi)容物管腔的一次性聲門(mén)上通氣裝置, 在置入喉罩及麻醉期間可即刻評(píng)估喉罩的位置是否正確［5］, 經(jīng)引流管腔插入吸痰管吸引胃內(nèi)容物, 有效防范胃液返流誤吸, 保護(hù)氣道, 降低胃脹氣, 為腹腔鏡手術(shù)提供良好視野［3］；LMAS充氣囊經(jīng)過(guò)改進(jìn)能夠提供可靠的氣道和良好的氣道密封性［6］, 減少正壓通氣時(shí)喉罩氣囊周圍的漏氣, 降低胃脹氣發(fā)生率。Ⅰ組腹腔鏡手術(shù)患者通氣效果與Ⅱ組相同, 無(wú)一例發(fā)生返流誤吸及胃脹氣, 進(jìn)一步說(shuō)明LMAS可適合替代氣管插管用于擇期腹腔鏡手術(shù)的患者［7］, LMAS全身麻醉可滿足此類手術(shù)麻醉的要求。

LMAS經(jīng)過(guò)塑型處理, 更符合人體咽喉部解剖生理曲線,無(wú)論操作者是否有經(jīng)驗(yàn), 均可快速而容易地置入喉罩, 經(jīng)過(guò)幾個(gè)簡(jiǎn)單測(cè)試即能明確喉罩對(duì)位是否準(zhǔn)確；Ⅰ組第一次置入喉罩成功率達(dá)92.68%, 說(shuō)明操作簡(jiǎn)單, 容易掌握, 成功率高；Ⅰ組咽喉痛明顯少于Ⅱ組, 顯示LMAS容易插入, 咽喉部舒適度優(yōu)越, 氣道發(fā)病率低［8］。Ⅰ組28例經(jīng)調(diào)整第二次重新置入LMAS后正常, 2例女性患者反復(fù)調(diào)整喉罩不佳改為氣管插管, 雖然按體重選擇相應(yīng)型號(hào)的喉罩, 但發(fā)生喉罩型號(hào)偏大情形, 需重新置入喉罩完成麻醉通氣。女性患者如何選擇(按體重、身高及口咽腔大小)合適型號(hào)的LMAS還有待進(jìn)一步研究。

綜上所述, LMAS用于全身麻醉與氣管插管的通氣效果相同, 具有血流動(dòng)力學(xué)穩(wěn)定、操作簡(jiǎn)單、不良反應(yīng)少等優(yōu)點(diǎn),可完全替代氣管插管, 安全有效地用于婦科、乳腺外科手術(shù)和部分肝膽外科、骨科、腫瘤外科、普外科、燒傷科的手術(shù),尤其適用于合并有高血壓、ECG異常的老年患者。但用于頭頸手術(shù)、開(kāi)胸手術(shù)、俯臥位、側(cè)臥位、嚴(yán)重肥胖、手術(shù)時(shí)間冗長(zhǎng)的手術(shù)存在一定局限性及氣道管理的風(fēng)險(xiǎn)。

［1］ Barreira SR, Souza CM, Fabrizia F, et al.Prospective, randomized clinical trial of laryngeal mask airway Supreme(?) used in patients undergoing general anesthesia.Braz J Anesthesiol, 2013, 63(6):456-460.

［2］ Maitra S, Khanna P, Baidya DK.Comparison of laryngeal mask airway Supreme and laryngeal mask airway Proseal for controlled ventilation during general anesthesia in adult patients: A metaanalysis.Eur J Anaesthesiol, 2014, 31(5): 266-273.

［3］ 馮宇峰, 陳紹語(yǔ).LMA Supreme喉罩全麻在腹腔鏡膽囊手術(shù)中的可行性.中國(guó)實(shí)用醫(yī)藥, 2011, 6(7):12-13.

［4］ Hayashi K, Suzuki A, Kasai T, et al.Comparison of the Supreme laryngeal mask airway (SLMA), single use, with the reusable Proseal laryngeal mask airway (PLMA) in anesthetized adult Japanese patients.Masui, 2012, 61(10):1048-1052.

［5］ Sharma V, Verghese C, McKenna PJ.Prospective audlt on the use of the LMA-Supreme for airway management of adult patients undergoing elective orthopaedic surgery in prone position.Br J Anaesth, 2010, 105(2):228-232.

［6］ Cook TM, Gatward JJ, Handel J, et al.Evaluation of the LMA Supreme in 100 non-paralysed patients.Anaesthesia, 2009, 64(5):555-562.

［7］ Aydogmus MT, Turk HS, Oba S, et al.Can supreme? laryngeal mask airway be an alternative to endotracheal intubation in laparoscopic surgery? Braz J Anesthesiol, 2014, 64(1):66-70.

［8］ Timmermann A, Cremer S, Eich C, et al.Prospective clinical and fiberoptic evaluation of the Supreme laryngeal mask airway.Anesthesiology, 2009, 110(2):262-265.

The value and status of laryngeal mask airway Supreme used in patients undergoing general anesthesia

HONG Jia-geng, LIU Xiao-fang, FENG Yu-feng, et al.
Department of Anesthesiology, First Affiliated Hospital of Xiamen University, Xiamen 361003, China

Objective To evaluate the application value and status of laryngeal mask airway Supreme (LMAS) in patients undergoing general anesthesia.Methods A total of 820 cases with ASA grade I～Ⅲundergoing general anesthesia were randomly divided into two groups.GroupⅠ (n=410)

general anesthesia through LMAS and groupⅡ(n=410) received general anesthesia through endotracheal tube (ETT).The changes of HR、SBP、DBP were recorded as the basal values, during intubation and extubation.Operation time, anesthesia time and patients recovery time were observed; The success rate of the first attempt insertion, the peak inspiratory airway pressure (Ppeak), end-tidal carbon dioxide (PETCO2) and the effectiveness of ventilation were recorded during operation.The adverse reactions of anesthesia were recorded, such as countercurrent, bucking, aspiration, body movement, and postoperative pharyngalgia.Results HR, SBP, DBP of group Ⅱ were significantly higher than the basal value during intubation and extubation, and the difference was statistically significant (P<0.05).HR、SBP、DBP of group I were significantly lower than those in groupⅡ, and the difference had statistical significance (P<0.01).The patients recovery times were significantly shorter in group I than that in groupⅡ, and the difference had statistical significance (P<0.05).The success rates of the first attempt insertion were 92.68% (LMAS) and 90.73% (ETT), and the differences between Ppeak, PETCO2and the effectiveness of ventilation were not statistically significant in the two groups (P>0.05).No bucking, body movement, countercurrent and aspiration appeared in the two groups during intubation, and there was no significant difference (P>0.05).The patients’bucking, body movement, postoperative pharyngalgia in group I were significantly lower than those in groupⅡ, and the differences were statistically significant (P<0.05).Conclusion LMAS in general anesthesia has stability on the hemodynamic change, and can reduce the adverse effects of cardiovascular system, which can insert easy with fewer complications.It can be a substitute for tracheal intubation and safely and effectively used for laparoscope and breast surgery, especially for old patients with hypertension and electrocardiograph (ECG) abnormality．

Laryngeal mask airway Supreme; General anesthesia; General; Endotracheal tube

2014-05-27］

361003 廈門(mén)大學(xué)附屬第一醫(yī)院麻醉科(洪甲庚馮宇峰 韓明杰 高海鷹 張慶洪 陳曲敏 王慶祥)；廈門(mén)市婦幼保健院麻醉科(劉曉芳 梁小玲)

馮宇峰