劉婷潔 沈 霞 李文獻(xiàn)

(復(fù)旦大學(xué)附屬眼耳鼻喉科醫(yī)院麻醉科 上海 200031)

地氟醚用于支撐顯微喉鏡下聲帶手術(shù)對(duì)蘇醒的影響

劉婷潔 沈 霞△李文獻(xiàn)

(復(fù)旦大學(xué)附屬眼耳鼻喉科醫(yī)院麻醉科 上海 200031)

目的 觀察地氟醚用于支撐顯微喉鏡下聲帶手術(shù)對(duì)復(fù)蘇的影響。方法 40例ASA Ⅰ～Ⅱ級(jí)擇期行支撐顯微喉鏡下聲帶手術(shù)的成年患者隨機(jī)分為地氟醚組(D組,n=20)和七氟醚組(S組,n=20) 。記錄手術(shù)結(jié)束至自主呼吸恢復(fù)時(shí)間、拔除氣管導(dǎo)管時(shí)間和麻醉后恢復(fù)室(postanesthesia care unit,PACU)逗留時(shí)間;記錄兩組患者拔管時(shí)嗆咳反應(yīng)和拔管后咳嗽事件;記錄圍手術(shù)期各時(shí)間點(diǎn)的心率和血壓變化:麻醉前(T0)、置入硬喉鏡(Tlary)、呼氣末吸入麻醉藥達(dá)1.3 MAC時(shí)(T1.3mac)、呼氣末吸入麻醉藥達(dá)1.3 MAC后1 min ( T1.3mac+1)、送入PACU (Tpacu)、拔管即刻(Textu)、拔出氣管導(dǎo)管后1 min (Textu+1)、5 min (Textu+5) 和出PACU (Tdis)。結(jié)果 兩組患者自主呼吸恢復(fù)時(shí)間差異無統(tǒng)計(jì)學(xué)意義; 地氟醚組拔管時(shí)間比七氟醚組早4.6 min (P<0.05); 地氟醚組PACU逗留時(shí)間比七氟醚組晚5 min (P<0.05);地氟醚組拔管時(shí)嗆咳發(fā)生率為100%,高于七氟醚組的55% (P<0.05),拔管后兩組間咳嗽事件發(fā)生率的差異無統(tǒng)計(jì)學(xué)意義;兩組間圍術(shù)期血壓和心率變化差異無統(tǒng)計(jì)學(xué)意義。結(jié)論 地氟醚用于顯微喉鏡下聲帶手術(shù)利于患者術(shù)后快速蘇醒,地氟醚組患者拔管時(shí)嗆咳的發(fā)生率高于七氟醚組,但持續(xù)時(shí)間短暫。

顯微喉鏡手術(shù); 聲帶; 地氟醚; 麻醉蘇醒; 并發(fā)癥

支撐顯微喉鏡下聲帶手術(shù)的特點(diǎn)是手術(shù)時(shí)間短,但由于手術(shù)刺激大需要在全身麻醉下實(shí)施手術(shù)。全身麻醉必須為這類手術(shù)提供完善的手術(shù)條件、保障患者術(shù)后的快速蘇醒、同時(shí)避免麻醉相關(guān)的不良反應(yīng)。麻醉實(shí)施中多采用短效的藥物以確保患者術(shù)后快速蘇醒和手術(shù)的快速周轉(zhuǎn)[1]。七氟醚是目前支撐顯微喉鏡下全身麻醉維持中被普遍使用的吸入麻醉藥。地氟醚較七氟醚具有更低的血?dú)夥峙湎禂?shù)(七氟醚為0.65,地氟醚為0.42)。前瞻性研究證實(shí)手術(shù)時(shí)間較長時(shí)術(shù)中使用地氟醚的患者術(shù)后蘇醒和早期恢復(fù)都優(yōu)于七氟醚[2-3]。但是對(duì)于短時(shí)的支撐顯微喉鏡下聲帶手術(shù),地氟醚較七氟醚是否也具有快速蘇醒優(yōu)勢(shì)目前并不明了。本研究選擇手術(shù)時(shí)間短于30 min的支撐顯微喉鏡下聲帶手術(shù),主要觀察地氟醚和七氟醚麻醉維持對(duì)術(shù)后患者蘇醒時(shí)間的影響,其次觀察蘇醒期氣道不良事件和圍術(shù)期血流動(dòng)力學(xué)變化。

資 料 和 方 法

病例選擇 采用隨機(jī)、雙盲、平行、對(duì)照的臨床研究方法。選擇美國麻醉醫(yī)師協(xié)會(huì)(American society of Anesthesiologist,ASA) Ⅰ～Ⅱ級(jí),40例因聲帶手術(shù)(聲帶小結(jié),聲帶囊腫,聲帶白斑)擇期行全麻下顯微喉鏡手術(shù)的患者,年齡18～60歲,體質(zhì)指數(shù)18～30 kg/m2,無高血壓病史,無明顯心肺疾病,無肝腎功能損害,術(shù)前未用任何影響心臟及血管的藥物,按隨機(jī)數(shù)字表法將患者分為地氟醚組(D組,n=20)和七氟醚組 (S 組,n=20)。

麻醉方法 患者術(shù)前6 h禁食,2 h禁飲。入手術(shù)室后前臂留置20G留置針開放靜脈,持續(xù)輸注乳酸鈉8～10 mL/kg。監(jiān)測無創(chuàng)血壓(間隔時(shí)間2 min),心電圖、脈搏血氧飽和度。麻醉誘導(dǎo):患者靜脈注射異丙酚2.0 mg/kg、舒芬太尼0.1 μg/kg、瑞芬太尼1 μg/kg和司可林1.5 mg/kg,1 min后進(jìn)行氣管插管。確認(rèn)氣管插管完成后行機(jī)械通氣,潮氣量6～8 mL/kg,呼吸頻率13～15次/min,吸呼比1∶2,新鮮氣流2 L/min,吸入氧濃度40%,維持呼氣末CO2(end tidal CO2,ETCO2)35～40 mmHg(1 mmHg=0.133 kPa,下同),患者根據(jù)分組情況吸入地氟醚或七氟醚,使呼氣末濃度維持在1.3個(gè)最低肺泡氣有效濃度 (minimum alveolar concentration,MAC)。心率低于50次/min 給予阿托品,并根據(jù)血壓和心率予硝酸甘油和(或)艾司洛爾控制血壓。并給予地塞米松0.01 mg/kg和格拉司瓊0.06 mg/kg預(yù)防術(shù)后惡心、嘔吐。手術(shù)結(jié)束后由手術(shù)醫(yī)師用喉麻管在聲門下噴射利多卡因20 mg,停止吸入地氟醚或七氟醚,轉(zhuǎn)入麻醉后恢復(fù)室(postanesthesia care unit,PACU),純氧洗脫吸入麻醉藥,待患者蘇醒。拔管指征:呼之睜眼,自主呼吸恢復(fù),呼吸頻率10～20次/min,ETCO2≤45 mmHg,呼吸空氣SpO2≥95%,潮氣量>8 mL/kg?；颊咿D(zhuǎn)出PACU的指征為改良Aldrete評(píng)分≥9分。

觀察指標(biāo) (1)自主呼吸恢復(fù)、拔管時(shí)間及麻醉后恢復(fù)室逗留時(shí)間。(2) 拔管時(shí)嗆咳評(píng)分:0分無嗆咳;1分嗆咳次數(shù)小于3次;2分嗆咳次數(shù)3～5次;3分嗆咳次數(shù)大于5次。(3)拔管后嗆咳事件:0分無咳嗽事件;1分咳嗽事件小于3次;2分咳嗽事件3～5次; 3分咳嗽事件大于5次。(4)圍術(shù)期血壓和心率變化:時(shí)間點(diǎn)包括麻醉誘導(dǎo)前(T0)、支撐喉鏡置入(Tlary)、呼氣末吸入麻醉藥達(dá)1.3 MAC時(shí)(T1.3mac)、呼氣末吸入麻醉藥達(dá)1.3 MAC后1 min (T1.3mac+1)、送入術(shù)后恢復(fù)室(Tpacu)、拔管即刻(Textu)、拔出氣管導(dǎo)管后1 min (Textu+1)、5min(Textu+5)和出術(shù)后恢復(fù)室(Tdis)。(5)其他指標(biāo):麻醉和手術(shù)時(shí)間及蘇醒期不良反應(yīng),如喉痙攣、去氧合的發(fā)生情況。

結(jié) 果

患者一般情況 兩組患者性別、年齡、體重指數(shù)、麻醉和手術(shù)時(shí)間差異無統(tǒng)計(jì)學(xué)意義(表1)。

表1 地氟醚組和七氟醚組患者的一般情況Tab1 Demorgraphic data of desflurane group and sevoflurane group

NS:There are not any significantly different between the two groups.

患者復(fù)蘇情況 地氟醚組患者術(shù)后自主呼吸恢復(fù)時(shí)間早于七氟醚組,但差異無統(tǒng)計(jì)學(xué)意義(14.4 minvs.17.2 min,P=0.0908)。地氟醚組患者拔管時(shí)間短于七氟醚組(14.5 minvs.19.1 min,P=0.002 5),地氟醚組患者離開PACU的時(shí)間也短于七氟醚組(22.3 minvs.27.3 min,P=0.041 7)。拔管時(shí)地氟醚組所有患者均出現(xiàn)不同程度的嗆咳:1分9人,2分4人,3分7人;七氟醚組有9人拔管時(shí)無嗆咳:1分2人,2分6人,3分3人,兩組間差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。拔管后兩組患者發(fā)生咳嗽事件差異無統(tǒng)計(jì)學(xué)意義(表2)。

表2 地氟醚組和七氟醚組患者的蘇醒期情況Tab 2 Emergency profiles in desflurane group and sevoflurane group

圍術(shù)期血流動(dòng)力學(xué)變化 Two-way ANOVA重復(fù)測量顯示血壓和心率變化在分組和時(shí)間雙因素交互作用下差異無統(tǒng)計(jì)學(xué)意義,post hoc Befferoni 分析顯示兩組患者在各時(shí)間點(diǎn)血壓和心率的差異無統(tǒng)計(jì)學(xué)意義(圖1)。

其他 兩組患者均沒有出現(xiàn)嚴(yán)重的呼吸道不良事件和去氧合等情況。

T0:Before anesthesia induction;Tlary:On suspension laryngoscope instrument;T1.3mac:Gas concentration reached 1.3 MAC;T1.3mac+1:1 min after 1.3 MAC;Tpacu:On arrival at postanesthesia care unit;Textu:On extubation;Textu+1:1 min after extubation;Textu+5:5 min after extubation;Tdis:On discharge from postanethesia care unit.No significant difference was found between the two groups.

討 論

本研究發(fā)現(xiàn)支撐顯微喉鏡下聲帶手術(shù)中,地氟醚麻醉維持較七氟醚麻醉維持可以提供術(shù)后快速蘇醒并縮短患者離開PACU的時(shí)間。雖然地氟醚組患者在氣管拔管時(shí)嗆咳的發(fā)生率高于七氟醚組患者,但是氣管導(dǎo)管拔除后兩組患者咳嗽事件發(fā)生率的差異無統(tǒng)計(jì)學(xué)意義。其次,兩組患者圍術(shù)期各時(shí)間點(diǎn)血流動(dòng)力學(xué)變化差異無統(tǒng)計(jì)學(xué)意義。

地氟醚的血?dú)夥峙湎禂?shù)低于七氟醚,提示地氟醚較七氟醚更快被洗脫,從而提供術(shù)后快速蘇醒。研究證實(shí)地氟醚較七氟醚在麻醉后復(fù)蘇和早期康復(fù)方面具有顯著的優(yōu)勢(shì)[3-4]。尤其應(yīng)用于耗時(shí)較長的手術(shù),地氟醚成為保障術(shù)后患者快速蘇醒的不二之選。但是對(duì)于短時(shí)間手術(shù),地氟醚是否在術(shù)后復(fù)蘇方面仍然較七氟醚具有優(yōu)勢(shì)存在爭議。有研究支持地氟醚用于門診短時(shí)手術(shù)較七氟醚利于快速蘇醒和早期康復(fù)[5],但是有一項(xiàng)回顧性研究卻認(rèn)為對(duì)于手術(shù)時(shí)間約40 min的手術(shù),地氟醚并不能為患者提供快速蘇醒[6]。在本前瞻性研究中,我們發(fā)現(xiàn)對(duì)于手術(shù)時(shí)間短于30 min的支撐顯微喉鏡下聲帶手術(shù),地氟醚在術(shù)后拔管時(shí)間和離開PACU的時(shí)間仍短于七氟醚組。由于納入本研究的兩組患者一般情況如ASA 分級(jí)、身高、體重等無顯著差異;除吸入麻醉藥使用不同外,患者在麻醉誘導(dǎo)和維持中所接受的其他處理均相同,所以我們認(rèn)為,地氟醚組患者術(shù)后拔管和離開PACU的時(shí)間短于七氟醚組是因?yàn)榈胤丫哂懈脱獨(dú)夥峙湎禂?shù)。

地氟醚具有氣道刺激作用,所以不推薦用于麻醉誘導(dǎo)。有研究發(fā)現(xiàn)使用地氟醚的氣管插管患者會(huì)在蘇醒期出現(xiàn)顯著的咳嗽等氣道不良反應(yīng)[7]。雖然本研究在聲門下進(jìn)行了2%利多卡因局部氣道黏膜表面麻醉,但是患者拔管時(shí)仍出現(xiàn)咳嗽反應(yīng),地氟醚組所有患者均出現(xiàn)不同程度的嗆咳,但是兩組患者在拔管后咳嗽事件的發(fā)生率差異無統(tǒng)計(jì)學(xué)意義。說明地氟醚對(duì)氣道的刺激作用比較短暫,可能與其被快速從體內(nèi)洗脫有關(guān)。

既往研究提示,迅速提升地氟醚吸入濃度可能導(dǎo)致循環(huán)系統(tǒng)激動(dòng),主要表現(xiàn)為在快速提升地氟醚濃度后1 min心率和血壓顯著上升,持續(xù)時(shí)間約4 min[8]。本研究中,并未觀察到地氟醚快速提升相關(guān)的心率和血壓上升,可能的原因是誘導(dǎo)時(shí)所使用的瑞芬太尼和丙泊酚等藥物具有交感抑制的作用,提升地氟醚濃度時(shí)瑞芬太尼和丙泊酚的交感抑制的作用尚存在。

本研究的不足之處在于所納入的樣本量較少,所以雖然地氟醚組術(shù)后自主呼吸恢復(fù)時(shí)間短于七氟醚組,但差異未見統(tǒng)計(jì)學(xué)意義;其次,本研究只觀察了患者氣管導(dǎo)管拔除時(shí)間和離開PACU的時(shí)間,對(duì)于其早期的日常生活未進(jìn)行觀察;此外,本研究中的觀察對(duì)象是體質(zhì)指數(shù)正常的年輕人群,有研究發(fā)現(xiàn)地氟醚用于肥胖患者[9]或老年患者[10]時(shí),較七氟醚具有快速蘇醒和提高認(rèn)知功能的優(yōu)勢(shì)。

綜上所述,地氟醚用于短時(shí)支撐顯微喉鏡下聲帶手術(shù)較七氟醚更利于患者蘇醒并加快手術(shù)周轉(zhuǎn)。

[1] WHITE PF,KEHLETH,NEAL JM,etal.The role of the anesthesiologistin fast-track surgery:from multimodal analgesia to perioperative medical care[J].AnesthAnalg,2007,104(6):1380-1396.

[2] SONG D,JOSHI GP,WHITE PF.Fast-track eligibility after ambulatory anesthesia:a comparison of desflurane,sevoflurane,and propofol[J].AnesthAnalg,1998,86(2):267-273.

[3] NORDMANN GR,READ JA,SALE SM,etal.Emergence and recovery in children after desflurane and isoflurane anesthesia:effect of anesthetic duration[J].BrJAnaesth,2006,96(6):779-785.

[4] MCKAY RE,LARGE MJC,BALEA MC,etal.Airway reflexes return more rapidly after desflurane anesthesia than after sevoflurane anesthesia[J].AnesthAnalg,2005,100(3):697-700.

[5] MAHMOUND NA,ROSE DJA,LAURENCE AS.Desflurane or sevoflurane for gynaecological day-case anesthesia with spontaneous respiration?[J].Anaesthesia,2001,56(2):171-174.

[6] TESSLER MJ,ROCHON AG,SHRIER I.Desflurane does not accelerate recovery from operations of short duration:a practice audit[J].CanJAnesth,2004,51(3):222-225.

[7] YU SH,BEIRNE OR.Laryngeal mask airways have a lower risk of airway complications compared with endotracheal intubation:a systematic review[J].JOralMaxillofacSurg,2010,68(10):2359-2376.

[8] GORMLER WP,MURRAY JM,TRINIC TR,etal.Intravenous lidocaine dose not attenuate the cardiovascular and catecholamine response to a rapid increase in desflurane concentration[J].AnesthAnalg,1996,82(2):358-361.

[9] STRUM EM,SZENOHRADSZKI J,KAUFMAN WA,etal.Emergence and recovery characteristics of desflurane versus sevoflurane in morbidly obese adult surgical patients:a prospective,randomized study[J].AnesthAnalg,2004,99(6):1848-1853.

[10] CHEN XG,ZHAO M,WHITE PH,etal.The recovery of cognitive function after general anesthesia in elderly patients:a comparison of desflurane and sevoflurane[J].AnesthAnalg,2001,93(6):1489-1494.

Desflurane accelerates emergence after self-retaining laryngoscope under the microscope in the surgery of vocal cord

LIU Ting-jie, SHEN Xia△, LI Wen-xian

(DepartmentofAnesthesiology,Eye,EarandENTHospital,FudanUniversity,Shanghai200031,China)

Objective To evaluate the effect of desflurane on emergency in patients undergoing suspension microlaryngoscopy surgery. Methods Forty adult patients with ASA Ⅰ-Ⅱ who underwent elective microlaryngoscopy surgery were randomly divided into desflurane group (group D,n=20) and sevoflurane group (group S,n=20).Time from end of the surgery to resume of spontaneous breathing,extubation,and discharge from postanesthesia care unit (PACU) were recorded.The extent of cough reflex during extubation and cough episode after extubation were recorded.Perioperative mean arterial pressure (MAP) and heart rate (HR) were recorded before anesthesia induction (T0),on suspension laryngoscope instrument (Tlary),the gas concentration reached 1.3 MAC (T1.3mac),1 min after 1.3 MAC (T1.3mac+1),on arrival at PACU (Tpacu),on extubation (Textu),1 min after extubation (Textu+1),5 min after extubation (Textu+5),and on discharge from PACU (Tdis).Results Time from end of the surgery to resume of spontaneous breathing was not significantly different between the two groups.Time to extubation in group D was 4.6 min,which was shorter than it was in group S (P<0.05).Time to discharge from PACU was 5.0 min in group D,which was shorter than it was in group S (P<0.05).Incidence of cough was 100% in group D and 55% in group S during extubation (P<0.05).The episode of coughing after extubation was not significantly different between the two groups.Perioperatively,changes of MAP and HR between the two groups were not significantly different (P>0.05). Conclusions Desflurane for adult patients undergoing suspension microlaryngoscopy surgery was associated with fast emergence.The incidence of cough was higher in group D than it was in group S during extubation,but it continued a short duration.

microlaryngoscopy surgery; vocal cord; desflurance; emergence; complications

R614.2+1

A

10.3969/j.issn.1672-8467.2017.02.011

2016-06-19;編輯:張秀峰)

△Corresponding author E-mail:shenxia@eentanesthesia.com