“深肌松”在肥胖患者行机器人辅助腹腔镜下根治性前列腺癌切除术中的应用观察

doi:10.3969/j.issn.1009-976X.2020.04.014

摘要/Abstract

摘要： 目的探讨“深肌松”方案在肥胖患者行机器人辅助腹腔镜下根治性前列腺癌切除术中的应用效果及优势。方法择期行机器人辅助腹腔镜下根治性前列腺癌切除术的肥胖患者48例,随机分为常规（中度）肌松组（M组）和深肌松组（D组）。两组采用统一的镇静镇痛方案,其中M组诱导时予顺式阿曲库铵0.15~0.2 mg/kg iv,之后每间隔约45 min~1 h单次静推顺式阿曲库铵5 mg维持;D组诱导时则予罗库溴铵0.6 mg/kg静注,PTC=1~2时行气管插管;麻醉维持采用连续输注,切皮前予罗库溴铵0.6 mg/kg iv,当神经肌肉阻滞开始恢复时以5~10 μg/（kg·min）泵注。比较两组诱导插管时间、苏醒时间、拔管后视觉模拟评分法VAS评分及躁动发生率;分别于诱导前（T₀）、手术开始1小时（T₁）、术毕时（T₂）及离开PACU前（T3）抽取动脉血2 mL行血气分析,比较两组患者乳酸、血糖等结果的差异。结果与M组相比,D组插管时间、苏醒时间较短,拔管后VAS疼痛评分及躁动发生率较低,两组差别有统计学意义（P<0.05）。同时刻相比,T₂、T₃时刻D组的乳酸、血糖值较低,与M组比较差别有统计学意义（P<0.05）。结论与常规肌松组相比,“深肌松”麻醉方案可缩短该类患者插管时间,加速苏醒,减轻术后疼痛和躁动应激,或可改善总体麻醉质量。

关键词: 中度肌松, 深度肌松, 前列腺癌, 肥胖, 机器人辅助腹腔镜手术

Abstract: Objective To investigate the application advantages of deep neuromuscular block in obese patients undergoing robot-assisted laparoscopic radical prostatectomy. Method Forty-eight obese patients undergoing robot-assisted laparoscopic radical prostatectomy were randomly divided into moderate neuromuscular block group （group M） and deep neuromuscular block group （group D）. Patients ingroup M were induced with cisatracurium 0.15~0.2 mg/kg iv, followed by cisatracurium 5 mg iv at an interval of about 45 min. Patients in group D was given 0.6 mg/kg rocuronium at induction, and then in the maintenance of anesthesia, rocuronium was given 0.6 mg/kg iv before skin incision and pumped 5~10 μg/（kg·min） when neuromuscular block began to recover. The following targets werecompared between the two groups： the intubation time, the wake-up time, VAS pain score and the incidence of agitation after extubation. The blood gas analysis was performed before induction （T₀）, 1 hour after the operation （T₁）, at the end of the operation （T₂） and before leaving the PACU（T₃）, and the levels of lactic acidas and blood glucose were compared between the two groups. Results Compared with group M, the intubation time and resuscitation time in group D were shorter, and the VAS pain score and the incidence of agitation after extubation were also lower. At the time of T₂ and T₃, the levels of lactic acid and blood glucose in group D were lower than group M. The differences between the two groups were statistically significant （P < 0.05）. Conclusion Compared with the moderate neuromuscular block, applying the strategy of deep neuromuscular block could shorten the intubation time, accelerate the recovery, reduce postoperative pain and agitation stress in obese patients undergoing robot and laparoscopic assisted radical prostatectomy.

Key words: obesity, robot and laparoscopic assisted surgery, deep neuromuscular blockade, prostate cancer, moderate neuromuscular blockade

中图分类号:

R614

陈美贤, 杨雪莹, 廖朝霞, 叶西就, 陆福鼎. “深肌松”在肥胖患者行机器人辅助腹腔镜下根治性前列腺癌切除术中的应用观察[J]. 岭南现代临床外科, 2020, 20(04): 468-471.

CHEN Mei-xian, YANG Xue-ying, LIAO Zhao-xia, YE Xi-jiu, LU Fu-ding. Application of deep neuromuscular blocking in obese patients undergoing robot-assisted laparoscopic radical prostatectomy[J]. Lingnan Modern Clinics in Surgery, 2020, 20(04): 468-471.

参考文献

[1] Lin C, Wan F, Lu Y, et al.Enhanced recovery after surgery protocol for prostate cancer patients undergoing laparoscopic radical prostatectomy[J]. J Int Med Res, 2019, 47(1): 114-121.
[2] Torensma B, Martini CH, Boon M, et al.Deep Neuromuscular Block Improves Surgical Conditions during Bariatric Surgery and Reduces Postoperative Pain: A Randomized Double Blind Controlled Trial[J]. PLoS One, 2016, 11(12): e0167907.
[3] Madsen MV, Scheppan S, Mørk E, et al.Influence of deep neuromuscular block on the surgeon? assessment of surgical conditions during laparotomy: a randomized controlled double blinded trial with rocuronium and sugammadex[J]. Br J Anaesth, 2017, 119(6):1247.
[4] 车璐,徐仲煌. 加速康复外科在麻醉医学中的应用与展望[J]. 临床误诊误治, 2017, (4):1-4.
[5] Dec M, Andruszkiewicz P.Anaesthesia for minimally invasive surgery[J]. WideochirInne Tech Maloinwazyjne, 2016, 10(4):509-514.
[6] Henny CP, Hofland J.Laparoscopic surgery: pitfalls due to anesthesia, positioning, and pneumoperitoneum[J]. Surg Endosc, 2005, 19(9):1163-1171.
[7] Nguyen NT, Ho HS, Fleming NW, et al.Cardiac function during laparoscopic vs open gastric bypass[J]. Surg Endosc, 2002, 16(1):78-83.
[8] 纪妹. 机器人在子宫内膜癌中的应用[J]. 中华腔镜外科杂志(电子版),2017,10(5):297-299.
[9] Madsen MV, Staehr-Rye AK, Gätke MR, et al.Neuromuscular blockade for optimising surgical conditions during abdominal and gynaecological surgery: a systematic review[J]. Acta Anaesthesiol Scand, 2015, 59(1):1-16.
[10] Brull SJ, Kopman AF.Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities[J]. Anesthesiology, 2017, 126(1):173-190.
[11] 中华医学会麻醉学分会. 肌肉松弛药合理应用的专家共识(2013)[J]. 临床麻醉学杂志,2013,29(7):712-715.
[12] Dubois PE, Putz L, Jamart J, et al.Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: a randomised controlled trial[J]. Eur J Anaesthesiol, 2014, 31(8):430-436.
[13] Özdemir-van Brunschot DM, van Laarhoven KC, Scheffer GJ, et al. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review[J]. Surg Endosc, 2016, 30(5):2049-2065.
[14] Kopman AF, Naguib M.Is deep neuromuscular block beneficial in laparoscopic surgery? No, probably not[J]. Acta Anaesthesiol Scand, 2016, 60(6):717-722.
[15] Madsen MV, Staehr-Rye AK, Claudius C, et al.Is deep neuromuscular blockade beneficial in laparoscopic surgery?Yes, probably[J]. Acta Anaesthesiol Scand, 2016, 60(6):710-716.
[16] Gijsenbergh F, Ramael S, Houwing N, et al.First human exposure of Org 25969, a novel agent to reverse the action of rocuronium bromide[J]. Anesthesiology, 2005, 103(4):695-703.
[17] Jones RK, Caldwell JE, Brull SJ, Soto RG.Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine[J]. Anesthesiology, 2008, 109(5):816-824.
[18] Yu BW, Wang XG, Hans SHH, et al.Sugammadex 4.0 mg kg-1 Reversal of Deep Rocuronium-Induced Neuromuscular Blockade: A Multicenter Study in Chinese and Caucasian Patients[J]. J Anesth Clin Res 2014, 5:5.