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在我国,由于遗传、生活习惯以及饮食方式等多种因素,结直肠癌已成为消化系统中患病率最高的恶性肿瘤,且发病年龄呈现出年轻化的趋势,严重威胁着我国人民群众的生命健康[1]。手术是治疗结直肠癌的常用方法,与传统的开腹手术相比,腹腔镜手术带来的创伤小,使病人恢复更快并且能缩短住院时间,因而广泛应用于临床[2]。《肌肉松弛药合理应用的专家共识(2013)》[3]指出,腹腔镜手术中维持深度肌松水平,同时将气腹压设置低于10 mmHg,可获得满意的手术操作视野。本研究拟将深度肌松应用于腹腔镜结直肠癌手术病人中,探讨是否可以促进病人术后更好更快的康复,为围术期麻醉管理提供思路。现作报道。
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2组病人一般情况各项指标差异均无统计学意义(P>0.05)(见表 1)。
分组 n 年龄/岁 身高/cm 体质量/kg 男 女 结肠癌 直肠癌 BMI/(kg/m2) ASA分级 Ⅰ Ⅱ A组 39 55.56±6.25 164.56±8.29 61.00±5.98 20 19 16 23 22.59±2.35 18 21 B组 39 56.79±5.24 164.21±7.09 60.62±5.76 18 21 18 21 22.54±2.38 16 23 t — 0.94 0.20 0.28 0.21△ 0.21△ 0.09 0.21△ P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 △示χ2值 表 1 2组病人一般情况比较(x±s)
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2组SRS评分、手术时间、PACU驻留时间差异均无统计学意义(P>0.05)。B组平均气腹压、平均气道压均低于A组(P < 0.01),B组苯磺顺阿曲库铵使用量、恢复指数、拔管时间均高于A组(P < 0.01)(见表 2)。
分组 n 平均气腹压/mmHg 平均气道压/cmH2O SRS评分/分 手术时间/min 苯磺顺阿曲库铵用量/mg 恢复指数/min 拔管时间/min PACU驻留时间/min A组 39 12.46±0.86 22.61±2.41 4.64±0.48 201.51±24.32 16.91±2.22 22.12±2.75 32.35±2.52 30.30±4.14 B组 39 8.12±0.29 18.97±3.95 4.51±0.50 198.89±19.70 29.72±3.63 34.38±2.70 48.64±3.67 31.58±3.20 t — 29.56△ 4.90 1.14 0.52△ 18.77△ 19.84 28.98 1.52△ P — < 0.01 < 0.01 >0.05 >0.05 < 0.01 < 0.01 < 0.01 >0.05 △示t′值 表 2 2组病人术中及复苏情况各项指标比较(n=39;x±s)
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B组病人术后各时间点肩痛评分均低于A组(P < 0.01),术后6、24 h,B组病人内脏痛及恶心、呕吐评分均低于A组病人(P < 0.01)(见表 3)。
分组 n 肩痛评分 切口痛评分 内脏痛评分 恶心、呕吐评分 术后6 h A组 39 6.23±0.66 5.56±0.75 5.61±0.84 5.94±0.75 B组 39 4.17±0.60 5.28±0.72 4.23±0.70 5.00±0.64 t — 14.26 1.68 7.84 5.93 P — < 0.01 >0.05 < 0.01 < 0.01 术后24 h A组 39 5.25±0.59 4.61±0.87 4.56±0.82 4.87±0.52 B组 39 3.61±0.63 4.38±0.71 3.69±0.61 4.53±0.50 t — 11.79 1.27 5.31△ 2.86△ P — < 0.01 >0.05 < 0.01 < 0.01 术后48 h A组 39 4.00±0.64 3.71±0.85 3.66±0.86 3.53±0.50 B组 39 2.82±0.55 3.43±0.71 3.43±0.59 3.38±0.54 t — 8.62 1.57 1.36△ 1.29 P — < 0.01 >0.05 >0.05 >0.05 术后72 h A组 39 2.48±0.88 2.43±0.59 2.38±0.63 1.35±1.00 B组 39 1.53±0.50 2.38±0.54 2.33±0.47 0.97±0.84 t — 5.81△ 0.39 0.40△ 1.77 P — < 0.01 >0.05 >0.05 >0.05 △示t′值 表 3 2组病人术后疼痛及恶心、呕吐情况比较(x±s;分)
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术后1、3 d,B组病人QoR-15量表评分均高于A组病人(P < 0.01)(见表 4)。
分组 n 术前1 d 术后1 d 术后3 d A组 39 137.07±4.79 101.56±5.94 118.56±6.32 B组 39 135.46±5.94 110.23±7.54 127.89±6.05 t — 1.32 5.63 6.65 P — >0.05 < 0.01 < 0.01 表 4 2组病人QoR-15量表评分比较(x±s;分)
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B组排气时间、排便时间、肠鸣音恢复时间及住院时间均短于A组(P < 0.01)(见表 5)。
分组 n 排气时间/h 排便时间/h 肠鸣音恢复时间/h 住院时间/d A组 39 68.00±5.17 131.66±14.38 57.66±5.55 10.15±1.61 B组 39 57.30±5.42 104.82±14.13 43.94±4.01 8.35±1.20 t — 8.90 8.31 12.49 5.56△ P — < 0.01 < 0.01 < 0.01 < 0.01 △示t′值 表 5 2组病人术后恢复情况比较(x±s)
深度肌松对腹腔镜结直肠癌病人术后康复的影响
Effect of deep neuromuscular blockade on postoperative rehabilitation in patients undergoing laparoscopic colorectal-carcinoma surgery
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摘要:
目的评价深度肌松对腹腔镜结直肠癌病人术后康复的影响。 方法择期行腹腔镜结直肠癌手术病人78例,随机分为2组,各39例,分为中度肌松组(A组)和深度肌松组(B组)。A组在肌松监测下泵注苯磺顺阿曲库铵注射液,维持中度肌松;B组在肌松监测下泵注苯磺顺阿曲库铵注射液,维持深度肌松。2组病人术中容量管理均采用目标导向液体治疗策略,入复苏室后继续进行肌松监测,在肌松监测仪指导下给予肌松拮抗药及拔除气管导管。记录并比较2组病人手术视野评分、平均气腹压及平均气道压,恢复指数、拔管时间及复苏室驻留时间,术后疼痛及恶心、呕吐评分,术后早期恢复质量评分、胃肠道功能恢复情况及住院时间。 结果B组平均气腹压、平均气道压均低于A组(P < 0.01),B组苯磺顺阿曲库铵使用量、恢复指数、拔管时间均高于A组(P < 0.01)。B组病人术后各时间段肩痛评分均低于A组病人(P < 0.01),术后6、24 h,B组病人内脏痛及恶心呕吐评分均低于A组病人(P < 0.01)。B组术后1、3 d的恢复质量评分均高于A组(P < 0.01)。B组排气时间、排便时间、肠鸣音恢复时间及住院时间均短于A组(P < 0.01)。 结论将深度肌松应用于腹腔镜结直肠癌手术中,能够在保证术野的前提下降低气腹压力,提高病人早期恢复质量,促进胃肠道功能恢复,有利于病人术后康复,为围术期麻醉管理提供思路。 Abstract:ObjectiveTo investigate the effect of deep neuromuscular blockade on postoperative rehabilitation of patients undergoing laparoscopic colorectal-carcinoma surgery. MethodsSeventy-eight patients undergoing laparoscopic colorectal-carcinoma surgery were randomly divided into two groups as moderate neuromuscular blockade group(Group A, n=39) and deep neuromuscular blockade group(Group B, n=39).Patients in group A were pumped with cisatracurium under muscle relaxation monitoring to maintain the level of modern neuromuscular blockade.Other patients in group B were pumped with cisatracurium under muscle relaxation monitoring to maintain the level of deep neuromuscular blockade.Goal-directed fluid therapy was performed for intraoperative volume management in both groups.After entering the postanesthesia care unit, neuromuscular blockade monitoring was continued for patients in both groups.Then, muscle relaxation antagonists and extubation of endotracheal tubes were performed in both groups under the guidance of neuromuscular monitoring.The surgical field score, mean pneumoperitoneum pressure, and mean airway pressure were recorded; the time of recovery index, the time of removing the tracheal intubation, and the stay time in the postanesthesia care unit were recorded; the scores of postoperative pain, nausea, and vomiting were recorded; the score of recovery quality scale, recovery of gastrointestinal function, and hospital stay were recorded. ResultsThe mean artificial pneumoperitoneum pressure and mean airway pressure in group B were lower than those in group A(P < 0.01).The usage of cisatracurium, the time of TOF ratio from 0.25 to 0.75, and the time of removing the tracheal intubation in group B were higher than those in group A(P < 0.01).The shoulder pain scores of patients in group B were lower than those in group A at all postoperative periods(P < 0.01).At 6 and 24 hours after operation, the scores of visceral pain, nausea, and vomiting in group B were lower than those in group A(P < 0.01).At 1 and 3 days after operation, the score of recovery quality in group B was higher than that in group A(P < 0.01).The exhaust time, defecation time, bowel sound recovery time and hospital stay in group B were shorter than those in group A(P < 0.01). ConclusionsThe application of deep neuromuscular blockade in laparoscopic colorectal-carcinoma surgery can reduce the pneumoperitoneum pressure under the premise of ensuring the surgical field, improve the early postoperative recovery quality of patients, promote the gastrointestinal function recovery, and benefit the postoperative rehabilitation of patients, providing ideas for perioperative anesthesia management. -
表 1 2组病人一般情况比较(x±s)
分组 n 年龄/岁 身高/cm 体质量/kg 男 女 结肠癌 直肠癌 BMI/(kg/m2) ASA分级 Ⅰ Ⅱ A组 39 55.56±6.25 164.56±8.29 61.00±5.98 20 19 16 23 22.59±2.35 18 21 B组 39 56.79±5.24 164.21±7.09 60.62±5.76 18 21 18 21 22.54±2.38 16 23 t — 0.94 0.20 0.28 0.21△ 0.21△ 0.09 0.21△ P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 △示χ2值 表 2 2组病人术中及复苏情况各项指标比较(n=39;x±s)
分组 n 平均气腹压/mmHg 平均气道压/cmH2O SRS评分/分 手术时间/min 苯磺顺阿曲库铵用量/mg 恢复指数/min 拔管时间/min PACU驻留时间/min A组 39 12.46±0.86 22.61±2.41 4.64±0.48 201.51±24.32 16.91±2.22 22.12±2.75 32.35±2.52 30.30±4.14 B组 39 8.12±0.29 18.97±3.95 4.51±0.50 198.89±19.70 29.72±3.63 34.38±2.70 48.64±3.67 31.58±3.20 t — 29.56△ 4.90 1.14 0.52△ 18.77△ 19.84 28.98 1.52△ P — < 0.01 < 0.01 >0.05 >0.05 < 0.01 < 0.01 < 0.01 >0.05 △示t′值 表 3 2组病人术后疼痛及恶心、呕吐情况比较(x±s;分)
分组 n 肩痛评分 切口痛评分 内脏痛评分 恶心、呕吐评分 术后6 h A组 39 6.23±0.66 5.56±0.75 5.61±0.84 5.94±0.75 B组 39 4.17±0.60 5.28±0.72 4.23±0.70 5.00±0.64 t — 14.26 1.68 7.84 5.93 P — < 0.01 >0.05 < 0.01 < 0.01 术后24 h A组 39 5.25±0.59 4.61±0.87 4.56±0.82 4.87±0.52 B组 39 3.61±0.63 4.38±0.71 3.69±0.61 4.53±0.50 t — 11.79 1.27 5.31△ 2.86△ P — < 0.01 >0.05 < 0.01 < 0.01 术后48 h A组 39 4.00±0.64 3.71±0.85 3.66±0.86 3.53±0.50 B组 39 2.82±0.55 3.43±0.71 3.43±0.59 3.38±0.54 t — 8.62 1.57 1.36△ 1.29 P — < 0.01 >0.05 >0.05 >0.05 术后72 h A组 39 2.48±0.88 2.43±0.59 2.38±0.63 1.35±1.00 B组 39 1.53±0.50 2.38±0.54 2.33±0.47 0.97±0.84 t — 5.81△ 0.39 0.40△ 1.77 P — < 0.01 >0.05 >0.05 >0.05 △示t′值 表 4 2组病人QoR-15量表评分比较(x±s;分)
分组 n 术前1 d 术后1 d 术后3 d A组 39 137.07±4.79 101.56±5.94 118.56±6.32 B组 39 135.46±5.94 110.23±7.54 127.89±6.05 t — 1.32 5.63 6.65 P — >0.05 < 0.01 < 0.01 表 5 2组病人术后恢复情况比较(x±s)
分组 n 排气时间/h 排便时间/h 肠鸣音恢复时间/h 住院时间/d A组 39 68.00±5.17 131.66±14.38 57.66±5.55 10.15±1.61 B组 39 57.30±5.42 104.82±14.13 43.94±4.01 8.35±1.20 t — 8.90 8.31 12.49 5.56△ P — < 0.01 < 0.01 < 0.01 < 0.01 △示t′值 -
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