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中华腔镜外科杂志(电子版)

中华腔镜外科杂志(电子版) ›› 2020, Vol. 13 ›› Issue (06): 342 -346. doi: 10.3877/cma.j.issn.1674-6899.2020.06.006

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不插管麻醉在剑突下单孔胸腔镜手术中的临床实践
陈志刚 1, 施佳敏 2 , †( ), 施哲 3, 蔡剑桥 3, 朱余明 3, 戴丽华 1, 吕欣 1, 蒋雷 3   
  1. 1. 200433 上海，同济大学附属上海市肺科医院麻醉科
    2. 200433 上海，同济大学附属上海市肺科医院手术室
    3. 200433 上海，同济大学附属上海市肺科医院胸外科
  • 收稿日期:2020-09-07 出版日期:2020-12-30
  • 通信作者: 施佳敏

Clinical analysis of nonintubated anesthesia in subxiphoid uniportal video-assisted thoracic surgery

Zhigang Chen 1, Jiamin Shi 2 , †( ), Zhe Shi 3, Jianqiao Cai 3, Yuming Zhu 3, Lihua Dai 1, Xin Lyu 1, Lei Jiang 3   

  1. 1. Department of Anesthesiology, Shanghai Pulmonary Hospital, Shanghai 200433, China.
    2. Department of Operation, Shanghai Pulmonary Hospital, Shanghai 200433, China.
    3. Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Shanghai 200433, China
  • Received:2020-09-07 Published:2020-12-30
  • Corresponding author: Jiamin Shi
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目的

探讨不插管麻醉在剑突下单孔胸腔镜手术中的可行性和安全性。

方法

收集同济大学附属上海市肺科医院2019年4月至2020年4月完成的60例不插管麻醉在经剑突下单孔胸腔镜手术中的病例资料。对围手术期并发症及处理措施、术后恢复和住院时间等情况进行分析总结，对不插管麻醉在剑突下单孔胸腔镜手术中的安全性和可行性进行评估。

结果

60例患者均在不插管麻醉下行剑突下单孔胸腔镜手术，包括肺叶切除术21例、肺段切除术7例、肺楔形切除术24例、胸腺切除术8例；肺叶切除术、肺段切除术、肺楔形切除术、胸腺切除术的手术时间分别为(71.8±25.7)min、(68.9±27.3)min、(41.5±11.1)min、(103.9±22.3)min，术中出血量分别为(47.6±18.4)ml、(45.6±16.8)ml、(26.5±13.3)ml、(65.8±24.5)ml；其中29例(48.3%)术中需要放置口咽通气道、17例(28.3%)出现术中低血压、9例(15.0%)发生心律失常，无术中知晓事件发生，4例(6.7%)发生术后并发症，无严重不良事件发生；平均住院时间(7± 4.0)d。

结论

不插管麻醉在经剑突下入路单孔胸腔镜手术中具有可行性和一定优势，更多支持证据尚需大规模临床对照研究。

关键词: 不插管麻醉, 剑突下单孔胸腔镜, 普胸手术
Objective

To investigate the feasibility and security of nonintubated anesthesia(NA) in subxiphoid uniportal video-assisted thoracic surgery (SVATS).

Methods

A total of 60 consecutive cases underwent non-intubated SVATS between Apr. 2019 to Apr. 2020 in our hospital were performed. The perioperative complications and treatment measures, postoperative recovery and length of stay were summarized and analyzed. The safety and feasibility of NA in SVATS were evaluated.

Results

All the 60 patients successfully underwent SVATS with NA, including lobectomy in 21 cases, segmental resection in 7 cases, wedge resection in 24 cases, and thymotomy in 8 cases. The operation time was(71.8 ± 25.7)min, (68.9 ± 27.3)min, (41.5 ± 11.1)min and (103.9 ± 22.3)min respectively. The blood loss was (47.6 ± 18.4)ml, (45.6 ± 16.8)ml, (26.5 ± 13.3)ml and(65.8 ± 24.5)ml respectively. Among them, 29 (48.3%) cases needed to insert oropharyngeal airway; 17 (28.3%) cases had intraoperative hypotension; 9 (15.0%) cases had arrhythmia; 4 (6.7%) cases had postoperative complications; There was no serious adverse events of these patients. The average length of stay was (7 ± 4.0) days.

Conclusions

NA is feasibility and has certain advantages in SVATS, large-scale clinical controlled studies are needed to provide more convincing evidence.

Key words: Nonintubated anesthesia, Subxiphoid uniportal video-assisted, Thoracic surgery
图1 鼻导管吸氧
图2 剑突下切口局部麻醉(2%利多卡因100 mg混合0.75%布比卡因18.5 mg行皮下局部浸润)
图3 放置口咽通气道(术中出现呼吸不畅或低氧血症时)
图4 面罩辅助呼吸(加深麻醉造成一过性呼吸抑制或高流量鼻导管吸氧也无法纠正的低氧血症时采用)
表1 60例剑突下单孔胸腔镜手术不同手术类型的患者围手术期手术情况
项目 肺叶切除术(21例) 肺段切除术(7例) 肺楔形切除术(24例) 纵隔肿瘤切除术(8例)
手术时间(min， ±s) 71.8±25.7 68.9±27.3 41.5±11.1 103.9±22.3
术中出血量(ml， ±s) 47.6±18.4 45.6±16.8 26.5±13.3 65.8±24.5
呛咳(例) 4 2 1 1
低血压(例) 8 2 3 4
心律失常(例)        
  室性期前收缩 2 1 0 1
  心房纤颤 1 0 0 1
  窦性心律失常 1 1 1 0
表2 60例剑突下单孔胸腔镜手术不同手术类型的患者围手术期麻醉情况
项目 肺叶切除术(21例) 肺段切除术(7例) 肺楔形切除术(24例) 纵隔肿瘤切除术(8例)
低氧血症(例) 4 1 2 3
术毕PaO2(mmHg， ±s) 142.8±50.5 136.3±28.6 146.1±57.8 103.8±48.3
术毕PaCO2(mmHg， ±s) 68.5±9.7 66.5±8.3 63.3±7.4 70.1±7.8
置入口咽通气道(例) 11 4 10 4
口腔分泌物(例) 2 1 0 1
表3 60例剑突下单孔胸腔镜手术不同手术类型的患者术后情况
项目 肺叶切除术(21例) 肺段切除术(7例) 肺楔形切除术(24例) 纵隔肿瘤切除术(8例)
术后PaO2(mmHg， ±s) 157.8±27.6 145.3±21.2 161.1±23.5 120.8±22.7
术后PaCO2(mmHg， ±s) 46.5±6.7 45.8±5.3 43.9±5.8 43.1±5.9
术后下床活动时间(h， ±s) 14.8±1.7 14.8±1.7 11.2±2.1 15.7±2.1
术后进食时间(h， ±s) 12.5±1.9 12.5±1.9 10.4±1.8 13.2±2.1
术后恶心、呕吐(例) 3 1 2 1
术后24 h VAS(分， ±s) 3.3±1.3 3.6±1.1 3.8±1.5 4.0±1.5
术后引流管拔除时间(d， ±s) 3±1.0 3±1.0 1±1.0 2±1.0
术后并发症(例)        
  低氧血症 0 0 0 1
  漏气 1 0 0 0
  心律失常 1 0 0 1
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