本文選題：非氣管插管 + 胸腔鏡��； 參考：《大連醫(yī)科大學》2017年碩士論文

【摘要】：目的:探討不同氣道管理方式下行胸腔鏡肺大皰切除術(shù)的臨床應(yīng)用效果。方法:回顧性分析2016年1月至2017年2月就診于大連醫(yī)科大學附屬第二醫(yī)院胸外科行肺大皰切除術(shù)的患者共計87例,根據(jù)本研究納入標準:ASA分級Ⅰ-Ⅱ級,BMI25kg/m2,單純原發(fā)性自發(fā)性氣胸,單孔胸腔鏡下手術(shù);排除標準:年齡60歲,ASA分級≥Ⅲ級,BMI≥25kg/m2,中轉(zhuǎn)開胸手術(shù),合并呼吸系統(tǒng)、循環(huán)系統(tǒng)疾病、血液系統(tǒng)疾病,精神異常不能合作者。最后共有60例患者納入本次回顧性研究,其中氣管插管組(A組)患者30例,非氣管插管組(B組)患者30例。所有患者術(shù)前禁食、禁飲6小時,入室后常規(guī)開放上肢靜脈通路,連接監(jiān)護儀,選擇健側(cè)橈動脈穿刺,監(jiān)測收縮壓(SBP)、舒張壓(DBP)、心率(HR)、脈搏血氧飽和度(SpO_2)、心電圖(ECG)、腦電雙頻指數(shù)(BIS)、血氣分析。術(shù)前用藥鹽酸戊乙奎醚注射液0.5mg靜脈注射。麻醉誘導前所有患者均選擇胸段椎旁神經(jīng)阻滯,擺側(cè)臥位,手術(shù)側(cè)向上,弓背、低頭,手術(shù)側(cè)切口對應(yīng)肋間隙(T4~T5或T5~T6)距脊柱正中線旁開2.5 cm,常規(guī)皮膚消毒,超聲引導下行椎旁神經(jīng)阻滯,回抽無血后,推注0.33%羅哌卡因30ml。氣管插管組常規(guī)麻醉誘導后置入雙腔氣管插管,纖維支氣管鏡調(diào)整導管位置,插管成功后給予純氧機械通氣;非氣管插管組不使用肌松藥物,采用保留自主呼吸、麻醉機面罩給氧完成手術(shù)。比較兩組患者生理指標:術(shù)中收縮壓(SBP),舒張壓(DBP),心率(HR),脈搏血氧飽和度(SPO_2);PH,動脈血氧分壓(PaO_2),動脈血二氧化碳分壓(PaCO_2),鉀離子(K+);術(shù)中評估指標:手術(shù)時間,視野暴露情況,麻醉效果,蘇醒時間;術(shù)后恢復評估指標:術(shù)后進食時間,術(shù)后下地時間,胸腔引流管拔除時間,住院時間;術(shù)后并發(fā)癥評估指標:術(shù)后咽痛發(fā)生率,術(shù)后惡心、嘔吐發(fā)生率,肺部并發(fā)癥,循環(huán)系統(tǒng)系統(tǒng)并發(fā)癥。其他指標還包括:麻醉藥物費用,手術(shù)費用及住院費用。結(jié)果:兩種通氣方式下均順利完成手術(shù),所有患者均生命體征平穩(wěn),術(shù)野及麻醉效果滿意。兩組患者年齡、身高及體重差異無統(tǒng)計學意義(P0.05)。兩組患者T0時刻收縮壓(SBP)、舒張壓(DBP)、心率(HR)及脈搏血氧飽和度(SPO_2)比較差異無統(tǒng)計學意義(P0.05)。A組和B組SBP及DBP在T1、T2、T3、T4、T5時刻較T0時刻有所下降,差異具有統(tǒng)計學意義(P0.05);A組vs B組僅有T5時刻SBP及DBP比較略高,差異具有統(tǒng)計學意義(P0.05)。T1、T5時刻脈搏血氧飽和度(SP02)A組vs B組差異具有統(tǒng)計學意義(P0.05)。T1時刻腦電雙頻指數(shù)(BIS)A組vs B組[(43.5±4.4)vs(50.5±8.3)],差異具有統(tǒng)計學意義(P0.05)。動脈血二氧化碳分壓(Pa CO2)B組在T2時刻、T3時刻、T4時刻、T5時刻明顯高于A組[(37.7±2.3)mm Hg vs(59.1±9.9)mm Hg、(37.2±2.5)mm Hg vs(66.7±8.4)mm Hg、(39.0±2.3)mm Hg vs(62.1±6.6)mm Hg、(40.7±4.0)mm Hg vs(56.6±6.7)mm Hg],且差異具有統(tǒng)計學意義(P0.05)。T2、T3、T4、T5時刻A組PaO_2與B組相比較差異具有統(tǒng)計學意義;術(shù)中評估指標:視野暴露情況及麻醉滿意度無明顯差異;B組vs A組在手術(shù)時間[(43.6±8.4)min vs(63.6±22.2)min]、蘇醒時間[(9.3±4.2)min vs(19.8±15.2)min]明顯縮短,且差異具有統(tǒng)計學意義(P0.05);術(shù)后恢復評估指標:A組vs B組術(shù)后進食時間[(0.51±0.1)天vs(0.26±0.04)天]、術(shù)后下地時間[(1.00±0.18)天vs(0.67±0.11)天]明顯縮短,差異具有統(tǒng)計學意義(P0.05);胸腔引流管拔出時間、住院時間比較無統(tǒng)計學差異(P0.05);術(shù)后并發(fā)癥評估指標:術(shù)后咽痛發(fā)生率B組vs A組[(0/30)vs(18/30),P0.05],差異有統(tǒng)計學意義(P0.05);術(shù)后惡心、嘔吐發(fā)生率B組vs A組[(0/30)vs(2/30)]。僅A組1例患者出現(xiàn)肺部并發(fā)癥,所有患者均無循環(huán)系統(tǒng)并發(fā)癥發(fā)生。其他指標:A組vs B組在麻醉藥物費用[(1724.23±296.52)元vs(1128.53±395.28)元,P0.05]、住院費用[(35678.95±9632.88)元vs(31483.78±5666.00)元]有所減少,差異具有統(tǒng)計學意義(P0.05),手術(shù)費用[(5565.23±806.27)元vs(5181.70±680.52)元,P0.05],未見明顯差異。結(jié)論:青中年患者在不同氣道管理方式下均能安全順利完成胸腔鏡肺大皰切除術(shù)。非氣管插管行胸腔鏡肺大皰切除術(shù)手術(shù)時間縮短,術(shù)后蘇醒迅速,麻醉藥物費用及住院費用減少,值得臨床進一步推廣。
[Abstract]:Objective: To investigate the clinical effect of VATS pulmonary bullectomy under different airway management methods. Methods: a retrospective analysis of 87 cases of pulmonary bullectomy in Department of thoracic surgery, Second Affiliated Hospital of Dalian Medical University from January 2016 to February 2017 was retrospectively analyzed. According to the study, ASA grade I - II, BMI25kg/m2, single Primary spontaneous pneumothorax, single hole thoracoscopic surgery, exclusion criteria: age 60 years old, ASA grade more than grade III, BMI > 25kg/m2, transthoracic surgery, respiratory system, circulatory system disease, blood system disease, abnormal psychosis. Finally, 60 patients were included in this retrospective study, in which the tracheal intubation group (Group A) patients 30 cases, non tracheal intubation group (group B), 30 cases. All patients were fasting before operation and no drink for 6 hours. After admission, routine open upper limb vein access, connecting monitor, selective radial artery puncture, monitoring systolic pressure (SBP), diastolic pressure (DBP), heart rate (HR), pulse blood oxygen saturation (SpO_2), electrocardiogram (ECG), electroencephalogram double frequency index (BIS), blood gas analysis. Intravenous injection of Penehyclidine Hydrochloride Injection 0.5mg. All patients before induction of anesthesia were treated with thoracic paravertebral block, lateral position, lateral, dorsal, low head, 2.5 cm adjacent to the midline of the spine (T4~T5 or T5~T6), routine skin disinfection, ultrasound guided paravertebral block, and blood withdrawal. After the 0.33% ropivacaine 30ml. tracheal intubation group was injected into the double lumen tracheal intubation after routine anesthesia induction, the position of the catheter was adjusted by fiberoptic bronchoscope and the catheterization was performed after the intubation was successful. The non tracheal intubation group did not use muscle relaxant drugs, and the autonomic breathing was retained and the anesthesia machine mask was used to complete the operation. The physiological indexes of the two groups were compared. : intraoperative systolic pressure (SBP), diastolic pressure (DBP), heart rate (HR), pulse oxygen saturation (SPO_2); PH, arterial oxygen partial pressure (PaO_2), arterial blood carbon dioxide partial pressure (PaCO_2), potassium ion (K+); operation time, visual field exposure, anesthesia effect, revival time; postoperative recovery evaluation index: postoperative feeding time, postoperative down time, chest The extraction time, hospitalization time, postoperative complications assessment index: postoperative sore pain, postoperative nausea, vomiting, pulmonary complications, circulatory system complications. The other indicators include the cost of narcotic drugs, surgical costs and hospitalization costs. Results: the operation was completed successfully under the two types of ventilation. All patients were born There was no significant difference in age, height and weight between the two groups (P0.05). There was no significant difference in T0 systolic pressure (SBP), diastolic pressure (DBP), heart rate (HR) and pulse oxygen saturation (SPO_2) in the two groups (P0.05) and SBP and DBP in group.A and B. The difference was statistically significant (P0.05), and in group A vs B only T5 time SBP and DBP were slightly higher, the difference was statistically significant (P0.05).T1, T5 time pulse oxygen saturation (SP02) A group differences had statistical significance (43.5 + 4.4) (50.5 + 8.3), and the difference was statistically significant P0.05 (Pa CO2) B group at T2 moment, T3 moment, T4 moment, T5 moment obviously higher than group A [(37.7 + 2.3) mm Hg vs (59.1 + 9.9), 66.7 + 8.4), and (39 + 2.3) The difference between group A PaO_2 and group B at T5 time was statistically significant, and there was no significant difference in the evaluation index in the operation, and in group vs A in group B (((((43.6 + 8.4) min vs (63.6 + 22.2) min], and (9.3 + 4.2) min vs (19.8 + 15.2)) in group B, and the difference was statistically significant. Re evaluation index: the time of postoperative feeding in group A vs B [(0.51 + 0.1) days vs (0.26 + 0.04) days], postoperative lower ground time [(1 + 0.18) days vs (0.67 + 0.11) days] significantly shortened, the difference was statistically significant (P0.05); thoracic drainage tube extraction time and hospitalization time were not statistically different (P0.05); postoperative complications assessment index: postoperative sore throat B group vs A Group [(0/30) vs (18/30), P0.05], the difference was statistically significant (P0.05); postoperative nausea and vomiting occurred in the B group vs A Group [(0/30)]. Only 1 patients had pulmonary complications, all patients had no circulatory complications. P0.05], hospitalization expenses [(35678.95 + 9632.88) yuan vs (31483.78 + 5666) yuan] decreased, the difference was statistically significant (P0.05), operation cost [(5565.23 + 806.27) yuan vs (5181.70 + 680.52) yuan, P0.05], no obvious difference. Conclusion: middle-aged patients with different airway management can successfully complete thoracoscopic bullous resection. The operation time of the thoracoscopic bullectomy with non tracheal intubation is shortened, the postoperative recovery is rapid, the cost of narcotic drugs and the cost of hospitalization are reduced. It is worthy of further clinical promotion.
【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R614

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