内镜面罩与鼻导管吸氧用于高龄患者内镜逆行胰胆管造影监护麻醉的对比观察

Comparative observation of oxygen inhalation by endoscopic mask and nasal catheter under monitored anesthesia care in elderly patients with ERCP

摘要:

目的 将内镜面罩和鼻导管两种吸氧方法用于高龄患者内镜逆行胰胆管造影（ERCP）行监护麻醉（MAC），探讨两者预防术中低氧血症的效果。方法 择期拟行ERCP术的高龄患者60例（年龄≥70岁），美国麻醉医师协会（ASA）分级为Ⅱ级或Ⅲ级，按随机数字表法分为鼻导管吸氧组（C组）和内镜面罩吸氧组（M组），氧流量均设置为5 L/min。缓慢静脉推注舒芬太尼0.05～0.10 μg/kg和丙泊酚1.0～2.0 mg/kg，诱导后术中持续静脉泵注丙泊酚6～10 mg/（kg·h）、右美托咪定0.2～0.8 μg/（kg·h）维持镇静深度。记录术中亚临床低氧血症［脉搏血氧饱和度（SpO₂）< 95%］、低氧血症（SpO₂为75%～89%，< 60 s）和严重低氧血症（SpO₂ < 75%或SpO₂ < 90%且 > 60 s）的例数；于诱导前（T₀）、诱导后（T₁）、进镜入咽部（T₂）、置入十二指肠乳头（T₃）、退镜（T₄）和苏醒时（T₅）记录患者心率（HR）、平均动脉压（MAP）、SpO₂、呼吸频率（RR）和脑电双频指数（BIS）；于T₀、术中每间隔15 min（诱导后到退镜）和T₅时抽取桡动脉血行血气分析。结果 两组患者术中亚临床低氧血症发生率比较，差异无统计学意义，M组患者低氧血症发生率明显低于C组（3.3%和30.0%，P = 0.006），两组术中均未发生严重低氧血症；M组患者在诱导后15 min动脉血氧分压（PaO₂）高于C组；M组患者SpO₂在T₁、T₂、T₃和T₄时点均高于C组，诱导后30 min动脉血二氧化碳分压（PaCO₂）明显高于C组［（52.62±7.44）和（41.17±4.45）mmHg，P = 0.006］，pH值明显低于C组［（7.30±0.07）和（7.38±0.03），P = 0.027］；M组内镜医生、麻醉医生和患者满意度明显高于C组，两组比较，差异均有统计学意义（P < 0.05）。结论 高龄患者行ERCP时同时行MAC，使用内镜面罩较鼻导管吸氧可以明显降低术中低氧血症的发生率。但随着手术时间的延长，内镜面罩组患者可能有二氧化碳潴留的风险。内镜医生、麻醉医生和患者对使用内镜面罩满意度更高。

Abstract:

Objective By comparing endoscopic mask and nasal catheter oxygen inhalation in elderly patients with endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC), the purpose of this study was to explore the effect of endoscopic mask and nasal catheter in the prevention of hypoxemia.Methods 60 elderly patients, ASA Ⅱ or Ⅲ, aged ≥ 70 years, scheduled for elective ERCP were randomly divided into two groups: nasal catheter oxygen inhalation group (group C) and endoscopic mask oxygen inhalation group (group M). The oxygen flow rate was set to 5 L/min. After slow intravenous infusion of sufentanil 0.05～0.10 μg/kg and propofol 1.0～2.0 mg/kg, propofol 6～10 mg/(kg·h) and dexmetomide 0.2～0.8 μg/(kg·h) were continuously injected intraoperatively to maintain the depth of sedation. The number of patients with subclinical hypoxemia (SpO₂ < 95%), hypoxemia (SpO₂: 75%~89%, < 60 s) and severe hypoxemia (SpO₂ < 75% or SpO₂ < 90% and > 60 s) during operation was recorded, and the values of heart rate (HR), mean artery pressure (MAP), pulse oxygen saturation (SpO₂), respiratory rate (RR) and bispectral index (BIS) were recorded before induction (T₀), after induction (T₁), entering pharynx (T₂), inserting duodenal papilla (T₃), retreating mirror (T₄) and awakening (T₅), and radial artery blood was taken for blood gas analysis at T₀, every 15 min after induction (after induction) and T₅.Results There was no significant difference in the incidence of subclinical hypoxemia between the two groups, but the incidence of hypoxemia in group M was significantly lower than that in group C (3.3% vs 30.0%, P = 0.006), and no severe hypoxemia occurred during the operation. The arterial partial pressure of oxygen (PaO₂) of patients in group M was higher than that in group C when 15 min was induced. Compared with group C, SpO₂ in group M was higher at T₁, T₂, T₃ and T₄, but during post-induction 30 min, partial pressure of carbon dioxide in artery (PaCO₂) in group M was significantly higher than that in group C [(52.62 ± 7.44) mmHg vs (41.17 ± 4.45) mmHg, P = 0.006], and pH was significantly lower than that in group C [(7.30 ± 0.07) vs (7.38 ± 0.03), P = 0.027]. The satisfaction of endoscopic physicians, anesthesiologists and patients in group M was significantly higher than that in group C, and there was significant difference between the two groups (P < 0.05).Conclusion In elderly patients with ERCP under monitored anesthesia care, compared with nasal catheters, the use of endoscopic mask can significantly reduce the incidence of intraoperative hypoxemia. However, with the extension of surgery time, patients in the endoscopic mask group may be at risk of carbon dioxide retention. Endoscopic doctors, anesthesiologists and patients are more satisfied with the use of endoscopic masks.