胃镜喉罩无肌松正压通气在肥胖患者内镜黏膜下剥离术中的应用

Application of muscle-free positive pressure ventilation with laryngeal mask in endoscopic submucosal dissection for obese patients

摘要:

目的 评价胃镜喉罩无肌松正压通气在肥胖患者内镜黏膜下剥离术（ESD）中的应用效果。方法 选取2024年6月－2024年12月该院拟行无痛ESD的肥胖患者179例，采用随机数表法分为3组：C组（鼻咽通气导管）61例，L1组（胃镜喉罩+顺式阿曲库铵）58例，L2组（胃镜喉罩）60例。C组静注咪达唑仑、舒芬太尼和丙泊酚后，置入鼻咽通气导管，维持自主呼吸。L1组在C组诱导用药的基础上，追加顺式阿曲库铵后置入胃镜喉罩，通过麻醉机正压通气。L2组不使用肌松剂，余用药同L1组。C组术中泵入丙泊酚2～4 mg/（kg·h），诱导后60 min追加舒芬太尼5～10 μg。L1组和L2组均泵入丙泊酚2～4 mg/（kg·h）和瑞芬太尼2～3 μg/（kg·h）。记录术中循环和呼吸变化情况，监测动脉血气分析相关指标，记录术中体动和术后并发症发生情况，记录内镜医师和患者的满意度。结果 L1组和L2组在麻醉维持期（T₂）的收缩压变异系数和舒张压变异系数小于C组，差异均有统计学意义（P < 0.05）。L1组和L2组的低氧血症和呼吸抑制的发生率低于C组，差异均有统计学意义（P < 0.05）。与术前、L1组和L2组比较，诱导后60 min，C组的pH值降低，动脉血二氧化碳分压（PaCO₂）和乳酸（Lac）升高，差异均有统计学意义（P < 0.05）。L1组和L2组术中体动发生率明显低于C组，术后咽喉疼痛发生率明显高于C组，差异均有统计学意义（P < 0.05）；L1组术后乏力发生率明显高于C组和L2组，差异均有统计学意义（P < 0.05）。L2组患者总体满意度高于L1组，L1组和L2组内镜医生总体满意度高于C组，差异均有统计学意义（P < 0.05）。结论 胃镜喉罩无肌松正压通气应用于肥胖患者ESD，可维持血流动力学稳定，降低呼吸相关并发症发生率，并提高总体满意度，具有较好的安全性和较高的临床应用价值。

Abstract:

Objective To evaluate the effect of positive pressure ventilation with laryngeal mask airway without muscle relaxant under gastroscope in obese patients undergoing endoscopic submucosal dissection (ESD).Methods Obese patients who planned to undergo painless ESD in our hospital from June 2024 to December 2024 were divided into three groups: group C (nasopharyngeal airway catheter, n = 61), group L1 (gastroscopic laryngeal mask combined with cisatracurium, n = 58), and group L2 (gastroscopic laryngeal mask, n = 60).In group C, midazolam, sufentanil and propofol were given intravenously, and then a nasopharyngeal airway catheter was placed to maintain spontaneous breathing. In group L1, on the basis of the induction drug in group C, cisatracurium was added, then a gastroscopic laryngeal mask was inserted, and positive pressure ventilation was performed by an anesthesia machine. In group L2, muscle relaxants were not used, and the other drugs were the same as those in group L1. In group C, propofol 2 ~ 4 mg/(kg·h) was pumped during the operation, and sufentanil 5 ~ 10 μg was added 60 min after induction. In L1 and L2 groups, propofol 2 ~ 4 mg/(kg·h) and remifentanil 2 to 3 μg/(kg·h) were pumped. The changes in circulation and respiration during operation were recorded.The relevant indicators of arterial blood gas analysis were monitored. The intraoperative body movement and postoperative complications were recorded. The satisfaction of endoscopists and patients was recorded.Results The coefficient of variation of systolic blood pressure and diastolic blood pressure in the L1 and L2 groups during the anesthesia maintenance period (T₂) was lower than that in group C, and the differences were statistically significant (P < 0.05). The incidence of hypoxemia and respiratory depression in group L1 and group L2 was lower than those in group C, and the differences were statistically significant (P < 0.05). At 60 min after induction, the pH value in group C decreased, while the arterial partial pressure of carbon dioxide (PaCO₂) and lactate (Lac) increased, which were significantly different from those before induction and those in group L1 and L2 (P < 0.05). The incidence of intraoperative movement in group L1 and L2 was significantly lower than that in group C, while the incidence of postoperative throat pain was significantly higher than that in group C, the differences were statistically significant (P < 0.05); the incidence of postoperative fatigue in group L1 was significantly higher than that in group C and L2, and the differences were also statistically significant (P < 0.05). The overall satisfaction of patients in group L2 was higher than that in group L1, the overall satisfaction of endoscopists in group L1 and L2 was higher than that in group C, the differences were statistically significant (P < 0.05).Conclusion Positive pressure ventilation with laryngeal mask airway without muscle relaxant for ESD in obese patients, it can maintain hemodynamic stability, reduce the incidence of respiratory complications, and has a high overall satisfaction. It is a safe and effective anesthesia method.