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Medicina

非插管视频辅助胸腔镜手术

Published: May 26, 2023
doi:
10.3791/65235
, , , , ,
1Department of Anesthesia,Second Affiliated Hospital of Zhejiang University School of Medicine, 2Department of Anesthesia,The First Affiliated Hospital of Ningbo University, 3Health Science Center,Ningbo University

Summary

在这里，我们提出了一种非插管方案，用于在保留自主呼吸的情况下进行视频辅助胸腔镜手术。

Abstract

全身麻醉下的双腔插管是目前肺切除术、肺楔形切除术和肺叶切除术最常用的插管技术。然而，气管插管全身麻醉引起的肺部并发症发生率很高。保留自主呼吸的非插管是麻醉的替代方法。非插管操作可最大限度地减少气管插管和全身麻醉的不良反应，例如插管相关的气道创伤、通气引起的肺损伤、残留的神经肌肉阻滞以及术后恶心和呕吐。然而，许多研究没有详细说明非插管程序的步骤。在这里，我们提出了一个简明的非插管方案，用于在保留自主呼吸的情况下进行视频辅助胸腔镜手术。本文确定了从非插管麻醉转换为插管麻醉的必要条件，并讨论了非插管麻醉的优点和局限性。在这项工作中，对58名患者进行了这种干预。此外，还介绍了回顾性研究的结果。与插管全身麻醉相比，非插管视频辅助胸外科组患者术后肺部并发症发生率更低，手术时间更短，术中失血更少，PACU住院时间更短，胸引流移除天数更少，术后引流更少，住院时间更短。

Introduction

近十年来，非插管视频辅助胸外科（NIVATS）麻醉逐渐被临床实践所接受1,2,3。尽管这种新策略提高了患者的快速恢复，并避免了全身麻醉（GA）和单肺通气的并发症4，但许多外科医生认为这种方法不如传统的肺隔离技术理想。

血氧水平随着年龄的增长而下降，一些患者可能出现肺功能下降或接近肺功能。GA 可能与此类患者并发症风险增加有关，包括麻醉延迟出现、气道并发症、声音嘶哑、缺氧和样肛脱位 5,6,7,8,9。相比之下，多项研究记录了接受NIVATS治疗的患者住院时间缩短，低风险患者与全身麻醉相比，呼吸系统并发症减少10;此外，甚至在肺功能非常差的高危患者中也报道了成功的手术11,12,13。

手术期间的自主通气是通过仔细施用的局部麻醉或辅以镇静剂的区域神经阻滞来实现的，但在NIVATS期间，咳嗽反射伴意外的肺运动可能会出现问题。对于可能干扰外科手术的纵隔扑动、刺激性咳嗽或呼吸急促，很少强调也没有标准治疗方法。初步观察结果显示，七氟醚在保持自主呼吸的同时，可降低NIVATS期间的呼吸频率和纵隔扑动的发生14。因此，可以假设七氟醚吸入可以预防咳嗽并减少机械通气的需求，从而减少术后肺部并发症（PPCs）。

首先，本报告提供了一个分步方案，详细说明了非插管视频辅助胸腔镜手术的执行。其次，进行回顾性研究，调查非插管麻醉对术后结局的潜在益处。

Protocol

该研究于2018年12月10日获得宁波大学医学院附属医院伦理委员会（KY20181215）的批准。 1. 入选标准 包括所有接受肺大疱切除术、肺楔形切除术或肺叶切除术的患者（>18 岁）。 2. 排除标准 根据美国麻醉医师协会 （ASA） 的躯体状态分类 >315 排除患者。 排除体重指数 （BMI） …

Representative Results

回顾性收集了2016年1月至2022年12月连续接受非插管视频辅助胸腔镜手术的58例患者的临床数据。麻醉师对患者进行了术前访问，并在麻醉前对麻醉知情同意书的内容进行了详细说明。允许患者选择麻醉的两组（NIVATS组或GA组）之一，并签署知情同意书。 GA组患者诱导咪达唑仑0.04mg/kg、丙泊酚2.5mg/kg、依托咪酯0.3mg/kg、舒芬太尼0.5μg/kg、罗库溴铵1.2mg/kg。正性肌力药物完全起效后，…

Discussion

该方案的优点如下：（i）提供七氟醚吸入麻醉方案以减少胸腔镜手术期间的咳嗽反射;（ii） 尽量减少过度镇静，同时为接受胸外科手术的患者提供安全无痛的手术环境;（iii）尽量减少患者在手术过程中的自主呼吸和纵隔振荡，同时考虑到相关的技术挑战。这是通过提供先发制人的术中局部麻醉来实现的。

2004年，蓬佩奥等首次报道了胸腔镜肺结节切除术的完成，无需气管插?…

Divulgazioni

The authors have nothing to disclose.

Acknowledgements

这项工作得到了第三批宁波市卫生青年技术干部计划（朱彬斌博士）和浙江省医学会临床研究基金项目（高斌博士）（2018ZYC-A66）的支持。

Materials

20-G top-winged infusion needle BD Intima II 383012 Puncture with a 20-G top-winged infusion needle into the dorsal vein of the non-operative side of the hand.
24-G top-winged infusion needle BD Intima II 383033 Thoracoscopic vagal block techniques
Anesthesia machine Drager A300 Maintenance of respiratory function; Inhalation anesthesia; Monitor for electrocardiography, blood pressure, pulse oxygen saturation (SpO2), end-tidal carbon dioxide and respiratory rate
Atropine Jiuquan Dadeli Pharma H62020772 Control of heart rate
BIS COVIDIEN B277243 Monitor the level of consciousness
Disposable nerve block needle Tuoren Medical Device  202303007 Nerve block
Facial mask Emedica EM01-105S Provides an effective non-invasive breathing circuit
Fentanyl. Renfu Pharma 21D04021 Analgesia
Flurbiprofen Daan Pharma H20183054 Analgesia
Laryngeal mask  Ambu Aura-i 2012-2664652 Airway management to preserve voluntary breathing
Levobupivacaine Rundu Pharma H20050403 Local Anaesthesia
Lidocaine Kelun Pharma F221129C Local skin infiltration
Norepinephrine Lijun Pharma H61021666 Control of blood pressure
Portable color doppler ultrasound SonoSite M-Turbo Guided nerve block
Propofol Guorui Pharma H20030114 Sedation and hypnosis
Ropivacaine Aspen Pharma 6091403219940 Paravertebral nerve block
Saline Kelun Pharma c221201E1 Assisted subsonic localisation
Sevoflurane  Shanghai Hengrui Pharmaceutical Co.,Ltd 9081931 Anesthesia induction and maintenance
Sufentanil Jiangsu Enhua Pharmaceutical Co., Ltd H20203650 Postoperative analgesia
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Tags

Keywords: Non-intubated Video-assisted Thoracoscopic SurgeryNIVATSMultimodal AnalgesiaThoracic Paravertebral BlockadeSevoflurane Inhalation AnesthesiaSpontaneous BreathingPulmonary ComplicationsGeneral AnesthesiaIntubation-related Airway TraumaVentilation-induced Lung InjuryPost-operative Nausea And Vomiting
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Citazione di questo articolo
Bin, G., Wenjun, L., Yu, G., Zhipeng, X., Binbin, Z., Lina, Y. Non-Intubated Video-Assisted Thoracoscopic Surgery. J. Vis. Exp. (195), e65235, doi:10.3791/65235 (2023).
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