JoVE Journal > Medicine
Summary
Abstract
Introduction
Protocol
Risultati
Discussion
Divulgazioni
Acknowledgements
Materials
Riferimenti
Traduzione automatica
Please note that all translations are automatically generated. Click here for the English version.
Medicina

挿管されていないビデオ支援胸腔鏡手術

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

ここでは、自律呼吸を維持しながらビデオ支援胸腔鏡手術を行うための非挿管プロトコルを紹介します。

Abstract

全身麻酔下での二重管腔挿管は、現在、肺摘出術、肺のくさび切除術、および葉切除術で最も一般的に行われている挿管技術です。しかし、気管挿管による全身麻酔に起因する肺合併症の発生率は高い。自発呼吸の維持を伴う非挿管は、麻酔に代わるものです。挿管以外の処置は、挿管関連の気道外傷、換気誘発性肺損傷、残存神経筋遮断、術後の悪心および嘔吐など、気管挿管および全身麻酔の悪影響を最小限に抑えます。ただし、挿管以外の手順の手順は、多くの研究では詳しく説明されていません。ここでは、自律呼吸を維持したビデオ支援胸腔鏡手術を行うための簡潔な非挿管プロトコルを紹介します。この記事では、挿管されていない麻酔から挿管された麻酔に変換するために必要な条件を特定し、挿管されていない麻酔の利点と制限についても説明します。この研究では、この介入は58人の患者に対して行われました。さらに、後ろ向き研究の結果が提示されます。挿管された全身麻酔と比較して、挿管されていないビデオ支援胸部手術群の患者は、術後肺合併症の発生率が低く、手術時間が短く、術中の失血が少なく、PACU滞在が短く、胸腔ドレーン除去までの日数が少なく、術後ドレナージが少なく、入院期間が短かった。

Introduction

過去10年間で、挿管されていないビデオ支援胸部手術(NIVATS)麻酔は、臨床診療で徐々に受け入れられてきました1,2,3。この新しい戦略は、患者の迅速な回復を促進し、全身麻酔(GA)と片肺換気4の合併症を回避しますが、多くの外科医は、このアプローチを従来の肺隔離技術よりも望ましくないと考えています。

血中酸素濃度は年齢とともに低下し、一部の患者は肺機能が低下しているか、境界化している可能性があります。GAは、麻酔からの出芽の遅れ、気道合併症、嗄声、低酸素症、披裂脱臼など、そのような患者の合併症のリスクの増加と関連している可能性があります5,6,7,8,9。対照的に、複数の研究では、NIVATSで管理されている患者の入院期間が短く、低リスク患者の全身麻酔と比較して呼吸器合併症が減少していることが記録されています10;さらに、肺機能が非常に悪い高リスク患者でも手術の成功が報告されています11,12,13。

手術中の自発換気は、慎重に投与された局所麻酔または鎮静を補った局所神経ブロックによって達成されますが、予期しない肺の動きを伴う咳反射は、NIVATS中に問題になる可能性があります。縦隔粗動、刺激性咳、または頻呼吸に対する標準的な治療法はほとんど強調されておらず、外科的処置を混乱させる可能性があります。予備観察では、結果は、セボフルランが自発呼吸を維持しながら、NIVATS中の呼吸数と縦隔フラッターの発生を減少させる可能性があることを示しました14。したがって、セボフルラン吸入は咳を防ぎ、機械的換気の必要性を減らし、それによって術後肺合併症(PPC)を減らす可能性があるという仮説を立てることができます。

まず、このレポートは、挿管されていないビデオ支援胸腔鏡手術の実行を詳述する段階的なプロトコルを提示します。第二に、術後転帰に対する挿管されていない麻酔の潜在的な利益を調査するために後ろ向き研究が実施されました。

Protocol

この研究は、2018年12月10日に寧波大学医学部(KY20181215)の関連病院の倫理委員会によって承認されました。 1.選択基準 肺水疱切除術、肺ウェッジ切除術、または葉切除術を受けているすべての患者(>18歳)が含まれます。 2. 除外基準 米国麻酔科学会(ASA)の身体的状態分類に基づいて患者を除外します >3<sup class=…

Representative Results

臨床データは、2016年1月から2022年12月までに挿管されていないビデオ支援胸腔鏡手術を受けた58人の連続した患者について遡及的に収集されました。麻酔科医による術前訪問を受け,麻酔前に麻酔インフォームドコンセント書の内容について詳細な説明を受けた.患者は麻酔の2つのグループ(NIVATSグループまたはGAグループ)のいずれかを選択することを許可され、インフォームドコンセントフォ?…

Discussion

このプロトコルの利点は次のとおりです:(i)胸腔鏡手術中の咳反射を軽減するためのセボフルラン吸入麻酔レジメンの提供;(ii)胸部手術を受ける患者に安全で痛みのない手術環境を提供しながら、過剰鎮静を最小限に抑える。(iii)関連する技術的課題を考慮して、手順中の患者の自発呼吸および縦隔振動を最小限に抑える。これは、先制的な術中局所麻酔を提供することによって達成されまし?…

Divulgazioni

The authors have nothing to disclose.

Acknowledgements

この作業は、寧波健康青年技術幹部プログラムの第3バッチ(ビンビン・チュー博士)と浙江医師会臨床研究基金プロジェクト(ビン・ガオ博士)(2018ZYC-A66)によってサポートされました。

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
DOWNLOAD MATERIALS LIST

Riferimenti

  1. Sedrakyan, A., vander Meulen, J., Lewsey, J., Treasure, T. Video assisted thoracic surgery for treatment of pneumothorax and lung resections: Systematic review of randomised clinical trials. British Medical Journal. 329 (7473), 1008 (2004).
  2. Luh, S. P., Liu, H. P. Video-assisted thoracic surgery–The past, present status and the future. Journal of Zhejiang University Science B. 7 (2), 118-128 (2006).
  3. Hung, M. H., Hsu, H. H., Cheng, Y. J., Chen, J. S. Nonintubated thoracoscopic surgery: State of the art and future directions. Journal of Thoracic Disease. 6 (1), 2-9 (2014).
  4. Kelkar, K. V. Post-operative pulmonary complications after non-cardiothoracic surgery. Indian Journal of Anaesthesia. 59 (9), 599-605 (2015).
  5. Knoll, H., et al. Airway injuries after one-lung ventilation: A comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial. Anesthesiology. 105 (3), 471-477 (2006).
  6. Zhong, T., Wang, W., Chen, J., Ran, L., Story, D. A. Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: a randomised, prospective trial. Anaesthesia and Intensive. 37 (3), 441-446 (2009).
  7. Mikuni, I., et al. Arytenoid cartilage dislocation caused by a double-lumen endobronchial tube. British Journal of Anaesthesia. 96 (1), 136-138 (2006).
  8. Kurihara, N., et al. Hoarseness caused by arytenoid dislocation after surgery for lung cancer. General Thoracic and Cardiovascular Surgery. 62 (12), 730-733 (2014).
  9. Ceylan, K. C., et al. Intraoperative management of tracheobronchial rupture after double-lumen tube intubation. Surgery Today. 43 (7), 757-762 (2013).
  10. Yu, M. G., et al. Non-intubated anesthesia in patients undergoing video-assisted thoracoscopic surgery: A systematic review and meta-analysis. PloS One. 14 (11), (2019).
  11. Ambrogi, V., Sellitri, F., Perroni, G., Schillaci, O., Mineo, T. C. Uniportal video-assisted thoracic surgery colorectal lung metastasectomy in non-intubated anesthesia. Journal of Thoracic Disease. 9 (2), 254-261 (2017).
  12. Guo, Z., et al. Video-assisted thoracoscopic surgery segmentectomy by non-intubated or intubated anesthesia: A comparative analysis of short-term outcome. Journal of Thoracic Disease. 8 (3), 359-368 (2016).
  13. Liu, J., et al. The impact of non-intubated versus intubated anaesthesia on early outcomes of video-assisted thoracoscopic anatomical resection in non-small-cell lung cancer: A propensity score matching analysis. European Journal of Cardio-Thoracic Surgery. 50 (5), 920-925 (2016).
  14. Hausman, M. S., Jewell, E. S., Engoren, M. Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: Does avoiding general anesthesia reduce the risk of postoperative complications. Anesthesia and Analgesia. 120 (6), 1405-1412 (2015).
  15. Grott, M., et al. Thoracic surgery in the non-intubated spontaneously breathing patient. Respiratory Research. 23 (1), (2022).
  16. Hung, M. H., et al. Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation. European Journal of Cardio-Thoracic Surgery. 46 (4), 620-625 (2014).
  17. Guo, Z., et al. Analysis of feasibility and safety of complete video-assisted thoracoscopic resection of anatomic pulmonary segments under non-intubated anesthesia. Journal of Thoracic Disease. 6 (1), 37-44 (2014).
  18. Jammer, I., et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. European Journal of Anaesthesiology. 32 (2), 88-105 (2015).
  19. Pompeo, E., Mineo, D., Rogliani, P., Sabato, A. F., Mineo, T. C. Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. The Annals of Thoracic Surgery. 78 (5), 1761-1768 (2004).
  20. Ali, J. M., Volpi, S., Kaul, P., Aresu, G. Does the ‘non-intubated’ anaesthetic technique offer any advantage for patients undergoing pulmonary lobectomy. Interactive Cardiovascular and Thoracic Surgery. 28 (4), 555-558 (2019).
  21. Okuda, K., Nakanishi, R. The non-intubated anesthesia for airway surgery. Journal of Thoracic Disease. 8 (11), 3414-3419 (2016).
  22. Prince, J., Goertzen, C., Zanjir, M., Wong, M., Azarpazhooh, A. Airway complications in intubated versus laryngeal mask airway-managed dentistry: A meta-analysis. Anesthesia Progress. 68 (4), 193-205 (2021).
  23. Amer, G. F., Abdeldayem, O. T., Lahloub, F. M. F. Effect of local anesthesia and general anesthesia using I-gel laryngeal mask airway in diabetic patients undergoing cataract surgery: Comparative study. Anesthesia, Essays and Researches. 13 (2), 209-213 (2019).
  24. Sorbello, M., Afshari, A., De Hert, S. Device or target? A paradigm shift in airway management: Implications for guidelines, clinical practice and teaching. European Journal of Anaesthesiology. 35 (11), 811-814 (2018).
  25. Yamaguchi, T., et al. Feasibility of total intravenous anesthesia by cardiologists with the support of anesthesiologists during catheter ablation of atrial fibrillation. Journal of Cardiology. 72 (1), 19-25 (2018).
  26. Koyama, T., et al. Laryngeal mask versus facemask in the respiratory management during catheter ablation. BMC Anesthesiology. 20 (1), (2020).
  27. Qamarul Hoda, ., Samad, M., Ullah, K., H, ProSeal versus Classic laryngeal mask airway (LMA) for positive pressure ventilation in adults undergoing elective surgery. The Cochrane Database of Systematic Reviews. 7 (7), (2017).
  28. van Esch, B. F., Stegeman, I., Smit, A. L. Comparison of laryngeal mask airway vs tracheal intubation: A systematic review on airway complications. Journal of Clinical Anesthesia. 36, 142-150 (2017).
  29. Vanni, G., et al. Impact of awake videothoracoscopic surgery on postoperative lymphocyte responses. The Annals of Thoracic Surgery. 90 (3), 973-978 (2010).
  30. Liu, J., et al. Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study. Surgical Innovation. 22 (2), 123-130 (2015).
  31. Tacconi, F., Pompeo, E., Sellitri, F., Mineo, T. C. Surgical stress hormones response is reduced after awake videothoracoscopy. Interactive Cardiovascular and Thoracic Surgery. 10 (5), 666-671 (2010).
  32. Lai, H. C., et al. Sevoflurane is an effective adjuvant to propofol-based total intravenous anesthesia for attenuating cough reflex in nonintubated video-assisted thoracoscopic surgery. Medicina. 97 (42), (2018).
  33. Navarro-Martínez, J., et al. Intraoperative crisis resource management during a non-intubated video-assisted thoracoscopic surgery. Annals of Translational Medicine. 3 (8), 111 (2015).
  34. Melnyk, V., Ibinson, J. W., Kentor, M. L., Orebaugh, S. L. Updated retrospective single-center comparative analysis of peripheral nerve block complications using landmark peripheral nerve stimulation versus ultrasound guidance as a primary means of nerve localization. Journal of Ultrasound in Medicine. 37 (11), 2477-2488 (2018).
  35. Reynolds, R. P., Effer, G. W., Bendeck, M. P. The upper esophageal sphincter in the cat: The role of central innervation assessed by transient vagal blockade. Canadian Journal of Physiology and Pharmacology. 65 (1), 96-99 (1987).
  36. Neville, A. L., et al. Esophageal dysfunction in cervical spinal cord injury: a potentially important mechanism of aspiration. The Journal of Trauma. 59 (4), 905-911 (2005).
  37. Nishino, T., Kochi, T., Ishii, M. Differences in respiratory reflex responses from the larynx, trachea, and bronchi in anesthetized female subjects. Anesthesiology. 84 (1), 70-74 (1996).
  38. Regli, A., von Ungern-Sternberg, B. S. Anesthesia and ventilation strategies in children with asthma: part I – preoperative assessment. Current Opinion in Anaesthesiology. 27 (3), 288-294 (2014).
  39. Regli, A., von Ungern-Sternberg, B. S. Anesthesia and ventilation strategies in children with asthma: part II – intraoperative management. Current Opinion in Anaesthesiology. 27 (3), 295-302 (2014).
  40. Hung, M. H., et al. Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesia and intercostal blockade: A retrospective cohort study of 238 cases. Medicina. 94 (13), 727 (2015).
  41. Solli, P., Brandolini, J., Bertolaccini, L. Tubeless thoracic surgery: Ready for prime time. Journal of Thoracic Disease. 11 (3), 652-656 (2019).
  42. Deng, H. Y., et al. Non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia for thoracic surgery: A meta-analysis. Interactive Cardiovascular and Thoracic Surgery. 23 (1), 31-40 (2016).
  43. Liu, C. Y., et al. Tubeless single-port thoracoscopic sublobar resection: Indication and safety. Journal of Thoracic Disease. 10 (6), 3729-3737 (2018).
  44. Wu, C. Y., et al. Feasibility and safety of nonintubated thoracoscopic lobectomy for geriatric lung cancer patients. The Annals of Thoracic Surgery. 95 (2), 405-411 (2013).
  45. Pompeo, E., et al. Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery. The Journal of Thoracic and Cardiovascular Surgery. 143 (1), 47-54 (2012).
  46. Murphy, G. S., et al. Postoperative residual neuromuscular blockade is associated with impaired clinical recovery. Anesthesia and Analgesia. 117 (1), 133-141 (2013).
  47. Bevilacqua Filho, ., T, C., et al. Risk factors for postoperative pulmonary complications and prolonged hospital stay in pulmonary resection patients: A retrospective study. Brazilian Journal of Anesthesiology. 71 (4), 333-338 (2021).

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
check_url/it/65235?article_type=t

Play Video
PDF
DOI
DOWNLOAD MATERIALS LIST
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).
Scarica citazione
Ristampe e autorizzazioni

View Video

✖

To prove you're not a robot, please enter the text in the image below

CAPTCHA Image
Play CAPTCHA Audio
Refresh Image