喉罩与气管插管对腹腔镜下胆囊切除术患者胃胀气及术后恶心呕吐的影响

2020-08-31 11:32:23 中国当代医药 2020年20期

邹鲁 屈媛媛 许旭东

[摘要]目的 探討喉罩与气管插管对腹腔镜下胆囊切除术患者胃胀气及术后恶心呕吐(PONV)的影响。方法 选取2016年9月~2017年9月在常州市中医医院行择期腹腔镜下胆囊切除术的90例患者,按照随机数字表法分为气管插管(T)组、喉罩压力控制通气(P)组和喉罩容量控制通气(V)组,每组各30例。使用超声测定喉罩(或气管导管)置入成功后(T0)和手术结束后(T1)的胃窦面积(GAA)变化,并比较三组患者术后恶心呕吐发生率。结果  三组患者T0时的GAA比较,差异无统计学意义(P>0.05);V组和P组T1时的GAA大于T0,差异有统计学意义(P<0.05);V组和P组T1时的GAA大于T组,差异有统计学意义(P<0.05);V组和P组T1时PONV的发生率高于T组,差异有统计学意义(P<0.05)。 结论 与常规气管插管比较,喉罩全身麻醉患者术后胃胀气以及PONV发生率明显增高。

[关键词]喉罩;全身麻醉;胃胀气;超声;恶心呕吐

[中图分类号] R614          [文献标识码] A          [文章编号] 1674-4721(2020)7(b)-0153-04

Influence of laryngeal mask airway and tracheal intubation on flatulence and postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

ZOU Lu   QU Yuan-yuan   XU Xu-dong

Department of Anaesthesiology, Changzhou Traditional Chinese Medicine Hospital, Jiangsu Province, Changzhou   213001, China

[Abstract] Objective To investigate the influence of laryngeal mask airway and tracheal intubation on flatulence and postoperative nause and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy. Methods A total of 90 patients undergoing elective laparoscopic cholecystectomy at Changzhou Traditional Chinese Medicine Hospital from September 2016 to September 2017 were enrolled. According to the random number table methods, they were divided into the tracheal intubation (T) group, the laryngeal mask pressure control ventilation (P) group and the laryngeal mask volume control ventilation (V) group, 30 cases in each group. Ultrasound was used to measure changes in gastric antrum area (GAA) after successful placement of the laryngeal mask or tracheal tube (T0) and after surgery (T1), and the incidence of PONV were compared between the three groups. Results There were no significant differences in GAA between the three groups at T0 (P>0.05). The GAA of group V and group P at T1 were larger than those at T0, the differences were statistically significant (P<0.05). The GAA at T1 of group V and group P were larger than those of group T, the differences were statistically significant (P<0.05). The incidence of PONV of group V and group P were higher than that of group T, and the differences were statistically significant (P<0.05). Conclusion Compared with conventional tracheal intubation, the degree of gastric distention and the incidence of PONV after general anesthesia with LMA are significantly increased.

[Key words] Laryngeal mask airway; General anesthesia; Flatulence; Ultrasound; Nausea and vomiting

2结果

2.1三组患者T0及T1时GAA的比较

三组患者T0时的GAA比较,差异无统计学意义(P>0.05)。V组和P组T1时的GAA大于T0时,差异有统计学意义(P<0.05);T组T1时的GAA与T0时比较,差异无统计学意义(P>0.05);V组和P组T1时的GAA大于T组,差异有统计学意义(P<0.05);V组和P组T1时的GAA比较,差异无统计学意义(P>0.05)(表2)。

2.2三组患者术后24 h内PONV发生率的比较

T组术后24 h内PONV发生3例,V组术后24 h内PONV发生12例,P组术后24 h内PONV发生11例,三组比较差异有统计学意义(χ2=7.897,P=0.019)。V组患者的PONV发生率高于T组,差异有统计学意义(χ2=7.200,P=0.007);P组患者的PONV发生率高于T组,差异有统计学意义(χ2=5.963,P=0.015);V组与P组患者的PONV发生率比较,差异无统计学意义(χ2=0.071,P=0.791)。

3讨论

LMA因其不良反应少、操作相对简便,被广泛应用于短时全身麻醉手术中,尤其是腔镜手术中[6]。随着科学技术的进步以及新材料的应用,LMA控制通气的可靠性明显改善[7],但由于固有的结构特点,其插入下咽腔的部位会引起食管括约肌不能完全关闭,气道也无法保证绝对密闭,这使得胃肠道胀气的风险高于常规气管插管[8]。Park等[9]观察到在儿童手术中使用i-gel喉罩,如果不同时置入胃管,无论使用何种通气模式,术后胃胀气均会发生。

超声检查因其具有无创、方便、安全等优点,近年来广泛用于检测胃容积及胃排空情况,尤其适用于孕妇及儿童。超声测定方法一般分为全胃体积法、胃窦体积法、胃窦单切面积法3种,目前多采用胃窦单切面积法。Hamada等[10]采用超声检测危重患者GAA并计算其胃容积大小,证实了实时超声法在危重病患特别是具有高度误吸风险的病患中测定其胃排空具有可行性和有效性。Bouvet等[11]的研究也同样显示,超声测定GAA与真实胃容量具有良好的相关性,因此,通过超声测量麻醉前后GAA,可以较好地判定胃的胀气程度。本研究结果显示,V组和P组患者T1时的GAA测量值均较T0时显著增加,差异有统计学意义(P<0.05),T组比较无统计学意义(P>0.05),提示LMA通气与常规气管插管相比,无论采用压力控制或者容量控制通气模式,都会增加患者术后胃胀气的程度。

胃胀气带来的胃体积变大除了会影响手术视野、增加手术难度以外,还可能增加术后并发症的风险。既往文献报道,患者全身麻醉诱导后胃胀气的程度与术后早期恶心呕吐的发生率成正相关[12],胃胀气超过诱导前的10%就会明显增加患者PONV的发生率[13]。在本研究中,与T组比较,V组和P组术后24 h内的PONV发生率显著升高,差异有统计学意义(P<0.017),进一步说明术后胃胀气的程度与PONV的发生率具有一致性。分析其原因可能为:①气体进入胃肠道后,牵拉胃壁及肠管,兴奋迷走和内脏传入神经,并传至中枢神经系统,最终诱发呕吐反射[14];②胃胀气影响患者术后胃肠功能的恢复[15];③胃胀气可能会导致患者的胃液反流,刺激咽喉部,诱发恶心呕吐。

综上所述,与常规气管插管比较,喉罩全身麻醉术后胃胀气以及PONV发生率明显增高。因此,对于PONV高危患者以及未严格禁食的急诊患者,如何选择最佳的通气装置,减少术后并发症,提高术后恢复期的满意度,缩短患者住院时间,是临床上需要进一步研究的问题。

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(收稿日期:2020-01-22)