全麻誘導(dǎo)前加溫SLIPA喉罩對(duì)術(shù)后咽喉部并發(fā)癥的影響

耿桂啟　陳穎潔　劉海戀　劉　艷

(復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院麻醉科　上海　200090)

?

全麻誘導(dǎo)前加溫SLIPA喉罩對(duì)術(shù)后咽喉部并發(fā)癥的影響

耿桂啟△陳穎潔劉海戀劉艷

(復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院麻醉科上海200090)

目的探討預(yù)先加熱流線形尾管的咽部氣道(streamlined liner of pharyngeal airway,SLIPA)喉罩的安全性以及對(duì)術(shù)后并發(fā)癥的影響。方法將10只SLIPA喉罩連同紙塑包裝一起預(yù)先放至42 ℃暖箱中,24 h后取出打開包裝以無菌棉簽擦拭表面進(jìn)行細(xì)菌培養(yǎng),室溫放置的10只SLIPA喉罩同樣進(jìn)行細(xì)菌培養(yǎng)。選擇全麻下婦科宮腔鏡手術(shù)患者100例,隨機(jī)分為加溫組和對(duì)照組(各50例);加溫組在全麻誘導(dǎo)前先將SLIPA喉罩預(yù)先放入42 ℃暖箱中1 h,誘導(dǎo)后將加溫的SLIPA喉罩涂抹石蠟油后進(jìn)行置入;對(duì)照組則在全麻誘導(dǎo)后將室溫SLIPA喉罩涂抹石蠟油進(jìn)行置入;所有喉罩置入均由同一操作者進(jìn)行。記錄喉罩置入時(shí)間、最大氣道密封壓、置入前后血流動(dòng)力學(xué)變化、喉罩拔除后血跡陽(yáng)性率、咽喉痛及視覺模擬評(píng)分情況。結(jié)果兩組SLIPA喉罩細(xì)菌培養(yǎng)結(jié)果均為陰性。加溫組和對(duì)照組喉罩置入時(shí)間分別為(7.1±2.5) s和(8.8±3.8) s,差異有統(tǒng)計(jì)學(xué)意義(P=0.02);兩組最大氣道密封壓分別為25.1 cmH2O和23.5 cmH2O,差異無統(tǒng)計(jì)學(xué)意義;喉罩置入后平均動(dòng)脈壓以及心率較置入前均明顯升高,但組間比較差異無統(tǒng)計(jì)學(xué)意義;加溫組喉罩拔除后血跡陽(yáng)性率、咽喉痛發(fā)生率以及咽喉痛評(píng)分(12%、56%、1.4±1.1)顯著低于對(duì)照組(40%、100%、3.1±2.4)(P < 0.05)。結(jié)論SLIPA喉罩預(yù)先加溫有利于置入,并可以降低置入后相關(guān)并發(fā)癥。

加溫處理;SLIPA喉罩;咽喉痛

流線形尾管的咽部氣道 (streamlined liner of pharyngeal airway,SLIPA)喉罩由軟塑料吹制塑形而成,結(jié)構(gòu)簡(jiǎn)單,無充氣罩,在使用中具有放置簡(jiǎn)便、無需喉鏡暴露聲門、不刺激氣管、機(jī)體應(yīng)激反應(yīng)小及患者耐受性好等優(yōu)點(diǎn),能夠獲得良好的呼吸道密封,并可用于正壓通氣。因此SLIPA喉罩在全麻中的使用越來越廣泛,特別是短小手術(shù)的全麻[1-2]。但是近年來也有文獻(xiàn)報(bào)道[3-4],由于SLIPA喉罩材質(zhì)硬及其形狀特點(diǎn),其導(dǎo)致術(shù)后咽喉痛發(fā)生幾率更高、疼痛程度更嚴(yán)重,咽喉?yè)p傷出血的幾率也更高。

一定范圍內(nèi)加溫處理可以軟化塑料材質(zhì),加溫軟化后的SLIPA是否影響其無菌性,對(duì)置入后氣道密封性以及相關(guān)的并發(fā)癥是否有影響,這方面未見文獻(xiàn)報(bào)道,本研究對(duì)這些問題進(jìn)行了探討。

資 料 和 方法

喉罩加溫試驗(yàn)將10只SLIPA喉罩(浙江杭州富善醫(yī)療器械有限公司)連同紙塑包裝一起放入42 ℃暖箱(日本Sanyo公司)中,放置24 h后打開外包裝,以無菌棉簽擦拭喉罩罩體外表面后進(jìn)行細(xì)菌培養(yǎng);對(duì)照組為室溫放置的10只SLIPA喉罩,同樣方法進(jìn)行細(xì)菌培養(yǎng)。

喉罩試驗(yàn)分組及實(shí)施在前述試驗(yàn)的基礎(chǔ)上,經(jīng)復(fù)旦大學(xué)附屬婦產(chǎn)科醫(yī)院倫理學(xué)委員會(huì)同意,選擇本院2015年8月——9月行婦科宮腔鏡手術(shù)患者100例,年齡18～60歲,體重50～75 kg,ASA分級(jí)Ⅰ-Ⅱ級(jí)。隨機(jī)分為加溫組(n=50)和對(duì)照組(n=50)。排除標(biāo)準(zhǔn):近期有上呼吸道感染,既往有慢性咽喉炎病史,合并高血壓、心臟病者,體質(zhì)指數(shù)≥30 kg/m2。所有患者簽署知情同意書。

所有患者均未用術(shù)前藥?；颊哌M(jìn)入手術(shù)室后常規(guī)監(jiān)測(cè)無創(chuàng)動(dòng)脈血壓、心電圖、脈搏氧飽和度,記錄基礎(chǔ)血壓及心率,經(jīng)面罩進(jìn)行吸氧。建立靜脈通道,以乳酸鈉林格氏注射液500 mL輸液。靜脈給予瑞芬太尼1 μg/ kg及丙泊酚2 mg/kg,待患者意識(shí)消失靜注琥珀酰膽堿1mg/kg后以手控通氣,1 min后由同一操作者徒手法進(jìn)行喉罩置入;加溫組SLIPA喉罩預(yù)先放入42 ℃暖箱中1h,對(duì)照組放置室溫中(22 ℃～24 ℃)。喉罩型號(hào)選擇根據(jù)廠家推薦方法:體重41～60 kg選用49號(hào),體重61～70 kg選用51號(hào)。本研究中部分患者體重稍大于70 kg,也選擇使用51號(hào)。

喉罩置入時(shí)間以喉罩接觸牙齒開始至喉罩調(diào)整到位,喉罩置入后觀察PetCO2矩形曲線及呼吸音聽診調(diào)整位置,插入成功標(biāo)志:PetCO2波形正常,無氣體從口咽部漏出,通氣阻力小、雙側(cè)胸廓起伏良好[5]。置入成功后關(guān)閉呼吸閥,新鮮氣流量限制在3.0 L/min時(shí),氣道壓開始上升,當(dāng)氣道壓達(dá)到最高而形成平臺(tái)時(shí),此時(shí)的平臺(tái)氣道壓為呼吸道密封壓[6]。以麻醉機(jī)(Datex-ohmeda,美國(guó)GE公司)行機(jī)械通氣,潮氣量8 mL/kg,呼吸頻率10～12次/分,以丙泊酚6～8 mg·kg-1·h-1、瑞芬太尼0.25 μg·kg-1·min-1維持麻醉,記錄喉罩置入前后1 min以及術(shù)中每5分鐘患者平均動(dòng)脈壓及心率變化。麻醉誘導(dǎo)后經(jīng)靜脈給予氟比洛芬酯50 mg用于術(shù)后鎮(zhèn)痛。

術(shù)后觀察指標(biāo)手術(shù)結(jié)束待患者自主呼吸恢復(fù)后拔除喉罩,觀察并記錄喉罩表面是否有血跡,患者在恢復(fù)室觀察1 h后,由一位不明分組的護(hù)士采用視覺模擬評(píng)分(visual analoge scale,VAS)詢問患者靜息狀態(tài)以及吞咽時(shí)咽喉疼痛評(píng)分,以0～10分表示,0分表示不痛,10分表示最痛。

結(jié)　　　果

一般情況兩組喉罩細(xì)菌培養(yǎng)結(jié)果均為陰性,說明加溫軟化SLIPA面罩后對(duì)無菌性沒有影響。

所有患者均完成試驗(yàn),麻醉及手術(shù)過程平穩(wěn)順利,兩組患者一般情況以及麻醉持續(xù)時(shí)間無明顯差別(表1)。

表1　兩組患者一般情況比較

置入情況比較加溫組患者第一次置入成功率為100%,對(duì)照組為96%,對(duì)照組有2例經(jīng)換用小一號(hào)SLIPA喉罩才放置成功,但兩組成功率差異無統(tǒng)計(jì)學(xué)意義;加溫組患者置入時(shí)間為(7.1±2.5)s,對(duì)照組為(8.8±3.8) s,差異有統(tǒng)計(jì)學(xué)意義(t=2.36,P=0.02)。兩組患者氣道密封壓分別為(25.1±5.2) cmH2O和(23.5±4.7) cmH2O (1cmH2O=0.098 kPa),差異無統(tǒng)計(jì)學(xué)意義。

兩組患者喉罩置入后平均動(dòng)脈壓均顯著升高,同置入前相比,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05);喉罩置入前后兩組患者心率均明顯升高(P<0.01);但兩組之間比較差異無統(tǒng)計(jì)學(xué)意義(表2)。

術(shù)后情況比較在喉罩拔除后,加溫組患者共有6例發(fā)生喉罩表面帶血,而對(duì)照組共有20例發(fā)生喉罩表面帶血,差異具有顯著統(tǒng)計(jì)學(xué)意義(χ2=8.78,P=0.003)。無論是靜息狀態(tài)下還是吞咽時(shí),加溫組患者VAS均顯著低于對(duì)照組(t=3.62,P=0.001)和(t=4.07,P=0.000 1);對(duì)照組咽喉痛發(fā)生率顯著高于加溫組(χ2=5.09,P=0.024)(表3)。

表2　兩組患者喉罩置入前后平均動(dòng)脈壓及心率變化

MAP:Mean arterial pressure;HR:Heart rate;a1 mmHg=0.133 kPa;(1)vs.MAP before insertion,(2)vs.HR before insertion,P < 0.05.

表3　SLIPA喉罩置入后相關(guān)并發(fā)癥

VAS:Visual analoge scale;(1)vs.control group,P < 0.05.

討　　　論

本研究中對(duì)照組SLIPA喉罩第一次置入成功率為96%,與文獻(xiàn)報(bào)道相一致。Markus等[7]比較了第一代經(jīng)典LMA喉罩和SLIPA喉罩的首次置入成功率,分別為100%和98%,Miller等[8]也報(bào)道了相似的成功率。由于SLIPA喉罩結(jié)構(gòu)上與咽喉部形狀相似,因此選擇合適的型號(hào)非常重要。在本研究中,喉罩選擇均按照統(tǒng)一標(biāo)準(zhǔn),置入操作均由同一人完成;但在對(duì)照組,仍有2例患者經(jīng)換用小一號(hào)SLIPA喉罩才置入成功,可能與SLIPA喉罩的固定形狀及其材質(zhì)相對(duì)較硬有關(guān)。在加溫組,SLIPA喉罩均一次置入成功,加溫后喉罩形狀并未改變但變得相對(duì)柔軟,使得喉罩在置入過程中遇到阻力后容易彎曲,因而更容易置入。從兩組患者喉罩置入時(shí)間來看,加溫組需用的時(shí)間更短,提示加溫后的SLIPA喉罩更有利于置入。

既往有文獻(xiàn)[9]比較了SLIPA 和第三代PLMA喉罩置入時(shí)對(duì)于血壓和心率的影響,發(fā)現(xiàn)SLIPA喉罩組血流動(dòng)力學(xué)改變更明顯,說明SLIPA喉罩由于形狀特點(diǎn)以及材質(zhì)關(guān)系,引起的應(yīng)激反應(yīng)相對(duì)更為明顯。本研究中,SLIPA喉罩置入后平均動(dòng)脈壓和心率較置入前均顯著升高,但組間比較差異無統(tǒng)計(jì)學(xué)意義。 因此,如何提高SLIPA置入技巧、改變材質(zhì)以及選擇合適型號(hào)對(duì)于減少應(yīng)激反應(yīng)十分重要。

當(dāng)氣道壓力超過封閉壓時(shí),就會(huì)出現(xiàn)氣體漏出,這可能導(dǎo)致通氣不足[10]。在本研究中,兩組患者氣道封閉壓無明顯差異,說明加溫變軟后的SLIPA喉罩并不影響其密封性。

Miller等[8]報(bào)道了SLIPA喉罩引起咽喉痛的發(fā)生率為49%。這與本研究中對(duì)照組咽喉痛發(fā)生率相一致。為了保持固定的形狀,SLIPA喉罩選擇相對(duì)更硬的材質(zhì)[4],這也是SLIPA喉罩導(dǎo)致術(shù)后咽喉痛發(fā)生率高的原因之一;而在加溫組,由于SLIPA加溫變軟后,其對(duì)咽喉部黏膜刺激的強(qiáng)度降低,術(shù)后喉罩表面血跡陽(yáng)性率、咽喉痛的發(fā)生率以及疼痛嚴(yán)重程度均明顯降低。在對(duì)照組,更長(zhǎng)的喉罩置入時(shí)間,甚至需要不斷調(diào)整方向才能順利置入,這可能也是兩組間咽喉痛具有顯著差異的原因之一。

在本試驗(yàn)中,我們將暖箱的溫度設(shè)置在42 ℃,是因?yàn)镾LIPA喉罩需要在全麻誘導(dǎo)前從暖箱中拿出,而且要在置入前涂抹石蠟油,后者也會(huì)進(jìn)一步降低喉罩的溫度;由于條件限制,加溫后的SLIPA喉罩在置入前其表面溫度并沒有準(zhǔn)確測(cè)量,這也是本研究的局限性之一。另外由于宮腔鏡是短小手術(shù),術(shù)中沒有使用長(zhǎng)效阿片類藥物,瑞芬太尼引起的痛覺過敏無法排除,是否會(huì)影響術(shù)后咽喉痛的嚴(yán)重程度尚不得而知。

總之,通過加溫可使SLIPA喉罩軟化,可以有利于置入,并降低SLIPA喉罩引起的咽喉痛等相關(guān)并發(fā)癥,該方法操作簡(jiǎn)便,減少了應(yīng)用藥物預(yù)防咽喉痛所造成的不良反應(yīng)。

[1]ROBAK O,LEONARDELLI M,ZEDTWITZ-LIEBENSTEIN K,et al.Feasibility and speed of insertion of seven supraglottic airway devices under simulated airway conditions [J].CJEM,2012,14(6):330-334.

[2]TIMMERMANN A.Supraglottic airways in difficult airway management:successes,failures,use and misuse [J].Anaesthesia,2011,66 (Suppl 2):45-56.

[3]ABDELLATIF AA,ALI MA.Comparison of streamlined liner of the pharynx airway (SLIPATM) with the laryngeal mask airway ProsealTMfor lower abdominal laparoscopic surgeries in paralyzed,anesthetized patients [J].Saudi J Anaesth,2011,5(3):270-276.

[4]CHOI YM,CHA SM,KANG H,et al.The clinical effectiveness of the streamlined liner of pharyngeal airway (SLIPA) compared with the laryngeal mask airway ProSeal during general anesthesia [J].Korean J Anesthesiol,2010,58(5):450-457.

[5]段宏軍,時(shí)勝男,左明章.Supreme喉罩用于腹腔鏡手術(shù)患者氣道管理的效果[J].中華麻醉學(xué)雜志,2010,30(3):341-343.

[6]KELLER C,BRIMACOMBE JR,KELLER K,et al.Comparison of four methods for assessing airway sealing pressure with the laryngeal mask airway in adult patients [J].Br J Anaesth,1999,82(2):286-287.

[7]MARKUS L,FRANZ K.The effectiveness and patient comfort of the novel streamlined pharynx airway liner (SLIPA) compared with the conventional laryngeal mask airway in ophthalmic surgery [J].Anesth Analg,2007,104(2):431-434.

[8]MILLER DM,CAMPOROTA L.Advantages of ProSeal and SLIPA airways over tracheal tubes for gynecological laparoscopies [J].Can J Anaesth,2006,53(2):188-193.

[9]PURI GD,HEGDE HV,JAYANT A,et al.Haemodynamic and Bispectral index response to insertion of the Streamlined Liner of the Pharynx Airway (SLIPA):comparison with the laryngeal mask airway [J].Anaesth Intensive Care,2008,36(3):404-410.

[10]WEILER N,LATORRE F,EBERLE B,et al.Respiratory mechanics,gastric insufflation pressure and air leakage of the laryngeal mask airway [J].Anesth Analg,1997,84(5):1025-1028.

E-mail:mzgengguiqi@163.com

The effects of thermal softening of streamlined liner of pharyngeal airway before anesthesia induction on postoperative throat complications

GENG Gui-qi△, CHEN Ying-jie, LIU Hai-lian, LIU Yan

(Department of Anesthesiology,Obstetrics & Gynecology Hospital,Fudan University,Shanghai 200090,China)

ObjectiveTo verify the safty of streamlined liner of pharyngeal airway (SLIPA) and whether preheating it could decrease the associated complication of placement.MethodsBacterial culture was conducted for SLIPA at room temperature and SLIPA heated at 42 ℃ for 24 hours.One hundred patients scheduled for hysteroscopic surgery to whom SLIPA was considered suitable were randomly allocated to preheating group or control group(50 cases for each group).The SLIPA in preheating group was placed in incubator which was set at 42 ℃ 1 hour before using and that in the control group was placed in room temperature of 24 ℃.The procedure was manipulated by the same operator.The duration of insertion,mean maximum sealing pressure and hemodynamics change as well as bloodstain incidence were evaluated and compared between the two groups.Patients were interviewed at recovery room about sore throat and visual analoge scale (VAS) score.Results Bacterial culture was negative in SLIPA at room temperature and SLIPA heated at 42 ℃ for 24 hours.The duration of insertion was (7.1±2.5) s in preheating group and (8.8±3.8) s in control group with significant statistical difference (P=0.02).There was no statistical difference in the maximum sealing pressure between the two groups (25.1 cmH2O vs.23.5 cmH2O).Mean arterial pressure and heart rate were all elevated after SLIPA was inserted either in preheating group or in the control group,but no significant difference was found between the two groups.There were statistical differences in incidence of blood stains,sore throat and VAS score of sore throat between preheating group(12%,56%,1.4±1.1)and control group(40%,100%,3.1±2.4) (P < 0.05).ConclusionsPreheating of the SLIPA decreased the complications related with the insertion of SLIPA.

heating precondition;SLIPA laryngeal mask;sore throat

R614.2

Bdoi: 10.3969/j.issn.1672-8467.2016.05.014

2016-02-19;編輯:張秀峰)