南方医科大学学报

南方医科大学学报 ›› 2020, Vol. 40 ›› Issue (11): 1543-1549.doi: 10.12122/j.issn.1673-4254.2020.11.02

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快充式经鼻湿化高流量通气对肥胖患者全麻诱导期胃进气的影响： 基于超声评估的90例前瞻性临床试验

  

  • 出版日期:2020-11-20 发布日期:2020-11-23

Ultrasound assessment of gastric insufflation in obese patients receiving transnasal humidified rapid-insufflation ventilatory exchange during general anesthesia induction

  • Online:2020-11-20 Published:2020-11-23

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摘要： 目的 通过超声实时监测胃窦进气情况，评估快充式经鼻湿化高流量通气（THRIVE）在全身麻醉诱导时对肥胖患者胃进气的影响。方法 纳入90例于全麻下行腹腔镜胆囊手术的肥胖患者，BMI：30~39.9 kg/m2，随机分为面罩组（M组）、快充式经鼻湿化高流量通气（THRIVE）组（T组）、面罩复合THRIVE组（M+T组），30例/组。全麻诱导期，M组经面罩预给氧并在诱导给药后行面罩辅助通气（FMV）；T组经THRIVE给氧；M+T组经面罩复合THRIVE预给氧，于诱导给药后行FMV复合THRIVE给氧。气管插管期，T组及M+T组患者接受THRIVE持续给氧。超声监测各患者胃窦部，超声图像出现“彗尾征”则定义为胃进气阳性（GI+）。测量预给氧前后以及插管后的胃窦部横截面积（CSA-GA），记录T（1 入室）、T（2 预充氧5 min后）、T（3 诱导给药5 min后）、T（4 插管后即刻）各时点脉搏氧饱和度（SpO2）、血氧分压（PaO2）、二氧化碳分压（PaCO2）及术后恶心呕吐等不良事件发生率。结果 与T组比较，M和M+T组胃进气发生率显著增加（P<0.05）。与T1时间点比较，M组和M+T组CSA-GA在T4时间点显著增加；与T1时间点比较，M组和M+T组的GI+亚组CSA-GA在T4时间点均显著增加；在T4时间点，M组和M+T组的GI+亚组CSA-GA大于本组GI-亚组（P<0.05）。T组各时间点的CSA-GA无统计学差异（P>0.05）。腔镜直视下胃胀分级结果提示，与T组比较，M组和M+T组腔镜直视下胃胀分级Ⅰ°患者占比例显著减少，Ⅱ°患者占比例显著增加（P<0.05）。窒息插管期（即T3~T4），M组PaO2变化值（ΔPaO2）显著大于T组和M+T组（P<0.05）。结论 超声监测观察胃窦部“彗尾征”及CSA-GA变化是一种可行、可靠的胃进气检测方法；而THRIVE用于肥胖病例的麻醉诱导能够在保证患者氧合的情况下不会进一步增加胃进气。

关键词: 胃超声, 胃窦面积, 胃进气, 肥胖, 快充式经鼻湿化高流量通气

Abstract: Objective To assess the effect of transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) on gastric insufflation during general anesthesia induction in obese patients. Methods Ninety obese patients (BMI 30-39.9 kg/m2) undergoing laparoscopic cholecystectomy under general anesthesia were randomized into 3 groups (n=30) to receive facemask pre- oxygenation followed by face mask ventilation (FMV) after administration of anesthetics (Group M), oxygenation with THRIVE (Group T), or pre-oxygenation with facemask combined with THRIVE followed continuous oxygenation with both FMV and THRIVE after administration of anesthetics (Group M+T). The patients in the latter two groups received continuous oxygen via THRIVE during tracheal intubation. All the patients received real-time ultrasound monitoring of the gastric antrum, and positive gastric insufflation (GI+) was defined by the presence of comet-tail artifacts. The cross-sectional area of the gastic antrum (CSA-GA) was measured by ultrasound before and after pre-oxygenation and after intubation. The patients' SpO2, PaO2, and PaCO2 at admission (T1), 5 min after pre-oxygenation (T2), 5 min after medication (T3), and immediately after intubation (T4) were recorded, and the incidence of postoperative adverse events was assessed. Results The incidence of gastric insufflation was significantly higher in Group M and Group M+T than in Group T (P<0.05). The CSA-GA was significantly greater at T4 than at T1 in Group M and Group M+T and in their GI+s ubgroups. The GI+ subgroups in Group M and Group M+T had significantly larger CSA-GA at T4 than the GI- subgroups (P<0.05). CSA-GA did not vary significantly during anesthesia induction in Group T (P>0.05). The incidence of grade I gastric distension was lower but grade II gastric distention was higher in Group M and Group M+T than in Group T (P<0.05). Group M showed significantly greater variations of PaO2 at T3 and T4 than Group T and Group M+T (P<0.05). Conclusion Ultrasound monitoring of the comet tail sign and the changes of CSA-GA in the gastric antrum is feasible and reliable for detecting gastrointestinal airflow, and in obese patients, the application of THRIVE for induction of anesthesia can ensure the oxygenation level without further increasing gastric insufflation.

Key words: gastric ultrasound, antrum area, gastric insufflation, obesity, transnasal humidified rapidinsufflation ventilatory exchange