丁玲玲 張宏 馬鑫 張旭 王濤

1首都醫(yī)科大學(xué)附屬北京中醫(yī)醫(yī)院麻醉科 100853 北京2中國(guó)人民解放軍總醫(yī)院麻醉手術(shù)中心3中國(guó)人民解放軍總醫(yī)院泌尿外科

腎動(dòng)脈低溫灌注腹腔鏡腎部分切除術(shù)麻醉蘇醒期管理策略

丁玲玲1, 2張宏2馬鑫3張旭3王濤2

1首都醫(yī)科大學(xué)附屬北京中醫(yī)醫(yī)院麻醉科 100853 北京2中國(guó)人民解放軍總醫(yī)院麻醉手術(shù)中心3中國(guó)人民解放軍總醫(yī)院泌尿外科

目的探討腎動(dòng)脈低溫灌注腹腔鏡腎部分切除術(shù)對(duì)麻醉蘇醒期的影響及相關(guān)麻醉策略。方法回顧性分析40例完全內(nèi)生型腎腫瘤患者的臨床資料，40例分別采用腎動(dòng)脈低溫灌注與常規(guī)熱缺血腹腔鏡下腎部分切除術(shù)治療。40例美國(guó)麻醉醫(yī)師協(xié)會(huì)麻醉評(píng)分(ASA)為Ⅰ～Ⅲ級(jí)的腎腫瘤手術(shù)患者分為低溫灌注組(A組)20例，常規(guī)熱缺血組(B組)20例。A組患者首先在介入科放射手術(shù)室經(jīng)腹主動(dòng)脈行腎動(dòng)脈置管，放置Fogarty雙腔球囊導(dǎo)管后再送往手術(shù)室。兩組采用相同的麻醉誘導(dǎo)及術(shù)中用藥，維持腦電雙頻指數(shù)(BIS)值為40～60。手術(shù)顯露腎臟腫瘤后A組患者使用4℃ 200 ml灌注液使腎臟降溫，阻斷腎靜脈，經(jīng)球囊導(dǎo)管加壓注入灌注液；手術(shù)顯露腎臟腫瘤后B組患者分離腎動(dòng)脈，以血管夾夾閉腎動(dòng)脈。觀察指標(biāo)：記錄患者麻醉前 (T0)、蘇醒時(shí)(T1)、拔管即刻(T2)、拔管后 5 min( T3)四個(gè)時(shí)間點(diǎn)的平均動(dòng)脈壓(MAP)、心率(HR)、體溫、BIS值；記錄呼吸恢復(fù)時(shí)間、意識(shí)恢復(fù)時(shí)間和拔管時(shí)間；記錄拔管后鎮(zhèn)靜程度(Ramsay)及術(shù)后躁動(dòng)評(píng)分,比較手術(shù)前后肌酐，腎小球?yàn)V過率估算值的變化。結(jié)果術(shù)中體溫變化：A組下降(2.0±0.5)℃, B組下降(0.8±0.2)℃，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；自主呼吸恢復(fù)時(shí)間：A組(10.0±4.5)min，B組(6.8±2.1)min，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；完全清醒時(shí)間：A組(13.0±4.6)min，B組(10.2±2.6)min，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；拔管時(shí)間：A組(12.0±3.6)min，B組(10.5±3.2)min，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；鎮(zhèn)靜程度Ramsay評(píng)分：A組(4.1±1.3)分，B組(2.4±0.5)分，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；躁動(dòng)評(píng)分：A組(3.2±0.6)分，B組(1.8±0.4)分，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；手術(shù)前后肌酐和腎小球?yàn)V過率變化A組均低于B組(P<0.05)。結(jié)論與動(dòng)脈阻斷組比較，低溫灌注組術(shù)中中心體溫自主下降增加，寒戰(zhàn)比例增加；呼吸恢復(fù)時(shí)間、拔管時(shí)間、完全清醒時(shí)間延長(zhǎng)；躁動(dòng)比例增加。腎動(dòng)脈低溫灌注手術(shù)為臨床新開展的前沿手術(shù)，臨床經(jīng)驗(yàn)表明腎功能恢復(fù)優(yōu)于腎動(dòng)脈阻斷病歷，麻醉醫(yī)生應(yīng)了解手術(shù)方式的變化同時(shí)加強(qiáng)麻醉期的管理，降低蘇醒期并發(fā)癥。

腎腫瘤； 腎動(dòng)脈低溫灌注； 腹腔鏡技術(shù)；麻醉

隨著影像學(xué)技術(shù)的提高，腎臟腫瘤的檢出率逐年升高，當(dāng)對(duì)側(cè)腎功能不全、孤立腎或雙腎腫瘤時(shí)，保留腎單位的手術(shù)尤顯重要。2013年3月開始，中國(guó)人民解放軍總醫(yī)院泌尿外科開展了經(jīng)腎動(dòng)脈低溫灌注技術(shù)，在冷缺血條件下共實(shí)施了腹腔鏡下腎腫瘤部分切除20例，按1∶1比例配對(duì)選取同一術(shù)者同期熱缺血條件下，實(shí)施腹腔鏡下腎腫瘤部分切除20例作為對(duì)照組?，F(xiàn)將手術(shù)麻醉管理的初步經(jīng)驗(yàn)總結(jié)并報(bào)告如下。

1 資料與方法

1.1臨床資料

本研究開始前已經(jīng)過中國(guó)人民解放軍總醫(yī)院倫理委員會(huì)審查批準(zhǔn)，所有研究全程接受該倫理委員會(huì)監(jiān)督。所有患者均簽署知情同意書。40例美國(guó)麻醉醫(yī)師協(xié)會(huì)麻醉評(píng)分(ASA)Ⅰ～Ⅲ級(jí)的腎腫瘤手術(shù)患者，男32例，女8例，年齡35～77歲。體質(zhì)指數(shù)(BMI)：19.3～33.8 kg/m2。低溫灌注組(A組)20例，常規(guī)熱缺血組(B組)20例。所有手術(shù)均由同一術(shù)者經(jīng)腹腔鏡下完成。所有患者術(shù)前均完善相關(guān)檢查并進(jìn)行增強(qiáng)CT或MRI檢查，術(shù)前均診斷為腎腫瘤，術(shù)前術(shù)中均發(fā)現(xiàn)遠(yuǎn)處轉(zhuǎn)移。A組患者首先在介入科放射手術(shù)室經(jīng)腹主動(dòng)脈行腎動(dòng)脈置管，放置Fogarty雙腔球囊導(dǎo)管后送往腔鏡一體化手術(shù)室。手術(shù)顯露腎臟腫瘤后A組患者使用4℃ 200 ml灌注液使腎臟降溫，再Bulldog阻斷腎靜脈后，經(jīng)球囊導(dǎo)管加壓注入灌注液；手術(shù)顯露腎臟腫瘤后B組患者分離腎動(dòng)脈后，以血管夾夾閉腎動(dòng)脈。手術(shù)室溫度控制在21～24℃，輸注液體全部來自于手術(shù)室37℃恒溫溫箱。除覆蓋手術(shù)敷料外，所有患者均覆蓋手術(shù)室肩被(蓋于肩部)，外展手臂覆蓋敷料保溫?；颊唧w溫低于35℃時(shí)使用溫毯升溫。麻醉誘導(dǎo)：采用快誘導(dǎo)氣管插管。芬太尼3 μg/kg滴壺注入，靜注咪達(dá)唑侖0.04 mg/kg、丙泊酚1～2 mg/kg，患者入睡后給予順勢(shì)阿曲庫(kù)胺2 mg/kg。連接Ohmeda麻醉機(jī)機(jī)械通氣。吸入1∶2空氣與氧氣混合氣體，流量2 L/min，潮氣量為6～12 ml/kg，呼吸頻率為10～20 次/min，力圖維持氣道峰壓<4.655 kPa(35 mm Hg)，呼氣末CO2分壓(PETCO2)<5.985 kPa(45 mm Hg)。右頸內(nèi)靜脈穿刺監(jiān)測(cè)中心靜脈壓力，左橈動(dòng)脈穿刺監(jiān)測(cè)有創(chuàng)動(dòng)脈壓力，食道溫探頭監(jiān)測(cè)中心溫度。麻醉維持：持續(xù)吸入0.6 MAC(最低肺泡有效濃度)七氟醚、靜脈泵注丙泊酚2～4 mg·kg-1·h-1和瑞芬太尼0.1～0.3 μg·kg-1·min-1，維持BIS值在40～60，術(shù)中間斷按需靜脈注射順勢(shì)阿曲庫(kù)胺0.5 mg/kg?；颊哌M(jìn)入手術(shù)間完成麻醉誘導(dǎo)后，立即置入經(jīng)食道體溫探頭監(jiān)測(cè)中心體溫。記錄誘導(dǎo)后基礎(chǔ)體溫(TT0)，A組經(jīng)球囊導(dǎo)管加壓注入4℃灌注液后10 min體溫(AT1)，B組夾閉腎動(dòng)脈后10 min體溫(BT1)。兩組溫度變化分別指AT1，BT1與基礎(chǔ)體溫TT0的差值。

1.2觀察指標(biāo)

記錄患者麻醉前 (T0)，蘇醒時(shí)(T1)、拔管即刻(T2)、拔管后 5 min(T3)四個(gè)時(shí)間點(diǎn)的平均動(dòng)脈壓(MAP)、心率(HR)、腦電雙頻指數(shù)(BIS)數(shù)值；記錄呼吸恢復(fù)時(shí)間、意識(shí)恢復(fù)時(shí)間和拔管時(shí)間；記錄拔管后鎮(zhèn)靜程度(Ramsay)及術(shù)后躁動(dòng)情況。鎮(zhèn)靜程度評(píng)分為1 分：不安靜、煩躁；2 分：安靜合作；3 分：嗜睡，能聽從指令；4 分：睡眠狀態(tài)，可喚醒；5 分：呼喚反應(yīng)遲鈍；6 分：深睡狀態(tài)，呼喚不醒。躁動(dòng)評(píng)分為1 分：安靜、合作、無躁動(dòng)； 2 分：焦慮、激動(dòng)，但可配合；3 分：輕度躁動(dòng)，哭鬧，需固定上肢；4 分：嚴(yán)重躁動(dòng)，定向力障礙，試圖拔除各種引流管，需外力按壓四肢。

1.3統(tǒng)計(jì)學(xué)方法

2 結(jié)果

兩組患者年齡、體重、手術(shù)時(shí)間、出血量及輸液量差異無統(tǒng)計(jì)學(xué)意義(P>0.05)(表1)。兩組患者血流動(dòng)力學(xué)變化： 兩組平均動(dòng)脈壓、心率、BIS 數(shù)值在四個(gè)時(shí)刻之間差異無統(tǒng)計(jì)學(xué)意義(P>0.05)(表2)；蘇醒期及術(shù)后等指標(biāo)見表3。

項(xiàng)目A組(n=20)B組(n=20)年齡/歲57．5±12．854．2±11．8男/女16/416/4體重/kg67．9±10．264．5±11．4體質(zhì)指數(shù)/(kg·m-2)24．9±2．423．2±2．5手術(shù)時(shí)間/min111±21115±17出血量/ml208±37225±40輸液量/ml807±38796±40

項(xiàng)目與分組麻醉前(T0)蘇醒時(shí)(T1)拔管即刻(T2)拔管5min(T3)MAP/mmHg A組95±1199±1791±16100±13 B組97±1099±1799±1899±15HR/bpm A組70±1280±1178±1378±10 B組71±1179±1073±1577±13BIS A組55±487±689±788±6 B組54±385±690±589±7

1 mm Hg=0.133 kPa。

項(xiàng)目A組B組體溫下降/℃2．0±0．51)0．8±0．2寒戰(zhàn)/例51)1手術(shù)時(shí)間/min111±21115±17自主呼吸恢復(fù)時(shí)間/min10．0±4．51)6．8±2．1完全清醒時(shí)間/min13．0±4．61)10．2±2．6拔管時(shí)間/min12．0±3．61)10．5±3．2鎮(zhèn)靜程度評(píng)分/分4．1±1．31)2．4±0．5躁動(dòng)評(píng)分/分3．2±0．61)1．8±0．4肌酐/(μmol·L-1) 術(shù)前93．3±36．492．6±38．6 出院時(shí)110．1±45．41)134．6±42．6 變化值13．2±5．31)33．2±5．3eGFR/(ml·min-1·1．73m-2) 術(shù)前76．7±33．277．3±32．6 出院時(shí)63．1±23．61)78．7±29．6 變化值12．±4．741)2．8±1．2

與B組比較，1)P<0.05。

3 討論

在保留腎單位手術(shù)中，由于手術(shù)時(shí)間的不確定性，如何在手術(shù)過程中最大程度的減少出血及保存腎組織活性是兩大最關(guān)鍵問題。根據(jù)器官移植理論，通過降低酶的活性作用減慢反應(yīng)的速度和細(xì)胞死亡,是器官保存的必要條件[1, 2]。Becker等[3]系統(tǒng)地回顧了以往文獻(xiàn)后指出，手術(shù)過程中，熱缺血不應(yīng)超過20 min，冷缺血不應(yīng)超過2 h，最好不超過35 min，否則會(huì)增加患者急性腎衰和慢性腎功能不全的風(fēng)險(xiǎn)[3]。因此，對(duì)于預(yù)計(jì)阻斷時(shí)間比較長(zhǎng)的復(fù)雜的腎臟腫瘤，最好采取冷缺血的方法。目前應(yīng)用于腔鏡下的腎臟冷缺血方法有：表面冰屑低溫，表面凝膠低溫，經(jīng)輸尿管逆行插管低溫和經(jīng)腎動(dòng)脈低溫灌注[5～7]。與其他三種方法比較，經(jīng)腎動(dòng)脈低溫灌注可以將熱缺血變?yōu)槔淙毖?，可以有效的保護(hù)腎功能。前期研究表明：低溫灌注組腎臟僅發(fā)生細(xì)胞水腫變性等可逆性變化，并未發(fā)生腎細(xì)胞壞死現(xiàn)象，免疫組化顯示其凋亡指數(shù)亦未發(fā)生明顯改變[8～10]。我們前期的研究 也觀察到低溫灌注組術(shù)后肌酐及腎小球?yàn)V過率指標(biāo)較常溫組改善明顯[11]。

腎動(dòng)脈低溫灌注手術(shù)為臨床新開展的前沿手術(shù)，初步臨床結(jié)果顯示腎功能恢復(fù)優(yōu)于腎動(dòng)脈阻斷病例。與常規(guī)熱缺血組比較，低溫灌注組術(shù)中中心體溫自主下降加大，寒戰(zhàn)比例增加；呼吸恢復(fù)時(shí)間、拔管時(shí)間、完全清醒時(shí)間延長(zhǎng)；躁動(dòng)比例增加。引起全麻患者溫度變化的原因主要有以下幾點(diǎn)[12～14]：手術(shù)過程中低溫液體滴入人體；手術(shù)時(shí)室溫低于正常溫度；手術(shù)時(shí)間較長(zhǎng)，患者身體熱量損失過多；持續(xù)不加溫的CO2氣體的進(jìn)入；麻醉后患者的產(chǎn)熱功能減少，體溫調(diào)節(jié)系統(tǒng)受到抑制。麻醉方法及麻醉藥物均可影響機(jī)體的體溫調(diào)節(jié)。全身麻醉通過對(duì)中樞及外周神經(jīng)的雙重影響而削弱了機(jī)體的體溫調(diào)節(jié)作用[15]。全麻藥不但抑制體溫調(diào)節(jié)中樞的功能，而且還干擾機(jī)體隨環(huán)境溫度變化的體液轉(zhuǎn)移反應(yīng)；肌松藥使骨骼肌麻醉，喪失增加肌張力的產(chǎn)熱作用。全身麻醉過程中的低體溫問題不容忽視，人體體溫降低使肝臟功能減弱，多種全身靜脈麻醉藥物代謝率降低，藥物作用時(shí)間延長(zhǎng)，蓄積于體內(nèi)，延長(zhǎng)了患者從麻醉過渡到蘇醒狀態(tài)的時(shí)間[16,17]。研究表明，患者的核心溫度下降 2℃，肌肉阻滯藥物的作用時(shí)間可延長(zhǎng)至原來藥效的一倍左右[18]，導(dǎo)致患者拔管時(shí)間延長(zhǎng)。

本研究結(jié)果表明，腎動(dòng)脈低溫灌注腹腔鏡下腎部分切除術(shù)治療完全內(nèi)生型腎腫瘤安全可行。但本研究病例數(shù)量有限，有待進(jìn)一步增加例數(shù)并觀察遠(yuǎn)期療效。盡管本研究中采用先快速灌注少量灌注液使腎臟降溫，再阻斷腎靜脈，切除腫瘤過程中讓灌注液從創(chuàng)面流出，這樣最大程度減少冰的灌注液直接進(jìn)入體循環(huán)，但仍有部分低溫灌注也進(jìn)入體循環(huán)，導(dǎo)致中心溫度下降。麻醉醫(yī)生應(yīng)重視恢復(fù)期低溫的并發(fā)癥，可以采用消毒液、輸注液體加溫、溫毯加溫、加蓋暴露部位的綜合保溫措施維持中心體溫。麻醉醫(yī)生應(yīng)了解手術(shù)方式的變化同時(shí)加強(qiáng)麻醉期的管理，降低蘇醒期并發(fā)癥。

[1] Huang WC, Levey AS, Serio AM, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol, 2006,7(9):735-740.

[2] Lane BR, Campbell SC, Gill IS. 10-year oncologic outcomes after laparoscopic and open partial nephrectomy. J Urol, 2013,190(1):44-49.

[3] Becker F, Van Poppel H, Hakenberg OW, et al. Assessing the impact of ischaemia time during partial nephrectomy. Eur Urol, 2009,56(4):625-634.

[4] Kim DK, Komninos C, Kim L, et al. Robot-assisted Partial Nephrectomy for Endophytic Tumors. Curr Urol Rep, 2015,16(11):76.

[5] Gill IS, Kavoussi LR, Lane BR, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol, 2007,178(1):41-46.

[6] Lane BR, Gill IS. 7-Year oncological outcomes after laparoscopic and open partial nephrectomy. J Urol, 2010,183(2):473-479.

[7] Phillips CK, Taneja SS, Stifelman MD. Robot-assisted laparoscopic partial nephrectomy: the NYU technique. J Endourol, 2005,19(4):441-445; discussion 445.

[8] Crain DS, Spencer CR, Favata MA, et al. Transureteral saline perfusion to obtain renal hypothermia: potential application in laparoscopic partial nephrectomy. JSLS, 2004,8(3):217-222.

[9] Moers C, Smits JM, Maathuis MH, et al. Machine perfusion or cold storage in deceased-donor kidney transplantation. N Engl J Med, 2012,360(1):770-771.

[10] Schreinemachers MC, Doorschodt BM, Florquin S, et al. Pulsatile perfusion preservation of warm ischaemia-damaged experimental kidney grafts. Br J Surg, 2010,97(3):349-358.

[11] 馬鑫,劉新,鄭濤,等.腎動(dòng)脈低溫灌注聯(lián)合腹腔鏡腎部分切除術(shù)處理復(fù)雜腎腫瘤的初步經(jīng)驗(yàn).微創(chuàng)泌尿外科雜志,2014,3(2):80-83.

[12] 李翠霞,洪華,易衛(wèi)東.術(shù)中保溫對(duì)低體溫創(chuàng)傷患者麻醉恢復(fù)期的影響.臨床護(hù)理雜志,2010,9(4):9-11.

[13] 文素芳,林高翔,譚永星,等.兩種加溫輸液液體加溫效果及對(duì)患者術(shù)中體溫的影響.護(hù)理實(shí)踐與研究,2010,7(20):3-4,6.

[14] 胡光俊,陳敏,黎筆熙,等.輸注預(yù)熱液體防治老年患者術(shù)中低溫的臨床觀察.臨床麻醉學(xué)雜志,2011,27(5):421-423.

[15] 蓋慧玲.淺談術(shù)中病人低體溫對(duì)術(shù)后恢復(fù)的影響.中外健康文摘,2010,7(27):109-110.

[16] Frank SM, Beattie C, Christopherson R, et al. Epidural versus general anesthesia, ambient operating room temperature, and patient age as predictors of inadvertent hypothermia. Anesthesiology, 1992,77(2):252-257.

[17] 張紅,馮藝,潘芳,等.全身麻醉術(shù)后寒戰(zhàn)相關(guān)危險(xiǎn)因素的研究.臨床麻醉學(xué)雜志,2010,26(3):203-205.

[18] Lepousé C, Lautner CA, Liu L, et al. Emergence delirium in adults in the post-anaesthesia care unit. Br J Anaesth, 2006,96(6):747-753.

Managementstrategyofanesthesiaduringrecoveryperiodafterlaparoscopicpartialnephrectomyusingrenalarterycoldperfusion

DingLingling1, 2ZhongHong2MaXin3ZhangXu3WangTao2

(1Department of Anesthesiology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing 100853, China;2Department of Anesthesia & Surgery Center;3Department of Urology, Chinese PLA General Hospital)

Ding Lingling, dinglingling301@126.com

Objective: To investigate the effect of laparoscopic partial nephrectomy on the recovery period of anesthesia and the related anesthetic strategies.MethodsThe clinical data of 40 patients with completely intraparenchymal tumors treated by renal artery perfusion and conventional warm ischemia laparoscopic partial nephrectomy were analyzed retrospectively. Forty cases of renal tumor were divided into cold perfusion group (group A) and warm ischemic group (group B) (n=20 each group). In group A Fogarty double lumen balloon catheter was placed before operation. The two groups received the same anesthesia induction and intraoperative medication. After surgery revealed renal tumors, patients in group A were treated with 4℃ 200 mL perfusion solution to cool the kidneys. After surgery revealed renal tumors, the renal arteries were occluded by blood vessel clamp in group B. The MAP, BIS and temperature were recorded at different time points. Temperature respiratory recovery time, consciousness recovery time, extubation time, Ramsay and postoperative sedation-agitation scale were compared between two groups. The changes of CR and eGFR were compared before and after the operation in two groups.ResultsThere was no statistically significant difference in MAP, HR and BIS between two groups at different time points. The temperature in group A was obviously decreased as compared with that in group B (P<0.05). The spontaneous breathing recovery time in group A was obviously prolonged as compared with that in group B (P<0.05). The fully awake time and the extubation time in group A were obviously prolonged as compared with those in group B (P<0.05). The Ramsay scores in group A were obviously increased as compared with those in group B (P<0.05). The sedation-agitation scale in group A was obviously increased as compared with that in group B (P<0.05). The changes of CR and eGFR before and after operation in group A were decreased as compared with those in group B.ConclusionsRenal artery cold perfusion is a new frontier surgery clinically. The clinical experience shows that the recovery of renal function in renal artery cold perfusion is better than in renal artery occlusion. The anesthesia doctors should understand the change of surgical procedures and strengthen management simultaneously in order to reduce the postoperative complications.

kidney neoplasms; renal artery cold perfusion; laparoscopy; anesthesia

R737.11

A

丁玲玲，dinglingling301@126.com

2017-06-07

10.19558/j.cnki.10-1020/r.2017.05.006

北京市科學(xué)技術(shù)委員會(huì)資助項(xiàng)目(Z171100001017061)；北京市屬醫(yī)院科研培育資助項(xiàng)目(PZ2017028)；首都中醫(yī)藥專項(xiàng)(17ZY04)