張 濤 郭慶林
不同濃度七氟醚聯(lián)合丙泊酚麻醉對(duì)腹腔鏡肝癌切除術(shù)患者術(shù)后蘇醒及安全性的影響
張 濤 郭慶林
目的探討不同濃度七氟醚聯(lián)合丙泊酚麻醉對(duì)腹腔鏡肝癌切除術(shù)患者術(shù)后蘇醒及安全性的影響。方法
選取腹腔鏡下多功能手術(shù)解剖器(peng's multi-functional operative dissector,PMOD) 刮吸法斷肝技術(shù)行腹腔鏡肝癌切除術(shù)患者60例,分為實(shí)驗(yàn)組A、實(shí)驗(yàn)組B和對(duì)照組,每組各20例。全部患者均行PMOD術(shù),實(shí)驗(yàn)組A選擇0.5 MAC七氟醚聯(lián)合靜脈注射丙泊酚麻醉,實(shí)驗(yàn)組B選擇1.0 MAC七氟醚聯(lián)合靜脈注射丙泊酚麻醉,對(duì)照組選擇單純靜脈注射丙泊酚麻醉。觀察和比較3組患者拔管即刻(T0)、拔管5 min后(T1)和拔管15 min后(T2)的SPO2、HR、MAP和OAA/S評(píng)分、改良Aldrete評(píng)分。記錄和比較3組患者丙泊酚用量、麻醉時(shí)間、自主呼吸恢復(fù)時(shí)間、蘇醒時(shí)間和拔管時(shí)間。記錄和對(duì)比2組患者麻醉蘇醒后躁動(dòng)情況。結(jié)果T0和T1時(shí),實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者HR值顯著低于對(duì)照組患者(P<0.05),實(shí)驗(yàn)組B患者HR值顯著低于實(shí)驗(yàn)組A患者(P<0.05);T0時(shí),實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者M(jìn)AP值顯著高于對(duì)照組患者(P<0.05)。實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者丙泊酚量、蘇醒時(shí)間和拔管時(shí)間均顯著低于對(duì)照組(P均<0.05);實(shí)驗(yàn)組B患者自主呼吸恢復(fù)時(shí)間為(22.6±12.5)min,顯著低于對(duì)照組患者(22.6±12.5)min(P<0.05)。實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者OAA/S評(píng)分和改良Aldrete評(píng)分顯著高于對(duì)照組患者(P<0.05)。實(shí)驗(yàn)組患者躁動(dòng)情況和對(duì)照組患者比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。各項(xiàng)指標(biāo)改善情況均呈七氟醚依賴性加強(qiáng)。結(jié)論七氟醚復(fù)合丙泊酚麻醉有助于提高PMOD肝癌切除術(shù)患者術(shù)后的蘇醒質(zhì)量及安全性,且1.0 MAC七氟醚效果更佳。
七氟醚;丙泊酚麻醉;腹腔鏡肝癌切除術(shù);蘇醒
目前,我國(guó)肝癌的發(fā)病率較高,是常見(jiàn)的惡性腫瘤之一,其早期起病隱匿、癥狀不明顯及無(wú)特異性體征[1],故病情進(jìn)展快、患者預(yù)后差,若不及時(shí)、合理治療,死亡率較高。外科手術(shù)是肝癌首選治療方法之一,隨著微創(chuàng)治療理念的普及,腹腔鏡肝癌切除手術(shù)推廣迅速、療效較優(yōu),但微創(chuàng)手術(shù)仍可致機(jī)體損傷[2],因此,需合理的麻醉方案以降低術(shù)中機(jī)體應(yīng)激反應(yīng),保障手術(shù)成功率和患者生命安全。七氟醚聯(lián)合丙泊酚麻醉具有麻醉誘導(dǎo)快、蘇醒時(shí)間短及安全性高等優(yōu)點(diǎn)[3],但關(guān)于其用于腹腔鏡肝癌切除術(shù)的效果及安全性,少見(jiàn)諸于報(bào)道。本文選取腹腔鏡下多功能手術(shù)解剖器(peng's multi-functional operative dissector,PMOD) 刮吸法斷肝技術(shù)行腹腔鏡肝癌切除術(shù)患者60例,旨在探討不同濃度七氟醚聯(lián)合丙泊酚麻醉對(duì)患者術(shù)后蘇醒質(zhì)量的影響及安全性,現(xiàn)報(bào)告如下。
選取本院于2013年1月至2016年6月收治腹腔鏡下多功能手術(shù)解剖器(Peng's multi-functional operative dissector,PMOD) 刮吸法斷肝技術(shù)行腹腔鏡肝癌切除術(shù)患者60例作為觀察對(duì)象。納入標(biāo)準(zhǔn)[4]:①Child-Pugh分級(jí)A或B,BCLC分級(jí)0或者A;②腫瘤灶位于肝臟邊緣或肝表面;③無(wú)肝內(nèi)及遠(yuǎn)端轉(zhuǎn)移灶和門(mén)靜脈、肝靜脈及二級(jí)分支侵犯;④美國(guó)麻醉協(xié)會(huì)(ASA)分級(jí)Ⅰ~Ⅲ級(jí)。排除標(biāo)準(zhǔn)[5]:①合并心、肺、腎等重要器官嚴(yán)重疾病者;②合并中樞神經(jīng)系統(tǒng)病變及心腦血管疾病者;③近期有服用精神類藥物史者。所有患者按隨機(jī)數(shù)字表分為對(duì)照組、實(shí)驗(yàn)組A和實(shí)驗(yàn)組B,每組均20例。3組患者性別、年齡、體重及ASA分級(jí)差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),見(jiàn)表1,具有可比性。全部患者或其家屬均自愿簽訂知情同意書(shū),參與本研究。本研究通過(guò)醫(yī)院倫理委員會(huì)審核。
表1 3組患者一般情況比較
全部患者術(shù)前均肌肉注射魯米那鈉(國(guó)藥準(zhǔn)字H12020381,天津金耀藥業(yè)有限公司)0.1 mg、阿托品(國(guó)藥準(zhǔn)字H33020089,杭州民生藥業(yè)有限公司)0.5 mg,結(jié)束后,連接上海創(chuàng)迅醫(yī)療器械有限公司的MP5多功能監(jiān)護(hù)儀連續(xù)監(jiān)測(cè)心電圖(ECG)、血氧飽和度(SPO2)、心率(HR)和平均動(dòng)脈壓(MAP)。麻醉誘導(dǎo)靜脈注射咪達(dá)唑侖(國(guó)藥準(zhǔn)字H20113387,生產(chǎn)企業(yè):浙江九旭藥業(yè)有限公司)0.03 mg/kg、丙泊酚2 mg/kg(國(guó)藥準(zhǔn)字H20073642,揚(yáng)子江藥業(yè)集團(tuán)江蘇海慈生物藥業(yè)有限公司)、瑞芬太尼(國(guó)藥準(zhǔn)字H42022076,宜昌人福藥業(yè)有限責(zé)任公司)2.5 mg/kg和羅庫(kù)溴銨(國(guó)藥準(zhǔn)字H20123439,重慶福安藥業(yè)集團(tuán)股份有限公司)50 mg。肌肉松弛完善后氣管插管機(jī)械通氣,60%O2:2 L/min,VT:9~10 ml/kg,RR:12~15次/min。對(duì)照組患者全程靶注丙泊酚3~6 μg/ml和瑞芬太尼3~6 ng/ml;實(shí)驗(yàn)組復(fù)合吸入七氟醚麻醉,A組維持CETSev:0.5 MAC,B組維持CETSev:1.0 MAC,監(jiān)測(cè)呼吸末七氟醚濃度,待BIS值均維持40~50,停止吸入七氟醚。術(shù)畢送至PACU觀察,待患者完全清醒、肌松殘余作用完全消失,SPO2>96% 5~10 min,SPO2>80 mmHg,PaCO2<50 mmHg時(shí)[6],吸痰拔除氣管導(dǎo)管。
患者麻醉后,臍下緣取1~1.5 cm小切口,插入氣腹針建立CO2氣腹(腹內(nèi)壓約為14 mmHg),臍下套管置入30°腹腔鏡,若右肝腫瘤灶,于劍突下套管置入PMOD,右鎖骨中線及右腋中線分別套管置入1把抓鉗;若左肝腫瘤灶,于左鎖骨中線肋緣下套管置入PMOD,劍突下及右鎖骨中線分別套管置入1把抓鉗。患者取頭高腳低30°體位,分離肝周韌帶,游離肝臟至離腫瘤塊邊緣2 cm處,PMOD切開(kāi)肝包膜刮扒肝組織,顯露出管道鉗夾處理,吸除刮碎肝實(shí)質(zhì)碎片、電灼處理肝切面滲血,顯露細(xì)管道電灼處理、粗管道鉗夾處理,認(rèn)真反復(fù)操作至完成肝組織切除但未阻斷肝門(mén),沖洗干凈肝臟創(chuàng)面、止血徹底,常規(guī)放置腹腔引流管。
觀察和比較3組患者拔管即刻(T0)、拔管5 min后(T1)和拔管15 min后(T2)的SPO2、HR及MAP值。記錄和比較3組患者丙泊酚用量、麻醉時(shí)間、自主呼吸恢復(fù)時(shí)間、蘇醒時(shí)間和拔管時(shí)間。記錄和比較3組患者T0、T1和T2時(shí)改良OAA/S評(píng)分、改良Aldrete評(píng)分。記錄和對(duì)比2組患者麻醉蘇醒后躁動(dòng)情況,評(píng)估標(biāo)準(zhǔn)[7]:輕:患者有輕度、可耐受不適感;中:患者出現(xiàn)胸悶、難耐受、頭頻繁移動(dòng);重:患者表現(xiàn)煩躁、肢體有躁動(dòng),并有頭暈、惡心,極難耐受。
患者HR值呈時(shí)間依賴性顯著下降(F=4.21,P<0.05),MAP值呈時(shí)間依賴性顯著上升(F=4.56,P<0.05);各時(shí)間點(diǎn),3組患者SPO2值差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);T0和T1時(shí),實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者HR值顯著低于對(duì)照組患者(P<0.05),實(shí)驗(yàn)組B患者HR值顯著低于實(shí)驗(yàn)組A患者(P<0.05);T0時(shí),實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者M(jìn)AP值顯著高于對(duì)照組患者(P<0.05),見(jiàn)表2。
表2 各組患者不同時(shí)間SPO2、HR和MAP值對(duì)比
注:*為與對(duì)照組比較,P<0.05;#為與實(shí)驗(yàn)組A比較,P<0.05。
實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者丙泊酚量、蘇醒時(shí)間和拔管時(shí)間均顯著低于對(duì)照組(P均<0.05);實(shí)驗(yàn)組B患者自主呼吸恢復(fù)時(shí)間顯著低于對(duì)照組患者(P<0.05);各組患者麻醉時(shí)間差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),見(jiàn)表3。
表3 各組患者時(shí)間指標(biāo)及麻醉劑量比較
注:與對(duì)照組比較,*為P<0.05,**為P<0.01。
患者OAA/S評(píng)分和改良Aldrete評(píng)分呈時(shí)間依賴性上升;實(shí)驗(yàn)組患者OAA/S評(píng)分(分)和改良Aldrete評(píng)分呈七氟醚劑量依賴性上升;實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者OAA/S評(píng)分和改良Aldrete評(píng)分顯著高于對(duì)照組患者(P<0.05),見(jiàn)表4。
表4 各組患者不同時(shí)間OAA/S評(píng)分和改良Aldrete評(píng)分對(duì)比
注:*為與對(duì)照組比較,P<0.05。
實(shí)驗(yàn)組患者躁動(dòng)情況和對(duì)照組患者比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),實(shí)驗(yàn)組A和實(shí)驗(yàn)組B患者躁動(dòng)情況比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),見(jiàn)表5。
表5 各組患者體位改變后躁動(dòng)程度對(duì)比/例
丙泊酚和七氟醚作為微創(chuàng)手術(shù)中常用麻醉藥劑,均具有誘導(dǎo)迅速、術(shù)后患者蘇醒快及可控性優(yōu)等特點(diǎn),并可降低手術(shù)所致的肝臟缺血再灌注損傷。研究顯示[8],長(zhǎng)時(shí)間單純性靜脈輸注丙泊酚,可改變?cè)撍幋鷦?dòng)力學(xué),加深其鎮(zhèn)靜效果,造成患者術(shù)后蘇醒時(shí)間久和拔管延遲。趙迎春等報(bào)道稱[9],七氟醚吸入復(fù)合靜注丙泊酚可有效穩(wěn)定術(shù)中患者麻醉深度平穩(wěn),并可抑制拔管刺激引起的血液動(dòng)力學(xué)波動(dòng),較單純靜注丙泊酚麻醉,患者血氧、心律及動(dòng)脈壓更加穩(wěn)定。在本研究中,拔管后,實(shí)驗(yàn)組患者HR值顯著低于對(duì)照組患者(P<0.05),且實(shí)驗(yàn)組B患者HR值顯著低于實(shí)驗(yàn)組A患者(P<0.05),且實(shí)驗(yàn)組患者M(jìn)AP值顯著高于對(duì)照組患者(P<0.05),結(jié)果與他人一致[10],表明七氟醚復(fù)合丙泊酚麻醉可更有效地穩(wěn)定患者拔管后血液動(dòng)力學(xué),抑制血壓及心律波動(dòng),這可能因?yàn)槠叻褜?duì)氣道無(wú)刺激性,不增加心肌對(duì)兒茶酚胺敏感性,可有效抑制拔管后心律波動(dòng)。在研究中,各時(shí)間點(diǎn),3組患者SPO2值差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),這可能因?yàn)槿鸱姨釓?fù)合七氟醚和丙泊酚配伍可達(dá)到降壓、鎮(zhèn)痛作用,充分抑制了拔管刺激引起的呼吸功能下降,緩解血氧供應(yīng)不足。
閆承文[11]通過(guò)研究開(kāi)腹肝臟部分切除術(shù)患者麻醉后蘇醒質(zhì)量可得,不同濃度七氟醚復(fù)合丙泊酚麻醉均可降低丙泊酚使用量,加快患者蘇醒及拔管時(shí)間,推斷1.0 MAC七氟醚復(fù)合丙泊酚使用效果最佳。在本研究中,實(shí)驗(yàn)組患者丙泊酚量、蘇醒時(shí)間和拔管時(shí)間均顯著低于對(duì)照組(P均<0.05),且改善效果呈現(xiàn)七氟醚劑量依賴性上升,與其研究結(jié)果相符,這表明相比于單純靜注丙泊酚,七氟醚復(fù)合丙泊酚使用可加快腹腔鏡肝癌切除術(shù)術(shù)后蘇醒及拔管速度,可能縮短患者整體治療時(shí)間。
Lin等[12]認(rèn)為七氟醚復(fù)合丙泊酚麻醉不僅可以加快手術(shù)患者蘇醒速度,還可有效改善其蘇醒質(zhì)量。OAA/S評(píng)分和改良Aldrete評(píng)分均為臨床中常用的鎮(zhèn)靜深度改變觀察指標(biāo),研究中,實(shí)驗(yàn)組患者OAA/S評(píng)分和改良Aldrete評(píng)分顯著高于對(duì)照組患者(P<0.05),且評(píng)分值呈七氟醚劑量依賴性上升,結(jié)果進(jìn)一步印證他人研究中[13]無(wú)論腹腔鏡手術(shù)還是傳統(tǒng)開(kāi)放性外科手術(shù),七氟醚復(fù)合丙泊酚麻醉均可減少患者蘇醒時(shí)間和提升其蘇醒后神經(jīng)鎮(zhèn)靜程度,這可能因?yàn)槠叻呀?jīng)肺清除代謝,相比于丙泊酚經(jīng)肝臟代謝,其在患者機(jī)體內(nèi)藥物分布和體積較小,造成周邊室清除率高、血藥濃度低,具有更快藥物代謝速度,而復(fù)合使用可減少丙泊酚使用量,因此加快患者蘇醒速度。
肝臟手術(shù)后蘇醒期可出現(xiàn)不同程度的躁動(dòng),發(fā)生率為14.2%~39.2%[14],有研究[15-17]推斷七氟醚吸入麻醉可增加術(shù)后蘇醒期躁動(dòng)發(fā)生率及程度,在本研究中,實(shí)驗(yàn)組患者躁動(dòng)情況與對(duì)照組患者對(duì)比無(wú)明顯差異(P>0.05),結(jié)果與他人研究不同。我們認(rèn)為原因可能為肝癌患者術(shù)前停止吸入七氟醚,術(shù)畢時(shí)體內(nèi)七氟醚已完全排出,而復(fù)合使用丙泊酚,可借助該藥作用于中樞GABA及其受體,從而抑制興奮性神經(jīng)遞質(zhì)釋放和降低雙或多突觸活性,并有效拮抗電休克和多種化學(xué)制劑引起的躁動(dòng),由此,我們認(rèn)為腹腔鏡肝癌切除術(shù)患者接受七氟醚聯(lián)合丙泊酚麻醉時(shí),應(yīng)于術(shù)畢前停用七氟醚。
綜上所述,七氟醚復(fù)合丙泊酚麻醉有助于提高PMOD肝癌切除術(shù)患者術(shù)后的蘇醒質(zhì)量,且1.0 MAC七氟醚復(fù)合丙泊酚術(shù)后蘇醒時(shí)間更快、安全性更高。
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EffectofDifferentConcentrationsofSevofluraneCombinedwithPropofolAnesthesiaonRecoveryandSafetyofLiverCancerPatientsafterLaparoscopicHepatectomy
ZHANGTao,GUOQinglin.
ChongqingThreeGorgesCentralHospital,Chongqing,404000
ObjectiveTo investigate the effects of different concentrations of sevoflurane combined with propofol anesthesia on recovery and safety of liver cancer patients after laparoscopic hepatectomy.Methods60 cases of liver cancer treated by laparoscopic hepatectomy were selected and divided into the experimental group A,the experimental group B and the control group,20 cases in each group.All patients were treated with PMOD,the experimental group A was given 0.5 MAC sevoflurane combined with propofol anesthesia,the experimental group B was given 1 MAC sevoflurane combined with propofol anesthesia,the control group were given intravenous anesthesia with propofol.Extubation immediately (T0),extubation after 5min (T1) and extubation 15 T2 (min) SPO2,HR,MAP and OAA/S score,modified Aldrete score of the 3 groups were observed and compared.The dosage of propofol,anesthesia time,recovery time,recovery time and extubation time were recorded and compared among the 3 groups.The 3 groups after anesthesia agitation situation were recorded and compared.ResultsT0 and T1,HR values of the experimental group A and the experimental group B were significantly lower than that of the control group (P<0.05),the HR values of the experimental group B was significantly lower than that of the experimental group A (P<0.05);T0,MAP values of the experimental group A and the experimental group B were significantly higher than that of the control group (P<0.05).The propofol,recovery time and extubation time of the experimental group A and the experimental group B were significantly lower than those of the control group (P<0.05);spontaneous breathing recovery time (22.6±12.5)of the experimental group B was lower than that of the control group (22.6±12.5) min (P<0.05).The OAA/S score and modified Aldrete score of the experimental group B and the experimental group were significantly higher than those of the control group A (P<0.05).There was no signifi cant difference between the experimental group and the control group (P>0.05).Indicators to improve the situation was to strengthen the dependence of sevoflurane.ConclusionSevoflurane combined with propofol anesthesia can improve the recovery quality and safety of hepatocellular carcinoma patients after PMOD hepatectomy,and sevoflurane at dose of 1.0 MAC are the most effective.
Sevoflurane;Propofol anesthesia;Laparoscopic liver resection;Recovery
(ThePracticalJournalofCancer,2017,32:1855~1859)
404000 重慶三峽中心醫(yī)院
郭慶林
10.3969/j.issn.1001-5930.2017.11.034
R735.7
A
1001-5930(2017)11-1855-05
2016-09-23
2017-05-23)
(編輯:甘艷)