膈肌超声评估新斯的明与舒更葡糖钠拮抗后肌松残余的随机双盲对照试验

目的 运用膈肌超声评估比较新斯的明和舒更葡糖钠拮抗后术后肌松残余(PORC)的发生率。方法 纳入2021年3月至8月行择期关节置换手术的患者100例,美国麻醉医师协会分级Ⅰ~Ⅱ级,年龄、性别不限,按照随机数字表法分为新斯的明+阿托品组(N+A组,n=51)和舒更葡糖钠组(SUG组,n=49)。麻醉过程中行拇内收肌四个成串刺激(TOF)监测肌松。N+A组患者予新斯的明50 μg/kg+阿托品15 μg/kg,SUG组予舒更葡糖钠2 mg/kg拮抗,并在TOF比率≥0.9时拔除气管导管。在术前,拔管后10、30 min分别行膈肌超声检查。采用低频探头于右侧锁骨中线、右肋缘下方测量深呼吸时膈肌移动度(DE-DB)和嗅物吸气时膈肌运动速度(V-S),再采用高频探头于右侧膈肌附着点测量深呼吸时膈肌厚度变化率(TF-DB)。主要结局指标为两组PORC发生率,次要结局指标为DE-DB、TF-DB、V-S等。结果 以TF-DB≤36%定义PORC,SUG组10(4.3%比31.1%;χ²=11.541,P=0.001)、30 min(0比17.6%;P=0.001)PORC发生率显著低于N+A组;以TF-DB≤36%或DE-DB≤4 cm定义PORC,SUG组10(8.2%比33.3%;χ²=9.543,P=0.002)、30 min(0比19.6%;χ²=8.608,P=0.003)PORC发生率显著低于N+A组。拔管后10、30 min SUG组DE-DB(6.5±1.6)cm比(5.6±1.4)cm;t=-3.185,P=0.002和(6.9±1.5)cm比(6.1±1.4)cm;t=-2.712,P=0.008]和TF-DB(60.1±18.8)%比(49.1±20.0)%;t=2.739,P=0.007和(65.0±20.1)%比(49.9±19.1)%,t=-3.686,P<0.001]显著高于N+A组。结论 舒更葡糖钠与新斯的明相比,可以显著改善术后膈肌运动,降低PORC发生率。

Evaluation of Postoperative Residual Curarisation after Administration of Neostigmine or Sugammadex by Diaphragmatic Ultrasonography:A Randomized Double-blind Controlled Trial

Objective To evaluate and compare the incidence of postoperative residual curarisation (PORC) after administration of neostigmine or sugammadex by diaphragmatic ultrasonography.Methods A total of 100 patients with American Society of Anesthesiologists grade Ⅰ or Ⅱ who underwent elective joint replacement surgery from March to August in 2021 were randomly enrolled into the neostigmine+atropine group(N+A group,n=51) and sugammadex group(SUG group,n=49) according to a random number table.Muscle relaxation was monitored by train of four(TOF) stimulation of adductor pollicis muscle during anesthesia.The patients in N+A group were administrated with neostigmine 50 μg/kg + atropine 15 μg/kg and those in SUG group with sugammadex 2 mg/kg for reversing muscle relaxation.Endotracheal tube was removed only when TOF ratio≥0.9. Diaphragmatic ultrasonography was performed before surgery,10 min and 30 min after extubation.The right diaphragm excursion during deep breathing(DE-DB) and the diaphragm movement velocity during sniffing(V-S) were measured,with the low-frequency probe placed at the intersection of the right midclavicular line and the right costal margin.The diaphragmatic thickening fraction during deep breathing(TF-DB) was measured with the high-frequency probe placed at zone of apposition.The incidence of PORC was taken as the primary outcome,and DE-DB,TF-DB,and V-S as the secondary outcomes.Results When PORC was defined as TF-DB≤36%,the incidence of PORC in the SUG group was lower than that in the N+A group 10 min(4.3% vs.31.1%;χ²=11.541,P=0.001) and 30 min(0 vs.17.6%;P=0.001) after extubation.When PORC was defined as TF-DB≤36% or DE-DB≤4 cm,the incidence of PORC in the SUG group was also lower than that in the N+A group 10 min(8.2% vs.33.3%;χ²=9.543,P=0.002) and 30 min(0 vs.19.6%;χ²=8.608,P=0.003) after extubation.The DE-DB in the SUG group was higher than that in the N+A group 10 min(6.5±1.6) cm vs.(5.6±1.4) cm;t=-3.185,P=0.002] and 30 min(6.9±1.5) cm vs.(6.1±1.4) cm;t=-2.712,P=0.008] after extubation.The TF-DB in the SUG group was also higher than that in the N+A group 10 min(60.1±18.8)% vs.(49.1±20.0)%;t=2.739,P=0.007] and 30 min(65.0±20.1)% vs.(49.9±19.1)%,t=-3.686,P<0.001] after extubation.Conclusion Compared with neostigmine,sugammadex can significantly improve the postoperative diaphragm movement and decrease the incidence of PORC.