胸椎旁神经阻滞与硬膜外麻醉对非气管插管肺叶切除术患者镇痛和免疫的影响*

目的?比较胸椎旁神经阻滞（TPVB）和硬膜外阻滞（EB）对非气管插管肺叶切除术患者镇痛和免疫的影响。方法?选取2019年1月—2019年6月在青岛大学附属青岛市市立医院东院区行胸腔镜下肺叶切除术的120例非小细胞肺癌患者,用随机数字表法分为TPVB组、EB组和全身麻醉（GA）组。比较各组患者围手术期镇痛和芬太尼追加量情况、细胞免疫及体液免疫水平。结果?3组术后1?h、2?h、6?h、12?h、24?h和48?h VAS评分在不同时间、不同组间及变化趋势上有差异（P?<0.05）。3组芬太尼追加量比较,差异有统计学意义（P?<0.05）,GA组高于TPVB组、EB组（P?<0.05）。3组术后第1天和第3天CD3+CD4+、CD3+CD8+水平在不同时间、不同组间有差异（P?<0.05）,变化趋势无差异（P?>0.05）。3组术后第1天和第3天CD3-CD16+CD56+、CD19+水平在不同时间、不同组间及变化趋势上无差异（P?>0.05）。3组术后第1天和第3天IgG、IgM、IgA在不同时间有差异（P?<0.05）,不同组间及变化趋势上无差异（P?>0.05）。与EB组比较,TPVB组患者围手术期低血压发生率降低（P?<0.05）。结论?对于非气管插管肺叶切除术患者,TPVB和EB均能提供有效的围手术期镇痛;同时TPVB术后镇痛时间更持久,术后T淋巴细胞免疫抑制减轻。     

Video-assisted thoracoscopic surgery segmentectomy by non-intubated or intubated anesthesia: a comparative analysis of short-term outcome

Background

The aim of this study was to reveal the short-term outcomes of video-assisted thoracoscopic surgery (VATS) segmentectomy without tracheal intubation compared with intubated general anesthesia with one-lung ventilation (OLV).

Methods

We performed a retrospective review of our institutional database of consecutive 140 patients undergoing VATS anatomical segmentectomy from July 2011 to June 2015. Among them, 48 patients were treated without tracheal intubation using a combination of thoracic epidural anesthesia (TEA), intrathoracic vagal blockade, and sedation (non-intubated group). The other 92 patients were treated with intubated general anesthesia (intubated group). Safety and feasibility was evaluated by comparing the perioperative profiles and short-term outcomes of these two groups.

Results

Two groups had comparable surgical durations, intraoperative blood loss, postoperative chest tube drainage volume, and numbers of dissected lymph nodes (P>0.05). Patients who underwent non-intubated segmentectomy had higher peak end-tidal carbon dioxide (EtCO₂) during operation (44.81 vs. 33.15 mmHg, P<0.001), less white blood cell changes before and after surgery (△WBC) (6.08×10⁹ vs. 7.75×10⁹, P=0.004), earlier resumption of oral intake (6.76 vs. 17.58 hours, P<0.001), shorter duration of postoperative chest tube drainage (2.25 vs. 3.16 days, P=0.047), less cost of anesthesia (¥5,757.19 vs. ¥7,401.85, P<0.001), and a trend toward shorter postoperative hospital stay (6.04 vs. 7.83 days, P=0.057). One patient (2.1%) in the non-intubated group required conversion to intubated OLV since a significant mediastinal movement. In the intubated group, there was one patient (1.1%) required conversion to thoracotomy due to uncontrolled bleeding. The incidence difference of postoperative complications between groups was not significant (P=0.248). There was no in-hospital death in either group.

Conclusions

Compared with intubated general anesthesia, non-intubated thoracoscopic segmentectomy is a safe, technically feasible and economical alternative with comparable short-term outcomes. Patients underwent non-intubated thoracoscopic segmentectomy could gain a prompt recovery.     

无阿片类药物麻醉在非插管胸腔镜手术中的应用

目的 评价无阿片类药物麻醉在非插管胸腔镜手术中的安全性和可行性。方法 选取2019年5月—2019年11月在胜利油田中心医院行胸腔镜下单侧肺叶切除术（肺叶、肺段楔形）患者60例作为研究对象。采用随机数字表法分为无阿片麻醉组和对照组,每组30例。无阿片麻醉组采取无阿片类药物麻醉诱导后置入喉罩保留自主呼吸,对照组行传统全身麻醉双腔气管插管。记录两组患者的麻醉满意度、手术视野暴露满意度、手术时间、苏醒时间、拔管（喉罩）时间、术毕主动下床活动时间和出院时间;记录术中及术后24 h内不良反应发生例数。结果 两组的麻醉效果、手术视野暴露满意度比较,差异无统计学意义（P >0.05）;两组术后苏醒时间、拔管时间、术毕下床活动时间和出院时间比较,无阿片麻醉组少于对照组（P <0.05）;两组术中呛咳、低氧血症、二氧化碳蓄积发生例数比较,差异无统计学意义（P >0.05）。术中心血管不良事件无阿片麻醉组7例,对照组21例,两组比较,差异有统计学意义（P <0.05）;两组术后呼吸抑制、躁动、头晕、皮肤瘙痒患者比较,无阿片麻醉组少于对照组（P <0.05）;两组术后24 h内恶心、呕吐比较,差异无统计学意义（P >0.05）,但术后6 h内无阿片麻醉组恶心和呕吐的发生少于对照组（P <0.05）。结论 无阿片类药物麻醉应用于非插管胸腔镜手术安全可行,可减少术后不良反应,有利于患者的快速康复。     

Non-intubated resection and reconstruction of trachea for the treatment of a mass in the upper trachea

Tumors of the upper trachea are typically treated by tracheal resection and reconstruction via neck incision under general anesthesia. In recent years, non-intubated thoracic surgery has been widely applied for the treatment of lung diseases due to its advantages including quick postoperative recovery. In this article, we describe the application of non-intubated tracheal resection and reconstruction in one patient for the treatment of a mass in upper trachea.     

Nursing for the complete VATS lobectomy performed with non-tracheal intubation

Video-assisted thoracoscopic surgery (VATS) has without doubt been the most important advance in thoracic surgery. The general anesthesia before the tracheal intubation for VATS was often accompanied with tracheal mucosa and lung injuries, which were typically manifested as painful throat, nausea, vomiting, and other symptoms. However, the non-intubated anesthesia VATS can avoid these shortcomings due to its shorter anesthesia time, simpler steps, and quicker post-operative recovery. A total of 63 patients underwent VATS lobectomy under non-intubated anesthesia from July 2012 to July 2013. Good teamwork, proper pre-operative visit, and comfortable intra-operative position had ensured the success of these operations. In conclusion, adequate pre-operative preparation, careful nursing, and close cooperation can achieve a successful non-intubated anesthesia VATS.     

Non-intubated complete thoracoscopic bronchial sleeve resection for central lung cancer

Bronchial sleeve resection has emerged as an effective thoracoscopic approach for central lung cancer with reduced operation mortality rates, optimal lung function and long-term survival. Endobronchial intubation is a commonly used method of anesthesia for such thoracoscopic procedures, but is associated with increased intubation-related and lung complications. Non-intubated epidural anesthesia represents an alternative approach which may avoid such difficulties, particularly in complicated sleeve resection situations. Here we have described a case of complete endoscopic bronchial sleeve resection of right lower lung cancer under non-intubated epidural anesthesia.     

Non-intubated pyeloplasty for pelviureteric junction obstruction in children

Sixty-one consecutive patients undergoing pyeloplasty (5 bilateral) were reviewed retrospectively; 54 pyeloplasties were non-intubated (NIP) and 12 were intubated. NIPs were managed by an extrarenal wound drain, which was removed after 2–4 days in 44 repairs with minimal or no urinary leakage and after 6–8 days in 10 with significant leakage. Fifty-two were successful after the primary procedure. One patient who developed a urinoma after drain removal required a percutaneous nephrostomy followed by a revision pyeloplasty. A second revision pyeloplasty was necessary for persistent postoperative obstruction. The results of NIP compared favorably with series where intubation was used routinely and were superior to alternative methods of management such as endopyelotomy.     

A risk score for predicting postoperative complications in non-intubated thoracic surgery

BackgroundThe risk factors for postoperative complications in non-intubated video-assisted thoracoscopic surgery (VATS) have not been observed before. Here to develop a simple risk score to predict the risk of postoperative complications for patients who scheduling non-intubated VATS, which is beneficial to guide the clinical interventions.MethodsA total of 1,837 patients who underwent non-intubated VATS were included from January 2011 to December 2018. A development data set and a validation data set were allocated according to an approximate 3:2 ratio of total cases. The stepwise logistic regression was used to establish a risk score model, and the methods of bootstrap and split-sample were used for validation.ResultsMultivariable analysis revealed that the forced expiratory volume in the first second in percent of predicted, the anesthesia method, blood loss, surgical time, and preoperative neutrophil ratio were risk factors for postoperative complications. The risk score was established with these 5 factors, varied from 0 to 53, with the corresponding predicted probability of postoperative complications occurrence ranged from 1% to 92% and was calibrated (Hosmer-Lemeshow χ² =6.261; P=0.618). Good discrimination was acquired in the development and validation data sets (C-statistic 0.705 and 0.700). A positive correlation was between the risk score and postoperative complications (P for trend <0.01). Three levels of low-risk (0–15 points], moderate-risk (15–30 points], and high-risk (>30 points] were established based on the score distribution of postoperative complications.ConclusionsThis simple risk score model based on risk factors of postoperative complications can validly identify the high-risk patients with postoperative complications in the non-intubated VATS, and allow for early interventions.     

非气管插管胸腔镜肺叶切除术前TPVB及EB的术后镇痛效果及对血清炎症因子、疼痛介质水平影响

目的 探讨非气管插管胸腔镜肺叶切除术前胸椎旁神经阻滞(TPVB)及硬膜外阻滞(EB)的术后镇痛效果及对血清炎症因子、疼痛介质水平影响。方法 选取2020年10月—2022年10月胜利油田中心医院收治198例行非气管插管胸腔镜肺叶切除术的患者,采用单纯随机抽样法分为TPVB组、EB组和对照组,每组66例。对照组采用保留自主呼吸的非气管插管麻醉,TPVB组采用TPVB复合保留自主呼吸的非气管插管麻醉,EB组采用EB复合保留自主呼吸的非气管插管麻醉。比较3组围手术期指标、心率(HR)、平均动脉压(MAP)、视觉模拟评分法(VAS)评分、Ramsay镇静评分、血清疼痛介质[5-羟色胺(5-HT)、P物质(SP)、去甲肾上腺素(NE)、多巴胺(DA)]、炎症因子[超敏C反应蛋白(hs-CRP)、肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)],体液免疫功能[免疫球蛋白A(IgA)、免疫球蛋白G(IgG)、免疫球蛋白M(IgM)],记录围手术期不良反应。结果 3组麻醉时间、手术时间、右美托咪定用量、丙泊酚用量比较,差异均无统计学意义(P>0.05)。TPVB组、EB组芬太尼用量低...     

Comparison of two preoperative positioning techniques and unpositioning methods in non-intubated video-assisted thoracoscopic surgery

BackgroundUsing the non-intubated video-assisted thoracoscopic surgery (VATS) approach for small pulmonary nodules (SPNs) can accelerate patients’ postoperative recovery. However, locating the SPNs intraoperatively by palpation can be difficult for thoracic surgeons. The advantages of using different preoperative positioning materials are different, especially for pulmonary-nodule-location-needle (P-N-L-N) and the microcoil. This retrospective study analyzed the advantages of two preoperative positioning techniques for VATS under non-intubation anesthesia.MethodsThe data were collected for a total of 150 patients with pulmonary nodules who underwent non-intubated VATS at the First People’s Hospital of Yunnan Province from January 2018 to January 2021. The patients were divided into a preoperative positioning group (including a P-N-L-N group and microcoil group) and an unlocalized group. These included patients were all compliant with surgical guidelines and were suitable for preoperative localization. Their intraoperative and postoperative indicators were compared, and among these indicators, the operative time, number of postoperative drainage days, postoperative total drainage volume, postoperative discharge time was efficacy group and the intraoperative blood loss was safety group.ResultsPreoperative localization helped surgeons to explore nodules faster intraoperatively and remove SPNs precisely under non-intubated VATS. But the advantages of using different preoperative positioning materials are different. Positioning with either microcoil or P-N-L-N resulted in less operation time (P-N-L-N group: 94.90±28.42 min, microcoil group: 112.80±28.6 min, P<0.05), less intraoperative blood loss (P-N-L-N group: 35.80±21.17 mL, microcoil group: 75.00±65.22 mL, P<0.001) and less postoperative thoracic drainage volume (P-N-L-N group: 64.90±181.96 mL, microcoil group: 648.52±708.81 mL, P<0.001). However, the postoperative discharge time (P-N-L-N group: 5.02±1.35 days, microcoil group: 5.40±2.79 days, P=0.38) and postoperative drainage time(P-N-L-N group: 2.58±1.70 days, microcoil group: 3.18±2.49 days, P=0.16) was not statistically significant. Positioning with P-N-L-N seemed to have a better auxiliary effect for non-intubated VATS, suggesting its use can assist surgeons to determine the location of the lesion more accuracy intraoperatively. There was no significant difference in the pathological results among the groups.ConclusionsLocalization of SPNs is beneficial in non-intubated VATS, and the use of P-N-L-N was more effective than the microcoil in reducing operative time, intraoperative blood loss, postoperative total drainage volume, and postoperative discharge time.