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A comparative study of laryngeal mask and endotracheal tube in anesthesia for adult NUSS surgery

2018-9-13 2611
Pectus excavatum (PE) is a chest wall deformity characterized by a funnel-shaped depression in the chest wall. It is the most common congenital chest wall malformation, accounting for about 90% of all chest wall malformations. Clinically, almost all patients with funnel chest have a typical posture, they are tall and thin, chest wall depression, abdominal bulging and scoliosis, but the etiology has not been conclusive. PE patients may only show physical defects, but due to their special anatomy, they can cause respiratory infections, dyspnea, chest pain, heart disease and heart-related diseases.

       Since the first description in the 16th century, the funnel chest has received increasing attention from the medical community. In order to improve the therapeutic effect of the funnel chest patient, it was corrected by surgical treatment in 1911. In this century, the surgical methods have been continuously improved. The sternal osteotomy, sternal inversion, sternal lift and their related improvements have been introduced, but these traditional surgical methods have been operated for a long time, have more bleeding, and are more traumatic to patients. In 1988, Nuss introduced the minimally invasive repair of pectus excavatum (MIRPE, also known as NUSS). At this point, the treatment of the funnel chest has made a breakthrough. The NUSS technique uses a micro-incision to correct the funnel chest under thoracoscopy. Because of the advantages of small surgical trauma, short operation time, less intraoperative blood loss, and quick recovery of the surgeon, NUSS is becoming more and more popular, and it has become the standard surgical method for treating funnel chest. Currently, for thoracoscopic surgery, single-lung ventilation is often performed under general anesthesia with dual-lumen bronchial intubation. Bronchial cannula can separate the ventilation of the two lungs to achieve the purpose of lung collapse on one side, ensuring the ventilation of the lungs while exposing the surgical field and facilitating operation. Single-cavity bronchial catheters can also be used for single non-isolation, with consistent results. Thoracoscopy is highly demanding for lung isolation and often requires fiberoptic bronchoscopy for precise positioning. Intraoperative single-lung ventilation is prone to hypoxemia and requires close monitoring during anesthesia. In addition, it is also possible to perform a thoracoscopic surgery directly with a tracheal intubation under the premise of filling the artificial pneumoperitoneum with C02. However, both bronchial intubation and endotracheal intubation are prone to complications of intubation, catheter misuse of esophagus, soft tissue damage, hoarseness, sore throat and aspiration. In order to reduce these intubation complications, thoracic epidural anesthesia has entered people's field of vision. The study found that thoracic epidural block combined with general anesthesia under tracheal intubation compared with simple tracheal intubation, the anesthetic dose was significantly reduced, intraoperative hemodynamic stability, postoperative wakefulness and good analgesic effect . In 1983, the laryngeal mask was invented and then used clinically, and its use in endoscopic surgery has become more common. It has been reported that laryngeal masks are used in gynecological, pediatric, cholecystectomy and lobectomy for spontaneous pneumothorax, and the vital signs are stable and the surgical results are satisfactory. Objective To observe perioperative leukocyte and neutrophil changes and intraoperative hemodynamics (mean arterial pressure and heart rate) in patients with minimally invasive funnel thoracic surgery (NUSS) under two different anesthesia modes: tracheal intubation and laryngeal mask. Changes, pulse oximetry (SP02), end-tidal carbon dioxide partial pressure (PetC02) intraoperative blood gas analysis (PH, PaO2, PaC02), intraoperative anesthetic total dose, anesthesia effect grading, etc., postoperative patient awake Time, complications, and clinical indicators are used to explore anesthesia that is more suitable for NUSS. Materials and Methods 1. Experimental group Patients who were diagnosed as funnel chest and performed NUSS surgery in Guangdong Provincial People's Hospital from September 1, 2012 to March 1, 2014 were randomly assigned to the tracheal intubation group and laryngeal mask. Group, each group reached 30 cases. 2. General information of patients From September 1, 2012 to March 1, 2014, patients with NUSS in the funnel chest in our hospital, ASA grade I to II, age 17-24 years old, all patients were performed before surgery Medical history inquiry, physical examination and other related examinations. Patients with severe heart, kidney and kidney dysfunction can not tolerate surgery; poor lung function (FEV 160%), with pulmonary infection; patients with mental illness who have long-term antipsychotic drugs, central systemic diseases, history of anesthesia allergy, etc. Not included in the scope of the experiment. 3. Anesthesia method 1) Anesthesia method and maintenance treatment of laryngeal mask intravenous injection of midazolam 0.05~0.1 mg/kg, fentanyl citrate injection 2 ug/kg, then target-controlled infusion of propofol The injection (plasma target concentration 1.5-2 ug/kg) was induced, and the patient's consciousness disappeared and the laryngeal mask was placed. The ventilator was set to SIMV mode. During the operation, the plasma target concentration of propofol injection was 2 to 4 ug/ml, and remifentanil was maintained at 0.1 to 0.2 ug/(kg·min), and was adjusted according to the depth of anesthesia (Narcotrend). And to ensure that the heart rate is in the range of 50 to 100 beats / min, the pulse oxygen saturation is maintained at 95% and above, the blood pressure is controlled at not less than or higher than 20% before surgery, and the anesthesia depth (Narcotrend) is maintained in the range of 50-64. Inside. Add 2 ug/kg of fentanyl at the end of the operation. When the patient can respond, and can follow the instructions to complete blinking, head-up, etc., the patient's oxygen saturation is maintained above 95% when inhaling air, pull out LMA, observe 15 minutes and return to the thoracic surgery ward, continue Nasal oxygen tube was observed by oxygen absorption 2 L/min. 2) Anesthesia method and maintenance treatment of tracheal intubation with intravenous administration of midazolam 0.05-0.1 mg/kg, fentanyl citrate injection 4ug/kg, and then start target-controlled infusion of propofol injection The solution (plasma target concentration 1.5-2 ug/kg) was injected with 0.2 mg/kg of atracurium cis-sulfonate after the patient's consciousness disappeared. After the effect, tracheal intubation was performed and the ventilator was set to VPV mode. During the operation, the plasma target concentration of propofol injection was 2~4ug/ml, remifentanil 0.1~0.2 ug/(kg·min), and atracurium cis-sulfonate 2 ug/(kg.min) was maintained. And then adjust according to the depth of anesthesia (Narcotrend). The heart rate fluctuates within the range of 50-100 beats/min, the pulse oximetry is maintained at 95% or above, the blood pressure is controlled to be no less than or higher than 20% before surgery, and the anesthesia depth (Narcotrend) is maintained at 50-64. Additional fentanyl 2 ug/kg was added at the end of the operation. When the patient has self-breathing and then give muscle relaxant medicine, the patient can respond to it, and can complete the blinking, head-up and other actions according to the instructions, get rid of the ventilator for more than 10 minutes, and the breathing is smooth, the spontaneous breathing frequency is 14-20 times/min. The patient's oxygen saturation was maintained above 95% when inhaling air. The tracheal tube was withdrawn and returned to the thoracic surgery ward after 15 minutes. Continue to observe the oxygenation of the nasal oxygen tube at a flow rate of 2 L/min. 4. Postoperative treatment The patient remained supine, given a conventional intravenous analgesia pump and supplemented with non-steroidal analgesics to relieve pain. The patient can start drinking freely and eating 2 hours after returning to the ward. The chest X-ray was reviewed in the morning after the second day after surgery. If the closed thoracic drainage tube indicates that there is no gas leakage or the 24-hour drainage volume is less than 100 ml, consider removing the closed thoracic drainage tube. 5. Observed hemodynamic changes such as mean arterial pressure difference (△MAP) and heart rate difference (△HR) before and after surgery; blood gas analysis during operation; anesthesia recovery time after surgery, intraoperative sedative, analgesia The amount of drug, muscle relaxant, peak C02 at the end of breath, and the classification of anesthesia; the amount of blood loss from surgery (statistical suction bottle and the amount of gauze) and the length of surgery (the time from the incision to the surgical incision); the patient's after surgery Pain, the change in white blood cell count (△WBC) and neutrophil ratio (△NEU%) on the first postoperative day; the time of the patient's start of eating, the digestive tract reaction, the throat, Whether the voice is hoarse and the patient's hospital stay and the total cost of anesthesia. 6. Statistical methods Measurement data were expressed as x±s, and t-test was used for comparison between groups; categorical variables were expressed as percentages and analyzed by X2 test. All data were statistically analyzed and processed using SPSS 22.0, and P0.05 was statistically significant.

       Results 1. General information on the general data mask group and endotracheal intubation group, including age, gender, height, weight, BMI, Haller index and smoking history. There were no statistical differences between these indicators (P<0.05). The general situation of the two groups was balanced and comparable. 2. The intraoperative observation index of the laryngeal mask group and the endotracheal intubation group were all smooth, and there was no intraoperative transfer and thoracotomy. The laryngeal mask and tracheal intubation were smooth and there were no cases of altered anesthesia. The anesthetic effect was satisfactory, no serious complications occurred during the operation, and there was no vomiting, reflux or aspiration after surgery. In the laryngeal mask group, the change in white blood cell count ratio (AWBC) and the change in neutrophil ratio (ANEU%) on the first day before and after surgery were significantly lower than those in the endotracheal intubation group. Significance (P<0.05); hemodynamic changes such as mean arterial pressure difference (△MAP) and heart rate difference (△HR) before and after surgery, and the laryngeal mask group was significantly more stable than the endotracheal intubation group. Statistically significant (P<0.05); postoperative recovery time, laryngeal mask group was significantly shorter than endotracheal intubation group, the two were statistically significant (P<0.05); intraoperative tracheal intubation group used opioid analgesia The drug was significantly more than the laryngeal mask group. The tracheal intubation group required routine use of muscle relaxants to meet the surgical requirements. The laryngeal mask group did not use the muscle relaxant to meet the surgical requirements. The total cost of the laryngeal mask group was also significantly lower than that of the tracheal insertion. Tube group. Blood gas analysis during operation; there was no significant difference between the peak of end-tidal C02, the amount of blood loss, the length of operation, the time of anesthesia, and the grade of anesthesia. It was not statistically significant (PO.05) 3. Postoperative observation index The patient's eating time, the number of adverse reactions in the digestive tract, the number of cases of throat discomfort and the number of cases of hoarseness, the laryngeal mask group were smaller than the endotracheal intubation group, and the two were statistically significant (P<0.05). There was no significant difference in the length of hospital stay between the two groups, and there was no statistical significance (P<0.05). Conclusion In the airway management of adult VATS-NUSS surgery, the laryngeal mask has certain advantages over the endotracheal intubation. Compared with the tracheal intubation, the laryngeal mask is simple to operate, has no mechanical stimulation of the larynx and trachea, has less cardiovascular adverse reactions during insertion and extraction, and has more stable hemodynamics during surgery, reducing opioid analgesics and muscles. The use of loose medicine, the total anesthesia cost is reduced, the postoperative recovery is fast, the incidence of cough and sore throat is low, and the white blood cell count ratio is low, which is a more suitable method.