深度与中度神经肌肉阻滞对腹腔镜减肥手术外科手术条件和术后呼吸功能的影响：随机双盲临床试验
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The Effect of Deep Versus Moderate Neuromuscular Block on Surgical Conditions and Postoperative Respiratory Function in Bariatric Laparoscopic Surgery: A Randomized, Double Blind Clinical Trial .
背景与目的
据近来的文献报道，深度神经肌肉阻滞（NMB）在腹腔镜检查中改善了手术条件; 然而，支持这一观点的证据是有限的，而且这种观点在腹腔镜减肥手术中并没有进行调查研究。此外，神经肌肉阻滞的残余作用可能会损害术后呼吸功能。 我们测试了与中度NMB相比深度NMB可以提高腹腔镜减肥手术的外科手术条件质量的假设，并研究了：与中度NMB相比深度NMB是否会将患者置于术后呼吸障碍的风险中。
方 法
60例患者均匀随机分为深度NMB组（单次快速注射和输注罗库溴铵维持强直后刺激计数为1-2次），中度NMB组（单次快速注和输注罗库溴铵维持四个成串刺激后计数为1-2次））。 用异丙酚和瑞芬太尼诱导和维持麻醉。 主要结局指标是：外科手术条件这由单独的外科医生使用5分评定量表（1 =极差，5 =最佳），腹内压升高> 18 cmH2O的例数和手术持续时间。 次要结局指标是：通过呼气峰值流量，一秒用力呼气量和用力肺活量，以及需要术后呼吸支持来评估的术后肺功能。组间比较，数据以平均数±标准偏差估计的治疗效果（ETE：均值差的置信区间[ 95% CI]）。
结 果
外科医生对深度和中度NMB组手术质量的评分差异无统计学意义（4.2±1.0 vs 3.9±1.1; P = .16; ETE：0.4 [-0.1，0.9 ]）。两组之间5分评分量表的手术条件评分等级比例无差异（P = .91）。深度VS中度NMB组，腹内压升高> 18 cmH2O的例数和手术持续时间差异无统计学意义（0.2±0.9 vs 0.3±1.0; P = .69; ETE：-0.1 [-0.5,0.4]和61.3±15.1min VS70.6±20.8min ; P = .07，ETE：-9.3 [-18.8,0.1]）。与基线相比，两组患者的肺功能检查均明显受损（P <0.001）。深度和中度NMB组之间呼气峰值流量，一秒用力呼气量，用力肺活量（以基线的百分比变化表示）差异无统计学意义。
结 论
与中度NMB相比，没有足够的证据可以得出深度NMB在腹腔镜减肥手术中改善手术条件的结论。腹腔镜减肥手术术后肺功能大大减少这与使用的NMB方案并无相关性。而且本研究受到小样本量的限制
原始文献摘要
Sam Baete, MD,* Gerd Vercruysse, MD,* Margot Vander Laenen, MD,* Pieter De Vooght, MD,*Jeroen Van Melkebeek, MD,* Dimitri Dylst, MD,* Maud Beran, MD,* Jan Van Zundert, MD, PhD,*René Heylen, MD, PhD,* Willem Boer, MD,* Sam Van Boxstael, MD,* Tom Fret, MD,* Hans Verhelst, MD,†Cathy De Deyne, MD, PhD,*‡ Frank Jans, MD, PhD,*‡ and Pascal Vanelderen, MD, PhD*‡.The Effect of Deep Versus Moderate Neuromuscular Block on Surgical Conditions and Postoperative Respiratory Function in Bariatric Laparoscopic Surgery: A Randomized, Double Blind Clinical Trial .Anesth Analg 2017
BACKGROUND: In recent literature, it has been suggested that deep neuromuscular block (NMB) improves surgical conditions during laparoscopy; however, the evidence supporting this statement is limited, and this was not investigated in laparoscopic bariatric surgery. Moreover,residual NMB could impair postoperative respiratory function. We tested the hypotheses that deep NMB could improve the quality of surgical conditions for laparoscopic bariatric surgery compared with moderate NMB and investigated whether deep NMB puts patients at risk for postoperative respiratory impairment compared with moderate NMB.
METHODS:Sixty patients were evenly randomized over a deep NMB group (rocuronium bolus and infusion maintaining a posttetanic count of 1–2) and a moderate NMB group (rocuronium bolus and top-ups maintaining a train-of-four count of 1–2). Anesthesia was induced and maintained with propofol and remifentanil. The primary outcome measures were the quality of surgical conditions assessed by a single surgeon using a 5-point rating scale (1 = extremely poor, 5 = optimal)，the number of intra-abdominal pressure increases >18 cmH2O and the duration of surgery.Secondary outcome measure was the postoperative pulmonary function assessed by peak expiratory flow, forced expiratory volume in 1 second, and forced vital capacity, and by the need for postoperative respiratory support. Data are presented as mean ± standard deviation with estimated treatment effect (ETE: mean difference [95% confidence interval]) for group comparisons.
RESULTS:There was no statistically significant difference in the surgeon’s rating regarding the quality of the surgical field between the deep and moderate NMB group (4.2 ± 1.0 vs 3.9 ± 1.1;P = .16, respectively; ETE: 0.4 [−0.1, 0.9]). There was no difference in the proportional rating of surgical conditions over the 5-point rating scale between both groups (P = .91). The number of intra-abdominal pressure increases >18 cmH2O and the duration of surgery were not statistically different between the deep and moderate NMB group (0.2 ± 0.9 vs 0.3 ± 1.0; P = .69; ETE:−0.1 [−0.5, 0.4] and 61.3 ± 15.1 minutes vs 70.6 ± 20.8 minutes; P = .07, ETE: −9.3 [−18.8,0.1], respectively). All the pulmonary function tests were considerably impaired in both groups when compared with baseline (P < .001). There was no statistically significant difference in the decrease in peak expiratory flow, forced expiratory volume in 1 second, and forced vital capacity (expressed as % change from baseline) between the deep and the moderate NMB group.
CONCLUSIONS：Compared with a moderate NMB, there was insufficient evidence to conclude that deep NMB improves surgical conditions during laparoscopic bariatric surgery. Postoperative pulmonary function was substantially decreased after laparoscopic bariatric surgery independently of the NMB regime that was used. The study is limited by a small sample size.
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