目的:探讨肾动脉低温灌注腹腔镜肾部分切除术对麻醉苏醒期的影响及相关麻醉策略.方法:回顾性分析40例完全内生型肾肿瘤患者的临床资料,40例分别采用肾动脉低温灌注与常规热缺血腹腔镜下肾部分切除术治疗.40例美国麻醉医师协会麻醉评分(ASA)为Ⅰ～Ⅲ级的肾肿瘤手术患者分为低温灌注组(A组)20例,常规热缺血组(B组)20例.A组患者首先在介入科放射手术室经腹主动脉行肾动脉置管,放置Fogarty双腔球囊导管后再送往手术室.两组采用相同的麻醉诱导及术中用药,维持脑电双频指数(BIS)值为40～60.手术显露肾脏肿瘤后A组患者使用4℃200 ml灌注液使肾脏降温,阻断肾静脉,经球囊导管加压注入灌注液;手术显露肾脏肿瘤后B组患者分离肾动脉,以血管夹夹闭肾动脉.观察指标:记录患者麻醉前(T0)、苏醒时(T1)、拔管即刻(T2)、拔管后5 min(T3)四个时间点的平均动脉压(MAP)、心率(HR)、体温、BIS值;记录呼吸恢复时间、意识恢复时间和拔管时间;记录拔管后镇静程度(Ramsay)及术后躁动评分,比较手术前后肌酐,肾小球滤过率估算值的变化.结果:术中体温变化:A组下降(2.0±0.5)℃,B组下降(0.8±0.2)℃,差异有统计学意义(P＜0.05);自主呼吸恢复时间:A组(10.0±4.5)min,B组(6.8±2.1)min,差异有统计学意义(P＜0.05);完全清醒时间:A组(13.0±4.6) min,B组(10.2±2.6)min,差异有统计学意义(P＜0.05);拔管时间:A组(12.0±3.6)min,B组(10.5±3.2) min,差异有统计学意义(P＜0.05);镇静程度Ramsay评分:A组(4.1±1.3)分,B组(2.4±0.5)分,差异有统计学意义(P＜0.05);躁动评分:A组(3.2±0.6)分,B组(1.8±0.4)分,差异有统计学意义(P＜0.05);手术前后肌酐和肾小球滤过率变化A组均低于B组(P＜0.05).结论:与动脉阻断组比较,低温灌注组术中中心体温自主下降增加,寒战比例增加;呼吸恢复时间、拔管时间、完全清醒时间延长;躁动比例增加.肾动脉低温灌注手术为临床新开展的前沿手术,临床经验表明肾功能恢复优于肾动脉阻断病历,麻醉医生应了解手术方式的变化同时加强麻醉期的管理,降低苏醒期并发症.%Objective:To investigate the effect of laparoscopic partial nephrectomy on the recovery period of anesthesia and the related anesthetic strategies.Methods:The clinical data of 40 patients with completely intraparenchymal tumors treated by renal artery perfusion and conventional warm ischemia laparoscopic partial nephrectomy were analyzed retrospectively.Forty cases of renal tumor were divided into cold perfusion group (group A) and warm ischemic group (group B) (n =20 each group).In group A Fogarty double lumen balloon catheter was placed before operation.The two groups received the same anesthesia induction and intraoperative medication.After surgery revealed renal tumors,patients in group A were treated with 4℃ 200 mL perfusion solution to cool the kidneys.After surgery revealed renal tumors,the renal arteries were occluded by blood vessel clamp in group B.The MAP,BIS and temperature were recorded at different time points.Temperature respiratory recovery time,consciousness recovery time,extubation time,Ramsay and postoperative sedation-agitation scale were compared between two groups.The changes of CR and eGFR were compared before and after the operation in two groups.Results:There was no statistically significant difference in MAP,HR and BIS between two groups at different time points.The temperature in group A was obviously decreased as compared with that in group B (P＜0.05).The spontaneous breathing recovery time in group A was obviously prolonged as compared with that in group B (P＜0.05).The fully awake time and the extubation time in group A were obviously prolonged as compared with those in group B (P＜0.05).The Ramsay scores in group A were obviously increased as compared with those in group B (P＜0.05).The sedation-agitation scale in group A was obviously increased as compared with that in group B (P＜0.05).The changes of CR and eGFR before and after operation in group A were decreased as compared with those in group B.Conclusions:Renal artery cold perfusion is a new frontier surgery clinically.The clinical experience shows that the recovery of renal function in renal artery cold perfusion is better than in renal artery occlusion.The anesthesia doctors should understand the change of surgical procedures and strengthen management simultaneously in order to reduce the postoperative complications.
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