Liu Yang, Cao Wen, Liu Yu, Wang Yun, Lang Ren, Yue Yun, Wu An-Shi
Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China.
Department of Ultrasonography, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, 100020, Beijing, China.
BMC Anesthesiol. 2017 Mar 20;17(1):45. doi: 10.1186/s12871-017-0335-1.
A moderate insufflation pressure and deep neuromuscular blockade (NMB) have been recommended in laparoscopic surgery in consideration of the possible reduction in splanchnic perfusion due to the CO-pneumoperitoneum. Since the liver is the major organ for rocuronium metabolism, the question of whether NMB of rocuronium would change with the variation of liver perfusion during pneumoperitoneum during laparoscopic surgery merits investigation.
In this prospective study, a total of sixty female patients scheduled for either selective laparoscopic gynaecological surgery (group laparoscopy) or laparotomy for gynaecological surgery (group control) were analyzed. Rocuronium was administered with closed-loop feedback infusion system, which was also applied to monitor NMB complied with good clinical research practice (GCRP). The onset time, clinical duration, and recovery index were measured. Hepatic blood flow was assessed by laparoscopic intraoperative ultrasonography before insufflation/after entering the abdominal cavity (T1), 5 min after insufflation in the Trendelenburg position/5 min after skin incision (T2), 15 min after insufflation in the Trendelenburg position/15 min after skin incision (T3), 30 min after insufflation in the Trendelenburg position/30 min after skin incision (T4), and 5 min after deflation/before closing the abdomen (T5) in group laparoscopy/group control respectively. The relationship between the clinical duration of rocuronium and portal venous blood flow was analyzed using linear or quadratic regression.
The clinical duration and RI of rocuronium were both prolonged significantly in group laparoscopy (36.8 ± 8.3 min; 12.8 ± 5.5 min) compared to group control (29.0 ± 5.8 min; 9.8 ± 4.0 min) (P < 0.0001; P = 0.018). A significant decrease was found in portal venous blood flow during the entire pneumoperitoneum period in group laparoscopy compared with group control (P < 0.0001). There was a significant correlation between the clinical duration of rocuronium and portal venous blood flow (Y = 51.800-0.043X + (1.86E-005) X ; r = 0.491; P < 0.0001).
Rocuronium-induced NMB during laparoscopic gynaecological surgery might be prolonged due to the decrease in portal venous blood flow induced by CO-pneumoperitoneum. Less rocuronium could be required to achieve a desirable NMB in laparoscopic gynaecological surgery.
ChiCTR. Registry number: ChiCTR-OPN-15007524 . Date of registration: December 4, 2015.
考虑到二氧化碳气腹可能导致内脏灌注减少，腹腔镜手术中推荐采用适度的气腹压力和深度神经肌肉阻滞（NMB）。由于肝脏是罗库溴铵代谢的主要器官，在腹腔镜手术气腹期间，罗库溴铵的神经肌肉阻滞是否会随肝脏灌注变化而改变，这一问题值得研究。
在这项前瞻性研究中，共分析了60例计划行选择性腹腔镜妇科手术的女性患者（腹腔镜组）和开腹妇科手术的女性患者（对照组）。使用闭环反馈输注系统给予罗库溴铵，该系统也用于监测符合良好临床研究规范（GCRP）的神经肌肉阻滞。测量起效时间、临床作用时间和恢复指数。分别在腹腔镜组/对照组气腹前/进入腹腔后（T1）、头低脚高位气腹5分钟/皮肤切开后5分钟（T2）、头低脚高位气腹15分钟/皮肤切开后15分钟（T3）、头低脚高位气腹30分钟/皮肤切开后30分钟（T4）以及放气后5分钟/关腹前（T5），通过腹腔镜术中超声评估肝血流量。使用线性或二次回归分析罗库溴铵的临床作用时间与门静脉血流量之间的关系。
与对照组（29.0±5.8分钟；9.8±4.0分钟）相比，腹腔镜组罗库溴铵的临床作用时间和恢复指数均显著延长（36.8±8.3分钟；12.8±5.5分钟）（P<0.0001；P = 0.018）。与对照组相比，腹腔镜组在整个气腹期间门静脉血流量显著降低（P<0.0001）。罗库溴铵的临床作用时间与门静脉血流量之间存在显著相关性（Y = 51.800 - 0.043X + (1.86E - 005)X²；r = 0.491；P<0.0001）。
腹腔镜妇科手术期间，由于二氧化碳气腹导致门静脉血流量减少，罗库溴铵诱导的神经肌肉阻滞可能会延长。在腹腔镜妇科手术中，可能需要较少的罗库溴铵来达到理想的神经肌肉阻滞效果。
中国临床试验注册中心。注册号：ChiCTR - OPN - 15007524。注册日期：2015年12月4日。
