深度神经肌肉阻滞减少脊柱手术术中出血：随机临床试验

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Deep neuromuscular blockade during spinal surgery reduces intra-operative blood loss A randomised clinical trial

背景与目的

脊柱手术通常采用后路与俯卧位进行。然而，俯卧位可能会导致背部静脉充血，从而在手术中增加手术出血。俯卧位也会影响心输出量，因为大血管被压缩，减少静脉回流到心脏。我们假设在俯卧位脊柱手术中，深度神经肌肉阻滞与较少的手术出血有关。

方法

88名患者随机分为中度神经肌肉阻滞组和深度神经肌肉阻滞组。在中度神经肌肉阻滞组，调整罗库溴铵的给药剂量，使四个成串刺激比值为1：2。在深度神经肌肉阻滞组，调整罗库溴铵给药剂量，使四个成串刺激计数为零，强直刺激数目少于2。研究的主要结果是测量术中出血量。评估外科医生对手术条件、血流动力学和呼吸状态的满意度，以及术后疼痛评分。

                                             结果

深度神经肌肉阻滞组术中出血量明显少于中度神经肌肉阻滞组；300ml[200~494vs.415ml[240~601]；差异：117ml(95%可信区间，9~244；P=0.044)。深度神经肌肉阻滞组的外科医生对手术条件的满意度高于中度神经肌肉阻滞组；3.5 ± 1.0vs.2.9±0.9(P=0.004)。呼吸变量组间比较，深度神经肌肉阻滞组吸气峰压总体较低(P<0.001)。深度神经肌肉阻滞组术后疼痛评分中位数为50[36~60]，低于中度神经肌肉阻滞组的60[50~70]，差异有统计学意义(P<0.023)。

                                                  结论

深度神经肌肉阻滞减少了接受脊柱手术患者术中出血。与中度神经肌肉阻滞相比，可能与背部肌肉松弛，术中吸气峰值压降低有关。

原始文献摘要

Kang WS, Oh CS, Rhee KY, et,al.Deep neuromuscular blockade during spinal surgery reduces intra-operative blood loss A randomised clinical trial[J].Eur J Anaesthesiol 2020Mar;37(3)

BACKGROUND Spinal surgery is usually performed in the prone position using a posterior approach. However, the prone position may cause venous engorgement in the back and thus increase surgical bleeding with interruption of surgery. The prone position alsoaffects cardiac output since large vessels are compressed decreasing venous return to the heart.

OBJECTIVE We hypothesised that deep neuromuscular blockade would be associated with less surgical bleeding during spinal surgery in the prone position.

DESIGN Randomised, single blinded trial.

SETTING University teaching hospital.

PARTICIPANTS Eighty-eight patients in two groups.

INTERVENTIONS Patients were randomly assigned to moderate neuromuscular blockade or deep neuromuscular blockade. In the moderate neuromuscular blockade group,administration of rocuronium was adjusted such that the train-of-four count was one to two. In the deep neuromuscular blockade group, rocuronium administration was adjusted such that the train-of-four count was zero with a posttetanic count 2 or less.

MAIN OUTCOME MEASURES The primary outcome was the volume of intra-operative surgical bleeding. The surgeon’s  satisfaction  with  operating  conditions,haemodynamic and respiratory status, and postoperative pain scores were evaluated.

RESULTS The median [IQR] volume of intra-operative surgical bleeding was significantly less in the deep neuromuscular blockade group than in the moderate neuromuscular blockade group; 300 ml [200 to 494] vs. 415 ml [240 to 601]; difference: 117 ml (95% CI, 9 to 244; P=0.044). The mean+/-SD surgeon’s satisfaction with the intra-operative surgical conditions was greater in the deep neuromuscular blockade group than in the moderate neuromuscular blockade group; 3.5+/-1.0 vs. 2.9+/-0.9 (P=0.004). In intergroup comparisons of respiratory variables, peak inspiratory pressure was lower in the deep neuromuscular blockade group overall (P<0.001). The median [IQR] postoperative pain score was lower in the deep neuromuscular blockade group than the moderate neuromuscular blockade group; 50 [36 to 60] vs. 60 [50 to 70], (P=0.023).

CONCLUSION Deep neuromuscular blockade reduced intra-operative surgical bleeding in patients undergoing spinal surgery. This may be related to greater relaxation in the back muscles and lower intra-operative peak inspiratory pressure when compared with moderate neuromuscular blockade.

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翻译：牛振瑛    编辑：冯玉蓉  审校：王贵龙