这项工作得到了第三批宁波市卫生青年技术干部计划（朱彬斌博士）和浙江省医学会临床研究基金项目（高斌博士）（2018ZYC-A66）的支持。

该研究于2018年12月10日获得宁波大学医学院附属医院伦理委员会（KY20181215）的批准。
1. 入选标准
<ol><li>包括所有接受肺大疱切除术、肺楔形切除术或肺叶切除术的患者（>18 岁）。</li>
</ol>2. 排除标准
<ol><li>根据美国麻醉医师协会 （ASA） 的躯体状态分类 >315 排除患者。</li>
	<li>排除体重指数 （BMI） 16 >30 kg/m2.</li>
	<li>排除食管癌、全肺切除术和切除肋骨的心脏直视手术患者。</li>
	<li>排除既往有支气管扩张症、肺破坏或慢性阻塞性肺病 （COPD） 病史的患者。</li>
	<li>术前排除有明确多发性肺部感染或炎症的患者，以及其他严重的全身性疾病。</li>
	<li>排除凝血障碍和严重精神或神经系统疾病患者。</li>
</ol>3.麻醉前的准备
<ol><li>手术前禁食患者8小时。</li>
	<li>将操作室温度调整为24°C至26°C之间。</li>
	<li>将 20 G 顶翼输液针插入手部的非手术背静脉。</li>
	<li>监测患者的心电图、血压、脉搏血氧饱和度 （SpO2） 和呼吸频率。</li>
	<li>将双光谱指数 （BIS） 四分传感器应用于每位患者的前额。 注意：如有必要，持续监测桡动脉压和中心静脉压。</li>
</ol>4.超声引导下胸椎旁阻滞
<ol><li>将患者置于侧卧位。</li>
	<li>将超声探头直接放置在第三胸椎和第七胸椎的棘突上方，并获得棘突的横截面图像。 注意：图像中间是具有后声阴影的高回声棘突，棘突两侧具有后声阴影的骨结构依次是椎板和横向突。</li>
	<li>横向移动超声探头以显示整个横向过程。</li>
	<li>向外移动超声探头以可视化横向过程、横向肋关节和肋骨。</li>
	<li>向尾部移动超声探头，直到在图像中检测到横突、胸膜和它们之间的胸椎旁间隙。</li>
	<li>通过注射 2 mL 的 1% 利多卡因局部麻醉皮肤。</li>
	<li>在超声引导下，用面内入路将块针从外侧插入到内侧。</li>
	<li>注射前小心增加抽吸。确保没有观察到血液反流。 注意：此步骤的目的是防止局部麻醉剂的全身毒性。</li>
	<li>注射2mL生理盐水，然后用超声观察胸膜的前移和胸椎旁间隙的增宽。</li>
	<li>以T3和T7水平注射15mL的0.375%罗哌卡因。</li>
</ol>5.麻醉诱导
<ol><li>将 1% 左旋布比卡因 （3 mL） 喷洒在喉咙上。</li>
	<li>注射1.5微克/千克芬太尼和1-1.5毫克/千克丙泊酚。</li>
	<li>对于持续供氧，放置面罩或插入喉罩气道（双管面罩;#3用于30-50公斤，#4用于50-70公斤，#5用于70-100公斤）。氧气通过面罩或喉罩 进入 患者的气道。 注意：调整注射剂量以达到40-6016之间的BIS值。</li>
</ol>6. 麻醉的维持
<ol><li>保持0.5-1升/分钟的氧气流速。</li>
	<li>人工气胸后将七氟醚的浓度维持在1.5%-2.0%。 注意：如果术中自主呼吸频率高于20次/分钟或出现纵隔扑动或咳嗽，则注射0.5μg/ kg芬太尼。七氟醚通过面罩或喉罩 进入 患者的气道。</li>
	<li>监测吸入氧浓度和潮气末二氧化碳 （ETCO2 < 60 mmHg）。</li>
	<li>监测体温。监测意识水平，并保持BIS值为40-6016,17。</li>
	<li>如果患者出现窦性心动过缓（HR ≤ 50 次/分钟），则注射 20μg/kg 阿托品。</li>
	<li>如果收缩压低于 30% 或 90 mmHg，则使用输液泵连续灌注 2 μg/kg/h 去甲肾上腺素。</li>
	<li>手术结束前15分钟进行动脉血气分析。</li>
	<li>手术结束前30分钟注射1mg / kg氟比洛芬。</li>
</ol>7.胸腔镜迷走神经阻滞技术与胸膜浸润麻醉
<ol><li>进行右侧手术时，使用 24 G 顶翼输液针在下气管水平的迷走神经附近产生 0.375% 罗哌卡因 （3 mL） 的浸润。</li>
	<li>进行左侧手术时，使用 24 G 顶翼输液针在迷走神经附近主肺窗水平产生 0.5% 罗哌卡因 （3 mL） 的浸润。</li>
	<li>使用 10 mL 注射器将 10 mL 2% 利多卡因喷洒到内脏胸膜表面。</li>
</ol>8.从非插管麻醉转为插管全身麻醉
<ol><li>如果患者满足以下条件之一，则将非插管麻醉转换为插管全身麻醉： -严重低氧血症（脉搏血氧饱和度<80%） -严重高碳酸血症（PaCO2 > 80 mmHg） -血流动力学不稳定：顽固性心律失常和右心室衰竭 -持续咳嗽导致手术变得困难或不可能 -术中出血需要开胸术</li>
</ol>9. 术后护理
<ol><li>完全清醒后，要求患者深呼吸并咳嗽以重新扩张塌陷的肺。</li>
	<li>将患者控制的静脉镇痛 （PCA） 泵连接到静脉导管，并在 PCA 储液袋中加入 100 mL 溶液（含有 1 μg/kg 舒芬太尼和 0.9% 氯化钠注射液），并滴定 2 mL/h 的 PCA 溶液。</li>
	<li>当咳嗽时无漏气，胸部 X 线检查无明显液体气胸，24 小时引流 <300 mL 时，应取出胸腔引流管。</li>
</ol>

保留自主呼吸的视频辅助胸腔镜手术的非插管方案

作者没有什么可透露的。

该方案的优点如下：（i）提供七氟醚吸入麻醉方案以减少胸腔镜手术期间的咳嗽反射;（ii） 尽量减少过度镇静，同时为接受胸外科手术的患者提供安全无痛的手术环境;（iii）尽量减少患者在手术过程中的自主呼吸和纵隔振荡，同时考虑到相关的技术挑战。这是通过提供先发制人的术中局部麻醉来实现的。
2004年，蓬佩奥等首次报道了胸腔镜肺结节切除术的完成，无需气管插?...

近十年来，非插管视频辅助胸外科（NIVATS）麻醉逐渐被临床实践所接受1,2,3。尽管这种新策略提高了患者的快速恢复，并避免了全身麻醉（GA）和单肺通气的并发症4，但许多外科医生认为这种方法不如传统的肺隔离技术理想。
血氧水平随着年龄的增长而下降，一些患者可能出现肺功能下降或接近肺功能。GA 可能与此类患者并发症风险增加有关，包括麻醉延迟出现、气道并发症、声音嘶哑、缺氧和样肛脱位 5,6,7,8,9。相比之下，多项研究记录了接受NIVATS治疗的患者住院时间缩短，低风险患者与全身麻醉相比，呼吸系统并发症减少10;此外，甚至在肺功能非常差的高危患者中也报道了成功的手术11,12,13。
手术期间的自主通气是通过仔细施用的局部麻醉或辅以镇静剂的区域神经阻滞来实现的，但在NIVATS期间，咳嗽反射伴意外的肺运动可能会出现问题。对于可能干扰外科手术的纵隔扑动、刺激性咳嗽或呼吸急促，很少强调也没有标准治疗方法。初步观察结果显示，七氟醚在保持自主呼吸的同时，可降低NIVATS期间的呼吸频率和纵隔扑动的发生14。因此，可以假设七氟醚吸入可以预防咳嗽并减少机械通气的需求，从而减少术后肺部并发症（PPCs）。
首先，本报告提供了一个分步方案，详细说明了非插管视频辅助胸腔镜手术的执行。其次，进行回顾性研究，调查非插管麻醉对术后结局的潜在益处。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>20-G top-winged infusion needle</td>
			<td>BD Intima II</td>
			<td>383012</td>
			<td>Puncture with a 20-G top-winged infusion needle into the dorsal vein of the non-operative side of the hand.</td>
		</tr>
		<tr>
			<td>24-G top-winged infusion needle</td>
			<td>BD Intima II</td>
			<td>383033</td>
			<td>Thoracoscopic vagal block techniques</td>
		</tr>
		<tr>
			<td>Anesthesia&#160;machine</td>
			<td>Drager</td>
			<td>A300</td>
			<td>Maintenance of respiratory function; Inhalation anesthesia; Monitor for electrocardiography, blood pressure, pulse oxygen saturation (SpO2), end-tidal carbon dioxide and respiratory rate</td>
		</tr>
		<tr>
			<td>Atropine</td>
			<td>Jiuquan Dadeli Pharma</td>
			<td>H62020772</td>
			<td>Control of heart rate</td>
		</tr>
		<tr>
			<td>BIS</td>
			<td>COVIDIEN</td>
			<td>B277243</td>
			<td>Monitor the level of consciousness</td>
		</tr>
		<tr>
			<td>Disposable nerve block needle</td>
			<td>Tuoren Medical Device&#160;</td>
			<td>202303007</td>
			<td>Nerve block</td>
		</tr>
		<tr>
			<td>Facial mask</td>
			<td>Emedica</td>
			<td>EM01-105S</td>
			<td>Provides an effective non-invasive breathing circuit</td>
		</tr>
		<tr>
			<td>Fentanyl.</td>
			<td>Renfu Pharma</td>
			<td>21D04021</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Flurbiprofen</td>
			<td>Daan Pharma</td>
			<td>H20183054</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Laryngeal mask&#160;</td>
			<td>Ambu Aura-i</td>
			<td>2012-2664652</td>
			<td>Airway management to preserve voluntary breathing</td>
		</tr>
		<tr>
			<td>Levobupivacaine</td>
			<td>Rundu Pharma</td>
			<td>H20050403</td>
			<td>Local Anaesthesia</td>
		</tr>
		<tr>
			<td>Lidocaine</td>
			<td>Kelun Pharma</td>
			<td>F221129C</td>
			<td>Local skin infiltration</td>
		</tr>
		<tr>
			<td>Norepinephrine</td>
			<td>Lijun Pharma</td>
			<td>H61021666</td>
			<td>Control of blood pressure</td>
		</tr>
		<tr>
			<td>Portable color doppler ultrasound</td>
			<td>SonoSite</td>
			<td>M-Turbo</td>
			<td>Guided nerve block</td>
		</tr>
		<tr>
			<td>Propofol</td>
			<td>Guorui Pharma</td>
			<td>H20030114</td>
			<td>Sedation and hypnosis</td>
		</tr>
		<tr>
			<td>Ropivacaine</td>
			<td>Aspen Pharma</td>
			<td>6091403219940</td>
			<td>Paravertebral nerve block</td>
		</tr>
		<tr>
			<td>Saline</td>
			<td>Kelun Pharma</td>
			<td>c221201E1</td>
			<td>Assisted subsonic localisation</td>
		</tr>
		<tr>
			<td>Sevoflurane</td>
			<td>&#160;Shanghai Hengrui Pharmaceutical Co.,Ltd</td>
			<td>9081931</td>
			<td>Anesthesia induction and maintenance</td>
		</tr>
		<tr>
			<td>Sufentanil</td>
			<td>Jiangsu Enhua Pharmaceutical Co., Ltd</td>
			<td>H20203650</td>
			<td>Postoperative analgesia</td>
		</tr>
	</tbody>
</table>

non-intubated video-assisted thoracoscopic surgery

全身麻醉下的双腔插管是目前肺切除术、肺楔形切除术和肺叶切除术最常用的插管技术。然而，气管插管全身麻醉引起的肺部并发症发生率很高。保留自主呼吸的非插管是麻醉的替代方法。非插管操作可最大限度地减少气管插管和全身麻醉的不良反应，例如插管相关的气道创伤、通气引起的肺损伤、残留的神经肌肉阻滞以及术后恶心和呕吐。然而，许多研究没有详细说明非插管程序的步骤。在这里，我们提出了一个简明的非插管方案，用于在保留自主呼吸的情况下进行视频辅助胸腔镜手术。本文确定了从非插管麻醉转换为插管麻醉的必要条件，并讨论了非插管麻醉的优点和局限性。在这项工作中，对58名患者进行了这种干预。此外，还介绍了回顾性研究的结果。与插管全身麻醉相比，非插管视频辅助胸外科组患者术后肺部并发症发生率更低，手术时间更短，术中失血更少，PACU住院时间更短，胸引流移除天数更少，术后引流更少，住院时间更短。

In the past decade, non-intubated video-assisted thoracic surgery (NIVATS) anesthesia has gradually been accepted in clinical practice1,2,3. Although this novel strategy enhances the rapid recovery of patients and avoids the complications of general anesthesia (GA) and one-lung ventilation4, many surgeons regard this approach as less desirable than the traditional lung isolation technique.
Blood oxygen levels decline with age, and some patients may have decreased or borderline pulmonary function. GA may be associated with an increased risk of complications in such patients, including delayed emergence from anesthesia, airway complications, hoarseness, hypoxia, and arytenoid dislocation5,6,7,8,9. In contrast, multiple studies have documented shorter hospital stays among patients managed with NIVATS, as well as a reduction in respiratory complications compared to general anesthesia among low-risk patients10; additionally, successful surgery has even been reported in high-risk patients with very poor pulmonary function11,12,13.
Spontaneous ventilation during surgery is achieved with carefully administered local anesthesia or a regional nerve block supplemented with sedation, but the cough reflex with unexpected lung movement can be problematic during NIVATS. There is little emphasis on and no standard treatment for mediastinal flutter, irritating cough, or tachypnoea, which may disrupt a surgical procedure. In preliminary observations, the results showed that sevoflurane could decrease the respiratory rate and the occurrence of mediastinal flutter during NIVATS while maintaining spontaneous breathing14. Therefore, it could be hypothesized that sevoflurane inhalation may prevent coughing and reduce the requirement for mechanical ventilation, thereby reducing post-operative pulmonary complications (PPCs).
Firstly, this report presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. Secondly, a retrospective study was conducted to investigate the potential benefits of non-intubated anesthesia on post-operative outcomes.

作者聚焦： 一种具有多模式镇痛和七氟烷吸入麻醉的非插管视频辅助胸腔镜手术 

非插管视频辅助胸腔镜手术

This research presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. The protocol of NIVATS is based on multimodal analgesia, including ultrasound-guided thoracic paravertebral blockade. A thoracoscopic make a block, and plural infiltration anesthesia.Multimodal analgesia effectively relieves intraoperative pain and inhibits the cough reflex. This protocol provides a sevoflurane inhalation anesthesia regimen to reduce the cough reflex during thoracoscopic surgery, minimizes oversedation, while providing a safe and a pain-free operating environment for patients. We maintain the patient's spontaneous breathing and minimize mediastinal oscillations during the procedure, while taking into account the associated aided technical challenges.

回顾性收集了2016年1月至2022年12月连续接受非插管视频辅助胸腔镜手术的58例患者的临床数据。麻醉师对患者进行了术前访问，并在麻醉前对麻醉知情同意书的内容进行了详细说明。允许患者选择麻醉的两组（NIVATS组或GA组）之一，并签署知情同意书。
GA组患者诱导咪达唑仑0.04mg/kg、丙泊酚2.5mg/kg、依托咪酯0.3mg/kg、舒芬太尼0.5μg/kg、罗库溴铵1.2mg/kg。正性肌力药物完全起效后，...

Watch this Scientific Journal Video about A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia at JoVE.com

在这里，我们提出了一种非插管方案，用于在保留自主呼吸的情况下进行视频辅助胸腔镜手术。

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

本研究提出了一个分步方案，详细说明了非插管视频辅助胸腔镜手术的执行。NIVATS 的方案基于多模式镇痛，包括超声引导的胸椎旁阻滞。胸腔镜做阻滞，复数浸润麻醉。多模式镇痛可有效缓解术中疼痛，抑制咳嗽反射。该方案提供了一种七氟醚吸入麻醉方案，以减少胸腔镜手术期间的咳嗽反射，最大限度地减少过度镇静，同时为患者提供安全无痛的操作环境。我们保持患者的自主呼吸，并尽量减少手术过程中的纵隔振荡，同时考虑到相关的辅助技术挑战。

non-intubated-video-assisted-thoracoscopic-surgery

Research

JoVE Journal

Medicine

Non-Intubated Video-Assisted Thoracoscopic Surgery

1.1K 次观看.  Second Affiliated Hospital of Zhejiang University School of Medicine. 本研究提出了一个分步方案，详细说明了非插管视频辅助胸腔镜手术的执行。NIVATS 的方案基于多模式镇痛，包括超声引导的胸椎旁阻滞。胸腔镜做阻滞，复数浸润麻醉。多模式镇痛可有效缓解术中疼痛，抑制咳嗽反射。该方案提供了一种七氟醚吸入麻醉方案，以减少胸腔镜手术期间的咳嗽反射，最大限度地减少过度镇静，同时为患者提供安全无痛的操作环境。我们保持...

视频: 作者聚焦： 一种具有多模式镇痛和七氟烷吸入麻醉的非插管视频辅助胸腔镜手术 

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

科研

医学

Non-Intubated Ultrasound-Guided Thoracic Paravertebral Blockade Under Anesthesia

Begin by adjusting the temperature of the operating room to between 24 to 26 degrees Celsius. Insert a 20-gauge top-winged infusion needle into the elbow vein of the non-surgical hand of the patient. Now monitor the electrocardiography, blood pressure, pulse oxygen saturation, and respiratory rate of the patient.Apply a Bispectral Index Quatro Sensor to the patient's forehead. To induce anesthesia by continuous oxygen administration, insert a laryngeal mask airway. Maintain the sevoflurane concentration at 1.5 to 2%and an oxygen flow rate of 0.5 to one liter per minute.Monitor the inhaled oxygen concentration, the end tidal carbon dioxide, the body temperature, and the level of consciousness. Place the patient in a lateral decubitus position and place the ultrasound probe directly above the spinous processes of the third and seventh thoracic vertebrae. Obtain a cross-sectional image of the spinous processes.Move the ultrasound probe laterally to show the transverse process in its entirety. Move it outward to visualize the transverse process, transverse rib joints, and the ribs. Keep moving the probe caudally until the transverse process, pleura, and the thoracic paravertebral space are detected in the image.Under ultrasound guidance, insert a block needle with the in plain approach from the lateral to the medial side. Next, carefully increase the aspiration before the injection to ensure no blood reflux is seen. After injecting 0.5 milliliters of ropivacaine, visualize the anterior displacement of the pleura and the widening of the thoracic paravertebral space.Maintain a Bispectral Index value of 40 to 60. Using an infusion pump, continuously perfuse norepinephrine. Perform arterial blood gas analysis 15 minutes before the end of the surgery.Inject one milligram per kilogram of flurbiprofen 30 minutes before the end of the surgery. The pulmonary complication rate was observed to be significantly lower in the non-intubated video-assisted thoracic surgery, or NIVATS group, related to the general anesthesia, or GA group. Six patients in the GA group developed postoperative pneumothorax.Three patients in the GA group developed plural effusion compared to one in the NIVATS group, which was not statistically significant. Seven patients in the GA group developed pneumonia compared to none in the NIVATS group, and the difference between the two groups was statistically significant. Additionally, three GA patients developed pulmonary atelectasis and two developed pulmonary embolisms.Neither group developed acute respiratory distress syndrome. The NIVATS group showed reduced intraoperative blood loss at 20 milliliters, shorter mean surgery duration, and post-anesthesia care unit stay time. Furthermore, the chest drain was removed from the NIVATS group on day two and the GA group on day three, which was significant.Significant differences were observed in the amount of postoperative chest drainage between the NIVATS and the GA group. Three patients in the GA group had prolonged ICU stays, and four had postoperative chest tightness with shortness of breath. Relative to the GA group, the NIVATS group had significantly shorter hospital stay lengths at five days.

作者聚焦： 一种具有多模式镇痛和七氟烷吸入麻醉的非插管视频辅助胸腔镜手术

作者聚焦：一种具有多模式镇痛和七氟烷吸入麻醉的非插管视频辅助胸腔镜手术