中国老年胶质瘤患者术前评估专家共识(2019)

中国医师协会脑胶质瘤专委会老年胶质瘤学组

中国医师协会脑胶质瘤专委会老年胶质瘤学组. 中国老年胶质瘤患者术前评估专家共识(2019)[J]. 协和医学杂志, 2019, 10(4): 326-335. DOI: 10.3969/j.issn.1674-9081.2019.04.004
引用本文: 中国医师协会脑胶质瘤专委会老年胶质瘤学组. 中国老年胶质瘤患者术前评估专家共识(2019)[J]. 协和医学杂志, 2019, 10(4): 326-335. DOI: 10.3969/j.issn.1674-9081.2019.04.004
Glioma Committee of the Gerontology Section of Chinese Medical Doctor Association. Expert Consensus on the Preoperative Geriatric Assessments of Elderly Patients with Glioma (2019)[J]. Medical Journal of Peking Union Medical College Hospital, 2019, 10(4): 326-335. DOI: 10.3969/j.issn.1674-9081.2019.04.004
Citation: Glioma Committee of the Gerontology Section of Chinese Medical Doctor Association. Expert Consensus on the Preoperative Geriatric Assessments of Elderly Patients with Glioma (2019)[J]. Medical Journal of Peking Union Medical College Hospital, 2019, 10(4): 326-335. DOI: 10.3969/j.issn.1674-9081.2019.04.004

中国老年胶质瘤患者术前评估专家共识(2019)

基金项目: 

中国医学科学院医学与健康科技创新工程 2016-I2M-2-001

详细信息
    通讯作者:

    中国医师协会脑胶质瘤专委会老年胶质瘤学组: 马文斌电话:010-69152530,E-mail: mawb2001@hotmail.com

  • 中图分类号: R739.41

Expert Consensus on the Preoperative Geriatric Assessments of Elderly Patients with Glioma (2019)

More Information
    Corresponding author:

    Glioma Committee of the Gerontology Section of Chinese Medical Doctor Association: MA Wen-bin Tel:86-10-69152530, E-mail: mawb2001@hotmail.com

  • 摘要: 胶质瘤是成年人中最常见的原发性脑肿瘤,其中以胶质母细胞瘤(glioblastoma,GBM)恶性程度最高。目前针对胶质瘤患者的治疗方式主要包括手术切除、放疗和化疗,而GBM的治疗策略,特别是老年GBM患者的治疗策略,尤其是手术方式,常因其自身特点而产生差异。术前系统而全面的评估有助于总结老年GBM的临床特点及相应诊疗方案,为临床医生提供更全面的患者信息,以更加准确判断老年患者对手术的耐受程度以及预测患者预后。本专家共识在对最新研究证据进行系统回顾的基础上,将目前已广泛应用的胶质瘤术前评估项目及评估工具进行总结,初步建立中国老年胶质瘤患者术前评估体系。
    Abstract: Glioma is the most common primary brain tumor in adults, among which glioblastoma (GBM) is the most malignant. At present, the therapeutic regimen for patients with glioma mainly includes surgery, radiotherapy, and chemotherapy. However, the treatment strategy for elderly patients with GBM often varies because of their characteristics. A systematic and comprehensive assessment before the operation will be helpful to summarize clinical characteristics of elderly patients with GBM, and can provide clinicians with more comprehensive clinical information in order to evaluate the patient's tolerance to surgery and predict the prognosis. Based on a systematic review of the latest research, this expert consensus summarizes the most widely used and studied tools of preoperative assessment of glioma, and initially establishes a preoperative evaluation system for elderly patients with glioma in China.
  • Shikani可视插管镜(视可尼可视光学导芯,Shikani optical stylet/seeing optical stylet,SOS)是可视硬质管芯类无创困难气道工具的代表之一,于1996年通过美国食品和药物管理局(Food and Drug Administration,FDA)批准并应用于临床气道管理[1],尤其适用于困难气道的气管插管,如张口度受限、颈椎活动度受限、Cormack分级高的患者。本研究将Shikani可视插管镜与Macintosh喉镜用于非困难气道患者,比较两种喉镜的插管反应和插管并发症,评价Shikani可视插管镜的临床应用价值和前景。

    本研究共纳入2010年10月至2011年5月40例拟在气管插管全身麻醉下接受妇科腹腔镜或开腹手术的女性患者。研究开始前获得本院伦理委员会批准,试验开始前与患者签署知情同意书。纳入标准:美国麻醉医师协会(American Society of Anesthesiologists,ASA)分级Ⅰ级,术前气道评估排除困难气道(Mallampati分级Ⅰ或Ⅱ级,上下门齿间距>3 cm,甲颏距>6 cm,头后仰不受限),无高血压、心动过速或心动过缓、心律失常。排除标准:合并循环系统疾病,术前评估疑为困难气道,拒绝签署知情同意书。

    根据随机表将40例患者随机分成两组,分别为Macintosh喉镜组(D组),20例; Shikani可视插管镜组(L组),20例。

    所有患者均采用静脉快速诱导气管内插管全身麻醉。患者入室后即建立20G静脉通路,立即快速输注乳酸钠林格500 ml进行容量补充。监测无创血压(noninvasive blood pressure,NBP)、心电图(electrocardiogram,ECG)、脉搏氧饱和度(oxygen saturation by pulse oximetry,SpO2)。经静脉给予咪达唑仑40 μg/kg、芬太尼2 μg/kg、昂丹司琼4 mg,随即开始为患者吸氧去氮,5 min后开始用GRASBY3500靶控注射泵靶控输注丙泊酚,初始靶浓度为6 μg/ml,待患者意识消失后给予罗库溴铵0. 6 mg/kg,1 min后进行气管插管。各组气管插管操作均由同一位有经验的麻醉医师完成。另一位麻醉医师于插管前后分别测量并记录患者的平均动脉压、心率以及气管导管误入食道的次数和从插管工具置入患者口中至气管插管到位所需时间。插管完成后听诊双侧呼吸音,确认导管位置适合后,固定导管并开始机械通气。

    麻醉维持采用1:1氧气和笑气,丙泊酚靶浓度为3. 0 ~ 4. 0 μg/ml,根据需要间断追加芬太尼和罗库溴铵。术毕停止丙泊酚,唤醒患者送至恢复室,待患者完全清醒符合离开恢复室标准后记录其咽痛、声嘶主诉。

    D组行常规Macintosh喉镜插管。患者头部取嗅物位,将3号Macintosh镜片从右侧口角置入患者口中,逐渐深入,依次观察到悬雍垂、会厌、声门,将导管送入气管内。

    L组应用Shikani可视插管镜。预先将气管导管套在Shikani可视插管镜上,导芯尖端不超过气管导管的开口,以免造成组织损伤或分泌物模糊视野。将室内光线调暗,提起患者下颌,从左侧口角置入Shikani可视插管镜,注意观察患者颈部甲状软骨后方的光斑,继续推进Shikani可视插管镜,直至观察到光斑由弥散的圆形逐渐聚拢成线形并向胸骨上窝方向放射,此时表明气管导管尖端已进入声门,经目镜可窥见气管软骨环,一手固定Shikani可视插管镜,另一手将导管送入气管内。

    应用SPSS 17. 0和Microsoft Office Excel 2007进行统计分析。计量资料采用x ± s表示; 组间血压、心率、插管时间比较采用两独立样本t检验,组内血压、心率比较采用配对样本t检验,咽痛、声嘶比较采用χ2检验。P<0. 05表示差异有统计学意义。

    40例患者全部完成试验。D组及L组患者平均年龄分别为(35. 5 ± 7. 6)和(36. 6 ± 8. 1)岁(P = 0. 662),平均身高分别为(162. 1 ± 3. 4)和(160. 3 ± 3. 7) cm (P = 0. 114),平均体重分别为(57. 0 ± 7. 6)和(60. 3 ± 8. 9) kg (P = 0. 214),平均手术时间分别为(81. 8 ± 17. 7)和(82. 3 ± 18. 7) min (P = 0. 931),两组比较差异均无统计学意义。

    40例患者均未发生气管导管误入食道。插管时间D组为(21. 6 ± 13. 4) s,L组为(27. 5 ± 19. 6) s (P = 0. 273)。

    两组患者喉镜入镜时的平均动脉压和心率比较差异均无统计学意义(P>0. 05);两组患者出镜时的平均动脉压及心率均高于入镜时(P<0. 05),D组出镜时平均动脉压及心率与L组比较差异有统计学意义(P<0. 05) (表 1)。

    表  1  气管插管期两组患者血流动力学变化(x ± s)
    气管插管期 平均动脉压(mm Hg) 心率(次/min)
    D组 L组 D组 L组
    入镜时 69. 3 ± 9. 0 69. 0 ± 6. 7 71. 2 ± 12. 5 70. 8 ± 8. 8
    出镜时 93. 6 ± 8. 9* 86. 0 ± 11. 6* 87. 6 ± 13. 5* 78. 3 ± 9. 9*
    D组使用Macintosh喉镜,L组使用Shikani可视插管镜; 1 mm Hg = 0. 133 kPa; 与入镜时比较,* P<0. 05;与D组比较,P<0. 05
    下载: 导出CSV 
    | 显示表格

    D组咽痛和声嘶发生率分别为5例(25%)和2例(10%),高于L组的3例(15%)和0例,但两组比较差异无统计学意义(P>0. 05)。

    气管插管会引起心血管系统交感反应,也称气管插管应激反应,其表现为喉镜和插管操作期间发生血压升高和心率加快,并可能诱发心律失常。目前认为三个因素与插管应激反应有关:插管工具对组织的作用力[2],操作持续时间[2]及气管插管的次数[3]。本研究结果提示,在非困难气道女性患者中,应用Shikani可视插管镜行气管插管仍然会引起明显的心血管反应,表现为平均动脉压升高和心率增快,但Macintosh喉镜引起的心血管反应更明显。Shikani可视插管镜和Macintosh喉镜具有相似的插管成功率和插管速度。

    通常麻醉医师会采取加深麻醉深度、缩短喉镜操作时间、表面麻醉等方法以减轻插管反应的强度与持续时间。不同的气道工具引起的气管插管反应也可能不同。Macintosh喉镜是经典的气管插管工具,也是多数麻醉医师最熟悉且应用最为熟练的气道工具之一。在使用Macintosh喉镜插管时需要将其镜片置于会厌上方并用力上提,此时作用在局部组织的力量会达到约5. 4 kg[4]。喉镜对牙齿的作用力也会很大,Fukuda等[5]记录下喉镜对上颌切牙的作用力最大可达到40. 2 N。视频喉镜可以显著降低这种作用力。根据Lee等[6]报道,Macintosh喉镜对上颌切牙的作用力范围是0 ~ 87. 4 N,而视频喉镜(Karl Storz,Tuttlingen)的范围是0 ~ 45. 2 N。Shikani可视插管镜是可视硬质管芯类气道工具之一,操作时不需要上提动作,从而减少了对会厌、舌根及咽部组织的机械刺激,也就减轻了患者的心血管反应,本研究得到的结果与之前的研究一致。赵诗斌等[7]发现Shikani可视插管镜正中入路经口气管插管的血流动力学反应轻于Macintosh直接喉镜气管插管。Yao等[8]发现Shikani可视插管镜的插管速度更快,并可以减轻插管时的心血管反应,减轻口咽和牙齿损伤。

    Takahashi等[9]比较Macintosh喉镜对咽部刺激和气管插管通过气道时对气管的刺激,发现用直接喉镜显露声门但不插管引起的血压波动明显小于用直接喉镜显露声门并进行气管插管,因此认为血流动力学变化主要来自插管对气道的直接刺激而不是喉镜对咽部的刺激。笔者认为,Shikani可视插管镜引起的血流动力学波动是插管对气管刺激引起的,而Macintosh喉镜引起的血流动力学波动是插管对气管刺激和喉镜对咽部刺激两者之和。所以,Macintosh喉镜引起的血流动力学波动大于Shikani可视插管镜。

    Yao等[8]比较Shikani可视插管镜和Macintosh喉镜后发现,Shikani可视插管镜可减轻对口咽和牙齿的损伤; 而本研究结果却显示两种方法引起的咽痛和声嘶发生率差异无显著统计学意义。造成结果不一致的原因可能是试验设计的不同:虽然本研究评估咽痛和声嘶的时间点均选在患者离开恢复室时,但Yao等术中使用瑞芬太尼,本研究使用镇痛作用更长的芬太尼,从而降低了咽痛的发生率。

    气道工具操作具有主观性,操作者熟练程度对试验结果会有影响,不同的操作者可能获得不同的数据,这可能是本研究与其他研究结果有区别的原因。评估插管前后血压变化的理想方法是有创血压监测,但由于临床实际工作的限制,本研究使用的是无创血压监测,这可能导致数据的误差和延迟。本研究是在非困难气道患者得出的结果,困难气道人群的操作时间可能会增加。本研究样本量可能尚不足以体现气道并发症的统计学差异。

    综上,在非困难气道女性患者中,应用Shikani可视插管镜行气管插管仍然会引起明显的心血管反应,表现为平均动脉压升高和心率增快,但不如Macintosh喉镜的波动明显。

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  • 图  1   老年胶质瘤患者术前评估相关文献检索及筛查流程图

    表  1   老年胶质瘤患者手术治疗方案相关文献

    作者 发表时间 平均年龄(岁) 性别(男/女, n) 干预措施 结果 随访时间(年) 研究类型
    试验组 对照组
    Gupta等[7] 2018年 6.3 23/27 活检术 50例弥漫内生性脑干胶质瘤患者中,46例成功获得活检组织并指导进一步诊治 随访至死亡 单臂临床研究
    Kellermann等[8] 2017年 74 129/101 立体定向活检术 239例老年胶质瘤患者中230例接受了立体定向活检术,其中222例成功取得组织学诊断并有171例接受了后续辅助治疗 1 回顾性研究
    Tanaka等[9] 2013年 74.1 61/44 立体定向活检术 常规外科手术 接受立体定向活检术的患者术后出血风险较常规外科手术高 5 回顾性研究
    下载: 导出CSV

    表  2   老年胶质瘤患者术前评估相关文献

    作者 发表时间 平均年龄(岁) 性别(男/女, n) 干预措施 结果 平均随访时间(年) 研究类型 评估项目
    试验组 对照组
    Johnson等[17] 2012年 53.9 55/36 WAIS-R, WAIS-Ⅲ, HVLT-R量表 认知功能中的执行力与注意力均与胶质母细胞瘤患者的预后有关 9 回顾性研究 认知功能
    Rambeau等[20] 2018年 78 25/41 MMSE量表 MoCA量表 MoCA量表比MMSE量表在评估认知功能方面更加精确 1 临床对照研究 认知功能
    Fiorentino等[21] 2012年 72 17/18 - - 对合并症的评估也是对老年胶质母细胞瘤患者预后预测十分有效的工具 6 单臂临床研究 合并症
    Ening等[22] 2015年 62 117/116 - - 年龄越大、KPS越低、CCI越高,则难治性胶质母细胞瘤患者的总生存期或肿瘤无进展生存期越短 5 回顾性研究 合并症
    Villani等[23] 2019年 73 70/48 - - CIRS合并症指数得分越高,老年胶质母细胞瘤患者手术、放/化疗或单纯放疗的预后越差 1 前瞻性队列研究 合并症
    Cloney等[24] 2015年 NA NA - - 虚弱的老年胶质母细胞瘤患者更不倾向于接受手术治疗,其卧床时间较长,且术后并发症发生率较高 12 回顾性研究 虚弱
    Peters等[26] 2014年 50 161/76 - - 疲惫独立影响复发高级别胶质瘤患者的预后,疲惫感越强则预后越差;生活质量并非预后的独立预测因素 2 前瞻性队列研究 疲惫与生活质量
    Borg等[42] 2011年 60.1 419/266 - - 术前低蛋白血症患者较正常者术后生存期短 10 回顾性研究 实验室检验
    He等[49] 2017年 44 197/129 - - 术前高纤维蛋白原和低血胆红素的新诊断高级别患者肿瘤进展和死亡风险更大 2 单臂临床研究 实验室检验
    -:未分组评估;WAIS-R:Wechsler成人智力量表(修订版); HVLT-R:霍普金斯词语学习测验(修订版); MMSE:简易精神状态检查; MoCA:蒙特利尔认知评估; KPS:卡式评分; CCI:查尔森合并症指数;CIRS:累积疾病评分量表
    下载: 导出CSV

    表  3   老年胶质瘤患者术前评估筛查方法相关文献

    作者 发表时间 平均年龄(岁) 性别(男/女,n) 测量方法/量表 结果 研究类型 评估项目
    Kane等[54] 2012年 NA NA 通过8项老年综合征指标(合并症、认知功能障碍、虚弱、残疾、营养不良、内分泌紊乱、慢性炎症等)评估 对老年综合征的评估对年龄稍小老龄患者意义更大;对年龄较大老龄患者意义不大 系统综述 老年综合征
    Soubeyran等[11] 2014年 78 434/1001 用G8量表和老年人受伤情况调查(第13版)量表对老年癌症患者进行多维度老年评估,包括特异度、敏感度、阳性预测值、阴性预测值,1年生存期预测等 G8量表的敏感度较VES-13高,但特异度则比VES-13低。G8量表评分可以独立预测老年癌症患者的1年生存期 前瞻性队列研究 多维度老年学评估
    Svendsboe等[56] 2015年 74.9 72/114 RSS,认知功能(MMSE、CDR-SOB),精神心理状态(NPI、MADRS、UPDRS),其他变量因素(CIRS、RDRS-2) 照护者在阿尔茨海默病和路易氏痴呆患者的发病初期,可能会有轻到中度的照护者负担问题,同样也会有精神问题的可能 横断面研究 照护提供者
    RSS:照护者负担量表;MMSE:简易精神状态量表;CDR-SOB:临床痴呆评定量表;NPI:神经精神症状问卷;MADRS:蒙哥马利和阿斯伯格抑郁症等级量表;UPDRS:帕金森分级量表;CIRS:累积疾病评分量表;RDRS-2:快速残疾评定量表
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