保持自主通气的坐式镇静镇痛，以促进转换到仰卧位后的插管：病例报告

摘要(中文译文)

对于因创伤后疼痛或其他情况无法耐受仰卧位的患者，坐位全麻诱导可能与静脉回流减少导致的血流动力学不稳定以及因气道操作受限带来的气道管理困难相关，但坐位诱导可能不可避免。在本报告中，我们描述了一例在坐位下开始镇静、在转为仰卧位过程中保留自主呼吸、随后行气管插管的病例，实现了安全的麻醉管理。患者为一名40多岁肥胖女性，拟行机器人辅助手术治疗与不典型子宫内膜增生相关的子宫恶性肿瘤。她有因道路交通事故继发腰椎压缩性骨折的病史，清醒状态下无法耐受仰卧位。到达手术室后，在补充吸氧下开始以6 mg·kg⁻¹·h⁻¹的速度输注瑞马唑仑。随后在保持自主呼吸的情况下将患者转为仰卧位。给予罗库溴铵和瑞芬太尼后，使用视频喉镜行气管插管。诱导期间未观察到包括外周血氧饱和度下降在内的任何并发症。患者术后病程平稳，拔管后无低氧血症，于术后第4天出院。对于因严重疼痛而无法耐受仰卧位的肥胖患者，采用瑞马唑仑在半坐位下保留自主呼吸并过渡至仰卧位的诱导策略可能是一种有用的选择。在坐位下进行诱导时，制定以具有可用拮抗剂的药物为中心的麻醉方案可能进一步增强患者安全性。

Abstract

Induction of general anesthesia in the sitting position may be associated with hemodynamic instability resulting from decreased venous return, as well as challenges in airway management due to limited access to the airway. However, in patients who cannot tolerate the supine position because of post-traumatic pain or other conditions, induction in the sitting position may be unavoidable. In this report, we describe a case in which sedation was initiated in the sitting position, spontaneous respiration was preserved during the transition to the supine position, and tracheal intubation was subsequently performed, resulting in safe anesthetic management. The patient was a woman in her 40s with obesity who was scheduled to undergo robot-assisted surgery for a uterine malignancy associated with atypical endometrial hyperplasia. She had a history of a lumbar vertebral compression fracture secondary to a road traffic accident and was unable to tolerate the supine position while awake. After arrival in the operating room, remimazolam infusion was initiated at 6 mg·kg⁻¹·hour⁻¹ under supplemental oxygen. The patient was then moved to the supine position while maintaining spontaneous respiration. Following the administration of rocuronium and remifentanil, tracheal intubation was performed using a video laryngoscope. No complications, including decreased peripheral oxygen saturation, were observed during induction. The patient's postoperative course was uneventful without hypoxemia after extubation, and she was discharged on postoperative day 4. In patients with obesity who cannot tolerate the supine position due to severe pain, an induction strategy using remimazolam that preserves spontaneous respiration in the semi-sitting position while transitioning to the supine position may be a useful option. When performing induction in the sitting position, developing an anesthetic plan centered on agents with available antagonists may further enhance patient safety.

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