摘要目的:探讨膈肌超声指标呼吸频率（RR）与膈肌增厚分数（DTF）比值（RR/DTF）和四个成串刺激比值（TOFr）在腰椎手术患者术后肌松残余监测中的应用价值。方法:随机对照研究。纳入2023年6月—2024年5月蚌埠医科大学第一附属医院择期行腰椎手术患者71例，其中男27例、女44例，年龄17~62［48（36，57）］，美国麻醉协会（ASA）分级Ⅰ级2例、Ⅱ级40例、Ⅲ级29例。患者均于全身麻醉下行俯卧位腰椎1~3个节段的手术，围术期监测患者RR、DTF、RR/DTF以及TOFr。患者采用数字表法随机分为2组，术后分别参照膈肌超声测量的不同指标予以拔管：RR/DTF组（36例）以RR/DTF≤0.81为拔管指征；TOFr组（35例）以TOFr>0.9为拔管指征。观察指标：（1）比较2组患者性别、年龄、体质量指数、ASA分级等基线资料，以及术中俯卧位通气时间、苯磺顺阿曲库铵和舒芬太尼的使用剂量、输液量和失血量等术中一般观察指标；（2）比较2组患者拔管相关指标，包括拔管时的动脉氧分压、动脉二氧化碳分压、咳嗽半定量评分（SCSS）、入麻醉后监测室到拔管的时间（T PACU）；（3）比较2组患者术前（T 0）、拔管后即刻（T 1）、拔管后10 min（T 2）、拔管后30 min（T 3）时RR、DTF以及RR/DTF；（4）以T 1各指标观察结果为基础值，比较2组患者T 2和T 3的RR变化量（ ΔRR）、DTF变化量（ ΔDTF）、RR/DTF变化量（ ΔRR/DTF）。（5）比较2组患者拔管后24 h并发症发生情况。 结果:（1）2组患者基线资料及术中一般观察指标比较，差异均无统计学意义（ P值均>0.05）。（2）2组患者拔管时动脉氧分压、动脉二氧化碳分压、SCSS差异均无统计学意义（ P值均>0.05）；RR/DTF组T PACU为（15.0±2.9）min，短于TOFr组的（17.0±3.2）min，差异有统计学意义（ t=2.62， P=0.011）。（3）组间不同时间点呼吸和膈肌指标比较：除T 1时RR/DTF组的RR/DTF大于TOFr组，差异有统计学意义（ t=8.84， P=0.004），其余时间点RR、DTF、RR/DTF组间比较差异均无统计学意义（ P值均>0.05）。组内不同时间点比较：T 0~T 3间RR/DTF组与TOFr组的RR、DTF、RR/DTF的差异均有统计学意义（ P值均<0.001）。（4）RR/DTF组患者T 2-T 1的 ΔRR、 ΔDTF、 ΔRR/DTF均大于TOFr组，差异均有统计学意义（ P值均<0.05）；2组T 3-T 1的 ΔRR、 ΔDTF、 ΔRR/DTF比较差异均无统计学意义（ P值均>0.05）；（5）2组患者拔管后24 h并发症发生情况差异均无统计学意义（ P值均>0.05）。 结论:与TOFr监测相比，膈肌超声测量指标RR/DTF可指导俯卧位腰椎手术患者麻醉术后肌松残余的实时监测，且重复性高；以RR/DTF≤0.81为拔管指征，术后拔管时间更早，患者呼吸功能恢复更快。

abstractsObjective:This study aimed to investigate the value of the ratio between respiratory rate (RR) and diaphragm thickening fraction (DTF) (RR/DTF) and four cluster stimulation ratio (TOFr) in the monitoring of postoperative muscle relaxation in patients undergoing lumbar surgery.Methods:A randomized controlled study was conducted, involving 71 patients who underwent elective lumbar spine surgery at the First Affiliated Hospital of Bengbu Medical University between June 2023 and May 2024. The participants were composed of 27 males and 44 females aged 17-62 (48 [36, 57]). Two patients had American Society of Anesthesiologists (ASA) grade Ⅰ, 40 had grade Ⅱ, and 29 had grade Ⅲ. The patients were divided into two groups with the random number method, and extubation was performed according to different parameters measured using diaphragm ultrasound. In the RR/DTF group (36 cases), an RR/DTF ratio of ≤0.81 was considered an indication of extubation. In the TOFr group, a TOFr>0.9 was the indication of extubation. For the identification of observation indexes, (1) the baseline treatment data, such as gender, age, body mass index, ASA classification, prone position ventilation time, doses of cisatracurium besylate and sufentanil, intraoperative fluid infusion, and blood loss, of the groups were compared, (2) the arterial oxygen partial pressure, arterial carbon dioxide partial pressure, cough semiquantitative scoring (SCSS) scores of the 2 groups at the time of extubation (T 1), the time from admission to the post-anesthesia monitoring unit to extubation (T PACU) were compared, (3) the RR, DTF, and RR/DTF ratios of the two groups at the preoperative period (T 0), immediate moment of extubation (T 1), 10 min of extubation (T 2), and 30 min after extubation (T 3) were compared, and (4) changes in T 2 and T 3 RR ( ΔRR), DTF ( ΔDTF), and RR/DTF ( ΔRR/DTF) in the two groups were compared, (5) the two groups were compared in terms of incidence of complications 24 h after extubation. Results:(1) No significant differences in baseline data and intraoperative general observation indexes were found between two groups (all P values>0.05). (2) A comparison of the arterial partial pressure of oxygen, arterial partial pressure of carbon dioxide, and SCSS scores at extubation between the groups showed no statistically significant differences (all P values>0.05). The T PACU value of the RR/DTF group was 15.0±2.9 min, which was significantly shorter than that of the TOFr group (17.0±3.2 min; t=2.62; P=0.011). (3) In the comparison of indicators between two groups at different time points, the RR/DTF group showed higher values in all indicators except the RR/DTF ratio than TOFr group at T 1, and the differences was statistically significant ( t=8.84, P=0.004). Differences among the RR, DTF, and RR/DTF groups at the other time points were not statistically significant (all P values>0.05). In the within-group comparison, differences in RR, DTF, and RR/DTF ratio between the RR/DTF and TOFr groups at T 0-T 3 were statistically significant (all P values<0.001). (4) The ΔRR, ΔDTF, and ΔRR/DTF values of patients in the RR/DTF group were greater than those in the TOFr group at T 2-T 1, and the differences were statistically significant (all P values<0.05). Changes in ΔRR, ΔDTF, and ΔRR/DTF values in the two groups at T 3-T 1 were not statistically significant (all P values>0.05). (5) The incidence of complications in both groups 24 h after extraction was not statistically significant (all P values>0.05). Conclusion:Compared with TOF monitoring, diaphragmatic ultrasound RR/DTF≤0.81 guides the postoperative muscle relaxation residual monitoring of anesthesia in patients undergoing lumbar spine surgery in the prone position, allowing for short extubation times, real-time application, and reproducibility of results and accelerating the recovery of short-term respiratory function.