目的 1.以膈肌超声评估：与新斯的明相比，舒更葡糖钠是否可以降低术后肌松残余（PORC）发生率。2.以术后随访和肺超声（LUS）评估：与新斯的明相比，舒更葡糖钠拮抗是否可以降低术后肺部并发症（PPCs）发生率及LUS表现是否更佳。

方法 纳入2021年3月-2021年12月于北京协和医院行髋或膝关节置换手术的患者121名，ASA分级I-III级，年龄≥60岁，性别不限，按随机数表随机纳入舒更葡糖钠组（SUG组，n=61）和新斯的明+阿托品组（N+A组，n=60）。麻醉过程中行拇内收肌四个成串刺激（TOF）监测肌松。术毕N+A组患者予新斯的明50μg/kg+阿托品15μg/kg，SUG组予舒更葡糖钠2mg/kg拮抗，并在TOFr≥0.9时拔除气管导管。在术前、拔管后10min和30min分别行膈肌超声和LUS检查。膈肌超声：将低频探头置于右侧锁骨中线、右肋缘下方，测量右侧膈肌移动度（DE），并嘱患者嗅物呼吸测量膈肌运动速度（V-S）；再将高频探头置于右侧膈肌附着点（ZOA），测量膈肌厚度变化率（TF）。LUS：观察胸廓6个检查区并以0-3分评分，双侧共有12个肺区，LUS得分0-36分，评分越高，肺状况越差。主要结局指标：两组肌松残余发生率，次要结局指标：两组膈肌超声表现（DE，TF及 V-S），PPCs发生率及类型等。

结果 若以深呼吸膈肌移动度（DE-DB）≤4cm定义PORC，10min和30min时SUG组PORC发生率均显著低于N+A组（P=0.037，P=0.027）；若以深呼吸膈肌厚度变化率（TF-DB）≤36%定义PORC，10min和30min时SUG组PORC发生率均显著低于N+A组（P＜0.001，P＜0.001）；若以DE-DB≤4cm或TF-DB≤36%定义为PORC，10min和30min时SUG组PORC发生率亦均显著低于N+A组（P＜0.001，P＜0.001）。术毕拔管后10min SUG组平静呼吸膈肌移动度（DE-normal breath，DE-NB）、DE-DB和TF-DB均显著高于N+A组患者（P=0.007，P＜0.001，P＜0.001），拔管后30min SUG组DE-NB、DE-DB、平静呼吸膈肌厚度变化率（TF-normal breath，TF-NB）和TF-DB显著高于N+A组（P=0.015，P=0.002，P=0.043，P＜0.001）。拔管后10min与30min DE-NB、DE-DB、TF-NB、TF-DB及V-S与术前这些指标的差值进行组间比较，均存在显著性差异（P均＜0.05）。N+A组PPCs发生率为11.7%（7/60），SUG组4.9%（3/61），均为术后肺炎，差别无统计学意义（P=0.205）；拔管后10min和30min两组LUS表现无差异性（P=0.948，P=0.925）。

结论 1.膈肌超声证实，与新斯的明相比，舒更葡糖钠可以降低PORC发生率。2.与新斯的明相比，舒更葡糖钠不能降低PPCs发生率。3.与新斯的明相比，舒更葡糖钠不能改善肺超声表现。

Objectives 1. To evaluate whether sugammadex could reduce the incidence of PORC by diaphragmatic ultrasonography, compared with neostigmine. 2. Postoperative follow-up and lung ultrasound were used to evaluate whether sugammadex could reduce the incidence of PPCs and better LUS performance.

Methods 121 patients over 60 years who underwent hip or knee replacement surgery in Peking Union Medical College Hospital from March 2021 to December 2021 were enrolled, with American Society of Anesthesiologists (ASA) grade I-III. They were randomly assigned to sugammadex group (SUG group, n=61) and neostigmine + atropine group (N+A group, n=60) according to a random number table. Train of four (TOF) stimulation of adductor hallucis muscle was performed during anesthesia. At the end of operation, patients from N+A group were treated with neostermine 50μg/kg+ atropine 15μg/kg, while those from SUG group with sugammadex 2mg/kg. Endotracheal tube was removed when TOFr≥0.9. Diaphragmatic ultrasound and LUS were performed before surgery, 10min and 30min after extubation, respectively. Diaphragmatic ultrasound: A low-frequency probe was placed on the right midclavicular line and below the right costal margin to measure the right diaphragm excursion (DE) and diaphragm contraction velocity during sniffing (V-S). Then the high-frequency probe was placed at the zone of apposition of right diaphragm to measure the thickening fraction (TF) of diaphragm. LUS: Each hemithorax could be divided into 6 examination regions and scored with 0-3. That is, there are in total 12 regions for each patient, and the LUS score ranges from 0 to 36. The higher the score, the worse the lung condition. Primary endpoint: incidence of PORC in two groups, secondary endpoints: diaphragm ultrasonography in two groups (DE, TF and V-S), incidence and types of PPCs in two groups.

Results If PORC was defined as diaphragm excursion during deep breath (DE-DB) ≤4cm, the incidence of PORC in SUG group was significantly lower than that in N+A group at 10min and 30min after extubation (P=0.037, P=0.027). If PORC was defined as thickening fraction during deep breath (TF-DB) ≤36%, the incidence of PORC in SUG group was significantly lower than N+A group at 10min and 30min after extubation (P<0.001, P<0.001). If PORC was defined as DE-DB≤4cm or TF-DB≤36%, the incidence of PORC in SUG group was also significantly lower in N+A group at 10min and 30min after extubation (P<0.001, P<0.001). Diaphragm excursion during normal breath (DE-NB), DE-DB and TF-DB in SUG group were significantly higher than N+A group (P=0.007, P<0.001, P<0.001) 10min after extubation. DE-NB, DE-DB, thickening fraction during normal breath (TF-NB) and TF-DB in SUG group were significantly higher than N+A group 30min after extubation (P=0.015, P=0.002, P=0.043, P<0.001). The difference values between DE-NB, DE-DB, TF-NB, TF-DB, V-S 10min after extubation and DE-NB, DE-DB, TF-NB, TF-DB, V-S before surgery in SUG group were significantly higher than in N+A group (P<0.05). The difference values between DE-NB, DE-DB, TF-NB, TF-DB, V-S 30min after extubation and those before surgery in SUG group were also significantly higher than in N+A group (P<0.05), indicating better muscle recovery after sugammadex reversal than neostigmine. The incidence of PPCs, all of which were postoperative pneumonia, was 11.7% (7/60) in N+A group and 4.9% (3/61) in SUG group, with no significant difference (P=0.205). There was also no significant difference in LUS between the two groups 10min and 30min after extubation (P=0.948, P=0.925). LUS before surgery, 10min and 30min after extubation were not correlated with the incidence of PPCs (P=0.999, P=0.781, P=0.931).

Conclusions 1. Diaphragmatic ultrasound confirmed that sugammadex could reduce the incidence of PORC compared with neostigmine. 2. Compared with neostigmine, sugammadex could not reduce the incidence of PPCs. 3. Compared with neostigmine, sugammadex could not improve LUS performance.