小潮气量加手法叹气通气在腹腔镜胆囊切除术中的应用

发布时间：2018-03-07 15:43

  本文选题：小潮气量　切入点：机械通气　出处：《河北医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:在腹腔镜胆囊切除手术中,需要二氧化碳气腹,其对呼吸功能影响较大,包括改变呼吸动力学,影响肺循环功能,二氧化碳吸收入血发生酸中毒等。术中呼吸管理时,应注重保护肺功能,维持适当的气体交换,使组织氧合充分,减轻或避免干扰血流动力学[1-2],降低呼吸机相关性肺损伤。在传统的机械通气中,潮气量通常为10-15ml/kg,高于患者静息状态时的潮气量(7-8ml/kg),容易引发肺泡的过度扩张和吸气压增高,导致压力-容量性肺损伤。而小潮气量(6-8ml/kg)通气可以避免此现象[3]。临床上常选择小潮气量或小潮气量联合PEEP或肺复张的方法保护肺功能[4],既可避免肺部气压伤,又能减少肺不张、肺萎陷的发生,降低肺水含量,使呼气末容积增加,改善肺顺应性,改善患者氧合[5]。叹气法属于肺复张方法的一种,有研究在小潮气量通气的基础上,采用叹气法对急性呼吸窘迫综合征(ARDS)患者进行肺复张治疗时[6],发现持续的叹气可使患者的氧合状态及胸肺顺应性得以明显改善,且对血流动力学影响轻微[7-8]。目前,人们对小潮气量加手法叹气通气作为肺保护性通气策略在腹腔镜胆囊切除术中应用的研究还是比较少的。尚无研究证实,术中持续控制通气期间间断给予叹气通气,是否会对患者生命体征及血气指标产生积极的影响。本研究旨在观察探讨腹腔镜胆囊切除手术中,应用小潮气量加手法叹气的通气方式作为肺保护性通气策略的安全有效性。方法:选择2016年1月至2016年12月期间,在石家庄市第三医院行腹腔镜胆囊切除手术的患者45例,经过患者家属同意,但未告知患者本人。用随机数表进行编号,保证双盲试验。随机分成三组,每组15例。患者入室监护生命体征,建立静脉液路后,在局麻下行左桡动脉穿刺置管术。麻醉诱导后,口中置入喉罩连接呼吸机。分组情况如下:Ⅰ组:气腹前后设定机械通气参数均为:VT8ml/kg,F12次/分,I:E为1:2,PEEP5cm H2O。Ⅱ组:气腹前设定机械通气参数VT8ml/kg,F12次/分,I:E为1:2,PEEP5cm H2O。气腹后设定机械通气参数:VT6ml/kg,F16次/分,I:E为1:2,PEEP5cm H2O。Ⅲ组:气腹前设定机械通气参数VT8ml/kg,F12次/分,I:E为1:2,PEEP5cm H2O。气腹后设定机械通气参数:VT6ml/kg,f16次/分,I:E为1:2,PEEP5cm H2O。每10分钟手法叹气一组,叹气总时间120秒,每次4秒,共30次[4]。每次手法叹气潮气量为1.5倍潮气量(VT),并维持平台期时间占吸气时间百分比的50%。记录机械通气5分钟后气腹建立前时间T1。气腹建立后10分钟、20分钟、30分钟分别记录时间为T2、T3、T4。手术结束患者清醒拔出喉罩后,吸空气10分钟时记录时间为T5。分别记录各时间点的MAP、HR。分别于T1-T4机械通气期间记录Ppeak、Pmean、Cdyn、Pet CO2等呼吸力学指标。分别于T1、T4、T5时间点抽取1ml动脉血记录血气指标值:p H值、Pa O2、Pa CO2,及肺氧合功能指标值:A-a DO2、OI、RI。结果:三组患者一般情况比较,以及各时点MAP、HR、Pa O2组间比较差异无显著性。Ppeak、Pmean:三组机械通气期间,各时点对比T1均升高(P0.05);组间比较,各时点T2T3T4Ⅲ组均高于Ⅰ组(P0.05)。肺动态顺应性(Cdyn):三组机械通气期间各时点对比T1均降低(P0.05);组间比较,气腹30分钟(T4)时Ⅲ组高于Ⅰ组(P0.05)。Pet CO2:Ⅰ、Ⅱ组T4对比T1均升高(P0.05),Ⅲ组各时点对比T1无明显变化(P0.05);组间比较,T4时,Ⅱ组高于Ⅰ组P0.05),Ⅲ组低于Ⅰ组(P0.05)。分别记录3组患者T1、T4、T5时间点时血气指标值:p H值:Ⅰ组、Ⅱ组中,与T1相比,T4、T5时均降低(P0.05),Ⅲ组中与T1相比,T4、T5无明显变化(P0.05);组间比较,T4、T5时,Ⅱ组均低于Ⅰ组(P0.05),Ⅲ组均高于Ⅰ组(P0.05)。Pa CO2:Ⅰ组、Ⅱ组中,与T1相比,T4、T5时均升高(P0.05),Ⅲ组中,与T1相比,T4、T5时无明显变化(P0.05);组间比较,T4、T5时Ⅱ组均高于Ⅰ组(P0.05),Ⅲ组均低于Ⅰ组(P0.05)。A-a DO2:三组中,与T1相比,在气腹后30分钟(T4)时均明显升高(P0.01),拔管后10分钟(T5)时均明显降低(P0.01);组间比较,T4时Ⅱ组高于Ⅰ组,T5时Ⅱ组低于Ⅰ组。OI:Ⅰ、Ⅱ组中,与T1相比,拔管后10分钟(T5)时均明显降低(P0.01),Ⅲ组中与T1相比,拔管后10分钟(T5)无明显变化(P0.05);组间比较,T5时Ⅲ组高于Ⅰ组(P0.05)。RI:三组中,与T1相比,T5时均明显降低(P0.01),组间比较,差异无显著性(P0.05)。结论:在腹腔镜胆囊切除术中,小潮气量机械通气加手法叹气,既可以有效降低术中气道压,又能增加呼气末容积,减少闭合气量,防治肺萎陷,改善胸肺的顺应性,改善肺组织氧合,因此,可作为肺保护性通气策略安全应用于腹腔镜胆囊切除术的呼吸管理中。
[Abstract]:Objective: in laparoscopic cholecystectomy, need carbon dioxide pneumoperitoneum on respiratory function and its influence, including the change of respiratory dynamics, pulmonary circulation function, carbon dioxide is absorbed into blood acidosis. Respiratory management during operation, should pay attention to the protection of lung function, maintain adequate gas exchange, make adequate tissue oxygenation, alleviate avoid interference or hemodynamic [1-2], reducing ventilator-associated lung injury. In the traditional mechanical ventilation, tidal volume is usually higher than the resting state 10-15ml/kg, tidal volume (7-8ml/kg) of the patients, easily lead to excessive expansion of the alveoli and suction pressure increased, resulting in pressure volume of lung injury. But the low tidal volume ventilation (6-8ml/kg) you can avoid this phenomenon [3]. clinically choose low tidal volume or low tidal volume combined with PEEP or lung protection of pulmonary function [4] method, which can avoid the pulmonary barotrauma, and can reduce the lung The occurrence of atelectasis, lung collapse, reduce lung water content, the end expiratory volume increase, improve lung compliance and improved oxygenation in patients with [5]. sigh method belongs to the lung recruitment methods, research based on low tidal volume ventilation on the sigh of the acute respiratory distress syndrome (ARDS) patients RM treatment [6], found persistent sigh can make patients with oxygenation and lung compliance were improved, but have little influence on hemodynamics of [7-8]. at present, people to the small tidal volume ventilation plus manual sigh as protective lung ventilation in laparoscopic cholecystectomy of intraoperative application is still relatively small. There is no research confirmed that intraoperative continuous controlled ventilation during intermittent ventilation to sigh, whether it will have a positive impact on the patient's vital signs and blood gas indexes. The purpose of this study was to observe the laparoscopic resection, should Ventilation with low tidal volume and sigh technique as a lung protective ventilation strategy is safe and effective. Methods: January 2016 to December 2016, 45 patients underwent laparoscopic cholecystectomy surgery of the Third Hospital of Shijiazhuang City, approved by the families of patients, but did not inform the patient himself. Numbers with a random number, guarantee the double blind test. Randomly divided into three groups, 15 cases in each group. A monitoring of vital signs were the establishment of intravenous fluid after local anesthesia during left radial artery catheterization. After induction of anesthesia in LMA group. Connected to the ventilator as follows: group I: before and after pneumoperitoneum set mechanical ventilation parameters are: VT8ml/kg F12, I:E 1:2, PEEP5cm / min, H2O. II Group: before pneumoperitoneum set mechanical ventilation parameters VT8ml/kg, F12 I:E 1:2, PEEP5cm / min, H2O. after pneumoperitoneum set mechanical ventilation parameters: VT6ml/kg F16, I:E 1:2, PEEP5c / min M H2O. group: before pneumoperitoneum set mechanical ventilation parameters VT8ml/kg, F12 I:E 1:2, PEEP5cm / min, H2O. after pneumoperitoneum set mechanical ventilation parameters: VT6ml/kg F16, I:E 1:2, PEEP5cm / min, H2O. every 10 minutes a sigh sigh technique group, the total time of 120 seconds, every 4 seconds, a total of 30 [4]. each way sigh moisture was 1.5 times of the tidal volume (VT), and the maintenance of 50%. ventilation platform time accounted for the percentage of inspiratory time 5 minutes after pneumoperitoneum for 10 minutes before the time of T1. pneumoperitoneum after 20 minutes, 30 minutes were recorded for T2, T3, T4. after operation of patients awake LMA extubation. Suck the air 10 minutes recording time of T5. were recorded at each time point MAP, HR. respectively to record Ppeak, T1-T4 during mechanical ventilation in Pmean, Cdyn, Pet and CO2. The respiratory mechanics indexes were T1, T4, T5 time points from 1ml arterial blood gas index record values: P H, Pa O2, Pa CO2, 鍙婅偤姘у悎鍔熻兘鎸囨爣鍊，

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