血压对单肺通气患者动脉二氧化碳分压与呼气末二氧化碳分压差的影响

发布时间：2018-05-06 03:24

本文选题：呼气末二氧化碳分压 + 动脉二氧化碳分压　；参考：《南方医科大学》2014年硕士论文

【摘要】：单肺通气(one-lung ventilation, OLV)可以使手术侧肺萎陷,提供良好的视野和手术条件,同时可以防治手术侧血液及分泌物进入非手术侧,避免造成健侧肺部交叉感染,实现双肺隔离,是胸科手术麻醉确保患者安全和手术顺利进行的重要组成部分。但OLV易因双腔管位置不良影响通气、双肺的通气血流比失衡、肺本身的病变等引起氧合不良造成低氧血症,同时OLV这种非生理性的机械通气较双肺通气更容易引起或加重呼吸相关性肺损伤(ventilator associated lung injury,VALI)。OLV除可能产生严重低氧血症及VALI外,PaCO2呈增高趋势,易致CO2蓄积,因此术中C02的监测显得尤为重要。PetCO2是呼吸周期中测定的C02的最高值,可代表肺泡气的二氧化碳分压(PCO2),因此肺泡气的PCO2与PaCO2很接近。目前的研究认为在双肺通气血流动力学稳定下监测PetCO2可以反映PaCO2的变化,PetCO2与PaCO2具有良好相关性,但缺乏对OLV不同血压时PaCO2与PetCO2相关性的研究报道。目的探讨胸科手术单肺通气(OLV)期不同血压对动脉-呼气末二氧化碳分压差「(Pa-et)CO2」及对肺内分流(Qs/Qt)的影响。方法选择行右肺叶手术需行左OLV患者42例,年龄18-65岁,男32例,女10例。ASA工或Ⅱ级。所有患者无心、肝、肾疾患,无高血压病史,肺功能基本正常,无手术史。患者术前均肌注阿托品注射液0.5mg。入室后行心率(HR)、血压(Bp)、脉搏血氧饱和度(Sp02)及脑电双频谱指数(BIS)监测。局麻下行足背动脉穿刺置管连续监测直接动脉压。麻醉诱导：静脉注射力月西0.05mg/kg后,启动血浆靶控输注丙泊酚3-4ug/ml瑞芬太尼4ng/ml,患者入睡后给予顺阿曲库铵0.2mg/kg。根据患者X线后前位胸片锁骨胸骨端气管内径测量值预先选定的Mallinckrodt左双腔支气管导管的型号,经口明视插管,插管后常规用纤支镜定位。用带心电监测的中心静脉导管行右颈内静脉穿刺置管术,确认中心静脉导管进入右心房。靶控输注瑞芬太尼(2-6ng/ml)和丙泊酚(2-5ug/ml)维持麻醉,使BIS值维持在40-60之间,术中按需追加舒芬太尼及顺阿曲库铵。插管后接麻醉呼吸机行间歇正压通气(IPPV),TLV时均采用潮气量(VT)6-8ml/kg,呼吸频率12次/分,吸呼比(I：E)1：2,吸入氧浓度(Fi02)50%。OLV后VT5-7ml/kg,呼吸频率13-15次/分,开始吸入氧浓度(Fi02)100%,待Sp02100%后,调整Fi02为60%,维持分钟通气量相等。OLV期间,非通气侧肺的支气管导管均直接开口于大气中。按OLV20min后平均动脉压(MAP)在基础值±10%以内为A组(22例),MAP低于基础值30%为B组(20例)。麻醉诱导插管后用监护仪主流型C02红外分析法监钡PetCO2,在每次使用前均用空气调零；PaCO2用血气分析仪监测,分别在诱导插管后TLV20min(T1),OLV肺完全萎陷后20min(T2),B组MAP恢复到基础值±10%后30min(T3),恢复TLV20min(T4)等时间点采集动脉血及中心静脉血1ml行血气分析。在以上时间点记录SpO2,HR, MAP,BIS,PetCO2等。计算各时间点动脉-呼气末二氧化碳分压差「(Pa-et) CO2」及Qs/Qt。根据肺血流分布标准三室模型计算Qs/Qt,Qs/Qt=(CcO2-Ca O2)/(CcO2-CvO2)×100%。采用SPSS13.0软件进行统计分析,计量数据以均数±标准差表示,各组间各时间点PetC02的比较与各组间各时间点PaCO2的比较用方差分析,各组内相同时间点PetCO2与PaCO2及「(Pa-et) CO2」与Qs/Qt的相关性分析采用pearson相关性分析。P0.05为差异有统计学意义。结果 1.二组患者的一般资料性别比、年龄、体重和OLV时间无差异(P0.05)。 2.A组患者PetC02与PaC02在OLV与TLV时均密切相关(P0.05),相关系数r值分别为0.93、0.87、0.88；B组各时间点PetC02与PaC02相关系数r值分别为0.91、0.75、0.89及0.97。B组T2时期PetC02为31.0±2.9mmHg,较A组同一时点(34.2±2.5mmHg)低；B组T2时期「(Pa-et)C02」为7.8±2.2mmHg,与A组同一时点(3.2±1.5mmHg)比较明显增大(P0.05)；B组T3时期与A组T2时期「(Pa-et)C02」无明显差异(P0.05)；B组低血压期间PetC02与PaC02仍具有相关性(P0.05),相关系数r值为0.75。 3.OLV与TLV比较,二组Qs/Qt均增加。A组TLV时Qs/Qt为1.5±1.4%,OLV时上升为9.4±4.9%,恢复TLV后为2.1±2.0%；B组TLV时Qs/Qt为1.6±0.9%,OLV低血压时上升为11.9±6.0%,OLV血压恢复时为10.7±6.2%,恢复TLV后为2.0±1.5%。B组T2时期Qs/Qt高于A组T2时期(P0.05)。在观察时间内,OLV期「(Pa-et)CO2」与(Qs/Qt)没有相关性(P0.05)。结论 1.行右肺叶手术肺功能基本正常的患者,术中左单肺通气期间,血流动力学稳定时PetC02与PaC02相关性好(r=0.87)；低血压期间,「(Pa-et)CO2」明显增大,PetC02虽然能反映PaC02(r=0.75)的变化趋势,但准确性不如正常血压时。 2.单肺通气肺内分流增加,低血压期肺内分流增加更明显。肺内分流对「(Pa-et)CO2」影响不大。
[Abstract]:Single lung ventilation (one-lung ventilation, OLV) can make the operation side of the lung collapse, provide good vision and operation conditions, and can prevent the blood and secretion of the operative side into the non operative side, avoid the cross infection of the healthy side of the lung, and realize the double lung isolation. It is an important component of the safety and operation of the thoracic surgery to ensure the safety of the patients and the operation. Part. But OLV is easily affected by the bad position of the double lumen tube, the air flow ratio of the two lungs is unbalance, the lung itself causes the hypoxia to cause hypoxemia. At the same time, the non physiological mechanical ventilation of OLV is more likely to cause or aggravate the respiratory associated lung injury (ventilator associated lung injury, VALI) than the double lung ventilation (VALI).OLV In addition to the occurrence of severe hypoxemia and VALI, the trend of PaCO2 is increasing, and CO2 accumulates easily. Therefore, the monitoring of C02 in the operation is particularly important for the.PetCO2 is the highest value of C02 measured in the respiratory cycle, and can represent the partial pressure of carbon dioxide (PCO2) of the alveolar gas (PCO2). Therefore, the PCO2 of the alveolar gas is very close to PaCO2. Under mechanical stability, monitoring PetCO2 can reflect the changes of PaCO2. PetCO2 and PaCO2 have good correlation, but there is no research report on the correlation between PaCO2 and PetCO2 at different blood pressure of OLV.
Objective to investigate the effect of different blood pressure on the end expiratory carbon dioxide partial pressure (Pa-et) CO2 and the intrapulmonary shunt (Qs/Qt) in thoracic surgery with one lung ventilation (OLV).
Methods 42 patients with left OLV were selected for right lobectomy. Age 18-65, male 32, female 10,.ASA or class II. All patients were careless, liver, kidney disease, no history of hypertension, normal lung function and no history of operation.
The heart rate (HR), blood pressure (Bp), pulse oxygen saturation (Sp02) and electroencephalogram index (BIS) were monitored before the intramuscular injection of atropine injection 0.5mg.. The direct arterial pressure was continuously monitored by the puncture and catheterization of the foot dorsal artery under local anesthesia. Anesthesia induction: after the intravenous force month West 0.05mg/kg, the plasma target controlled infusion of propofol 3-4ug/ml Rui was started. Fentanyl 4ng/ml, patients with CIS atracurium 0.2mg/kg. were given a pre selected Mallinckrodt left double lumen bronchial tube based on the measured value of the endotracheal endotracheal diameter of the clavicular sternum at the front of the chest X-ray of the patient's chest X-ray. The intubation was performed through the oral intubation, and the routine bronchoscopy was used after intubation. The right internal jugular vein was performed with a central venous catheter with ECG monitoring. Puncture catheterization was performed to confirm the central venous catheter entering the right atrium.
The target controlled infusion of remifentanil (2-6ng/ml) and propofol (2-5ug/ml) maintained the anesthesia and maintained the BIS value between 40-60 and sufentanil and cisatracurium on demand. After the intubation, the anesthesia ventilator interbed positive pressure ventilation (IPPV) was inserted after the intubation. The tidal volume (VT) 6-8ml/kg, respiratory frequency 12 / fraction, respiratory rate (I:E) 1:2, and inhaled oxygen concentration were used in TLV. (Fi02) after 50%.OLV VT5-7ml/kg, the respiratory rate was 13-15 / sub, and the inhalation oxygen concentration (Fi02) was 100%. After Sp02100%, the Fi02 was adjusted to 60% and the minute ventilation was equal to.OLV, the non ventilated lung bronchoducts were directly open in the atmosphere. The average arterial pressure (MAP) after OLV20min was in the A group (22 cases) and MAP below the base. The base value of 30% was group B (20 cases).
After the anesthesia induction, the main stream C02 infrared analysis method was used to monitor barium PetCO2, and the air was adjusted to zero before each use. PaCO2 was monitored by blood gas analyzer, TLV20min (T1) after induction of intubation, 20min (T2) after OLV lung was completely collapsed, MAP of B group recovered to 30min (T3) after the base value of + 10%. SpO2, HR, MAP, BIS, PetCO2, etc. were recorded at the point of time of the central venous blood. The differential pressure difference "(Pa-et) CO2" and Qs/Qt. in each time point were calculated and Qs/Qt. based on the standard three compartment model of the pulmonary blood flow distribution, Qs/Qt, Qs/Qt= (CcO2-Ca) / 1ml
Statistical analysis was carried out with SPSS13.0 software, and the measurement data were expressed with mean standard deviation. The comparison of PetC02 in each time point between each group and the PaCO2 of each time point between each group was analyzed by variance. The correlation analysis of the same time point PetCO2 and PaCO2 and the correlation analysis of (Pa-et) CO2 with Qs/Qt using Pearson correlation analysis.P0.05 was the difference between each group Statistical significance.
Result
1. there was no difference in the sex ratio, age, weight and OLV time between the two groups (P0.05).
In group 2.A, both PetC02 and PaC02 were closely related to OLV and TLV (P0.05), and the correlation coefficient r value was 0.93,0.87,0.88, and the PetC02 and PaC02 correlation coefficient r values of B group at each time point were respectively 31 +, compared with the same time point (34.2 +). Hg, the same time point (3.2 + 1.5mmHg) in group A was significantly increased (P0.05), and there was no significant difference between B group T3 period and A group T2 period (Pa-et) C02.
Compared with TLV, the two groups of Qs/Qt increased the TLV of the.A group, Qs/Qt was 1.5 + 1.4%, OLV increased to 9.4 + 4.9%, and TLV was 2.1 + 2%, B group TLV Qs/Qt was 1.6 + 0.9%, OLV hypotension was 11.9 + 6%. There was no correlation between OLV (Pa-et) CO2 and Qs/Qt (P0.05).
conclusion
In 1. lines of right pulmonary lobectomy, the patients with normal lung function, during the course of left single lung ventilation during the operation, the correlation of PetC02 and PaC02 was good (r=0.87). During the period of hypotension, "(Pa-et) CO2" was obviously increased, and PetC02 could reflect the change trend of PaC02 (r=0.75), but the accuracy was not as good as normal blood pressure.
2. there was an increase in intrapulmonary shunt in one lung ventilation, and increased in intrapulmonary shunt during hypotension. Pulmonary shunt had little effect on (Pa-et) CO2.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614

【参考文献】