肺保护性通气策略在腹腔镜手术患者的临床应用研究

发布时间：2018-06-17 06:09

本文选题：肺保护性通气策略 + 小潮气量　；参考：《广西医科大学》2014年硕士论文

【摘要】：目的通过在腹腔镜盆腔手术麻醉过程中对患者实施肺复张手法后对潮气量（VT）、呼吸频率（f）、吸气呼气时间比（I:E）、呼气末正压（PEEP）四项呼吸参数进行不同水平的组合设定，观察其对患者术中呼吸功能的影响，探讨腹腔镜盆腔手术麻醉时应用肺保护性通气策略的理想通气参数组合。方法选择36例行择期腹腔镜宫颈癌根治术手术患者，ASA分级I～Ⅱ级，按四因素三水平重复正交试验设计分为九组，每组四例患者。每例患者均行全凭静脉麻醉，术中行间歇正压通气。在建立稳定的二氧化碳气腹及调整体位后，对每例患者均实施肺复张手法，之后恢复机控通气，同时按设定的试验分组调节相应的呼吸参数。四因素设定为潮气量（A）、呼吸频率（B）、吸气呼气时间比（C）、呼气末正压（D）,各因素水平设定为1、2、3三水平。监测患者麻醉前、气腹前、气腹后60分钟的MAP，HR，SPO2, PETCO2及PIP和Pmean等。于气腹开始前及气腹后60分钟分别抽取桡动脉血做血气分析。结果⑴各组患者手术均顺利完成，试验过程中患者心率、血压平稳，血氧饱和度监测97-100％。其中3例患者术中出现偶发室性早搏，血流动力学平稳，未予特殊处理。所有患者ECG监测未发现心肌缺血表现。气腹60分钟时各组患者HR、MAP、PaO2之间比较无统计学差异。 ⑵极差分析结果： ①四因素对PaCO2的影响程度大小是：fVTPEEPI:E,使PaCO2较低的最优组合是：f=18次/min,VT=12ml/kg,I:E=1:2,PEEP=10cmH2O； ②四因素对PIP的影响程度大小是VTPEEPI:Ef，使PIP较低的最优组合是：f=10次/min,VT=6ml/kg,I:E=2:1,PEEP=4cmH20； ③四因素对Pmean的影响程度大小是PEEPI:EVTf，使Pmean较低的最优组合是：f=10次/min,VT=6ml/kg,I:E=1:2,PEEP=4cmH20。 ⑶方差分析结果： ①VT、f、PEEP的不同水平对PaCO2的影响存在显著统计学意义(PO.01)，I:E的不同水平对PaCO2的影响没有统计学意义(P0.05)； ②四因素的不同水平对PIP的影响均存在显著统计学意义(PO.01)； ③四因素的不同水平对Pmean的影响均存在显著统计学意义(PO.01)。结论全身麻醉下腹腔镜盆腔手术患者行肺复张手法后的理想术中通气组合模式为A1B3C3D1，，即VT=6ml/kg，f=18次/min，I:E=1:2，PEEP=4cmH2O。
[Abstract]:Objective to set different levels of respiratory parameters such as tidal volume, respiratory frequency, inspiratory and expiratory time ratio (I / E) and positive end-expiratory pressure (PEEP) during laparoscopic pelvic anaesthesia. To observe the effect of lung protective ventilation on the respiratory function of patients during laparoscopic pelvic surgery, and to explore the ideal ventilation parameter combination of lung protective ventilation strategy during laparoscopic pelvic surgery. Methods A total of 36 patients undergoing laparoscopic radical cervical cancer surgery were divided into nine groups according to four factors and three levels repeated orthogonal design. Each patient received total intravenous anesthesia and intermittent positive pressure ventilation. After establishing stable carbon dioxide pneumoperitoneum and adjusting body position, each patient was treated with pulmonary retensioning manipulation, and then the mechanical ventilation was restored, and the corresponding respiratory parameters were adjusted according to the set test group at the same time. Four factors were determined as tidal volume, respiratory frequency, inspiratory expiratory time ratio, positive end-expiratory pressure and three levels. MAPHRO _ 2, PET _ 2, PIP and Pmean were monitored before anesthesia and 60 minutes after pneumoperitoneum. Radial artery blood was collected before pneumoperitoneum and 60 minutes after pneumoperitoneum for blood gas analysis. Results 1 the operation was completed successfully in each group. The heart rate, blood pressure and blood oxygen saturation were stable, and the blood oxygen saturation was monitored 97-100 in the course of the experiment. Among them, 3 cases had occasional ventricular premature beat during operation, the hemodynamics was stable and no special treatment was given. No myocardial ischemia was found by ECG monitoring in all patients. At 60 minutes after pneumoperitoneum, there was no statistical difference between the two groups. 2 the results of the range difference analysis showed that: 1 the influence of four factors on Paco _ 2 was: (1) the degree of influence of four factors on Paco _ 2 was: 1: fVTPEEPI: e, the best combination with lower Paco _ 2 was 12 ml / kg I-1: E1: 2 / PEEP10cmH _ 2O; (2) the influence of four factors on PIP is VTPE EPI: Ef. the best combination with lower PIP is: 10 / min / min VTT = 6 ml / kg / kg = 2: 1 PEEPI = 4cmH20; 3 the degree of influence of four factors on Pmean is PEEPI: EVTf. the best combination with lower Pmean is: 10 / min / min VT = 6 ml / kg / kg = 1: 1: 2 / PEEP 4cm H20.3 ANOVA results: 1VTfpeep has significant effect on PaCO2 at different levels. The effect of different levels of I: e on PaCO2 was not statistically significant (P 0.05). (2) the influence of four factors on PIP was statistically significant (P < 0.01), and the influence of four factors on Pmean was statistically significant (P < 0.01). Conclusion the ideal intraoperative ventilation combination model for patients undergoing laparoscopic pelvic surgery under general anesthesia is A1B3C3D1, that is, VTT 6ml / kg / min / min I / e 1: 2PEEPN 4cm H _ 2O.
【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614

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