不同PEEP水平对老年患者单肺通气局部脑氧饱和度的影响

发布时间：2018-06-25 23:09

本文选题：局部脑氧饱和度 + 呼气末正压　；参考：《郑州大学》2017年硕士论文

【摘要】：背景和目的胸腔镜手术常需单肺通气(One lung ventilation,OLV),以便将患侧肺与健侧肺分离并提供良好的术野。随着社会老龄化的到来,老年胸腔镜手术日益增多。OLV会对机体呼吸循环机制产生严重的干扰,引起一系列的病理生理改变,如气道压升高,通气血流比例失调,缺氧性肺血管收缩、激活炎症反应等,影响机体氧合,在老年患者更为明显。研究表明,OLV可导致局部脑氧饱和度(rSO_2)降低,且rSO_2降低与老年患者术后认知功能障碍(Postoperative cognitive dysfunction,POCD)的发生有关。肺保护性策略(Lung protect ventilation strategy,LPVS)是针对呼吸机相关肺损伤,如气压伤、容积伤、生物伤、剪切力伤等提出来的。包括PEEP的采用,小潮气量通气以及肺复张策略,最早用于ICU中ARDS患者。研究表明,LPVS可提高ARDS患者的生存率。近些年来,随着人们对LPVS认识的加深,其在全身麻醉病人中的应用也逐渐增多。国内外有大量研究表明,LPVS可降低全身麻醉病人机械通气相关肺损伤(VILI)发生率。近年来,有研究认为小潮气量通气虽然可减轻肺损伤,但可加重肺不张,而PEEP的应用对减轻肺不张有重要意义,因此,小潮气量通气联合适当的PEEP会是一种很好的通气方式。研究发现,当PEEP在5cm H_2O水平是改善OLV引起的通气血流比例失调的最佳水平。也有研究表明,当PEEP在5-10cm H_2O时能最大程度的改善单肺通气时机体氧合。因此,有研究提出,将PEEP在5cm H_2O时设定为标准PEEP水平。目前,关于不同PEEP水平对老年患者OLV期间rSO_2的影响尚不清楚。本研究通过联合肺复张法和PEEP滴定实验法来确定个体化PEEP(Individualized PEEP)水平,观察个体化PEEP水平与标准PEEP(Standardized PEEP)水平(PEEP为5cm H_2O)对OLV时rSO_2、肺通气功能的影响。方法选择我院2015年11月至2016年2月择期行胸腔镜手术的老年患者46例,年龄65-80岁,ASAⅠ-Ⅲ级,性别不限,无严重心脑血管疾病。采用随机数字表法,将患者随机分两组(n=23),PEEP=5cm H_2O为C组(The Control group)和个体化PEEP组为S组(The Study group)。患者入室后开放静脉通路,监测ECG,心率(HR),血压(BP),脉搏氧饱和度(Sp O_2),局麻下行桡动脉穿刺置管,术中连续监测动脉血压,与Vigileo监护仪连接,监测CI;麻醉诱导后行右侧颈内静脉穿刺置管。采用EGOS-600型近红外组织血氧参数监测仪(苏州爱琴生物医疗电子有限公司)监测rSO_2(传感器电极片粘贴于患者前额眉弓上方,并用不透光的塑料胶贴加以覆盖以避免周围光线对测量的影响)。依次静脉注射依托咪酯0.3-0.4mg/kg,舒芬太尼0.5-1.0μg/kg,顺式阿曲库铵1.5-2.0mg/kg行麻醉诱导,在可视喉镜引导下行双腔支气管插管,并用纤维支气管镜辅助定位。术中所有患者使用Leon麻醉机进行机械通气,采用容量控制通气模式,吸入纯氧,流量2.0L/min,S组:双肺通气时VT 8ml/kg,吸呼比1:2;OLV时VT 5-7ml/kg,根据PEEP滴定实验法来确定OLV时PEEP水平,吸呼比1:2;C组:双肺通气时VT 8ml/kg,吸呼比1:2,OLV时VT 5-7ml/kg,吸呼比1:2,PEEP设定为5 cm H_2O(1 cm H_2O=0.098 k Pa);两组均调节呼吸频率,维持PETCO_235-45mm Hg(1 mm Hg=0.133 k Pa),平台压(Plateu pressure,Pplat)低于25 cm H_2O。当Pplat高于25 cm H_2O时逐渐减少潮气量,每次减少1ml/kg,直至Pplat低于25cm H_2O。为了避免OLV过程中低氧血症的发生和排除氧浓度对动脉血氧分压测定的影响,术中均吸入100%纯氧。术中吸入2%七氟醚,持续静脉泵注瑞芬太尼0.2-2.0μg·kg-1·min-1,间断静脉注射顺式阿曲库铵维持麻醉。维持术中脉搏氧饱和度Sp O_2≥95%,脑电双频谱指数(Bispectral index,BIS)值维持在40~55。分别于麻醉诱导前T0、侧卧位双肺通气5min T1、单肺通气开始后肺复张前5min T2、单肺通气后20min T3、单肺通气结束肺复张前T4、双肺通气拔出气管导管T5记录各观察指标。观察指标:由专门护理人员于各时间点取样进行血气分析,并观察记录患者rSO_2、Pa O_2、Pa CO_2、CI值、p H值、最佳PEEP值、气道平台压、肺静态顺应性、气道阻力。用SPSS17.0统计软件进行统计学分析。计量资料以均数±标准差((?)±s)表示。组内比较采用重复测量资料方差分析,组间比较采用成组t检验,以P0.05为差异有统计学意义。结果1.两组患者一般情况,如年龄、性别、体重、手术时间、单肺通气时间、ASA分级等比较,差异无统计学意义。2.OLV期间,S组患者rSO_2、Pa O_2高于C组患者,差异有统计学意义。3.肺静态顺应性:与T1相比,T2时两组均下降;肺复张后,T3、T4时S组明显升高,T3时,S组高于C组,差异有统计学意义。4.气道阻力:与T1相比,T2时两组均升高,差异无统计学意义。结论1.与PEEP=5cm H_2O相比,个体化PEEP联合肺复张法可明显改善老年患者OLV时rSO_2。2.与PEEP=5cm H_2O相比,个体化PEEP联合肺复张法可明显提高老年患者OLV时肺顺应性,降低气道阻力,减轻肺损伤。
[Abstract]:Background and objective thoracoscopic surgery often requires single lung ventilation (One lung ventilation, OLV) so as to separate the affected lung from the healthy side of the lung and provide a good surgical field. With the aging of the society, the increasing number of.OLV in the senile thoracoscopic surgery will cause severe interference to the mechanism of respiratory circulation and cause a series of pathophysiological changes, such as gas. The increase of the pressure, the imbalance of the blood flow rate, the hypoxic pulmonary vasoconstriction and the activation of the inflammatory reaction, which affect the oxygenation of the body, are more obvious in the elderly patients. The study shows that OLV can lead to the decrease of local cerebral oxygen saturation (rSO_2) and the decrease of rSO_2 and the occurrence of Postoperative cognitive dysfunction, POCD after the operation of the elderly patients. Lung protect ventilation strategy (LPVS) is proposed for ventilator related lung injury, such as air pressure, volume injury, biological injury, and shear injury. The use of PEEP, small tidal volume ventilation and lung Zhang Celve are first used in ARDS patients in ICU. The study shows that LPVS can improve the survival rate of ARDS patients. In recent years, with the deepening of people's understanding of LPVS, its application in general anesthesia patients is increasing. A large number of studies have shown that LPVS can reduce the incidence of mechanical ventilation related lung injury (VILI) in patients with general anesthesia. In recent years, there have been studies that although the volume of small tidal air can reduce lung injury, but it can aggravate atelectasis, and PEEP It is of great significance to alleviate atelectasis. Therefore, the combination of appropriate PEEP with small tidal volume ventilation is a very good ventilation. The study found that PEEP at 5cm H_2O level is the best level to improve the imbalance of the ventilation flow ratio caused by OLV. There are also studies showing that PEEP can improve single lung ventilation at the maximum of 5-10cm H_2O. As a result, a study has been proposed to set PEEP at 5cm H_2O as a standard PEEP level. At present, the effect of different PEEP levels on rSO_2 during OLV in elderly patients is not clear. In this study, the level of individual PEEP (Individualized PEEP) was determined by combined pulmonary extension and PEEP titration, and the individual PEEP level was observed. The effect of standard PEEP (Standardized PEEP) level (PEEP is 5cm H_2O) on rSO_2 and pulmonary ventilation in OLV. Methods 46 elderly patients who underwent thoracoscopic surgery from November 2015 to February 2016 were selected. The age 65-80 years old, ASA I - III, sex unlimited, no severe barycenter cerebrovascular disease. The randomized digital table method was used to divide the patients to two randomly. Group (n=23), PEEP=5cm H_2O for group C (The Control group) and individual PEEP group as S group (The Study group). The right internal jugular vein catheterization was followed by a EGOS-600 near infrared tissue blood oxygen parameter monitor (Suzhou Aegean Bio Medical Electronics Co., Ltd.) monitoring rSO_2 (sensor electrode pasted above the forehead eyebrow bow and covered with opaque plastic glue to avoid the influence of ambient light on the measurement). Etomidate 0.3-0.4mg/kg, sufentanil 0.5-1.0 g/kg and CIS atracurium 1.5-2.0mg/kg were induced by anesthesia induced by CIS atracurium. Double lumen bronchus intubation under the guidance of visual laryngoscope and assisted by fiberoptic bronchoscope were used. All patients in the operation were ventilated with Leon anesthesia machine, using volume control ventilation mode, inhaling pure oxygen, flow 2.0L/min, S. Group: VT 8ml/kg, suction ratio 1:2 and VT 5-7ml/kg at OLV, according to PEEP titration test to determine PEEP level at OLV, 1:2 in OLV, C group: 5 lung ventilation, expiratory ratio, suction ratio, and two groups are set to regulate respiratory frequency (1). Hg=0.133 K Pa), the platform pressure (Plateu pressure, Pplat) is lower than 25 cm H_2O. when Pplat is higher than 25 cm H_2O. % sevoflurane, continuous intravenous infusion of remifentanil 0.2-2.0 mu g. Kg-1. Min-1, continuous intravenous injection of CIS atracurium anesthesia. Maintenance of pulse oxygen saturation in the maintenance of Sp O_2 > 95%, the bispectral index of electroencephalogram (Bispectral index, BIS) is maintained at 40~55. before induction of anesthesia induction, lateral position double lung ventilation 5min, single lung ventilation after the start of the lung. 5min T2 before one lung, 20min T3 after single lung ventilation, T4 before lung ventilation at the end of one lung ventilation, and T5 recording of tracheal tube by double lung ventilation. Observation indexes: the blood gas analysis was taken by special nursing staff at every time point, and the patients' rSO_2, Pa O_2, Pa CO_2, CI value, optimal value, airway pressure, and lung static CIS value were observed. Stress and airway resistance. Statistical analysis was performed with SPSS17.0 statistical software. The measurement data were expressed with mean + + standard deviation ((?) + s). The group was compared with the repeated measurement data ANOVA, group t test was used in groups, and the difference of P0.05 was statistically significant. Results 1. groups of patients, such as age, sex, weight, operation time, were statistically significant. Single lung ventilation time, ASA classification, and so on, the difference was not statistically significant.2.OLV, group S patients rSO_2, Pa O_2 higher than the C group, the difference was statistically significant.3. lung static compliance: compared with T1, T2 two groups decreased; lung recovery, T3, T4 group was significantly higher than the group, the difference was statistically significant Compared with T2, the two groups were all higher, and the difference was not statistically significant. Conclusion compared with PEEP=5cm H_2O, individual PEEP combined with pulmonary re extension can obviously improve rSO_2.2. and PEEP=5cm H_2O in elderly patients, and individual PEEP combined with lung re extension can obviously improve lung compliance, decrease airway resistance and reduce lung injury in OLV of the elderly patients.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614

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