基于LPVS的人工气胸患者PEEP值选择研究

发布时间：2018-03-19 01:23

  本文选题：CO_2人工气胸　切入点：机械通气相关性肺损伤　出处：《郑州大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景与目的机械通气是保证全麻患者正常生命活动最基本的一项医疗技术,在给予患者呼吸支持,改善通气状态,促进机体氧合,防止缺氧和CO_2蓄积具有不可代替的作用。但是不合理的机械通气会改变患者正常肺组织的结构和功能,造成机械通气相关性肺损伤(ventilator-associated lung injury,VALI),增加了患者肺部等并发症的发生率,影响机体预后。作为国内常见恶性肿瘤之一的食管癌,目前最有效的治疗方法是外科手术切除,传统的开胸食管癌根治术对患者的创伤比较大,尤其是老年患者术后其并发症发生率较高,患者恢复较为缓慢。近些年随着微创外科技术的大力发展,电视辅助胸腔镜(video assisted thoracoscopic suigery,VATS)食管癌根治术因其术中创伤小,术后疼痛轻,患者康复快越来越受到患者和外科医生的青睐。然而,传统胸腔镜食管癌根治术患者多采用双腔气管插管单肺通气麻醉,双腔管不仅存在对位不良、反复调试易损伤气道、插管技术要求高和费用昂贵等问题,还存在部分患者术中出现低氧血症,不能长时间耐受单肺通气状态。近些年人工CO_2气胸单腔插管麻醉用于全腔镜食管癌根治术得到快速发展,人工CO_2气胸单腔插管成为继传统的单腔支气管导管、双腔支气管导管和支气管封堵器又一新型技术,其原理是人工向胸膜腔内持续注入CO_2气体并控制其流速,使胸膜腔内维持在一定正压水平,达到肺萎陷和手术术野暴露的目的。Flotrac/Vigileo监测系统具有微创、操作简单、并发症少的优点,可以通过分析外周动脉压力波形信息连续计算CO、SV、CI、SVV等血流动力学指标,并能通过中心静脉压和动脉血气相关数值衍生计算出氧输送指数(DO_2I)等数值,近年来在病情变化快、需要连续血流动力学监测的患者中应用日益广泛。保护性肺通气策略(lung protective ventilation strategy,LPVS)通常是指采取基于理想体重的小潮气量(VT)通气、选择适宜的呼气末正压(PEEP)、降低吸入氧浓度、限制一定的平台压(Pplat)和容许合适范围内高碳酸血症等措施的一项麻醉技术,然而LPVS对于人工CO_2气胸单腔插管全腔镜食管癌根治术患者的肺保护方面尚未见相关文献报道。本研究主要探讨LPVS对人工CO_2气胸单腔插管全腔镜下行食管癌根治术的患者肺功能及肺部并发症方面的影响,并探讨基于Flo Trac/Vigileo血流动力学及呼吸功能监测下如何选取最佳的PEEP值,以起到对患者更好的肺保护作用。材料与方法择期行电视辅助胸腔镜食管癌根治术患者300例,将患者随机分成六组:V0组、V1组、V2组、V3组、V4组和V5组,六组患者皆采取小潮气量通气,VT均设置为5ml/kg,吸入氧浓度(Fi O2=0.6),术中维持PETCO_2≤55mm Hg,设置V0组PEEP=0cm H_2O,V1组PEEP=2cm H_2O,V2组PEEP=4cm H_2O,V3组PEEP=6cm H_2O,V4组PEEP=8cm H_2O,V5组PEEP=10cm H_2O。分别于麻醉诱导后改左侧卧位(T0)、建立CO_2气胸60min(T1)抽取患者动脉血气,并记录相同时刻患者Pplat、肺顺应性(CL),心指数(CI)、每搏变异度(SVV)、氧输送指数(DO_2I)、呼出气冷凝液pH值和术毕拔出气管导管时间、并根据相应的时间点记录数值计算患者肺内分流率(Qs/Qt)、死腔率(Vd/Vt)和呼吸指数(RI),术后一天访视病人,抽取其动脉血检测并计算RI,记录患者肺部并发症的发生率、转入ICU的发生率及住院时长。统计学分析采用SPSS 21.0统计软件进行分析。对于符合正态分布的定量资料以均数±标准差((?)±s)表示,两组间的比较行独立样本t检验;多组间的比较运用单因素方差分析。定性资料比较采取X2检验。显著性检验水准取α=0.05。结果1六组患者术中Qs/Qt、Vd/Vt、RI、CL比较与T0时相比,六组患者T1时Qs/Qt、Vd/Vt、RI显著上升(P0.05),CL显著降低(P0.05)。与V0组相比,T1时V3、V4、V5组Qs/Qt、Vd/Vt、RI均降低,CL增加,差异均有统计学意义(P0.05)。与V0组相比,T1时V1、V2组Qs/Qt、Vd/Vt、RI、CL差异均不明显(P0.05),T1时V3、V4和V5组间Qs/Qt、Vd/Vt、RI、CL差异均不明显(P0.05)。2六组患者术中CI、SVV、DO_2I比较与T0时相比,六组患者T1时CI、DO_2I明显降低(P0.05),SVV明显上升(P0.05)。与V0组相比,T1时V3、V4、V5组DO_2I升高(P0.05),V5组CI降低、SVV升高(P0.05)。与V0组相比,T1时V1、V2组CI、SVV、DO_2I差异均不明显(P0.05)。与V0组相比,T1时V3、V4组CI、SVV差异均不明显(P0.05),T1时V3、V4和V5组间CI、SVV、DO_2I差异均不明显(P0.05)。3六组患者术中Pplat比较与T0时相比,T1时六组患者Pplat均明显上升(P0.05)。与V0组相比,T1时V5组Pplat上升明显(P0.05)。与V0组相比,T1时V1、V2、V3、V4组Pplat差异无统计学意义(P0.05),T1时V3、V4和V5组间Pplat差异均不明显(P0.05)。4六组患者术中呼出气冷凝液p H值比较与T0时相比,T1时六组患者呼出气冷凝液p H值均明显降低(P0.05)。与V0组相比,T1时V3、V4、V5组呼出气冷凝液p H值增高(P0.05)。与V0组相比,T1时V1、V2组呼出气冷凝液p H值差异无统计学意义(P0.05),T1时V3、V4和V5组间呼出气冷凝液p H值差异均不明显(P0.05)。5六组患者气管导管拔除时间及其术后24h RI值比较与V0组相比,V3、V4、V5组气管导管拔除时间明显缩短(P0.05)、术后24h RI明显降低(P0.05)。与V0组相比,V1、V2组气管导管拔除时间、术后24h RI差异无统计学意义(P0.05),T1时V3、V4和V5组间气管导管拔除时间及术后24h RI差异均不明显(P0.05)。6六组患者术后肺部并发症发生率及严重程度比较与V0组相比,V3、V4、V5组术后肺部并发症发生率、住院时长明显降低(P0.05);与V0组相比,V1、V2组术后肺部并发症发生率、住院时长差异无统计学意义(P0.05),T1时V3、V4和V5组间术后肺部并发症发生率及住院时长差异均不明显(P0.05)。V0组入住ICU3例、V1与V2组均为2例,V3、V4、V5组均未发现入住ICU病例。结论人工CO_2气胸单腔插管全腔镜食管癌根治术患者术中设置PEEP值6~8cm H_2O较为合适,能显著改善患者术中氧合状态及加速术后康复,并对术中血流动力学影响较小。
[Abstract]:Background and objective is to ensure the mechanical ventilation of patients with general anesthesia in normal life activities of a medical technology in the most basic, giving patients respiratory support, improve ventilation, promote the body oxygenation, prevent hypoxia and CO_2 accumulation plays an irreplaceable role. But the mechanical ventilation is not reasonable will change the structure and function of the patients with normal lung tissue. Cause ventilator induced lung injury (ventilator-associated lung, injury, VALI) increased in patients with lung and other complications, affect the prognosis. As the one of the most common malignant tumors of esophagus cancer, currently the most effective treatment is surgical resection, traditional open thoracic esophageal cancer radical surgery is the trauma of the patient. Especially in elderly patients with the higher incidence of complications, patients recover more slowly. In recent years, with the development of minimally invasive surgical techniques, video assisted thoracoscopic (video assisted thoracoscopic Suigery, VATS) for the resection of esophageal carcinoma with small trauma, less postoperative pain, quicker recovery of patients more and more patients and surgeons favor. However, the use of double lumen endotracheal intubation anesthesia in patients undergoing radical gas Dan Feitong traditional thoracoscopic esophageal cancer, double lumen tube not only malalignment. Debugging is easy to damage the airway intubation, high technical requirements and expensive, there are still some patients with hypoxemia, not long time tolerance of single lung ventilation state. In recent years the artificial pneumothorax CO_2 single lumen intubation anesthesia for the rapid development of full endoscopic esophageal cancer radical resection, artificial pneumothorax CO_2 single lumen intubation became the second single the traditional lumen tube, double lumen tube and bronchial occluder and a new type of technology, its principle is to continue the intrapleural injection of CO_2 artificial gas and control the velocity of the. The pleural cavity is maintained at a certain level of positive pressure, to achieve the purpose of the.Flotrac/Vigileo monitoring system of atelectasis and surgical field exposure with minimally invasive, simple operation, less complications, through the analysis of peripheral arterial pressure waveform information for calculation of CO, SV, CI, SVV blood flow mechanics index, and through the central venous pressure and arterial blood gas numerical derivative to calculate the oxygen delivery index (DO_2I) value, in recent years, the condition changes quickly, need increasingly widespread application of continuous hemodynamic monitoring in patients. Lung protective ventilation strategy (lung protective ventilation strategy, LPVS) usually refers to the low tidal volume of ideal body weight (VT) based on the selection of ventilation. Appropriate positive end expiratory pressure (PEEP), reduced oxygen concentration, restricted platform pressure (Pplat) and allow the appropriate range of hypercapnia measures such as an anesthetic technique, however, LPV S for lung protection in patients undergoing resection of artificial pneumothorax CO_2 single lumen intubation endoscopic esophageal cancer has not been reported in the literature. This study focused on LPVS CO_2 of artificial pneumothorax single lumen intubation underwent laparoscopic radical resection of esophageal cancer patients with the lung function and pulmonary complications, and the effect of Flo Trac/Vigileo on hemodynamics and respiratory function how to select the best monitoring based on the PEEP value, so as to protect the lung of patients better. Materials and methods of patients undergoing video-assisted thoracoscopic radical resection of esophageal cancer and 300 cases of patients were randomly divided into six groups: V0 group, V1 group, V2 group, V3 group, V4 group and V5 group, six patients are taking low tidal volume ventilation, VT is set to 5ml/kg, inhaled oxygen concentration (Fi O2=0.6), PETCO_2 = 55mm Hg to maintain the operation, set the V0 PEEP=0cm H_2O group, V1 group, PEEP=2cm H_2O group, V2 PEEP=4cm H_2O, V3 PEEP=6cm H_2O group, V4 group, PEEP= 8cm H_2O,V5缁凱EEP=10cm H_2O.鍒嗗埆浜庨夯閱夎�卞�煎悗鏀瑰乏渚у崸浣，

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