动静脉二氧化碳分压差在胸腔镜心脏手术中的应用价值

发布时间：2018-06-25 03:03

本文选题：动静脉二氧化碳分压差 + 胸腔镜　；参考：《济宁医学院》2015年硕士论文

【摘要】：目的:探讨动静脉二氧化碳分压差(Pcv-aCO2)在完全胸腔镜体外循环下心脏手术中的应用价值。方法:随机选取2013年1月到2014年10月济宁医学院附属医院心脏外科连续收治拟体外循环下行心脏手术的患者共100例,其中男性62例,女性48例,年龄21-63岁,平均年龄36岁,平均体重51kg。房间隔缺损(ASD)39例;室间隔缺损(VSD)34例;风湿性二尖瓣狭窄10例,二尖瓣关闭不全12例,狭窄伴关闭不全5例。所有患者均经心电图、胸部X线片和超声心动图检查确诊。50例在全麻低温体外循环完全胸腔镜下行手术治疗的先天性心脏病或风湿性心脏病患者为研究组,同期相似病种常规开胸手术患者50例为对照组。所有患者均采用气管插管全身麻醉,在低温、体外循环下施行手术。研究组采用胸腔镜手术,右腋中线3切口心脏停跳下完成手术,对照组,胸骨正中切口,心脏停跳后直视下完成心脏手术,常规关胸。研究组经股动脉插供血,经股静脉或者上腔静脉插管建立体外循环,而对照组采取经典胸部正中切口,常规插管建立体外循环,采用主动脉根部冷血停搏液心肌保护。术中经颈内静脉或锁骨下静脉留置中心静脉导管,通过血气分析计算出Pcv-aCO2,同时记录监测中心静脉血氧饱和度(ScvO2)。术后返回ICU均给予呼吸机辅助呼吸,呼吸机模式和参数设置要求相同。术后经桡动脉采动脉血,经中心静脉置管采中心静脉血,分别监测患者术后0h、6h、12h、18h四个时间点的Pcv-aCO2和ScvO2变化,心脏彩超评估术后0h、6h、12h、18h的心脏功能(左室射血分数EF值)。术后0h、6h、12h、18h四个不同时间点指标的比较,应用重复测量资料的方差分析;应用spearman分析各指标的相关性,P0.05认定为差异有统计学意义。结果:在进行胸腔镜心脏手术后0h、6h、12h、18h的Pcv-aCO2逐渐降低,ScvO2及EF逐渐增加,各时间点比较差异有统计学意义(P0.05);Pcv-aCO2、ScvO2、EF三个指标两组之间比较差异均有统计学意义(P0.05);三个指标处理与时间交互作用比较差异也均有统计学意义(P0.05)。术后Pcv-aCO2与Scv O2呈负相关(r=-0.602;P=0.006),Pcv-aCO2与EF呈负相关(r=-0.502;P=0.032)。结论:Pcv-aCO2的检测较动脉血气分析更能客观反映患者体内氧供需平衡情况,根据Pcv-aCO2监测结果并结合ScvO2以及其他临床数据,能够及时有效地进行临床处理措施指导,尽早预测和评估术后并发症,从而在临床上能尽早预防和及时有效处理并发症。Pcv-aCO2和ScvO2之间具有相关性,可用于手术前中后期的血气指标监控和心脏功能的评估和预后的判读。
[Abstract]:Objective: to investigate the value of arteriovenous carbon dioxide partial pressure difference (Pcv-aCO2) in cardiac surgery under complete thoracoscopic cardiopulmonary bypass (CPB). Methods: a total of 100 patients, 62 males and 48 females, aged 21-63 years, with an average age of 36 years, were selected randomly from January 2013 to October 2014 in the Cardiac surgery Department of the affiliated Hospital of Jining Medical College. The average weight was 51 kg. There were 39 cases of atrial septal defect (ASD), 34 cases of ventricular septal defect (VSD), 10 cases of rheumatic mitral stenosis, 12 cases of mitral insufficiency and 5 cases of stenosis with insufficiency. All the patients were diagnosed by electrocardiogram, chest X-ray and echocardiography. The study group consisted of 50 patients with congenital heart disease or rheumatic heart disease who were operated under general anesthesia cardiopulmonary bypass (CPB). At the same time, 50 patients with similar diseases were treated as control group. All patients were anesthetized by endotracheal intubation and operated under hypothermia and cardiopulmonary bypass. The patients in the study group underwent thoracoscopic surgery, right axillary midline 3 incision cardiac arrest, control group, median sternum incision, cardiac surgery under direct vision after cardiac arrest, and conventional closure of chest. In the study group, cardiopulmonary bypass (CPB) was established through femoral artery catheterization, femoral vein or superior vena cava catheterization, while in the control group, cardiopulmonary bypass was established by classical chest median incision and conventional catheterization. Cardiopulmonary bypass was protected by cold blood cardioplegic solution from aortic root. The central venous catheter was inserted through the internal jugular vein or subclavian vein during the operation. Pcv-aCO2 was calculated by blood gas analysis, and the central venous oxygen saturation (scvO2) was recorded. All the patients returned to ICU after operation were given ventilator assisted breathing, and the requirements of ventilator mode and parameter setting were the same. Arterial blood was collected through radial artery and central vein was inserted into central vein to collect central venous blood. The changes of Pcv-aCO2 and scvO2 were monitored at 0 h, 6 h, 12 h and 18 h, respectively. Cardiac function (EF value of left ventricular ejection fraction) was evaluated by echocardiography at 0 h, 6 h, 12 h and 18 h, respectively. The analysis of variance of repeated measurement data was used to compare the four different time points of 0 h ~ 6 h ~ 12 h ~ (18 h) after operation, and the correlation of each index was analyzed by spearman (P0.05). Results: Pcv-aCO2 decreased gradually after thoracoscopic cardiac surgery at 0 h, 6 h and 12 h and 18 h after thoracoscopic cardiac surgery, and the levels of scvO2 and EF increased gradually. There were significant differences in the three indexes of Pcv-aCO2O2EF between the two groups (P0.05), and there were also significant differences between the three indexes of processing and time interaction (P0.05). There was a negative correlation between Pcv-aCO2 and scvO2 (rcv-0.602P0. 006) Pcv-aCO2 and EF (rcv-0.502a CO _ 2 was 0.032). Conclusion compared with arterial blood gas analysis, the detection of Pcv-aCO2 can objectively reflect the balance of oxygen supply and demand in patients. According to the monitoring results of Pcv-aCO2 and SCVO _ 2 and other clinical data, the clinical management can be guided in time and effectively. To predict and evaluate the postoperative complications as early as possible, so as to prevent and deal with the complications. Pcv-aCO2 and ScvO2 in clinical as early as possible. It can be used to monitor the blood gas index before and after operation, to evaluate the cardiac function and to interpret the prognosis.
【学位授予单位】：济宁医学院
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R654.2

【参考文献】