本文關(guān)鍵詞： 單肺通氣 開胸手術(shù) 小潮氣量通氣 IPPV 炎性反應(yīng)　出處：《河北醫(yī)科大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：目的：本研究擬評價(jià)單肺通氣時(shí)術(shù)側(cè)肺輔助小潮氣量IPPV對周圍型肺癌開胸患者氧合和炎性因子及術(shù)后恢復(fù)的影響。 方法：隨機(jī)選取行周圍型肺癌切除術(shù)患者20例，年齡45~65歲，性別不限，體重49~80Kg�；颊呔鶠锳SAⅠ~Ⅱ級，術(shù)前患者未經(jīng)過放療、化療等治療，并且無內(nèi)分泌及免疫系統(tǒng)疾病，無激素及免疫藥物應(yīng)用史，無嚴(yán)重心肺肝腎功能障礙。選取同一組醫(yī)生手術(shù)的肺癌患者。將患者按照完全隨機(jī)對照原則分為IPPV組（A組）和對照組（B組）。所有患者入室后均建立上肢靜脈通路，隨后在局麻下橈動脈穿刺置管，術(shù)中連續(xù)監(jiān)測有創(chuàng)動脈壓。術(shù)前30min靜脈注射阿托品0.5mg，咪達(dá)唑侖0.05mg/kg。用IntelliVue MP50多功能監(jiān)護(hù)儀監(jiān)測患者的心電圖（ECG），脈搏氧飽和度（SpO2），呼氣末二氧化碳分壓（PETCO2），在全麻誘導(dǎo)結(jié)束后頸內(nèi)靜脈置管監(jiān)測中心靜脈壓（CVP）。麻醉誘導(dǎo)：所有患者均采用芬太尼、依托咪酯、順阿曲庫胺誘導(dǎo)，其劑量為芬太尼2～4μg/kg,依托咪酯0.2～0.3mg/kg，順式阿曲庫胺0.3mg/kg，3min后插入雙腔支氣管導(dǎo)管，然后用纖維支氣管鏡定位維持雙腔管的正常位置，側(cè)臥位后再次用纖維支氣管鏡定位，以確保導(dǎo)管位置良好。兩組通氣均采用Datex-Ohmeda7100麻醉機(jī)控制呼吸，雙肺通氣時(shí)潮氣量為8~10ml/kg，呼吸頻率為12次/分，吸呼比為1:2，單肺通氣時(shí)潮氣量為6~8ml/kg，呼吸頻率為15~17次/分，吸呼比為1:2，，根據(jù)呼氣末二氧化碳分壓（正常值為35~45mmHg）調(diào)整呼吸參數(shù)；同時(shí)監(jiān)測患者的氣道峰壓(Ppeak)，氣道平臺壓（Pplat），使氣道壓低于30cmH2O。麻醉維持采用瑞芬太尼和七氟醚靜吸復(fù)合麻醉，吸入七氟烷（1～3%），微量泵泵注瑞芬太尼0.5～1μg/kg/min。術(shù)中使患者的BIS值維持于40～60之間。間斷靜脈注射順式阿曲庫胺0.05mg/kg維持肌肉松弛，術(shù)中采用肌松監(jiān)測儀監(jiān)測肌松。兩組患者單肺通氣新鮮氣體流量都給予1L/min。在單肺通氣期間，對照組術(shù)側(cè)肺的支氣管導(dǎo)管直接開口于空氣處于自然萎陷狀態(tài)，試驗(yàn)組的術(shù)側(cè)肺支氣管導(dǎo)管接Datex-Ohameda7100呼吸機(jī)，新鮮氣體流量為1L/min。呼吸參數(shù)設(shè)定：潮氣量為1.2ml/kg，頻率為15次/分,吸呼比為1:2。常規(guī)補(bǔ)液，輸注15ml/kg/h乳酸鈉林氏液和羥乙基淀粉氯化鈉130/0.4注射液，晶膠比2：1，以維持血流動力學(xué)平穩(wěn)，通過調(diào)整麻醉深度或使用藥物使平均動脈壓（MAP）和心率（HR）的變化幅度不超過基礎(chǔ)值的20%。在麻醉前自主呼吸空氣時(shí)（t0），肺葉切除后（t1），單肺通氣結(jié)束時(shí)（t2），分別采集動脈血，用Cabs b123型號血?dú)夥治鰞x測定并記錄血?dú)夥治鰌H值、動脈血氧分壓（PaO2）、動脈二氧化碳分壓（PaCO2）、血乳酸值（Lac）、BE值。同時(shí)記錄患者在上述時(shí)間點(diǎn)的心率（HR）、脈搏血氧飽和度（SpO2）、平均動脈壓（MAP）、中心靜脈壓（CVP）。 記錄單肺通氣的時(shí)間、手術(shù)時(shí)間、補(bǔ)液量、尿量、出血量、輸血量。分別于插管即刻（T0）、手術(shù)結(jié)束即刻(T1)、術(shù)后24小時(shí)（T2）、術(shù)后48小時(shí)（T3）時(shí)，抽取中心靜脈血4ml，測定血清IL-8、IL-10、TNF-α的水平。 術(shù)后隨訪：患者胸腔引流時(shí)間、引流量、拔管時(shí)間、抗生素使用時(shí)間、住院時(shí)間、費(fèi)用、是否轉(zhuǎn)ICU、生命體征、體溫變化。 結(jié)果： (1)一般情況：兩組患者年齡、體重指數(shù)、性別構(gòu)成比、單肺通氣時(shí)間、術(shù)時(shí)間、補(bǔ)液量、尿量、出血量，組間比較差異無統(tǒng)計(jì)學(xué)意義（P＞0.05）兩組患者術(shù)中均未輸血，血紅蛋白的量在正常范圍。 (2)檢測指標(biāo) ①組間比較，T0時(shí)兩組患者血漿中IL-8、IL-10、TNF-α的水平差異沒有統(tǒng)計(jì)學(xué)意義。（P＞0.05） ②組間比較，TI、T2、T3時(shí)IPPV組和對照組相比兩組患者的IL-8、IL-10、TNF-α的水平差異沒有統(tǒng)計(jì)學(xué)意義（P＞0.05）。 ③A組患者血漿中的IL-8、IL-10、TNF-α的水平在T0、T1、T2、T3四個(gè)時(shí)間點(diǎn)比較差異有統(tǒng)計(jì)學(xué)意義（P＜0.05），IL-8的水平在T1點(diǎn)比T0點(diǎn)明顯提高，在T2點(diǎn)開始降低，并且在T2、T3的水平明顯低于T0。IL-10的水平在T1點(diǎn)比T0點(diǎn)明顯提高，在T2點(diǎn)開始降低，并且在T2、T3的水平明顯低于T0。TNF-α的水平并沒有明顯的變化趨勢。 ④B組患者血漿中的IL-8、IL-10、TNF-α的水平在T0、T1、T2、T3四個(gè)時(shí)間點(diǎn)比較差異有統(tǒng)計(jì)學(xué)意義（P＜0.05），IL-8的水平在T1點(diǎn)比T0點(diǎn)明顯提高，在T2點(diǎn)開始降低，并且在T2，T3的水平明顯低于T0。IL-10的水平在T1點(diǎn)比T0點(diǎn)明顯提高，在T2點(diǎn)開始降低，并且在T2、T3的水平明顯低于T0。TNF-α的水平并沒有明顯的變化趨勢。 ⑤兩組患者體溫、引流時(shí)間、住院時(shí)間、住院費(fèi)用、心率、血氧飽和度，組間比較差異無統(tǒng)計(jì)學(xué)意義（P＞0.05），引流量和抗生素使用時(shí)間組間比較差異有統(tǒng)計(jì)學(xué)意義（P＜0.05）。 ⑥兩組患者在t0、t1、t2三個(gè)時(shí)間點(diǎn)的動脈血?dú)夥治鰌H、PaCO2、Lac、BE值，通過比較差異均沒有統(tǒng)計(jì)學(xué)意義（P＞0.05）但是PaO2通過比較在t1時(shí)間點(diǎn)差異有統(tǒng)計(jì)學(xué)意義（P0.05）。 結(jié)論：對周圍型肺癌需行開胸手術(shù)的患者，在單肺通氣期間對周圍型肺癌患者非通氣側(cè)肺輔助1.2ml/kg的小潮氣量IPPV既不影響術(shù)者操作又能提高氧分壓，而且對患者術(shù)后恢復(fù)有一定的改善作用，但是對炎性因子沒有影響。
[Abstract]:Objective: this research is to evaluate the effect of single lung ventilation with low tidal volume IPPV side lung assist for peripheral lung cancer patients with thoracic oxygenation and inflammatory factors and postoperative recovery.
Methods: 20 cases randomly selected patients undergoing resection for peripheral lung cancer, aged 45~65 years old, male or female, weight 49~80Kg. patients were ASA grade I-II, preoperative patients without radiotherapy, chemotherapy, and endocrine and immune system diseases, no hormones and immunosuppressive drugs should be used in history, no serious heart liver and kidney dysfunction. The same group of doctors surgery in patients with lung cancer. The patients were randomly divided into the control principle of IPPV group (A group) and control group (B group) were established. Upper extremity venous access in all patients after admission, followed by the radial artery puncture under local anesthesia, intraoperative continuous monitoring of arterial blood pressure. Preoperative 30min intravenous injection of atropine 0.5mg, midazolam 0.05mg/kg. with ECG IntelliVue MP50 multi-function monitor to monitor patients (ECG), pulse oxygen saturation (SpO2), end tidal carbon dioxide partial pressure (PETCO2), after induction of general anesthesia in internal jugular vein indwelling Tube monitoring central venous pressure (CVP). The induction of anesthesia: all patients were treated with fentanyl, etomidate, cisatracurium induced, the dose of fentanyl 2~4 g/kg, etomidate 0.2 ~ 0.3mg/kg, cisatracurium 0.3mg/kg, 3min after insertion of double lumen tube, then by bronchofibroscope location maintenance double lumen tube in normal position, lateral position again with bronchofibroscope location, to ensure good ventilation catheter position. The two group were treated with Datex-Ohmeda7100 anesthesia machine control breathing, double lung ventilation with a tidal volume of 8~10ml/kg, respiratory rate was 12 beats per minute, respiratory ratio is 1:2, during one lung ventilation tidal volume is 6~8ml/kg. The respiratory rate is 15~17 / min, suction call ratio was 1:2, according to the PetCO2 (normal 35~45mmHg) to adjust the respiratory parameters; at the same time, peak airway pressure (Ppeak) monitoring patients, airway pressure (Pplat) platform, the airway pressure is lower than 30 CmH2O. maintain anesthesia with remifentanil and sevoflurane combined anesthesia, inhalation of seven halothane (1 ~ 3%), micro pump infusion of remifentanil in 0.5 ~ 1 g/kg/min. of patients BIS value maintained at 40~60. Intermittent intravenous injection of cisatracurium 0.05mg/kg to maintain muscle relaxation, intraoperative use of muscle relaxation monitoring muscle relaxation. Single lung ventilation in patients of two groups were given 1L/min. fresh gas flow during one lung ventilation, control group lung bronchial catheter directly opening in the air in the natural state of collapse, the operative side bronchial catheter. Datex-Ohameda7100 ventilator test group, fresh gas flow was set 1L/min. respiratory parameters: tidal volume is 1.2ml/kg. The frequency of 15 beats per minute, respiratory ratio of 1:2. conventional fluid infusion of 15ml/kg/h, sodium lactate and sodium chloride hydroxyethyl starch solution by 130/0.4 injection, 2:1 crystal glue to maintain hemodynamics Stable, by adjusting the depth of anesthesia or the use of drugs to mean arterial pressure (MAP) and heart rate (HR) change rate does not exceed the value of the 20%. based autonomous breathing air before anesthesia (T0) when, after pulmonary resection (T1), at the end of one lung ventilation (T2), arterial blood were collected by Cabs type B123 blood gas analyzer was used to measure and record the blood gas analysis pH value, arterial oxygen pressure (PaO2), arterial partial pressure of carbon dioxide (PaCO2), blood lactate (Lac), BE values were recorded at the same time. The heart rate (HR), pulse oxygen saturation (SpO2), mean arterial pressure (MAP), central venous pressure (CVP).
The time of single lung ventilation, operation time, fluid volume, urine volume, bleeding volume and blood transfusion volume were recorded. At the time of immediate intubation (T0), immediately after operation (T1), 24 hours after operation (T2), and 48 hours after operation (T3), the central venous blood 4ml was drawn, and the levels of serum IL-8, IL-10 and TNF- alpha were measured.
Postoperative follow-up: thoracic drainage time, flow rate, extubation time, antibiotic use time, hospitalization time, cost, ICU, life sign, temperature change.
Result錛

本文編號：1516254