本文選題：呼氣末二氧化碳分壓 + 動脈二氧化碳分壓��； 參考：《南方醫(yī)科大學(xué)》2014年碩士論文

【摘要】：單肺通氣(one-lung ventilation, OLV)可以使手術(shù)側(cè)肺萎陷,提供良好的視野和手術(shù)條件,同時可以防治手術(shù)側(cè)血液及分泌物進(jìn)入非手術(shù)側(cè),避免造成健側(cè)肺部交叉感染,實(shí)現(xiàn)雙肺隔離,是胸科手術(shù)麻醉確保患者安全和手術(shù)順利進(jìn)行的重要組成部分。但OLV易因雙腔管位置不良影響通氣、雙肺的通氣血流比失衡、肺本身的病變等引起氧合不良造成低氧血癥,同時OLV這種非生理性的機(jī)械通氣較雙肺通氣更容易引起或加重呼吸相關(guān)性肺損傷(ventilator associated lung injury,VALI)。OLV除可能產(chǎn)生嚴(yán)重低氧血癥及VALI外,PaCO2呈增高趨勢,易致CO2蓄積,因此術(shù)中C02的監(jiān)測顯得尤為重要。PetCO2是呼吸周期中測定的C02的最高值,可代表肺泡氣的二氧化碳分壓(PCO2),因此肺泡氣的PCO2與PaCO2很接近。目前的研究認(rèn)為在雙肺通氣血流動力學(xué)穩(wěn)定下監(jiān)測PetCO2可以反映PaCO2的變化,PetCO2與PaCO2具有良好相關(guān)性,但缺乏對OLV不同血壓時PaCO2與PetCO2相關(guān)性的研究報(bào)道。 目的探討胸科手術(shù)單肺通氣(OLV)期不同血壓對動脈-呼氣末二氧化碳分壓差「(Pa-et)CO2」及對肺內(nèi)分流(Qs/Qt)的影響。 方法選擇行右肺葉手術(shù)需行左OLV患者42例,年齡18-65歲,男32例,女10例。ASA工或Ⅱ級。所有患者無心、肝、腎疾患,無高血壓病史,肺功能基本正常,無手術(shù)史。 患者術(shù)前均肌注阿托品注射液0.5mg。入室后行心率(HR)、血壓(Bp)、脈搏血氧飽和度(Sp02)及腦電雙頻譜指數(shù)(BIS)監(jiān)測。局麻下行足背動脈穿刺置管連續(xù)監(jiān)測直接動脈壓。麻醉誘導(dǎo)：靜脈注射力月西0.05mg/kg后,啟動血漿靶控輸注丙泊酚3-4ug/ml瑞芬太尼4ng/ml,患者入睡后給予順阿曲庫銨0.2mg/kg。根據(jù)患者X線后前位胸片鎖骨胸骨端氣管內(nèi)徑測量值預(yù)先選定的Mallinckrodt左雙腔支氣管導(dǎo)管的型號,經(jīng)口明視插管,插管后常規(guī)用纖支鏡定位。用帶心電監(jiān)測的中心靜脈導(dǎo)管行右頸內(nèi)靜脈穿刺置管術(shù),確認(rèn)中心靜脈導(dǎo)管進(jìn)入右心房。 靶控輸注瑞芬太尼(2-6ng/ml)和丙泊酚(2-5ug/ml)維持麻醉,使BIS值維持在40-60之間,術(shù)中按需追加舒芬太尼及順阿曲庫銨。插管后接麻醉呼吸機(jī)行間歇正壓通氣(IPPV),TLV時均采用潮氣量(VT)6-8ml/kg,呼吸頻率12次/分,吸呼比(I：E)1：2,吸入氧濃度(Fi02)50%。OLV后VT5-7ml/kg,呼吸頻率13-15次/分,開始吸入氧濃度(Fi02)100%,待Sp02100%后,調(diào)整Fi02為60%,維持分鐘通氣量相等。OLV期間,非通氣側(cè)肺的支氣管導(dǎo)管均直接開口于大氣中。按OLV20min后平均動脈壓(MAP)在基礎(chǔ)值±10%以內(nèi)為A組(22例),MAP低于基礎(chǔ)值30%為B組(20例)。 麻醉誘導(dǎo)插管后用監(jiān)護(hù)儀主流型C02紅外分析法監(jiān)鋇PetCO2,在每次使用前均用空氣調(diào)零；PaCO2用血?dú)夥治鰞x監(jiān)測,分別在誘導(dǎo)插管后TLV20min(T1),OLV肺完全萎陷后20min(T2),B組MAP恢復(fù)到基礎(chǔ)值±10%后30min(T3),恢復(fù)TLV20min(T4)等時間點(diǎn)采集動脈血及中心靜脈血1ml行血?dú)夥治�。在以上時間點(diǎn)記錄SpO2,HR, MAP,BIS,PetCO2等。計(jì)算各時間點(diǎn)動脈-呼氣末二氧化碳分壓差「(Pa-et) CO2」及Qs/Qt。根據(jù)肺血流分布標(biāo)準(zhǔn)三室模型計(jì)算Qs/Qt,Qs/Qt=(CcO2-Ca O2)/(CcO2-CvO2)×100%。 采用SPSS13.0軟件進(jìn)行統(tǒng)計(jì)分析,計(jì)量數(shù)據(jù)以均數(shù)±標(biāo)準(zhǔn)差表示,各組間各時間點(diǎn)PetC02的比較與各組間各時間點(diǎn)PaCO2的比較用方差分析,各組內(nèi)相同時間點(diǎn)PetCO2與PaCO2及「(Pa-et) CO2」與Qs/Qt的相關(guān)性分析采用pearson相關(guān)性分析。P0.05為差異有統(tǒng)計(jì)學(xué)意義。 結(jié)果 1.二組患者的一般資料性別比、年齡、體重和OLV時間無差異(P0.05)。 2.A組患者PetC02與PaC02在OLV與TLV時均密切相關(guān)(P0.05),相關(guān)系數(shù)r值分別為0.93、0.87、0.88；B組各時間點(diǎn)PetC02與PaC02相關(guān)系數(shù)r值分別為0.91、0.75、0.89及0.97。B組T2時期PetC02為31.0±2.9mmHg,較A組同一時點(diǎn)(34.2±2.5mmHg)低；B組T2時期「(Pa-et)C02」為7.8±2.2mmHg,與A組同一時點(diǎn)(3.2±1.5mmHg)比較明顯增大(P0.05)；B組T3時期與A組T2時期「(Pa-et)C02」無明顯差異(P0.05)；B組低血壓期間PetC02與PaC02仍具有相關(guān)性(P0.05),相關(guān)系數(shù)r值為0.75。 3.OLV與TLV比較,二組Qs/Qt均增加。A組TLV時Qs/Qt為1.5±1.4%,OLV時上升為9.4±4.9%,恢復(fù)TLV后為2.1±2.0%；B組TLV時Qs/Qt為1.6±0.9%,OLV低血壓時上升為11.9±6.0%,OLV血壓恢復(fù)時為10.7±6.2%,恢復(fù)TLV后為2.0±1.5%。B組T2時期Qs/Qt高于A組T2時期(P0.05)。在觀察時間內(nèi),OLV期「(Pa-et)CO2」與(Qs/Qt)沒有相關(guān)性(P0.05)。 結(jié)論 1.行右肺葉手術(shù)肺功能基本正常的患者,術(shù)中左單肺通氣期間,血流動力學(xué)穩(wěn)定時PetC02與PaC02相關(guān)性好(r=0.87)；低血壓期間,「(Pa-et)CO2」明顯增大,PetC02雖然能反映PaC02(r=0.75)的變化趨勢,但準(zhǔn)確性不如正常血壓時。 2.單肺通氣肺內(nèi)分流增加,低血壓期肺內(nèi)分流增加更明顯。肺內(nèi)分流對「(Pa-et)CO2」影響不大。
[Abstract]:Single lung ventilation (one-lung ventilation, OLV) can make the operation side of the lung collapse, provide good vision and operation conditions, and can prevent the blood and secretion of the operative side into the non operative side, avoid the cross infection of the healthy side of the lung, and realize the double lung isolation. It is an important component of the safety and operation of the thoracic surgery to ensure the safety of the patients and the operation. Part. But OLV is easily affected by the bad position of the double lumen tube, the air flow ratio of the two lungs is unbalance, the lung itself causes the hypoxia to cause hypoxemia. At the same time, the non physiological mechanical ventilation of OLV is more likely to cause or aggravate the respiratory associated lung injury (ventilator associated lung injury, VALI) than the double lung ventilation (VALI).OLV In addition to the occurrence of severe hypoxemia and VALI, the trend of PaCO2 is increasing, and CO2 accumulates easily. Therefore, the monitoring of C02 in the operation is particularly important for the.PetCO2 is the highest value of C02 measured in the respiratory cycle, and can represent the partial pressure of carbon dioxide (PCO2) of the alveolar gas (PCO2). Therefore, the PCO2 of the alveolar gas is very close to PaCO2. Under mechanical stability, monitoring PetCO2 can reflect the changes of PaCO2. PetCO2 and PaCO2 have good correlation, but there is no research report on the correlation between PaCO2 and PetCO2 at different blood pressure of OLV.
Objective to investigate the effect of different blood pressure on the end expiratory carbon dioxide partial pressure (Pa-et) CO2 and the intrapulmonary shunt (Qs/Qt) in thoracic surgery with one lung ventilation (OLV).
Methods 42 patients with left OLV were selected for right lobectomy. Age 18-65, male 32, female 10,.ASA or class II. All patients were careless, liver, kidney disease, no history of hypertension, normal lung function and no history of operation.
The heart rate (HR), blood pressure (Bp), pulse oxygen saturation (Sp02) and electroencephalogram index (BIS) were monitored before the intramuscular injection of atropine injection 0.5mg.. The direct arterial pressure was continuously monitored by the puncture and catheterization of the foot dorsal artery under local anesthesia. Anesthesia induction: after the intravenous force month West 0.05mg/kg, the plasma target controlled infusion of propofol 3-4ug/ml Rui was started. Fentanyl 4ng/ml, patients with CIS atracurium 0.2mg/kg. were given a pre selected Mallinckrodt left double lumen bronchial tube based on the measured value of the endotracheal endotracheal diameter of the clavicular sternum at the front of the chest X-ray of the patient's chest X-ray. The intubation was performed through the oral intubation, and the routine bronchoscopy was used after intubation. The right internal jugular vein was performed with a central venous catheter with ECG monitoring. Puncture catheterization was performed to confirm the central venous catheter entering the right atrium.
The target controlled infusion of remifentanil (2-6ng/ml) and propofol (2-5ug/ml) maintained the anesthesia and maintained the BIS value between 40-60 and sufentanil and cisatracurium on demand. After the intubation, the anesthesia ventilator interbed positive pressure ventilation (IPPV) was inserted after the intubation. The tidal volume (VT) 6-8ml/kg, respiratory frequency 12 / fraction, respiratory rate (I:E) 1:2, and inhaled oxygen concentration were used in TLV. (Fi02) after 50%.OLV VT5-7ml/kg, the respiratory rate was 13-15 / sub, and the inhalation oxygen concentration (Fi02) was 100%. After Sp02100%, the Fi02 was adjusted to 60% and the minute ventilation was equal to.OLV, the non ventilated lung bronchoducts were directly open in the atmosphere. The average arterial pressure (MAP) after OLV20min was in the A group (22 cases) and MAP below the base. The base value of 30% was group B (20 cases).
After the anesthesia induction, the main stream C02 infrared analysis method was used to monitor barium PetCO2, and the air was adjusted to zero before each use. PaCO2 was monitored by blood gas analyzer, TLV20min (T1) after induction of intubation, 20min (T2) after OLV lung was completely collapsed, MAP of B group recovered to 30min (T3) after the base value of + 10%. SpO2, HR, MAP, BIS, PetCO2, etc. were recorded at the point of time of the central venous blood. The differential pressure difference "(Pa-et) CO2" and Qs/Qt. in each time point were calculated and Qs/Qt. based on the standard three compartment model of the pulmonary blood flow distribution, Qs/Qt, Qs/Qt= (CcO2-Ca) / 1ml
Statistical analysis was carried out with SPSS13.0 software, and the measurement data were expressed with mean standard deviation. The comparison of PetC02 in each time point between each group and the PaCO2 of each time point between each group was analyzed by variance. The correlation analysis of the same time point PetCO2 and PaCO2 and the correlation analysis of (Pa-et) CO2 with Qs/Qt using Pearson correlation analysis.P0.05 was the difference between each group Statistical significance.
Result
1. there was no difference in the sex ratio, age, weight and OLV time between the two groups (P0.05).
In group 2.A, both PetC02 and PaC02 were closely related to OLV and TLV (P0.05), and the correlation coefficient r value was 0.93,0.87,0.88, and the PetC02 and PaC02 correlation coefficient r values of B group at each time point were respectively 31 +, compared with the same time point (34.2 +). Hg, the same time point (3.2 + 1.5mmHg) in group A was significantly increased (P0.05), and there was no significant difference between B group T3 period and A group T2 period (Pa-et) C02.
Compared with TLV, the two groups of Qs/Qt increased the TLV of the.A group, Qs/Qt was 1.5 + 1.4%, OLV increased to 9.4 + 4.9%, and TLV was 2.1 + 2%, B group TLV Qs/Qt was 1.6 + 0.9%, OLV hypotension was 11.9 + 6%. There was no correlation between OLV (Pa-et) CO2 and Qs/Qt (P0.05).
conclusion
In 1. lines of right pulmonary lobectomy, the patients with normal lung function, during the course of left single lung ventilation during the operation, the correlation of PetC02 and PaC02 was good (r=0.87). During the period of hypotension, "(Pa-et) CO2" was obviously increased, and PetC02 could reflect the change trend of PaC02 (r=0.75), but the accuracy was not as good as normal blood pressure.
2. there was an increase in intrapulmonary shunt in one lung ventilation, and increased in intrapulmonary shunt during hypotension. Pulmonary shunt had little effect on (Pa-et) CO2.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R614

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