本文選題：局部腦氧飽和度 + 呼氣末正壓　； 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：背景和目的胸腔鏡手術(shù)常需單肺通氣(One lung ventilation,OLV),以便將患側(cè)肺與健側(cè)肺分離并提供良好的術(shù)野。隨著社會(huì)老齡化的到來,老年胸腔鏡手術(shù)日益增多。OLV會(huì)對機(jī)體呼吸循環(huán)機(jī)制產(chǎn)生嚴(yán)重的干擾,引起一系列的病理生理改變,如氣道壓升高,通氣血流比例失調(diào),缺氧性肺血管收縮、激活炎癥反應(yīng)等,影響機(jī)體氧合,在老年患者更為明顯。研究表明,OLV可導(dǎo)致局部腦氧飽和度(rSO_2)降低,且rSO_2降低與老年患者術(shù)后認(rèn)知功能障礙(Postoperative cognitive dysfunction,POCD)的發(fā)生有關(guān)。肺保護(hù)性策略(Lung protect ventilation strategy,LPVS)是針對呼吸機(jī)相關(guān)肺損傷,如氣壓傷、容積傷、生物傷、剪切力傷等提出來的。包括PEEP的采用,小潮氣量通氣以及肺復(fù)張策略,最早用于ICU中ARDS患者。研究表明,LPVS可提高ARDS患者的生存率。近些年來,隨著人們對LPVS認(rèn)識的加深,其在全身麻醉病人中的應(yīng)用也逐漸增多。國內(nèi)外有大量研究表明,LPVS可降低全身麻醉病人機(jī)械通氣相關(guān)肺損傷(VILI)發(fā)生率。近年來,有研究認(rèn)為小潮氣量通氣雖然可減輕肺損傷,但可加重肺不張,而PEEP的應(yīng)用對減輕肺不張有重要意義,因此,小潮氣量通氣聯(lián)合適當(dāng)?shù)腜EEP會(huì)是一種很好的通氣方式。研究發(fā)現(xiàn),當(dāng)PEEP在5cm H_2O水平是改善OLV引起的通氣血流比例失調(diào)的最佳水平。也有研究表明,當(dāng)PEEP在5-10cm H_2O時(shí)能最大程度的改善單肺通氣時(shí)機(jī)體氧合。因此,有研究提出,將PEEP在5cm H_2O時(shí)設(shè)定為標(biāo)準(zhǔn)PEEP水平。目前,關(guān)于不同PEEP水平對老年患者OLV期間rSO_2的影響尚不清楚。本研究通過聯(lián)合肺復(fù)張法和PEEP滴定實(shí)驗(yàn)法來確定個(gè)體化PEEP(Individualized PEEP)水平,觀察個(gè)體化PEEP水平與標(biāo)準(zhǔn)PEEP(Standardized PEEP)水平(PEEP為5cm H_2O)對OLV時(shí)rSO_2、肺通氣功能的影響。方法選擇我院2015年11月至2016年2月?lián)衿谛行厍荤R手術(shù)的老年患者46例,年齡65-80歲,ASAⅠ-Ⅲ級,性別不限,無嚴(yán)重心腦血管疾病。采用隨機(jī)數(shù)字表法,將患者隨機(jī)分兩組(n=23),PEEP=5cm H_2O為C組(The Control group)和個(gè)體化PEEP組為S組(The Study group)�；颊呷胧液箝_放靜脈通路,監(jiān)測ECG,心率(HR),血壓(BP),脈搏氧飽和度(Sp O_2),局麻下行橈動(dòng)脈穿刺置管,術(shù)中連續(xù)監(jiān)測動(dòng)脈血壓,與Vigileo監(jiān)護(hù)儀連接,監(jiān)測CI;麻醉誘導(dǎo)后行右側(cè)頸內(nèi)靜脈穿刺置管。采用EGOS-600型近紅外組織血氧參數(shù)監(jiān)測儀(蘇州愛琴生物醫(yī)療電子有限公司)監(jiān)測rSO_2(傳感器電極片粘貼于患者前額眉弓上方,并用不透光的塑料膠貼加以覆蓋以避免周圍光線對測量的影響)。依次靜脈注射依托咪酯0.3-0.4mg/kg,舒芬太尼0.5-1.0μg/kg,順式阿曲庫銨1.5-2.0mg/kg行麻醉誘導(dǎo),在可視喉鏡引導(dǎo)下行雙腔支氣管插管,并用纖維支氣管鏡輔助定位。術(shù)中所有患者使用Leon麻醉機(jī)進(jìn)行機(jī)械通氣,采用容量控制通氣模式,吸入純氧,流量2.0L/min,S組:雙肺通氣時(shí)VT 8ml/kg,吸呼比1:2;OLV時(shí)VT 5-7ml/kg,根據(jù)PEEP滴定實(shí)驗(yàn)法來確定OLV時(shí)PEEP水平,吸呼比1:2;C組:雙肺通氣時(shí)VT 8ml/kg,吸呼比1:2,OLV時(shí)VT 5-7ml/kg,吸呼比1:2,PEEP設(shè)定為5 cm H_2O(1 cm H_2O=0.098 k Pa);兩組均調(diào)節(jié)呼吸頻率,維持PETCO_235-45mm Hg(1 mm Hg=0.133 k Pa),平臺壓(Plateu pressure,Pplat)低于25 cm H_2O。當(dāng)Pplat高于25 cm H_2O時(shí)逐漸減少潮氣量,每次減少1ml/kg,直至Pplat低于25cm H_2O。為了避免OLV過程中低氧血癥的發(fā)生和排除氧濃度對動(dòng)脈血氧分壓測定的影響,術(shù)中均吸入100%純氧。術(shù)中吸入2%七氟醚,持續(xù)靜脈泵注瑞芬太尼0.2-2.0μg·kg-1·min-1,間斷靜脈注射順式阿曲庫銨維持麻醉。維持術(shù)中脈搏氧飽和度Sp O_2≥95%,腦電雙頻譜指數(shù)(Bispectral index,BIS)值維持在40~55。分別于麻醉誘導(dǎo)前T0、側(cè)臥位雙肺通氣5min T1、單肺通氣開始后肺復(fù)張前5min T2、單肺通氣后20min T3、單肺通氣結(jié)束肺復(fù)張前T4、雙肺通氣拔出氣管導(dǎo)管T5記錄各觀察指標(biāo)。觀察指標(biāo):由專門護(hù)理人員于各時(shí)間點(diǎn)取樣進(jìn)行血?dú)夥治?并觀察記錄患者rSO_2、Pa O_2、Pa CO_2、CI值、p H值、最佳PEEP值、氣道平臺壓、肺靜態(tài)順應(yīng)性、氣道阻力。用SPSS17.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差((?)±s)表示。組內(nèi)比較采用重復(fù)測量資料方差分析,組間比較采用成組t檢驗(yàn),以P0.05為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果1.兩組患者一般情況,如年齡、性別、體重、手術(shù)時(shí)間、單肺通氣時(shí)間、ASA分級等比較,差異無統(tǒng)計(jì)學(xué)意義。2.OLV期間,S組患者rSO_2、Pa O_2高于C組患者,差異有統(tǒng)計(jì)學(xué)意義。3.肺靜態(tài)順應(yīng)性:與T1相比,T2時(shí)兩組均下降;肺復(fù)張后,T3、T4時(shí)S組明顯升高,T3時(shí),S組高于C組,差異有統(tǒng)計(jì)學(xué)意義。4.氣道阻力:與T1相比,T2時(shí)兩組均升高,差異無統(tǒng)計(jì)學(xué)意義。結(jié)論1.與PEEP=5cm H_2O相比,個(gè)體化PEEP聯(lián)合肺復(fù)張法可明顯改善老年患者OLV時(shí)rSO_2。2.與PEEP=5cm H_2O相比,個(gè)體化PEEP聯(lián)合肺復(fù)張法可明顯提高老年患者OLV時(shí)肺順應(yīng)性,降低氣道阻力,減輕肺損傷。
[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.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R614

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7 藍(lán)嵐;單肺通氣時(shí)間對肺損傷的影響[D];南方醫(yī)科大學(xué);2012年

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10 劉睿;七氟醚抗單肺通氣致急性肺損傷保護(hù)作用機(jī)制[D];昆明醫(yī)科大學(xué);2013年

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