本文選題：CO_2人工氣胸　切入點(diǎn)：機(jī)械通氣相關(guān)性肺損傷　出處：《鄭州大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：背景與目的機(jī)械通氣是保證全麻患者正常生命活動(dòng)最基本的一項(xiàng)醫(yī)療技術(shù),在給予患者呼吸支持,改善通氣狀態(tài),促進(jìn)機(jī)體氧合,防止缺氧和CO_2蓄積具有不可代替的作用。但是不合理的機(jī)械通氣會(huì)改變患者正常肺組織的結(jié)構(gòu)和功能,造成機(jī)械通氣相關(guān)性肺損傷(ventilator-associated lung injury,VALI),增加了患者肺部等并發(fā)癥的發(fā)生率,影響機(jī)體預(yù)后。作為國(guó)內(nèi)常見惡性腫瘤之一的食管癌,目前最有效的治療方法是外科手術(shù)切除,傳統(tǒng)的開胸食管癌根治術(shù)對(duì)患者的創(chuàng)傷比較大,尤其是老年患者術(shù)后其并發(fā)癥發(fā)生率較高,患者恢復(fù)較為緩慢。近些年隨著微創(chuàng)外科技術(shù)的大力發(fā)展,電視輔助胸腔鏡(video assisted thoracoscopic suigery,VATS)食管癌根治術(shù)因其術(shù)中創(chuàng)傷小,術(shù)后疼痛輕,患者康復(fù)快越來越受到患者和外科醫(yī)生的青睞。然而,傳統(tǒng)胸腔鏡食管癌根治術(shù)患者多采用雙腔氣管插管單肺通氣麻醉,雙腔管不僅存在對(duì)位不良、反復(fù)調(diào)試易損傷氣道、插管技術(shù)要求高和費(fèi)用昂貴等問題,還存在部分患者術(shù)中出現(xiàn)低氧血癥,不能長(zhǎng)時(shí)間耐受單肺通氣狀態(tài)。近些年人工CO_2氣胸單腔插管麻醉用于全腔鏡食管癌根治術(shù)得到快速發(fā)展,人工CO_2氣胸單腔插管成為繼傳統(tǒng)的單腔支氣管導(dǎo)管、雙腔支氣管導(dǎo)管和支氣管封堵器又一新型技術(shù),其原理是人工向胸膜腔內(nèi)持續(xù)注入CO_2氣體并控制其流速,使胸膜腔內(nèi)維持在一定正壓水平,達(dá)到肺萎陷和手術(shù)術(shù)野暴露的目的。Flotrac/Vigileo監(jiān)測(cè)系統(tǒng)具有微創(chuàng)、操作簡(jiǎn)單、并發(fā)癥少的優(yōu)點(diǎn),可以通過分析外周動(dòng)脈壓力波形信息連續(xù)計(jì)算CO、SV、CI、SVV等血流動(dòng)力學(xué)指標(biāo),并能通過中心靜脈壓和動(dòng)脈血?dú)庀嚓P(guān)數(shù)值衍生計(jì)算出氧輸送指數(shù)(DO_2I)等數(shù)值,近年來在病情變化快、需要連續(xù)血流動(dòng)力學(xué)監(jiān)測(cè)的患者中應(yīng)用日益廣泛。保護(hù)性肺通氣策略(lung protective ventilation strategy,LPVS)通常是指采取基于理想體重的小潮氣量(VT)通氣、選擇適宜的呼氣末正壓(PEEP)、降低吸入氧濃度、限制一定的平臺(tái)壓(Pplat)和容許合適范圍內(nèi)高碳酸血癥等措施的一項(xiàng)麻醉技術(shù),然而LPVS對(duì)于人工CO_2氣胸單腔插管全腔鏡食管癌根治術(shù)患者的肺保護(hù)方面尚未見相關(guān)文獻(xiàn)報(bào)道。本研究主要探討LPVS對(duì)人工CO_2氣胸單腔插管全腔鏡下行食管癌根治術(shù)的患者肺功能及肺部并發(fā)癥方面的影響,并探討基于Flo Trac/Vigileo血流動(dòng)力學(xué)及呼吸功能監(jiān)測(cè)下如何選取最佳的PEEP值,以起到對(duì)患者更好的肺保護(hù)作用。材料與方法擇期行電視輔助胸腔鏡食管癌根治術(shù)患者300例,將患者隨機(jī)分成六組:V0組、V1組、V2組、V3組、V4組和V5組,六組患者皆采取小潮氣量通氣,VT均設(shè)置為5ml/kg,吸入氧濃度(Fi O2=0.6),術(shù)中維持PETCO_2≤55mm Hg,設(shè)置V0組PEEP=0cm H_2O,V1組PEEP=2cm H_2O,V2組PEEP=4cm H_2O,V3組PEEP=6cm H_2O,V4組PEEP=8cm H_2O,V5組PEEP=10cm H_2O。分別于麻醉誘導(dǎo)后改左側(cè)臥位(T0)、建立CO_2氣胸60min(T1)抽取患者動(dòng)脈血?dú)?并記錄相同時(shí)刻患者Pplat、肺順應(yīng)性(CL),心指數(shù)(CI)、每搏變異度(SVV)、氧輸送指數(shù)(DO_2I)、呼出氣冷凝液pH值和術(shù)畢拔出氣管導(dǎo)管時(shí)間、并根據(jù)相應(yīng)的時(shí)間點(diǎn)記錄數(shù)值計(jì)算患者肺內(nèi)分流率(Qs/Qt)、死腔率(Vd/Vt)和呼吸指數(shù)(RI),術(shù)后一天訪視病人,抽取其動(dòng)脈血檢測(cè)并計(jì)算RI,記錄患者肺部并發(fā)癥的發(fā)生率、轉(zhuǎn)入ICU的發(fā)生率及住院時(shí)長(zhǎng)。統(tǒng)計(jì)學(xué)分析采用SPSS 21.0統(tǒng)計(jì)軟件進(jìn)行分析。對(duì)于符合正態(tài)分布的定量資料以均數(shù)±標(biāo)準(zhǔn)差((?)±s)表示,兩組間的比較行獨(dú)立樣本t檢驗(yàn);多組間的比較運(yùn)用單因素方差分析。定性資料比較采取X2檢驗(yàn)。顯著性檢驗(yàn)水準(zhǔn)取α=0.05。結(jié)果1六組患者術(shù)中Qs/Qt、Vd/Vt、RI、CL比較與T0時(shí)相比,六組患者T1時(shí)Qs/Qt、Vd/Vt、RI顯著上升(P0.05),CL顯著降低(P0.05)。與V0組相比,T1時(shí)V3、V4、V5組Qs/Qt、Vd/Vt、RI均降低,CL增加,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。與V0組相比,T1時(shí)V1、V2組Qs/Qt、Vd/Vt、RI、CL差異均不明顯(P0.05),T1時(shí)V3、V4和V5組間Qs/Qt、Vd/Vt、RI、CL差異均不明顯(P0.05)。2六組患者術(shù)中CI、SVV、DO_2I比較與T0時(shí)相比,六組患者T1時(shí)CI、DO_2I明顯降低(P0.05),SVV明顯上升(P0.05)。與V0組相比,T1時(shí)V3、V4、V5組DO_2I升高(P0.05),V5組CI降低、SVV升高(P0.05)。與V0組相比,T1時(shí)V1、V2組CI、SVV、DO_2I差異均不明顯(P0.05)。與V0組相比,T1時(shí)V3、V4組CI、SVV差異均不明顯(P0.05),T1時(shí)V3、V4和V5組間CI、SVV、DO_2I差異均不明顯(P0.05)。3六組患者術(shù)中Pplat比較與T0時(shí)相比,T1時(shí)六組患者Pplat均明顯上升(P0.05)。與V0組相比,T1時(shí)V5組Pplat上升明顯(P0.05)。與V0組相比,T1時(shí)V1、V2、V3、V4組Pplat差異無統(tǒng)計(jì)學(xué)意義(P0.05),T1時(shí)V3、V4和V5組間Pplat差異均不明顯(P0.05)。4六組患者術(shù)中呼出氣冷凝液p H值比較與T0時(shí)相比,T1時(shí)六組患者呼出氣冷凝液p H值均明顯降低(P0.05)。與V0組相比,T1時(shí)V3、V4、V5組呼出氣冷凝液p H值增高(P0.05)。與V0組相比,T1時(shí)V1、V2組呼出氣冷凝液p H值差異無統(tǒng)計(jì)學(xué)意義(P0.05),T1時(shí)V3、V4和V5組間呼出氣冷凝液p H值差異均不明顯(P0.05)。5六組患者氣管導(dǎo)管拔除時(shí)間及其術(shù)后24h RI值比較與V0組相比,V3、V4、V5組氣管導(dǎo)管拔除時(shí)間明顯縮短(P0.05)、術(shù)后24h RI明顯降低(P0.05)。與V0組相比,V1、V2組氣管導(dǎo)管拔除時(shí)間、術(shù)后24h RI差異無統(tǒng)計(jì)學(xué)意義(P0.05),T1時(shí)V3、V4和V5組間氣管導(dǎo)管拔除時(shí)間及術(shù)后24h RI差異均不明顯(P0.05)。6六組患者術(shù)后肺部并發(fā)癥發(fā)生率及嚴(yán)重程度比較與V0組相比,V3、V4、V5組術(shù)后肺部并發(fā)癥發(fā)生率、住院時(shí)長(zhǎng)明顯降低(P0.05);與V0組相比,V1、V2組術(shù)后肺部并發(fā)癥發(fā)生率、住院時(shí)長(zhǎng)差異無統(tǒng)計(jì)學(xué)意義(P0.05),T1時(shí)V3、V4和V5組間術(shù)后肺部并發(fā)癥發(fā)生率及住院時(shí)長(zhǎng)差異均不明顯(P0.05)。V0組入住ICU3例、V1與V2組均為2例,V3、V4、V5組均未發(fā)現(xiàn)入住ICU病例。結(jié)論人工CO_2氣胸單腔插管全腔鏡食管癌根治術(shù)患者術(shù)中設(shè)置PEEP值6~8cm H_2O較為合適,能顯著改善患者術(shù)中氧合狀態(tài)及加速術(shù)后康復(fù),并對(duì)術(shù)中血流動(dòng)力學(xué)影響較小。
[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緇凱EEP=10cm H_2O.鍒嗗埆浜庨夯閱夎瀵煎悗鏀瑰乏渚у崸浣，

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