本文選題：食管癌 + 單肺通氣　； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:食管癌開(kāi)左胸手術(shù)中,在支氣管封堵管(BB)下進(jìn)行單肺通氣,參照Campos肺萎陷和手術(shù)野的評(píng)估方法[1]和雙腔管下肺萎陷和手術(shù)野的評(píng)估方法[2],計(jì)算應(yīng)用支氣管封堵器技術(shù)開(kāi)左側(cè)胸肺萎陷分級(jí)的百分比,便于指導(dǎo)臨床評(píng)估開(kāi)胸手術(shù)患側(cè)肺萎陷程度。方法:由于Campos分級(jí)是術(shù)側(cè)肺自然萎陷狀態(tài)下的評(píng)估。雙腔管下分級(jí)是對(duì)術(shù)側(cè)肺進(jìn)行小潮氣量通氣,經(jīng)過(guò)干預(yù)后,根據(jù)術(shù)者對(duì)手術(shù)野暴露的滿意度以及是否影響手術(shù)操作的評(píng)估分級(jí)的定義:Ⅰ級(jí)術(shù)側(cè)肺基本萎陷,不經(jīng)過(guò)干預(yù)后手術(shù)野暴露滿意,不影響手術(shù)操作。Ⅱ級(jí)術(shù)側(cè)肺部分萎陷,經(jīng)過(guò)干預(yù)后手術(shù)野暴露可,但不影響手術(shù)操作。Ⅲ級(jí)術(shù)側(cè)肺萎陷差,經(jīng)過(guò)干預(yù)后仍嚴(yán)重影響手術(shù)野暴露,手術(shù)無(wú)法進(jìn)行。支氣管封堵技術(shù)下分級(jí)是對(duì)支氣管封堵管中心導(dǎo)管進(jìn)行小潮氣量通氣,經(jīng)過(guò)氧氣通氣干預(yù)后,根據(jù)術(shù)者對(duì)手術(shù)野暴露的滿意度以及是否影響手術(shù)操作的評(píng)估,分級(jí)的定義如雙腔管分級(jí)。隨機(jī)選取同一組手術(shù)醫(yī)生2016年2月至2016年10月?lián)衿诘?0例食管癌患者,男女不限,體重為49~80kg,身高155~175cm,全部選擇開(kāi)左胸食管癌根治術(shù)。ASA分級(jí)為Ⅰ~Ⅱ級(jí),術(shù)前心電圖、心臟超聲以及肺功能檢查未見(jiàn)異常,依據(jù)肺功能報(bào)告,記載患者預(yù)計(jì)肺總量,近期無(wú)上呼吸道感染,血常規(guī)和生化檢查無(wú)明顯異常,既往體健,無(wú)系統(tǒng)疾病。根據(jù)研究需要隨機(jī)分三組:A組(n1=20)、B組(n2=20)和C組(n3=20)�；颊弑凰腿胧中g(shù)室,完善三方核對(duì),手術(shù)室護(hù)士建立外周液路,切皮前30min,戊乙奎醚1mg和咪達(dá)唑侖0.05mg/kg入壺。用IntelliVue MP50監(jiān)護(hù)儀記錄其脈搏血氧飽和度(SpO2)和心電圖(ECG),2%利多卡因局麻后進(jìn)行有創(chuàng)穿刺,包括深靜脈和橈動(dòng)脈,記錄CVP和ABP,進(jìn)行術(shù)前吸空氣的動(dòng)脈血?dú)夥治�。面罩�?00%純氧吸入,增加氧儲(chǔ)備,靜脈注射舒芬太尼0.2~0.4μg/kg,依托咪酯0.2~0.3mg/kg,患者入睡后推注順式阿曲庫(kù)銨0.3mg/kg,輔助呼吸和面罩人工通氣5min后由同一高年資麻醉醫(yī)生經(jīng)口明視插入7.5~8.0號(hào)單腔氣管導(dǎo)管,固定單腔氣管導(dǎo)管,然后經(jīng)單腔管置入支氣管封堵管,置入左主支氣管。先用聽(tīng)診法檢查封堵管套囊對(duì)位是否良好,再用纖維支氣管鏡檢查,確定對(duì)位良好,同時(shí)檢查氣道情況,確保通暢。固定支氣管封堵管,進(jìn)行雙肺通氣。用datex-ohmeda7100呼吸機(jī)控制呼吸以及監(jiān)測(cè)氣道平臺(tái)壓(pplat)和氣道峰壓(ppeak)、呼末二氧化碳分壓(petco2)。術(shù)中麻醉采用瑞芬太尼-七氟烷靜吸復(fù)合麻醉維持,微量泵瑞芬太尼(0.5~1μg/kg/min)和吸入七氟烷(1~3%),每半小時(shí)靜推順式阿曲庫(kù)銨0.05mg/kg。進(jìn)胸前雙肺通氣,呼吸參數(shù)設(shè)定為:潮氣量(vt)8ml/kg,呼吸頻率(f)12次/分,吸呼比(i:e)1:2。進(jìn)胸后改為單肺通氣模式,呼吸參數(shù)設(shè)定:潮氣量為6ml/kg,呼吸頻率15次/分,吸呼比1:2。在左側(cè)肺完全萎陷后,手術(shù)進(jìn)行到過(guò)主動(dòng)脈弓階段時(shí)給予注入氧氣(濃度0.8)干預(yù)(附圖),使b組和c組分別達(dá)到肺萎陷程度分級(jí)的Ⅱ級(jí)和Ⅲ級(jí)(附圖),記錄下此時(shí)的注氣總量(v1,v2),給予小潮氣量1ml/kg維持萎限程度。同時(shí)抽血?dú)庥涗沺h,肺泡動(dòng)脈氧分壓差(a-ado2),動(dòng)脈血氧分壓(pao2),二氧化碳分壓(paco2)。并記錄三組的有創(chuàng)動(dòng)脈壓(abp)、中心靜脈壓(cvp)、心率(hr)和脈搏氧飽和度(spo2)。記錄術(shù)后2天內(nèi)聲音嘶啞、咽痛的發(fā)生例數(shù),和術(shù)后7天內(nèi)肺部發(fā)生感染的例數(shù)。結(jié)果:1基本情況:三組患者的性別、年齡、體重、身高、術(shù)前pao2、fvc、fev1/fvc(%)、dlco、單肺通氣時(shí)間、手術(shù)時(shí)間、血紅蛋白含量、手術(shù)中補(bǔ)液量、術(shù)中尿量,差異均無(wú)統(tǒng)計(jì)學(xué)意義(p0.05)。2與a組比較,b組和c組患者的血?dú)夥治鲋衟h值,動(dòng)脈血二氧化碳分壓(paco2),心率(hr),平均動(dòng)脈壓(mbp),中心靜脈壓(cvp)的差異沒(méi)有統(tǒng)計(jì)學(xué)意義(p0.05)。3與a組比較,b組和c組患者的pao2和a-ado2差異有統(tǒng)計(jì)學(xué)意義(p0.05)。4與b組比較,c組患者的pao2和a-ado2的差異沒(méi)有統(tǒng)計(jì)學(xué)意義(p0.05)。5a組的萎陷程度為100%,b組萎陷程度為80.2%,c組萎陷程度為72.2%,6 ABC三組開(kāi)左胸側(cè)肺萎陷程度的差異有統(tǒng)計(jì)學(xué)意義(P0.05)。7 ABC三組患者術(shù)后2天內(nèi)聲音嘶啞、咽痛的發(fā)生情況,和術(shù)后7天內(nèi)肺部發(fā)生感染的情況無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:行左開(kāi)胸食管癌根治術(shù)時(shí),術(shù)側(cè)肺通過(guò)不同程度的膨脹,能夠提高動(dòng)脈氧分壓,降低低氧血癥等并發(fā)癥,保證手術(shù)的順利進(jìn)行。左側(cè)肺的萎陷分別為Ⅰ級(jí)萎陷100%~80.2%,Ⅱ級(jí)萎陷80.2%~72.2%,Ⅲ級(jí)萎陷低于72.2%。同時(shí),肺萎陷程度在80.2%的情況下既不影響患者的血流動(dòng)力學(xué)又不干擾手術(shù)操作。術(shù)后聲音嘶啞、咽痛和肺部發(fā)生感染等并發(fā)癥的發(fā)生率比雙腔管低。
[Abstract]:Objective: during the operation of the left thoracic surgery for esophageal cancer, single lung ventilation was carried out under the bronchial plugging tube (BB). The evaluation method of Campos lung collapse and surgical field, [1] and the evaluation method of the pulmonary collapse and surgical field of the double lumen tube, [2], were used to calculate the percentage of the classification of the left thoracic lung collapse with the application of the bronchial occluder technique, so as to guide the clinical evaluation of the thoracotomy hands. Method: the degree of lung collapse in the side of the operation. The Campos classification is an assessment of the natural collapse of the lung. The sub lumen tube classification is a small tidal volume ventilation for the lateral lung. The operation field was satisfactorily exposed to the operation. The operation was not affected by the operation. The second stage of the lung was partly collapsed, and the operation field was exposed after intervention, but it did not affect the operation. After low tidal volume ventilation, after oxygen ventilation, according to the satisfaction of surgical field exposure and the evaluation of surgical operation, the classification was defined as a double lumen tube classification. 60 cases of esophageal cancer who were selected by the same group of surgeons from February 2016 to October 2016 were selected randomly, the weight was 49~80kg, and the height was 155~1. 75cm, all selected open left thoracic esophagus cancer radical operation.ASA grade I to grade I ~ II, before the operation electrocardiogram, echocardiography and lung function examination no abnormal, according to the lung function report, record the patient's estimated lung total, no upper respiratory tract infection, blood routine and biochemical examination no obvious abnormalities, previous body health, no systemic disease. According to the research needs The patients were divided into three groups: group A (n1=20), group B (n2=20) and C group (n3=20). The patients were sent to the operation room to perfect the three party check. The nurses in the operation room set up the peripheral liquid, 30min before cutting the skin, the amyl quetidine 1mg and midazolam 0.05mg/kg into the pot. The pulse oxygen saturation (SpO2) and electrocardiogram were recorded with IntelliVue MP50 monitor, and 2% lidocaine local anesthesia was followed. Invasive puncture, including deep vein and radial artery, CVP and ABP, arterial blood gas analysis before operation, 100% pure oxygen inhalation under mask, increased oxygen reserve, intravenous injection of sufentanil 0.2~0.4 mu g/kg, etomidate 0.2~0.3mg/kg, patients after falling asleep, followed by CIS atracurium 0.3mg/kg, assisted breathing and mask artificial ventilation 5min after 5min The same senior anaesthetized anesthesiologist inserted the single lumen tracheal tube of 7.5~8.0, fixed a single lumen tracheal tube, and then inserted the single lumen tube into the bronchial tube and placed the left main bronchus. First, the auscultation method was used to check the position of the closure of the trachea well, and then the bronchoscopy was used to determine the good position, and the airway was checked, and the airway situation was confirmed. Keep the bronchus blocked and double lung ventilation, control breathing with datex-ohmeda7100 respirator, airway pressure (pplat) and airway peak pressure (ppeak), end of the respiratory pressure (PetCO2). Intraoperative anesthesia was maintained by remifentanil - seven fluoroalkanes combined anesthesia, micro Reventa Ni (0.5~1, g/kg/min) and inhalation seven Halothane (1~3%) was injected into the chest with 0.05mg/kg. per half hour. The parameters of respiratory parameters were as follows: tidal volume (VT) 8ml/kg, respiratory frequency (f) 12 / sub, i:e 1:2. into the chest and the single lung ventilation mode, and the breathing parameters were set: the tidal volume was 6ml/kg, the respiratory rate was 15 times per cent, and the respiratory rate was completely collapsing in the left lung. After the operation, the oxygen (0.8) was injected into the aortic arch (0.8), and the group of C and the group of the group of B and C were divided into grade II and grade III (attached map) respectively, and the total gas injection (V1, V2) was recorded at this time, and the small tidal volume 1ml/kg was maintained. Meanwhile, the blood gas was recorded and the oxygen differential of alveolar artery (A-aDO2) was recorded. Arterial oxygen pressure (PaO2), carbon dioxide pressure (PaCO2) and three groups of invasive arterial pressure (ABP), central venous pressure (CVP), heart rate (HR) and pulse oxygen saturation (SpO2). The number of cases of hoarseness, sore pain within 2 days after operation, and cases of pulmonary infection within 7 days after the operation were recorded. Results: 1 basic cases: the sex, age, age, and sex of the three groups of patients. Weight, height, preoperative PaO2, FVC, fev1/fvc (%), DLCO, single lung ventilation time, operation time, hemoglobin content, fluid volume, intraoperative urine volume, difference were not statistically significant (P0.05).2 and a group, B and C group of patients with pH value, arterial carbon dioxide partial pressure (PaCO2), heart rate (HR), mean arterial pressure (HR), mean arterial pressure, central vein The difference of pressure (CVP) was not statistically significant (P0.05).3 and a, the difference between PaO2 and A-aDO2 in group B and C group was statistically significant (P0.05), and there was no significant difference between.4 and B group. There was no statistically significant difference between the C group and the B group. The degree of collapse of the group was 100%, the degree of collapse was 80.2%, the degree of collapse was 72.2%, and 6 of the three groups were open. The difference in the degree of left chest lateral lung collapse was statistically significant (P0.05) the hoarseness in the.7 ABC three group, the occurrence of sore throat within 2 days after operation, and the incidence of pulmonary infection within 7 days after the operation were not statistically significant (P0.05). Conclusion: during the radical operation of left open thoracic esophagus cancer, the operation of the lung through different degrees of expansion could improve the oxygen partial pressure of the artery, The complications such as hypoxemia and other complications were reduced to ensure the smooth operation. The left lung collapse was grade I 100%~80.2%, stage II collapsing 80.2%~72.2%, stage III depression lower than 72.2%., and the degree of lung collapse in the case of 80.2% did not affect the patient's hemodynamics without interfering with the operation. The incidence of complications, such as infection, is lower than that of the double lumen tube.

【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R614;R735.1

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