不同麻醉长时间单肺通气对肺内分流和氧合的影响  

Effect of four different anesthetic techniques on oxygenation and intrapulmonary shunt during prolonged one-lung ventilation

作　　者：孙颖[1] 冯艺[1] 杨拔贤[1] 

机构地区：[1]北京大学人民医院麻醉科,100044

出　　处：《中华麻醉学杂志》2004年第5期339-344,共6页Chinese Journal of Anesthesiology

摘　　要：目的 观察四种常用麻醉方法用于长时间(180min)单肺通气时,肺内分流率、动脉氧合及血液动力学的变化。方法 40例ASAⅠ～Ⅱ择期需单肺通气开胸手术病人,随机分为4组:异氟醚吸入组(GI组,n=10),异氟醚吸入复合硬膜外组(GIE组,n=10),静脉异丙酚组(GP组,n=10)和静脉异丙酚复合硬膜外组(GPE组,n=10)。GIE组和GPE组均以0.5％罗哌卡因持续胸段硬膜外阻滞。连续监测平均动脉压(MAP)、平均肺动脉压(MPAP)、心输出量(CO)、心电图(ECG)、脉搏氧饱和度(SpO_2)等。通过脑电双频指数(BIS)调整异氟醚吸入浓度或异丙酚输注速率。分别于清醒仰卧位(T_1)、侧卧位双肺通气30(T_2)、侧卧位单肺通气5(T_3)、15(T_4)、30(T_5)、60(T_6)、120(T_7)、180(T_8)min及再次双肺通气30min(T_9)测定动脉及混合静脉血血气,计算肺内分流率(Qs/Qt)。结果 各组肺内分流率及动脉血氧分压(PaO_2)T_2明显高于T_1(P<0.05),单肺通气后肺内分流率进一步增加,分别在T_4、T_5时达到高峰(GI组46％±14％,GIE组34％±4％,GP组34％±5％,GPE组27％±7％),之后逐渐降低。而PaO_2在单肺通气后明显下降,T_4～T_6时达到最低点之后开始回升。T_8的分流率及PaO_2已恢复到与T_9差异无显著性的水平。GI组单肺通气后肺内分流率高于其它各组(P<0.05)。Objective To investigate the changes in oxygenation and intrapulmonary shunt during prolonged one-lung ventilation (OLV) and compare the effects of four different anesthetic techniques. Methods Forty ASAⅠ -Ⅱ patients (27 male, 13 female) aged 36-74 yr undergoing prolonged OLV during elective thoracic surgery were randomly allocated to one of four groups: (1) isoflurane (GI, n = 10); (2) isoflurane + epidural (GIE, n =10); (3) propofol (GP, n = 10); (4) propofol + epidural (GPE, n = 10). Radial artery was cannulated and Swan-Ganz catheter was placed via right internal jugular vein before induction of general anesthesia. In group 2 and 4 an epidural catheter was inserted at T_(7-8) or T_(8-9) and advanced 3 .5-4.0 cm in the epidural space cephalad. Epidural block was produced by a bolus of 0.5 % ropivacaine 7-9 ml followed by continuous infusion of 0. 5 % ropivacaine at 3-5 ml·h^(-1). Anesthesia was induced with propofol 1 .0-1. 5 mg·kg^(-1), fentanyl 3μg·kg^(-1) and vecuronium 0. 1 mg·kg^(-1). A left-sided double-lumen tube was inserted and correct position was confirmed. The patients were mechenically ventilated. The ventilation collditions were FiO_2 = 100 %, V_T = 8-10 ml·kg^(-1), I: E = 1: 5 and respiratory rate was adjusted to maintained P_(ET) CO_2 at 35-45 mm Hg during both two-lung ventilation (TLV) and OLV. Anesthesia was maintained with isoflurane inhalation in group 1 and 2 or continuous infusion of propofol in group 3 and 4 supplemented with intermittent i. v. boluses of fentanyl. MAP, HR, ECG, MPAP, CVP, continuous cardiac output (CCO), BIS and TOF were continuously monitored during anesthesia. BIS was maintained at 45-55. Arterial and pulmonary blood gases were analyzed before induction of anesthesia (T_1), 30 min after TLV was started (T_2 ), and 5, 15, 30, 60, 120 and 180 min after OLV was started (T_(3-8)) and 30 min after TLV was resum

关 键 词：长时间单肺通气 肺内分流 肺循环 硬膜外麻醉 开胸手术 

分 类 号：R614[医药卫生—麻醉学]