肺复张术在心脏外科手术后低氧患者的疗效观察  

Clinical effect of lung recruitment maneuver on hypoxemia for post operative cardiopulmonary bypass cardiac surgery patients

作　　者：张翔宇[1] 樊海蓉[1] 杨自建[1] 沈菊芳[1] 王启星[1] 陈亮[1] 

机构地区：[1]同济大学附属第十人民医院SICU,上海200072

出　　处：《同济大学学报（医学版）》2008年第2期73-76,共4页Journal of Tongji University(Medical Science)

摘　　要：目的观察肺复张术对体外循环心脏外科手术后低氧血症患者的疗效与可能出现的不良反应。方法体外循环心脏外科手术后低氧血症患者20例,术后循环稳定,24 h内因低氧而不能脱离机械通气。监测并记录有创持续动脉压(artery blood pressure,ABP)、中心静脉压(central venous pressure,CVP)、脉搏氧饱和度(pulse oximetricsaturation,SPO2)、血气分析(arterial blood gas,ABG)、呼吸系统静态顺应性(static compliance,Cst)。机械通气模式应用容量控制(volume control ventilation,VCV),潮气量(tidal volume,VT)6ml/kg,肺复张术在原有的呼气末正压(posi-tive end expiratory pressure,PEEP)水平基础上逐步提高PEEP,每次提高0.2 kPa,保持2 min,吸氧浓度(fraction of in-spired oxygen,FiO2)在原基础水平上提高10%;如果患者出现ABP或SPO2明显下降,或出现新发生的心律失常,立即中止肺复张术,逐步降低PEEP,每次下降0.2 kPa,保持2 min,注意患者SPO2,在SPO2开始下降时记录当时的PEEP水平,并以该水平+0.2 kPa作为下一次肺复张术之后维持PEEP的目标水平。结果20例患者共实施肺复张术39次,其中19例在肺复张术后氧合有明显改善(PaO2/FiO2从(118.6±36.6)升高至(232.8±47.5),P<0.01),所有病例在PEEP升高至一定水平时均会出现一过性动脉压下降,降低PEEP水平后很快恢复;1例在PEEP提高至1.2 kPa时动脉压下降明显而中止肺复张术,该例在PEEP降低之后PaO2/FiO2无任何改善。所有病例均顺利出院,未发生气压伤或其他并发症。结论肺复张术可以有效改善体外循环心脏手术后患者的低氧血症,心脏手术后心功能易受到PEEP升高的影响,有创持续动脉压监测是必要的。Objective To study clinical effectiveness and possible side effects of lung recruitment on hypoxemia for post operative cardiopulmonary bypass （CPB） cardiac surgery patients. Methods Twenty hypoxemic post operative CPB cardiac surgery patients were included. Circulation was stable among them. They could not be weaned from mechanical ventilation due to refractory hypoxemia. Bedside monitoring included invasive continuous artery blood pressure （ABP） ,central venous pressure （CVP） ,pulsoxymetry （SPO2 ） ,arterial blood gas （ABG） analysis,static compliance of respiratory system （Cst）. Patients were ventilated on volume control mode. Tidal volumes （Vt） set to 6ml/kg. Recruitment maneuvers were conducted by stepwise rising of positive end expiratory pressure （PEEP） level by incremental of 0.2 kPa, sustaining for 2 min. Maneuver should be aborted if patient＇ s ABP started dropping or new arrhythmia occurred. PEEP decreased by decrement of 0.2 kPa, and sustained for 2 min. When SPO2 started fall, note this PEEP level for next recruitment and keep post recruitment PEEP level above 0.2 kPa of that titrated PEEP. Results Thirty-nine recruitments were completed on these 20 cases. PaO2/FiO2 improved significantly in 19 cases （ PaO2/FiO2 increased from （ 118.6 ± 36.6） to （ 232.8 ± 47.5 ）, P 〈 0.01 ）. All cases appeared transient ABP drop when PEEP rose to certain level. ABP quickly returned to former level as PEEP decreased down. One case appeared ABP and SPO2 sharps drop when PEEP rose to 1.2 kPa. PaO2/FiO2 got no improvement on this case. No complication was encountered. All patients were discharged successfully. Conclusion Hypoxemia following CPB cardiac surgery could be improved by lung recruitment maneuver. Continuous invasive artery blood pressure needs to be monitored for these patients because the heart functions were easily influenced by the increasing of PEEP after cardiac surgery.

关 键 词：肺复张术 低氧血症 体外循环 心脏手术 

分 类 号：R56[医药卫生—呼吸系统]