不同呼气末正压水平对肺复张患者脑灌注压及血流动力学的影响  

The impact of positive end-expiratory pressure on cerebral perfusion pressure and hemodynamics in patients receiving lung recruitment maneuver

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

机构地区：[1]同济大学附属上海市第十人民医院SICU,200072

出　　处：《中国危重病急救医学》2008年第10期588-591,共4页Chinese Critical Care Medicine

摘　　要：目的观察肺复张（RM）对颅内压（ICP）、脑灌注压（CPP）及平均动脉压（MAP）的影响。方法选择因严重颅脑疾患伴肺损伤需要进行机械通气的6例患者，在进行RM的同时进行持续ICP、MAP、中心静脉压（CVP）、脉搏血氧饱和度（SpO2）等监测。RM采用压力控制通气模式，逐步提升呼气末正压（PEEP）的方法。结果6例患者共进行22例次RM，2例次分别在3cm H2O（1cm H2O=0．098kPa）和6cm H2O PEEP水平出现MAP、CPP显著降低而终止。其余20例次RM中不同PEEP水平相应的MAP、CVP、ICP、CPP平均值与基础值相比差异均无统计学意义（P均〉0．05）；MAP与CPP呈高度相关性（r=0．706，P=0.000）。20例次RM中，单次RM内参数间呈高度相关性的比例：MAP与CPP占85％（17／20）；PEEP与CVP占75％（15／20）；PEEP与ICP占75％（15／20）;PEEP与CPP占400．4（8／20）。22例次RM中MAP随PEEP变化有6种趋势：8例次相对稳定；6例次随PEEP增加而降低，然后随PEEP降低而逐渐回升；2例次随PEEP增加而升高，随PEEP降低逐渐回到基础值；2例次随PEEP增加而降低，PEEP降低后MAP不能相应升高；2例次随PEEP增加而增加，在PEEP降到基础值后MAP仍维持在高水平；2例次随PEEP增加MAP急剧降低而终止RM。11例次RM中ICP随PEEP升高而升高，随PEEP降低而降低；6例次在RM过程中无明显变化；3例次RM后ICP处于高值末回到基线。12例次RM中CPP随PEEP升高而降低，随PEEP降低而增加，并随PEEP回到基线时恢复到基础值；6例次无明显变化；2例次CPP维持在低值，分别在PEEP回到基线后10min、20min恢复到基础值。结论RM对MAP、ICP、CPP的影响存在明显的个体差异。ICP监测有助于保障脑部疾患合并肺损伤患者RM实施的安全性。Objective To explore the impact of lung recruitment maneuver （RM） on intracranial pressure （ICP）, cerebral perfusion pressure （CPP） and mean arterial pressure （MAP）. Methods RM was performed and ICP, MAP, central venous pressure （CVP）, saturation of arterial oxygen （SpO2） were monitored continuously in 6 severe cerebral injury patients combined with lung injury, who were indicated for mechanical ventilation and meeting the criteria for intracranial pressure monitoring. RM included pressure control ventilation with stepwise increase in positive end-expiratory pressure （PEEP）. Results RM was performed for 22 times in 6 patients, among them two were moribund due to sharp drop of blood pressure and CPP. In the remaining 20 attempts, the mean values of MAP, CVP, ICP, CPP measured at each PEEP level showed no significant difference compared with baseline values （all P 〉 0. 05）. MAP was significantly correlated with CPP （r= 0. 706, P = 0. 000）. In the remaining RMs, a correlation between MAP and CPP accounted for 85% （17/20） of total RMs, that between PEEP and CVP accounted for 75% （15/20）, that between PEEP and ICP accounted for 75% （15/20）, and that between PEEP and CPP existed in 40% （8/20）. In a total of 22 cases, there were 6 patterns of response of MAP to alteration in PEEP： MAP maintained relatively stable in 8 case, MAP decreased when PEEP increased and increased when PEEP decreased in 6 case; in 2 cases MAP elevated with increase in PEEP, and drop to baseline with decrease in PEEP, in 2 cases it fell with increase in PEEP but it did not rise with decrease in PEEP, in 2 cases it rose with increase in PEEP but remained at a high level with PEEP decreased to baseline, in 2 cases, MAP dropped abruptly with increase in PEEP resulting in termination of RM. In 11 cases, ICP increased with increase in PEEP and decreased with lowering of PEEP. ICP maintained stable in 6 cases, and ICP maintained at a high level and did not return to baseline after RM in 3 cases. CP

关 键 词：肺复张 血流动力学 肺损伤 颅脑损伤 

分 类 号：R686[医药卫生—骨科学]