呼气末正压递增法肺复张对左胸微创冠状动脉旁路移植术患者血流动力学及呼吸力学的影响  

Effects of Alveolar Recruitment Maneuver With Incremental Positive End-expiratory Pressure on Hemodynamics and Respiratory Mechanics in Patients Undergoing Minimally Invasive Coronary Artery Bypass Grafting via Left Thoracotomy

作　　者：钱敏[1] 傅元豪[2] 凌云鹏[2] 徐懋[1] Qian Min;Fu Yuanhao;Ling Yunpeng(Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China;不详)

机构地区：[1]北京大学第三医院麻醉科,北京100191 [2]北京大学第三医院心外科,北京100191

出　　处：《中国微创外科杂志》2021年第8期710-715,共6页Chinese Journal of Minimally Invasive Surgery

基　　金：北京大学第三医院临床重点项目·培育探索项目(BYSY2016004)。

摘　　要：目的探讨呼气末正压(positive end-expiratory pressure,PEEP)递增法肺复张(alveolar recruitment maneuver,ARM)对左胸微创冠状动脉旁路移植术(minimally invasive direct coronary artery bypass grafting,MIDCABG)患者的血流动力学及呼吸力学的影响。方法选取2019年1月~2020年12月我院择期MIDCABG 20例,术中采用肺保护性通气策略,在双肺通气(two-lung ventilation,TLV)和单肺通气(one-lung ventilation,OLV)时分别实施PEEP递增法ARM,观察ARM前后血流动力学、呼吸力学和氧合水平的变化。结果TLV时,ARM 10 min后患者氧分压及氧合指数较ARM前明显升高(t=15.983,P=0.000;t=15.983,P=0.000),混合静脉血氧饱和度明显升高(t=14.606,P=0.000),肺动态顺应性及静态顺应性显著增加(t=8.452,P=0.000;t=3.612,P=0.002),肺驱动压显著下降(t=4.055,P=0.001)。TLV时,ARM过程中平均动脉压显著下降(F=71.011,P=0.000),并持续到ARM结束后5 min(P=0.004);心脏指数显著下降(P=0.001),中心静脉压、平均肺动脉压、肺动脉楔压、肺循环阻力指数显著增加(P<0.05),ARM结束后均逐渐恢复至基础水平(P>0.05)。OLV时,ARM 10 min后患者氧分压及氧合指数较ARM前明显升高(t=11.535,P=0.000;t=11.535,P=0.000),混合静脉血氧饱和度明显升高(t=6.216,P=0.000),肺动态顺应性及静态顺应性显著增加(t=10.697,P=0.000;t=6.447,P=0.000),肺驱动压显著下降(t=8.556,P=0.000)。OLV时,ARM可引起平均动脉压显著下降(F=75.692,P=0.000),并持续到ARM结束后5 min(P=0.000);ARM过程中中心静脉压、平均肺动脉压、肺动脉楔压、肺循环阻力指数显著增加(P<0.05),但ARM结束后5 min内均恢复至基础水平(P>0.05);OLV时ARM对心脏指数无明显影响(F=2.817,P=0.069)。结论MIDCAB术中间断行PEEP递增法ARM可提高患者氧合水平,改善组织缺氧,增加肺顺应性,对血流动力学影响短暂,对肺复张安全有效。Objective To investigate the effects of alveolar recruitment maneuver(ARM)with incremental positive end-expiratory pressure(PEEP)on hemodynamics and respiratory mechanics in patients undergoing minimally invasive coronary artery bypass grafting(MIDCABG)via left thoracotomy.Methods A total of 20 patients undergoing MIDCABG from January 2019 to December 2020 in our hospital were selected.Protective lung ventilation strategy was adopted during surgery,and ARM with incremental PEEP was implemented during both two-lung ventilation(TLV)and one-lung ventilation(OLV).Hemodynamics,respiratory mechanics and oxygenation levels before and after ARM were compared,respectively.Results During TLV,the oxygen partial pressure(PaO2)(t=15.983,P=0.000),oxygenation index(OI)(t=15.983,P=0.000)and mixed venous oxygen saturation(SvO2)(t=14.606,P=0.000)increased significantly 10 minutes after ARM;the pulmonary dynamic compliance(Cdyn)(t=8.452,P=0.000)and static compliance(Csta)(t=3.612,P=0.002)also increased significantly;the lung driving pressure(DP)decreased significantly(t=4.055,P=0.001).The mean arterial pressure(MAP)dropped during ARM(F=71.011,P=0.000)and remained decreased 5 minutes after ARM(P=0.004).During ARM,the cardiac index(CI)decreased significantly(P=0.001)and central venous pressure(CVP),mean pulmonary artery pressure(MPAP),pulmonary artery wedge pressure(PCWP),and pulmonary circulatory resistance index(PVRI)increased significantly(P<0.05).All the above hemodynamic parameters returned to baseline values within 5 minutes after ARM(P>0.05).During OLV,the PaO2(t=11.535,P=0.000),OI(t=11.535,P=0.000)and SvO2(t=6.216,P=0.000)increased significantly 10 minutes after ARM;the Cdyn(t=10.697,P=0.000)and Csta(t=6.447,P=0.000)also increased;the DP decreased significantly 10 minutes after ARM(t=8.556,P=0.000).The MAP decreased significantly with ARM(F=75.692,P=0.000)and remained decreased 5 minutes after ARM(P=0.000).The CVP,MPAP,PCWP and PVRI increased significantly during ARM(P<0.05)and returned to baseline values within 5 minutes aft

关 键 词：肺复张 肺保护通气 微创冠状动脉旁路移植术 

分 类 号：R54[医药卫生—心血管疾病]