个体化呼气末正压对后腹腔镜肾癌手术老年患者术中肺通气效果及术后谵妄的影响  

Effect of individualized positive end‑expiratory pressure on pulmonary ventilation and postoperative delirium in elderly patients under retroperitoneal laparoscopic operation of renal carcinoma

作　　者：张雨涵 苏杨 王立伟 Zhang Yuhan;Su Yang;Wang Liwei(School of Anesthesiology,Xuzhou Medical University,Xuzhou 221004,China;Department of Anesthesiology,Xuzhou Central Hospital,Xuzhou 221009,China)

机构地区：[1]徐州医科大学麻醉学院,徐州221004 [2]徐州市中心医院麻醉科,徐州221009

出　　处：《国际麻醉学与复苏杂志》2022年第7期673-677,共5页International Journal of Anesthesiology and Resuscitation

基　　金：国家自然科学基金(81870857)。

摘　　要：目的探究在老年患者后腹腔镜肾癌手术中,采用动态调整呼气末正压(positive end⁃expiratory pressure,PEEP)的肺保护性通气策略(lung protective ventilation strategies,LPVS)对术中肺通气效果及术后谵妄(postoperative delirium,POD)的影响。方法选择择期拟行后腹腔镜肾癌手术患者138例,年龄65~80岁,ASA分级Ⅰ~Ⅲ级,采用随机数字表法将患者分为两组:常规通气组(A组)和个体化PEEP组(B组),每组69例。A组设置潮气量(tidal volume,V_(T))为8 ml/kg[两组患者V_(T)按照预测体重(predicted body weight,PBW)设置],呼吸频率(respiration rate,RR)为12~20次/min;B组通过肺动态顺应性(dynamic compliance,Cdyn)滴定最佳PEEP值,联合低V_(T)(6 ml/kg)及肺复张(recruitment maneuver,RMs)。记录两组患者麻醉诱导后(T_(1))、改侧卧位后5 min(T_(2))、气腹后每隔30 min(T_(3)、T_(4)、T_(5))、手术结束即刻(T_(6))的Cdyn、气道平台压(plateau pressure,Pplat)、氧合指数(oxygenation index,OI)、PaCO_(2)及局部脑氧饱和度(regional cerebral oxygen saturation,rSO_(2)),记录两组患者拔管时间、PA⁃CU停留时间及住院时间,ELISA法测定两组患者术前及术后第3天血清中枢神经特异性蛋白(central nervous system specific protein,S100⁃β)、IL⁃6、TNF⁃α的浓度,记录两组患者术后3 d POD发生情况及严重程度。结果与T_(1)时比较,两组患者T_(3)~T_(6)时Cdyn及rSO_(2)均下降(P<0.05),Pplat及PaCO_(2)均升高(P<0.05),B组患者T_(4)~T_(6)时OI下降,A组患者T_(3)~T_(6)时OI下降(P<0.05)。与A组比较,B组患者T_(3)~T_(6)时Cdyn及Pplat升高(P<0.05),T_(4)~T_(6)时rSO_(2)与OI升高(P<0.05),T_(4)~T_(6)时PaCO_(2)下降(P<0.05),拔管时间缩短(P<0.05),术后第3天的血清S100⁃β、IL⁃6及TNF⁃α浓度降低(P<0.05)。A组患者术后3 d POD发生率23.9%(16例)高于B组10.4%(7例)(P<0.05),而两组患者的POD严重程度差异无统计学意义(P>0.05)。结论最佳PEEP联合低V_(T)和RMs的LPVS可改善后腹腔镜肾癌手术�Objective To explore the effect of lung protective ventilation strategies(LPVS)with dynamic adjustment of posi⁃tive end⁃expiratory pressure(PEEP)on pulmonary ventilation and postoperative delirium(POD)in elderly patients under retroperitone⁃al laparoscopic operation of renal carcinoma.Methods One hundred thirty⁃eight patients(aged 65−80 years,ASA gradeⅠ−Ⅲ)scheduled to undergo the retroperitoneal laparoscopic operation of renal carcinoma were divided into two groups:traditional ventilation group(group A,n=69)and individualized PEEP group(group B,n=69),according to the random number table method.In group A,tidal volume(V_(T))8 ml/kg(predicted body weight,PBW),respiration rate(RR)12−20 times/min.In group B,optimal PEEP was guided by dy⁃namic compliance(Cdyn)combined with V_(T)6 ml/kg(PBW)and recruitment maneuvers(RMs)(30 min/time).Cdyn,plateau pressure(Pplat),oxygenation index(OI),arterial partial pressure of carbon dioxide(PaCO_(2)),and regional cerebral oxygen saturation(rSO_(2))were recorded after anesthesia induction(T_(1)),5 min after a change to lateral position(T_(2)),every 30 min after CO_(2)entered the abdominal cavi⁃ty(T_(3),T_(4),T_(5))and immediately after surgery(T_(6)).Record the extubation time,post⁃anesthesia care unit(PACU)stay time and hospital stay.The concentration of serum central nervous system specific protein(S100⁃β),interleukin⁃6(IL⁃6),tumor necrosis factor⁃α(TNF⁃α)were determined by enzyme⁃linked immunosorbent assay(ELISA)before operation and on the third day after the operation.The occurrence and severity of delirium within 3 d after operation were recorded.Results Compared with T_(1),the Cdyn and rSO_(2)de⁃creased at T_(3)-T_(6)(P<0.05),the Pplat and PaCO_(2)increased(P<0.05),while OI decreased at T_(4)-T_(6)(OI decreased at T_(3)-T_(6)in group A)(P<0.05)in both groups A and B.Compared with group A,the Cdyn and Pplat in group B were significantly improved at T_(3)-T_(6),while the rSO_(2)and OI in group B were increased at T_(4)-T_(6)(P<0.05),the Pa

关 键 词：呼吸末正压 动态顺应性 肺保护性通气策略 后腹腔镜肾癌手术 老年患者 术后谵妄 

分 类 号：R737.11[医药卫生—肿瘤] R614[医药卫生—临床医学]