呼气末正压对左室舒张早期功能障碍患者心功能的影响究——一项前瞻性队列研  

Effect of positive end-expiratory pressure on cardiac function in patients with early left ventricular diastolic dysfunction:a prospective cohort study

作　　者：胡家瑞 涂育铭 张扬[1] 高巨[1] Hu Jiarui;Tu Yuming;Zhang Yang;Gao Ju(Department of Anesthesiology,Subei People's Hospital,Yangzhou 225001,Jiangsu,China)

机构地区：[1]江苏省苏北人民医院麻醉科,扬州225001

出　　处：《中华危重病急救医学》2022年第10期1066-1071,共6页Chinese Critical Care Medicine

基　　金：国家自然科学基金(82172190);江苏省卫生健康委员会医学科研项目面上项目(2021-166);江苏省扬州市重点实验室培育专项基金(YZ20211148)。

摘　　要：目的评价呼气末正压(PEEP)通气对行腹腔镜胃癌根治术的左室舒张早期功能障碍患者心功能的影响。方法选择2021年7月至2022年2月在苏北人民医院择期行全麻下腹腔镜胃癌根治术患者作为研究对象〔年龄60~75岁,美国麻醉医师协会(ASA)分级Ⅰ~Ⅱ级,左室射血分数(LVEF)>0.50〕。入室前行经胸超声心动图(TTE)检查,记录二尖瓣口舒张早期峰值速度(E峰)和舒张晚期峰值速度(A峰),并计算E/A比值、E峰减速时间(DT);记录等容舒张时间(IVRT)、二尖瓣环舒张早期峰值速度(e'),并计算左心室E/e'(LVE/e')比值。根据E/A、二尖瓣e'、LVE/e'、DT和IVRT将患者分为左室舒张早期功能障碍组(E/A<1,二尖瓣e'<7 cm/s,LVE/e'>14,DT>200 ms,IVRT>100 ms)和心功能正常组(1<E/A<2,160 ms<DT<240 ms,70 ms<IVRT<90 ms)。两组均于气腹开始5 min后给予固定5 cmH2O(1 cmH2O≈0.098 kPa)PEEP,直至手术结束。使用容量控制通气模式,潮气量(VT)7 mL/kg,吸入氧浓度0.60,吸呼比1∶2。于气管插管后气腹前(T_(0))、气腹开始5 min后(T_(1))、PEEP通气5 min后(T_(2))、PEEP通气30 min后(T_(3))、气腹结束5 min后(T_(4))时,通过经食管超声心动图(TEE)测量左、右心肌收缩和舒张功能相关参数,包括LVEF、左心室整体纵向应变值(LVGLS)、三尖瓣环收缩期位移(TAPSE)、二尖瓣和三尖瓣瓣口的舒张早期峰值速度(E峰)与相应瓣环的舒张早期峰值速度(e'),计算左心室和右心室心肌做功指数(LVMPI/RVMPI)。结果最终60例患者纳入分析,其中左室舒张早期功能障碍组28例,心功能正常组32例。与T_(0)时比较,心功能正常组T_(1)时与左室舒张早期功能障碍组T_(1)、T_(2)、T_(3)时平均动脉压(MAP)、LVEF、二尖瓣e'、LVGLS、三尖瓣e'、TAPSE均显著降低,LVMPI、LVE/e'、RVE/e'、RVMPI均显著升高。T_(4)时,左室舒张早期功能障碍组LVE/e'、RVE/e'均显著高于T_(0)时(LVE/e':16.52±1.26比14.32±1.09,RVE/e':18.71±1.74比16.51±1.93,均P<0.05),�Objective To evaluate the effect of positive end-expiratory pressure(PEEP)ventilation on cardiac function in patients with early left ventricular(LV)diastolic dysfunction undergoing laparoscopic radical gastrectomy.Methods Patients who underwent laparoscopic radical gastrectomy under elective general anesthesia from July 2021 to February 2022 at the Subei People's Hospital were enrolled[age 60-75 years old,American Society of Anesthesiologists(ASA)gradeⅠ-Ⅱ,and left ventricular ejection fraction(LVEF)>0.50].Transthoracic echocardiography(TTE)was performed before operation,and the peak early diastolic velocity(E peak)and peak late diastolic velocity(A peak)at the mitral ostium were recorded and the E/A and E peak deceleration time(DT)were calculated.Then isovolumic relaxation time(IVRT)and early peak mitral annular diastolic velocity(e')were recorded and left ventricular E/e'(LVE/e')was calculated.According to the E/A,mitral e',LVE/e',DT,and IVRT,the patients were divided into early LV diastolic dysfunction group(E/A<1,mitral e'<7 cm/s,LVE/e'>14,DT>200 ms,and IVRT>100 ms)and normal cardiac function group(1<E/A<2,160 ms<DT<240 ms,and 70 ms<IVRT<90 ms),with 35 patients in each group.Both groups were received fixed 5 cmH2O(1 cmH2O≈0.098 kPa)PEEP 5 minutes after the beginning of the pneumoperitoneum until the end of the procedure.A volume controlled ventilation was used with a tidal volume(VT)of 7 ml/kg,an inspired oxygen concentration of 0.60,and an inspiratory to expiratory ratio of 1∶2.Left and right myocardial systolic and diastolic function related parameters,including LVEF,LV global longitudinal strain(LVGLS),tricuspid annulus plane systolic migration(TAPSE),the peak early diastolic velocity(E peak)at the mitral and tricuspid valve ostia and the peak early diastolic velocity(e')at the corresponding annulus were measured by transesophageal echocardiography(TEE)before tracheal intubation(T_(0)),5 minutes after the pneumoperitoneum(T_(1)),5 minutes after PEEP ventilation(T_(2)),30 minutes after PEEP ventilat

关 键 词：呼气末正压 腹腔镜 心功能 左室舒张早期功能障碍 

分 类 号：R735.2[医药卫生—肿瘤]