肺动态顺应性指导个体化呼气末正压通气对老年患者腹腔镜结直肠癌术中肺功能的影响  

Effect of dynamic lung compliance⁃guided individual positive end⁃expiratory pressure titration on pulmonary function in elderly patients undergoing laparoscopic colorectal cancer surgery

作　　者：石进涛 朱娟[1] 邓鉴 吉慧 姚强 田伟千[1] SHI Jin-tao;ZHU Juan;DENG Jian;JI Hui;YAO Qiang;TIAN Weiqian(Department of Anesthesiology,Affiliated Hospital of Nanjing University of Traditional Chinese Medicine,Nanjing 210029,China)

机构地区：[1]南京中医药大学附属医院麻醉科,210029

出　　处：《临床麻醉学杂志》2024年第1期36-41,共6页Journal of Clinical Anesthesiology

摘　　要：目的观察肺动态顺应性(Cdyn)指导个体化呼气末正压通气(PEEP)对老年患者腹腔镜结直肠癌术中肺功能的影响。方法选择择期行腹腔镜结直肠癌根治术的老年患者68例,男37例,女31例,年龄65~79岁,BMI<30 kg/m^(2),ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组:个体化PEEP组(P组)和对照组(C组),每组34例。P组在插管完成即刻、气腹-屈氏体位建立即刻、气腹结束即刻行肺复张及PEEP滴定试验,C组设置固定PEEP 5 cmH_(2)O。记录P组3次滴定时最佳PEEP和实际VT。记录气管插管完成后10 min(T_(1))、气腹-屈氏体位建立后10 min(T_(2))、60 min(T_(3))、手术结束拔管前(T_(4))PaO_(2)、PaCO_(2)、PETCO_(2),计算氧合指数(OI)、死腔/潮气量比值(Vd/VT)、肺泡-动脉血氧分压差(A-aDO_(2))、驱动压和Cdyn。采用ELISA法测定麻醉诱导前(T0)、拔管后10 min(T5)的白细胞介素-8(IL-8)、肿瘤坏死因子-α(TNF-α)、肺Clara细胞分泌蛋白(CC16)及肺泡表面活性物质-D(SP-D)的浓度。记录术后肺部并发症(PPCs)的发生情况。结果P组滴定最佳PEEP的中位数为4 cmH_(2)O。与C组比较,P组T_(4)时PaO_(2)、OI明显升高,T_(1)、T_(3)、T_(4)时Cdyn明显升高,T_(1)—T_(4)时驱动压明显降低,T5时CC16血清浓度明显降低(P<0.05)。两组T_(1)—T_(4)时PaCO_(2)、PETCO_(2)、A-aDO_(2)、Vd/VT差异无统计学意义。两组术后3 d均未发生严重PPCs。结论在老年患者腹腔镜结直肠癌根治术中,采用压力控制通气下肺动态顺应性指导个体化PEEP的肺保护通气策略,可提高患者术中肺动态顺应性,降低驱动压,改善手术结束时氧合,降低术后CC16血清浓度,改善术中肺功能。Objective To investigate the effects of dynamic lung compliance(Cdyn)⁃guided indi⁃vidual positive end⁃expiratory pressure(PEEP)titration on pulmonary function in elderly patients undergoing laparoscopic colorectal cancer surgery.Methods Sixty⁃eight elderly patients were selected for laparoscopic radical resection of colorectal cancer,37 males and 31 females,aged 65-79 years,BMI<30 kg/m^(2),ASA physical statusⅡorⅢ.The patients were divided into two groups using the random number table method:individualized PEEP group(group P)and control group(group C),34 patients in each group.In group P,the patients received recruitment maneuvers and PEEP titration test at immediately after intubation,immediately after establishing pneumoperitoneum⁃Trendelenburg position and immediately after pneumoperitoneum.The patients in group C received PEEP 5 cmH_(2)O during procedure.The three best titra⁃tion PEEP and the actual tidal volume(VT)in group P were also recorded.PaO_(2),PaCO_(2),PETCO_(2)10 mi⁃nutes after the tracheal intubation(T_(1)),10 minutes(T_(2))and 1 hour(T_(3))after establishing pneumoperito⁃neum⁃Trendelenburg position,at the end of the surgery but before extubation(T_(4))were recorded,and the oxygenation index(OI),physiological dead space to tidal volume(Vd/VT),alveolar arterial oxygen differ⁃ence(A⁃aDO_(2)),driving pressure,and Cdyn were calculated.Concentrations of interleukin⁃8(IL⁃8),tumor necrosis factor⁃α(TNF⁃α),Clara cell secretoyr protein(CC16)and lung alveolar surface active sub⁃stances⁃D(SP⁃D)in the serum samples were determined by ELISA before anesthesia induction(T0)and 10 minutes after extubation(T5).Postoperative pulmonary complications(PPCs)were also recordrd.Results The individualized PEEP of Cdyn⁃guided PEEP titration was 4 cmH_(2)O.Compared with group C,the PaO_(2)and OI in group C were significantly increased at T_(4),the Cdyn was significantly increased at T_(1),T_(3),and T_(4),the driving pressure was significantly decreased at T_(1)-T_(4),the serum conce

关 键 词：动态顺应性 压力控制通气 结直肠癌 个体化呼气末正压通气滴定 肺通气保护策略 

分 类 号：R614[医药卫生—麻醉学] R735.34[医药卫生—外科学]