文章摘要
间歇呼吸暂停联合低水平PEEP通气策略在输尿管软镜手术中的应用
Application of intermittent apnea combined with low-level PEEP ventilation strategy in patients undergoing flexible ureteroscopy
  
DOI:10.12089/jca.2020.09.010
中文关键词: 间歇呼吸暂停  呼气末正压  通气策略  输尿管软镜手术
英文关键词: Intermittent apnea  Positive end expiratory pressure  Ventilation strategy  Flexible ureteroscopy
基金项目:山西省自然科学基金(201801D121226);山西医科大学第一医院青年基金(YQ161705)
作者单位E-mail
刘淑芳 030000,太原市,山西医科大学麻醉学院  
田首元 山西医科大学第一医院麻醉科 chinatsyjj@126.com 
李超 030000,太原市,山西医科大学麻醉学院  
张文颉 山西医科大学第一医院麻醉科  
王鑫 山西医科大学第一医院麻醉科  
张海滨 山西医科大学第一医院麻醉科  
苏学森 山西医科大学第一医院麻醉科  
苑昕 山西医科大学第一医院麻醉科  
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中文摘要:
      
目的 探讨间歇呼吸暂停联合低水平呼气末正压(PEEP)通气策略对输尿管软镜手术患者的影响。
方法 选择接受输尿管软镜钬激光碎石术的患者73例,男59例,女14例,年龄25~60岁,BMI 18~28 kg/m2,ASA Ⅰ或Ⅱ级,随机分为三组:呼吸暂停联合低水平PEEP组(P组,n=25)、呼吸暂停组(A组,n=28)和对照组(C组,n=20)。P组术中采用呼吸暂停联合低水平PEEP (5 cmH2O)通气模式,A组术中采用传统呼吸暂停通气模式,C组术中采用常规通气模式。P组和A组于麻醉诱导前(T0)、插管后10 min(T1)、第1次呼吸暂停前(T2)、最后1次呼吸暂停结束后即刻(T3)和拔管后30 min(T4)时,C组于T0—T1、术者第1次要求呼吸暂停前(T2)、碎石结束后即刻(T3)、T4时记录基本生命体征并抽取桡动脉及颈内静脉血进行血气分析,术后24 h(T5)时抽取颈内静脉血。记录T0—T4时PaCO2、pH、氧合指数(OI)、脑氧饱和度(rSO2)、脑氧摄取率(CERO2)、动脉和颈内静脉血氧分压差(Pa-jvO2)、动脉和颈内静脉血氧饱和度差(Sa-jvO2);T0、T4—T5时血清肺Clara细胞分泌蛋白(CC16)、静脉血清S100β蛋白含量、静脉血清肌钙蛋白(cTnT和cTnI)、肌红蛋白(Mb)和肌酸激酶同工酶(CK-MB)。记录激光碎石时间和术者满意程度评分。
结果 与C组比较,T3时A组PaCO2明显升高、pH、OI明显降低(P<0.05)。与A组比较,T3时P组PaCO2明显降低、pH、OI明显升高(P<0.05)。三组不同时点rSO2、CERO2、Pa-jvO2、Sa-jvO2、CC16、S100β蛋白、cTnT、cTnI、Mb、CK-MB差异均无统计学意义。与C组比较,P组和A组激光碎石时间明显缩短(P<0.05),术者满意程度评分明显升高(P<0.05)。
结论 间歇呼吸暂停联合低水平PEEP(5 cmH2O)通气策略可安全地用于输尿管软镜手术,既保留了传统呼吸暂停通气策略的优势,同时减少了其带来的不利影响,是一种更优化的通气策略。
英文摘要:
      
Objective To explore the effect of intermittent apnea combined with low-level positive end expiratory pressure (PEEP) ventilation strategy on patients undergoing ureteroscopic surgery.
Methods Seventy-three cases of ureteroscopic holmium laser lithotripsy,59 males and 14 females, aged 25-60 years, BMI 18-28 kg/m2, ASA physical status Ⅰ or Ⅱ, were randomly divided into three groups: apnea combined PEEP group (group P, n = 25), apnea group (group A, n = 28) and control group (group C, n = 20). In group P, apnea combined with low-level PEEP (5 cmH2O) ventilation mode was used, in group A, traditional apnea ventilation mode was used, and in group C, conventional ventilation mode was used. Before anesthesia induction (T0), 10 min after intubation (T1), before the first apnea (T2), immediately after the end of the last apnea (T3), and 30 min after extubation (T4) in group P and A at T0-T1, prior to the surgeon's first request for apnea (T2), immediately after completion of rubble (T3), T4 in group C, the basic vital signs were recorded and the radial artery and internal jugular vein blood were extracted for blood gas analysis. The internal jugular venous blood were extracted at 24 h after surgery (T5). PaCO2, pH, oxygenation index (OI), cerebral indicators including cerebral regional oxygen saturation (rSO2), cerebral extraction rate of oxygen (CERO2), arterial and internal jugular venous oxygen pressure difference (Pa-jvO2) and arterial and internal jugular venous oxygen saturation (Sa-jvO2) were recorded at T0-T4. Serum lung Clara cell secreted protein (CC16), venous S100β protein, cardiac correlation indicators including Troponin (cTnT and cTnI), myoglobin (Mb) and creatine kinase isoenzyme (CK-MB) were recorded at T0, T4- T5. Recording surgery-related indicators including the laser lithotripsy time, the operator satisfaction score of the three groups of patients.
Results Compared with group C, PaCO2 in group A was significantly increased, pH and OI were significantly reduced at T3(P < 0.05). Compared with group A, PaCO2 in group P was significantly reduced, pH and OI were significantly increased at T3(P < 0.05). Compared with group C, laser lithotripsy time was significantly shortened in group P and group A (P < 0.05), operator satisfaction score significantly increased (P<0.05).
Conclusion Intermittent apnea combined with low-level PEEP (5 cm H2O) ventilation strategy can be safely used in ureteroscopic surgery. It doesnt only retains the advantages of traditional apnea ventilation strategy, but also makes up for its disadvantages. It is a more optimized ventilation strategy.
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