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| 多维度综合肺保护策略在老年脆弱肺功能患者腹腔镜结直肠癌根治术中的应用 |
| Application of multi-dimensional comprehensive lung protection strategy in elderly patients with fragile lung function undergoing laparoscopic radical resection of colorectal cancer |
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| DOI：10.12089/jca.2025.12.006 |
| 中文关键词: 多维度综合肺保护策略 脆弱肺功能 老年 术后肺部并发症 结直肠癌根治术 腹腔镜手术 |
| 英文关键词: Multi-dimensional comprehensive lung protection strategy Fragile lung function Aged Postoperative pulmonary complications Radical resection of colorectal cancer Laparoscopic surgery |
| 基金项目:上海市浦东新区卫生健康委员会联合攻关项目（PW2022D02）；上海市浦东新区卫生系统重点学科群建设项目（PWZxq2022-05） |
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| 中文摘要: |
目的：观察联合小潮气量、个体化 PEEP、目标导向液体治疗（GDFT）及腹横肌平面阻滞（TAPB）的多维度综合肺保护策略在老年脆弱肺功能患者腹腔镜结直肠癌根治术中的应用效果。
方法：选择2022年12月至 2024年12月行全身麻醉下腹腔镜结直肠癌根治术且术前存在脆弱肺功能（FEV1/FVC<70%）的老年患者120例，男66例，女54例，年龄≥ 65岁，BMI 18.5～28.0 kg/m2，ASA Ⅱ或Ⅲ级。采用随机数字表法将患者分为三组：小潮气量+固定PEEP组（LPV1组）、小潮气量+个体化PEEP组（LPV2组）和小潮气量+个体化PEEP+GDFT+TAPB组（LPV3 组），每组40例。三组均在气腹建立改换Trendelenburg体位后进行PEEP设置。记录机械通气5 min、PEEP滴定5 min、气腹结束平卧位5 min的肺动态顺应性（Cdyn）、驱动压（DP）。记录麻醉诱导前、术毕、术后1 d血清白细胞介素-6（IL-6）、白细胞介素-10（IL-10）、肿瘤坏死因子-α（TNF-α）、克拉拉细胞蛋白-16（CC-16）、晚期糖基化终产物受体（RAGE）、肺泡表面活性蛋白-D（SP-D）、血管紧张素-2（Ang-2）浓度。记录镇痛泵总按压次数和补救镇痛例数。记录术后7 d内术后肺部并发症（PPCs）的发生情况。
结果：与LPV1组比较，LPV2组和LPV3组PEEP滴定5 min、气腹结束平卧位5 min Cdyn明显升高，DP明显降低，术后7 d内PPCs发生率明显降低（P<0.05）；LPV3组术毕、术后1 d血清 IL-6、IL-10、TNF-α、CC-16、RAGE、SP-D、Ang-2浓度、补救镇痛率明显降低，镇痛泵总按压次数明显减少（P<0.05）。与LPV2组比较，LPV3组术毕、术后1 d血清 IL-6、IL-10、TNF-α、CC-16、RAGE、SP-D、Ang-2浓度明显降低（P<0.05）；LPV3组镇痛泵总按压次数明显减少，补救镇痛率明显降低，术后7 d内PPCs发生率明显降低（P<0.05）。
结论：对于行腹腔镜结直肠癌根治术的老年脆弱肺功能患者，术中采用小潮气量、个体化PEEP联合GDFT及TAPB的多维度综合肺保护策略可显著降低术后7 d内PPCs发生率。 |
| 英文摘要: |
Objective: To observe the application effect of multi-dimensional comprehensive lung protection strategy (combination of low tidal volume, individualized peep, goal-directed fluid therapy, and transversus abdominis plane block) in elderly patients with fragile lung function undergoing laparoscopic radical resection of colorectal cancer.
Methods: A total of 120 elderly patients with fragile lung function (FEV1/FVC < 70%) who were scheduled to undergo laparoscopic radical resection of colorectal cancer under general anesthesia from December 2022 to December 2024, 66 males and 54 females, aged ≥ 65 years, BMI 18.5-28.0 kg/m2, ASA physical status Ⅱ or Ⅲ, were selected in this study. The patients were divided into three groups by random number table method: low tidal volume + fixed PEEP group (group LPV1), low tidal volume + individualized PEEP group (group LPV2), and low tidal volume + individualized PEEP + GDFT + TAPB group (group LPV3), 40 patients in each group. All the three groups underwent PEEP setting after the establishment of pneumoperitoneum and the switch to the Trendelenburg position. The lung dynamic compliance (Cdyn) and driving pressure (DP) at 5 minutes of mechanical ventilation, 5 minutes of PEEP titration, and 5 minutes of supine position at the end of pneumoperitoneum were recorded. The concentrations of serum interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor-α (TNF-α), cralla-cell protein-16 (CC-16), receptor for advanced glycation end products (RAGE), alveolar surfactant protein-D (SP-D), and angiotensin-2 (Ang-2) were recorded before anesthesia induction, at the end of the operation, and 1 day after the operation. The total number of compressions of the analgesic pump and the number of cases for remedial analgesia were recorded. The occurrence of postoperative pulmonary complications (PPCs) within 7 days postoperatively were recorded.
Results: Compared with group LPV1, Cdyn in groups LPV2 and LPV3 was significantly increased at 5 minutes of PEEP titration and 5 minutes of supine position at the end of pneumoperitoneum, while DP was significantly decreased (P < 0.05). Compared with group LPV1, the concentrations of serum IL-6, IL-10, TNF-α, CC-16, RAGE, SP-D, and Ang-2, as well as the rate of remedial analgesia, were significantly decreased in group LPV3 at the end of the operation and 1 day after the operation, and the total number of compressions of the analgesic pump was significantly reduced (P < 0.05). Compared with group LPV1, the incidence of PPCs within 7 days postoperatively in groups LPV2 and LPV3 was significantly reduced (P < 0.05). Compared with group LPV2, the concentrations of serum IL-6, IL-10, TNF-α, CC-16, RAGE, SP-D, and Ang-2 in group LPV3 were significantly decreased at the end of the operation and 1 day after the operation (P < 0.05). Compared with group LPV2, the total number of compressions of the analgesic pump in group LPV3 was significantly reduced, the rate of remedial analgesia was significantly decreased, and the incidence of PPCs within 7 days postoperatively was significantly reduced (P < 0.05).
Conclusion: For elderly patients with fragile lung function undergoing laparoscopic radical resection of colorectal cancer, the multi-dimensional comprehensive lung protection strategy of low tidal volume, individualized PEEP combined with goal-directed fluid therapy and transversus abdominis plane block can significantly reduce the incidence of PPCs within 7 days postoperatively. |
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