老年病人腹腔镜全麻胃癌根治术中肺保护性通气的应用

APPLICATION OF PROTECTIVE LUNG VENTILATION IN THE ELDERLY PATIENTS UNDERGOING LAPARASCOPIC RADICAL GASTRECTOMY UNDER GENERAL ANESTHESIA

目的探讨老年病人全身麻醉腹腔镜胃癌根治术中应用小潮气量（VT）、低气道平台压（Pplat）联合不同水平呼气末正压通气（PEEP）与单纯常规潮气量通气对呼吸功能的影响，为老年病人腹腔镜上腹部手术的全麻选择安全、有效的通气方式。方法36例ASAⅠ或Ⅱ级全身麻醉行腹腔镜胃癌根治术老年病人，随机分为A、B、C3组，每组12例。A组机械通气模式为间歇正压通气（IPPV）加0．5kPa PEEP，VT=6mL／kg，呼吸频率（f）=16min；B组机械通气模式为IPPV加1．0kPaPEEP，VT=6mL／kg，f=16min^-1；C组机械通气模式为IPPV，VT=9mL／kg，f=12min^-1。观察并比较各组术前、麻醉插管后30min、拔管后15min的动脉氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）、肺泡-动脉氧分压差（A—aDO2）、平均动脉压（MAP）、中心静脉压（CVP）及术中的气道峰压（Ppeak）。结果麻醉插管后30min，A组Ppeak较B、C组明显降低（F=17．61，q=5．43--8．84，P〈0．05）。拔管后15min，A组PaO2较B、C组则明显升高（F=11．18，q=2．42～7．43，P〈0．05），A-aDO2较B、C组明显降低（F=66．46，q=3．95～16．25，P〈0．05）；B组PaCO2较A、C两组明显升高（F=5．95，q=3．44～3．81，P〈0．05）。其他时点A、B、C3组PaO2、PaCO2、A-aDO2、MAP、CVP比较差异无统计学意义（P〉0．05）。结论小潮气量、低气道平台压联合低水平PEEP通气能够有效改善老年腹腔镜胃癌根治术病人的动脉氧合，是老年病人腹腔镜全麻上腹部手术安全、有效的通气方式。

Objective To investigate the effect of small tidal volume （VT）, Pplat combined with different levels of posi tive end-expiratory pressure （PEEP）, and simple conventional VT on respiratory function in elderly patients undergoing laparoscopic radical gastrectomy （LRG） under general anesthesia （GA） so as to choose a safe and effective venting for them. Methods Thirty-six elderly patients, with ASA Ⅰ or Ⅱ, undergoing LRG under GA were evenly randomized to groups A, B and C. The mechanical ventilation mode in group A was intermittent positive pressure ventilation （IPPV） with 0.5 kPa PEEP, VT= 6 mL/kg, respiratory frequency （f）=16 min^-1 group B was IPPV plus 1.0 kPa PEEP, VT=6 mL/kg, f=16 min^-1 and group C was IPPV, VT= 9 mL/kg, f= 12 min^-1. Arterial oxygen pressure （PaO2）, arterial carbon dioxide tension （PaCO2）, alveolar arterial oxygen difference （A-aDO2）, mean arterial pressure （MAP）, central venous pressure （CVP） before operation, 30 min after anesthesia intubation and 15 rain after extnbation and intraoperative airway peak value （APV） were observed and the results were compared among the groups. Results Thirty minutes after intubation, the APV of group A was significantly lower than that of groups B and C （F=17.61;q= 5.43-8.84;P〈0.05）, and 15 minutes after extubation, the PaO2 was significantly higher than that of groups B and C （F= 11. 18;q=2. 42-7.43;P〈0.05）. In group B, the PaCO2 was much higher than that in groups A and C （F=5.95;q=3.44-3.81;P〈0.05）. There was no significant difference in PaO2, PaCO2, A-aDO2, MAP, CVP, among the three groups at other time points. Conclusion Small tidal volume, low airway plateau pressure ventilation combined with low PEEP can improve arterial oxygenation in the elderly undergoing laparoseopic radical gastrectomy, which is a safe and effective ventilation mode of surgery under general anesthesia.