妇科腹腔镜手术对肥胖患者呼吸力学和肺换气功能的影响

Effect of gynecological laparoscopic operation on respiratory mechanics and lung ventilation function of obese patients

目的 探讨妇科腹腔镜手术对肥胖患者呼吸力学和肺换气功能的影响。方法 择期选择妇科腹腔镜手术90例,按体质指数（BMI）分为肥胖组（OB组）（BMI≥30 kg/m2）45例和符合同一纳入标准的正常体重组（NB组）（BMI为20~24 kg/m2）45例。给予气管内插管全身麻醉,分别于麻醉诱导前（T0）、麻醉后气腹前（T1）、气腹后30 min（T2）、气腹解除后10 min（T3）和术毕气管导管拔除后10 min（T4）,以上5个不同时点监测气道峰压（Ppeak）、气道平台压（Pplat）、肺动态顺应性（Cdyn）、呼气末二氧化碳分压（PETCO2）、p H、氧分压（Pa O2）、动脉血二氧化碳分压（Pa CO2）、氧合指数值（OI）、肺泡动脉血氧分压（A-a DO2）及呼吸指数（RI）。结果 在T2肥胖组的Ppeak、Pplat和PETCO2（值分别为0.000、0.000和0.015）均高于正常体重组,Cdyn低于正常体重组（P=0.012〈0.05）;与T0、T1比较,两组患者在T2、T3、T4时点p H值（均P=0.000）显著下降,Pa CO2（均P=0.000）升高;与NB组比,OB组在T2、T3、T4时点p H值（值分别为0.009、0.002和0.000）小于NB组,Pa CO2（P值分别=0.014、0.004和0.013）则相反。与T0比较,两组患者在T1、T2、T3时点Pa O2（均P=0.000）、OI（值分别为0.000、0.000和0.003;0.000、0.000和0.000）、A-a DO2（均P=0.000）显著升高,而RI（均P=0.000）显著降低（P〈0.05）,T4恢复正常;与NB组比,OB组在T1、T2、T3时点OI（值分别为0.041、0.023和0.000）、A-a DO2（值分别为0.000、0.003和0.008）、RI（值分别为0.000、0.000和0.004）小于NB组,在T2、T3时点Pa O2（均P=0.000）低于NB组（P〈0.05）。结论 肥胖患者在妇科腹腔镜手术中较正常体重组易于出现气道压力升高,肺顺应性下降,氧合能力降低,易于二氧化碳蓄积,需要严密监测。

[ Objective ] To investigate the effect of laparoscopic operation on respiratory mechanics and lung ven- tilation function of obesity patients. [Methods] Ninety patients undergoing elective gynecologic laparoscopic opera- tion, according to body mass index （BMI） were divided into obese group （OB group） （BMI ≥30 kg/rn2） and normal weight group （NB group） （BMI=20-24 kg/m2） wtih 45 cases in each group. After general anesthesia through trachea intubation respectively, peak airway pressure （Ppeak）, airway plateau pressure （Pplat）, respiratory dynamic compliance （Cdyn）, pressure of end-tidal carbon dioxide （PETC02）, PH, pressure of arterial oxygen （PaO2）, pressure of arterial carbon dioxide （PaCO2）, oxygenation index （OI）, alveolar arterial oxygen difference （A-aDO2） and respiratory index （RI） were monitored at five different time points： before induction of anesthesia （To）, after anesthesia and before pneu- moperitoneum （TI）, 30 min after pneumoperitoneum （T2）, 10 min after the release of pneumoperitoneum （T3）, 10 min after extubation （T4）. [Results] At T： time point, Ppeak, Pplat, PETCO2 （P = 0.000, 0.000, 0.015） in obese group were higher than those in normal weight group, while Cdyn （P = 0.012） was lower than that in normal weight group （P 〈 0.05）; compared with T0, T1, PH （all P = 0.000） at T2, T3, T4 decreased significantly in two groups, while PaCO2 （all P = 0.000） increased; compared with group NB, PH （P = 0.009, 0.002, 0.000） at T=, T3, T4was less in group OB, but PaCO2 （P = 0.014, 0.004, 0.013） was the opposite. Compared with To, Pa02 （all P = 0.000）, OI （P = 0.000, 0.000, 0.003; 0.000, 0.000, 0.000）, A-aDO2 （all P = 0.000） at T1, T2, T3 in the two groups significantly increased, while RI （all P = 0.000） significantly decreased （P 〈0.05）, they returned to normal at T4; compared with group NB, OI （P = 0.041, 0.023, 0.000）, A-aDO2 （P = 0.000, 0.003, 0.008）, RI （P = 0.000, 0.000, 0.004） at T1, Y2, T3 were less in group OB, PaOz （both P = 0.000） at T2, T3 were lower in group OB （P 〈 0.05）. [ Conclusion ] Compared with normal weight patients, obese patients in gyneeological laparoscopic operation is easy to have increased airway pressure, deereased lung compliance, reduced oxygenation capacity and aeeumulation of carbon dioxide, which requires close monitoring.