腹腔镜手术中复合应用保护性通气和盐酸戊乙奎醚对炎性介质的影响

Effect of Combined Application of Protective Ventilation and Penehyclidine Hydrochloride in the Laparoscopic Surgery on the Inflammatory Medium

目的探讨腹腔镜手术机械通气充入气腹时运用肺保护性通气策略(LPVS)复合应用盐酸戊乙奎醚,对患者术中炎性介质的影响。方法方便选择该院2014年10月—2016年10月行腹腔镜胆囊切除术患者120例,ASAⅠ~Ⅱ级,随机分为4组,麻醉方法相同,用多功能监测仪常规监测BP、ECG、Sp O2、Pet CO_2BIS、NMT值。气腹后机械通气策略:A组:常规机械通气:VT:10 m L·kg,f:12次/分,I:E比1:2。B组:先滴定最佳PEEP的,机械通气:VT:6 m L·kg,f:16次/分,滴定的PEEP,I:E比1:2。C组:患者入室后肌肉注射盐酸戊乙奎醚1 mg,机械通气同A组。D组:患者入室肌肉注射盐酸戊乙奎醚1 mg,滴定PEEP,通气模式同B组。分别于气腹前5 min(T0)、气腹后即刻(T1)、气腹后15 min(T2)、气腹后30 min(T3)、气腹后45 min(T4)和气腹放气后15 min(T5)时点取静脉血3 m L测定肿瘤坏死因子-α、白介素-6浓度,抽取动脉血2 m L测定血气指标pH值、PaO_2、Pa CO_2。结果与T0时比较,T2~T5时四组患者TNF-α、IL-6浓度均升高差异有统计学意义(P<0.05),A组的T4时点升高最明显[(37.9±9.3)pg/m L vs(17.7±6.8)pg/m L](P<0.01);与A组比较,B、C、D组在T2~T5时TNF-α、IL-6浓度均下降差异有统计学意义(P<0.05),D组下降最明显[T4时(27.4±7.7 pg/m L vs(37.9±9.3)pg/m L](P<0.01)。血气分析结果比较:与T0比较,T2~T5时点4组患者均PH值下降、PCO_2升高(P<0.05),B组T4时点下降最明显[pH值:(7.28±0.06)vs(7.39±0.04),PCO_2:(53.25±3.60)mm Hg vs(38.12±4.80)mm Hg](P<0.01),PO2差异无统计学意义(P>0.05)。与A组比较,C组在T2~T5时点PH升高,PCO_2降低差异有统计学ujyq[T4时pH值:(7.31±0.07)vs(7.30±0.08),PCO_2:(45.66±4.55)mm Hg vs(46.71±3.16)mm Hg](P<0.05);B、D组在T2~T5时点pH下降,PCO_2升高(P<0.05),PO2差异无统计学意义(P>0.05)。结论腹腔镜手术中应用肺保护性通气复合盐酸戊乙奎醚,能降低患者的炎性介质,对急性肺损伤有保护作用,且效果优于单独使用保护性通气。

Objective To study the combined application of protective ventilation and Penehyclidine hydrochloride in the laparoscopic surgery on the inflammatory medium. Methods 120 cases of patients with laparoscopic cholecystectomy whose ASA was between Ⅰand Ⅱ from October 2014 to October 2016 were convenient selected and randomly divided into four groups and the anesthesia method was the same, and the BP, ECG, SpO2, Pet CO2 BIS,NMT values were monitored by the multi-purpose monitor meter, and the group A, routine mechanical ventilation, VT：10 m L·kg, f： 12 times/min, I：E was 1：2,the group B, the best PEEP was dropped, mechanical ventilation： VT：6 m L·kg, f：16 times/min, and the I：E was 1：2, the group C： after admission, the patients were given the intramuscular injection of lmg penehyclidine hydrochloride, and themechanical ventilation was the same as that in the group A, the group D, after admission, the patients were given the intramuscular injection of 1 mg penehyclidine hydrochloride, titration of PEEP, and the ventilation model was the same as that in the group B, and the TNF-α and interleukin-6 level were measured by extracting 3 m L venous blood at 5 min before pneumoperitoneum（T0）, immediate pneumoperitoneum（T1）, at 15 min（T2）after pneumoperitoneum, at 30 min after pneumoperitoneum, at 45 min after pneumoperitoneum and at 15 min after pneumoperitoneum, and the blood gas index PH value, PaO2 and PaCO2 were measured by extracting 2 m L arterial blood. Results The TNF-α and IL-6 concentrations of the four groups at T2～T5 increased and the differences were statistically significant（P〈0.05）, and the increase of TNF-α and IL-6 concentrations at T4 in the group A was the most obvious[（37.9±9.3） pg/m L vs（17.7±6.8） pg/m L]（P〈0.01）, and the TNF-α and IL-6 concentrations at T2～T5 decreased in the group B, C and D compared with those in the group A, and the differences were statistically significant（P〈0.01）, and the decrease in the group D was the most obvious[（27.4±7.7） pg/m L vs（37.9±9.3） pg/m L] at T4（P〈0.01）. Blood gas analysis results showed that of the four groups at T2～T5, PH value decreased and PCO2 increased（P〈0.05）, and the decrease in the group B at T4 was the most obvious[pH value：（7.28±0.06）vs（7.39±0.04）,PCO2 ：（53.25±3.60）mm Hg vs（38.12±4.80）mm Hg]（P〈0.01）, and the difference in the PO2 was not statistically significant（P〈0.05）, and the pH value increased in the group C at T2 ～T5 and PCO2 decreased, and the differences were statistically significant[pH value（7.31±0.07） vs（7.30±0.08）, PCO2 ：（45.66±4.55） mm Hg vs（46.71±3.16） mm Hg]（P〈0.05） at T4, and the pH decreased and PCO2 increased at T2～T5 in the group B and group D（P〈0.05）, and the difference in the PO2 was not statistically significant（P〈0.05）. Conclusion The combined application of protective ventilation and penehyclidine hydrochloride in the laparoscopic surgery on the inflammatory medium can reduce the inflammatory medium of patients, which has a protection effect on the acute lung injury, and the effect is better than that of simple protective ventilation.