妇科腔镜手术中不同潮气量的机械通气对肺功能影响

Effect of gynecological laparoscopic surgery in different tidal volume mechanical ventilation on lung injury

目的探讨妇科腔镜手术中采用不同潮气量行机械通气对患者肺功能及炎性因子的影响。方法选择择期行妇科腔镜手术的患者45例，无心肺疾患，ASAⅠ-Ⅱ级，年龄20～45岁，体质量45～65kg，手术时间2—3h，按随机数字表法将其分为A、B、C三组，每组15例。给予三组患者不同的机械通气潮气量，A组、B组、C组分别为8mL／kg、9mL／kg、10mL／kg。分别于麻醉前（T0），机械通气后30min（T，）、60min（T2）、90min（T3）、120min（T4）时抽取动脉血做血气分析，并计算PA-aDO2，记录气道峰压和平均压。同时抽取桡动脉血测定血浆中IL-6、TNF-α和IL-10浓度。结果与A组比较，B组T，-T4时气道峰压、气道平均压升高（t=5．13、4．78、6．54、5．32和t=7．54、4．88、5．37、4．95，均P〈0．05）。C组T1-T4时气道峰压、气道平均压升高（t=7．76、8．87、7．23、8．99和t=6．42、7．38、7．62、9．86，均P〈0．05）。与B组比较，C组T1-T4时气道峰压、气道平均压升高（t=4．76、5．87、4．23、3．99和t=4．76、3．99、6．06、4．52，均P〈0．05）。与A组比较，发现B组和C组在T1、T2、T3、T4四个时刻的A—aDO2值均升高（t=5．32、5．48、4．88、5．69和t=7．85、7．32、8．45、6．67，均P〈0．05）。同B组的同一时间点比较，C组在T1-T4四个时刻的A—aDO2值均升高（t=5．62、4．38、6．95、4．22，均P〈0．05）。与A组比较，B组T2-T4时IL-6、TNF-α浓度升高（t=4．45、4．87、5．32、4．79和t=7．68、7．59、7．44、8．38，均P〈0．05），C组机械通气后各时间点IL-6、TNF-d浓度升高（t=4．78、5．56、7．62、8．03和t=3．98、4．52、5．46、6．23，均P〈0．05）。与T0比较，A组T2-T4时IL-6、TNF-α浓度差异均无统计学意义（均P〉0．05）。与B组比较，C组机械通气后各时间点IL-6、TNF-α浓度升高（t=4．58，4．99，6．53，4．77和t=5．62、7．89、6．43、4．52，均P〈0．05）。与T0比较，A组T2-T4时IL-6、TNF-α浓度差异均无统计学意义（均P〉0．05）。IL-10浓度在各组间差异均无统计学意义。结论妇科腔镜手术中根据呼气末二氧化碳分压（PetCO2）调节呼吸频率，使用8mL／kg潮气量行机械通气，对患者IL-6、TNF—α、IL-10等炎性因子没有影响，是较为合适的机械通气潮气量。

Objective To investigate the effects of different tidal volume mechanical ventilation on pulmonary function and inflammatory factors in gynecologic laparoscopic surgery. Methods 45 patients undergoing gynecological laparoscopic surgery without lung disease, ASA I - I1, aged 20 - 45 years old, weight 45 - 65 kg, operation time 2-3 hours,were randomly divided into A, B, C three groups, 15 cases in each group. Mechanical ventilation with different tidal volume of the three groups, A group, B group and C group were 8mL/kg,9mL/kg, 10mL/kg. Blood gas analysis was performed before anesthesia （ TO ）, 30 minutes （ T1 ）, （ T2 ）, PA - aDO2 （ 60 minutes） （ T3 ）, and 120 min （T4）, respectively, and the peak airway pressure and mean pressure were recorded. IL -6, TNF - α and IL - 10 levels in plasma by radial artery blood sampling were simultaneously determined. Results Compared with A group,the concentrations of Ppeak and Pmean were increased in B group at T1 - T4 （ t = 5.13,4.78,6.54,5.32 and t = 7.54,4.88,5.37,4.95 ; all P 〈 0.05 ）, the concentration of Ppeak and Pmean in C group at T1 - T4 increased （ t = 7.76,8.87,7.23,8.99 and t = 6.42,7.38,7.62,9.86 ; all P 〈 0.05 ）. Compared with B group, the concentrations of Ppeak and Pmean were increased in C group at T1 - T4 （ t = 4.76,5.87,4.23,3.99 and t = 4.76,3.99,6.06,4.52 ; all P 〈0.05 ）. Compared with A group ,the A - aDO2 values of B group and C group were increased at T1 ,T2 ,T3 and T4 （ t = 5.32,5.48,4.88,5.69 and t = 7.85,7.32,8.45,6.67 ; all P 〈 0.05 ）. Compared with B group at the same time point, the A - aDO2 value of C group increased at four times of T1 - T4 （ t = 5.62,4.38,6.94,4.22,P 〈 0.05 ）. Compared with group A, the concentration of A - aDO2 in C group was higher than that in B group at the same time point （ t = 4.45,4.87,5.32,4.79 and t = 7.68,7.59,7.44,8.38 ; all P 〈 0.05 ）. The levels of IL - 6 and TNF - α in C group were significantly higher than those in the control group （ t = 4.78,5.56,7.62,8.03 and t = 3.98,4.52, 5.46,6.23 ; all P 〈 0.05 ）. Compared with TO, IL - 6 and TNF - α concentrations AT T2 - T4 in A group had no statistically significant differences （ all P 〉 0. 05 ）. Compared with B group, the levels of IL - 6 and TNF - α in C group were significantly higher （ t = 4.58,4.99,6.53,4.77 and t = 5.62,7.89,6.43,4.52 ; all P 〈 0. 05 ）. Compared with TO, IL - 6 and TNF - αconcentrations at T2 - T4 in A group had no statistically significant differences （ all P 〉 0.05 ）. There was no significant difference in IL - 10 concentration among the thrce groups. Conclusion Laparoscopic surgery according to the end tidal carbon dioxide partial pressure （PetCO2 ） ventilation frequency, 8 mL/kg tidal volume mechanical ventilation has no effect on the IL- 6, TNF- alpha, IL- 10 and other inflammatory factors, mechanical ventilation tidal volume is more appropriate.