不同水平呼气末正压通气在老年人腹腔镜手术中应用的比较

Comparison the Effect of Different Level of Positive End-expiratory Pressure Ventilation in Laparoscopic Surgery in Elderly Patients

目的:比较不同水平呼气末正压通气(Positive end-expiratory pressure,PEEP)应用于老年人腹腔镜手术中的效果。方法:选取我院2016年12月—2018年2月择期全麻下行腹腔镜下直肠癌根治术患者75例,ASAⅠ~Ⅱ级,随机分为3组,每组25例,麻醉诱导维持用药相同,气管插管后行机械通气,CO_2气腹前3组通气参数均设定潮气量(VT)8ml/㎏,呼吸频率(RR)12次/min,吸呼比(I∶E)=1∶2,充CO_2气腹后呼吸参数设定为VT6ml/㎏,RR 18次/min,I∶E=1∶2,Ⅰ组PEEP=0cm H2O,Ⅱ组PEEP=5cm H2O,Ⅲ组PEEP=10cm H2O,气腹结束后呼吸参数设定同气腹前。在气腹前即刻(T0),充气腹后30min(T1)、60min(T2)、90min(T3)、120min(T4),气腹结束后20min(T5)记录气道峰压(Ppeak),平均气道压(Pmean),平均动脉压(MAP),并于T0、T1、T2、T3、T4、T5采动脉血行血气分析,记录动脉血氧分压(PaO_2)、动脉血CO_2分压(PaCO_2),并计算氧合指数(OI)。结果:3组患者气腹前T0时点Ppeak、Pmean、MAP比较差异无统计学意义(P>0.05),充CO_2气腹后3组T1、T2、T3、T4时点Ppeak、Pmean与T0组内比较均明显上升(P<0.05),其中Ⅲ组上升最明显。MAP气腹后T1、T2、T3、T4Ⅰ、Ⅱ组组间比较差异无统计学意义(P>0.05),Ⅲ组与Ⅰ、Ⅱ组比较MAP下降(P<0.05)。3组患者CO_2气腹后PaO_2、OI较气腹前均下降(P<0.05),其中Ⅰ组下降最明显;CO_2气腹后3组患者PaCO_2均上升(P<0.05),其中Ⅰ组上升最明显。CO_2气腹后T5PaO_2、OI、PaCO_2均恢复至气腹前水平。结论:小潮气量联合PEEP=5cm H_2O通气模式较小潮气量联合PEEP=10cm H2O通气模式更适用于老年人腹腔镜手术。

Objective： To investigate the effect of different positive end-expiratory pressure ventilation in laparoscopic surgery in elderly patients. Methods： Seventy-five ASA classⅠorⅡpatients scheduled to undergo an elective laparoscopic radical resection of rectal cancer were randomly divided into 3 groups with 25 cases in each. All the patients received mechanical ventilation （MV） with a tidal volume （V T） at 8ml/kg, respiration rate （RR） at 12 times/min,and I∶ E at 1∶ 2 after induction of anesthesia.Since CO 2 pneumoperitoneum, the V T at 6ml/kg,RR at 18 times/min,and I∶ E at 1∶ 2,groupⅠwith 0cmH 2O PEEP;groupⅡwith 5cmH 2O PEEP; groupⅢwith 10cmH 2O PEEP.The same MV setting with pre-pneumoperitoneum after the end of pneumoperitoneum.The P peak ,P mean ,MAP were recorded at the beginning of pre-pneumoperitoneum（T 0） and 30min（T 1）,60min（T 2）,90min（T 3）,120min（T 4） post-pneumoperitoneum and 20min after pneumoperitoneum（T 5） in three groups.The oxygenation index（OI） was calculated based on the measurements of PaO 2 and PaCO 2 at T 0,T1,T 2,T 3,T 4 and T 5. Results： Before CO 2 pneumoperitoneum （T 0） there were no significant difference in P peak ,P mean ,MAP in three groups（ P 〉0.05）.After CO 2 pneumoperitoneum the P peak and P mean increased significantly （ P 〈0.05） at T 1, T 2,T 3,T 4 compared with T 0 in three groups,especially the group Ⅲ.There was no significant difference in MAP between the groupⅠand groupⅡat T 1,T 2,T 3,T 4 （ P 〉0.05） after pneumoperitoneum. The MAP decreased significantly in group Ⅲcompared with the groupⅠand groupⅡat T 1,T 2,T 3,T 4 after pneumoperitoneum （ P 〈0.05）.The PaO 2 and OI decreased significantly after pneumoperitoneum in three groups,especially the groupⅠ（ P 〈0.05）.After CO 2 pneumoperitoneum the PaCO 2 increased in three groups,especially the groupⅠ（ P 〈0.05）.The PaO 2,OI and PaCO 2 were recovered to the level of pre-pneumoperitoneum at T 5 in three groups. Conclusion： Low tidal volume combined with 5cmH 2O PEEP was better than 10cmH 2O PEEP for MV in laparoscopic surgery in elderly patients.