肺保护通气对老年腹腔镜手术病人术后肺部并发症的影响

Effect of lung protective ventilation on postoperative pulmonary complications in elderly patients treated with laparoscopic surgery

目的:观察肺保护通气对老年腹腔镜手术病人术后肺部并发症的影响。方法:择期腹腔镜结直肠癌根治术老年病人80例,按随机数字表法分为肺保护通气组(P组)和对照组(C组)。麻醉诱导前(T0)、气管插管后5 min(T1)、气腹后1 h(T2)、手术结束时(T3)、拔管后2 h(T4)、术后24 h(T5),采集桡动脉血进行血气分析,记录术中呼吸力学指标及手术开始和结束时的桡动脉血浆中性粒细胞弹性蛋白酶(neutrophil elastase,NE)浓度,记录术后7 d内肺部并发症并予以临床肺部感染评分(CPIS),统计术后30 d的死亡病例数等。结果:PaO2/FiO2值T0、T1、T2、T4时2组差异无统计学意义(P>0.05),T3、T5时C组低于P组(P<0.05);PaCO2值T0、T1、T5时2组差异无统计学意义(P>0.05),T2~3时C组低于P组,而T4时C组高于P组(P<0.01);pH值T0、T1、T5时C组低于P组,而T2~4时C组高于P组(P<0.05~P<0.01)。C组T3~5时PaO2/FiO2较T0时下降,T4~5时PaCO2高于T0时,P组T3~4时PaO2/FiO2较T0时下降,T2~4时PaCO2高于T0时(P<0.05);P组T5时PaO2/FiO2和PaCO2均基本恢复到术前水平(P>0.05);T5时C组pH下降(P<0.05),而P组在T4-5时pH下降(P<0.05)。T1时2组气道峰压(Ppeak),气道平均压(Pmean)和肺动态顺应性(Cdyn)值差异均无统计学意义(P>0.05),T2时P组Ppeak,Pmean和Cdyn均高于C组(P<0.01)。与T1时比较,T2时2组病人Ppeak和Pmean均升高,而Cdyn则下降(P<0.05)。与T0时比较,2组病人T3时血浆NE浓度均升高(P<0.01);T0时2组病人血浆NE浓度差异无统计学意义(P>0.05),T3时P组血浆NE浓度低于C组(P<0.01)。2组病人术后7 d内肺部各并发症发生率及术后住院时间差异无统计学意义(P>0.05)。2组病人术后第7天CPIS评分较术后第1天降低(P<0.01),与C组相比P组在术后第7天CPIS评分更低(P<0.01)。结论:肺保护通气有利于改善老年腹腔镜结直肠癌根治术病人术后早期的氧合,减轻肺损伤,有利于老年病人手术的安全。

Objective:To study the effects of lung protective ventilation on postoperative pulmonary complications(PPCs)in elderly patients treated with laparoscopic surgery.Methods:Eighty colorectal carcinoma patients scheduled by laparoscopic radical resection were randomly divided into the lung protective ventilation group(group P)and control group(group C)(40 cases each group).Before general anesthesia induction(T0),after 5 minutes of intubation(T1),post-pneumoperitoneum 1 hour(T2),at the end of operation(T3),after 2 hours of extubation(T4)and postoperative 24 hours(T5),the blood gas analysis of radial artery was carried out.The intraoperative respiratory mechanical index and plasma neutrophil elastase(NE)concentration at the beginning and end of operation were recorded.The postoperative 7 days pulmonary complication and its score were recorded and analyzed using the clinical pulmonary infection score(CPIS),and the number of death after 30 days of operation were calculated.Results:The differences of the value of PaO2/FiO2 at T0,T1,T2 and T4 between two groups were not statistically significant(P>0.05),and which in group C were lower than that in group P at T3 and T5(P<0.05).The differences of the value of PaO2 at T0,T1 and T5 between two groups were not statistically significant(P>0.05),and which at T2-3 and T4 in group C were lower and higher than that in group P,respectively(P<0.01).The pH value at T0,T1 and T5 and T2-4 in group C was lower and higher than that in group P,respectively(P<0.05 to P<0.01).Compared with T0,the PaO2/FiO2 at T3-5 decreased in group C,and the PaO2/FiO2 in group C at T4-5 was higher than that at T0.Compared with T0,the PaO2/FiO2 at T3-4 decreased in group P,and the PaO2/FiO2 in P group at T2-4 was higher than that at T0(P<0.05).The PaO2/FiO2 and PaCO2 in group P at T5 basically restored to the preoperative level(P>0.05),and the pH value in group C at T5 and P group at T4-5 decreased(P<0.05).The differences of the Ppeak,Pmean and Cdyn at T1 between two groups were not statistical significance(P>0.05),and the Ppeak,Pmean and Cdyn in group P were higher than those in group C(P<0.05).Compared with at T1,the Ppeak and Pmean increased,and the Cdyn significantly decreased in two groups at T2(P<0.05).Compared with T0,the NE levels in two groups increased at T3(P<0.01),the difference of the NE level at T0 between two groups was not statistically significant(P>0.05),and the level of NE in group P was lower than that in group C at T3(P<0.01).The differences of the incidence rate of pulmonary complications within 7 days of operation and postoperative hospitalization time between two groups were not satistically significant(P>0.05).Compared with first day after operation,the CPIS scores in two groups decreased at seventh day after operation(P<0.01),and the CPIS score in group C at seventh day after operation was lower compared with P group(P<0.01).Conclusions:Lung protective ventilation in elderly colorectal carcinoma patients treated with laparoscopic radical resection can improve the early postoperative oxygenation,alleviate lung injury,and ensure the safety of patients.