极小潮气量机械通气在输尿管软镜手术中的应用

Application of minimal tidal volume mechanical ventilation strategy in patients undergoing flexible ureteroscopy

目的评价极小潮气量机械通气策略对输尿管软镜手术患者术中心肺脑功能的影响。方法选择择期气管内插管全麻下行输尿管软镜钬激光碎石术患者74例,男59例,女15例,年龄25~60岁,BMI 18~28 kg/m^2,ASAⅠ或Ⅱ级,根据不同通气方法随机分为三组:常规小潮气量机械通气组(C组,n=20)、间歇通气呼吸暂停组(A组,n=28)和极小潮气量机械通气组(M组,n=26)。术中呼吸参数设置:C组VT 6 ml/kg,RR 12次/分;A组VT 6 ml/kg,RR 12次/分,于碎石开始时暂停通气,碎石结束后恢复通气,最大暂停时间5 min,暂停次数依据碎石情况决定;M组VT 6 ml/kg,RR 12次/分,碎石开始时采用极小潮气量通气模式,VT 3 ml/kg,RR 24次/分,SpO2下降至95%时恢复正常通气。分别于麻醉前(T1)、手术开始前(T2)、碎石开始前(T3)、碎石结束后即刻(T4)、拔管后30 min(T5)行血气分析,记录pH、PaCO2,计算氧合指数(OI)、动-静脉氧分压差(Pa-jvO2)、动静脉血氧饱和度差(Sa-jvO2)、脑氧摄取率(CERO2)。T1、T5、术后24 h(T6)采用ELISA法测定静脉血S100β蛋白、肌红蛋白(MB)、肌酸激酶同工酶(CK-MB)、肌钙蛋白(cTnI、cTnT)浓度。记录激光碎石时间、术者满意程度评分。记录术中不良反应的发生情况。结果与A组比较,T4时C组和M组PaCO2明显降低,pH和OI明显升高(P<0.05)。与C组比较,A组和M组激光碎石时间明显缩短,术者满意程度评分明显提高(P<0.05)。三组不同时点rSO2、CERO2、Pa-jvO2、Sa-jvO2、S100β、MB、CK-MB、cTnI、cTnT浓度差异无统计学意义。三组不良反应发生率差异无统计学意义。结论极小潮气量机械通气策略可安全、有效地应用于输尿管软镜手术。

Objective To evaluate the effect of minimal tidal volume mechanical ventilation on the function of heart brain and lungs in patients undergoing flexible ureteroscopy. Methods Seventy-four patients scheduled for ureteroscopic holmium laser lithotripsy under tracheal intubation anesthesia, 59 males and 15 females, aged 25-60 years, with a BMI 18-28 kg/m^2, falling into ASA physical status Ⅰ or Ⅱ, were divided into 3 groups according to different ventilation methods randomly: conventional mechanical ventilation group(group C, n = 20), apena group(group A, n = 28), and minimal tidal volume mecha￣nical ventilation group(group M, n = 26). The intraoperative ventilation mode of group C was used VT 6 ml/kg and RR 12 times/min. In group A, VT 6 ml/kg and RR 12 times/min were used, mechanical ventilation was suspended at the beginning of lithotripsy and resumed after the lithotripsy was finished, the longest maximum pause time was 5 min and the times of pause were determined according to the condition of lithotripsy. In group M, VT 6 ml/kg and RR 12 times/min were used, the minimal tidal volume mechanical ventilation mode was used when the lithotripsy started, then we used VT 3 ml/kg and RR 24 times/min, as well as SpO2 decreased to 95% as the limit of restoring normal mechanical ventilation. Blood samples were collected before anesthesia(T1), before surgery(T2), before the start of lithotripsy(T3), after the completion of lithotripsy immediately(T4), and 30 min after extubation(T5) for blood gas analysis. pH, PaCO2 were recorded. Oxygenation index(OI), the arterial and internal jugular venous oxygen pressure difference(Pa-jvO2), blood oxygen saturation difference(Sa-jvO2), and cerebral extraction rate of oxygen(CERO2) were calculated. Blood samples were collected from the vein for determination of S100β protein, myoglobin(MB), creatine kinase(CK)-MB, and troponin I and T at T1, T5, and 24 h after surgery(T6). The time of laser lithotripsy and the score of the mobility of stones from surgeon were recorded. The intraoperative adverse reactions were recorded. Results Compared with group C, the value of PaCO2 in group A was significantly higher, while the value of pH and OI was significantly lower at T4(P < 0.05). Compared with group A, the value of PaCO2 in group M was significantly lower, while the value of pH and OI was significantly higher at T4(P < 0.05). The time of laser lithotripsy was significantly shortened, and the surgeon was more satisfied with the condition of the lithotripsy(P<0.05) in group A and group M. There was no significant difference in CC16, rSO2, CERO2, Pa-jvO2, Sa-jvO2, S100β protein, MB, CK-MB, and troponin I and T among three groups at each time point. The incidence of adverse reaction indicators had no difference among three groups. Conclusion The minimal tidal volume mechanical ventilation strategy can be safely and effectively applied to flexible ureteroscopy.