肺保护性通气策略在全身麻醉患者经后腹膜腹腔镜手术中的应用

Application of lung protective ventilation strategy in patients undergoing retroperitoneal approach laparoscopic surgery with general anesthesia

目的比较肺保护性通气策略与传统通气策略在全身麻醉患者经后腹膜腹腔镜手术中的通气效果。方法选取2017年1月至2019年6月于北京医院/国家老年医学中心/中国医学科学院老年医学研究院全身麻醉下侧卧折刀位行经后腹膜腹腔镜肾癌手术的患者60例,按照随机数字表法分为两组:传统通气策略组(A组)和肺保护性通气策略组(B组),A组和B组各30例。记录T1(全身麻醉插管后)、T2(侧卧折刀位5min)、T3(气腹30min)、T4(手术结束时)时刻的气道平均压、肺顺应性和呼气末二氧化碳(end-tidal carbon dioxide,EtCO2);记录T0(入手术室)、T2、T3、T4、T5(术后24h)时刻的动脉血pH、动脉血氧分压(arterial partial pressure of oxygen,PaO2)和动脉血二氧化碳分压(arterial partial pressure of carbon dioxide,PaCO2);记录有无术后呼吸衰竭。结果B组在T1、T2、T3、T4时刻的气道平均压均明显低于A组,B组在T1、T2、T3、T4时刻的肺顺应性和EtCO2均明显高于A组,差异有显著性(P<0.05)。B组在T2、T3时刻的PaCO2均明显高于A组,差异有显著性(P<0.05),而T4、T5时两组的PaCO2差异无显著性(P>0.05),其余血气指标差异无显著性(P>0.05)。两组患者术后均未发生呼吸衰竭。结论肺保护性通气策略降低术中气道压,具有更好的肺顺应性,术中PaCO2会有一过性升高但无相关并发症,可安全用于全身麻醉下经后腹膜腹腔镜手术。

Objective To compare the efficacy of protective ventilation strategy to traditional ventilation strategy in retroperitoneal approach laparoscopic surgery under general anesthesia.Method Sixty patients scheduled for elective retroperitoneal approach laparoscopic kidney cancer surgery in lateral clasp-knife position under general anesthesia from January 2017 to June 2019 were randomly divided into 2 groups,thirty patients in each group,traditional ventilation group(group A)and lung protective ventilation group(group B).Mean airway pressure,lung compliance and end-expiratory carbon dioxide(EtCO2)were recorded at T1(intubation),T2(5 mins after lateral claspknife position),T3(30 mins after pneumoperitoneum)and T4(end of surgery).Arterial blood pH,arterial partial pressure of oxygen(PaO2),arterial blood partial pressure of carbon dioxide(PaCO2)should be recorded at T0(entering the operating room),T2,T3,T4 and T5(24h after operation).Occurance of postoperative respiratory failure was recorded.Result Mean airway pressure in group B at T1,T2,T3,T4 were lower than group A(P<0.05).Lung compliance and EtCO2 in group B at T1,T2,T3,T4 were higher than group A(P<0.05).PaCO2 in group B at T2 and T3 were higher than group A(P<0.05).There was no difference on PaCO2 at T4 and T5 between two groups(P>0.05).There was no significant difference in other blood gas indexes(P>0.05).No postoperative respiratory failure occurred in the two groups.Conclusion Lung protective ventilation has lower airway pressure and better lung compliance during retroperitoneal approach laparoscopic surgery.There is transient increase in PaCO2 during the operation with no related complications.Lung protection ventilation model can be safely used in patients undergoing retroperitoneal approach laparoscopic surgery with general anesthesia.