肺保护性通气策略对PPCs中危患者腹部手术PPCs的影响

Effect of lung-protective ventilation strategy on PPCs in patients at moderate risk for PPCs undergoing abdominal surgery

目的评价肺保护性通气策略(LPVS)对术后肺部并发症(PPCs)中危患者腹部手术PPCs的影响。方法择期胃肠道肿瘤手术患者100例,年龄50~80岁,性别不限,ASA分级Ⅱ或Ⅲ级,预计加泰罗尼亚外科患者呼吸风险评估(ARISCAT)评分26~44分,采用随机数字表法分为传统通气策略组(T组)和LPVS组(L组),每组50例。T组VT10 ml/kg(理想体重),FiO20.5;L组VT 6 ml/kg(理想体重),FiO20.5、PEEP 6 cmH2O,每隔30 min进行1次手法肺复张(气道正压30 cmH2O,持续30 s)。于麻醉诱导前5 min(T0)、气管拔管后30 min(T1)、手术结束后24 h(T2)时取血样,采用ELISA法测定测定血清IL-6、TNF-α、NF-κB、可溶性细胞间粘附分子1(sICAM-1)浓度;术后7 d随访PPCs的发生情况和严重程度。结果最终T组纳入47例,L组纳入46例。与T0时比较,T1时T组血清IL-6、TNF-α、NF-κB和sICAM-1浓度升高(P<0.05),L组上述指标差异无统计学意义(P>0.05);与T1时比较,T2时T组血清IL-6、TNF-α、NF-κB和sICAM-1浓度降低,L组血清TNF-α和NF-κB浓度降低(P<0.05);与T组比较,L组T1时血清IL-6、TNF-α、NF-κB和sICAM-1浓度降低,PPCs发生率及其严重程度降低(P<0.05)。结论LPVS可减轻腹部手术PPCs中危患者全身炎症反应,降低PPCs的发生风险和严重程度。

Objective To evaluate the effect of lung-protective ventilation strategy(LPVS)on postoperative pulmonary complications(PPCs)in the patients at moderate risk for PPCs undergoing abdominal surgery.Methods One hundred patients of both sexes,aged 50-80 yr,of American Society of Anesthesiology physical statusⅡorⅢ,with risk scores of 26-44 points predicted by the Assess Respiratory Risk in Surgical Patients in Catalonia,scheduled for elective gastrointestinal surgery,were randomized into conventional ventilation group(group T)and LPVS group(group L),with 50 patients in each group.The tidal volume(VT)was 10 ml/kg(ideal body weight),and FiO2 was 0.5 in group T.VT was 6 ml/kg(ideal body weight),FiO2 was 0.5,PEEP was 6 cmH2O,and recruitment maneuvres were performed every 30 min(positive airway pressure 30 cmH2O,lasting for 30 s)in group L.Blood samples were collected at 5 min before induction(T0),30 min after extubation(T1)and 24 h after the end of surgery(T2)to detect the concentrations of interleukin-6(IL-6),tumor necrosis factor-alpha(TNF-α),nuclear factor kappa B(NF-κB),and soluble intercellular adhesion molecule-1(sICAM-1).The patients were followed up for 7 days to record the development and severity of PPCs.Results Forty-seven cases were finally included in group T and 46 cases in group L.Compared with the baseline value at T0,the serum concentrations of IL-6,TNF-α,NF-κB and sICAM-1 were significantly increased at T1 in group T(P<0.05),and no significant change was found in the parameters mentioned above in group L(P>0.05).Compared with those at T1,the serum concentrations of IL-6,TNF-α,NF-κB and sICAM-1 were significantly decreased at T2 in group T,and the serum concentrations of TNF-αand NF-κB were significantly decreased at T2 in group L(P<0.05).Compared with group T,the serum concentrations of IL-6,TNF-α,NF-κB and sICAM-1 were significantly decreased at T1,and the incidence and severity of PPCs were decreased in group L(P<0.05).Conclusion LPVS can reduce the systemic inflammatory responses and decrease the occurrence and severity of PPCs in the patients at moderate risk for PPCs undergoing abdominal surgery.