通气侧肺前列腺素E_(1)雾化吸入对单肺通气患者氧合的影响

Effect of prostaglandin E_(1) nebulization inhalation on oxygenation in patients during one-lung ventilation

目的探讨通气侧肺前列腺素E_(1)(PGE_(1))雾化吸入预给药对食管癌患者FiO_(2)50%单肺通气(OLV)期间机体氧合的影响。方法选择拟行左剖胸食管癌根治术的患者113例,男92例,女21例,年龄18~79岁,BMI<30 kg/m^(2),ASAⅡ或Ⅲ级。采用随机数字表法将患者分为四组:PGE_(1)0.1μg/kg组(P1组,n=29)、PGE_(1)0.2μg/kg组(P2组,n=29)、PGE_(1)0.3μg/kg组(P3组,n=30)和生理盐水对照组(C组,n=25)。麻醉平稳改右侧卧位后,P1组、P2组和P3组分别给予右侧肺PGE_(1)0.1、0.2和0.3μg/kg(以生理盐水稀释至10 ml)雾化吸入,C组给予右侧肺生理盐水10 ml雾化吸入,雾化吸入时间均为10 min。记录术前PaO_(2)、手术时间、OLV时间、术中出血量、尿量、输液量。分别于全麻后右侧卧位时(T_(0))、OLV 10 min(T_(1))、OLV 15 min(T_(2))、OLV 30 min(T_(3))、OLV 60 min(T_(4))、OLV 120 min(T5)抽取桡动脉血和右颈内静脉血各2 ml,采样后立刻行血气分析,计算肺内分流率(Qs/Qt),记录T_(0)—T_(5)时PaO_(2)、PaCO_(2)、P_(ET)CO_(2)、MAP、HR、Ppeak。于T_(0)、T_(4)、OLV结束恢复双肺通气30 min(T_(6))及术后24 h(T_(7))抽取中心静脉血,采用ELISA法检测血清白细胞介素-6(IL-6)和肿瘤坏死因子-α(TNF-α)浓度。记录术后第2天临床肺部感染评分(CPIS),记录术后7 d内肺不张、吻合口瘘等肺部并发症的发生情况以及ICU停留时间、总住院时间。结果四组术前PaO_(2)、手术时间、OLV时间、术中出血量、尿量、输液量差异无统计学意义。T_(1)—T_(3)时P3组Qs/Qt明显低于其余三组,PaO_(2)明显高于其余三组(P<0.05);P2组Qs/Qt明显低于P1组和C组,PaO_(2)明显高于P1组和C组(P<0.05);P1组Qs/Qt明显低于C组,PaO_(2)明显高于C组(P<0.05)。T_(4)时P1组、P2组和P3组Qs/Qt明显低于C组,PaO_(2)明显高于C组(P<0.05);P3组Qs/Qt明显低于P1组,PaO_(2)明显高于P1组(P<0.05)。T_(1)、T_(2)时P3组MAP明显低于C组(P<0.05)。T_(4)、T_(6)、T_(7)时P1组、P2组和P3组血清IL-6、TNF-α浓度明显低于C组(P<0.05)。P1组、P2组和P3组CPIS评分明显低于C组(P<0.05)。四组术后肺不张、吻合口瘘发生率、ICU停留时间、总住院时间差异无统计学意义。结论在FiO_(2)50%的条件下,于双肺通气期间预先给予OLV期间的通气侧肺雾化吸入PGE_(1),可以通过降低肺内分流率而改善氧合,以保证机体氧供(该效应在OLV 10、15、30 min时呈明显的剂量依赖性),同时降低患者围术期血清IL-6和TNF-α浓度。

Objective To investigate the effect of prostaglandin E_(1)(PGE_(1))nebulization inhalation on oxygenation during one lung ventilation(OLV)in patients with esophageal cancer undergoing thoracotomy under FiO_(2)50%.Methods A total of 113 patients undergoing radical esophagectomy for left thoracotomy,92 males and 21 females,aged 18-79 years,BMI<30 kg/m^(2),ASA physical statusⅡorⅢ,were selected and randomly divided into four groups by random number table method:PGE_(1)0.1μg/kg group(group P1,n=29),PGE_(1)0.2μg/kg group(group P2,n=29),PGE_(1)0.3μg/kg group(group P3,n=30)and normal saline control group(group C,n=25).After the anesthesia was stable and changed to the right lateral position,groups P1,P2,and P3 were given PGE_(1)0.1,0.2,and 0.3μg/kg(diluted to 10 ml with normal saline)nebulization inhalation in the right lung respectively,and group C was given normal saline 10 ml nebulization inhalation in the right lung for 10 minutes.Preoperative PaO_(2),operation time,OLV time,intraoperative bleeding,urine volume and infusion volume were recorded.Radial artery blood 2 ml and right internal jugular vein blood 2 ml were taken after the anesthesia was stable and changed to the right lateral position(T_(0)),OLV 10 minutes(T_(1)),OLV 15 minutes(T_(2)),OLV 30 minutes(T_(3)),OLV 60 minutes(T_(4))and OLV 120 minutes(T5),and blood gas analysis was performed immediately after sampling.Intrapulmonary shunt rate(Qs/Qt)was calculated.PaO_(2),PaCO_(2),P_(ET)CO_(2),MAP,HR,and Ppeak at T_(0)-T_(5) were recorded.The central venous blood was collected at T_(0),T_(4),30 minutes after two lung ventilation was restored(T_(6))and 24 hours after operation(T_(7)),and the concentration of serum interleukin-6(IL-6)and tumor necrosis factor-α(TNF-α)were detected by enzyme-linked immunosorbent assay(ELISA).The clinical pulmonary infection score(CPIS)was recorded on the second day after operation,the occurrence of pulmonary complications such as atelectasis and anastomotic fistula within 7 days after operation,the length of stay in ICU,and the total length of hospital stay were recorded.Results There were no significant differences in preoperative PaO_(2),operation time,OLV time,intraoperative bleeding,urine volume,and infusion volume between the four groups.At T_(1)-T_(3),the Qs/Qt in group P3 was significantly lower than that in the other three groups,the PaO_(2)was significantly higher than that in the other three groups(P<0.05),the Qs/Qt in group P2 was significantly lower than that in groups P1 and C,the PaO_(2)was significantly higher than that in groups P1 and C(P<0.05),the Qs/Qt in group P1 was significantly lower than that in group C,and the PaO_(2)was significantly higher than that in group C(P<0.05).At T_(4),the Qs/Qt in groups P1,P2,and P3 was significantly lower than that in group C,and the PaO_(2)was significantly higher than that in group C;the Qs/Qt in group P3 was significantly lower than that in group P1,and the PaO_(2)was significantly higher than that in group P1(P<0.05).MAP in group P3 was significantly lower than that in group C at T_(1)and T_(2)(P<0.05).The concentrations of serum IL-6 and TNF-αin groups P1,P2,and P3 were significantly lower than that in group C at T_(4),T_(6),and T_(7)(P<0.05).The postoperative CPIS in groups P1,P2,and P3 was significantly lower than that in group C(P<0.05).There were no significant differences in the incidences of postoperative atelectasis,anastomotic fistula,ICU stay,and total hospital stay among the four groups.Conclusion Under the condition of FiO_(2)50%,nebulization inhalation of prostaglandin E_(1) during bilateral rentilation can improve oxygenation by reducing the intrapulmonary shunt rate dose-dependently at OLV 10,15,and 30 minutes,and reduce the perioperative serum inflammatory factors IL-6 and TNF-α.