不同肺保护性通气策略在老年腹腔镜结直肠手术患者中的应用效果及安全性分析

Analysis on application effect and safety of different lung protective ventilation strategies in elderly patients undergoing laparoscopic colorectal surgery

目的探究不同肺保护性通气策略在老年腹腔镜结直肠手术患者中的应用效果及安全性。方法前瞻性选取2022年6月至2023年5月该院老年腹腔镜结直肠手术患者100例作为研究对象,按照随机数字表法以1∶1比例分为观察组和对照组,各50例。观察组采用驱动压导向的个体化呼气末正压通气(PEEP)模式,对照组采用传统PEEP模式。比较两组气管插管后5 min(T_(1)),气腹后5 min(T_(2)),手术开始1 h(T_(3)),手术开始2 h(T_(4)),腹腔关闭后(T_(5))血流动力学指标(平均动脉压、心率)、肺顺应性、气体交换指标[动脉血氧分压(PaO_(2))、氧合指数(OI)、肺泡-动脉血氧分压差(A-aDO_(2))、死腔/潮气量比值(Vd/Vt)],麻醉前、T_(5)时刻肺损伤标志物[白细胞介素-6(IL-6)、克拉拉细胞蛋白16(CC16)]水平,以及术后肺部并发症(PPCS)发生率。结果T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时刻两组平均动脉压、心率比较,差异无统计学意义(P>0.05);T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时刻观察组肺顺应性高于对照组(P<0.05);T_(1)、T_(2)、T_(3)、T_(4)、T_(5)时刻观察组PaO_(2)、OI高于对照组,A-aDO_(2)、Vd/Vt低于对照组(P<0.05);对照组T_(3)、T_(4)、T_(5)时刻A-aDO_(2)明显高于T_(1)时刻,观察组仅T_(4)时刻A-aDO_(2)明显高于T_(1)时刻(P<0.05);T_(5)时刻两组血清IL-6、CC16水平明显高于麻醉前,但观察组明显低于对照组(P<0.05);观察组PPCS发生率明显低于对照组(P<0.05)。结论老年腹腔镜结直肠手术中,驱动压导向的个体化PEEP模式可改善患者肺动态顺应性及气体交换,减轻炎症反应与术中肺损伤,降低PPCS发生率,更充分发挥PEEP的肺保护作用。

Objective To explore the application effect and safety of different lung protective ventilation strategies in elderly patients undergoing laparoscopic colorectal surgery.Methods A total of 100 elderly patients undergoing laparoscopic colorectal surgery in this hospital from June 2022 to May 2023 were prospectively selected as the research subjects and divided into the observation group and control group according to the random number table method in a ratio of 1∶1,50 cases in each group.The observation group adopted the driven pressure-oriented individualized positive end expiratory pressure(PEEP)model,while the control group adopted the traditional PEEP model.The hemodynamic indicators(mean arterial pressure,heart rate),lung compliance,gas exchange indicators[partial pressure of oxygen in arterial blood(PaO_(2)),oxygenation index(OI),alveola-arterial oxygen partial pressure difference(A-aDO_(2)),dead space/tidal volume ratio(Vd/Vt),at 5 min after endotracheal intubation(T_(1)),5 min after pneumoperitoneum(T_(2)),1,2 h after operation(T_(3),T_(4)),and after abdominal closure(T_(5)),the levels of lung injury markers interleukin-6(IL-6),clara cell protein 16(CC16)]before anesthesia and at T_(5),and the incidence rate of postoperative pulmonary complications(PPCS)were compared between the two groups.Results There was no statistically significant differences in mean arterial pressure and heart rate at T_(1),T_(2),T_(3),T_(4)and T_(5)between the two groups(P>0.05).The lung compliance at T_(1),T_(2),T_(3),T_(4)and T_(5)in the observation group was higher than that in the control group(P<0.05).PaO_(2)and OI at T_(1),T_(2),T_(3),T_(4)and T_(5)in the observation group were higher than those in the control group,while A-aDO_(2)and Vd/Vt in the observation group were lower than those in the control group(P<0.05).A-aDO_(2)at T_(3),T_(4)and T_(5)in the control group was higher than that at T_(1),while A-aDO_(2)at T_(4)in the observation group was only higher than that at T_(1)(P<0.05).The levels of serum IL-6 and CC16 at T_(5)in the two groups were higher than those before anesthesia,but the observation group was significantly lower than the control group(P<0.05).The incidence rate of PPCS in the observation group was significantly lower than that in control group(P<0.05).Conclusion In the elderly patients with laparoscopic colorectal surgery,driven pressure-oriented individualized PEEP model could improve the lung dynamic compliance and gas exchange,reduce the inflammatory response and intraoperative lung injury,reduce the incidence rate of PPCS,and give full play to the lung protective effect of PEEP.