压力控制容量保证通气联合个性化呼气末正压通气对脑肿瘤手术患者氧合功能及术后肺部并发症的影响

The effect of pressure controlled ventilation-volume guaranteed combined with personalized positive end expiratory pressure ventilation on oxygenation function and postoperative pulmonary complications in patients undergoing brain tumor surgery

目的探讨术中采用压力控制容量保证通气(PCV-VG)模式联合个性化呼气末正压通气(PEEP)的通气策略,对脑肿瘤手术患者氧合功能及术后肺部并发症(PPCs)发生率的影响。方法选择2023年1月至2023年6月临沂市人民医院60例择期行脑肿瘤手术的患者,采用随机数字表法将患者分为PCV-VG通气模式组(T组)和容量控制通气(VCV)模式组(C组),每组30例。T组因病情变化排除1例,实际纳入29例患者。T组采用PCV-VG通气模式并通过滴定PEEP寻找动态肺顺应性(Cdyn)最大值,与Cdyn最大值对应的PEEP即为最佳PEEP,保持至机械通气结束。C组采用VCV加5 cmH_(2)O定值PEEP的通气模式。所有患者于麻醉诱导前(T_(1))、设定通气模式后15 min(T_(2))、拔管后15 min(T_(3))进行动脉血气分析,记录动脉血氧分压(PaO_(2))、二氧化碳分压(PaCO_(2))、乳酸(Lac)和血糖(Glu),计算氧合指数(PaO_(2)/FiO_(2))。记录术前、术后72 h白细胞(WBC)、C-反应蛋白(CRP)、降钙素原(PCT)水平。观察术后72 h PPCs的发生率。结果C组和T组PaO_(2)、PaCO_(2)的分组效应及时间效应的差异有统计学意义(均P<0.05),交互效应的差异无统计学意义(均P>0.05);C组和T组PaO_(2)/FiO_(2)的分组效应、时间效应和交互效应的差异有统计学意义(均P<0.05)。T组滴定得出的最佳化PEEP的平均值为7.48 cmH_(2)O,对应平台压(Pplat)的平均值为14.90 cmH_(2)O,对应Cdyn最大值的平均值53.37 ml/cmH_(2)O,与C组定值5 cmH_(2)O PEEP对应的Pplat和Cdyn相比,T组最佳化PEEP对应的Pplat低于C组(P<0.05),Cdyn高于C组(P<0.05)。T组术后72 h的CRP水平、PPCs的发生率明显低于C组(均P<0.05)。结论与VCV相比,PCV-VG联合个性化PEEP的通气模式能够改善脑肿瘤患者术中肺通气及氧合功能,减少术后72 h肺部炎症的发生,降低PPCs的发生率。

Objective To explore the ventilation strategy of using pressure controlled ventilation-volume guaranteed(PCV-VG)mode combined with personalized positive end expiratory pressure(PEEP)during surgery,and its impact on oxygenation function and incidence of postoperative pulmonary complications(PPCs)in patients undergoing brain tumor surgery.Methods Sixty patients who underwent elective brain tumor surgery at the Linyi People′s Hospital from January 2023 to June 2023 were selected.The patients were randomly divided into PCV-VG ventilation mode group(T group)and volume controlled ventilation(VCV)mode group(C group)using a random number table method,with 30 patients in each group.One patient was excluded from group T due to changes in the condition,and 29 patients were actually included.Group T adopted PCV-VG ventilation mode and searched for the maximum dynamic lung compliance(Cdyn)by titrating PEEP.The PEEP corresponding to the maximum Cdyn value was the optimal PEEP,which was maintained until the end of mechanical ventilation.Group C adopted a ventilation mode of VCV plus 5 cmH_(2)O fixed value PEEP.All patients underwent arterial blood gas analysis before anesthesia induction(T_(1)),15 minutes after setting ventilation mode(T_(2)),and 15 minutes after extubation(T_(3)),recording arterial oxygen partial pressure(PaO_(2)),carbon dioxide partial pressure(PaCO_(2)),lactate(Lac),and blood glucose(Glu),and calculating oxygenation index(PaO_(2)/FiO_(2)).The levels of white blood cells(WBC),C-reactive protein(CRP),and procalcitonin(PCT)were recorded before and 72 hours after surgery.The incidence of postoperative PPCs at 72 hours was observed.Results There was a statistically significant difference in the grouping effect and time effect of PaO_(2) and PaCO_(2) between group C and group T(all P<0.05),while there was no statistically significant difference in the interaction effect(all P>0.05);The differences in grouping effects,time effects,and interaction effects of PaO_(2)/FiO_(2) between group C and group T were statistically significant(all P<0.05);The average value of the optimized PEEP obtained by T-group titration was 7.48 cmH_(2)O,corresponding to an average platform pressure(Pplat)of 14.90 cmH_(2)O,and an average value of 53.37 ml/cmH_(2)O corresponding to the maximum Cdyn value.Compared with the Pplat and Cdyn corresponding to the fixed value of 5 cmH_(2)O PEEP in Group C,the Pplat corresponding to the optimized PEEP in Group T was lower than that in Group C(P<0.05),and the Cdyn was higher than that in group C(P<0.05).The CRP level and incidence of PPCs in group T after 72 hours of surgery were significantly lower than those in group C(all P<0.05).Conclusions Compared with VCV,the ventilation mode of PCV-VG combined with personalized PEEP can improve intraoperative lung ventilation and oxygenation function in patients with brain tumors,reduce the occurrence of pulmonary inflammation 72 hours after surgery,and lower the incidence of PPCs.