人工气胸对食管癌切除术患者围术期凝血-纤溶功能的影响
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摘要
目的观察CO_2人工气胸对胸腹腔镜联合食管癌切除术患者围术期凝血-纤溶功能的影响。方法选择2017年11月至2018年6月我院择期行胸腹腔镜联合食管癌切除术患者80例,随机分为CO_2人工气胸组(P组)和非CO_2人工气胸组(N组),每组40例,分别于麻醉前(T1)、人工气胸开始60 min后或单肺通气60 min后(T2)、人工气胸停止30 min后或双肺通气30 min后(T3)、术后第1天(T4)、第3天(T5) 5个时间点测定患者组织型纤溶酶原激活物(t-PA)、纤溶酶原激活剂抑制物(PAI-1)、血栓弹力图(TEG)、D_2-聚体(D-D)及血气分析。结果与N组相比,P组于人工气胸开始60 min后(T2) pH值明显降低(P <0. 05),PaCO_2明显增高(P <0. 05),TEG测定R值和K值显著延长(P <0. 05),α角、MA值显著减小(P <0. 05),t-PA明显升高(P <0. 05);人工气胸结束30 min后,pH值、PaCO_2和t-PA逐渐恢复至术前水平(P> 0. 05);术后第1天TEG测定R值、K值、α角、MA值恢复至术前水平(P> 0. 05); 2组术后D-D均显著升高(P <0. 05),但组间比较差异无统计学意义(P> 0. 05)。结论 CO_2人工气腹建立后导致的呼吸性酸中毒可使患者术中凝血功能显著降低,纤溶功能增强,术后第1天恢复至术前水平。
Objective To observe the effect of CO_2 artificial pneumothorax on perioperative coagulation-fibrinolysis in patients undergoing thoracoscopic esophagectomy. Methods A total of 80 patients with thoracic-laparoscopic combined esophageal resection in our hospital from November 2017 to June 2018 were randomly divided into CO_2 artificial pneumothorax group( P group) and non-CO_2 artificial pneumothorax group( N group),40 cases in each group. The patient's tissue plasminogen activator( t-PA),plasminogen activator inhibitor( PAI-1),thromboelastogram( TEG),Polymer( D-D) and blood gas analysis were measured at 5 time points included before anesthesia( T1),artificial pneumothorax 60 minutes or single lung ventilation 60 minutes( T2),artificial pneumothorax stop 30 minutes or double lung ventilation 30 minutes( T3),postoperative first day( T4) and postoperative third day( T5). Results Compared with the N group,the p H value of the P group was significantly decreased at T2( P < 0. 05),the PaCO_2 was significantly increased( P < 0. 05),and the R and K values of the TEG were significantly prolonged( P < 0. 05),the angle and MA decreased significantly( P < 0. 05),t-PA increased significantly( P < 0. 05). After30 minutes of artificial pneumothorax,the p H value,PaCO_2 and t-PA gradually recovered to the preoperative level( P > 0. 05). On the first day after operation,the R value,K value,α angle and MA value of TEG were restored to the preoperative level( P > 0. 05). The postoperative DD was significantly increased in both groups( P < 0. 05),but there was no statistically significant difference between two groups( P > 0. 05).Conclusion Respiratory acidosis caused by the establishment of CO_2 pneumoperitoneum can significantly reduce the coagulation function of patients during the operation,enhance the fibrinolysis function,and return to the preoperative level on the first day after the operation.
Objective To observe the effect of CO_2 artificial pneumothorax on perioperative coagulation-fibrinolysis in patients undergoing thoracoscopic esophagectomy. Methods A total of 80 patients with thoracic-laparoscopic combined esophageal resection in our hospital from November 2017 to June 2018 were randomly divided into CO_2 artificial pneumothorax group( P group) and non-CO_2 artificial pneumothorax group( N group),40 cases in each group. The patient's tissue plasminogen activator( t-PA),plasminogen activator inhibitor( PAI-1),thromboelastogram( TEG),Polymer( D-D) and blood gas analysis were measured at 5 time points included before anesthesia( T1),artificial pneumothorax 60 minutes or single lung ventilation 60 minutes( T2),artificial pneumothorax stop 30 minutes or double lung ventilation 30 minutes( T3),postoperative first day( T4) and postoperative third day( T5). Results Compared with the N group,the p H value of the P group was significantly decreased at T2( P < 0. 05),the PaCO_2 was significantly increased( P < 0. 05),and the R and K values of the TEG were significantly prolonged( P < 0. 05),the angle and MA decreased significantly( P < 0. 05),t-PA increased significantly( P < 0. 05). After30 minutes of artificial pneumothorax,the p H value,PaCO_2 and t-PA gradually recovered to the preoperative level( P > 0. 05). On the first day after operation,the R value,K value,α angle and MA value of TEG were restored to the preoperative level( P > 0. 05). The postoperative DD was significantly increased in both groups( P < 0. 05),but there was no statistically significant difference between two groups( P > 0. 05).Conclusion Respiratory acidosis caused by the establishment of CO_2 pneumoperitoneum can significantly reduce the coagulation function of patients during the operation,enhance the fibrinolysis function,and return to the preoperative level on the first day after the operation.
引文
[1]张博友,耿庆.全胸腹腔镜食管癌根治术与加速康复食管外科[J].世界华人消化杂志,2016,24(33):4423-4429. doi:10. 11569/wcjd. v24. i33. 4423.
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[3]Mcgrath B,Tennuci C,Lee G. The history of one-lung anesthesia and the double-lumen tube[J]. J Anesth Hist,2017,3(3):76. doi:10. 1016/j.janh. 2017. 05. 002.
[4]Wanathawthorne A,Stubblefield J,Lynch I,et al. Successful use of a double lumen endotracheal tube and bronchial blocker for lung isolation in pulmonary mucormycosis[J]. J Cardiothorac Vasc Anesth,2019,33(3):776-780. doi:10. 1053/j. jvca. 2018. 03. 011.
[5]Purohit A,Bhargava S,Mangal V,et al. Lung isolation,one-lung ventilation and hypoxaemia during lung isolation[J]. Indian J Anaesth,2015,59(9):606-617. doi:10. 4103/0019-5049. 165855.
[6]Lin M,Shen Y,Wang H,et al. A comparison between two lung ventilation with CO2artificial pneumothorax and one lung ventilation during thoracic phase of minimally invasive esophagectomy[J]. J Thorac Dis,2018,10(3):1912. doi:10. 21037/jtd. 2018. 01. 150.
[7] Caso R,Kelly CH,Marshall MB. Single lumen endotracheal intubation with carbon dioxide insufflation for lung isolation in thoracic surgery[J].Surg Endosc,2018. doi:10. 1007/s00464-018-06614-9.
[8]Brock H,Rieger R,Gabriel C,et al. Haemodynamic changes during thoracoscopic surgery the effects of one-lung ventilation compared with carbon dioxide insufflation[J]. Anaesthesia,2000,55(1):10-16. doi:10. 1046/j. 1365-2044. 2000. 01123. x.
[9]Sancheti MS,Dewan BP,Pickens A,et al. Thoracoscopy without lung isolation utilizing single lumen endotracheal tube intubation and carbon dioxide insufflation[J]. Ann Thorac Surg,2013,96(2):439-444.doi:10. 1016/j. athoracsur. 2013. 04. 060.
[10]Tran DTT,Badner NH,Nicolaou G,et al. Arterial p CO2changes during thoracoscopic surgery with CO2insufflation and one lung ventilation[J].HSR Proc Intensive Care Cardiovasc Anesth,2010,2(3):191-197.
[11]White H,Bird R,Sosnowski K,et al. An in vitro analysis of the effect of acidosis on coagulation in chronic disease states-a thromboelastograph study[J]. Clin Med(Lond),2016,16(3):230-234. doi:10.7861/clinmedicine. 16-3-230.
[12]Lv X,Mao Y,Qin Z. Evaluation for effects of severe acidosis on hemostasis in trauma patients using thrombelastography analyzer[J]. Am J Emerg Med,2018,36(8):1332. doi:10. 1016/j. ajem. 2017. 12. 037.
[13] Gissel M,Brummel-Ziedins KE,Butenas S,et al. Effects of an acidic environment on coagulation dynamics[J]. J Thromb Haemost,2016,14(12):2001-2010. doi:10. 1111/jth. 13418.
[14]Shenkman B,Budnik I,Einav Y,et al. Model of trauma-induced coagulopathy including hemodilution,fibrinolysis,acidosis and hypothermia:Impact on blood coagulation and platelet function[J]. J Trauma Acute Care Surg,2016,82(2):287. doi:10. 1097/TA. 0000000000001282.
[15]Meng ZH,Wolberg AS,Hoffman M. The effect of temperature and pH on the activity of factor VIIa:implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients[J]. J Trauma,2003,55(5):886-891. doi:10. 1097/01. TA. 0000066184. 20808. A5.
[16]Martini WZ,Pusateri AE,Uscilowicz JM,et al. Independent contributions of hypothermia and acidosis to coagulopathy in swine[J]. J Trauma,2005,58(3):1002-1010. doi:10. 1097/01. TA. 0000156246.53383. 9F.
[17]Kashuk JL,Moore EE,Sawyer M,et al. Postinjury coagulopathy management:goal directed resuscitation via POC thrombelastography[J]. Ann Surg,2010,251(4):604-614. doi:10. 1097/SLA. 0b013e3181d3599c.
[18]Martini WZ,Dubick MA,Pusateri AE,et al. Does bicarbonate correct coagulation function impaired by acidosis in swine?[J]. J Trauma,2006,61(1):99-106. doi:10. 1097/01. ta. 0000215574. 99093. 22.
[19]Martini WZ,Dubick MA,Wade CE,et al. Evaluation of tris-hydroxymethylaminomethane on reversing coagulation abnormalities caused by acidosis in pigs[J]. Crit Care Med,2007,35(6):1568-1574. doi:10. 1097/01. CCM. 0000266682. 74602. 6A.
[20]Abdelrazeq AS,Dwaik MA,Aldoori MI,et al. Laparoscopy-associated portal vein thrombosis:description of an evolving clinical syndrome[J]. J Laparoendosc Adv Surg Tech A,2006,16(1):9-14. doi:10.1089/lap. 2006. 16. 9.
[21]Mantziari S,Gronnier C,Pasquer A,et al. Incidence and risk factors related to symptomatic venous thromboembolic events after esophagectomy for cancer[J]. Ann Thorac Surg,2016,102(3):979-984. doi:10. 1016/j. athoracsur. 2016. 03. 093.
[22]Kato F,Takeuchi H,Matsuda S,et al. Incidence of and risk factors for venous thromboembolism during surgical treatment for esophageal cancer:a single-institution study[J]. Surg Today,2015,46(4):1-8. doi:10. 1007/s00595-015-1196-1.
[23]Marshall-Webb M,Bright T,Price T,et al. Venous thromboembolism in patients with esophageal or gastric cancer undergoing neoadjuvant chemotherapy[J]. Dis Esophagus,2016,30(2):1-7. doi:10. 1111/dote.12516.
[2] Kawakubo H,Takeuchi H,Kitagawa Y. Current status and future perspectives on minimally invasive esophagectomy[J]. Korean J Thorac Cardiovasc Surg,2013,46(4):241-248. doi:10. 5090/kjtcs. 2013.46. 4. 241.
[3]Mcgrath B,Tennuci C,Lee G. The history of one-lung anesthesia and the double-lumen tube[J]. J Anesth Hist,2017,3(3):76. doi:10. 1016/j.janh. 2017. 05. 002.
[4]Wanathawthorne A,Stubblefield J,Lynch I,et al. Successful use of a double lumen endotracheal tube and bronchial blocker for lung isolation in pulmonary mucormycosis[J]. J Cardiothorac Vasc Anesth,2019,33(3):776-780. doi:10. 1053/j. jvca. 2018. 03. 011.
[5]Purohit A,Bhargava S,Mangal V,et al. Lung isolation,one-lung ventilation and hypoxaemia during lung isolation[J]. Indian J Anaesth,2015,59(9):606-617. doi:10. 4103/0019-5049. 165855.
[6]Lin M,Shen Y,Wang H,et al. A comparison between two lung ventilation with CO2artificial pneumothorax and one lung ventilation during thoracic phase of minimally invasive esophagectomy[J]. J Thorac Dis,2018,10(3):1912. doi:10. 21037/jtd. 2018. 01. 150.
[7] Caso R,Kelly CH,Marshall MB. Single lumen endotracheal intubation with carbon dioxide insufflation for lung isolation in thoracic surgery[J].Surg Endosc,2018. doi:10. 1007/s00464-018-06614-9.
[8]Brock H,Rieger R,Gabriel C,et al. Haemodynamic changes during thoracoscopic surgery the effects of one-lung ventilation compared with carbon dioxide insufflation[J]. Anaesthesia,2000,55(1):10-16. doi:10. 1046/j. 1365-2044. 2000. 01123. x.
[9]Sancheti MS,Dewan BP,Pickens A,et al. Thoracoscopy without lung isolation utilizing single lumen endotracheal tube intubation and carbon dioxide insufflation[J]. Ann Thorac Surg,2013,96(2):439-444.doi:10. 1016/j. athoracsur. 2013. 04. 060.
[10]Tran DTT,Badner NH,Nicolaou G,et al. Arterial p CO2changes during thoracoscopic surgery with CO2insufflation and one lung ventilation[J].HSR Proc Intensive Care Cardiovasc Anesth,2010,2(3):191-197.
[11]White H,Bird R,Sosnowski K,et al. An in vitro analysis of the effect of acidosis on coagulation in chronic disease states-a thromboelastograph study[J]. Clin Med(Lond),2016,16(3):230-234. doi:10.7861/clinmedicine. 16-3-230.
[12]Lv X,Mao Y,Qin Z. Evaluation for effects of severe acidosis on hemostasis in trauma patients using thrombelastography analyzer[J]. Am J Emerg Med,2018,36(8):1332. doi:10. 1016/j. ajem. 2017. 12. 037.
[13] Gissel M,Brummel-Ziedins KE,Butenas S,et al. Effects of an acidic environment on coagulation dynamics[J]. J Thromb Haemost,2016,14(12):2001-2010. doi:10. 1111/jth. 13418.
[14]Shenkman B,Budnik I,Einav Y,et al. Model of trauma-induced coagulopathy including hemodilution,fibrinolysis,acidosis and hypothermia:Impact on blood coagulation and platelet function[J]. J Trauma Acute Care Surg,2016,82(2):287. doi:10. 1097/TA. 0000000000001282.
[15]Meng ZH,Wolberg AS,Hoffman M. The effect of temperature and pH on the activity of factor VIIa:implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients[J]. J Trauma,2003,55(5):886-891. doi:10. 1097/01. TA. 0000066184. 20808. A5.
[16]Martini WZ,Pusateri AE,Uscilowicz JM,et al. Independent contributions of hypothermia and acidosis to coagulopathy in swine[J]. J Trauma,2005,58(3):1002-1010. doi:10. 1097/01. TA. 0000156246.53383. 9F.
[17]Kashuk JL,Moore EE,Sawyer M,et al. Postinjury coagulopathy management:goal directed resuscitation via POC thrombelastography[J]. Ann Surg,2010,251(4):604-614. doi:10. 1097/SLA. 0b013e3181d3599c.
[18]Martini WZ,Dubick MA,Pusateri AE,et al. Does bicarbonate correct coagulation function impaired by acidosis in swine?[J]. J Trauma,2006,61(1):99-106. doi:10. 1097/01. ta. 0000215574. 99093. 22.
[19]Martini WZ,Dubick MA,Wade CE,et al. Evaluation of tris-hydroxymethylaminomethane on reversing coagulation abnormalities caused by acidosis in pigs[J]. Crit Care Med,2007,35(6):1568-1574. doi:10. 1097/01. CCM. 0000266682. 74602. 6A.
[20]Abdelrazeq AS,Dwaik MA,Aldoori MI,et al. Laparoscopy-associated portal vein thrombosis:description of an evolving clinical syndrome[J]. J Laparoendosc Adv Surg Tech A,2006,16(1):9-14. doi:10.1089/lap. 2006. 16. 9.
[21]Mantziari S,Gronnier C,Pasquer A,et al. Incidence and risk factors related to symptomatic venous thromboembolic events after esophagectomy for cancer[J]. Ann Thorac Surg,2016,102(3):979-984. doi:10. 1016/j. athoracsur. 2016. 03. 093.
[22]Kato F,Takeuchi H,Matsuda S,et al. Incidence of and risk factors for venous thromboembolism during surgical treatment for esophageal cancer:a single-institution study[J]. Surg Today,2015,46(4):1-8. doi:10. 1007/s00595-015-1196-1.
[23]Marshall-Webb M,Bright T,Price T,et al. Venous thromboembolism in patients with esophageal or gastric cancer undergoing neoadjuvant chemotherapy[J]. Dis Esophagus,2016,30(2):1-7. doi:10. 1111/dote.12516.
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