低中心静脉压联合急性高容量血液稀释对胸科手术患者肺内分流及动脉氧分压的影响
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摘要
目的探讨低中心静脉压(LCVP)联合急性高容量血液稀释(AHHD)在胸科手术单肺通气期间对肺内分流和动脉氧分压(PO_2)的影响。方法选择2015年1月~2017年12月汕头大学医学院附属粤北人民医院ASA分级为I~Ⅱ级择期全麻下行肺癌根治切除术的胸科患者50例,随机分为两组:LCVP联合AHHD组(LA组)和对照组(C组),每组25例。其中LA组麻醉后先行LCVP技术,采取限制晶体输液量并硝酸甘油持续微泵注射的方法,控制术中CVP在2~5 cm H_2O,随后再联合应用AHHD技术,快速输注6%羟乙基淀粉(130/0.4)15 m L/kg进行血液稀释,使血细胞比容维持在25%~30%;C组术中始终维持中心静脉压在正常水平6~12 cm H_2O。分别在平卧位双肺通气10 min(Tadb)、平卧位单肺通气10 min(T1)、侧卧位单肺通气10 min(T2)、肺叶切除后10 min(T3)等时间点采集肘静脉血测定血糖(GLU)和血清皮质醇(COR)水平;采集桡动脉血和右心房混合静脉血行血气分析,并记录GLU、COR水平、动脉血氧含量(CaO_2)、混合静脉血氧含量(CvO_2)、动脉血和混合静脉血氧分压PO_2、动脉血和混合静脉血血红蛋白氧饱和度(SO_2)、动脉血和混合静脉血血红蛋白等。根据肺血流分布标准三室模型计算各时间点肺内分流率(Qs/Qt),Qs/Qt=(CcO_2-CaO_2)/(CcO_2-CvO_2)×100%。结果两组患者各时点GLU、COR、SpO_2、HR、MAP、BIS、Pet CO_2基本稳定,但在单肺通气后,LA组和C组肺内分流明显增加(P<0.05),其中平卧位分别增加13.7%和14.9%,侧卧位分别增加11.4%和14.3%;两组动脉氧分压明显下降(P<0.05),且平卧位较侧卧位下降更明显,但两组间差异无统计学意义(P>0.05)。在肺叶切除后,LA组和C组肺内分流明显减少(P<0.05),分别减少7.2%和8.6%,两组动脉血氧分压明显升高(P<0.05),但两组间差异无统计学意义(P>0.05)。术中LA组输血比例明显低于C组(χ~2=4.902,P<0.05)。结论低中心静脉压联合急性高容量血液稀释在胸科手术单肺通气期间对肺内分流、动脉氧分压无明显的抑制,且可明显减少术中输血比例。
Objective To investigate the effect of low central venous pressure(LCVP) combined with acute hypervolemic hemodilution(AHHD) on intrapulmonary shunt and arterial oxygen partial pressure during one lung ventilation in thoracic surgery. Methods From January 2015 to December 2017, ASA grade Ⅰ-Ⅱ undergoing elective radical resection of lung cancer and 50 thoracic surgery patients in the Affiliated Yuebei People's Hospital, Shantou University Medical College, were randomly divided into two groups: group AHHD with LCVP(group LA) and control group(group C), each group had 25 cases. Group LA was given the limited crystalloid the amount of nitroglycerin and continuousmicro pump injection method after anesthesia in advance of LCVP technology, control of CVP in 2-5 cm H_2 O, then combined with the application of AHHD technology, rapid infusion of 6% hydroxyethyl starch(130/0.4) 15 m L/kg on blood thinners, keep Hct at 25%-30%. Group C was maintained at the normal level of 6-12 cm H_2O CVP. On the each time as 10 min after double lung ventilation in the supine position(T_0), 10 min after one lung ventilation in supine position (T_1), 10 min after single lung ventilation in lateral position(T_2), 10 min after pulmonary lobectomy(T_3), the blood glucose and cortisol level were measured by collecting, and the blood of the elbow. The radial artery blood and right atrial mixed venous blood was collected for blood gas analysis, and record blood glucose concentration, serum cortisol level, SpO_2, HR, MAP, CVP, BIS, PetCO_2, arterial oxygen content(CaO_2), mixed venous oxygen content(CvO_2), arterial and mixed venous blood oxygen partial pressure(PO_2), arterial and mixed venous blood oxygen saturation of hemoglobin(SO_2), arterial and mixed venous blood hemoglobin(Hb) etc.. The rate of intrapulmonary shunt(Qs/Qt), Qs/Qt =(CcO_2-CaO_2)/(CcO_2-CvO_2)×100% were calculated according to the standard three compartment model of pulmonary blood flow distribution. Results The blood glucose concentration, serum cortisol level, SpO_2, HR, MAP, BIS, Pet CO_2 of patients in two groups at each time point was basically stable, but after one lung ventilation, LA group and group C significantly increased intrapulmonary shunt(P < 0.05), which increased by 13.7% and 14.9% respectively in supine position, lateral position increased 11.4% and 14.3% respectively. arterial oxygen partial pressure of two groups were significantly decreased(P < 0.05), and compared with the supine lateral position decreased more obviously, but there was no significant difference between the two groups(P > 0.05). After lobectomy, the intrapulmonary shunt in group LA and group C was significantly reduced(P < 0.05), 7.2% and 8.6% respectively, and the arterial oxygen partial pressure increased significantly in two groups(P < 0.05), but there was no significant difference between the two groups(P >0.05). The proportion of blood transfusion in group LA was significantly lower than that in group C(χ~2= 4.902, P <0.05). Conclusion Low central venous pressure combined with acute hypervolemic hemodilution has no significant inhibition on intrapulmonary shunt and arterial oxygen partial pressure during one lung ventilation during thoracic surgery,and can significantly reduce the proportion of intraoperative blood transfusion.
Objective To investigate the effect of low central venous pressure(LCVP) combined with acute hypervolemic hemodilution(AHHD) on intrapulmonary shunt and arterial oxygen partial pressure during one lung ventilation in thoracic surgery. Methods From January 2015 to December 2017, ASA grade Ⅰ-Ⅱ undergoing elective radical resection of lung cancer and 50 thoracic surgery patients in the Affiliated Yuebei People's Hospital, Shantou University Medical College, were randomly divided into two groups: group AHHD with LCVP(group LA) and control group(group C), each group had 25 cases. Group LA was given the limited crystalloid the amount of nitroglycerin and continuousmicro pump injection method after anesthesia in advance of LCVP technology, control of CVP in 2-5 cm H_2 O, then combined with the application of AHHD technology, rapid infusion of 6% hydroxyethyl starch(130/0.4) 15 m L/kg on blood thinners, keep Hct at 25%-30%. Group C was maintained at the normal level of 6-12 cm H_2O CVP. On the each time as 10 min after double lung ventilation in the supine position(T_0), 10 min after one lung ventilation in supine position (T_1), 10 min after single lung ventilation in lateral position(T_2), 10 min after pulmonary lobectomy(T_3), the blood glucose and cortisol level were measured by collecting, and the blood of the elbow. The radial artery blood and right atrial mixed venous blood was collected for blood gas analysis, and record blood glucose concentration, serum cortisol level, SpO_2, HR, MAP, CVP, BIS, PetCO_2, arterial oxygen content(CaO_2), mixed venous oxygen content(CvO_2), arterial and mixed venous blood oxygen partial pressure(PO_2), arterial and mixed venous blood oxygen saturation of hemoglobin(SO_2), arterial and mixed venous blood hemoglobin(Hb) etc.. The rate of intrapulmonary shunt(Qs/Qt), Qs/Qt =(CcO_2-CaO_2)/(CcO_2-CvO_2)×100% were calculated according to the standard three compartment model of pulmonary blood flow distribution. Results The blood glucose concentration, serum cortisol level, SpO_2, HR, MAP, BIS, Pet CO_2 of patients in two groups at each time point was basically stable, but after one lung ventilation, LA group and group C significantly increased intrapulmonary shunt(P < 0.05), which increased by 13.7% and 14.9% respectively in supine position, lateral position increased 11.4% and 14.3% respectively. arterial oxygen partial pressure of two groups were significantly decreased(P < 0.05), and compared with the supine lateral position decreased more obviously, but there was no significant difference between the two groups(P > 0.05). After lobectomy, the intrapulmonary shunt in group LA and group C was significantly reduced(P < 0.05), 7.2% and 8.6% respectively, and the arterial oxygen partial pressure increased significantly in two groups(P < 0.05), but there was no significant difference between the two groups(P >0.05). The proportion of blood transfusion in group LA was significantly lower than that in group C(χ~2= 4.902, P <0.05). Conclusion Low central venous pressure combined with acute hypervolemic hemodilution has no significant inhibition on intrapulmonary shunt and arterial oxygen partial pressure during one lung ventilation during thoracic surgery,and can significantly reduce the proportion of intraoperative blood transfusion.
引文
[1]陈婷,魏福生,姜敏,等.胸科手术单肺通气相关性肺损伤机制研究进展[J].江西医药,2017,52(2):186-188.DOI:10.3969/j.issn.1006-2238.2017.02.036
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[3]杨金凤,高星杨,董长生,等.肝叶切除术患者低中心静脉压联合急性高容量血液稀释的血液保护效应[J].中华麻醉学杂志,2008,28(5):417-420.
[4]张德平.静脉血气分析及其临床应用进展[J].医学研究生学报,2004,17(8):741-748.
[5]廖梅嫣.危重病患者周围动脉和中心静脉血气分析的对比研究[J].中国医药指南,2013,11(15):470-471.
[6]曾昭燕,叶靖,赵振龙,等.平均动脉压对单肺通气患者动脉二氧化碳分压与呼气末二氧化碳分压差的影响[J]南方医科大学学报2014,34(12):1834-1837.DOI:10.3969j.issn.1673-4254.2014.12.27
[7]陈启智,刘流,徐军美,等.右心房、右心室、上腔和下腔静脉血氧饱和度与肺动脉血氧饱和度的相关性[J].湖南医科大学学报,1997,22(5):463-464.
[8]黄荣智,曾惠雪,张奕,等.胸腔镜下行肺癌根治术对肺癌的治疗价值评析[J].中外医学研究,2016,14(34):35-36.Doi:10.14033/j.cnki.cfmr.2016.34.018
[9]明月,岳秀娟.中老年患者不同水平LCVP下肝叶切除术生命指征相关性比较[J].中国老年学杂志,2013,33(21):5453-5455.
[10]李印玉,刘伟,候俊锋.控制性低中心静脉压在肝脏手术中的应用[J].国际医药卫生导报,2016,22(20):3115-3117.DIO:10.3760/cam.j.issn.1007-1245.2016.20.020
[11]张俊杰,刘心瑶,张成梁,等.控制性低中心静脉压对脊柱手术患者血管外肺水和失血量的影响[J].临床麻醉学杂志,2015,31(5):427-431.
[12]黄婵燕,华赟鹏,邬艳,等.控制性低中心静脉压对右半肝切除术患者术后重要脏器功能的影响[J].中华普通外科学文献:电子版,2013,7(1):29-33.DIO:10.3877/cam.j.issn.1647-0793.2013.01.008
[13]李娅蓉.6%羟乙基淀粉急性高容量血液稀释后对老年脊柱手术患者血液动力学及凝血功能的影响[J].河北医学,2016,22(6):901-904.DIO:10.3969/j.issn.1006-6233.2016.06.008
[14]邱平洋,马传根,陈宗,等.急性高容量血液稀释对中老年腰硬麻醉患者血流动力学及凝血功能的影响[J].现代中西医结合杂志,2014,23(31):3444-3446.DIO:10.3969/j.issn.1008-8849.2014.31.008
[15]周波,张晓峰,徐美英.不同容量治疗对老年肺切除术患者血流动力学和血管外肺水的影响[J].上海医学,2010,33(2):147-150.
[16]牛纪元,姚立农,杨永惠,等.急性高容量血液稀释对单肺通气犬血管外肺水的影响[J].临床麻醉学杂志,2007,23(10):845-847.
[17]赵冬梅,马传根.急性高容量血液稀释联合控制性降压用于胸科手术的观察[J].中国医师杂志,2004,6(10):1349-1351.
[18]乔瑞冬,王昊,季中华.高容量血液稀释结合控制性降压用于肺手术的观察[J].临床麻醉学杂志,2005,22(1):7-9.
[19]柳欢,温丽娟.低中心静脉压联合急性高容量血液稀释在肝叶切除术中的应用效果[J].实用临床医学,2014,15(3):52-54.
[20]李经纬,谭洪光,姚爱军.急性高容量血液稀释并低中心静脉压对肝叶切除患者失血和肝肾功能的影响[J].国际医药卫生导报,2012,18(10):1435-1438.DIO:10.3760/cam.j.issn.1007-1245.2012.10.027
[21]刘忠民,冯趁霞,冯桂真.单肺通气麻醉在胸腔镜手术中对患者下肺灌流的影响[J].淮海医学,2017,35(3):259-260.
[22]张光燕,崔建修.低氧性肺血管收缩的研究现状[J].实用医学杂志,2011,27(1):142-144.DIO:10.3969/j.issn.1006-5725.2011.01.064
[23]盖祥云,林鹏程,何彦峰.低氧性肺动脉高压中低氧性肺血管收缩的作用[J].中国药理学通报,2016,32(6):768-772.DIO:10.3969/j.issn.1001-1978.2016.06.007
[24]任铭,张望平,祝胜美.反比通气联合PEEP对肺叶切除患者单肺通气时肺功能的影响[J].临床麻醉学杂志,2017,33(3):218-221.
[2]杨东升,侯彦深,蒋晖.急性高容量血液稀释联合低中心静脉压在肝叶切除术中的应用[J].临床麻醉学杂志,2012,28(4):355-356.
[3]杨金凤,高星杨,董长生,等.肝叶切除术患者低中心静脉压联合急性高容量血液稀释的血液保护效应[J].中华麻醉学杂志,2008,28(5):417-420.
[4]张德平.静脉血气分析及其临床应用进展[J].医学研究生学报,2004,17(8):741-748.
[5]廖梅嫣.危重病患者周围动脉和中心静脉血气分析的对比研究[J].中国医药指南,2013,11(15):470-471.
[6]曾昭燕,叶靖,赵振龙,等.平均动脉压对单肺通气患者动脉二氧化碳分压与呼气末二氧化碳分压差的影响[J]南方医科大学学报2014,34(12):1834-1837.DOI:10.3969j.issn.1673-4254.2014.12.27
[7]陈启智,刘流,徐军美,等.右心房、右心室、上腔和下腔静脉血氧饱和度与肺动脉血氧饱和度的相关性[J].湖南医科大学学报,1997,22(5):463-464.
[8]黄荣智,曾惠雪,张奕,等.胸腔镜下行肺癌根治术对肺癌的治疗价值评析[J].中外医学研究,2016,14(34):35-36.Doi:10.14033/j.cnki.cfmr.2016.34.018
[9]明月,岳秀娟.中老年患者不同水平LCVP下肝叶切除术生命指征相关性比较[J].中国老年学杂志,2013,33(21):5453-5455.
[10]李印玉,刘伟,候俊锋.控制性低中心静脉压在肝脏手术中的应用[J].国际医药卫生导报,2016,22(20):3115-3117.DIO:10.3760/cam.j.issn.1007-1245.2016.20.020
[11]张俊杰,刘心瑶,张成梁,等.控制性低中心静脉压对脊柱手术患者血管外肺水和失血量的影响[J].临床麻醉学杂志,2015,31(5):427-431.
[12]黄婵燕,华赟鹏,邬艳,等.控制性低中心静脉压对右半肝切除术患者术后重要脏器功能的影响[J].中华普通外科学文献:电子版,2013,7(1):29-33.DIO:10.3877/cam.j.issn.1647-0793.2013.01.008
[13]李娅蓉.6%羟乙基淀粉急性高容量血液稀释后对老年脊柱手术患者血液动力学及凝血功能的影响[J].河北医学,2016,22(6):901-904.DIO:10.3969/j.issn.1006-6233.2016.06.008
[14]邱平洋,马传根,陈宗,等.急性高容量血液稀释对中老年腰硬麻醉患者血流动力学及凝血功能的影响[J].现代中西医结合杂志,2014,23(31):3444-3446.DIO:10.3969/j.issn.1008-8849.2014.31.008
[15]周波,张晓峰,徐美英.不同容量治疗对老年肺切除术患者血流动力学和血管外肺水的影响[J].上海医学,2010,33(2):147-150.
[16]牛纪元,姚立农,杨永惠,等.急性高容量血液稀释对单肺通气犬血管外肺水的影响[J].临床麻醉学杂志,2007,23(10):845-847.
[17]赵冬梅,马传根.急性高容量血液稀释联合控制性降压用于胸科手术的观察[J].中国医师杂志,2004,6(10):1349-1351.
[18]乔瑞冬,王昊,季中华.高容量血液稀释结合控制性降压用于肺手术的观察[J].临床麻醉学杂志,2005,22(1):7-9.
[19]柳欢,温丽娟.低中心静脉压联合急性高容量血液稀释在肝叶切除术中的应用效果[J].实用临床医学,2014,15(3):52-54.
[20]李经纬,谭洪光,姚爱军.急性高容量血液稀释并低中心静脉压对肝叶切除患者失血和肝肾功能的影响[J].国际医药卫生导报,2012,18(10):1435-1438.DIO:10.3760/cam.j.issn.1007-1245.2012.10.027
[21]刘忠民,冯趁霞,冯桂真.单肺通气麻醉在胸腔镜手术中对患者下肺灌流的影响[J].淮海医学,2017,35(3):259-260.
[22]张光燕,崔建修.低氧性肺血管收缩的研究现状[J].实用医学杂志,2011,27(1):142-144.DIO:10.3969/j.issn.1006-5725.2011.01.064
[23]盖祥云,林鹏程,何彦峰.低氧性肺动脉高压中低氧性肺血管收缩的作用[J].中国药理学通报,2016,32(6):768-772.DIO:10.3969/j.issn.1001-1978.2016.06.007
[24]任铭,张望平,祝胜美.反比通气联合PEEP对肺叶切除患者单肺通气时肺功能的影响[J].临床麻醉学杂志,2017,33(3):218-221.