全身麻醉手术患者术前术中锁骨下静脉与动脉血气比较的临床研究
|
摘要
目的探讨全麻术中以锁骨下静脉血气评估动脉血气的临床意义。方法选取2018年3～10月昆山市中医医院择期行下腹部及四肢手术患者27例,男14例,女13例,年龄25～65岁,ASA分级Ⅰ或Ⅱ级,分别在入室后(T0)、气管插管后10 min(T_1)、气管插管后30 min(T_2)采集动脉血液与锁骨下静脉血液进行血气分析,统计分析术前、术中锁骨下静脉血氧分压(PvO_2)及静脉血氧饱和度(SvO_2)改变,计算成对静脉血PH值(PHv)与动脉血PH值(PH)、静脉血二氧化碳分压(PvCO_2)与动脉血二氧化碳分压(PaCO_2)、动脉血和静脉血剩余碱(BE)、全细胞外剩余碱(BeeC)、缓冲碱(BB)、血乳酸(Lac)、血糖(Glu)的差值。结果不同时段所采集获得的动脉血样指标与静脉血样指标的变化趋势均一致(同步),T_0、T_1、T_2时静脉血Lac、Glu与动脉血Lac、Glu比较,差异无统计学意义(P> 0. 05);术前(T_0)、术中(T_1、T_2)静脉血PH值与动脉血PH差值分别为-0. 025±0. 014与-0. 043±0. 024,差异有统计学意义(P <0. 05);术前(T0)、术中(T_1、T_2)静脉血BE、BB与动脉血差值分别为2. 18±1. 56、2. 31±1. 56和2. 15±1. 59、2. 60±1. 88,差异无统计学意义(P> 0. 05);全麻机械通气后,锁骨下PvO_2、SvO_2分别上升至(54. 31±8. 39) mmH g和(86. 21±5. 01)%,与T0比较,差异均有统计学意义(P <0. 01);与T_0比较,T_1时PvCO_2升高有统计学意义(P <0.05),T_0、T_1、T_2时锁骨下静脉血与动脉血二氧化碳分压差(ΔPCO2)分别为(6. 10±3. 70) mmH g、(9. 18±4. 01) mmH g、(6. 79±4. 05) mmH g,T_0、T_2与T_1比较,差异有统计学意义(P <0. 05)。结论围术期锁骨下静脉血气改变与动脉血气改变存在内在关联,可以依据锁骨下静脉血气分析估算动脉血气,对患者病情做出正确的判断:静脉血血红蛋白、电解质、Glu、Lac值可以直接引用;术前、术中锁骨下静脉血与动脉血BE、BB之间、PHv与PH之间有固定差值作为估算依据;围术期患者PvO_2、SvO_2有相对平稳的变化区间,SvO_2异常改变结合ΔPCO_2趋势可以发现术中组织灌注不足或通气不足,并指导液体复苏。
Objective To compare the blood gas with subclavian venous and artery in general anesthesia. Methods Twenty-seven ASA Ⅰ or Ⅱ patients who were scheduled for lower abdomen or limbs surgery were recruited,arterial blood and subclavian vein blood samples were collected and analyzed for blood gas after entering the operating room( T_0),10 min after endotracheal intubation( T_1),and30 min after endotracheal intubation( T_2),respectively. Changes of oxygen partial pressure( PvO_2) and oxygen saturation( SvO_2) in subclavian venous blood were analyzed preoperatively and intraoperatively,the difference of PH( PHv and PH),partial pressure of carbon dioxide( PvCO_2 and PaCO_2),base excess( BE),whole extracellular base excess( BeeC),buffer base( BB),blood lactate( Lac),and blood glucose( Glu) between paired venous blood and arterial blood was evaluated. Results The arterial blood samples that were collected at different time points was consistent with the trend of the venous blood sample,there was no significant difference of Lactic acid and Glucose level in venous blood in comparison with arterial blood samples at T_0,T_1 and T_2( P > 0. 05); the difference of PH value of venous blood and arterial blood pH at T_0,T_1 and T_2 were-0. 025 ± 0. 014 and-0. 043 ± 0. 024,respectively,and the difference was statistically significant( P < 0. 05); the difference of BE,BB of arterial blood and venous blood at T_0,T_1 and T_2 were 2. 18 ± 1. 56,2. 31 ±1. 56 and 2. 15 ± 1. 59,2. 60 ± 1. 88,respectively,and there was no significant difference( P > 0. 05); after general anesthesia mechanical ventilation,the subclavian venous oxygen partial pressure( PvO_2) and venous oxygen saturation( SvO_2) increased to( 54. 31 ± 8. 39)mmH g and( 86. 21 ± 5. 01) %,compared with T_0,the difference was statistically significant( P < 0. 01); compared with T_0,the venous blood carbon dioxide partial pressure( PvCO_2) increased at T_1,the difference was statistically significant( P < 0. 05),at T_0,T_1,T_2,the subclavian venous blood and arterial blood gas carbon dioxide partial pressure difference( ΔPCO_2) were( 6. 10 ± 3. 70) mmH g,( 9. 18 ± 4. 01) mmH g,( 6. 79 ± 4. 05) mmH g,respectively,the difference between T_0 and T_2 was significantly lower than that of T_1( P < 0. 05). Conclusion There is a correlation between perioperative subclavian venous blood gas and arterial blood gas changes,it is possible to estimate arterial blood gas based on blood gas analysis of the subclavian vein and make an intelligent prediction of patient's condition: Venous hemoglobin,electrolyte,Glucose,Lactic acid values can be directly quoted; there was a predictable difference as an estimate between BE and BB,PHv and PH of subclavian venous blood and arterial blood at preoperative and intraoperative,patients have relatively stable intervals of PvO_2 and SvO_2 at perioperative,abnormal changes in SvO_2 adjunction with ΔPCO_2 trends can be found in intraoperative tissue hypoperfusion or hypoventilation which can guide direct fluid resuscitation.
Objective To compare the blood gas with subclavian venous and artery in general anesthesia. Methods Twenty-seven ASA Ⅰ or Ⅱ patients who were scheduled for lower abdomen or limbs surgery were recruited,arterial blood and subclavian vein blood samples were collected and analyzed for blood gas after entering the operating room( T_0),10 min after endotracheal intubation( T_1),and30 min after endotracheal intubation( T_2),respectively. Changes of oxygen partial pressure( PvO_2) and oxygen saturation( SvO_2) in subclavian venous blood were analyzed preoperatively and intraoperatively,the difference of PH( PHv and PH),partial pressure of carbon dioxide( PvCO_2 and PaCO_2),base excess( BE),whole extracellular base excess( BeeC),buffer base( BB),blood lactate( Lac),and blood glucose( Glu) between paired venous blood and arterial blood was evaluated. Results The arterial blood samples that were collected at different time points was consistent with the trend of the venous blood sample,there was no significant difference of Lactic acid and Glucose level in venous blood in comparison with arterial blood samples at T_0,T_1 and T_2( P > 0. 05); the difference of PH value of venous blood and arterial blood pH at T_0,T_1 and T_2 were-0. 025 ± 0. 014 and-0. 043 ± 0. 024,respectively,and the difference was statistically significant( P < 0. 05); the difference of BE,BB of arterial blood and venous blood at T_0,T_1 and T_2 were 2. 18 ± 1. 56,2. 31 ±1. 56 and 2. 15 ± 1. 59,2. 60 ± 1. 88,respectively,and there was no significant difference( P > 0. 05); after general anesthesia mechanical ventilation,the subclavian venous oxygen partial pressure( PvO_2) and venous oxygen saturation( SvO_2) increased to( 54. 31 ± 8. 39)mmH g and( 86. 21 ± 5. 01) %,compared with T_0,the difference was statistically significant( P < 0. 01); compared with T_0,the venous blood carbon dioxide partial pressure( PvCO_2) increased at T_1,the difference was statistically significant( P < 0. 05),at T_0,T_1,T_2,the subclavian venous blood and arterial blood gas carbon dioxide partial pressure difference( ΔPCO_2) were( 6. 10 ± 3. 70) mmH g,( 9. 18 ± 4. 01) mmH g,( 6. 79 ± 4. 05) mmH g,respectively,the difference between T_0 and T_2 was significantly lower than that of T_1( P < 0. 05). Conclusion There is a correlation between perioperative subclavian venous blood gas and arterial blood gas changes,it is possible to estimate arterial blood gas based on blood gas analysis of the subclavian vein and make an intelligent prediction of patient's condition: Venous hemoglobin,electrolyte,Glucose,Lactic acid values can be directly quoted; there was a predictable difference as an estimate between BE and BB,PHv and PH of subclavian venous blood and arterial blood at preoperative and intraoperative,patients have relatively stable intervals of PvO_2 and SvO_2 at perioperative,abnormal changes in SvO_2 adjunction with ΔPCO_2 trends can be found in intraoperative tissue hypoperfusion or hypoventilation which can guide direct fluid resuscitation.
引文
[1]卢其玲.动脉血采集失败原因分析与对策[J].实用临床医学,2014,15(6):23,26.
[2]田秀平,车欣.危重患者血气分析标本采集的护理体会[J].中国实用护理杂志,2015,31(z2):109-110.
[3]曾居华,杨黎,王勇,等.快速锁骨上两指定位法行锁骨下静脉穿刺置管在抢救失血性休克中的应用[J].西南国防医药,2009,19(7):721-722.DOI:10.3969/j.issn.1004-0188.2009.07.028.
[4]罗振吉,磨勇华,苏小妮,等.中心静脉及动脉穿刺留置导管采血途径在危重症患者中的应用[J].右江医学,2013,41(6):877-879.DOI:10.3969/j.issn.1003-1383.2013.06.033.
[5]那昱华.成人动脉血气分析标本采集技术的研究进展[J].中国医学创新,2015,12(1):153-156.DOI:10.3969/j.issn.1674-4985.2015.01.053.
[6]胡宏强,沈七襄,张正迪,等.中心静脉血、肘静脉血与混合静脉血血气指标值相关性研究[J].临床军医杂志,2011,39(2):212-213.DOI:10.3969/j.issn.1671-3826.2011.02.04.
[7]孙兴国,王桂芝,吕婧,等.摄氧和二氧化碳排出通气效率是反映循环功能的指标[J].中华心血管病杂志,2014,42(12):1022-1028.DOI:10.3760/cam.j.issn.0253-3758.2014.12.010.
[8]杜微,刘大为,隆云,等.静动脉二氧化碳分压差联合上腔静脉血氧饱和度指导休克患者复苏[J].中华医学杂志,2012,92(13):909-914.DOI:10.3760/cma.j.issn.0376-2491.2012.13.012.
[9]李光庭,黄日安.感染性休克与血气分析关系的相关性研究[J].临床和实验医学杂志,2007,6(6):61-62.Doi:10.3969/j.issn.1671-4695.2007.06.033.
[10]苏淑红,张大鹏,王志方.动脉血气分析和急诊静脉血生化检查中血糖水平差异的对比分析[J].实验与检验医学,2014,32(2):199-200.DOI:10.3969/j.issn.1674-1129.2014.02.036.
[11]邓小明,曾因明.米勒麻醉学[M].7版.北京:北京大学医学出版社,2011:1433-1434.
[12]JONES A E,SHAPIRO N I,TRZECIAK S,et al.Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy:a randomiazed clinical trial[J].JAMA,2010,303(8):739-746.DOI:10.1001/jama.2010.158.
[13]BEEST VAN P A,HOFSTRA J J,SCHULTZ M J,et al.The incidence of low venous oxygen saturation on admission to the intensive care unit:a multi-center observational study in the Netherlands[J].Crit Care,2008,12:R33.DOI:10.1186/cc6811.
[14]杨昆,吴玉成,韩猛,等.静动脉二氧化碳分压差在感染性休克患者液体复苏中的临床应用[J].临床医药文献电子杂志,2018,5(16):8,10.DOI:10.3877/j.issn.2095-8242.2018.16.005.
[15]陈玉红,赵钗,赵倩,等.中心静脉血氧饱和度联合静动脉二氧化碳分压差指导脓毒症患者容量管理[J].中国全科医学,2016,19(11):1276-1281.DOI:10.3969/j.issn.1007-9572.2016.11.010.
[16]高雪花,李培杰,曹雯.中心静脉-动脉二氧化碳分压差与动脉-中心静脉氧含量差的比值联合乳酸清除率指导脓毒症休克早期复苏治疗[J].中华医学杂志,2018,98(7):508-513.DOI:10.3760/cma.j.issn.0376-2491.2018.07.005.
[17]费建平,翁建东,雷月.喉罩通气全身麻醉在高龄患者髋部手术中的应用[J].河北医药,2016,38(5):672-675.DOI:10.3969/j.issn.1002-7386.2016.05.009.
[2]田秀平,车欣.危重患者血气分析标本采集的护理体会[J].中国实用护理杂志,2015,31(z2):109-110.
[3]曾居华,杨黎,王勇,等.快速锁骨上两指定位法行锁骨下静脉穿刺置管在抢救失血性休克中的应用[J].西南国防医药,2009,19(7):721-722.DOI:10.3969/j.issn.1004-0188.2009.07.028.
[4]罗振吉,磨勇华,苏小妮,等.中心静脉及动脉穿刺留置导管采血途径在危重症患者中的应用[J].右江医学,2013,41(6):877-879.DOI:10.3969/j.issn.1003-1383.2013.06.033.
[5]那昱华.成人动脉血气分析标本采集技术的研究进展[J].中国医学创新,2015,12(1):153-156.DOI:10.3969/j.issn.1674-4985.2015.01.053.
[6]胡宏强,沈七襄,张正迪,等.中心静脉血、肘静脉血与混合静脉血血气指标值相关性研究[J].临床军医杂志,2011,39(2):212-213.DOI:10.3969/j.issn.1671-3826.2011.02.04.
[7]孙兴国,王桂芝,吕婧,等.摄氧和二氧化碳排出通气效率是反映循环功能的指标[J].中华心血管病杂志,2014,42(12):1022-1028.DOI:10.3760/cam.j.issn.0253-3758.2014.12.010.
[8]杜微,刘大为,隆云,等.静动脉二氧化碳分压差联合上腔静脉血氧饱和度指导休克患者复苏[J].中华医学杂志,2012,92(13):909-914.DOI:10.3760/cma.j.issn.0376-2491.2012.13.012.
[9]李光庭,黄日安.感染性休克与血气分析关系的相关性研究[J].临床和实验医学杂志,2007,6(6):61-62.Doi:10.3969/j.issn.1671-4695.2007.06.033.
[10]苏淑红,张大鹏,王志方.动脉血气分析和急诊静脉血生化检查中血糖水平差异的对比分析[J].实验与检验医学,2014,32(2):199-200.DOI:10.3969/j.issn.1674-1129.2014.02.036.
[11]邓小明,曾因明.米勒麻醉学[M].7版.北京:北京大学医学出版社,2011:1433-1434.
[12]JONES A E,SHAPIRO N I,TRZECIAK S,et al.Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy:a randomiazed clinical trial[J].JAMA,2010,303(8):739-746.DOI:10.1001/jama.2010.158.
[13]BEEST VAN P A,HOFSTRA J J,SCHULTZ M J,et al.The incidence of low venous oxygen saturation on admission to the intensive care unit:a multi-center observational study in the Netherlands[J].Crit Care,2008,12:R33.DOI:10.1186/cc6811.
[14]杨昆,吴玉成,韩猛,等.静动脉二氧化碳分压差在感染性休克患者液体复苏中的临床应用[J].临床医药文献电子杂志,2018,5(16):8,10.DOI:10.3877/j.issn.2095-8242.2018.16.005.
[15]陈玉红,赵钗,赵倩,等.中心静脉血氧饱和度联合静动脉二氧化碳分压差指导脓毒症患者容量管理[J].中国全科医学,2016,19(11):1276-1281.DOI:10.3969/j.issn.1007-9572.2016.11.010.
[16]高雪花,李培杰,曹雯.中心静脉-动脉二氧化碳分压差与动脉-中心静脉氧含量差的比值联合乳酸清除率指导脓毒症休克早期复苏治疗[J].中华医学杂志,2018,98(7):508-513.DOI:10.3760/cma.j.issn.0376-2491.2018.07.005.
[17]费建平,翁建东,雷月.喉罩通气全身麻醉在高龄患者髋部手术中的应用[J].河北医药,2016,38(5):672-675.DOI:10.3969/j.issn.1002-7386.2016.05.009.