允许性高碳酸血症在腹腔镜直肠癌手术中的应用及对循环的影响
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摘要
目的:研究允许性高碳酸血症在腹腔镜直肠癌手术中的应用效果、最佳适宜范围及对患者循环功能的影响。方法:选取沧州市中心医院拟择期行腹腔镜直肠癌手术的患者90例,随机分为试验1组、2组和对照组3组,每组30例。试验1组血二氧化碳分压(partial pressure of carbon dioxide,PaCO_2)维持在56～65 mm Hg,试验2组PaCO_2维持在46～55 mm Hg,对照组PaCO_2维持在35～45 mm Hg。观察并比较三组患者气腹时间、机械通气时间、手术时间、拔管时间、苏醒时间,气腹前10 min(T_1)、气腹后1 h(T_2)、气腹后2 h(T_3)、放气后15 min(T_4)时间点的平均动脉压、心率、气道峰压,计算动态肺顺应性、氧合指数,记录皮下气肿、呕吐、烦躁及术后认知功能障碍等并发症的发生情况。结果:三组患者手术时间、气腹时间、机械通气时间、拔管时间和苏醒时间比较差异无统计学意义(P>0.05)。与对照组相比,试验组T_2、T_3时心率(heart rate,HR)、血氧分压(partial pressure of oxygen,PaO_2)、肺动态顺应性(lung dynamic compliance,Cdyn)均明显升高,P_(max)明显下降(P<0.05);与T_1相比,试验组T_2、T_3时HR、气道峰压(Pmax)、PaO_2均升高,Cdyn下降(P<0.05);与试验2组比较,试验1组HR、P_(max)明显更低,PaO_2、Cdyn明显更高(P<0.05),但三组氧合指数(oxy-genation Index,OI)比较差异无统计学意义(P>0.05)。与对照组相比,试验组T_2、T_3时动脉血二氧化碳分压(partial pressure of car-bon dioxide,PaCO_2)、Qs/Qt均升高,氢离子浓度指数(hydrogen ion concentration,pH)、平均动脉压(mean arterial pressure,MAP)下降;与T_1相比,试验组T_2、T_3时PaCO_2、Qs/Qt均升高,pH、MAP下降;与试验2组比较,试验1组PaCO_2、PaCO_2明显更低,pH明显更高(P<0.05),但三组MAP比较差异无统计学意义(P>0.05)。手术开始30 min和1 h,试验组中心静脉压(central venous pressure,CVP)、心输出量(cardiac output,CO)以及心脏指数(cardiac index,CI)较对照组更低,而试验1组较试验2组明显更低(P<0.05)。三组并发症的改善情况比较差异无统计学意义(x~2=0.1973,P=0.9954)。治疗后,试验组MMSE评分较治疗前明显降低,且试验组明显高于对照组,而试验1组又显著高于试验2组(P<0.05)。结论:允许性高碳酸血症在长时间腹腔镜直肠癌手术中在保障氧合同时降低气道压改善肺的顺应性,可一定程度上减少术后认知功能障碍的发生,有一定的脑保护作用。
Objective: To study the effect of permissible hypercapnia in laparoscopic rectal cancer surgery, the optimal range of application and the effect on the patient's circulatory function. Methods: 90 cases with rectal cancer were researched to undergoing laparoscopic surgery according to the random number table they were divided into Test 1 group, 2 groups and control group, 30 cases in each group. The PaCO_2 of the test group 1 was maintained at 56-65 mm Hg, the PaCO_2 of the test group 2 was maintained at 46-55 mm Hg, and the PaCO_2 of the control group was maintained at 35-45 mm Hg. They were compared with Pneumoperitoneum time, mechanical ventilation time, operation time, extubation time, wake-up time, mean arterial pressure, heart rate, and airway pressure at 10 minutes before pneumoperitoneum(T_1), 1 hour after pneumoperitoneum(T_2), 2 h after pneumoperitoneum(T_3), and 15 min after deflation(T_4). dynamic lung compliance, oxygenation index, recording of complications such as subcutaneous emphysema, vomiting, irritability and postoperative cognitive impairment. Results: There was no significant difference in the operation time, pneumoperitoneum time,mechanical ventilation time, extubation time and recovery time between the three groups(P>0.05). Compared with the control group,HR, PaO_2, and Cdyn in the test group significantly increased at T_2 and T_3, and Pmaxdecreased significantly; compared with T_1, HR, P_(max),and PaO_2 in the test group increased at T_2 and T_3, and Cdyn decreased; Compared with the experimental group 2, the HR and P_(max) of the experimental group 1 were significantly lower, PaO_2 and Cdyn were significantly higher, and the difference between the three groups was significant(P<0.05), but there was no significant difference in the OI between the three groups(P>0.05). Compared with the control group, the PaCO_2, Qs/Qt of the test group increased at T_2 and T_3, and the pH and MAP decreased. Compared with T_1, the PaCO_2, Qs/Qt of the test group increased at T_2 and T_3, and the pH and MAP decreased. Compared with the experimental group 2, the Pa-CO_2 and PaCO_2 in the experimental group 1 were significantly lower and the pH was significantly higher(P<0.05), but there was no sig-nificant difference in the MAP between the three groups(P>0.05). There was no significant difference in preoperative CO, CVP, and CI between the three groups(P>0.05). At 30 min and 1 h after surgery, CO, CVP, and CI were lower in the experimental group than in the control group,while the experimental group 1 was significantly more lower than the experimental group 2(P<0.05). There was no signifi-cant difference in the improvement of complications between the three groups(x~2=0.1973, P=0.9954); the MMSE score after treatment was significantly lower than before treatment, and the test group was significantly higher than the control group, and the test group 1 was significantly higher than the test 2 group(P<0.05). Conclusion: Permissive hypercapnia protects lung compliance by reducing airway pres-sure during oxygen laparoscopic surgery for prolonged laparoscopic rectal cancer surgery, and can reduce the occurrence of postoperative cognitive impairment to a certain extent, it has a certain degree of brain protection.
Objective: To study the effect of permissible hypercapnia in laparoscopic rectal cancer surgery, the optimal range of application and the effect on the patient's circulatory function. Methods: 90 cases with rectal cancer were researched to undergoing laparoscopic surgery according to the random number table they were divided into Test 1 group, 2 groups and control group, 30 cases in each group. The PaCO_2 of the test group 1 was maintained at 56-65 mm Hg, the PaCO_2 of the test group 2 was maintained at 46-55 mm Hg, and the PaCO_2 of the control group was maintained at 35-45 mm Hg. They were compared with Pneumoperitoneum time, mechanical ventilation time, operation time, extubation time, wake-up time, mean arterial pressure, heart rate, and airway pressure at 10 minutes before pneumoperitoneum(T_1), 1 hour after pneumoperitoneum(T_2), 2 h after pneumoperitoneum(T_3), and 15 min after deflation(T_4). dynamic lung compliance, oxygenation index, recording of complications such as subcutaneous emphysema, vomiting, irritability and postoperative cognitive impairment. Results: There was no significant difference in the operation time, pneumoperitoneum time,mechanical ventilation time, extubation time and recovery time between the three groups(P>0.05). Compared with the control group,HR, PaO_2, and Cdyn in the test group significantly increased at T_2 and T_3, and Pmaxdecreased significantly; compared with T_1, HR, P_(max),and PaO_2 in the test group increased at T_2 and T_3, and Cdyn decreased; Compared with the experimental group 2, the HR and P_(max) of the experimental group 1 were significantly lower, PaO_2 and Cdyn were significantly higher, and the difference between the three groups was significant(P<0.05), but there was no significant difference in the OI between the three groups(P>0.05). Compared with the control group, the PaCO_2, Qs/Qt of the test group increased at T_2 and T_3, and the pH and MAP decreased. Compared with T_1, the PaCO_2, Qs/Qt of the test group increased at T_2 and T_3, and the pH and MAP decreased. Compared with the experimental group 2, the Pa-CO_2 and PaCO_2 in the experimental group 1 were significantly lower and the pH was significantly higher(P<0.05), but there was no sig-nificant difference in the MAP between the three groups(P>0.05). There was no significant difference in preoperative CO, CVP, and CI between the three groups(P>0.05). At 30 min and 1 h after surgery, CO, CVP, and CI were lower in the experimental group than in the control group,while the experimental group 1 was significantly more lower than the experimental group 2(P<0.05). There was no signifi-cant difference in the improvement of complications between the three groups(x~2=0.1973, P=0.9954); the MMSE score after treatment was significantly lower than before treatment, and the test group was significantly higher than the control group, and the test group 1 was significantly higher than the test 2 group(P<0.05). Conclusion: Permissive hypercapnia protects lung compliance by reducing airway pres-sure during oxygen laparoscopic surgery for prolonged laparoscopic rectal cancer surgery, and can reduce the occurrence of postoperative cognitive impairment to a certain extent, it has a certain degree of brain protection.
引文
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[15]Kanchanatawan B,Hemrungrojn S,Thika S,et al.Changes in Tryptophan Catabolite(TRYCAT)Pathway Patterning Are Associated with Mild Impairments in Declarative Memory in Schizophrenia and Deficits in Semantic and Episodic Memory Coupled with Increased False-Memory Creation in Deficit Schizophrenia[J].Molecular neurobiology,2018,55(6):5184-5201
[16]Victor S,Mc Keering CM,Roberts SA,et al.Effect of permissive hypercapnia on background cerebral electrical activity in premature babies[J].Pediatric research,2014,76(2):184-189
[17]Beitler JR,Hubmayr RD,Malhotra A.CrossTalk opposing view:there is not added benefit to providing permissive hypercapnia in the treatment of ARDS[J].The Journal of physiology,2013,591(11):2767-2769
[18]Liu J,Wang LN.The efficacy and safety of riluzole for neurodegenerative movement disorders:a systematic review with meta-analysis[J].Drug delivery,2018,25(1):43-48
[19]Qu K,Zaba LC,Satpathy AT,et al.Chromatin Accessibility Landscape of Cutaneous T Cell Lymphoma and Dynamic Response to HDAC Inhibitors[J].Cancer cell,2017,32(1):27-41.e4
[20]Tregub P,Kulikov V,Bespalov A.Tolerance to acute hypoxia maximally increases in case of joint effect of normobaric hypoxia and permissive hypercapnia in rats[J].Pathophysiology:the official journal of the International Society for Pathophysiology,2013,20(3):165-170
[21]Curley GF,Laffey JG,Kavanagh BP.CrossTalk proposal:there is added benefit to providing permissive hypercapnia in the treatment of ARDS[J].The Journal of physiology,2013,591(11):2763-2765
[22]Zhang JS,Wang T,Du HP,et al.Impact of interval between noeadjuvant chemoradiotherapy and surgery on short and long-term outcomes of patients with rectal cancer[J].Zhonghua zhong liu za zhi[Chinese journal of oncology],2018,40(11):833-836
[23]Jones K,Qassem MG,Sains P,et al.Robotic total meso-rectal excision for rectal cancer:A systematic review following the publication of the ROLARR trial[J].World journal of gastrointestinal oncology,2018,10(11):449-464
[2]Schaap DP,Ogura A,Nederend J,et al.Prognostic implications of MRI-detected lateral nodal disease and extramural vascular invasion in rectal cancer[J].The British journal of surgery,2018,105(13):1844-1852
[3]Zhang XY,Wang S,Li XT,et al.MRI of Extramural Venous Invasion in Locally Advanced Rectal Cancer:Relationship to Tumor Recurrence and Overall Survival[J].Radiology,2018,289(3):677-685
[4]Kondo A,Tsukada Y,Kojima M,et al.Effect of preoperative chemotherapy on distal spread of low rectal cancer located close to the anus[J].International journal of colorectal disease,2018,33(12):1685-1693
[5]Prete FP,Pezzolla A,Prete F,et al.Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer:A Systematic Review and Meta-analysis of Randomized Controlled Trials[J].Annals of surgery,2018,267(6):1034-1046
[6]Nonaka T,Fukuda A,Maekawa K,et al.The Feasibility and Efficacy of Laparoscopic Extended Total Mesorectal Excision for Locally Advanced Lower Rectal Cancer[J].In vivo(Athens,Greece),2018,32(3):643-648
[7]Cheung HYC,Dent OF,Richardson GL,et al.Pathological outcomes in rectal cancer following laparoscopic surgery[J].Asia-Pacific journal of clinical oncology,2018,14(2):e175-e180
[8]Chen TC,Liang JT.Robotic D4 lymphadenectomy for the treatment of rectal cancer with metastasis to N3-N4 lymph nodes-a video vignette[J].Colorectal disease:the official journal of the Association of Coloproctology of Great Britain and Ireland,2018,20(4):352-353
[9]Rabe H,Fernandez-Alvarez JR.Permissive hypercapnia in preterm infants:the discussion continues[J].The Lancet Respiratory medicine,2015,3(7):499-501
[10]Thome UH,Genzel-Boroviczeny O,Bohnhorst B,et al.Permissive hypercapnia in extremely low birthweight infants(PHELBI):a randomised controlled multicentre trial[J].The Lancet.Respiratory medicine,2015,3(7):534-543
[11]Nayak S,Jindal A.Permissive hypercapnia:Is there any upper limit[J].Indian journal of critical care medicine:peer-reviewed,official publication of Indian Society of Critical Care Medicine,2015,19(1):56-57
[12]Victor S,Mc Keering CM,Roberts SA,et al.Effect of permissive hypercapnia on background cerebral electrical activity in premature babies[J].Pediatric research,2014,76(2):184-189
[13]Patel KP,Giraud AS,Samuel CS,et al.Combining an epithelial repair factor and anti-fibrotic with a corticosteroid offers optimal treatment for allergic airways disease[J].British journal of pharmacology,2016,173(12):2016-2029
[14]Reeves KW,Okereke OI,Qian J,et al.Depression,Antidepressant Use,and Breast Cancer Risk in Pre-and Postmenopausal Women:AProspective Cohort Study[J].Cancer epidemiology,biomarkers&prevention:a publication of the American Association for Cancer Research,cosponsored by the American Society of Preventive Oncology,2018,27(3):306-314
[15]Kanchanatawan B,Hemrungrojn S,Thika S,et al.Changes in Tryptophan Catabolite(TRYCAT)Pathway Patterning Are Associated with Mild Impairments in Declarative Memory in Schizophrenia and Deficits in Semantic and Episodic Memory Coupled with Increased False-Memory Creation in Deficit Schizophrenia[J].Molecular neurobiology,2018,55(6):5184-5201
[16]Victor S,Mc Keering CM,Roberts SA,et al.Effect of permissive hypercapnia on background cerebral electrical activity in premature babies[J].Pediatric research,2014,76(2):184-189
[17]Beitler JR,Hubmayr RD,Malhotra A.CrossTalk opposing view:there is not added benefit to providing permissive hypercapnia in the treatment of ARDS[J].The Journal of physiology,2013,591(11):2767-2769
[18]Liu J,Wang LN.The efficacy and safety of riluzole for neurodegenerative movement disorders:a systematic review with meta-analysis[J].Drug delivery,2018,25(1):43-48
[19]Qu K,Zaba LC,Satpathy AT,et al.Chromatin Accessibility Landscape of Cutaneous T Cell Lymphoma and Dynamic Response to HDAC Inhibitors[J].Cancer cell,2017,32(1):27-41.e4
[20]Tregub P,Kulikov V,Bespalov A.Tolerance to acute hypoxia maximally increases in case of joint effect of normobaric hypoxia and permissive hypercapnia in rats[J].Pathophysiology:the official journal of the International Society for Pathophysiology,2013,20(3):165-170
[21]Curley GF,Laffey JG,Kavanagh BP.CrossTalk proposal:there is added benefit to providing permissive hypercapnia in the treatment of ARDS[J].The Journal of physiology,2013,591(11):2763-2765
[22]Zhang JS,Wang T,Du HP,et al.Impact of interval between noeadjuvant chemoradiotherapy and surgery on short and long-term outcomes of patients with rectal cancer[J].Zhonghua zhong liu za zhi[Chinese journal of oncology],2018,40(11):833-836
[23]Jones K,Qassem MG,Sains P,et al.Robotic total meso-rectal excision for rectal cancer:A systematic review following the publication of the ROLARR trial[J].World journal of gastrointestinal oncology,2018,10(11):449-464