老年超重患者腹腔镜直肠癌根治术中呼气末正压通气和/或间歇性膨肺在改善氧合功能中的作用

Roles of positive end-expiratory pressure and/or recruitment maneuvers for improving oxygenation in laparoscopic radical resection for rectal carcinoma of old overweight patients

关键词:  一次性双管喉罩  呼气末正压通气  间歇性膨肺  肺不张  腹腔镜

Key words:  LMA-SupremeTM  positive end-expiratory pressure  recruitment maneuvers  lung atelectasis  laparoscopic

摘要:

目的　探讨老年超重患者在腹腔镜下直肠癌根治术中应用一次性双管喉罩行呼气末正压通气(positive end-expiratory pressure，PEEP)和/或间歇性膨肺(recruitment maneuvers，RM)对改善术中术后氧合功能的作用。方法　60例需行腹腔镜下直肠癌根治术的老年超重患者随机分为4组(组I，II，III，IV)，均使用一次性双管喉罩进行气道管理。容量控制通气模式下，组I加入PEEP=5 cmH₂O；组II在术中60 min和术毕均行1次气道压力30 cmH₂O，持续时间30 s的膨肺；组III在PEEP= 5 cmH₂O的基础上加入术中60 min和术毕均行1次气道压力30 cmH2O，持续时间30 s的膨肺；组IV作为对照组，只行容量控制通气。监测患者诱导前后，术中60 min、61 min(膨肺前后)及术后拔出喉罩前后心率(heart rate，HR)和平均动脉压(mean arterial pressure，MAP)，术中75 min和术后苏醒室30 min的血气分析，术后24 h各组需要吸氧才可以维持脉搏血氧92%的病例数，术后咽喉疼痛的发生率。结果　一次性双管喉罩在所有行腹腔镜下直肠癌根治术的患者中均插入成功，术中无明显异常发生。各组之间HR、MAP在诱导前后，苏醒期拔出喉罩前后及膨肺前后差异无显著性意义(P>0.05)。与其他3组比较，组III在术中和术毕进入麻醉恢复室后30 min动脉血氧分压高于其它组(P<0.05)，而且术后24 h需要吸氧的病人数少于其它组(P<0.05)。结论　一次性双管喉罩可以安全有效地应用于老年超重患者腹腔镜下直肠癌根治术的气道管理。术中应用PEEP协同RM可以有效改善患者术中和术后的氧合能力，减少肺不张的发生。

Abstract:

Objective　Using the LMA-SupremeTM (SLMA) airway management, to evaluate the roles of positive end-expiratory pressure (PEEP) and/or recruitment maneuvers (RM) for improving oxygenation in laparoscopic radical resection for rectal carcinoma of old overweight patients. Methods　This was an open prospective study with 60 consecutive old overweight patients who were inserted by SLMA under volume-controlled mechanical ventilation (VCV) in the study with PEEP and/or RM. The patients were divided into four groups, including Group I with PEEP of 5 cmH₂O, Group II with RM 30 cmH2O for 30 s at anesthesia 60 min and the end of surgery, Group III with PEEP of 5 cmH2O and RM 30 cmH2O for 30 s at anesthesia 60 min and the end of surgery, and Group IV with only VCV. Results　There were no failures of SLMA insertion or of maintenance of VCV during surgery. Groups were comparable with respect to demographic data. Compared to Groups I, II and IV, PaO₂ in Group III was significantly (P<0.05) higher at anesthesia 75 min and in the post-anesthetic care unit (PACU) 30 min. At postoperative 24 h, patients in Group III showed less need for FiO₂ than Group IV (P<0.05). Conclusion　SLMA is a useful alternative to tracheal intubations for old overweight patients in laparoscopic radical resection for rectal carcinoma. Intraoperative recruitment maneuvers with a VCV followed by PEEP 5 cmH₂O is effective in preventing lung atelectasis and is associated with better oxygenation.