本文選題：食管癌 + 單肺通氣　； 參考：《河北醫(yī)科大學》2017年碩士論文

【摘要】：目的:食管癌開左胸手術(shù)中,在支氣管封堵管(BB)下進行單肺通氣,參照Campos肺萎陷和手術(shù)野的評估方法[1]和雙腔管下肺萎陷和手術(shù)野的評估方法[2],計算應用支氣管封堵器技術(shù)開左側(cè)胸肺萎陷分級的百分比,便于指導臨床評估開胸手術(shù)患側(cè)肺萎陷程度。方法:由于Campos分級是術(shù)側(cè)肺自然萎陷狀態(tài)下的評估。雙腔管下分級是對術(shù)側(cè)肺進行小潮氣量通氣,經(jīng)過干預后,根據(jù)術(shù)者對手術(shù)野暴露的滿意度以及是否影響手術(shù)操作的評估分級的定義:Ⅰ級術(shù)側(cè)肺基本萎陷,不經(jīng)過干預后手術(shù)野暴露滿意,不影響手術(shù)操作。Ⅱ級術(shù)側(cè)肺部分萎陷,經(jīng)過干預后手術(shù)野暴露可,但不影響手術(shù)操作。Ⅲ級術(shù)側(cè)肺萎陷差,經(jīng)過干預后仍嚴重影響手術(shù)野暴露,手術(shù)無法進行。支氣管封堵技術(shù)下分級是對支氣管封堵管中心導管進行小潮氣量通氣,經(jīng)過氧氣通氣干預后,根據(jù)術(shù)者對手術(shù)野暴露的滿意度以及是否影響手術(shù)操作的評估,分級的定義如雙腔管分級。隨機選取同一組手術(shù)醫(yī)生2016年2月至2016年10月?lián)衿诘?0例食管癌患者,男女不限,體重為49~80kg,身高155~175cm,全部選擇開左胸食管癌根治術(shù)。ASA分級為Ⅰ~Ⅱ級,術(shù)前心電圖、心臟超聲以及肺功能檢查未見異常,依據(jù)肺功能報告,記載患者預計肺總量,近期無上呼吸道感染,血常規(guī)和生化檢查無明顯異常,既往體健,無系統(tǒng)疾病。根據(jù)研究需要隨機分三組:A組(n1=20)、B組(n2=20)和C組(n3=20)�；颊弑凰腿胧中g(shù)室,完善三方核對,手術(shù)室護士建立外周液路,切皮前30min,戊乙奎醚1mg和咪達唑侖0.05mg/kg入壺。用IntelliVue MP50監(jiān)護儀記錄其脈搏血氧飽和度(SpO2)和心電圖(ECG),2%利多卡因局麻后進行有創(chuàng)穿刺,包括深靜脈和橈動脈,記錄CVP和ABP,進行術(shù)前吸空氣的動脈血氣分析。面罩下100%純氧吸入,增加氧儲備,靜脈注射舒芬太尼0.2~0.4μg/kg,依托咪酯0.2~0.3mg/kg,患者入睡后推注順式阿曲庫銨0.3mg/kg,輔助呼吸和面罩人工通氣5min后由同一高年資麻醉醫(yī)生經(jīng)口明視插入7.5~8.0號單腔氣管導管,固定單腔氣管導管,然后經(jīng)單腔管置入支氣管封堵管,置入左主支氣管。先用聽診法檢查封堵管套囊對位是否良好,再用纖維支氣管鏡檢查,確定對位良好,同時檢查氣道情況,確保通暢。固定支氣管封堵管,進行雙肺通氣。用datex-ohmeda7100呼吸機控制呼吸以及監(jiān)測氣道平臺壓(pplat)和氣道峰壓(ppeak)、呼末二氧化碳分壓(petco2)。術(shù)中麻醉采用瑞芬太尼-七氟烷靜吸復合麻醉維持,微量泵瑞芬太尼(0.5~1μg/kg/min)和吸入七氟烷(1~3%),每半小時靜推順式阿曲庫銨0.05mg/kg。進胸前雙肺通氣,呼吸參數(shù)設定為:潮氣量(vt)8ml/kg,呼吸頻率(f)12次/分,吸呼比(i:e)1:2。進胸后改為單肺通氣模式,呼吸參數(shù)設定:潮氣量為6ml/kg,呼吸頻率15次/分,吸呼比1:2。在左側(cè)肺完全萎陷后,手術(shù)進行到過主動脈弓階段時給予注入氧氣(濃度0.8)干預(附圖),使b組和c組分別達到肺萎陷程度分級的Ⅱ級和Ⅲ級(附圖),記錄下此時的注氣總量(v1,v2),給予小潮氣量1ml/kg維持萎限程度。同時抽血氣記錄ph,肺泡動脈氧分壓差(a-ado2),動脈血氧分壓(pao2),二氧化碳分壓(paco2)。并記錄三組的有創(chuàng)動脈壓(abp)、中心靜脈壓(cvp)、心率(hr)和脈搏氧飽和度(spo2)。記錄術(shù)后2天內(nèi)聲音嘶啞、咽痛的發(fā)生例數(shù),和術(shù)后7天內(nèi)肺部發(fā)生感染的例數(shù)。結(jié)果:1基本情況:三組患者的性別、年齡、體重、身高、術(shù)前pao2、fvc、fev1/fvc(%)、dlco、單肺通氣時間、手術(shù)時間、血紅蛋白含量、手術(shù)中補液量、術(shù)中尿量,差異均無統(tǒng)計學意義(p0.05)。2與a組比較,b組和c組患者的血氣分析中ph值,動脈血二氧化碳分壓(paco2),心率(hr),平均動脈壓(mbp),中心靜脈壓(cvp)的差異沒有統(tǒng)計學意義(p0.05)。3與a組比較,b組和c組患者的pao2和a-ado2差異有統(tǒng)計學意義(p0.05)。4與b組比較,c組患者的pao2和a-ado2的差異沒有統(tǒng)計學意義(p0.05)。5a組的萎陷程度為100%,b組萎陷程度為80.2%,c組萎陷程度為72.2%,6 ABC三組開左胸側(cè)肺萎陷程度的差異有統(tǒng)計學意義(P0.05)。7 ABC三組患者術(shù)后2天內(nèi)聲音嘶啞、咽痛的發(fā)生情況,和術(shù)后7天內(nèi)肺部發(fā)生感染的情況無統(tǒng)計學意義(P0.05)。結(jié)論:行左開胸食管癌根治術(shù)時,術(shù)側(cè)肺通過不同程度的膨脹,能夠提高動脈氧分壓,降低低氧血癥等并發(fā)癥,保證手術(shù)的順利進行。左側(cè)肺的萎陷分別為Ⅰ級萎陷100%~80.2%,Ⅱ級萎陷80.2%~72.2%,Ⅲ級萎陷低于72.2%。同時,肺萎陷程度在80.2%的情況下既不影響患者的血流動力學又不干擾手術(shù)操作。術(shù)后聲音嘶啞、咽痛和肺部發(fā)生感染等并發(fā)癥的發(fā)生率比雙腔管低。
[Abstract]:Objective: during the operation of the left thoracic surgery for esophageal cancer, single lung ventilation was carried out under the bronchial plugging tube (BB). The evaluation method of Campos lung collapse and surgical field, [1] and the evaluation method of the pulmonary collapse and surgical field of the double lumen tube, [2], were used to calculate the percentage of the classification of the left thoracic lung collapse with the application of the bronchial occluder technique, so as to guide the clinical evaluation of the thoracotomy hands. Method: the degree of lung collapse in the side of the operation. The Campos classification is an assessment of the natural collapse of the lung. The sub lumen tube classification is a small tidal volume ventilation for the lateral lung. The operation field was satisfactorily exposed to the operation. The operation was not affected by the operation. The second stage of the lung was partly collapsed, and the operation field was exposed after intervention, but it did not affect the operation. After low tidal volume ventilation, after oxygen ventilation, according to the satisfaction of surgical field exposure and the evaluation of surgical operation, the classification was defined as a double lumen tube classification. 60 cases of esophageal cancer who were selected by the same group of surgeons from February 2016 to October 2016 were selected randomly, the weight was 49~80kg, and the height was 155~1. 75cm, all selected open left thoracic esophagus cancer radical operation.ASA grade I to grade I ~ II, before the operation electrocardiogram, echocardiography and lung function examination no abnormal, according to the lung function report, record the patient's estimated lung total, no upper respiratory tract infection, blood routine and biochemical examination no obvious abnormalities, previous body health, no systemic disease. According to the research needs The patients were divided into three groups: group A (n1=20), group B (n2=20) and C group (n3=20). The patients were sent to the operation room to perfect the three party check. The nurses in the operation room set up the peripheral liquid, 30min before cutting the skin, the amyl quetidine 1mg and midazolam 0.05mg/kg into the pot. The pulse oxygen saturation (SpO2) and electrocardiogram were recorded with IntelliVue MP50 monitor, and 2% lidocaine local anesthesia was followed. Invasive puncture, including deep vein and radial artery, CVP and ABP, arterial blood gas analysis before operation, 100% pure oxygen inhalation under mask, increased oxygen reserve, intravenous injection of sufentanil 0.2~0.4 mu g/kg, etomidate 0.2~0.3mg/kg, patients after falling asleep, followed by CIS atracurium 0.3mg/kg, assisted breathing and mask artificial ventilation 5min after 5min The same senior anaesthetized anesthesiologist inserted the single lumen tracheal tube of 7.5~8.0, fixed a single lumen tracheal tube, and then inserted the single lumen tube into the bronchial tube and placed the left main bronchus. First, the auscultation method was used to check the position of the closure of the trachea well, and then the bronchoscopy was used to determine the good position, and the airway was checked, and the airway situation was confirmed. Keep the bronchus blocked and double lung ventilation, control breathing with datex-ohmeda7100 respirator, airway pressure (pplat) and airway peak pressure (ppeak), end of the respiratory pressure (PetCO2). Intraoperative anesthesia was maintained by remifentanil - seven fluoroalkanes combined anesthesia, micro Reventa Ni (0.5~1, g/kg/min) and inhalation seven Halothane (1~3%) was injected into the chest with 0.05mg/kg. per half hour. The parameters of respiratory parameters were as follows: tidal volume (VT) 8ml/kg, respiratory frequency (f) 12 / sub, i:e 1:2. into the chest and the single lung ventilation mode, and the breathing parameters were set: the tidal volume was 6ml/kg, the respiratory rate was 15 times per cent, and the respiratory rate was completely collapsing in the left lung. After the operation, the oxygen (0.8) was injected into the aortic arch (0.8), and the group of C and the group of the group of B and C were divided into grade II and grade III (attached map) respectively, and the total gas injection (V1, V2) was recorded at this time, and the small tidal volume 1ml/kg was maintained. Meanwhile, the blood gas was recorded and the oxygen differential of alveolar artery (A-aDO2) was recorded. Arterial oxygen pressure (PaO2), carbon dioxide pressure (PaCO2) and three groups of invasive arterial pressure (ABP), central venous pressure (CVP), heart rate (HR) and pulse oxygen saturation (SpO2). The number of cases of hoarseness, sore pain within 2 days after operation, and cases of pulmonary infection within 7 days after the operation were recorded. Results: 1 basic cases: the sex, age, age, and sex of the three groups of patients. Weight, height, preoperative PaO2, FVC, fev1/fvc (%), DLCO, single lung ventilation time, operation time, hemoglobin content, fluid volume, intraoperative urine volume, difference were not statistically significant (P0.05).2 and a group, B and C group of patients with pH value, arterial carbon dioxide partial pressure (PaCO2), heart rate (HR), mean arterial pressure (HR), mean arterial pressure, central vein The difference of pressure (CVP) was not statistically significant (P0.05).3 and a, the difference between PaO2 and A-aDO2 in group B and C group was statistically significant (P0.05), and there was no significant difference between.4 and B group. There was no statistically significant difference between the C group and the B group. The degree of collapse of the group was 100%, the degree of collapse was 80.2%, the degree of collapse was 72.2%, and 6 of the three groups were open. The difference in the degree of left chest lateral lung collapse was statistically significant (P0.05) the hoarseness in the.7 ABC three group, the occurrence of sore throat within 2 days after operation, and the incidence of pulmonary infection within 7 days after the operation were not statistically significant (P0.05). Conclusion: during the radical operation of left open thoracic esophagus cancer, the operation of the lung through different degrees of expansion could improve the oxygen partial pressure of the artery, The complications such as hypoxemia and other complications were reduced to ensure the smooth operation. The left lung collapse was grade I 100%~80.2%, stage II collapsing 80.2%~72.2%, stage III depression lower than 72.2%., and the degree of lung collapse in the case of 80.2% did not affect the patient's hemodynamics without interfering with the operation. The incidence of complications, such as infection, is lower than that of the double lumen tube.

【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R614;R735.1

【參考文獻】

相關(guān)期刊論文 前10條

1 楊斐;胡海平;許小蘭;朱曉寧;魏文鑫;郭振光;劉征;蒲章玉;楊秀芹;厲帆;趙英;;MDCT Tissue Segmentation技術(shù)測定氣胸、液氣胸中肺壓縮比率方法研究[J];醫(yī)學影像學雜志;2016年09期

2 袁陽剛;;利用Photoshop軟件對CT片上肺萎陷程度進行計算初探[J];中國法醫(yī)學雜志;2016年03期

3 梁智勇;;胸外科開胸術(shù)后心律失常的臨床分析[J];當代醫(yī)學;2012年30期

4 陳小可;劉慧;彭蕻琳;劉念;陳霞;喻海瓊;;預計肺總量與胸腔總體積的相關(guān)性分析[J];現(xiàn)代醫(yī)藥衛(wèi)生;2009年12期

5 宋玉芳;田春芳;曹芳;;開胸手術(shù)患者單肺通氣過程中呼吸參數(shù)變化對氣道壓的影響[J];山東醫(yī)藥;2009年11期

6 楊光;曾憲陽;劉紀澤;張玉杰;;5%碳酸氫鈉用于單肺通氣的臨床研究[J];武警醫(yī)學;2008年12期

7 賈慧群;王勇;宋子賢;蔡巧穎;張翼;;食管癌根治術(shù)患者不同補液方案的效應[J];中華麻醉學雜志;2006年10期

8 初向陽,孫玉鶚;單肺通氣胸腔鏡手術(shù)對幼豬血流動力學及血氣的影響[J];中華胸心血管外科雜志;2001年03期

9 張勇,章李紅,張夷,何虹;單肺通氣在食管癌根治術(shù)中的應用[J];中國癌癥雜志;1999年03期

10 劉仁玉,杭燕南;單肺通氣方法和低氧血癥防治[J];臨床麻醉學雜志;1998年05期

，

本文編號：1871219