不同通气模式对腹腔镜肝切除...者出血量和术后肝功能的影响_张华明.pdf

临床研究不同通气模式对腹腔镜肝切除术患者出血量和术后肝功能的影响张华明杨佳章敏韩明明马骏李启健谢言虎DOI:1012089/jca202301002基金项目:中国博士后科学基金资助项目(2019M662179)作者单位:230001合肥市，中国科学技术大学附属第一医院麻醉科通信作者:谢言虎，Email:xyh200701 sinacn【摘要】目的探讨不同通气模式对腹腔镜肝切除术患者出血量和术后肝功能的影响。方法选择择期全麻下行腹腔镜肝切除术患者 60 例，男 35 例，女 25 例，年龄 18 64 岁，BMI 18.5 24.0kg/m2，ASA 或级。采用随机数字表法将患者分为两组:压力控制通气(PCV)组和容量控制通气(VCV)组，每组 30 例。PCV 组通过调整气道峰压，使术中 VT达到理想体重8 ml，同时调整 维持 PETCO23545 mmHg;V 组 VT设定为理想体重8 ml，同时调整 维持 PETCO23545 mmHg。记录麻醉诱导后 10 min(T0)、气腹后 10 min(T1)、切肝前 10 min(T2)、切肝后 10 min(T3)、气腹结束后 10 min(T4)吸气峰压(Ppeak)、气道平均压(Pmean)、CVP、PaCO2和氧合指数(PaO2/FiO2)。记录术中胶体液用量和出血量，术后 24、48 和 72 h 丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)以及腹腔引流量。结果与 T0时比较，T1T3时两组 Ppeak 均明显升高(P0.05);T1T4时VCV 组、T3和 T4时 PCV 组 CVP 均明显升高(P0.05)。与 VCV 组比较，PCV 组 T1、T2时 CVP 明显降低(P0.05)，术中胶体液用量和出血量明显减少(P0.05)。两组术后 24、48 和 72 h 的 ALT、AST和腹腔引流量差异无统计学意义。结论压力控制通气模式下腹腔镜肝切除术中患者出血量明显减少，可能与术中较低的气道峰压有关，但两种不同通气模式下患者术后肝功能损伤无明显差异。【关键词】腹腔镜肝切除术;压力控制通气;容量控制通气;吸气峰压;氧合指数Effects of different ventilation mode types on intra-operative blood loss and postoperative liver func-tion in patients undergoing laparoscopic hepatectomy ZHANG Huaming，YANG Jia，ZHANG Min，HAN Mingming，MA Jun，LI Qijian，XIE Yanhu Department of Anesthesiology，the First Affiliated Hos-pital of University of Science and Technology of China，Hefei 230001，ChinaCorresponding author:XIE Yanhu，Email:xyh200701 sinacn【Abstract】ObjectiveTo investigate the effects of different types of ventilation mode on intra-oper-ative blood loss and postoperative liver function in patients undergoing laparoscopic hepatectomy MethodsSixty patients，35 males and 25 females，aged 1864 years，BMI 18.524.0 kg/m2，ASA physical status or，who underwent laparoscopic hepatectomy were randomly allocated to receive pressure-controlledventilation(group PCV，n=30)and volume-controlled ventilation(group VCV，n=30)during generalanesthesia Group PCV:the tidal volume was set through adjusting the peak airway pressure，so that the tid-al volume of patients during operation was the ideal weight 8 ml，and the respiratory rate was adjusted tomaintain PETCO2between 35 and 45 mmHg Group VCV:the ideal weight 8 ml was used to set the tidalvolume of patients during operation，regardless of the airway pressure，and the respiratory rate was adjustedto maintain PETCO2between 35 and 45 mmHg The peak inspiratory pressure(Ppeak)，mean airway pres-sure(Pmean)，CVP，partial pressure of carbon dioxide(PaCO2)，oxygenation index(PaO2/FiO2)weremeasured for each patient 10 minutes after anesthesia induction(T0)，10 minutes after pneumoperitoneum(T1)，10 minutes before hepatectomy(T2)，10 minutes after hepatectomy(T3)，and 10 minutes afterpneumoperitoneum(T4)The intraoperative blood loss，transfusion volume，and urine volume during theoperation were recorded Alanine aminotransferase(ALT)，aspartate aminotransferase(AST)，and abdomi-nal drainage volume were also monitored and recorded 24，48，and 72 hours after surgery esultsCom-pared with T0，Ppeak of both groups was significantly increased at T1T3(P 0.05)，CVP in group VCVwas significantly increased at T1T4，and in group PCV at T3and T4(P 0.05)Compared with groupVCV，CVP in group PCV was significantly decreased at T1and T2(P 0.05)，the amount of colloid andblood loss in group PCV were significantly decreased(P 0.05)The two groups showed no significant8临床麻醉学杂志 2023 年 1 月第 39 卷第 1 期J Clin Anesthesiol，January 2023，Vol39，No1differences in ALT，AST levels and abdominal drainage volume between the two groups 24，48，and 72hours after operation ConclusionThe low blood loss in patients during laparoscopic hepatectomy in pres-sure-controlled ventilation mode may be related to the lower intraoperative airway peak pressure，but thepostoperative liver function impairment has no different between patients in the two different ventilationmodes【Key words】Laparoscopic liver resection;Pressure-controlled ventilation;Volume-controlled venti-lation;Peak inspiratory pressure;Oxygenation index目前肝癌仍以手术治疗为主，随着腔镜外科技术的发展，腹腔镜肝切除术应用日益广泛。但由于肝脏血供丰富，术中出血量大。出血不仅造成术野模糊，对患者预后和转归亦产生影响。因此，减少出血对手术的顺利进行及患者的预后具有一定意义。压力控制通气(pressure controlled ventilation，PCV)和容量控制通气(volume controlled ventilation，VCV)是常用的两种通气方式，在达到相同的 VT时，采用 PCV 需较低的气道峰压，而较低的气道峰压可降低胸腔内压力而使下腔静脉压力减小，从而有可能减少肝脏出血1。Kang 等2 研究表明，与VCV 模式比较，采用 PCV 式可减少脊柱手术患者的术中出血，而其对于腹腔镜肝切除术是否达到相同的效果目前研究较少，另外，腹腔镜肝切除术后肝功能损伤程度直接影响了患者的预后和康复，因此本研究拟评价 PCV 和 VCV 通气方式对腹腔镜肝切除术患者出血量和术后肝功能的影响，为促进患者早期康复提供参考。资料与方法一般资料本研究经中国注册临床试验伦理委员会批准(ChiECCT20210131)，患者或家属签署知 情 同 意 书，中 国 临 床 试 验 注 册 中 心 注 册(ChiCT2100042696)。选择 2021 年 5 月至 2022年 3 月择期行腹腔镜肝切除术患者，性别不限，年龄1864 岁，BMI 18.524.0 kg/m2，ASA 或级，NYHA 或级，Child-Pugh 评分 A 或 B 级，肿瘤直径10 cm。排除标准:既往有严重呼吸系统疾病、肝肾功能损害、脑血管疾病史及恶性心律失常等。剔除标准:中转开腹、诱导前动脉血气分析氧合指数(PaO2/FiO2)300 mmHg。采用随机数字表法将患者分为两组:PCV 组和 VCV 组。麻醉方法所有患者术前常规禁饮禁食，均未术前用药。入室后开放上肢外周静脉通路，常规监测 BP、SpO2、ECG、BIS。局麻下行桡动脉和右颈内静脉穿刺置管监测 MAP、CVP。麻醉诱导:静脉注射依托咪酯 0.2 mg/kg、舒芬太尼 0.5 g/kg 和罗库溴铵 0.6 mg/kg，气管插管后机械通气，设置 FiO250%，I E 1 2，新鲜气体流量为 2 L/min。PCV 组调整气道峰压，使术中 VT达到理想体重(身高105)8 ml，同时调整 维持 PETCO235 45mmHg;VCV 组 VT设定为理想体重(身高105)8ml，同时调整 维持 PETCO23545 mmHg。麻醉维持:吸入 1%2%七氟醚，靶控输注丙泊酚 4 8mg kg1 h1和瑞芬太尼 0.