摘要:
目的 评价肺保护性通气对单肺通气老年患者脑氧代谢和术后认知功能的影响.方法 择期全麻下行胸腔镜食管癌根治术的患者60例,性别不限,年龄65~80岁,体重45 ~ 75 kg,ASA分级Ⅱ或Ⅲ级.采用随机数字表法,将其分为2组(n=30):容量控制通气组(VCV组)和保护性通气组(PV组).VCV组双肺通气期间VT10 ml/kg,单肺通气期间VT7 ml/kg;PV组双肺通气期间VT7ml/kg+ PEEP 5 cmH2O+肺复张术,单肺通气期间VT5 ml/kg+PEEP 5 cmH2O+肺复张术.肺复张术:维持吸气压15、20、25 cmH2O,PEEP 5 cmH2O,每个压力3次呼吸,5 s/次,45 min复张1次.于诱导前(T1)、双肺通气10 min(T2)、单肺通气30 min(T3)、再次改为双肺通气15 min(T4)时采集桡动脉和颈静脉球部血样行血气分析,记录pH值、PaO2、PaCO2、SaO2、颈静脉球部血氧饱和度(SjvO2);计算氧合指数(OI)、肺内分流率(Qs/Qt)、动脉-颈内静脉血氧含量差(Da-jvO2)和脑氧摄取率(CE-RO2).于术后7d、1个月时采用简易精神状态检查量表(MMSE)评估认知功能,记录术后认知功能障碍的发生情况.结果 与T1时比较,2组T2-4时PaO2、Da-jvO2、CERO2和Qs/Qt升高,SjvO2和OI降低(P<0.05);与T2时比较,2组T3时PaO2、SjvO2和OI降低,Qs/Qt和CERO2升高,T3-4时Da-jvO2升高(P<0.05);与VCV组比较,PV组T3时PaO2、PaCO2、SjvO2和OI升高,Qs/Qt、Da-jvO2和CERO2降低,术后7d时MMSE评分升高,术后认知功能障碍发生率降低(P<0.05).结论 肺保护性通气策略有助于改善单肺通气老年患者术后脑功能.%Objective To evaluate the effects of lung-protective ventilation on the cerebral oxygen metabolism and postoperative cognitive function in elderly patients requiring one-lung ventilation (OLV).Methods Sixty patients of both sexes,aged 65-80 yr,weighing 45-75 kg,of American Society of Anesthesiologists physical status Ⅱ or Ⅲ,scheduled for elective radical resection for esophageal cancer performed via video-assisted thoracoscope with general aneshesia,were divided into 2 groups (n =30 each)using a random number table:volume-controlled ventilation group (group VCV) and protective ventilation group (group PV).In group VCV,the tidal volume (VT) was set at 10 ml/kg during two-lung ventilation (TLV) and at 7 ml/kg during OLV.In group PV,the VT was set at 7 ml/kg during TLV and at 5 ml/kg during OLV with positive end-expiratory pressure of 5 cmH2O,and lung recruitment maneuver was performed every 45 min with inspiratory pressure at 15,20 and 25 cmH2O,PEEP 5 cmH2O,3 breaths per pressure,5 s/breath.Before induction of anesthesia (T1),at 10 min of TLV (T2),at 30 min of OLV (T3) and at 15 min after restoration of TLV (T4),blood samples were taken from the radial artery and jugular bulb for blood gas analysis,and pH value,arterial oxygen partial pressure (PaO2),arterial carbon dioxide partial pressure (PaCO2),arterial oxygen saturation (SaO2) and jugular venous oxygen saturation (SjvO2) were recorded.Oxygenation index (OI),intrapulmonary shunt (Qs/Qt),arteriovenous blood O2 content difference (Da-jvO2) and cerebral O2 extraction rate (CERO2) were calculated at the same time.Cognitive function was assessed using Mini-Mental State Examination at 7 days and 1 month after operation,and the development of postoperative cognitive dysfunction was recorded.Results PaO2,DajvO2,CERO2 and Qs/Qt were significantly higher and SjvO2 and OI were lower at T2-4 than at T1 in two groups (P<0.05).PaO2,SjvO2 and OI were significantly lower and Qs/Qt and CERO2 were higher at T3 than at T2,and Da-jvO2 was higher at T3-4 than at T2 in two groups (P<0.05).Compared with group VCV,PaO2,PaCO2,SjvO2 and OI were significantly increased and Qs/Qt,Da-jvO2 and CERO2 were decreased at T3,the Mini-Mental State Examination scores were increased on postoperative day 7,and the incidence of postoperative cognitive dysfunction was decreased in group PV (P<O.05).Conclusion Lungprotective ventilation is helpful in improving postoperative brain function of elderly patients requiring OLV.