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Evaluation of Hemodynamic Status by Transesophageal Echo-cardiography during One-lung Ventilation with Low Tidal Volume and Positive End-expiratory Pressure in Left Lateral Position
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摘要:
目的 应用经食管超声心动图(transesophageal echocardiography, TEE)评价左侧卧位开胸手术患者采用小潮气量呼气末正压(positive end-expiratory pressure, PEEP)单肺通气时的血流动力学变化。 方法 选择本院美国麻醉医师协会(American Society of Anesthesiologists, ASA)分级Ⅰ-Ⅱ级择期行左侧卧位开胸肺叶切除手术患者10例。在全麻诱导后采用小潮气量呼气末正压通气, 潮气量4~6 ml/kg, PEEP 4~6 cm H2O, 呼吸频率12~16次/min。维持呼气末二氧化碳(end-tidal carbon dioxide, EtCO2)35~40 mm Hg, SpO2 > 96%, 并持续至研究观察结束。全麻诱导后30 min(约中心静脉穿刺后15 min)时测量患者平卧位双肺通气时的心率(heart rate, HR)、血压(blood pressure, BP)、中心静脉压(central venous pressure, CVP), 同时应用TEE经胃左心室中段短轴测量左室射血分数(left ventricular ejection fraction, EF)、每搏量(stroke volume, SV)、心输出量(cardiac output, CO)、心脏指数(cardiac index, CI)、每搏指数(stroke index, SI)、左室收缩末期容积(left ventricular end-systolic volume, LVESV)、左室舒张末期容积(left ventricular end-diastolic volume, LVEDV)、左室内径缩短分数(left ventricular dimension fractional shortening, LVDFS)和体循环阻力(systemic vascular resistance, SVR)。平卧位测试完毕后将患者移至左侧卧位, 胸腔打开前单肺通气, 于胸腔打开后约15 min同样测定上述参数, 数据测量结束后撤出食管探头, 结束实验。 结果 在小潮气量PEEP通气模式下, 左侧卧位单肺通气时的SV和SI较平卧位双肺通气时显著增高, 分别为(69.23±20.01)ml vs.(56.97±22.02)ml和(40.67±8.35)ml/m2 vs.(32.45±8.79)ml/m2(P < 0.05), 但HR、SBP、DBP和CVP两种体位比较差异无统计学意义; 且LVEF、CO、CI、LVESV、LVEDV、LVDFS和SVR比较差异也无统计学意义。 结论 在小潮气量呼气末正压通气模式下, 与平卧位双肺通气比较, 左侧卧位单肺通气不影响患者的心功能和血流动力学。 Abstract:Objective To evaluate the hemodynamic status by transesophageal echocardiography (TEE) during one-lung ventilation with low tidal volume and positive end-expiratory pressure (PEEP) in left lateral position. Methods Ten American Society of Anesthesiologists (ASA) class Ⅰ or Ⅱ patients undergoing elective right lung lobectomy in left lateral position were included in the study. After induction of anesthesia, ventilation parameters were set at TV 4-6 ml/kg, PEEP 4-6 cm H2O, and RR 12-16/min, maintaining (end-tidal carbon dioxide, EtCO2) at 35-40 mmHg and SpO2 > 96%. Thirty min later (about 15 min after central venous line insertion), heart rate (HR), blood pressure (BP), and central venous pressure (CVP) were recorded. Left ventricular ejection fraction (EF), stroke volume (SV), cardiac output (CO), cardiac index (CI), stroke index (SI), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), left ventricular dimension fractional shortening (LVDFS), and systemic vascular resistance (SVR) were measured by TEE through transgastric left ventricle short axis view during two-lung ventilation in supine position. Then, the patient was turned to left lateral position. One-lung ventilation was set just before thoracic cavity was opened and all the same hemodynamic data were repeatedly measured 15 min later. Results There were no significant difference in HR, SBP, DBP, CVP, EF, CO, CI, LVESV, LVEDV, LVDFS, and SVR between left lateral one-lung ventilation and supine two-lung ventilation with low tidal volume and PEEP. However, the SV and SI significantly increased in left lateral one-lung ventilation, (69.23±20.01) ml vs. (56.97±22.02) ml and (40.67±8.35) ml/m2 vs. (32.45±8.78) ml/m2 (P < 0.05). Conclusion When ventilated with low tidal volume and PEEP, one-way ventilation in left lateral position will not remarkably influence the hemodynamic status and cardiac function. -
表 1 两种体位下患者呼吸参数比较(n = 10，x±s)
体位 VT (ml) RR (次/min) PEEP (cm H2 O) 气道峰压(cm H2 O) EtCO2 (mm Hg) SpO2 平卧位 412. 00 ± 55. 78 14. 44 ± 1. 24 5. 67 ± 0. 50 16. 00 ± 2. 70 35. 33 ± 2. 60 99. 22 ± 0. 44 左侧卧位 404. 44 ± 60. 88 14. 22 ± 1. 10 5. 67 ± 0. 50 26. 33 ± 2. 50* 36. 89 ± 1. 54 98. 22 ± 0. 97* VT:潮气量; RR:呼吸频率; PEEP:呼气末正压; EtCO2呼气末二氧化碳: SpO2 :血氧饱和度; 与平卧位比较，* P＜0. 05 
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表 2 两种体位下患者血流动力学参数比较(n = 10，x±s)
体位 HR (次/min) SBP (mm Hg) DBP (mm Hg) CVP (mm Hg) EF (%) SV (ml) CO (ml /min) CI [ml / (min·m2)] SI (ml /m2) LVESV (ml) LVEDV (ml) LVDFS (%) SVR [dyn / (s·cm5)] 平卧位 79. 33 ± 2. 50 119. 44 ± 6. 44 78. 11 ± 8. 39 6. 56 ± 2. 35 64. 11 ± 15. 45 56. 97 ± 22. 02 4. 52 ± 1. 77 2. 57 ± 0. 71 32. 45 ± 8. 79 34. 30 ± 21. 50 90. 82 ± 34. 63 39. 03 ± 10. 93 1685. 88 ± 558. 10 左侧卧位 78. 33 ± 3. 61 121. 33 ± 6. 14 76. 56 ± 8. 86 7. 44 ± 2. 96 66. 11 ± 10. 81 69. 23 ± 20. 01* 5. 30 ± 1. 74 3. 06 ± 0. 86 40. 67 ± 8. 35* 36. 94 ± 15. 57 106. 2 ± 28. 01 42. 78 ± 17. 73 1420. 30 ± 575. 24 HR:心率; SBP:收缩压; DBP:舒张压; CVP:中心静脉压; EF:左室射血分数; SV:每搏量; CO:心输出量; CI:心脏指数; SI:每搏指数; LVESV:左室收缩末期容积; LVEDV:左室舒张末期容积; LVDFS:左室内径缩短分数; SVR:体循环阻力; 与平卧位比较，* P＜0. 05
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