开胸手术对肺氧合功能及血流动力学影响的临床研究
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摘要
目的
用反向Fick法研究开胸手术围术期氧供需是否平衡以及氧供氧耗关系的变化特点，开胸手术对机体血流动力学的影响。
方法
30例择期行开胸手术的患者常规插管麻醉后采用50％笑气复合静脉异丙酚、异氟醚维持麻醉，采用Hemosonic~(TM) 100经食道超声多谱勒连续监测心输出量(CO)，桡动脉穿刺行有创血压连续监测和动脉血气分析，经颈内静脉放置CVP测压管，同时抽取混合静脉血做血气分析。分别于入室后平卧自主呼吸(T_1)、插管后侧卧位双肺通气15分钟(T_2)、侧卧位单肺通气15分钟(T_3)、侧卧位单肺通气30分钟(T_4)、侧卧位单肺通气60分钟(T_5)、关胸后双肺通气10分钟(T_6)，分别抽取桡动脉血和混合静脉血做血气分析，同时抽取动脉血2ml测定动脉血乳酸浓度(ABL)。根据标准公式计算氧供(DO_2)、氧耗(VO_2)、氧摄取率(ERO_2)，观察在6个时间点上述指标和SvO_2、MAP、HR、CI、TSVR、ACC、LEVTi等血流动力学指标的变化趋势。
结果
单肺通气开始后动脉血氧分压PaO_2显著下降(从230mmHg下降到144mmHg)，但在单肺通气过程中PaO_2保持在一个相对稳定的水平(141-148mmHg)。关胸后TLV使PaO_2显著升高(从148mmHg上升到278mmHg)。插管后TLV时的氧供和麻醉诱导前相比显著下降(从480ml·min~(-1)·m~(-2)下降到413ml·min~(-1)·m~(-2))，氧耗明显下降(从97ml·min~(-1)·m~(-2)下降到64ml·min~(-1)·m~(-2))。OLV过程中与插管后TLV相比，氧供维持在一个相对恒定的水平(404-421ml·min~(-1)·m~(-2))，随着单肺通气时间的延长，氧耗逐渐增加(从78ml·min~(-1)·m~(-2)上升到89ml·min~(-1)·m~(-2))；同时摄氧率逐渐增加(从18％上升到24％)，动脉血乳酸浓度呈上升趋势(1.63～1.70mmol·L~(-1))。关胸后TLV与OLV过程相比，氧供明显提高(从404ml·min~(-1)·m~(-2)上升到457ml·min~(-1)·m~(-2))而氧耗维持在一恒定水平(91ml·min
勇叹珍~笋矛漪九节氛汾功柑及益葫动力笋影嗬必瑙诉比劝泞谐戈
摄氧率有所下降(从24%下降到22%)，同时动脉血乳酸浓度也下降。麻醉诱导后，
机体的心肌收缩力显著下降;到关胸时机体的心肌收缩力比麻醉诱导时显著上升。
开胸后心率显著升高，关胸后心率恢复正常。围术期机体的MAP保持相对恒定。
单肺通气过程中，碱剩余的负值逐渐增大。
结论
在目前常规的胸外科手术麻醉条件下(50%笑气复合静脉异丙酚维持麻醉)开
胸手术期间，机体的氧供和氧耗处于平衡状态。机体的血流动力学也处于平衡状
态。
The reverse Fick method was used to evaluate the characteristic of oxygen metabolism during thoracic surgical procedures, and examine the changes of oxygen supply and oxygen consumption balance during one-lung ventilation. Transesophageal Doppler echocardiograph (HemosonicTM 100) was used to evaluate the changes of hemodynamics during the perioperative period.
Methods
30 patients(18 male, 12 female) aged(41 ± 12 yr),undergoing pneumonectomy were studied. The patients were premedicated with pethidine 50mg promethazine 25mg and atropine 0. 5mg im 30 min before operation. Anesthesia was induced with fentanyl 2ug kg-1 , midazolam 0.1-0. 2mg kg-1, vecuronium 0.12-0.15mg kg-1, propofol 1. 5-2. 5 mg kg-1 and maintained with inhalation of 50% nitrous oxide in oxygen and TCI propofol and intermittent iv boluses of fentanyl and vecuronium. Radial artery was cannulated, central venous pressure catheter was placed via internal jugular vein. Arterial blood gas analasis and mixed venous blood gas analasis were respectively done from the sober state to closure of the pleura cavity. Hemodynamic parameters including mean arterial pressure(MAP) heart rate(HR) cardiac output index(CI) stroke volume(SV) total systemic vascular resistance for aortic circuit(TSVR) HR-corrected left ventricular ejection time (LVETi) and peak aortic flow acceleration (ACC) were measured and recorded. Oxygen d
elivery (DO2) oxygen consumption(VO2) oxygen extraction rate(ERO2) mixed venous
oxygen saturation(SvO2) arterial oxygen partial pressure(PaO2) and arterial blood lactate(ABL) were monitored during anesthesia.
Results
During OLV, PaO2 was decreased significantly(P < 0. 05). After the induction of anesthesia, oxygen delivery was decreased significantly compared with that of the sober state. During OLV, VO2 and ERO2 were increased gradually, while D02 was kept at a certain level(404-421 ml min-1 m-2).
After pleural cavity closure, DO2 was increased significantly (from 404 to 457 ml min-1 m-2)and VO2 was kept at a certain level (91 ml min-1 m -2). After the induction of anesthesia, the myocardial contractility decreased significantly. When the pleura cavity was closed, the myocardial contractility returned to the baseline. During the one-lung ventilation, the base excess decreased gradually.
Conclusions
Among patients undergoing pneumonectomy during one-lung ventilation, oxygen supply demand balance was kept and tissue hypoxia did not occur. During the thoracotomy period, the hemodynamic parameters including CI SV, MAP and LVETi were kept at a balance state.
用反向Fick法研究开胸手术围术期氧供需是否平衡以及氧供氧耗关系的变化特点，开胸手术对机体血流动力学的影响。
方法
30例择期行开胸手术的患者常规插管麻醉后采用50％笑气复合静脉异丙酚、异氟醚维持麻醉，采用Hemosonic~(TM) 100经食道超声多谱勒连续监测心输出量(CO)，桡动脉穿刺行有创血压连续监测和动脉血气分析，经颈内静脉放置CVP测压管，同时抽取混合静脉血做血气分析。分别于入室后平卧自主呼吸(T_1)、插管后侧卧位双肺通气15分钟(T_2)、侧卧位单肺通气15分钟(T_3)、侧卧位单肺通气30分钟(T_4)、侧卧位单肺通气60分钟(T_5)、关胸后双肺通气10分钟(T_6)，分别抽取桡动脉血和混合静脉血做血气分析，同时抽取动脉血2ml测定动脉血乳酸浓度(ABL)。根据标准公式计算氧供(DO_2)、氧耗(VO_2)、氧摄取率(ERO_2)，观察在6个时间点上述指标和SvO_2、MAP、HR、CI、TSVR、ACC、LEVTi等血流动力学指标的变化趋势。
结果
单肺通气开始后动脉血氧分压PaO_2显著下降(从230mmHg下降到144mmHg)，但在单肺通气过程中PaO_2保持在一个相对稳定的水平(141-148mmHg)。关胸后TLV使PaO_2显著升高(从148mmHg上升到278mmHg)。插管后TLV时的氧供和麻醉诱导前相比显著下降(从480ml·min~(-1)·m~(-2)下降到413ml·min~(-1)·m~(-2))，氧耗明显下降(从97ml·min~(-1)·m~(-2)下降到64ml·min~(-1)·m~(-2))。OLV过程中与插管后TLV相比，氧供维持在一个相对恒定的水平(404-421ml·min~(-1)·m~(-2))，随着单肺通气时间的延长，氧耗逐渐增加(从78ml·min~(-1)·m~(-2)上升到89ml·min~(-1)·m~(-2))；同时摄氧率逐渐增加(从18％上升到24％)，动脉血乳酸浓度呈上升趋势(1.63～1.70mmol·L~(-1))。关胸后TLV与OLV过程相比，氧供明显提高(从404ml·min~(-1)·m~(-2)上升到457ml·min~(-1)·m~(-2))而氧耗维持在一恒定水平(91ml·min
勇叹珍~笋矛漪九节氛汾功柑及益葫动力笋影嗬必瑙诉比劝泞谐戈
摄氧率有所下降(从24%下降到22%)，同时动脉血乳酸浓度也下降。麻醉诱导后，
机体的心肌收缩力显著下降;到关胸时机体的心肌收缩力比麻醉诱导时显著上升。
开胸后心率显著升高，关胸后心率恢复正常。围术期机体的MAP保持相对恒定。
单肺通气过程中，碱剩余的负值逐渐增大。
结论
在目前常规的胸外科手术麻醉条件下(50%笑气复合静脉异丙酚维持麻醉)开
胸手术期间，机体的氧供和氧耗处于平衡状态。机体的血流动力学也处于平衡状
态。
The reverse Fick method was used to evaluate the characteristic of oxygen metabolism during thoracic surgical procedures, and examine the changes of oxygen supply and oxygen consumption balance during one-lung ventilation. Transesophageal Doppler echocardiograph (HemosonicTM 100) was used to evaluate the changes of hemodynamics during the perioperative period.
Methods
30 patients(18 male, 12 female) aged(41 ± 12 yr),undergoing pneumonectomy were studied. The patients were premedicated with pethidine 50mg promethazine 25mg and atropine 0. 5mg im 30 min before operation. Anesthesia was induced with fentanyl 2ug kg-1 , midazolam 0.1-0. 2mg kg-1, vecuronium 0.12-0.15mg kg-1, propofol 1. 5-2. 5 mg kg-1 and maintained with inhalation of 50% nitrous oxide in oxygen and TCI propofol and intermittent iv boluses of fentanyl and vecuronium. Radial artery was cannulated, central venous pressure catheter was placed via internal jugular vein. Arterial blood gas analasis and mixed venous blood gas analasis were respectively done from the sober state to closure of the pleura cavity. Hemodynamic parameters including mean arterial pressure(MAP) heart rate(HR) cardiac output index(CI) stroke volume(SV) total systemic vascular resistance for aortic circuit(TSVR) HR-corrected left ventricular ejection time (LVETi) and peak aortic flow acceleration (ACC) were measured and recorded. Oxygen d
elivery (DO2) oxygen consumption(VO2) oxygen extraction rate(ERO2) mixed venous
oxygen saturation(SvO2) arterial oxygen partial pressure(PaO2) and arterial blood lactate(ABL) were monitored during anesthesia.
Results
During OLV, PaO2 was decreased significantly(P < 0. 05). After the induction of anesthesia, oxygen delivery was decreased significantly compared with that of the sober state. During OLV, VO2 and ERO2 were increased gradually, while D02 was kept at a certain level(404-421 ml min-1 m-2).
After pleural cavity closure, DO2 was increased significantly (from 404 to 457 ml min-1 m-2)and VO2 was kept at a certain level (91 ml min-1 m -2). After the induction of anesthesia, the myocardial contractility decreased significantly. When the pleura cavity was closed, the myocardial contractility returned to the baseline. During the one-lung ventilation, the base excess decreased gradually.
Conclusions
Among patients undergoing pneumonectomy during one-lung ventilation, oxygen supply demand balance was kept and tissue hypoxia did not occur. During the thoracotomy period, the hemodynamic parameters including CI SV, MAP and LVETi were kept at a balance state.
引文
1 刘秀文，谢荣．组织氧合及氧供-氧耗关系．国外医学麻醉学与复苏分册，1992，13：257-263．
2 杭燕南，庄心良 主编．当代麻醉学．上海．上海科学技术出版社．2002，8：1065．
3 姚泰，罗自强主编．生理学．北京．人民卫生出版社．2002，151．
4 Heinz Kerger, Darin J. Saltzman, Armando Gonzales. Microvascular oxygen delivery and interstitial oxygenation during sodium pentobarbital anesthesia. Anesthesiology, 1997,86:372-86.
5 詹仁知，孙大金．氧耗测定的原理方法及应用．国外医学麻醉学与复苏分册，1992，13：263-266．
Makita K. et al. Critical Care Medicine, 1990, 18:638.
6 芮燕，岳云，龙健晶．经食管超声多谱勒与Swan-ganz导管测定的连续心输出量相关性比较。中华麻醉学杂志，2002，22：91-93．
7 Cariou A, Monchi M, Joly LM. Noninvasive cardiac output monitoring by aortic blood flow determination:evalution of the sometec dynamo-3000 system. Critical Care Medicine, 1998,26:2066-2072.
8 Davis GG. et al. Critical Care Medicine, 1986, 14:881.
9 朱科明，徐美英，邓小明．全麻状态下急性等容血液稀释时氧代谢的变化．Chin J Care Med，1999，19：700-701．
10 Nunn JF. Factors influencing the arterial oxygen tension during halothane anaesthesia with spontaneous respiration, Br J Anesth, 1964,36:327-341.
11 Brismar B, hnesthesiology, 1985,62:422.
12 Rothen HU. et al. gr J Anesth, 1993,71:788.
13 Weiskopf RB. Anesthesiology, 1989, 70:793.
14 Hausmann D, Anesth Intensive Nothland, 1990,25:327.
15 W.C. Russell, R. Greer, N.J.N. Harper. The effect of neuromuscular blockade on oxygen supply, consumption, and total chest compliance in patients with high oxygen requirements undergoing mechanical ventilation. Anaesth Intensive Care, 2002,30:192-197.
16 Freebairn RC, Derrick J, Gomersall CD. Oxygen delivery, oxygen consumption, and gastric intramucosal pH are not improved by a computer-controlled, closed loop vecuronium infusion in severe sepsis and septic shock. Crit Care Med, 1997,25:72-77.
17 Irish CL, Murkin JM, Cleland A. Neuromuscular blockade significantly decreases systemic oxygen consumption during hypothermic cardiopulmonary bypass.J Cradiothorac Vasc Anesth, 1991,5:132-4.
18 Victor Werlhof, Daniel I. Sessler. Pancuronium does not decrease oxygen consumption during hypothermic or normothermic cardiopulmonary bypass. Anesth Analg, 1995,81:485-8.
19 Wasserman K, Whipp BJ. Exercise physiology in health and disease. Am Rev Respir Dis, 1975,112:219-249.
20 Cain SM. The respiratory system. Vol 4. Bethesda. American
21 Kinichi Shibutani, Toru Komatsu, Keshav Kubal, et al. Critical level of oxygen delivery in anesthetized man. Critical Care Medicine, 1983,11(7):640-3.
22 刘流，周建美，陈启智．心脏瓣膜置换术期间组织氧合变化与氧供氧耗关系．湖南医科大学学报，1998，23：272-273．
23 梁仕伟，古妙宁，林春水．腹部手术全身麻醉期问机体氧耗的临床研究临床麻醉学杂志，1999，15：14-15．
24 汤展宏，谭冠先，胡振快．老年病人麻醉期间氧供需平衡的研究．广西医科大学学报，2000，17：1002-5．
25 高勇，肖庆隆，沈华．开胸手术术中和术后氧代谢的变化．中华麻醉学杂志，
2002，22：312-3．
26 Shoemaker WC. The textbook of critical care medicine. 2nd. edition. 1989.
27 Shoemaker WC. Et. al. Chest, 1988, 94:1176.
28 Jonathan L. Benumof. One-lung ventilation and hypoxic pulmonary vasoconstriction: implications for anesthetic management. Anesth Analg, 1985, 64:821-33.
29 Kinichi Shibutani, Toru Komatsu, Keshav Kubal, et al. Critical level of oxygen delivery in anesthetized man. Critical Care Medicine, 1983,11(7):640-3.
30 Karen B. Domino, Lewis Wetstein, Steven A. Glasser. Influence of mixed venous oxygen tension on blood flow to atelectatic lung. Anesthesiology, 1983,59:428-434.
31 Eonrad Schwarzkopf, Torsten Schreiber, N.P. Preussier. Lung perfusion, shunt fraction, and oxygenation during one-lung ventilation in pigs: the effects of desflurane, isoflurane, and propofol. J Cradiothorac Vasc Anesth, 2003,17:73-75.
32 Linda Chen, Jay Williams, Christian M. Alexander. The effect of pleura1 pressure on the hypoxic pulmonary vasoconstrictor response in closed chest dogs. Anesth Analg, 1988,67:763-9.
33 O. Werner, G. Malmkvist, A. Beckman. Gas exchange and hemodynamics during thoracotomy. Br J Anesth, 1984.56:1343-1348.
34 Toshiya Shiga, Zen' ichiro Wajima, Tetsuo Inoue, et al. Nitrous oxide produces minimal hemodynamic changes in patients receiving a propofol-based anesthetic: an esophageal Doppler ultrasound study. Can J Anesth, 2003,50:649-652.
35 马宁，李树人，王芳．七氟醚、安氟醚对犬单肺通气期间肺分流氧供、氧耗的影响．Chin J Care Med，2000，20：4-7．
36 Kudnig ST, Monnet E, Riquelme M. Effect of one-lung ventilation on oxygen delivery in anesthetized dogs with an open thoracic cavity. Am J Vet Res, 2003, 64(4):443-8.
37 Joel M. Gore, Kathy Sloan, et al. Use of continuous monitoring of mixed venous saturation in the coronary care unit. Chest, 1984,86:757-761.
38 周顺利．氧输送及氧消耗原则的临床应用． 中日友好医院学报，1997，11，175-176．
39 Cain SM. Appearance of excess lactate in anesthetized dogs during anemic and hypoxic hypoxia. Am J Physio, 1965,209:604-610.
40 Cain SM. Metabolic alterations with hypoxia. Rean Urg, 1996,5:174-177.
41 J. Boldt, M. Papsdorf, D. Uphus. Changes in regulators of the circulation in patients undergoing lung surgery. Br J Anaesth 1997,79:733-739.
42 B. Vallet, B, Tavernier, N. Lund. Assessment of tissue oxygenation in the critically-ill. European J Anaesth, 2000,17:221-229.
43 Bowles SA, Schlichtig R, Kramer DJ. Arteriovenous Ph and partial pressure of carbon dioxide detect critical oxygen delivery during progressive hemorrhage in dogs. J Crit Care, 1992,7:95-105.
44 Gutierrez G, Clark C, Brown SD. Effect of dobutamine on oxygen consumption and gastric mucosal Ph in septic patients. Am J Respir Crit Care Medicine, 1994, 150:324-329.
45 汤耀卿．氧代谢动力学监测和循环呼吸支持． 中国实用外科杂志，1996，16：726-727．
2 杭燕南，庄心良 主编．当代麻醉学．上海．上海科学技术出版社．2002，8：1065．
3 姚泰，罗自强主编．生理学．北京．人民卫生出版社．2002，151．
4 Heinz Kerger, Darin J. Saltzman, Armando Gonzales. Microvascular oxygen delivery and interstitial oxygenation during sodium pentobarbital anesthesia. Anesthesiology, 1997,86:372-86.
5 詹仁知，孙大金．氧耗测定的原理方法及应用．国外医学麻醉学与复苏分册，1992，13：263-266．
Makita K. et al. Critical Care Medicine, 1990, 18:638.
6 芮燕，岳云，龙健晶．经食管超声多谱勒与Swan-ganz导管测定的连续心输出量相关性比较。中华麻醉学杂志，2002，22：91-93．
7 Cariou A, Monchi M, Joly LM. Noninvasive cardiac output monitoring by aortic blood flow determination:evalution of the sometec dynamo-3000 system. Critical Care Medicine, 1998,26:2066-2072.
8 Davis GG. et al. Critical Care Medicine, 1986, 14:881.
9 朱科明，徐美英，邓小明．全麻状态下急性等容血液稀释时氧代谢的变化．Chin J Care Med，1999，19：700-701．
10 Nunn JF. Factors influencing the arterial oxygen tension during halothane anaesthesia with spontaneous respiration, Br J Anesth, 1964,36:327-341.
11 Brismar B, hnesthesiology, 1985,62:422.
12 Rothen HU. et al. gr J Anesth, 1993,71:788.
13 Weiskopf RB. Anesthesiology, 1989, 70:793.
14 Hausmann D, Anesth Intensive Nothland, 1990,25:327.
15 W.C. Russell, R. Greer, N.J.N. Harper. The effect of neuromuscular blockade on oxygen supply, consumption, and total chest compliance in patients with high oxygen requirements undergoing mechanical ventilation. Anaesth Intensive Care, 2002,30:192-197.
16 Freebairn RC, Derrick J, Gomersall CD. Oxygen delivery, oxygen consumption, and gastric intramucosal pH are not improved by a computer-controlled, closed loop vecuronium infusion in severe sepsis and septic shock. Crit Care Med, 1997,25:72-77.
17 Irish CL, Murkin JM, Cleland A. Neuromuscular blockade significantly decreases systemic oxygen consumption during hypothermic cardiopulmonary bypass.J Cradiothorac Vasc Anesth, 1991,5:132-4.
18 Victor Werlhof, Daniel I. Sessler. Pancuronium does not decrease oxygen consumption during hypothermic or normothermic cardiopulmonary bypass. Anesth Analg, 1995,81:485-8.
19 Wasserman K, Whipp BJ. Exercise physiology in health and disease. Am Rev Respir Dis, 1975,112:219-249.
20 Cain SM. The respiratory system. Vol 4. Bethesda. American
21 Kinichi Shibutani, Toru Komatsu, Keshav Kubal, et al. Critical level of oxygen delivery in anesthetized man. Critical Care Medicine, 1983,11(7):640-3.
22 刘流，周建美，陈启智．心脏瓣膜置换术期间组织氧合变化与氧供氧耗关系．湖南医科大学学报，1998，23：272-273．
23 梁仕伟，古妙宁，林春水．腹部手术全身麻醉期问机体氧耗的临床研究临床麻醉学杂志，1999，15：14-15．
24 汤展宏，谭冠先，胡振快．老年病人麻醉期间氧供需平衡的研究．广西医科大学学报，2000，17：1002-5．
25 高勇，肖庆隆，沈华．开胸手术术中和术后氧代谢的变化．中华麻醉学杂志，
2002，22：312-3．
26 Shoemaker WC. The textbook of critical care medicine. 2nd. edition. 1989.
27 Shoemaker WC. Et. al. Chest, 1988, 94:1176.
28 Jonathan L. Benumof. One-lung ventilation and hypoxic pulmonary vasoconstriction: implications for anesthetic management. Anesth Analg, 1985, 64:821-33.
29 Kinichi Shibutani, Toru Komatsu, Keshav Kubal, et al. Critical level of oxygen delivery in anesthetized man. Critical Care Medicine, 1983,11(7):640-3.
30 Karen B. Domino, Lewis Wetstein, Steven A. Glasser. Influence of mixed venous oxygen tension on blood flow to atelectatic lung. Anesthesiology, 1983,59:428-434.
31 Eonrad Schwarzkopf, Torsten Schreiber, N.P. Preussier. Lung perfusion, shunt fraction, and oxygenation during one-lung ventilation in pigs: the effects of desflurane, isoflurane, and propofol. J Cradiothorac Vasc Anesth, 2003,17:73-75.
32 Linda Chen, Jay Williams, Christian M. Alexander. The effect of pleura1 pressure on the hypoxic pulmonary vasoconstrictor response in closed chest dogs. Anesth Analg, 1988,67:763-9.
33 O. Werner, G. Malmkvist, A. Beckman. Gas exchange and hemodynamics during thoracotomy. Br J Anesth, 1984.56:1343-1348.
34 Toshiya Shiga, Zen' ichiro Wajima, Tetsuo Inoue, et al. Nitrous oxide produces minimal hemodynamic changes in patients receiving a propofol-based anesthetic: an esophageal Doppler ultrasound study. Can J Anesth, 2003,50:649-652.
35 马宁，李树人，王芳．七氟醚、安氟醚对犬单肺通气期间肺分流氧供、氧耗的影响．Chin J Care Med，2000，20：4-7．
36 Kudnig ST, Monnet E, Riquelme M. Effect of one-lung ventilation on oxygen delivery in anesthetized dogs with an open thoracic cavity. Am J Vet Res, 2003, 64(4):443-8.
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