低中心静脉压联合急性高容量血液稀释对胸科手术患者肺内分流及动脉氧分压的影响

胡峥嵘　魏兵华　李长科

[摘要] 目的 探討低中心静脉压（LCVP）联合急性高容量血液稀释（AHHD）在胸科手术单肺通气期间对肺内分流和动脉氧分压（PO2）的影响。 方法 选择2015年1月～2017年12月汕头大学医学院附属粤北人民医院ASA分级为I～Ⅱ级择期全麻下行肺癌根治切除术的胸科患者50例，随机分为两组：LCVP联合AHHD组（LA组）和对照组（C组），每组25例。其中LA组麻醉后先行LCVP技术，采取限制晶体输液量并硝酸甘油持续微泵注射的方法，控制术中CVP在2～5 cmH2O，随后再联合应用AHHD技术，快速输注6%羟乙基淀粉（130/0.4）15 mL/kg进行血液稀释，使血细胞比容维持在25%～30%；C组术中始终维持中心静脉压在正常水平6～12 cmH2O。分别在平卧位双肺通气10 min（Tadb）、平卧位单肺通气10 min（T1）、侧卧位单肺通气10 min（T2）、肺叶切除后10 min（T3）等时间点采集肘静脉血测定血糖（GLU）和血清皮质醇（COR）水平；采集桡动脉血和右心房混合静脉血行血气分析，并记录GLU、COR水平、动脉血氧含量（CaO2）、混合静脉血氧含量（CvO2）、动脉血和混合静脉血氧分压PO2、动脉血和混合静脉血血红蛋白氧饱和度（SO2）、动脉血和混合静脉血血红蛋白等。根据肺血流分布标准三室模型计算各时间点肺内分流率（Qs/Qt），Qs/Qt = （CcO2-CaO2）/（CcO2-CvO2）×100%。 结果 两组患者各时点GLU、COR、SpO2、HR、MAP、BIS、PetCO2基本稳定，但在单肺通气后，LA组和C组肺内分流明显增加（P < 0.05），其中平卧位分别增加13.7%和14.9%，侧卧位分别增加11.4%和14.3%；两组动脉氧分压明显下降（P < 0.05），且平卧位较侧卧位下降更明显，但两组间差异无统计学意义（P > 0.05）。在肺叶切除后，LA组和C组肺内分流明显减少（P < 0.05），分别减少7.2%和8.6%，两组动脉血氧分压明显升高（P < 0.05），但两组间差异无统计学意义（P > 0.05）。术中LA组输血比例明显低于C组（χ2 = 4.902，P < 0.05）。 结论 低中心静脉压联合急性高容量血液稀释在胸科手术单肺通气期间对肺内分流、动脉氧分压无明显的抑制，且可明显减少术中输血比例。

[关键词] 低中心静脉压；急性高容量血液稀释；胸科手术；肺内分流；动脉氧分压

[中图分类号] R619.19 [文献标识码] A [文章编号] 1673-7210（2018）05（a）-0080-05

Effect of low central venous pressure combined with acute hypervolemic hemodilution on pulmonary shunt and arterial oxygen pressure in patients with thoracic surgery

HU Zhengrong1 WEI Binhua1 LI Changke1 TAN Jiangbo2 WU Qinru3

1.Department of Anesthesiology， the Affiliated Yuebei People's Hospital， Shantou University Medical College， Guangdong Province， Shaoguan 512026， China； 2.Department of Emergency， Zhujiang Hospital， Souther Medical University， Guangdong Province， Guangzhou 510080， China； 3.Clinical Laboratory， the Affiliated Yuebei People's Hospital， Shantou University Medical College， Guangdong Province， Shaoguan 512026， China

[Abstract] Objective To investigate the effect of low central venous pressure （LCVP） combined with acute hypervolemic hemodilution （AHHD） on intrapulmonary shunt and arterial oxygen partial pressure during one lung ventilation in thoracic surgery. Methods From January 2015 to December 2017， ASA grade Ⅰ-Ⅱ undergoing elective radical resection of lung cancer and 50 thoracic surgery patients in the Affiliated Yuebei People's Hospital， Shantou University Medical College， were randomly divided into two groups： group AHHD with LCVP （group LA） and control group （group C）， each group had 25 cases. Group LA was given the limited crystalloid the amount of nitroglycerin and continuousmicro pump injection method after anesthesia in advance of LCVP technology， control of CVP in 2-5 cmH2O， then combined with the application of AHHD technology， rapid infusion of 6% hydroxyethyl starch （130/0.4） 15 mL/kg on blood thinners， keep Hct at 25%-30%. Group C was maintained at the normal level of 6-12 cmH2O CVP. On the each time as 10 min after double lung ventilation in the supine position （T0）， 10 min after one lung ventilation in supine position （T1）， 10 min after single lung ventilation in lateral position （T2）， 10 min after pulmonary lobectomy （T3）， the blood glucose and cortisol level were measured by collecting， and the blood of the elbow. The radial artery blood and right atrial mixed venous blood was collected for blood gas analysis， and record blood glucose concentration， serum cortisol level， SpO2， HR， MAP， CVP， BIS， PetCO2， arterial oxygen content （CaO2）， mixed venous oxygen content （CvO2）， arterial and mixed venous blood oxygen partial pressure （PO2）， arterial and mixed venous blood oxygen saturation of hemoglobin （SO2）， arterial and mixed venous blood hemoglobin （Hb） etc.. The rate of intrapulmonary shunt （Qs/Qt）， Qs/Qt = （CcO2-CaO2）/（CcO2-CvO2）×100% were calculated according to the standard three compartment model of pulmonary blood flow distribution. Results The blood glucose concentration， serum cortisol level， SpO2， HR， MAP， BIS， PetCO2 of patients in two groups at each time point was basically stable， but after one lung ventilation， LA group and group C significantly increased intrapulmonary shunt （P < 0.05）， which increased by 13.7% and 14.9% respectively in supine position， lateral position increased 11.4% and 14.3% respectively. arterial oxygen partial pressure of two groups were significantly decreased （P < 0.05）， and compared with the supine lateral position decreased more obviously， but there was no significant difference between the two groups （P > 0.05）. After lobectomy， the intrapulmonary shunt in group LA and group C was significantly reduced （P < 0.05）， 7.2% and 8.6% respectively， and the arterial oxygen partial pressure increased significantly in two groups （P < 0.05）， but there was no significant difference between the two groups （P > 0.05）. The proportion of blood transfusion in group LA was significantly lower than that in group C （χ2 = 4.902， P < 0.05）. Conclusion Low central venous pressure combined with acute hypervolemic hemodilution has no significant inhibition on intrapulmonary shunt and arterial oxygen partial pressure during one lung ventilation during thoracic surgery， and can significantly reduce the proportion of intraoperative blood transfusion.

[Key words] Low Central venous pressure； Acute high volume blood dilution； Thoracic surgery； Pulmonary shunt； Oxygen partial pressure

近年来随着胸腔镜和气管重建技术的推广与进步，胸科手术常采用健……