【作者】 丁超；

【导师】 孙莉；

【作者基本信息】 北京协和医学院 ， 麻醉学， 2012， 博士

【摘要】 第一部分：老年食管癌患者单肺通气期间局部脑氧饱和度的变化及相关因素分析目的研究老年食管癌患者开胸手术单肺通气期间局部脑氧饱和度(rSO2)的变化及影响因素。方法随机选取20例年龄大于65岁,拟静脉麻醉诱导下行左后外切口开胸食管癌根治术的患者,采用左侧双腔支气管导管进行开胸后单肺通气(OLV)管理,吸入七氟醚维持全身麻醉,所有病例心率、血压均维持在基线波动20%以内,维持术中脉搏氧饱和度Sp02≥95%,ETCO235～40mmHg,脑电双频指数(BIS)值40～55。应用脑氧饱和度监测仪监测从清醒状态到气管拔管阶段的脑氧饱和度变化,在对应时间点进行血气分析。结果①T1：清醒仰卧位时测定局部脑氧饱和度(rSO2)为(66.9±6.2)%[60%-73%,中位数67%],T2：麻醉诱导后仰卧位双肺通气(SP-TLV)时rS02为(79.8±4.8)%[78%-84%,中位数81%],T3：侧卧位双肺通气(LD-TLV)时rS02为(75.5±6.6)%[71%-82%,中位数77%],T4：在侧卧位单肺通气(LD-OLV)期间rS02为(66.2±8.6)%[60%-75%,中位数66%],T5：拔管后仰卧位双肺通气(SP-TLV)时rSO2为(75.8±7.1)%[71%-83%,中位数78%]。设定T2：麻醉诱导后仰卧位双肺通气(SP-TLV)时rS02值为基线值,则在OLV期间的所有患者rSO2下降≥10%,rSO2基线变化率为(-18.2±7.9)%,40%(8/20)的患者rS02降幅超过20%,15%(3/20)的患者rS02降幅超过25%；T3(侧卧位双肺通气)较T2(仰卧位双肺通气)时rSO2降幅≤5%。②rSO2的降低与OLV时间、BIS值、SpO2、MAP、体温、PaCO2、PaO2、Hct、Hgb、SaO2等临床监测参数均无明显相关性(P>0.05)。结论老年食管癌患者单肺通气期间均发生局部脑氧饱和度的降低,rSO2基线变化率为(-18.2±7.9)%,有40%的患者rSO2降幅超过20%,rSO2的降低幅度与侧卧体位及常规临床监测参数间无明显相关性。第二部分：老年食管癌患者全身麻醉术后认知功能障碍与术中脑氧饱和度变化的关系目的研究老年食管癌患者全身麻醉术后认知功能障碍与术中局部脑氧饱和度(rSO2)变化之间的关系。方法随机选取78例年龄≥65岁,拟静吸复合全身麻醉下行左后外切口开胸食管癌根治术的患者,采用左侧双腔支气管导管进行单肺通气(OLV)管理,吸入七氟醚维持全身麻醉,所有病例心率、血压均维持在基线波动20%以内,维持术中脉搏氧饱和度SpO2≥95%, ETCO235～40mmHg,脑电双频指数(BIS)值40～55。应用脑氧饱和度监测仪监测从清醒状态到气管拔管阶段的局部脑氧饱和度(rSO2)变化,在对应时间点进行血气分析,所有患者术后均使用静脉自控镇痛。在术前2h和术后4d采用简易精神状态检查法(MMSE)评估患者认知功能,术后较术前MMSE评分降低一个标准差以上则认为存在POCD,根据评估结果分为POCD组和非POCD组,进行对比研究。结果64例老年食管癌患者入组,全身麻醉术后POCD发生率为25.0%(16/64)；设定麻醉诱导后仰卧位双肺通气时rSO2值为基线值(79.4±4.6)%,则在OLV期间,39.1%(25/64)的病例rSO2降幅大于20%,15.6%(15/64)的病例rS02降幅大于25%,rS02值低于65%的患者比率为37.5%(24/64),rS02值低于60%的患者比率为23.4%(15/64)；POCD组与非POCD组的年龄差异有统计学意义(P<0.05),性别比、体重、ASA分级、麻醉时间、OLV时间、受教育程度、合并高血压及糖尿病的比例、心梗史或脑卒史、术中失血量、术中最低氧分压及收缩压、术后镇痛VAS评分、术后呼吸道并发症等差异无统计学意义(P>0.05)；POCD与rSO2降低积分[(65%-当前rS02)·持续时间(秒)]大于(3000%·秒)有明显相关性(P<0.05)。结论老年食管癌患者术后早期POCD发病率较高,POCD与高龄明显相关,POCD与单肺通气期间rSO2降低积分有明显相关性。第三部分：肺保护性通气策略对老年食管癌患者局部脑氧饱和度的影响目的研究肺保护性通气策略对老年食管癌患者单肺通气期间局部脑氧饱和度的影响。方法选取40例年龄大于65岁,拟静吸复合全身麻醉下行左后外切口开胸食管癌根治术的患者,采用左侧双腔支气管导管进行单肺通气(OLV)管理。随机均分为保护性通气组(PV组)和常规通气组(CV组)。双肺及单肺通气参数设定：PV组VT为6ml／kg,吸呼比为1：2,并给予呼气末正压(PEEP)5cmH20。CV组VT为10ml／kg,PEEP为0,吸呼比为1：2,两组均调整呼吸频率维持ETCO235～40mmHg。应用脑氧饱和度监测仪监测从清醒状态到气管拔管阶段的局部脑氧饱和度变化,应用局部脑氧饱和度(rSO2)降低积分评价脑氧低饱和状态,观察记录脑电双频指数(BIS)和标准监测参数,在对应时间点进行血气分析,计算肺内分流率(Qs/Qt)。结果①CV组和PV组在清醒未吸氧状态时(T1)测定局部脑氧饱和度(rSO2)分别为(65.4±3.3)%和(66.7±3.1)%,麻醉诱导后侧卧位双肺通气l0min时(T2) rSO2分别为(76.1±4.6)%和(77.3±3.1)%,在OLV30min时(T3) rSO2分别降为(66.5±5.2)%和(68.8±5.8)%。②应用局部脑氧饱和度降低积分来评价有临床意义的低脑氧饱和度状态,局部脑氧饱和度降低积分的计算公式为：[(65%rSO2-即刻rSO2(%))×时间(秒)],当脑氧饱和度积分大于3000%时则定义为存在低脑氧饱和度。PV组和CV组低脑氧饱和度状态的发生率分别为15%(3/20)和30%(6/20),PV组较CV组明显降低,差异有统计学意义(P<0.05)。③与T1时比较,T2和T3时Pa02、Qs/Qt、rSO2升高(P<0.05)；与T2时比较,T3时PaO2、rSO2降低,Qs/Qt升高(P<0.01)；与CV组比较,PV组T3时PaO2、rS02升高,Qs/Qt降低(P<0.05)。④两组病人BIS值、SpO2、MAP、体温、Ph值、PaC02、Hct、Hgb、Sa02等临床监测参数组间比较均无统计学差异(P>0.05)。结论肺保护性通气策略可改善老年食管癌根治术患者单肺通气期间肺内分流和氧合,减少低脑氧饱和度状态的发生率。更多还原

【Abstract】 Part1:The changes and influencing factors in regional cerebral oxygen saturation during OLV Undergoing esophagectomyObjective To study both the changes and influencing factors in regional cerebral oxygen saturation (rSO2) during OLV in older patients undergoing esophagectomy.Methods20esophageal cancer patients,ASA Ⅱ～Ⅲ grade, age≥65years old, undergoing esophagectomy and necessitating OLV were randomly selected, Left double-lumen endotracheal tube was used for OLV, INVOS5100Cerebral Oximeter was used to measure regional cerebral oxygen saturation (rSO2) from the awake state to extubation phase, For intraoperative hemodynamic and respiratory managements,systolic blood pressure was maintained at≥80mmHg, fluctuation range≤20%, SpO2≥95%, ETCO235～40mmHg, the bispectral index (BIS)40～55, Other standard monitoring parameters and blood gas (ABG) analysis was observed and recorded at the corresponding time points.Results①n the awake state and supine position without O2inhalation (T1),patients showed a regional cerebral oxygen saturation (rSO2) of (66.9±6.2)%[60%-73%, median67%],Which increased to maximum(79.8≈4.8)%[78%-84%, median81%] after anesthesia induced and supine position with two lung ventilation by FiO2100%(SP-TLV,T2), During TLV in lateral decubitus(LD-TLV,T3) rSO2decreased to (75.5±6.6)%[71%-82%, median77%], When OLV in lateral decubitus(LD-OLV,T4) rSO2decreased to a minimum value of (66.2±8.6)%[60%-75%, median66%], which recover to (75.8±7.1)%[71%-83%, median78%]after extubation in supine position with TLV (SP-TLV,T5); Baseline rSO2was defined as the highest rSO2value obtained in supine position with two lung ventilation by FiO2100%(SP-TLV,T2),During LD-OLV (T4), all patients had decrease of more than10%of the baseline rSO2(SP-TLV,T2), The percent change from baseline rSO2was (-18.2±7.9)%,40%(8/20) of patients had a decrease of more than20%of the baseline rSO2,15%(3/20) of patients had a decrease of more than25%of the baseline rSO2;Compared to SP-TLV(T2),the changes of rSO2in LD-TLV(T3) less than5%.②The changes in rSO2was not correlated with lateral decubitus and any standard clinical monitoring parameters,which include BIS, SpO2, MAP, body temperature, PaCO2, PaO2, Hct, Hgb, SaO2(P>0.05)Conclusions Significant changes in regional cerebral oxygen saturation (rSO2) occurred during OLV in older patients undergoing esophagectomy, The percent change from baseline rSO2was (-18.2±7.9)%,40%of patients had a decrease of more than20%of the baseline rSO2, The changes rate in rSO2observed during OLV was not correlated with lateral decubitus and any standard clinical monitoring parameters. Part2:The correlation between the changes of regional cerebral oxygen saturation during OLV and POCD in older patients undergoing esophagectomyObjective To study the correlation between the changes of regional cerebral oxygen saturation (rSO2) during OLV and POCD in older patients undergoing esophagectomy.Methods Seventy-eight esophageal cancer patients were randomly selected to participated in this study, ASA Ⅱ～Ⅲ grade, age≥65years old, each of whom received general anesthesia and OLV using left double-lumen endotracheal tube undergoing esophagectomy, INVOS5100B (Somanetics, Troy, MI, USA) Cerebral Oximeter was used to measure regional cerebral oxygen saturation (rSO2) from the awake state to extubation phase, For intraoperative hemodynamic and respiratory managements,systolic blood pressure was maintained at>80mmHg, fluctuation range≤20%, SpO2≥95%, ETCO235～40mmHg, the bispectral index (BIS)40-55, Other standard monitoring parameters and arterial blood gas (ABG) analysis was observed and recorded at the corresponding time points,all patients take PICA for analgesia and VAS to value effects. Cognitive function was assessed using the mini mental state examination (MMSE) at the time2h preoperatively(baseline) and then repeated at4days postoperatively, any patient showing MMSE decline by more than or equal to one standard deviation of the pre-operative baseline value was defined as having POCD,The patients enrolled were classified into two groups:with (group POCD) and without (non POCD group) POCD. The rSO2desaturation score was calculated by multiplying rSO2below65%by time(seconds). Multivariate logistic regression models were used to assess POCD and the rS02desaturation score.Results Sixty-four patients undergoing esophagectomy enrolled in the study, Sixteen patients were included in group POCD(25.0%,16/64), Baseline rSO2was defined as the highest rSO2value obtained in supine position with two lung ventilation by FiO2100%(SP-TLV,T2), in this study the baseline rSO2was (79.4±4.6)%,39.1%(25/64) of patients had a decrease of more than20%of the baseline rSO2,15.6%(15/64) of patients had a decrease of more than25%of the baseline rSO2;There are37.5%(24/64) of the patients who rSO2value less than65%during OLV, There are23.4%(15/64) of the patients who rSO2value less than60%during OLV. There are statistically significant difference in the age between POCD group and non-POCD group (P<0.05).The POCD significantly correlates with the rSO2desaturation score (P<0.05). There are no statistically significant difference between POCD group and non-POCD group with gender ratio,weight,ASA grade,anesthesia time,OLV time,education degree, History of hypertension and diabetes, History of myocardial infarction or strokes, Intraoperative blood loss, minimum oxygen partial pressure and systolic blood pressure in the intraoperative postoperative analgesia VAS score, postoperative respiratory complications,et al (P>0.05)Conclusions Higher incidence of POCD in older patients undergoing esophagectomy. There are statistically significant difference in the age between POCD group and non-POCD group.The POCD significantly correlates with the rSO2desaturation score. Part3:Efficacy of lung protective ventilation regimen on regional cerebral oxygen saturation during OLV Undergoing esophagectomyObjective To investigate the efficacy of lung protective ventilation regimen on regional cerebral oxygen saturation (rSO2) during OLV in older patients undergoing esophagectomy.Methods Forty esophageal cancer patients participated in this study, age≥65years old,each of whom received general anesthesia and OLV using double-lumen endotracheal tube, were randomly divided into protective ventilation regimen group(PV)(n=20)and conventional ventilation group(CV)(n=20).In group PV,all patients received two-lung ventilation(TLV)and one-lung Ventilation (OLV) with tidal volume(VT) of6ml/kg with PEEP5cmH20,I:R=1:2;In group CV, all patients received TLV and OLV with VT of10ml/kg without PEEP,I:R=1:2. Regulating breathing frequency to maintain ETCO2at35-45mmHg during TLV and OLV. rSO2was measured using INVOS5100B(Somanetics, Troy, MI, USA) from the awake state to extubation phase, For intraoperative hemodynamic and respiratory managements,systolic blood pressure was maintained at≥80mmHg, fluctuation range≤20%, SpO2≥95%, ETCO235～40mmHg, the bispectral index (BIS)40-55, The rSO2desaturation score was calculated by multiplying rSO2below65%by time(seconds),which was calculated by the following formula:rSO2score=[65%rSO2-current rSO2(%)]×time (seconds). The rSO2desaturation score generated is an area under the curve measurement, which accounts for both depth and duration of desaturation below the65%saturation threshold. Arterial blood samples were taken before induction of anesthesia(T1) and at10min of TLV(T2) and30min of OLV (T3)for blood gas analysis. Qs/Qt was calculated, standard monitoring parameters was observed and recorded at the corresponding time points.Results①Fourty patients undergoing esophagectomy enrolled in the study, in the awake state and supine position without O2inhalation (T1),patients showed a regional cerebral oxygen saturation (rSO2) of (65.4±3.3)%and (66.7±3.1)%in group CV and group PV, During TLV10min in lateral decubitus(T2) rSO2increased to (76.1±4.6)%and (77.3±3.1)%in group CV and group PV, When OLV30min in lateral decubitus(T3) rSO2decreased to (66.5±5.2)%和(68.8±5.8)%in group CV and group PV.②Patients with rSO2desaturation score greater than3,000%-second respectively was15%(3/20) in group PV and30%(6/20)in group CV, there was significantly lower in group PV than that in group CV(P<0.05).③The PaO2,Qs/Qt,rSO2at T2and T3was higher than Tl in group CV and PV (P<0.05);Compared to T2,the PaO2,rSO2in T3was lower, the Qs/Qt was higher (P<0.01);Compared to group CV,the PaO2,rSO2at T3in group PV were higher,though Qs/Qt was lower (P<0.05).④There was no significant difference with other monitoring parameters between two groups,which include BIS, SpO2, MAP, body temperature, PaCO2, Hct, Hgb, SaO2(P>0.05)Conclusions Protective ventilation regimen can improve the Oxygenation and reduce Pulmonary shunt during OLV in older patients undergoing esophagectomy,and help to reduce the incidence of cerebral desaturation.更多还原