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全麻患者喉罩通气下平卧位和截石位的呼吸动力学比较
The comparison of respiratory dynamics between lithotomy and supine position in patients undergoing general anesthesia with LMA
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DOI:
作者:
赵晓 黄施伟 王兆民 陈莲华 李士通
ZHAO Xiao, HUANG Shi-wei, WANG Zhao-min, CHEN Lian-hua, LI Shi-tong
作者单位:
上海交通大学附属第一人民医院
Department of Anesthesiology, Shanghai First People's Hospital, Jiao Tong University
关键词:
机械通气;喉罩;平卧位;截石位;呼吸动力学
Controlled ventilation, laryngeal mask airway, supine position, lithotomy position, respiratory dynamics
摘要:
目的:喉罩通气道因为使用简单和置入时心血管反应小而得到广泛使用,但是仍然具有很多局限性,如:漏气和胃食道返流,尤其在一些特殊体位手术更为严重。本文通过比较喉罩通气下平卧位与截石位手术患者呼吸动力学监测指标的差异,验证不同手术体位对喉罩通气效果的影响,为临床上更合理使用喉罩通气,避免气道不良反应提供依据。 方法:选择全身麻醉择期手术患者60例,年龄20~65岁,美国麻醉医师学会(ASA)分级 I~II级。根据手术体位分为平卧位(SP,Supine Position, n=30)和截石位(LP,Lithotomy Position, n=30)两组,分别记录术前、术中各时点及拔除喉罩后的呼吸动力学监测指标:吸气平台压(Pplateau)、平均气道压(Pmean)、呼气末正压(PEEP)、吸气峰流速 (FImax)、呼气峰流速(FEmax)、呼末二氧化碳分压(PetCO2);诱导后15min监测动脉血气:动脉二氧化碳分压(PaCO2)、 动脉氧分压(PaO2);同时记录术中血流动力学指标变化和术中、术后喉罩不良反应发生情况。 结果:两组PIP、Pplateau、Ri、Re、WOB均随手术时间延长而逐渐增高,Cdyn、Cst逐渐降低,差异有显著统计学意义(P<0.05);LP组诱导后5 min、10 min、15 min、30 min和60min的PIP、Pplateau数值均大于SP组,差异有显著统计学意义(P<0.05),同时这些时间点的FImax、FEmax、Cdyn、Cst均小于SP组,差异有显著统计学意义(P<0.05);两组均没有明显的不良反应。 结论:全麻普通型喉罩通气下,气道压力和气道阻力均随手术时间的延长而增加,其中截石位相对于平卧位气道压力和气道阻力的增加更为显著,且伴有胸-肺顺应性的降低,这些呼吸动力学指标的变化在正常体重病人1小时以内手术没有达到产生不良反应的程度。
Objective: Laryngeal mask airway (LMA) has been widely used in clinical anesthesia for the advantages over endotracheal intubation of easier insertion and milder cardiovascular response to insertion. Meanwhile, some drawbacks limit the application of LMA in controlled ventilation, such as air leakage and gastric air insufflations. The risk is supposed to be increased if the patient is undergoing some special surgical position. The study was designed to investigate the differences of respiratory dynamics between supine and lithotomy position in patients under general anesthesia with laryngeal mask airway (LMA), to determine the effectiveness of ventilation through LMA under the two surgical positions, and finally, to provide evidences for the proper usage of LMA with less airway adverse events. Methods: 60 cases of patients with ASA status I or II, aged 20~65, underwent selective surgeries in general anesthesia were chosen to admitted in the study. The patients were divided into 2 groups according to the operation position: supine position group (SP, n=30) and lithotomy position group (LP, n=31). The parameters of respiratory dynamics such as, Pplateau, Pmean, PEEP, FImax and FEmax were recorded before and after the induction of anesthesia, during the scheduled time points in operation, and after removal of the LMA, respectively. After 15 minutes of induction, the arterial blood gases including PaCO2 and PaO2 were measured. Meanwhile, the hemodynamic changes and complications were recorded. Results:The PIP, Pplateau, Ri, Re and WOB were significantly elevated as the increasing of the duration of operation, meanwhile the Cdyn and Cst were significantly decreased (P<0.05). At the time points of 5 min, 10 min, 15 min, 30 min and 60min after the insertion of LMA, PIP and Pplateau in LP group were significantly higher than those in SP group (P<0.05), while the FImax, FEmax, Cdyn and Cst were significantly lower than those in SP group (P<0.05). No obvious complications including bucking and pharyngeal pain were founded in both groups. Conclusion: During the general anesthesia with controlled ventilation by typical LMA, both the airway pressure and airway resistance increase as the extending of surgical time, accompanied by the decreasing of pulmonary compliance, which is more obvious in lithotomy position than in supine position. However, these changes in respiratory dynamics does not reach the extent of causing adverse events in the patients with normal body mass index undergoing surgeries long as one hour.
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