围手术期正压通气.pdf

Anesthesiology, V 121 • No 2 August 2014 围手术期正压通气 ---一种改善肺护理的综合方法 Department of Anesthesiology and Critical Care Medicine, Estaing Teaching Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France 麻醉学杂志八月“重点文章” featured articles 机械通气可以造成健康肺的损伤，保护性的肺通气策略 可降低术后肺部并发症 腹部手术中低潮气量的使用 术后肺部并发症的危险因素 （手术、麻醉、患者） 研究背景 所有手术患者中5％~10％及开胸或开腹手术中高达30％~40％术后会出现肺部 并 发症。 肺部并发症的的出现与患者个人原因、外科手术、全身麻醉都有关系, 是术后死 亡率增加的重要原因 全身麻醉中，不合理的机械通气在通气之初就造成了肺功能的损伤，即使是健 康患者 ARDS Lung-protective ventilation Healthy lungs ？ “prevention is better than cure.” 目前术中机械通气存在的问题 1. 潮气量的计算使用实际体重而不是预测体重“PBW” 2. 20%~30%的术中潮气量设置>10ml/kg（PBW) 3. 80%术中机械通气设置没有PEEP 机械通气导致肺损伤的可能机制 保护性肺通气的最新发现 This study provides strong arguments that lung-protective ventilation improves several aspects of postoperative pulmonary function, chest radiograph, and a modified clinical pulmonary infection score during the first 5 days after surgery 保护性肺通气策略显著降低术后肺部并发症 Severgnini P: Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology 2013; 118:1307–21 保护性肺通气的最新发现 Compared with nonprotective ventilation, prophylactic lung-protective ventilation was associated with improved postoperative clinical outcomes, as suggested by a 69% reduction in the patients requiring intubation or noninvasive ventilation for postoperative respiratory failure 保护性肺通气策略使术后肺部并发症发生降低69% Futier E，IMPROVE Study Group: A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013; 369:428–37 保护性肺通气策略：预防性围术期正压通气 prophylactic Peri-Operative Positive pressure ventilation (the “P.O.P.-ventilation”) CPAP = continuous positive airway pressure; NIV = noninvasive ventilation; PBW = predicted body weight; PSV = pressure support ventilation 保护性肺通气策略：预防性围术期正压通气 prophylactic Peri-Operative Positive pressure ventilation (the “P.O.P.-ventilation”) 诱导期、术后的正压持续通气 术中：低VT+PEEP+膨肺 预防性围术期正压通气的相关风险 增加胸膜内压力（PEEP/RM) 增加右心房压，阻碍静脉回流 Zero peep 影响心左心排出量，从而影响血流动力学稳定性 no significant differences in the intraoperative volume of fluids perfused and in the need of vasoactive drugs with the use of low VT, moderate PEEP levels, and repeated RMs RMs should, however, be used with caution in patients with hemodynamic instability during surgery Little detailed information is available regarding tolerance of RM and/or high PEEP levels in patients with emphysema. 对血流动力学无显著影响 血流动力学不稳定患者、肺气 肿患者膨肺需谨慎 预防性围术期正压通气参数设置与目标 PBW： 女性=45.5+0.91（Hcm152.4) 男性=50+0.91（Hcm152.4）