单肺通气前通气侧肺前列腺素E_1超声雾化对气体交换的影响

目的观察单肺通气(OLV)前右侧肺前列腺素E1(PGE1)超声雾化对OLV期间肺内分流率(Qs/Qt)及动脉氧合的影响。方法择期行左胸食管癌根治术患者60例,随机均分为两组:在OLV前对右侧肺雾化吸入PGE10.2μg/kg(P组)和等量生理盐水(C组)。记录雾化吸入前(T1)、OLV 10min(T2)、OLV 15 min(T3)、OLV 30 min(T4)、OLV 60 min(T5)和OLV 120 min(T6)时的氧合指数及血流动力学指标。结果两组患者PaO2在OLV开始后均呈直线下降,其中C组在T4时降至最低点;T2~T4时P组PaO2明显高于C组(P0.05),且PaO2的最低值延迟至T5时出现。T2~T4时P组Qs/Qt明显低于C组(P0.05)。两组不同时点血流动力学差异无统计学意义。结论 OLV前右侧肺雾化吸入0.2μg/kg PGE1能减少肺内分流,改善氧合。     

七氟醚吸入对危重新生儿术中肺表面活性蛋白A和B的影响

目的观察吸入七氟醚对危重新生儿术中肺表面活性蛋白A(SPA)和肺表面活性蛋白B(SPB)的影响。方法选择行腹部手术危重新生儿40例,男29例,女11例,出生12～26 d,体重3.0～4.1 kg, ASAⅢ或Ⅳ级,随机分为两组:七氟醚组(S组)和对照组(C组),每组20例。S组于麻醉诱导气管内插管成功后,吸入2.5%七氟醚30 min;C组不予吸入麻醉药物。两组均在超声引导下行颈内静脉和桡动脉穿刺置管术,容量控制机械通气,持续泵入咪达唑仑2μg·kg~(-1)·min~(-1)、顺式阿曲库铵2～3μg·kg~(-1)·min~(-1)、芬太尼2～4μg·kg~(-1)·h~(-1)维持麻醉。记录机械通气开始时(T_0)、机械通气开始后30 min (T_1)、手术结束即刻(T_2)时PaCO_2和PaO_2,计算呼吸指数(RI)、氧合指数(OI),采用ELISA法检测动脉血血清SPA、SPB和IL-8浓度,记录肺炎、肺气漏、ARDS、颅内出血、DIC、电解质紊乱、切口感染等术后并发症发生情况。结果与T_0时比较,T_1—T_2时两组OI和血清SPA、SPB浓度明显降低(P0.05),RI和血清IL-8浓度明显升高(P0.05)。T_0时两组RI、OI、血清SPA、SPB和IL-8浓度差异无统计学意义。T_1—T_2时S组RI和血清IL-8浓度明显低于C组(P0.05),OI和血清SPA、SPB浓度明显高于C组(P0.05)。S组术后肺炎发生率明显低于C组(P0.05)。结论吸入七氟醚能减轻危重新生儿术中炎性介质的释放,改善肺氧合功能,减少术后并发症的发生。     

单肺通气期潮气量对肺内分流及动脉氧合的影响

目的 研究单肺通气(OLV)时不同潮气量(V_T)对肺内分流及动脉氧合的影响.方法 60例右肺部分切除术患者随机均分为A、B、C三组.全麻后双肺通气(TLV)时V_T均为10 ml/kg,RR均为12次/分,吸呼比(I:E)均为1:2.OLV期间,A组V_T6 ml/kg,RR 20次/分;B组V_T 8 ml/kg,RR 15次/分;C组V_T 10 ml/kg,RR 12次/分;分别于OLV前(T_1)及OLV后10 min(T_2)、20min(T_3)、30 min(T_4)行血气分析,计算肺内分流(Q_S/Q_T),同时监测气道压力并计算肺顺应性(Cdyn).结果 与T_1时比较,T_2～T_4时三组均有PaO_2下降,Q_S/Q_T气道峰压(P_(max))增高,Cdyn下降(P<0.05).与A组比较,B组PaO_2升高(P<0.05).结论 OLV期间采用V_T 8 ml/kg,RR 15次/分能够维持相对较好的PaO_2和CAyn,较小的Q_S/Q_T.     

通气侧肺动脉输注前列腺素E1对家猪单肺通气期间分流及氧合的影响

目的 探讨通气侧肺动脉输注前列腺素E1(PGE1)对家猪单肺通气(OLV)时血液动力学及呼吸功能的影响。方法 12头家猪建立OLV模型后,随机分为A组和B组,每组6头,A组、B组分别通气侧肺动脉输注PGE1、生理盐水。A组分别在双肺通气(TLV)30 min(TLV30)和OLV 60 min(OLV60)依次输注PGE10.01、0.02、0.04、0.06、0.08、0.1 μg·kg-1·min-1各20 min后(R0.01、R0.02、R0.04、R 0.06、R 0.08、R0.1)及停药20、40、60 min(T20、T40、T60)采集血液动力学和呼吸功能指标,B组在相应时间点采集指标。结果 A组:与TLV30时比较,平均动脉压(MAP)在R0.01-0.06、T20时、心输出量(CO)在其他所有时点均降低,平均肺动脉压(MPAP)及体血管阻力(SVR)在OLV 60、R 0.01、T40及T60时、肺血管阻力(PVR)在OLV60、T20-60时均升高(P<0.05);与OLV60时比较,MAP在R 0.06-0.1、T20时、MPAP在R0.04-0.1、T20时、PVR在R 0.06、R 0.08时降低(P<0.05);B组:与TLV 30时比较,在其他所有时点MPAP、PVR、SVR均升高,CO降低(P<0.05);与B组比较,A组MAP在R 0.06-0.1、T20时、MPAPR 0.02-0.1、T20时、PVR在R0.01-0.1时、SVR在R0.08-0.1时降低(P<0.05)。A组:与TLV30时比较,Cdyn、PaO2在其他所有时点均降低,PIP在OLV60、T20-60时、Qs/Qt在OLV60、R0.01-0.02、R0.08     

单肺通气前氯胺酮经单肺或双肺雾化吸入肺保护的研究

目的比较单肺通气(OLV)前氯胺酮经左单肺(OLV期间非通气侧肺)雾化或双肺雾化吸入的肺保护作用。方法择期行经左胸食管中段癌根治术患者60例,ASAⅠ或Ⅱ级,随机均分为两组:氯胺酮单肺雾化组(K1组),氯胺酮双肺雾化组(K2组)。静脉全麻双腔支气管插管后,K1组给予氯胺酮经左单肺雾化吸入(氯胺酮用量为1 mg/kg,用生理盐水稀释至10 ml),K2组给予氯胺酮经双肺雾化吸入(氯胺酮用量同K1组)。分别于雾化吸入前(T1)、OLV 30 min(T2)、OLV 60 min(T3)、OLV 120 min(T4)、OLV结束5 min(T5)、手术结束(T6)时抽取桡动脉血,行动脉血气分析,记录SpO2、P ET CO2、气道压(Paw)及血流动力学指标。于T1、T2、手术结束2 h(T7)抽取中心静脉血,检测血中IL-6、IL-8、可溶性细胞间粘附分子-1(sICAM-1)水平。结果两组患者PaO2水平在T2~T4时明显低于T1时(P0.05),其中K1组在T5时即显著回升至T1时水平,K2组至T5时明显回升,但仍明显低于T1时(P0.05),T6时则较T5时进一步显著回升至T1时水平。两组Paw在T2~T4时明显高于T1时(P0.05)。K1组患者T7时的血清IL-6、IL-8、水平明显高于T1时(P0.05),K2组患者T2、T7时的血清IL-6、IL-8、sICAM-1水平明显高于T1时(P0.05);K1组患者T7时的血清IL-6、IL-8、sICAM-1水平明显低于K2组(P0.05)。结论 OLV前经单肺(OLV期间非通气侧肺)雾化吸入氯胺酮的肺保护效果优于经双肺雾化吸入氯胺酮;OLV时两侧肺的损伤是不均一的,非通气侧肺的损伤程度重于通气侧肺。     

单肺通气时非通气侧肺持续中低流量给氧在老年患者肺癌根治术中的应用

目的探讨单肺通气(OLV)时非通气侧肺持续中低流量给氧对老年患者肺癌根治术中肺泡巨噬细胞(AM)铁死亡的影响。方法选择2019年12月至2020年8月择期行胸腔镜下肺癌根治术的老年患者60例,男31例,女29例,年龄65～80岁,BMI 18～25 kg/m~2,ASAⅡ或Ⅲ级。采用随机数字表法将患者分为两组:观察组和对照组,每组30例。OLV时观察组非通气侧肺给予1～4 L/min持续性中低流量给氧,对照组非通气侧肺不给予持续性中低流量给氧。于术前(T_0,基础值)、麻醉诱导后即刻(T_1)、OLV后30 min (T_2)、1 h (T_3)、2 h (T_4)采集桡动脉血并测定SpO_2、PaO_2和PaCO_2,计算氧合指数(OI=PaO_2/FiO_2)。记录术前一秒用力呼气容积(FEV_1)/用力肺活量(FVC)比值。T_3时采集支气管肺泡灌洗液(BALF),采用流式细胞术分选AM,比色法测定AM内Fe~(2+)、丙二醛(MDA)浓度和超氧化物歧化酶(SOD)活性,Western blot法检测AM内长链脂酰辅酶A合成酶4(ACSL4)及谷胱甘肽过氧化物酶4(GPX4)蛋白含量。T_3时切取肺癌周边正常肺组织,采用HE染色,光镜下观察肺组织病理学并进行肺组织损伤评分。记录PACU停留时间和住院时间,记录肺部并发症以及呼吸抑制、窦性心动过缓、窦性心动过速、高血压、低血压、恶心呕吐等不良事件发生情况。结果与T_0时比较,两组T_1—T_4时SpO_2明显升高(P0.05),T_1时PaCO_2明显降低(P0.05);对照组T_1和T_3时PaO_2明显升高(P0.05),T_2—T_4时PaCO_2明显升高(P0.05),T_1时OI明显升高(P0.05),T_2—T_3时OI明显降低(P0.05);观察组T_1—T_4时PaO_2明显升高(P0.05),T_3时PaCO_2明显降低(P0.05),T_1、T_3、T_4时OI明显升高(P0.05)。与对照组比较,观察组T_2—T_4时SpO_2、PaO_2和OI明显升高(P0.05),PaCO_2明显降低(P0.05);T_3时肺损伤评分明显降低(P0.05),AM内Fe~(2+)、MDA浓度明显降低(P0.05),SOD活性明显升高(P0.05),ACSL4蛋白含量明显降低(P0.05),GPX4蛋白含量明显升高(P0.05);术后住院时间明显缩短(P0.05),肺部并发症发生率明显降低(P0.05)。两组PACU停留时间以及不良事件发生率差异无统计学意义。对照组肺泡壁增厚、水肿,可见大量中性粒细胞和单核细胞,肺泡腔内可见较多炎性渗出,肺间质明显增生可见大量炎性细胞浸润。观察组肺泡间隔增宽,毛细血管未见明显充血,小部分肺泡腔可见红细胞及炎性渗出液,肺间质炎性细胞浸润明显减少。结论老年患者胸腔镜下肺癌根治术中非通气侧肺持续中低流量给氧可减轻非通气侧肺损伤,其机制可能与抑制AM铁死亡有关。     

小潮气量联合呼气末正压对单肺通气肺内分流及炎性反应的影响

目的研究单肺通气（OLV）时小潮气量联合呼气末正压（PEEP）对肺内分流及炎性反应的影响。方法食管癌根治术患者60例,年龄20～65岁,随机均分为三组,OLV时患者V_T均为6ml/kg,PEEP分别为0cmH₂O（A组）、5cmH₂O（B组）和10cmH₂O（C组）。记录患者气道压变化,采集桡动脉血和深静脉血行血气分析并计算氧合指数（OI）和肺内分流率（Qs/Qt）,采集外周静脉血进行炎性因子检测。结果与双肺通气30min时比较,三组OLV30、60、90min时Qs/Qt、肿瘤坏死因子α（TNF-α）、T₂、T₃时A、C组白细胞介素-8（IL-8）明显增高（P<0.05）,但B组Qs/Qt、IL-8显著低于A、C组（P<0.05）。A、C组OLV30、60、90min时OI较双肺通气30min时明显降低（P<0.05）;B组仅在OLV30min时降低（P<0.05）。与A、C组比较,B组OLV30、60、90min时IL-10显著增高（P<0.05）。结论 OLV中V_T6ml/kg联合PEEP5cmH₂O可以降低Qs/Qt,减轻炎性反应,改善氧合。     

急性高容量血液稀释对单肺通气犬血管外肺水的影响

目的研究单肺通气(OLV)犬行急性高容量血液稀释(AHHD)对血流动力学和血管外肺水的影响。方法15只健康杂种犬随机分为A、B、C组,每组5只。基础麻醉后OLV。C组以复方氯化钠匀速输入禁食和生理需要量,A组和B组以80ml·kg-1·h-1的速率分别输入羟乙基淀粉130/0.4和复方乳酸钠行AHHD,测定输注前即刻(T0)、Hct30%(T1)、20%(T2)水平时的血流动力学指标。达到T2水平稳定15min后,将每组实验犬颈动脉放血处死,摘取左右侧肺,重量法测定肺湿干比(W/D)、肺水含量(LW)和肺系数(L/B)。结果A组犬达到T1和T2时点的补液量为(41.3±13.2)和(86.6±19.1)ml/kg,B组为(80.1±16.1)和(206.7±14.2)ml/kg,与C组比较差异有统计学意义(P<0.05)。在血液稀释过程中,A、B两组CVP、肺动脉楔压(PAWP)持续升高,B组PAWP在T2时高出生理界值(P<0.05)。血管外肺水指标A组和B组差异无统计学意义,B组高于C组(P<0.05)。结论复方乳酸钠和羟乙基淀粉130/0.4用于OLV犬AHHD至20%对血管外肺水指标无明显改变,但羟乙基淀粉130/0.4在OLV犬AHHD中更能保持血流动力学的稳定。     

吸入伊洛前列素和一氧化氮治疗先天性心脏病术后肺动脉高压

目的 探讨吸入伊洛前列素对先天性心脏病(CHD)术后早期机械通气和持续吸入一氧化氮(NO)的基础上,仍合并肺动脉高压(PH)病儿的疗效及对预后的影响,并初步探讨其作用机制.方法 30例CHD根治手术后在机械通气和持续一氧化氮(NO)吸入的基础上仍合并PAH的病儿,随机分为试验(T)组和对照(C)组.在原治疗基础上,T组给予伊洛前列素100 ng·kg-1·min-1,吸入10 min,C组给予0.9%NaCl 4ml吸入.每4h一次,连续治疗48 h.超声和心电监测观察病儿的血流动力学和呼吸机条件的改变.对比首次吸药前后血浆环磷酸腺苷(cAMP)和环磷酸鸟苷(cGMP)浓度变化.结果 T组停止吸入伊洛前列素后20min,肺动脉收缩压(sPAP)和肺动脉收缩压/主动脉收缩压(sPAP/sBP)明显下降,分别为:(43.23±11.72)mm Hg(1 mm Hg=0.133 kPa)和0.48±0.13,均小于C组(53.13±13.60)mm Hg和0.60 ±0.15,P<0.05.停止吸药120 min,T组sPAP/sBP仍然小于C组(0.48±0.09对0.59±0.14,P<0.05).连续治疗24 h和48 h,T组sPAP和sPAP/sBP继续下降,均明显小于C组(P<0.01).停止首次吸药后20 min,T组cAMP(578.68±193.05)pg/dl较治疗前(406.64±179.18)pg/dl明显升高(P<0.01),也明显大于C组(392.26±94.46)pg/dl(P<0.01).C组2例因肺高压危象(PHC)死亡,T组无死亡.结论 CHD双心室矫正术后早期机械通气和持续吸入NO仍合并PH病儿,吸入伊洛前列素后可明显降低sPAP和sPAP/sBP.伊洛前列素可能减少肺高压危象(PHC)导致的死亡.其扩血管作用可能与血浆cAMP浓度升高有关.     

不同压力的持续气道正压对化疗后病人单肺通气氧合与分流的影响

目的　探讨应用一种新的持续气道正压 (CPAP)系统在肺癌病人化疗后单肺通气(OLV)时对病人氧合和肺内分流的影响。方法　择期手术病人 30例 ,ASAⅠ～Ⅲ级 ,随机分为对照组 (A组 )、CPAP 2组 (B组 )和CPAP 5组 (C组 ) ,每组 1 0例。A组在OLV期间非通气侧肺的支气管导管直接开口于大气中 ;B组OLV期间非通气侧持续给予CPAP(压力 2cmH2 O) ,C组OLV期间非通气侧持续给予CPAP(压力 5cmH2 O) ,并在平卧双肺通气 2 0min ,仰卧OLV 2 0min ,侧卧OLV2 0、4 0min和关胸双肺通气时 ,分别采取动脉血行血气分析并计算肺内分流率 (Qs/Qt)。结果在OLV后 2 0、4 0min时 ,B、C两组氧合明显高于A组 (P <0 .0 1 ) ,B、C两组Qs/Qt明显低于A组 (P<0 .0 5 ) ,B、C两组之间氧合和Qs/Qt仅在OLV后 4 0min时差异显著。结论　化疗后病人非通气侧持续CPAP ,有助于提高氧合 ,减少肺内分流 ,减少低氧血症的发生率 ,且CPAP 2cmH2 O更易为临床所接受     

Reperfusion pulmonary edema after pulmonary endarterectomy

Pulmonary artery thromboendarterectomy is a potentially curative procedure in chronic, major vessel thromboembolic pulmonary hypertension. However, persistent pulmonary hypertension and unrelenting reperfusion edema have serious complications, often requiring prolonged mechanical ventilation. A 50-year-old man who was diagnosed with a thromboembolism in both pulmonary arteries underwent a bilateral pulmonary endarterectomy. He received O2-isoflurane-fentanyl anesthesia. When the lungs were reperfused with CPB weaning, massive hemorrhage occurred in the left lung. After the operation, the patient was taken to the intensive care unit. Mechanical ventilation was performed immediately and then both inhaled NO and i.v. furosemide therapies were administered. The patient was discharged from ICU 15 days postoperation.     

Massive pulmonary hemorrhage after pulmonary thromboendarterectomy

Pulmonary thromboendarterectomy, the most common surgical treatment of chronic thromboembolic pulmonary hypertension, is being performed with increasing frequency throughout the world. Massive pulmonary hemorrhage is a potentially fatal complication of this procedure. In this report of three such cases, the diagnosis, clinical course, and possible treatments are discussed. Anesthesiologists involved in the care of patients receiving pulmonary thromboendarterectomy must be aware of the possibility of this complication, as well as the various techniques available for its treatment.     

肺小结节胸腔镜解剖性肺段切除术初步报道

目的探讨胸腔镜解剖性肺段切除术的可行性及安全性。 方法回顾性分析解放军总医院第一医学中心胸外科2017年3月至2018年12月行胸腔镜解剖性肺段切除术的86例临床资料。手术均为3切口。对术后住院时间、术后并发症发生率等情况进行总结,对解剖性肺段切除术的现况、优势及适应证进行分析。 结果86例患者顺利施行了胸腔镜解剖性肺段切除术,手术顺利,无中转开胸或改行肺叶切除病例。平均手术时间(160.59±42.43)min,平均术中出血量(27.06±1.23)ml,平均淋巴结清扫数量(6.78±3.54)枚,平均胸腔闭式引流管留置时间(4.84±2.12)d,平均术后住院时间(6.53±1.41)d。术后病理：腺癌78例,鳞状细胞癌1例,黏液腺癌1例,良性结节6例,其中原发非小细胞肺癌均为Ⅰa期。术后均未出现严重并发症、复发及死亡。 结论解剖性肺段切除术创伤小、恢复快、术后住院时间短,其远期预后效果缺乏前瞻性数据支持,必须严格把控肺段切除术的适应证。     

Idiopathic pulmonary artery aneurysm with pulmonary regurgitation

Idiopathic pulmonary artery aneurysms are rare and need a multidisciplinary approach to diagnosis and treatment. Surgery is the treatment of choice, especially when the aneurysms are large and when they are associated with pulmonary regurgitation. This report highlights a case in which successful surgical repair preserved the native pulmonary valve after pulmonary artery reconstruction.     

Retrograde pulmonary embolectomy in massive pulmonary embolism

The purpose of this study was introduction and evaluation of efficacy and safety of retrograde thromboembolectomy in acute massive pulmonary emboli. The method is described in a 56-year-old woman with acute massive pulmonary thromboemboli. Postoperative course was uneventful. The described surgical technique is not a panacea and definitely not the whole answer, but is a big part of the solution and may be accompanied with less adverse effects. Additionally, there is a need of being reviewed further in large experimental studies and measurements before it could be used safely as a new technique.     

Acquired pulmonary stenosis and pulmonary artery compression

Three patients suffering from acquired pulmonary stenosis are described resulting from compression of the main pulmonary artery by anterior mediastinal teratoma, Hodgkin's disease, and aneurysm of the ascending aorta, respectively; also four others who had compression of the right or left primary branch of the pulmonary artery. The pulmonary artery compression was demonstrated angiographically in every case, and in the patient with right and left pulmonary artery compression the main pulmonary artery pressure tracing was characteristic of bilateral pulmonary artery stenosis. Cardiac catheterization and selective angiography are indicated in patients who have evidence of right ventricular outflow obstruction to determine the site and severity of the obstruction and to differentiate between extrinsic compression and intrinsic stenosis.     

One-stage bilateral pulmonary resections for pulmonary metastases

Objective

We analyze the safety and efficacy of one-stage bilateral pulmonary resections for pulmonary metastases via a bilateral approach.

Methods

We retrospectively analyzed 154 cases with pathologically verified pulmonary metastases which underwent curative pulmonary resection. Intraoperative and perioperative variables were evaluated.

Results

One hundred and thirty cases underwent unilateral pulmonary metastasectomy (group U), and the other 24 cases with bilateral pulmonary metastases underwent one-stage bilateral pulmonary resections (group B). Operation time in group B was significantly longer than in group U (354 ± 132 vs. 203 ± 110 min; p < 0.001), but was not longer than double that in group U (407 ± 219 min; p = 0.540). Operative blood loss was not significantly greater in group B than group U (113 ± 158 vs. 76 ± 138 ml; p = 0.069). Neither duration of postoperative hospital stay nor incidence of postoperative complications differed between the two groups. Hospitalization costs in group B were significantly greater than in group U (257 ± 120 × 10⁴ vs. 168 ± 69.2 × 10⁴ yen; p < 0.001), but they were significantly less than double those in group U (336 ± 138 × 10⁴ yen; p < 0.001).

Conclusions

We consider one-stage bilateral pulmonary metastasectomy to be safe for bilateral pulmonary metastases. Moreover, it may offer an economic benefit by avoiding the expenses associated with a two-stage operation.     

Fatal intra-alveolar pulmonary bleeding complicating pulmonary embolectomy

Two patients are reported in whom fatal alveolar pulmonary haemorrhage occurred after pulmonary embolectomy. Possible causes and methods of prevention are discussed.