依达拉奉复合氯胺酮预处理对肺癌单肺通气患者围术期炎性细胞因子平衡的影响

目的观察依达拉奉复合氯胺酮预处理对肺癌单肺通气患者围术期炎性细胞因子平衡的影响。方法将择期拟行肺叶切除术肺癌患者48例随机分为对照组、依达拉奉组、氯胺酮组、联合组各12例。四组均先行麻醉诱导,依达拉奉组于诱导后予依达拉奉0.5 mg/kg,氯胺酮组于诱导前予氯胺酮0.5 mg/kg,联合组于诱导前予氯胺酮,诱导后予依达拉奉,剂量同前两组,对照组诱导前后予等量生理盐水。单肺通气时双腔管非通气侧开放,与大气相通,呼吸参数不变。于切皮前即刻、膨肺后60 min、术后60 min取四组血样测定TNF-α、IL-6和IL-10水平。结果依达拉奉组、氯胺酮组、联合组TNF-α、IL-6水平均明显低于对照组,IL-10水平明显高于对照组;依达拉奉组IL-10水平明显高于氯胺酮组;联合组TNF-α、IL-6水平均明显低于依达拉奉组及氯胺酮组,IL-10水平明显高于依达拉奉组;P均<0.05。联合组TNF-α/IL-10、IL-6/IL-10值均明显低于其他三组。结论依达拉奉复合氯胺酮预处理能更有效地抑制促炎性细胞因子生成、维持围术期促炎性细胞因子和抗炎性细胞因子相对平衡,有利于患者预后恢复。     

开胸手术单肺通气方式进展

为了给开胸手术操作提供最佳的术野,避免手术侧肺的分泌物或渗出物流入健侧通气肺,开胸手术通常采用单肺通气（One—lung ventilation,0LV）来隔离双侧肺。0LV的首要任务是维持开胸术中患者足够的氧合和排出二氧化碳,随着医学的发展,     

依达拉奉对肺叶切除术肺癌患者围术期炎性细胞因子和自由基的影响

目的探讨依达拉奉对肺叶切除术肺癌患者的效果及意义。方法将24例行肺叶切除术的肺癌患者随机分为观察组和对照组各12例。两组均静脉注射咪唑安定0．03mg／kg、芬太尼3μg／kg,吸入8％七氟醚。麻醉诱导后,观察组加依达拉奉0．5mg／kg;对照组予等量生理盐水。麻醉维持相同。两组均于麻醉后切皮前（T1）、单肺通气60min（T2）、膨肺后60min（T3）、术后1h（T4）、24h（T5）测定血清中TNF-α、IL-6、IL-8、超氧化物歧化酶（SOD）活性及丙二醛（MDA）浓度。结果两组TNF-α、IL-6、IL-8和MDA于他均明显升高（P〈0．05）,至T4时达峰值（P〈0．05）;与对照组比较,观察组血浆TNF-α和MDA浓度于12～4均明显降低（P〈0．05）,IL-6、IL-8浓度于耶明显降低,持续至T4（P〈0．05）。SOD活性在单肺通气后各时点无明显变化;对照组SOD活性在T2-4较明显低于基础值及观察组（P均〈0．05）。结论依达拉奉可减少氧自由基产生,抑制肺叶切除术的肺癌患者围术期全身性炎症反应,有利于改善患者预后。     

保护性肺通气策略在单肺通气中的应用

在胸外科手术麻醉中,单肺通气(one-lung ventilation,OLV)是一种很重要的通气方式。它既可防止术侧肺的血液及分泌物溢入健侧肺,保证呼吸道通畅,避免交叉感染,同时也利于手术操作。但是在开胸手术OLV中一些肺部并发症,如肺炎、脓胸、肺不张等不断有报道,目前认为这些症状都是开胸术后肺损伤(lung injury after thoracotomy,LIAT)的表现形式。其中不同的OLV模式可直接影响LIAT的发生。     

肺保护性通气方案对老年原发性肺癌单肺通气患者脑组织炎性反应的影响

目的探讨肺保护性通气方案对老年原发性肺癌单肺通气患者脑组织炎性反应的影响。方法选取2016年5月至2017年5月无锡第二人民医院,江南大学附属医院和江阴市中医院三家医院收治的82例原发性肺癌患者,随机分为对照组与观察组,每组各41例。对照组给予容量控制通气策略,观察组给予容量控制通气结合肺保护性通气策略,抽取两组患者单肺通气前后及术后静脉血,测定血清炎性因子和神经胶质纤维酸性蛋白(GFAP)的浓度,抽取动脉血进行血气分析,采用旁气流法测定不同时间点呼吸力学参数指标,采用简易智力状态检查量表(MMSE)评分法评价认知功能,同时记录术后发生谵妄的情况。结果观察组T2、T3时点呼吸力学参数指标气道峰压(Ppeak)、平台压(Pplat)、Raw与对照组比较差异显著(P<0.05)。T2~T4时点观察组血气分析参数指标氧分压(Pa O2)与对照组比较具有统计学意义(P<0.05)。T3、T4时点观察组IL-6与对照组比较具有统计学意义(P<0.05)。T2~T4时点观察组MMSE评分和谵妄发生率与对照组比较具有统计学意义(P<0.05)。结论肺保护性通气策略对老年原发性肺癌单肺通气患者脑组织炎性反应有重要影响,可有效降低单肺通气时气道压力及阻力,减少炎症因子的释放,减轻炎症反应的发生。     

亚麻醉剂氯氨酮对肺手术围术期细胞因子的影响

目的探讨亚麻醉剂氯氨酮在肺手术围术期对细胞因子产生的影响。方法肺大疱切除修补术的气胸患者40例,均分为氯胺酮组（K组）和对照组（C组）。麻醉后手术前给予K组病人氯胺酮并持续静脉滴注至手术结束,对照组采用生理盐水代替氯氨酮,在手术前、术后4 h、24 h、48 h及72 h分别测定IL-1β、IL-2、IL-6和TNF-α的血清浓度。结果术后24 h、48h、72 h,C组病人IL-2水平显著下降,而在K组IL-2能维持在术前水平。术后4 h C组IL-6分泌增加,与K组相比有统计学意义（P〈0.05）;术后4 h K组TNF-α产生的量与术前相似,而在C组显著增加（P〈0.05）。结论麻醉后手术前给予亚剂量氯氨酮能减弱促炎因子IL-6和TNF-α的产生。     

单肺通气模式下不同水平PEEP对肺损伤的影响

目的探讨单肺通气模式下不同水平呼气末正压通气(PEEP)对肺损伤的影响。方法选择拟单肺通气剖胸手术患者60例,随机分成三组,每组20例。A组单肺通气6 mL/kg+PEEP为0 cmH2O,B组单肺通气6mL/kg+PEEP为4 cmH2O,C组单肺通气6 mL/kg+PEEP为8 cmH2O,术中均为持续性单肺通气,并排除肺功能差或有肺部疾病者。通过监测单肺通气前(T1)、单肺通气30 min(T2)、单肺通气60 min(T3)、单肺通气90 min(T4)、单肺通气结束前(T5)、出室前(T6)的SpO2、MAP、HR。采集颈内静脉血5 mL进行肿瘤坏死因子(TNF-α)、IL-6检测。结果三组治疗不同时间点MAP、HR、SpO2无统计学差异(P均>0.05)。B、C两组从T3开始相对于A组炎性因子水平较低且有统计学差异(P均<0.05),而B、C两组间炎性因子水平比较无统计学差异(P均>0.05)。结论单肺通气6 mL/kg+PEEP 4 cmH2O对肺损伤影响最小。     

不同流量单肺通气对老年人术后认知功能的影响

老年患者在手术后常出现认知功能改变,表现为精神错乱、焦虑、人格的改变及记忆受损,这种手术后的变化称为术后认知障碍(POCD),其属于轻度认知障碍(MCI),诊断需神经心理学的测试。目前认为POCD是多种因素协同作用的结果,其确切病因现在仍不清楚,其潜在原因和危险因素包括心肺转流(CPB)、全麻药、低氧血症、高脂血症和低血压等。     

不同单肺通气模式对肺癌手术病人氧合和肺内分流的影响分析

目的 评价不同单肺通气模式对肺癌手术患者氧合和肺内分流的影响.方法 选择行肺叶切除手术的肺癌患者50例,按随机数字表将其分为三组,分别采用不同单肺通气后通气模式,观察和比较各组不同时间点氧合和肺内分流参数的变化.结果 B组T2和T3时刻OI值,显著高于A组和B组（P〈0.05）,与T0时刻无显著差异（P〉0.05）;B组T1和T2时刻Qs/Qt值,显著高于A组、B组和T0时刻（P〈0.05）;T3时刻Qs/Qt值显著高于A组和B组（P〈0.05）,与T0时刻无显著差异（P〉0.05）.结论 呼吸频率17次/min,潮气量6 mg/kg和呼吸末正压5 cmH2O,能显著提高氧分压,减少肺内分流,减轻对肺的损伤,是肺癌手术病人较为理想的单肺通气模式.     

PEEP对肺叶切除患者单肺通气中氧合及分流的影响

目的探讨肺叶切除患者单肺通气(OLV)时应用呼气末正压通气(PEEP)对氧合及分流的影响。方法将70例肺叶切除患者随机分为两组,每组35例,两组在OLV时潮气量6 ml/kg,呼吸频率16~18次/min,观察组同时应用PEEP 5 cm H2O,对照组不用PEEP,比较两组患者双肺通气时(T1)、单肺通气10 min(T2)及单肺通气30 min(T3)血气分析结果及平均肺动脉压(PAP)、平均动脉压(MAP)、心率(HR)、动脉血氧分压、混合静脉血氧饱和度(Sv O2)及肺内分流率(Qs/Qt)。结果对照组T2、T3时间点Pa O2较T1时下降(t=7.528、6.767,P=0.000、0.000),T2、T3时间点观察组Pa O2高于对照组(P=0.000),PH值、Pa CO2、BE、HCO-3各时间点组内、组间比较差异均无统计学意义;T2、T3时间点观察组Qs/Qt较分别较对照组降低(t=12.011、9.992,P=0.000、0.000),差异均有统计学意义,两组PAP、MAP、HR、Sv O2各时间点组间、组内比较差异均无统计学意义。结论肺叶切除手术OLV时应用PEEP可提高氧分压,降低肺内分流,是防治低氧血症的有效措施之一。     

Identifying biomarkers of ventilator induced lung injury during one-lung ventilation surgery: a scoping review

BackgroundVentilator-induced lung injury (VILI) can occur as a result of mechanical ventilation to two lungs. Thoracic surgery often requires one-lung ventilation (OLV). The potential for VILI is likely higher in OLV. The impact of OLV on development of post-operative pulmonary complications is not well understood. We aimed to perform a scoping review to determine reliable biomarkers of VILI after OLV.MethodsA scoping review was performed using Cochrane Collaboration methodology. We searched Medline, EMBASE and SCOPUS. Gray literature was searched. Studies of adult human or animal models without pre-existing lung damage exposed to OLV, with biomarker responses analyzed were included.ResultsAfter screening 5,613 eligible papers, 89 papers were chosen for full text review, with 29 meeting inclusion. Approximately half (52%, n=15) of studies were conducted in humans in an intra-operative setting. Bronchoalveolar lavage (BAL) & serum analyses with enzyme-linked immunosorbent assay (ELISA)-based assays were most commonly used. The majority of analytes were investigated by a single study. Of the analytes that were investigated by two or more studies (n=31), only 16 were concordant in their findings. Across all sample types and studies 84% (n=66) of the 79 inflammatory markers and 75% (n=6) of the 8 anti-inflammatory markers tested were found to increase. Half (48%) of all studies showed an increase in TNF-α or IL-6.ConclusionsA scoping review of the state of the evidence demonstrated that candidate biomarkers with the most evidence and greatest reliability are general markers of inflammation, such as IL-6 and TNF-α assessed using ELISA assays. Studies were limited in the number of biomarkers measured concurrently, sample size, and studies using human participants. In conclusion these identified markers can potentially serve as outcome measures for studies on OLV.     

Effect of different ventilation modes with FC-77 on pulmonary inflammatory reaction in piglets after cardiopulmonary bypass

RATIONALE: Cardiopulmonary bypass (CPB) causes pulmonary inflammatory reaction. Liquid ventilation with perfluorocarbon has shown an anti-inflammatory effect on severely injured lungs. The aim of this study is to investigate the treatment effect of different ventilation modes with perfluorocarbon on pulmonary inflammatory reaction in piglets after CPB. METHODS: After receiving CPB and subsequent infusion of lipopolysaccharide (1 microg/kg), 18 piglets were randomly treated with conventional gas ventilation, total liquid ventilation (TLV), or partial liquid ventilation (PLV) for 240 min. The lung tissue and blood samples were collected at the end of observation period. The pulmonary mRNA expressions and plasmatic concentrations of interleukin-6 (IL-6) and interleukin-8 (IL-8) were measured. Histological neutrophil count in lung parenchyma was performed. RESULTS: Hemodynamics, PaCO2 and PH did not differ among groups during the observation period. Both TLV and PLV showed significantly improved oxygenation, reduced pulmonary mRNA expressions and plasmatic levels of IL-6 and IL-8, and decreased total neutrophil count in lung parenchyma when compared with conventional gas ventilation. Furthermore, TLV resulted in significantly better oxygenation, lower pulmonary mRNA expressions of IL-6 and IL-8, and less total neutrophil count when compared with PLV. CONCLUSION: Both TLV and PLV improved oxygenation and reduced pulmonary inflammatory reaction in piglets after CPB, whereas TLV is more effective than PLV.     

Effects of independent lung ventilation and lateral position on cytokine markers of inflammation after unilateral lung acid injury in dogs

Background and objective: The aim of this study was to compare the effects of conventional ventilation, lateral (non‐injured lung‐dependent) position, asynchronous and synchronous independent lung ventilation on inflammatory markers in an animal model of unilateral lung acid injury. Methods: Twenty‐eight dogs underwent unilateral endobronchial instillation with hydrochloric acid and randomly received (n = 7 in each group) conventional ventilation in the supine (group I) or lateral position (group II), and independent lung ventilation in asynchronous (group III) or synchronous (group IV) modes. Arterial blood gases and serum cytokine levels were assessed at baseline, and 5 min and 4 h after mechanical ventilation. At the end of the study, cytokine levels were measured in individual lung lavage fluid. In three animals per group, differential lung perfusion was detected using a dual‐head gamma camera. Results: Unilateral acid injury alone worsened oxygenation as determined by the ratio of PaO₂ to fraction of inspired oxygen (PaO₂/FiO₂) and increased serum cytokine levels. Mean oxygenation (SD) was significantly preserved in group II, 338 (26); group III, 396 (28); and group IV, 395 (22) compared with group I, 173 (18) (all P < 0.01). Serum IL‐8, left‐lung lavage IL‐8 and matrix metalloproteinase‐9 levels were significantly lower in groups II–IV (all P < 0.05). Only group I showed significantly different left and right lung lavage fluid cytokine levels. Groups III and IV showed slightly decreased left lung perfusion. Cytokine levels and oxygenation were similar in groups III and IV. Conclusions: In this model of unilateral lung acid injury, lateral position and independent lung ventilation preserved oxygenation and attenuated the inflammatory response in serum and injured lung BAL fluid.     

肺癌术后患者睡眠状况调查及影响因素分析

目的研究和探讨肺癌术后患者睡眠状况及影响因素。方法采用匹兹堡睡眠质量指数量表(PSQI)和自行设计的睡眠影响因素量表,对山东省某三级医院胸心外科2013年8月1日~2014年8月31日收治的100例肺癌手术患者(观察组)进行问卷调查,另选取100例健康人(对照组)进行问卷调查后两组对比,分析术后影响因素。结果观察组睡眠情况均比对照组差,差异有统计学意义(P0.05);患者进行睡眠因素调查,主要影响因素为咳嗽引起不适(39.81%),其次为刀口疼痛(36.34%)。结论肺癌术后患者睡眠主要影响因素为咳嗽引起的不适,因此我们应采取相应措施提高患者的睡眠质量,对于患者疾病的康复具有重要的临床意义。     

Comparison of different modes of high-frequency ventilation in surfactant-deficient rabbits

Various modes of high-frequency ventilation (HFV) have been developed to avoid the disadvantages of conventional mechanical ventilation. In the present study, we examined the hypothesis that high-frequency oscillation (HFO) is superior to high-frequency positive pressure ventilation (HPPV) and combined high-frequency ventilation (CHFV) in surfactant-deficient rabbits. The aim of the ventilator strategy was to adjust the mean airway pressure to 2 cm above critical opening pressure of the inflation limb of the respiratory system pressure volume (P/V) curve, achieve a normal tidal volume (Vγ) (5 ml/kg body weight) and apply repeated sustained inflations. We studied the effect of these HFV modes on oxygenation, lung mechanics and lung histology in 15 New Zealand White rabbits during a 6-hour experiment. Statistically, the HFO group demonstrated significantly better oxygenation (P < 0.05), lung mechanics (lung stability index: P < 0.05), and better lung tissue histology compared to the HPPV and CHFV groups. In contrast to the HPPV and CHFV groups, the P/V curves of the HFO group showed significant recovery over the 6-hour period after lavage. The lungs of the HFO-treated group had a more uniform distribution of alveoli and less overdistention than the HPPV group (P < 0.002), and less atelectasis than the CHFV group (P < 0.05). The HFO group had less lung injury than the CHFV groups (P < 0.01) and its lungs contained significantly less water than both other groups (P < 0.05). We conclude that the relationship between mean and end-expiratory pressures impacts strongly on both oxygenation and the progression of injury during HFV at the same mean airway pressures. The HFO group showed less acute lung injury than the other ventilatory groups. Pediatr Pulmonol. 1996; 22:263–270. © 1996 Wiley-Liss, Inc.     

双侧肺同期手术中不同体位和单肺通气对病人呼吸力学的影响

目的观察双侧肺同期手术中体位改变和单肺通气时对病人呼吸力学的影响。方法选取我院2007年6月至2010年12月双侧肺同期手术病人142例,经气道旁路采用旁气流通气连续监测病人PIP、Pplat、Raw、Cdyn等呼吸力学指标,监测SpO2、PETCO2指标,分别在双腔支气管导管定位后,平卧改侧卧,单肺通气及改换通气方式后10 min抽取动脉血进行血气分析。结果病人双肺通气改变体位和单肺通气后,病人PIP、Pplat、Raw升高,Cdyn减少,PH值降低,PETCO2、PaCO2升高、SpO2、PaO2降低(P<0.05);双肺通气改换通气方式后,病人PIP、Pplat、Raw降低,Cdyn增加,PH值降低,PaO2、SpO2、PaCO2、PETCO2升高(P<0.05)。单肺通气38例病人改换通气方式后,病人PIP、Pplat、Raw降低,Cdyn增加,PH值、PaO2、SpO2升高,PaCO2、PETCO2降低(P<0.05)。结论双侧肺同期手术麻醉中不同体位和单肺通气对病人的呼吸力学影响较大,改换通气方式可改变病人呼吸力学指标。