单肺通气麻醉的研究现状

单肺通气麻醉在心胸外科手术中被广泛应用，低氧血症作为单肺通气麻醉的最大挑战，其产生原因众多，本文综合阐述了单肺通气麻醉的研究与进展，以期提高术中单肺通气的效果，降低低氧血症的发生。     

胸科手术患者单肺通气期间rScO2降低的危险因素

目的筛选胸科手术患者单肺通气期间局部脑氧饱和度(rScO2)降低的危险因素。方法选择2017年8月至2018年9月择期拟行胸科手术且需要单肺通气的患者175例,性别不限,年龄≥55岁,预计手术时间≥2 h。于麻醉诱导前开始持续监测rScO2至拔除气管插管后结束。采用全麻、全麻联合硬膜外阻滞或全麻联合局部神经阻滞。记录患者一般情况、既往病史和麻醉手术史、手术类型、麻醉方式、麻醉时间、单肺通气时间、手术时间和术中不良事件(低氧血症、低血压和心动过缓等)发生情况。根据单肺通气期间是否发生rScO2降低(rScO2绝对值小于65%或较基础值降低大于20%),将患者分为2组:rScO2降低组和rScO2正常组。采用多因素logistic回归分析筛选单肺通气期间rScO2降低的危险因素。结果有107例患者单肺通气期间发生了rScO2降低,发生率为61.1%。logistic回归分析结果显示,低氧血症是胸科手术患者单肺通气期间rScO2降低的独立危险因素,全麻联合硬膜外阻滞是rScO2降低的保护性因素(P<0.05)。结论低氧血症是胸科手术患者单肺通气期间rScO2降低的独立危险因素,而全麻联...     

单肺通气中低氧血症的防治进展

单肺通气为剖胸手术提供了良好的手术条件,但因其引起低氧血症的发生率高,威胁病人的安全,是对麻醉医 生的重大挑战。本文介绍了单肺通气中低氧血症的原因及其防治方法进展。     

开胸手术时双肺两种不同通气方式可行性应用

开胸手术行健侧单肺通气,所出现的肺内分流和低氧血症,倍受人们关注.我院在开胸手术中采用健侧肺间歇正压通气(intermittent positive pressure ventilation,IPPV),患侧肺采用持续正压通气(continuous positive airway pressure,CPAP),收到满意疗效.     

单肺通气中低氧血症的防治进展

单肺通气为剖脑手术提供了良好的手术条件，但因其引起低氧血症的发生率高，威胁病人的安全，是对麻醉医生的重大挑战。本文介绍了单肺通气中低氧血症的原因及其防治方法进展。     

单肺通气在胸外科手术中的应用

普通胸外科手术麻醉常用单肺通气技术，目的是为了防止术侧肺的分泌物或血液进入健侧肺，确保气道通畅、防止交叉感染和病原扩散，避免术侧肺膨胀，以利手术。主要的并发症是低氧血症。本文就其适应证、通气方法、低氧血症的原因与防治方面进行综述。     

低潮气量联合低呼气末正压通气用于老年患者单肺通气的临床研究

目的探讨低潮气量(VT)联合低呼气末正压通气(PEEP)对老年患者实施胸科手术单肺通气的临床有效性。方法选择实施胸科手术的老年患者60例。随机均分为研究组和对照组。研究组患者术中采用低VT联合低PEEP;对照组术中采用常规通气方案。记录两组术中PaO2、PaCO2、PETCO2、MAP、CVP及气道峰压(Ppeak)。结果与对照组比较,单肺通气60min时研究组PaO2显著升高,Ppeak明显下降(P<0.05);两组不同时点PaCO2、PETCO2及MAP差异无统计学意义;研究组患者术后3d内有3例术后并发症,明显低于对照组的6例(P<0.05)。结论对于老年患者实施胸科手术采用低VT联合低PEEP通气可有效改善患者术后低氧血症,减少术后肺部并发症,有利于患者术后呼吸功能的恢复,可以安全有效地应用于老年开胸手术。     

单肺麻醉的研究现状

单肺麻醉即单肺通气(OLV)麻醉，目的在防止血液或分泌物流向健侧肺；为手术操作提供相对静止的手术野。但是，OLV时，无通气侧肺的血液没有得到氧合就回到左心，可致静脉血掺杂，PaO2降低；无通气侧肺泡的低氧可致低氧性肺血管收缩(HPV)，使非通气侧肺血流减少并转向通气肺，由此使QS/QT减少，PaO2降低有所改善，但仍有约10％的病人发生显着低氧血症。所以，如何降低OLV时的QS／QT和怎样提高PaO2是单肺麻醉的关键问题。     

单肺通气对胸科手术病人开胸前血液动力学的影响

目前胸科手术麻醉普遍采用肺隔离技术,它可控制肺的复张与萎陷,提供良好的手术视野,确保健肺有效通气。但单肺通气的临床安全性是麻醉医生关注的问题。有研究表明采用不同方式单肺通气对开胸手术病人的血液动力学存在一定影响,而单肺通气对病人开胸前血液动力学的影响研究较少。本研究拟观察单肺通气对胸科手术病人开胸前血液动力学的影响。     

胸科手术中单肺通气期间不同通气方式的比较

目的 观察胸科手术病人麻醉中单肺通气（ＯＬＶ）期间不同通气方式的效果。方法 １０例择期胸科手术成年病人,ＡＳＡⅠ～Ⅱ级,在ＯＬＶ期间首先采用全潮气量（１０ｍｌ／ｋｇ）不加ＰＥＥＰ,随后采用半潮气量（５ｍｌ／ｋｇ）同时施加７ｃｍＨ２Ｏ ＰＥＥＰ两种通气方式,保持每分通气量不变。在开胸后ＯＬＶ前,ＯＬＶ时采用敏种通气方式后３０ｍｉｎ,以及恢复双肺通气（ＴＬＶ）后３０ｍｉｎ分别进行血气分析,同时监测气道     

Postoperative cardiac intensive care for patients with thoracic cancer: analysis of 430 cases]

430 patients with thoracic cancer were given intensive care after major thoracic surgery. Of those 188 (43.72%) developed cardiac complication during their stay in ICU and 2 (0.46%) died. The results indicated that postoperative cardiac complications were closely related to the patients age, preoperative concomitant cardiovascular diseases, duration of operation, hypoxemia, hypercapnia, and surgical complications. Postoperative cardiac intensive care could reduce the mortality rate.     

Relationship between postoperative hypoxemia and the operative site

The effect of the site of operation on postoperative hypoxemia was studied in 104 patients undergoing thoraco-abdominal, thoracic, upper abdominal, lower abdominal, extra-abdominal and non-thoracic operations. The degree of postoperative hypoxemia was the most extensive in patients undergoing thoraco-abdominal, moderate in thoracic and upper abdominal operations, and minimal in lower abdominal and other operations. On the other hand, the duration of hypoxemia also differed with the surgical procedures. Arterial oxygen tension returned to almost control values by the 3rd postoperative day in cases of lower abdominal and extremity operations and by the 7th postoperative day in those undergoing thoracic and upper abdominal surgery. Postoperative hypoxemia, however, remained throughout the fourteen day study period, in patients undergoing thoraco-abdominal operation. True shunt was measured in 27 patients with thoraco-abdominal, thoracic and upper abdominal operations. An increase in true shunt was evident postoperatively in the entire group of patients. The increase was significantly larger and longer lasting in cases of thoraco-abdominal incision than that in cases of thoracic and upper abdominal incision alone. Differences in postoperative true shunt between cases of thoracic and upper abdominal incisions were nil.     

Relationship between postoperative hypoxemia and the operative site

The effect of the site of operation on postoperative hypoxemia was studied in 104 patients undergoing thoraco-abdominal, thoracic, upper abdominal, lower abdominal, extra-abdominal and non-thoracic operations. The degree of postoperative hypoxemia was the most extensive in patients undergoing thoraco-abdominal, moderate in thoracic and upper abdominal operations, and minimal in lower abdominal and other operations. On the other hand, the duration of hypoxemia also differed with the surgical procedures. Arterial oxygen tension returned to almost control values by the 3rd postoperative day in cases of lower abdominal and extremity operations and by the 7th postoperative day in those undergoing thoracic and upper abdominal surgery. Postoperative hypoxemia, however, remained throughout the fourteen day study period, in patients undergoing thoraco-abdominal operation. True shunt was measured in 27 patients with thoraco-abdominal, thoracic and upper abdominal operations. An increase in true shunt was evident postoperatively in the entire group of patients. The increase was significantly larger and longer lasting in cases of thoraco-abdominal incision than that in cases of thoracic and upper abdominal incision alone. Differences in postoperative true shunt between cases of thoracic and upper abdominal incisions were nil.     

左右侧Mallinckrodt双腔管临床性能相同

背景以往的观点认为因左侧双腔管不易发生错位所以比右侧双腔管更安全。如果这种观点正确,那么胸科手术中,右侧双腔管的低氧血症、高碳酸血症、高气道压的发生率和严重程度直比左侧双腔管高。方法我们采用自动化麻醉信息管理系统回顾性分析了2003年4月15日到2004年12月31日的胸外科手术麻醉记录？该系统每隔30秒自动记录脉搏氧饱和度、呼气末二氧化碳浓度、气道峰压,也记录手术的部位和双腔管的位置。我们比较胸科麻醉医师使用左右侧双腔管的频率。继而,测定肺脏和胸壁手术患者的低氧血症（SpO2〈90％）、高碳酸血症（RtCO2〉45mmHg）和高气道压（气道峰压〉35cmH2O）的发生率、持续时间和严重程度,采用标准统计学方法比较各组的例数及数据。结果右侧双腔管（n=241）和左侧双腔管（n=450）广泛应用于对侧手术。在低氧血症、高碳酸血症或高气道压的发生率或持续时间上,两种方式没有显著差别。在左肺通气的患者中,EtCO2轻厦升高但差异有显著统计学意义。结论在手术期间,当低氧血症、高碳酸血症以及高气道压的发生率和严重程度作为安全标准时,比较来自同一厂家的两种双腔管的数据,本研究结果否定了左侧双腔管比右侧双腔管安全的推测。     

Case scenario – thoracic trauma

Among trauma patients, blunt chest trauma remains a major cause of morbidity and mortality. We report the case of an 85-year old patient under new oral anticoagulant implicated in a multiple-vehicle accident. The patient presented a complex thoracic trauma involving multiple rib fractures, flail chest, hemothorax and lung contusions. All the thoracic lesions were situated at the left side. Despite the absence of neurological lesion and hemodynamic instability, the patient required the admission in our intensive care unit related to the worsening of a respiratory distress. This respiratory distress resulted from the association of the thoracic injuries with related hypoxemia and a high level of pain. The management of this case included the reversal of the anticoagulant therapy, use of non-invasive ventilation, the placement of a paravertebral block and the surgical fixation of the flail chest. We provide a discussion of the risk/benefit balance for all the medical and surgical strategies used in this case as the interest of chest ultrasonography in thoracic trauma situations.     

Craniotomy during ECMO in a severely traumatized patient

Summary Extracorporeal membrane oxygenation (ECMO) can be a last resort treatment in acute respiratory distress syndrome after thoracic trauma. However, co-existent brain trauma is considered to be a contra-indication for ECMO. This is the first report on successful craniotomy under ECMO treatment in a multiply traumatized patient with severe thoracic and brain injuries. This successful treatment with beneficial neurological outcome suggests that ECMO therapy should not be withheld from severely injured patients with combined brain and thoracic trauma presenting with life-threatening hypoxemia. Moreover, even craniotomy may be performed during ECMO therapy without major bleeding and adverse effects on neurological function.     

Large Airway Response to Cemented Arthroplasty: Relationship to Hypoxaemia. An Experimental Study in Dogs

Alteration in airway smooth muscle tone has been implicated in the mechanism of hypoxemia, pulmonary hypertension and changes in dynamic thoracic compliance after total hip arthroplasty (THA). We used the pressure within a water-filled cuff of an endotracheal tube as a continuous measure of changes in tracheomotor tone during THA in mongrel dogs, while intermittently assessing gas exchange abnormalities. In all 16 dogs the instillation of polymethylmethacrylate (PMMA) into the femoral medullary shaft resulted in tracheal dilation. In ten dogs we demonstrated simultaneous hypotension, hypoxemia and increase in shunt fraction (Qs/Qt) after THA. In six dogs the medullary canal was thoroughly lavaged prior to PMMA injection, and no hypoxemia, hypotension or increased Qs/Qt was found in spite of persisting tracheomotor relaxation. We conclude that these well-documented gas-exchange abnormalities are not mediated by changes in large airway tone. Since the hypoxemia was abolished by medullary lavage in our animal model, we suggest that this syndrome is mediated by alterations in lung perfusion and associated small airway constriction and not by changes in large airway smooth muscle tone.     

Physiology of the lateral decubitus position and one-lung ventilation

OLV is most frequently utilized to provide a quiet field for the performance of many different surgical procedures. In some patients, severe hypoxemia may result, mandating the implementation of other therapies to provide adequate oxygenation. This paper has reviewed the physiological consequences of the lateral position that may contribute to the hypoxemia and the techniques we utilize at our institution for establishing OLV, maintaining OLV, and treating hypoxemia during OLV. Our technique is performed with the goal of maintaining adequate gas exchange and protecting the ventilated lung from potential overdistension and injury. It remains for future study to determine if the use of a lung protective strategy during intraoperative OLV offers any benefit to patients at risk for postoperative lung injury, such as those undergoing major lung resections.     

Airway management for one-lung ventilation

The progress in sophisticated and complex operating methods for intrathoracic procedures demands reliable lung separation with the possibility of one-lung ventilation. Patients with thoracic traumas and pulmonary emergencies can confront any anaesthesiologist with the need for lung separating procedures. This review describes the contemporary procedures for lung separation. The special aspects of difficult airway management during one-lung ventilation and the indications for one-lung ventilation are described in detail. The pathophysiological changes during one-lung ventilation and strategies to avoid hypoxemia and to preserve adequate oxygenation are discussed.     

Case of possible transfusion-related acute lung injury during thoracic endovascular aortic repair

Transfusion-related acute lung injury (TRALI) is a serious complication of blood transfusion, which is characterized by the acute onset of non-cardiogenic pulmonary edema and hypoxemia following the administration of blood products. We report a case of possible TRALI during thoracic endovascular aortic repair (TEVAR). The patient was a 61-year-old man (161 cm in height, 61 kg in weight) who underwent TEVAR for the traumatic injury at the isthmus of aorta. He had a light preexisting lung injury. About 1 hour following the blood transfusion (red cell concentrates, fresh-frozen plasma, and platelet concentrates), he suddenly fell into severe hypoxemia (PaO2 52 mmHg in FI(O2) of 1.0). The radiographic examination showed pulmonary edema, i. e., bilateral infiltrates and pleural effusion. No evidence of circulatory overload was observed. Anti-human leukocyte antigen antibodies in his serum and anti-granulocyte antibodies in the donor blood were detected. In spite of intensive care including artificial ventilation with positive end-expiratory pressure and the administration of methylprednisolone and a granulocyte elastase inhibitor, he died of exacerbated hypoxemia and hypotension 4 hours after the onset of acute lung injury. Of great importance is being aware of an unexpected occurrence of TRALI during and soon after blood transfusion.