中华急诊医学杂志
中華急診醫學雜誌
중화급진의학잡지
CHINESE JOURNAL OF EMERGENCY MEDICINE
2014年
12期
1309-1313
,共5页
颅脑损伤%脑灌注压%颈静脉血氧饱和度%呼吸衰竭%机械通气%肺损伤%潮气量%血气分析%呼气末正压
顱腦損傷%腦灌註壓%頸靜脈血氧飽和度%呼吸衰竭%機械通氣%肺損傷%潮氣量%血氣分析%呼氣末正壓
로뇌손상%뇌관주압%경정맥혈양포화도%호흡쇠갈%궤계통기%폐손상%조기량%혈기분석%호기말정압
Cerebral injury%Cerebral perfusion pressure%Jugular venous oxygen saturation%Respiratory failure%Mechanical ventilation%Acute lung injury%Tidal volume%Blood gas analysis%Positive end-expiratory pressure
目的 观察肺保护性机械通气对颅脑损伤患者脑灌注压(CPP)及脑氧代谢的影响.方法 选择ICU需要机械通气的严重颅脑损伤伴呼吸衰竭患者40例,所有患者均行颅内压(ICP)监测、右侧颈内静脉逆行穿刺置管.将患者随机(随机数字法)分为①肺保护性通气组:潮气量为6～8mL/kg,初始吸氧体积分数40％,逐步提升呼气末正压(PEEP),PEEP与吸氧(FiO2)匹配同步升高,保持FiO2允许性低值;②常规通气组(对照组):潮气量为8～ 12 mL/kg,FiO2与PEEP匹配同步升高,保持PEEP允许性低值.监测桡动脉血气、平均动脉压(MAP)、颈静脉血氧饱和度(SjVO2),颈静脉血二氧化碳分压(PjVCO2),计算CPP=MAP-ICP;氧合指数PaO2/FiO2.结果 肺保护性通气组PEEP(8.2 ±3.3) cmH2O(1 cmH2O=0.098 kPa)、ICP (19.7±3.6) mmHg(1 mmHg=0.133 kPa)、PaCO2 (54±7.3 mmHg)高于对照组,VT、FiO2低于对照组,差异具有统计学意义;两组PaO2/FiO2、SjVO2、MAP、CPP差异无统计学意义.相关分析提示PaCO2与CPP呈正相关(r=0.368,P=0.019),与ICP、PaO2、SjVO2、Pjv CO2等并无相关性(P＞0.05);PEEP与ICP呈正相关;PEEP分为≤5 cmH2O、6～ 10 cmH2O及＞10 cmH2O三组,各组间ICP两两比较差异有统计学意义;PEEP在0～ 10 cmH2O上升,CPP变化不明显;PEEP＞ 10cmH2O时与CPP呈明显负相关(r=-0.395,P=0.017),CPP(58.5±7.2) mmHg,低于PEEP 0 ～ 5cmH2O时的(69.1±9.7) mmHg,差异具有统计学意义;PEEP越高,氧合指数越低;不同的PEEP水平下MAP、SjVO2、PjVCO2无明显变化.将PaCO2分为35～45 mmHg和46～60mmHg组,后者的CPP高于前组者,差异具有统计学意义(P＜ 0.05).SjVO2与PaO2及PjvCO2相关,与PaCO2、CPP、ICP、MAP及PEEP等均无相关性.结论 肺保护性通气策略对颅脑损伤患者来说是相对安全的.适当的CO2潴留联合较高的PEEP不影响脑灌注.肺保护性通气与常规通气相比SjVO2差异无统计学意义.提示两种通气方式下脑氧代谢无变化.
目的 觀察肺保護性機械通氣對顱腦損傷患者腦灌註壓(CPP)及腦氧代謝的影響.方法 選擇ICU需要機械通氣的嚴重顱腦損傷伴呼吸衰竭患者40例,所有患者均行顱內壓(ICP)鑑測、右側頸內靜脈逆行穿刺置管.將患者隨機(隨機數字法)分為①肺保護性通氣組:潮氣量為6～8mL/kg,初始吸氧體積分數40％,逐步提升呼氣末正壓(PEEP),PEEP與吸氧(FiO2)匹配同步升高,保持FiO2允許性低值;②常規通氣組(對照組):潮氣量為8～ 12 mL/kg,FiO2與PEEP匹配同步升高,保持PEEP允許性低值.鑑測橈動脈血氣、平均動脈壓(MAP)、頸靜脈血氧飽和度(SjVO2),頸靜脈血二氧化碳分壓(PjVCO2),計算CPP=MAP-ICP;氧閤指數PaO2/FiO2.結果 肺保護性通氣組PEEP(8.2 ±3.3) cmH2O(1 cmH2O=0.098 kPa)、ICP (19.7±3.6) mmHg(1 mmHg=0.133 kPa)、PaCO2 (54±7.3 mmHg)高于對照組,VT、FiO2低于對照組,差異具有統計學意義;兩組PaO2/FiO2、SjVO2、MAP、CPP差異無統計學意義.相關分析提示PaCO2與CPP呈正相關(r=0.368,P=0.019),與ICP、PaO2、SjVO2、Pjv CO2等併無相關性(P＞0.05);PEEP與ICP呈正相關;PEEP分為≤5 cmH2O、6～ 10 cmH2O及＞10 cmH2O三組,各組間ICP兩兩比較差異有統計學意義;PEEP在0～ 10 cmH2O上升,CPP變化不明顯;PEEP＞ 10cmH2O時與CPP呈明顯負相關(r=-0.395,P=0.017),CPP(58.5±7.2) mmHg,低于PEEP 0 ～ 5cmH2O時的(69.1±9.7) mmHg,差異具有統計學意義;PEEP越高,氧閤指數越低;不同的PEEP水平下MAP、SjVO2、PjVCO2無明顯變化.將PaCO2分為35～45 mmHg和46～60mmHg組,後者的CPP高于前組者,差異具有統計學意義(P＜ 0.05).SjVO2與PaO2及PjvCO2相關,與PaCO2、CPP、ICP、MAP及PEEP等均無相關性.結論 肺保護性通氣策略對顱腦損傷患者來說是相對安全的.適噹的CO2潴留聯閤較高的PEEP不影響腦灌註.肺保護性通氣與常規通氣相比SjVO2差異無統計學意義.提示兩種通氣方式下腦氧代謝無變化.
목적 관찰폐보호성궤계통기대로뇌손상환자뇌관주압(CPP)급뇌양대사적영향.방법 선택ICU수요궤계통기적엄중로뇌손상반호흡쇠갈환자40례,소유환자균행로내압(ICP)감측、우측경내정맥역행천자치관.장환자수궤(수궤수자법)분위①폐보호성통기조:조기량위6～8mL/kg,초시흡양체적분수40％,축보제승호기말정압(PEEP),PEEP여흡양(FiO2)필배동보승고,보지FiO2윤허성저치;②상규통기조(대조조):조기량위8～ 12 mL/kg,FiO2여PEEP필배동보승고,보지PEEP윤허성저치.감측뇨동맥혈기、평균동맥압(MAP)、경정맥혈양포화도(SjVO2),경정맥혈이양화탄분압(PjVCO2),계산CPP=MAP-ICP;양합지수PaO2/FiO2.결과 폐보호성통기조PEEP(8.2 ±3.3) cmH2O(1 cmH2O=0.098 kPa)、ICP (19.7±3.6) mmHg(1 mmHg=0.133 kPa)、PaCO2 (54±7.3 mmHg)고우대조조,VT、FiO2저우대조조,차이구유통계학의의;량조PaO2/FiO2、SjVO2、MAP、CPP차이무통계학의의.상관분석제시PaCO2여CPP정정상관(r=0.368,P=0.019),여ICP、PaO2、SjVO2、Pjv CO2등병무상관성(P＞0.05);PEEP여ICP정정상관;PEEP분위≤5 cmH2O、6～ 10 cmH2O급＞10 cmH2O삼조,각조간ICP량량비교차이유통계학의의;PEEP재0～ 10 cmH2O상승,CPP변화불명현;PEEP＞ 10cmH2O시여CPP정명현부상관(r=-0.395,P=0.017),CPP(58.5±7.2) mmHg,저우PEEP 0 ～ 5cmH2O시적(69.1±9.7) mmHg,차이구유통계학의의;PEEP월고,양합지수월저;불동적PEEP수평하MAP、SjVO2、PjVCO2무명현변화.장PaCO2분위35～45 mmHg화46～60mmHg조,후자적CPP고우전조자,차이구유통계학의의(P＜ 0.05).SjVO2여PaO2급PjvCO2상관,여PaCO2、CPP、ICP、MAP급PEEP등균무상관성.결론 폐보호성통기책략대로뇌손상환자래설시상대안전적.괄당적CO2저류연합교고적PEEP불영향뇌관주.폐보호성통기여상규통기상비SjVO2차이무통계학의의.제시량충통기방식하뇌양대사무변화.
Objective To explore the impact of lung-protective mechanical ventilation (low tidal volume and optimal positive end-expiratory pressure (PEEP) on cerebral perfusion pressure (CPP) and cerebral oxygen metabolism.Methods Forty patients with severe cerebral injury along with respiratory failure were randomly assigned into two groups:lung-protective ventilation group A and conventional ventilation group B.Group A was planned to prescribe tidal volume 6 ～ 8 mL/kg,initial FiO240％,PEEP gradually increasing from 2 cmH2O to matched with FiO2 elevation,but the FiO2 was kept at permissive lower level.Group B was formulated with tidal volume 8 ～ 12 mL/kg,PEEP stepwise increasing from 0 2 cmH2O to match with FiO2 elevation,but PEEP was kept at permissive lower pressure.The intracranial pressure (ICP),mean arterial pressure (MAP),CPP,arterial and jugular venous blood gas were monitored.Results PEEP (8.2±3.32 cmH2O),ICP (19.7 ±3.6 mmHg),PaCO2 (54±7.3 mmHg),jugular venous carbon dioxide partial pressure (PjV CO2,56.7 ± 9.6 mmHg) in group A were higher than those (5.7±2.3 cmH2O,16.9±3.8 mmHg,41 ±5.2 mmHg,49.8 ±6.9 mmHg) in group B (P＜ 0.05 or P ＜ 0.01).VT,FiO2 in the group A were lower than those in the group B.There were no differences in PaO2/FiO2,jugular venous oxygen saturation (SjVO2),MAP,and CPP between two groups.PaCO2 were significantly correlated with CPP (r =0.368,P =0.019) while there was no correlation with ICP,PaO2,SjVO2,PjVCO2 (all P ＞0.05).CPP (69.7 ± 12.3 mmHg) was higher in case of PaCO2 (46 ～60mmHg) than those (61.5 ±9.1 mmHg) in case of PaCO2 (35 ～45 mmHg).There was correlation between PEEP and ICP (r =0.436,P =0.005).When PEEP was divided into three groups:≤52 cmH2O,6 ～ 102 cmH2O and ＞ 102 cmH2O,ICPs were different one another among three groups.When PEEP ＞ 102 cmH2O,it had a distinguished negative correlation with CPP (r =-0.395,P =0.017),while PEEP ≤ 102 cmH2O,CPP presented decreasing tendency.SjVO2 correlated with PaO2 (r =0.403,P =0.014) and PjVCO2 (r =-0.502,P =0.001) respectively.There were no significant relationships between SjVO2 and CPP,ICP,MAP,PEEP,respectively.Conclusions Lung-protective mechanical ventilation was relatively safer in patients with severe cerebral injury compared with conventional mechanical ventilation.Mild PaCO2 elevation (46 ～ 60 mmHg) combined with higher PEEP (＜ 102 cmH2O) did not decrease CPP.There was no difference in SjVO2 between the two modes of mechanical ventilation,suggesting no changes in cerebral metabolism occurred.
