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摘要：
目的 探究在老年患者后腹腔镜肾癌手术中，采用动态调整呼气末正压（positive end‑expiratory pressure, PEEP）的肺保护性通气策略（lung protective ventilation strategies, LPVS）对术中肺通气效果及术后谵妄（postoperative delirium, POD）的影响。 方法 选择择期拟行后腹腔镜肾癌手术患者138例，年龄65~80岁，ASA分级Ⅰ~Ⅲ级，采用随机数字表法将患者分为两组：常规通气组（A组）和个体化PEEP组（B组），每组69例。A组设置潮气量（tidal volume, VT）为 8 ml/kg［两组患者VT按照预测体重（predicted body weight, PBW）设置］，呼吸频率（respiration rate, RR）为12~20次/min；B组通过肺动态顺应性（dynamic compliance, Cdyn）滴定最佳PEEP值，联合低VT（6 ml/kg）及肺复张（recruitment maneuver, RMs）。记录两组患者麻醉诱导后（T1）、改侧卧位后5 min（T2）、气腹后每隔30 min（T3、T4、T5）、手术结束即刻（T6）的Cdyn、气道平台压（plateau pressure, Pplat）、氧合指数（oxygenation index, OI）、PaCO2及局部脑氧饱和度（regional cerebral oxygen saturation, rSO2），记录两组患者拔管时间、PACU停留时间及住院时间，ELISA法测定两组患者术前及术后第3天血清中枢神经特异性蛋白（central nervous system specific protein, S100‑β）、IL‑6、TNF‑α的浓度，记录两组患者术后3 d POD发生情况及严重程度。 结果 与T1时比较，两组患者T3~T6时Cdyn及rSO2均下降（P<0.05），Pplat及PaCO2均升高（P<0.05），B组患者T4~T6时OI下降，A组患者T3~T6时OI下降（P<0.05）。与A组比较，B组患者T3~T6时Cdyn及Pplat升高（P<0.05），T4~T6时rSO2与OI升高（P<0.05），T4~T6时PaCO2下降（P<0.05），拔管时间缩短（P<0.05），术后第3天的血清S100‑β、IL‑6及TNF‑α浓度降低（P<0.05）。A组患者术后3 d POD发生率23.9％（16例）高于B组10.4％（7例）（P<0.05），而两组患者的POD严重程度差异无统计学意义（P>0.05）。 结论 最佳PEEP联合低VT和RMs的LPVS可改善后腹腔镜肾癌手术老年患者围手术期的肺功能并降低POD的发生率。
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Abstract: Objective To explore the effect of lung protective ventilation strategies (LPVS) with dynamic adjustment of positive end‑expiratory pressure (PEEP) on pulmonary ventilation and postoperative delirium (POD) in elderly patients under retroperitoneal laparoscopic operation of renal carcinoma. Methods One hundred thirty‑eight patients (aged 65−80 years, ASA gradeⅠ−Ⅲ) scheduled to undergo the retroperitoneal laparoscopic operation of renal carcinoma were divided into two groups: traditional ventilation group (group A, n=69) and individualized PEEP group (group B, n=69), according to the random number table method. In group A, tidal volume (VT) 8 ml/kg (predicted body weight, PBW), respiration rate (RR) 12−20 times/min. In group B, optimal PEEP was guided by dynamic compliance (Cdyn) combined with VT 6 ml/kg (PBW) and recruitment maneuvers (RMs) (30 min/time). Cdyn, plateau pressure (Pplat), oxygenation index (OI), arterial partial pressure of carbon dioxide (PaCO2), and regional cerebral oxygen saturation (rSO2) were recorded after anesthesia induction (T1), 5 min after a change to lateral position (T2), every 30 min after CO2 entered the abdominal cavity (T3, T4, T5) and immediately after surgery (T6). Record the extubation time, post‑anesthesia care unit (PACU) stay time and hospital stay. The concentration of serum central nervous system specific protein (S100‑β), interleukin‑6 (IL‑6), tumor necrosis factor‑α (TNF‑α) were determined by enzyme‑linked immunosorbent assay (ELISA) before operation and on the third day after the operation. The occurrence and severity of delirium within 3 d after operation were recorded. Results Compared with T1, the Cdyn and rSO2 decreased at T3-T6 (P<0.05), the Pplat and PaCO2 increased (P<0.05), while OI decreased at T4-T6 (OI decreased at T3-T6 in group A) (P<0.05) in both groups A and B. Compared with group A, the Cdyn and Pplat in group B were significantly improved at T3-T6, while the rSO2 and OI in group B were increased at T4-T6 (P<0.05), the PaCO2 in group B was decreased at T4-T6 (P<0.05). Compared with group A, the extubation time of group B was shorter (P<0.05). Compared with group A, IL‑6, TNF‑α and S100‑β of group B were reduced at 3 d after the operation (P<0.05). There were 16 cases (23.9%) in group A and 7 cases of POD (10.4%) in group B. The incidence of POD in group A was higher than that in group B (P<0.05), while there was no significant difference in the severity of POD between the two groups (P>0.05). Conclusions Optimal PEEP combined with LPVS (low VT and RMs) can improve perioperative lung function and reduce the incidence of POD in elderly patients undergoing retroperitoneal laparoscopic renal cancer surgery.
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