医路顺风的YAO&ARTUSIO麻醉学读书日记

医路顺风

第二章感觉收获不大，今晚有空，延伸阅读一下。

Case Scenario: Management of Intraoperative Hypoxemia during One-lung Ventilation

Case Reports   
A 50-yr-old man undergoing resection of the upper right lung for neoplasia developed hypoxemia 15 min after the start of OLV.
患者男性，50岁，因肺癌行右上肺叶切除术，单肺通气15min后发生了低氧血症。

Preoperative examination revealed satisfactory cardiopulmonary status. Preoperative rest and dobutamine stress echocardiography revealed normal left ventricular function without any wall motion abnormalities. Doppler ultrasound examination of the carotid arteries was normal.
术前检查提示心肺功能正常，静息和多巴酚丁胺负荷超声心动图提示：左室功能正常，室壁运动无明显异常。多普勒超声提示颈动脉无明显异常。

Preoperative pulmonary function tests were normal without any obstructive disease (forced expired volume in 1 s was 3.71 and forced expired volume in 1 s/vital capacity was 73%). Blood electrolytes, hemoglobin concentration, and renal function were normal.
术前肺功能检查正常，未见任何梗阻性疾病表现（FEV1=3.71，FEV1/FVC=73%）。血清电解质，血红蛋白和肾功能正常。

There was no history of bronchopulmonary infection, and arterial blood gas values in room air were Pao2 83 mmHg, Paco2 38 mmHg, pH 7.40, and HCO3 25 mm.
无支气管肺感染病史，吸空气状况下动脉血气为PaO2 83 mmHg, PaCO2 38 mmHg, pH 7.40,  HCO3 25 mm.

Electrocardiogram showed regular sinus rhythm, and blood pressure on the morning of surgery was 128/65 mmHg.
心电图示窦性心律正常心电图，术晨血压为128/65 mmHg.

The patient refused epidural anesthesia for management of postoperative pain.
病人拒绝硬膜外麻醉术后镇痛。

Selective bronchial intubation of the left main-stem bronchus was performed with a 39F left-sided double lumen tube (DLT) (Broncho-part; Rüsch, Kermen, Germany). The correct position of the tube was immediately confirmed with a fiberoptic bronchoscopy, and the patient was then placed in the lateral position.
插入左侧双腔气管导管，纤支镜确认导管位置正确后，患者被置于侧卧位。

Volume-controlled ventilation, including a 7 ml/kg tidal volume (VT) of predicted body weight under 100% Fio2, a 12 cycles/min respiratory rate, and a 5 cm H2O positive end-expiratory pressure (PEEP), was used. End-tidal carbon dioxide and plateau pressure were 31 mmHg and 19 cm H2O, respectively. No intrinsic PEEP was observed. OLV was initiated without any change in ventilator settings.
容量控制通气，VT 7ml/kg（标准体重），FIO2 100%，RR 12次/分，PEEP 5 cm H2O。EtCO2 31mmHg，平台压19 cm H2O。未见内源性PEEP。单肺通气开始时维持原通气设置。

Fifteen minutes later, the patient exhibited profound hypoxemia with a significant decrease in pulse oxymetry from 94% to 88%. Arterial blood gas values were pH 7.41, Pao2 52 mmHg (100% Fio2), Paco2 40 mmHg, HCO3 24.8 mM, and 87% Sao2. The patient's hemodynamics and electrocardiogram remained stable. Expiratory flow and expiratory VT were unchanged, and no leak was noticed.
单肺通气15min后，病人发生明显的低氧血症，SPO2从94%下降至88%，动脉血气提示：pH 7.41, Pao2 52 mmHg (100% Fio2), Paco2 40 mmHg, HCO3 24.8 mM, Sao2. 87%。病人血流动力学和心电图一直保持稳定，呼吸流量和潮气量未发生明显变化，没有明显的泄露。

The correct position of the DLT was immediately confirmed by fiberoptic inspection. End-expiratory flow was not interrupted by the next insufflation and reached zero before the next respiratory cycle, therefore no dynamic hyperinflation or intrinsic PEEP (iPEEP) was observed.
立即用纤支镜确认双腔管位置正确，呼气末流速未被下次吸气打断并能在下次呼吸周期前达到零点，所以未发现过度通气和内源性PEEP。

Once the surgeon was informed, the nondependent lung (nonventilated lung) was expanded manually by administration of pure oxygen, and a continuous positive airway pressure (CPAP) at 5 cm H2O was subsequently applied. This strategy allowed rapid improvement of the patient's oxygenation, and oxymetry pulse could be maintained above 95% throughout the surgical procedure under OLV.
马上通知术者停止手术，纯氧手动膨胀非通气肺，随后给予上肺5 cm H2O CPAP。这些措施使病人的氧合状态迅速得到改善，SPO2一直维持在95%以上，最终单肺通气完成手术。

During the manual expansion of the nondependent (nonventilated) lung, hemodynamics remained stable. Because the surgical procedure was a right open thoracotomy, it was not impeded by the application of CPAP to the nondependent lung, which was stopped at the end of OLV.
在非通气肺手动膨肺过程中，血流动力学保持稳定。因为此手术是右侧开胸入路，所以对非通气肺行CPAP直到单肺通气结束，并未影响手术操作。

The postoperative course of this patient was uneventful. He did not exhibit any hypoxemia after tracheal extubation.
病人术后平稳恢复，拔出气管导管后未再发生低氧血症。

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医路顺风

最近杂事比较多，耽误读书了。打算利用这几天，把落下的不上来。:)第4章 肺移植，应该用不上，粗看一遍，集中精力解决前3章的问题。

mazuirenmazui

楼主辛苦了，读书心得写得很好。顶一下，:)

xjxialingww

像楼主学习，记录的很精辟，都是精华！很多东西我看过记不住:dizzy:

qwddvsv

回复 11# 医路顺风


    这本书我也看了，但是我发现实际临床应用过程中，七氟醚的刺激性气味其实是可以诱发哮喘的，有一次病人维持使用七氟醚，气道压突然增高，换成异丙酚后好转，所以不知道是偶然还是七氟醚的气味刺激气道要强于其对支气管平滑肌的舒张作用~求讨论:loveliness:

yanxin3688

喜欢，看得很细，有感触。。希望继续下去