经鼻高流量吸氧对老年经内镜逆行胰胆管造影手术监测麻醉中低氧血症发生率影响.pdf

围研究683:ClinJMedOff7,Jul,2023临床军医杂志2023年7 月第51卷第7 期经鼻高流量吸氧对老年经内镜逆行胰胆管造影手术监测麻醉中低氧血症发生率影响裘治慧，宋丹丹，刁玉刚，陈宁，许兆柱，赵婉彤北部战区总医院麻醉科，辽宁沈阳110 0 16摘要目的探讨经鼻高流量吸氧(HFNC)对老年经内镜逆行胰胆管造影(ERCP）手术监测麻醉中低氧血症发生率的影响。方法选取北部战区总医院2 0 2 1年3一10 月收治的10 4例行ERCP手术的老年患者为研究对象。采用随机数字表法将患者分为A组与B组,每组各52 例。两组患者均采用监测麻醉下行ERCP手术。A组患者采用HFNC预吸氧,B组患者采用鼻导管预吸氧。分别于预吸氧前（T。）、诱导后（T,）、进镜过咽喉（T）、十二指肠乳头插管（T，）、退镜（T4）、苏醒（T），记录并比较两组患者脉搏血氧饱和度（SpO,）、平均动脉压（MAP)、呼吸频率(RR）、心率（HR）、脑电双频指数（BIS）。分别于T。、T,、T,，记录并比较两组患者动脉血二氧化碳分压（PaCO,）、动脉血氧分压（PaO,）p H 值。记录两组患者总丙泊酚用量、手术时间及苏醒时间、不良反应发生情况。结果两组患者不同时间点MAP、H R、R R 比较，差异均无统计学意义（P0.05）。A组患者T,、T,、T 4、T，时的SpO,均高于B组,差异均有统计学意义(P0.05)。A 组患者T,、T,时的PaO,高于B组,T,时的PaCO,低于B组,差异均有统计学意义(P0.05）。A 组患者不良反应发生率为2 5.0 0%（13/52），低于B组的6 1.54%（32/52），差异有统计学意义（P0.05).SpO,levels at T,T,T4and T,in group A were higher than those in group B,and the differences were statistically significant(P0.05).The PaO,at T,andT,in group A was higher than that in group B,and the PaCO,at T,was lower than that in group B,with statistical significance(P0.05).The incidence of adverse reactions in group A was 25.00%(13/52),lower than that in group B 61.54%(32/52),and thedifference was statistically significant(P0.05),具有可比性。本研究经医院伦理委员会批准。所有患者均签署知情同意书。1.2麻醉方法去A组患者采用经鼻高流量方式供氧,麻醉诱导前采用HFNC鼻塞设置氧流量30 L/min，氧浓度10 0%，湿度50%，温度37，时间3min预吸氧9 。在术后在恢复室中换用鼻导管进行供氧（5L/mi n）。B组采用鼻导管方式供氧，麻醉诱导前后均运用鼻导管进行吸氧（氧流量5L/min，预吸氧3min）。术前禁食、禁水。人室后,监测心率(heartrate,HR）、呼吸频率（respiratoryrate,RR）、脉搏血氧饱和度（pulse oxygen saturation,SpO，）、心电图等指标，建立静脉通路，桡动脉穿刺并监测有创动脉血压及血气分析。患者左侧俯卧位,静卧2 3min,记录基础生命体征。A组患者应用HFNC,氧流量30 L/min。B组患者应用普通鼻导管供氧，氧流量5L/min。采用丙泊酚2 mg/kg与舒芬太尼0.10 g/kg 进行麻醉诱导10 。诱导后,A 组患者流量调为6 0 L/min，氧浓度为10 0%。静脉泵注丙泊酚610mg/(kgh)与右美托咪定0.2 0.8 g/(kgh)进行麻醉维持，术中脑电双频指数（bifrequency in-dex,BIS)保持在40 7 0,退镜时停药。术后恢复室观察,均改普通鼻导管吸氧,氧流量5L/min。如果心率 2 0%，给予6 mg麻黄碱；如果出现体动、呛咳等，追加0.5mg/kg丙泊酚；如果出现低氧血症，B组增加氧流量，由5L/min升至8 L/min；如果发生重度低氧血症（SpO，7 5%）,即刻退镜行面罩加压给氧或气管插管11.3观察指标分别于预吸氧前（T。）、诱导后（T）、进镜过咽喉（T,）、十二指肠乳头插管（T）、退镜（T）、苏醒（T，），记录并比较两组患者SpO2、平均动脉压(mean arterial pressure,MAP）、R R、H R、BIS。分别于T。、T z、T s，记录并比较两组患者二氧化碳分压（carbondioxide,PaCO,）、动脉血氧分压(arterial partial pressure of oxygen,PaO,）、p H 值。记录两组患者总丙泊酚用量、手术时间及苏醒时间、不良反应发生情况。1.4乡统计学方法采用SPSS25.0统计学软件对数据进行处理。计量资料用均数标准差（xs)表示，组间比较采用t检验。计数资料用例（百分率)表示,组间比较采用x检验。以P0.05)。见表1。表1两组患者不同时点血流动力学指标比较（xs)MAP/mmHg组别T。TT2T3T4T,A组100.81 5.7397.56 6.0896.15 6.3397.92 5.8198.78 7.2398.99 5.25B组98.89 6.7996.42 6.6698.35 6.89101.76 5.6598.83 6.56100.33 6.25P值0.050.050.050.050.050.05HR/次minl组别T。TT2T3T4T，A组72.27 8.3869.87 8.2868.67 7.4262.79 6.7068.35 6.9672.79 6.39B组73.06 6.7368.96 8.2075.92 7.0266.92 4.4771.65 7.8472.62 6.45P值0.050.050.050.050.050.05RR/次minl组别T。TT2TT4T,A组17.79 2.6914.94 2.3810.48 2.2411.62 2.8715.25 2.4717.96 2.51B组17.62 2.5913.92 2.668.29 2.828.73 2.8415.15 3.2917.50 2.29P值0.050.050.050.050.050.05注:1 mmHg=0.133 kPa2.2两组患者不同时点SpO,比较交A组患者T2、T,、T 4、T,时的SpO,均高于B组,差异均有统计学意义(P0.05)。见表2。2.3两组患者不同时点血气指标比较A组患者T,、T，时的PaO，高于B组，T,时的PaCO，低于B组,差异均有统计学意义（P0.05)。见表3。表2两组患者不同时点SpO,比较(xs)组别T。TTTT4T,A组98.14%1.24%94.52%2.62%93.48%2.87%95.45%3.03%95.69%3.04%98.07%1.30%B组98.08%1.54%93.46%3.06%89.31%2.54%91.44%3.04%92.85%3.38%98.07%1.03%P值0.050.050.050.050.050.050.050.050.050.050.050.052.4两组患者丙泊酚用量、手术时间及苏醒时间比较两组患者丙泊酚总用量、手术时间及苏醒时间比较,差异均无统计学意义(P0.05)。见表4。2.5两组患者各时点BIS比较两组患者各时间点BIS比较,差异均无统计学意义（P0.05）。见表5。表4两组患者总丙泊酚用量、手术时间及苏醒时间比较(xs)组别总丙泊酚用量/mg手术时间/min苏醒时间/minA组396.83 29.3343.69 6.3914.92 4.28B组407.88 33.2045.33 6.2315.42 4.64P值0.050.050.05.686.Clin J Med Offic,No.7,Jul,2023VO临床军医杂志2023年7 月第51卷第7 期表5两组患者各时点BIS比较（xs)组别T。TT2T3T4T，A组98.14 1.2464.52 2.6253.48 2.8755.45 3.0365.69 3.0488.27 1.30B组98.08 1.5463.46 3.0659.31 2.5461.44 3.0462.85 3.3888.07 1.03P值0.050.050.050.050.050.052.6两组患者不良反应发生情况比较A组：低氧血症3例，心动过缓1例，呛咳2 例，术中体动4例,恶心呕吐3例。B组：低氧血症11例,心动过缓3例，呛咳5例，术中体动9例，恶心呕吐4例。A组患者不良反应发生率为2 5.0 0%（13/52），低于B组的6 1.54%（32/52），差异有统计学意义（P0.05）。这提示，经鼻高流量吸氧虽然流量达6 0 L/min，患者舒适度佳，不影响血流动力学变化与自主呼吸频率。本研究结果显示，A组患者T2、T 3、T 4、T,时SpO,均高于B组，差异均有统计学意义（P0.05）。这提示，应用HFNC吸氧的患者在行ERCP手术期间,SpO，可维持相对高水平。本研究结果显示,A组患者T,、T，时PaO,高于B组，T，时PaCO低于B组,差异均有统计学意义（P0.05）。这提示,高流量吸氧可以明显提高患者PaO2,提高了氧储备能力,HFNC可以提供高流量高浓度氧气,增加肺泡呼气末压力，氧贮备能力显著提高，提高对缺氧的耐受性。老年患者肺泡萎缩,气道梗阻,HFNC能提供加温加湿气体使得呼吸道减缓黏膜干燥程度,且能加快清除气道的分泌物，减少支气管痉挛的发生。此外，A组患者不良反应发生率为25.00%（13/52），低于B组的6 1.54%（32/52），差异有统计学意义（P0.05）。这提示,应用HFNC患者有舒适、便捷的高流量纯氧预吸氧，患者氧储备更佳,低氧血症发生率更低。综上所述，HFNC可降低老年患者ERCP手术监测麻醉中低氧血症的发生率,不增加术中二氧化碳潴留风险，且安全舒适。参考文献：1 Cha B,Lee MJ,Park JS,et al.Clinical ficacy of high-flow nasaloxygen in patients undergoing ERCP under sedation J.Sci Rep,2021,11(1):350.2Nishimura M.High-flow nasal cannula oxygen therapy inadultsJ.J Intensive Care,2015,3(1):15.3 Pisani L,Vega ML.Use of nasal high flow in stable COPD:ration-ale and physiologyJ.COPD,2017,14(3):346-350.4Patel A,Nouraei SA.Transnasal humidified rapid-insufflation ven-tilatory exchange(THRIVE):a physiological method of increasingapnoea time in patients with difficult 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