在胸腔镜手术患者中,在疼痛控制和术后并发症发生率方面,多数研究结果表明,椎旁阻滞(paravertebral block, PVB)优于硬膜外镇痛(epidural analgesia, EP)。目前,直接比较PVB和EP在疼痛控制和术后结局方面的研究数量有限,尚无大规模的随机试验报道。但其中有4篇论文为此提供了最好的证据说明,四篇中有3篇是小型前瞻性随机试验,最后一篇文献是一项小的队列研究。从疼痛控制的角度来看,没有确凿的证据表明这两种方法谁更有效;一项研究表明EP显著降低了疼痛水平(P = 0.01),第二项研究表明PVB明显改善了疼痛控制(P <0.01),第三项研究未能证明任何显著差异(P = 0.899)。PVB组和EP组需要追加镇痛的频率相似(56% vs 48%, P = 0.26)。与EP相比,PVB的术后并发症发生率更低,特别是尿潴留(64% vs 34.6%, P = 0.0036)和低血压(32% vs 7%, P = 0.0031;21% vs 3%, P = 0.02) 。而在PVB组中,联合使用舒芬太尼的研究较少,其安全性和有效性值得我们深入研究。
呼气末二氧化碳分压(PETCO2)是指呼吸末呼出气中二氧化碳浓度,呼气末二氧化碳监测是一种无创监测手段。对于呼吸和循环功能监测最直接的方法是进行动脉血气分析,该法为有创操作、不能连续测定且费用较高昂,与血气分析相比PETCO2可以无创、实时、连续监测患者呼吸与循环功能,美国麻醉医师协会(ASA))早已规定PETCO2为麻醉期间的基本监察观测项目。现将从PETCO2监测的基本原理以及测定方法、PETCO2影响因素、PETCO2临床应用(包括气管导管位置确定、循环功能监测、肺栓塞等的辅助诊断)三大方面阐述PETCO2的临床应用进展,为一线医生们在评估病人病情时提供帮助。End-tidal carbon dioxide partial pressure (PETCO2) refers to the concentration of carbon dioxide in the exhaled breath at the end of respiration. End-tidal carbon dioxide monitoring is a non-invasive monitoring method. The most direct method for monitoring respiratory and circulatory function is to perform arterial blood gas analysis. This method is invasive, cannot be measured continuously and is expensive. Compared with blood gas analysis, PETCO2 can monitor the patient’s respiratory and circulatory functions non-invasively, in real time, and continuously. The American Association of Anesthesiologists (ASA) has long established PETCO2 as a basic monitoring and observation item during anesthesia. This paper expounds the progress of clinical application of PETCO2 from three aspects: the basic principle and determination method of PETCO2 monitoring, the influencing factors of PETCO2, and the clinical application of PETCO2 (including the location of endotracheal tube, monitoring of circulatory function, auxiliary diagnosis of pulmonary embolism, etc.), so as to provide help for front-line doctors in evaluating the condition of patients.
