Malbouisson Luiz Marcelo Sá, Brito Marcelo, Carmona Maria José Carvalho, Auler José Otávio Costa Júnior
Instituto do Coração do Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP.
Rev Bras Anestesiol. 2008 Mar-Apr;58(2):112-23. doi: 10.1590/s0034-70942008000200004.
Alveolar recruitment maneuver (ARM) with pressures of 40 cmH2O in the airways is effective in the reversal of atelectasis after myocardial revascularization (MR); however, there is a lack of studies evaluating the hemodynamic impact of this maneuver in patients who evolve with cardiogenic shock after MR. The objective of this study was to test the hemodynamic tolerance to ARM in patients who develop cardiogenic shock after MR.
Ten hypoxemic patients in cardiogenic shock after MR were evaluated after admission to the ICU and hemodynamic stabilization. Ventilatory adjustments included tidal volume of 8 mL x kg(-1), PEEP 5 cmH2O, RR 12, and FiO2 0.6. Continuous pressure of 40 cmH2O was applied to the airways for 40 seconds in three cycles. Between cycles, patients were ventilated for 30 seconds, and after the last cycle, PEEP was set at 10 cmH2O. Hemodynamic measurements were obtained 1, 10, 30, and 60 minutes after ARM, and arterial and venous blood samples were drawn 10 and 60 minutes after the maneuver to determine lactate levels and blood gases. ANOVA and the Friedman test were used to analyze the data. A p of 0.05 was considered significant.
Alveolar recruitment maneuver increased the ratio PaO2/ FiO2 from 87 to 129.5 after 10 minutes and to 120 after 60 minutes (p < 0.05) and reduced pulmonary shunting from 30% to 20% (p < 0.05). Hemodynamic changes or changes in oxygen transport immediately after or up to 60 minutes after the maneuver were not detected.
In patients who evolved to cardiogenic shock and hypoxemia after MR, ARM improved oxygenation and was well tolerated hemodynamically.
气道压力为40 cmH₂O的肺泡复张手法（ARM）对心肌血运重建（MR）后肺不张的逆转有效；然而，缺乏对该手法对MR后发生心源性休克患者血流动力学影响的研究。本研究的目的是测试MR后发生心源性休克患者对ARM的血流动力学耐受性。
10例MR后发生心源性休克的低氧血症患者入住重症监护病房（ICU）并血流动力学稳定后进行评估。通气调整包括潮气量8 mL×kg⁻¹、呼气末正压（PEEP）5 cmH₂O、呼吸频率12次/分钟和吸入氧浓度（FiO₂）0.6。在三个周期内，气道持续施加40 cmH₂O的压力40秒。周期之间，患者通气30秒，最后一个周期后，将PEEP设置为10 cmH₂O。在ARM后1、10、30和60分钟进行血流动力学测量，并在手法后10和60分钟采集动脉和静脉血样以测定乳酸水平和血气。采用方差分析和弗里德曼检验分析数据。p值<0.05被认为具有统计学意义。
肺泡复张手法使动脉血氧分压与吸入氧浓度比值（PaO₂/FiO₂）在10分钟后从87提高到129.5，60分钟后提高到120（p<0.05），并使肺内分流从30%降至20%（p<0.05）。未检测到手法后即刻或60分钟内血流动力学变化或氧输送变化。
在MR后发展为心源性休克和低氧血症的患者中，ARM改善了氧合，且血流动力学耐受性良好。
