Lichtenstein S V, Abel J G, Miyagishima R T, Ling H, Warriner C B, Stilwell M E, Thompson C R
Division of Cardiovascular and Thoracic Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
Ann Thorac Surg. 1994 Dec;58(6):1734-7. doi: 10.1016/0003-4975(94)91672-1.
Patients often are disconnected temporarily from the ventilator before sternotomy to avoid entering the pleural space with the sternal saw. Although this practice is widespread, it is based on questionable physiologic principles. To evaluate the efficacy of this maneuver in reducing the incidence of pleural space violation with first-time sternotomy, 126 cardiac patients were randomized prospectively to either lungs inflated or deflated during sternotomy with the surgeon blinded to the particular assignment. The incidence of pleural space violation overall was 12%, occurring in 15% of patients with deflated lungs and in 9% of those with inflated lungs (p = 0.455 by chi 2 test). Examining the effect of the direction of sternotomy on pleural space entry revealed a 4% incidence with sternotomy starting at the xiphoid versus a 21% incidence with sternotomy starting at the sternal notch (p = 0.009 by chi 2 test). Preexisting hyperinflation of the lungs as evaluated by chest radiograms did not influence the incidence of pleural space violation. To reduce pleural space violation, sternotomy should be performed from the xiphoid to the sternal notch. More importantly, disconnecting the patient from the ventilator does not reduce pleural space violation with sternotomy and its further use is not indicated. These findings are discussed in the context of relevant heart-lung pathophysiology.
在进行胸骨切开术之前，患者通常会暂时与呼吸机断开连接，以避免胸骨锯进入胸膜腔。尽管这种做法很普遍，但它基于值得怀疑的生理学原理。为了评估这种操作在首次胸骨切开术中降低胸膜腔侵犯发生率的效果，126例心脏病患者被前瞻性随机分为两组，一组在胸骨切开术期间肺部充气，另一组肺部放气，外科医生对具体分组不知情。总体胸膜腔侵犯发生率为12%，肺部放气的患者中发生率为15%，肺部充气的患者中发生率为9%（经卡方检验，p = 0.455）。检查胸骨切开方向对胸膜腔进入的影响发现，从剑突开始胸骨切开术的发生率为4%，而从胸骨切迹开始胸骨切开术的发生率为21%（经卡方检验，p = 0.009）。通过胸部X线片评估的肺部预先存在的过度充气情况并未影响胸膜腔侵犯的发生率。为了减少胸膜腔侵犯，胸骨切开术应从剑突向胸骨切迹进行。更重要的是，将患者与呼吸机断开连接并不能减少胸骨切开术时的胸膜腔侵犯，因此不建议进一步使用这种方法。这些发现将在相关心肺病理生理学的背景下进行讨论。
