| BackgroundChina has the world’s largest diabetes epidemic,which continues to increase.Diabetes Mellitus is a metabolic disease characterized by hyperglycemia acompanied with microangiopathy,and it subsequently has been confirmed that the lung is also a target for diabetic injury.During the surgery of laparoscopic for diabetic patients,the maintenance of pneumoperitoneum pressure is bound to affect respiratory function.The initial pathophysiological changes of lung tissue in diabetes are the thickening of alveolar epithelial and capillary endothelial basal layers,the destruction of elastin and collagen,the enlargement of pulmonary interstitium,the increase in the distance of gas dispersion,and a large number of advanced glycation end products(AGEs)are synthesized in the late stage.Combined with the autonomic neuropathy,non-adrenalin and non-cholinergic nerves have abnormal regulation of pulmonary vascular tension and pulmonary ventilation,which leads to a decrease in the release of non-adrenergic and non-cholinergic neurotransmitters(vasoactive intestinal peptides),also result in imbalance in the trachea.Long-term stimulation of hyperglycemia environment,chronic autoimmune inflammatory reaction and oxidative stress occur,resulting in dysfunction of pulmonary,small airway and diffuse capacity.Studies have shown that mechanical ventilation under general anesthesia in animal models of hyperglycemia leads to decreased lung function.What is the relevance of general anesthesia for laparoscopic surgery in patients with diabetes?Does the combined effect generate perioperative lung injury or the postoperative pulmonary complications will be more severe than non-diabetic patients?No detailed researches have been reported and it is worth further discussion.ObjectiveThe blood gas analysis,blood glucose,lactic acid,respiratory parameters,hemodynamic parameters were used to analysis pulmonary function between diabetic and non-diabetic patients during laparoscopic surgery.Combined with preoperative and postoperativewhite’s blood cells,urea nitrogen and breath-holding test to evaluat the pulmonary function during surgery and postoperative pulmonary complications in diabetic patients.It aims to provide a theoretical evidence to protect pulmonary function for diabetic patients using general anesthesia during laparoscopic surgery.MethodThis trial had taken thirty-four patients in diabetic group(G)and non-diabetic group(N),each group had 17 patients.They needed sign informed consent before operation.Before the operation 30 minutes,we gave Penicillin hydrochloride 0.01 mg/kg and midazolam 0.05 mg/kg.Using plasma effect chamber concentration mode(TCI)to control general anesthesia:ropofol 2.5～3.5 ug/ml,remifentanil 2.0～3.0 ng/ml,cis-atracurium 0.2 mg/kg.Using closed-loop muscle pine target-controlled infusion of muscle relaxant mogeneralnitor.Intermittent positive pressure ventilation was performed to maintain PetCO2 at 35～45 mmHg,I:E=1:(1.5～2).Tidal volume maintained at 6～9 ml/kg,and respiratory rate 12～20 beats/min.During the operation,the propofol was controled 2.5～3.5 ug/ml and the remifentanil was controled 2.0～6.0 ng/ml.Sufentanil 5～10 ug was used as appropriation.It needs to maintain the NT’s depth in D2～E1,the hemodynamic indicator within 25%of the baseline,and the total fluid volume is controlled at 15 ml/kg/h.After anesthesia the patients were sent to the recovery room.We used antagonistic muscles like neostigmine 40 μg/kg and atropine 20 μg/kg for each patient.All patients were returned to the ward for assessing postoperative pulmonary complications.General information such as age,gender,height,weight,BMI,ASA classification,operative time,and pneumoperitoneum should be recorded.Perioperative observation indicators during T1(30 minutes before induction),T3(30 minutes for pneumoperitoneum),T5(30 minutes after extubation)were recorded,like blood glucose,lactate values,hemodynamic parameters(MAP,HR,SpO2),arteries blood gas analysis(PH,PaO2,PaCO2,FiO2).We needed calculate the oxygenation index(OI),respiratory index(RI),alveolar-arterial oxygen partial pressure PA-aO2.Hemodynamic parameters and respiratory parameters(VT,Peak,Plet,Cdyn,PetCO2)were recorded for T2(5 minutes before pneumoperitoneum),T3(for 30 minutes for pneumoperitoneum),and T4(5 minutes before the end of surgery).Some other indicators such as MAP,HR,SpO2,respiratory rate,breath holding test,white blood cells,urea nitrogen,albumin,and postoperative pulmonary complications were recorded before and afterl day of surgery.Statistical analysisDescriptive statistics(χ±S)were used to summarize the continuous data,medians were used in categorical data.SPSS20.0 statistical software package was used for all analyses.The independent samples T test was used to compare demographic data and all testing indexs between the two groups,while analysis of variance of repeated measures data was used to compare intragroup variables of different periods.X2 test was used to compare count data.Pvalues<0.05were considered to be statistically significant.ResultThere were no significant differences in the general data of age,gender,height,weight,BMI,ASA grade,operation time,and pneumoperitoneum in 32 patients(G and N).There were no significant differences in urea nitrogen,HR,respiratory rate,and MAP between the two groups before and after surgery.Glycated hemoglobin in the two groups and preoperative and postoperative albumin,white blood cells,breath holding test,and SpO2 were statistically significant(P<0.05).The diabetic group had lower albumin,SpO2,poor breath holding test,and higher white blood cells.Albumin,white blood cells and SpO2 have the same trend before and after surgery.There were no significant differences in the hemodynamic parameters MAP and HR during the two groups.But the SpO2 during the surgery had a significant difference(P<0.05).And the G group had lower SpO2 than the N group.The MAP in the group showed statistical significance with time(P<0.05),and the trnd of change is the same.Blood gas analysis showed that the blood’s PH,and PaO2,blood glucose and lactic acid were statistically significant(P<0.05),also there were significant differences between the two groups at different time points(P<0.05).The PH and PaO2 had some interaction effects with time(P<0.05).The OI,RI and PA-aO2 not only had a significantly different between the two groups(P<0.05),at different time points had the interaction effects(P<0.05).The G group had lower oxygenation index than the N group.The alveolar-arterial oxygen pressure and respiratory index were higher than the N group.There were significant differences in intraoperative respiratory parameters between Ppeak,Plat and Cdyn(P<0.05).And there had some interaction effects with time between the two groups,like Ppeak(P<0.05).It showed that the changes of Cdyn,Ppeak,Plat and PetCO2 were the same in different groups during the surgery.Especially the Ppeak was higher than that of the non-diabetic group at each time point.It suggested compared with diabetic patients,in the diabetic groups had worse oxygen.No postoperative complications were seen in the non-diabetic group.Two people were diagnosed with pneumonia in the diabetic groups.ConclusionThe patients with diabetes mellitus during laparoscopic surgery,their pulmonary function was reduced during the perioperative period with general anesthesia.The risk of postoperative pulmonary complications probably higher than that of non-diabetic patients.It is necessary to take a lung protection strategy for diabetic patients. |
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