Imai Hiroto, Nakatani Naomi, Matsuda Shinya, Murakawa Kazushige, Tashiro Chikara
Department of Anesthesia, Sanda Municipal Hospital, Sanda.
Masui. 2005 Jun;54(6):658-61.
A 56-year-old woman with cholecystolithiasis was scheduled for laparoscopic cholecystectomy. Anesthesia was induced with fentanyl and propofol IV, and the trachea was intubated using vecuronium IV. Anesthesia was maintained with 60% nitrous oxide and propofol intravenously, and vecuronium was used for muscle relaxation. Following induction of carbon dioxide pneumoperitoneum, PETCO2 slightly increased. During pneumoperitoneum PETCO2 as easily controlled by increasing minute volume of ventilation. Fifty minutes after the start of pneumoperitoneum, suddenly the peak airway pressure increased and PETCO2 reached 70 mmHg continuously. At this time, severe massive subcutaneous emphysema from the anterior thorax to the head and neck was noted, and the manual lung ventilation was very difficult. After discontinuation of pneumoperitoneum, PETCO2 gradually decreased with improvement of the neck subcutaneous emphysema. At the same time the lung ventilation improved. We speculate that major causes of difficulty in ventilation were the decreased compliance and the tracheal tube comppression, which were due to massive subcutaneous emphysema. Our findings show that we have to stop pneumoperitoneum immediately, when we find a sudden increase of the peak airway pressure or PETCO2 with subcutaneous emphysema during laparoscopic cholecystectomy.
一名56岁患有胆囊结石的女性计划接受腹腔镜胆囊切除术。静脉注射芬太尼和丙泊酚诱导麻醉，静脉注射维库溴铵后进行气管插管。使用60%氧化亚氮和静脉注射丙泊酚维持麻醉，维库溴铵用于肌肉松弛。二氧化碳气腹诱导后，呼气末二氧化碳分压（PETCO2）略有升高。气腹期间，通过增加分钟通气量可轻松控制PETCO2。气腹开始50分钟后，气道峰压突然升高，PETCO2持续达到70 mmHg。此时，发现从前胸到头颈部出现严重的大面积皮下气肿，手动肺通气非常困难。停止气腹后，随着颈部皮下气肿的改善，PETCO2逐渐下降。同时肺通气得到改善。我们推测通气困难的主要原因是大面积皮下气肿导致的肺顺应性降低和气管导管受压。我们的研究结果表明，在腹腔镜胆囊切除术中，当发现气道峰压或PETCO2突然升高并伴有皮下气肿时，必须立即停止气腹。
