Sujata Nambiath, Tobin Raj, Mehta Punit, Girotra Gautam
Department of Anesthesia and Pain Management, Max Superspeciality Hospital, New Delhi, India.
Indian J Anaesth. 2019 Feb;63(2):138-141. doi: 10.4103/ija.IJA_88_19.
Robotic pelvic surgery requires steep Trendelenburg positioning with pneumoperitoneum which causes raised thoracic and intracranial pressures. In obese patients, the basal thoracic pressures are high. Increased intrathoracic pressure can decrease the cranial venous flow leading to deficient intracranial absorption of cerebrospinal fluid and a further increase in intracranial pressure. Operating times are also longer due to unfavorable anatomy. Such patients frequently have a delayed awakening from anaesthesia due to a combination of factors such as hypercapnoea, acidosis, and raised intracranial pressures. Normocapnoea can be achieved in a ventilated patient towards the end of surgery. In cases where the anaesthetic agents have been washed out and normocapnoea has been achieved, the intracranial pressure may be an important factor causing delayed emergence. The sonographically measured optic nerve sheath diameter correlates with the intracranial pressure. We report three cases of robot-assisted pelvic surgery in obese patients where we used the optic nerve sheath diameter as a guide for the timing of extubation.
机器人辅助盆腔手术需要采用头低脚高位并建立气腹，这会导致胸内压和颅内压升高。肥胖患者的基础胸内压较高。胸内压升高会减少颅内静脉血流，导致脑脊液在颅内的吸收不足，进而使颅内压进一步升高。由于解剖结构不利，手术时间也会更长。这类患者常因高碳酸血症、酸中毒和颅内压升高等多种因素综合作用，导致麻醉苏醒延迟。在手术接近尾声时，通气患者可实现正常碳酸血症。在麻醉药物已被清除且已实现正常碳酸血症的情况下，颅内压可能是导致苏醒延迟的重要因素。超声测量的视神经鞘直径与颅内压相关。我们报告了三例肥胖患者行机器人辅助盆腔手术的病例，在这些病例中，我们将视神经鞘直径作为拔管时机的指导依据。
