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腹腔镜子宫切除术中头低脚高位和气腹引起的血流动力学变化。

Hemodynamic changes due to Trendelenburg positioning and pneumoperitoneum during laparoscopic hysterectomy.

作者信息

Hirvonen E A, Nuutinen L S, Kauko M

机构信息

Department of Anesthesiology, Kuopio University Hospital, Finland.

出版信息

Acta Anaesthesiol Scand. 1995 Oct;39(7):949-55. doi: 10.1111/j.1399-6576.1995.tb04203.x.

Abstract

More prolonged gynecological laparoscopic operations are being performed in recent years, and a steeper head-down position is required. The early reports of hemodynamic changes during gynecologic laparoscopy are conflicting, and the effects of anesthesia, head-down tilt and pneumoperitoneum have not been clearly separated. Invasive hemodynamic monitoring was carried out in 20 female ASA Class I-II patients who underwent laparoscopic hysterectomy. Baseline measurements were made in the supine, supine-lithotomy and Trendelenburg (25-30 degrees) positions in awake patients. Measurements were repeated in the supine-lithotomy and Trendelenburg positions after induction of anesthesia, during laparoscopy 5 minutes after the beginning of peritoneal CO2-insufflation (intra-abdominal pressure 13-16 mmHg) and at 15-minute intervals thereafter, after laparoscopy in the Trendelenburg and supine positions, after extubation and in the recovery room at 30-minute intervals. Patients received balanced general anesthesia with isoflurane in 35% O2 in an oxygen/air mixture. End tidal PCO2 was maintained between 4.5-4.8 kPa (33-36 mmHg) by changing the minute volume of controlled ventilation. The Trendelenburg position in awake and anesthetized patients increased pulmonary arterial pressures (PAP), central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP). These pressures increased further at the start of CO2-insufflation, decreased towards the end of the laparoscopy and reached pre-insufflation levels after deflation of pneumoperitoneum. The mean arterial pressure (MAP) increased at the beginning of laparoscopy in comparison with the pre-laparoscopic values. Heart rate (HR) was quite stable during laparoscopy. The cardiac index (CI) decreased with anesthesia from 3.8 to 3.2 1.min-1.m-2 and further during laparoscopy to 2.7 1.min-1.m-2, returning to pre-insufflation values soon after deflation. The stroke index (SI) changed in concert with the CI changes. The right ventricular stroke work index decreased during laparoscopy more than the left ventricular stroke work index. The right atrial pressure (CVP) exceeded the PCWP more often during laparoscopy than during any other phase of the procedure. Anesthesia and the Trendelenburg position increased the CVP, PCWP and pulmonary arterial pressures and decreased cardiac output. Pneumoperitoneum increased these pressures further mostly in the beginning of the laparoscopy, and cardiac output decreased towards the end of the laparoscopy. The risk of systemic CO2-embolus was increased during laparoscopy.

摘要

近年来,越来越多的妇科腹腔镜手术时间延长,需要更陡峭的头低脚高位。关于妇科腹腔镜检查期间血流动力学变化的早期报告相互矛盾,麻醉、头低脚倾斜和气腹的影响尚未明确区分。对20例接受腹腔镜子宫切除术的美国麻醉医师协会(ASA)I-II级女性患者进行了有创血流动力学监测。在清醒患者的仰卧位、仰卧位-截石位和头低脚高位(25-30度)进行基线测量。在麻醉诱导后、腹腔镜检查开始腹膜二氧化碳充气5分钟后(腹腔内压力13-16 mmHg)及其后每隔15分钟、腹腔镜检查后处于头低脚高位和仰卧位时、拔管后以及在恢复室每隔30分钟,在仰卧位-截石位和头低脚高位重复测量。患者接受以异氟醚在35%氧气/空气混合物中进行的平衡全身麻醉。通过改变控制通气的分钟通气量,将呼气末二氧化碳分压维持在4.5-4.8 kPa(33-36 mmHg)之间。清醒和麻醉患者的头低脚高位均增加了肺动脉压(PAP)、中心静脉压(CVP)和肺毛细血管楔压(PCWP)。这些压力在二氧化碳充气开始时进一步升高,在腹腔镜检查接近结束时下降,气腹放气后恢复到充气前水平。与腹腔镜检查前的值相比,腹腔镜检查开始时平均动脉压(MAP)升高。腹腔镜检查期间心率(HR)相当稳定。心脏指数(CI)在麻醉期间从3.8降至3.2 1.min-1.m-2,在腹腔镜检查期间进一步降至2.7 1.min-1.m-2,气腹放气后不久恢复到充气前值。每搏指数(SI)与CI变化一致。腹腔镜检查期间右心室每搏功指数比左心室每搏功指数下降更多。与手术的任何其他阶段相比,腹腔镜检查期间右心房压力(CVP)超过PCWP的情况更频繁。麻醉和头低脚高位增加了CVP、PCWP和肺动脉压,并降低了心输出量。气腹大多在腹腔镜检查开始时进一步增加这些压力,心输出量在腹腔镜检查接近结束时下降。腹腔镜检查期间发生全身性二氧化碳栓塞的风险增加。

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