Zollinger A, Krayer S, Singer T, Seifert B, Heinzelmann M, Schlumpf R, Pasch T
Institute of Anaesthesiology, University Hospital, Zürich.
Eur J Anaesthesiol. 1997 May;14(3):266-75. doi: 10.1046/j.1365-2346.1997.00078.x.
We studied the haemodynamic changes induced by pneumoperitoneum (PP) in elderly patients with increased cardiac risk (ASA class III; n = 10; age 72.3 +/- 8.8 years, mean +/- SD, P < 0.05; group 2) and compared the results with patients at normal risk (ASA class I, II; n = 12; age 55.6 +/- 11.8 years; group 1). Thermodilution measurements were performed after induction of general anaesthesia (T1), after onset of PP (T2, intraabdominal pressure 14 mmHg) and after additional 15 degrees head-up tilt (T3). In both groups PP, as compared with T1, induced a significant increase in mean arterial pressure (MAP, mmHg, group 1: 77 +/- 14 to 96 +/- 18, P < 0.05/group 2: 75 +/- 10 to 102 +/- 18, P < 0.01), mean pulmonary artery pressure (MPAP, mmHg: 15 +/- 5 to 22 +/- 4, P < 0.01/18 +/- 3 to 25 +/- 5, P < 0.01), central venous pressure (CVP, mmHg: 7 +/- 2 to 15 +/- 3, P < 0.01/7 +/- 2 to 12 +/- 2, P < 0.01), pulmonary capillary wedge pressure (PCWP, mmHg: 9 +/- 4 to 16.3, P < 0.01/8 +/- 2 to 15 +/- 6, P < 0.01) and in systemic vascular resistance (SVR, dynes s cm-5: 1415 +/- 375 to 1873 +/- 412, P < 0.01/ 1502 +/- 360 to 2067 +/- 647, P < 0.01). Cardiac index (CI, L min-1 m-2: 2.3 +/- 0.3 to 1.9 +/- 0.3, P < 0.05/2.2 +/- 0.4 to 2.2 +/- 0.5 P = 0.76) and oxygen delivery index (DO2I, mL min-1 m-2: 388 +/- 54 to 324 +/- 61, P < 0.05/358 +/- 69 to 353 +/- 82, P = 0.77) decreased in group 1 but not in group 2. Heart rate, stroke Index, pulmonary vascular resistance, arteriovenous oxygen content difference and oxygen consumption index were unchanged. After head-up tilt MAP (mmHg, 92 +/- 15, P < 0.05/ 101 +/- 17, P < 0.01), MPAP (mmHg, 20 +/- 3, P < 0.01/22 +/- 4, P < 0.05), CVP (mmHg, 12 +/- 2, P < 0.01/10 +/- 2, P < 0.01) and PCWP (mmHg, 12 +/- 3, P < 0.05/12 +/- 5, P < 0.05) remained elevated compared with T1 in both groups, SVR (dynes s cm-5, 1575 +/- 372, P = 0.13/1793 +/- 528, P < 0.01) in group 2 only. No complications occurred. The results indicate that PP is associated with significant but relatively benign haemodynamic changes. Anaesthesia for laparoscopic cholecystectomy may be performed safely also in elderly ASA class III patients with increased cardiac risk. An adequate haemodynamic monitoring is recommended.
我们研究了气腹（PP）对心脏风险增加的老年患者（美国麻醉医师协会[ASA]Ⅲ级；n = 10；年龄72.3±8.8岁，均值±标准差，P < 0.05；第2组）血流动力学的影响，并将结果与正常风险患者（ASAⅠ、Ⅱ级；n = 12；年龄55.6±11.8岁；第1组）进行比较。在全身麻醉诱导后（T1）、PP开始后（T2，腹内压14 mmHg）以及额外头高位倾斜15度后（T3）进行热稀释测量。与T1相比，两组中的PP均导致平均动脉压（MAP，mmHg，第1组：77±14至96±18，P < 0.05/第2组：75±10至102±18，P < 0.01）、平均肺动脉压（MPAP，mmHg：15±5至22±4，P < 0.01/18±3至25±5，P < 0.01）、中心静脉压（CVP，mmHg：7±2至15±3，P < 0.01/7±2至12±2，P < 0.01）、肺毛细血管楔压（PCWP，mmHg：9±4至16.3，P < 0.01/8±2至15±6，P < 0.01）以及全身血管阻力（SVR，达因秒厘米⁻⁵：1415±375至1873±412，P < 0.01/1502±360至2067±647，P < 0.01）显著升高。第1组心脏指数（CI，升每分钟每平方米：2.3±0.3至1.9±0.3，P < 0.05/2.2±0.4至2.2±0.5，P = 0.76）和氧输送指数（DO2I，毫升每分钟每平方米：388±54至324±61，P < 0.05/358±69至353±82，P = 0.77）下降，而第2组未下降。心率、每搏指数、肺血管阻力、动静脉氧含量差和氧消耗指数未改变。头高位倾斜后，两组的MAP（mmHg，92±15，P < 0.05/101±17，P < 0.01）、MPAP（mmHg，20±3，P < 0.01/22±4，P < 0.05）CVP（mmHg，12±2，P < 0.01/10±2，P < 0.01）和PCWP（mmHg，12±3，P < 0.05/12±5，P < 0.05）与T1相比仍升高，仅第2组的SVR（达因秒厘米⁻⁵，1575±372，P = 0.13/1793±528，P < 0.01）升高。未发生并发症。结果表明，PP与显著但相对良性的血流动力学变化相关。对于心脏风险增加的老年ASAⅢ级患者，腹腔镜胆囊切除术的麻醉也可安全进行。建议进行充分的血流动力学监测。
