连续硬膜外麻醉下行腹腔镜手术中呼吸系统的临床观察

目的:观察连续硬膜外麻醉下行腹腔镜手术中,气腹前和气腹后20min患者呼吸频率及血气变化。方法:选择40例妇科和普外科腹腔镜手术患者,行连续硬膜外麻醉效果确切后,于气腹前和气腹后20min分别监测呼吸频率及血气分析。结果:气腹前和气腹后20min呼吸频率及血气分析差异有显著性(P<0.05)。结论:连续硬膜外麻醉下行腹腔镜手术建立CO2气腹后对患者的呼吸系统有显著影响,应予以重视。     

腹腔镜直肠癌手术中全身麻醉复合硬膜外麻醉对患者的影响

目的:探讨腹腔镜直肠癌手术中全身麻醉复合硬膜外麻醉对患者血流动力学、呼吸功能及苏醒时间的影响。方法:选取2014年5月至2016年5月收治的80例腹腔镜直肠癌手术患者,依据随机数字表法分为全身麻醉复合硬膜外麻醉组(联合麻醉组,n=40)与单独全身麻醉组(单独麻醉组,n=40),对比分析两组患者的血流动力学、呼吸功能及苏醒时间。结果:术中2h、术后联合麻醉组患者的心率、动脉压、气道压、呼吸末二氧化碳分压均显著低于单独麻醉组(P0.05),苏醒时间、意识恢复时间、回答问题切题时间、术后拔管时间均显著短于单独麻醉组(P0.05)。结论:腹腔镜直肠癌手术中全身麻醉复合硬膜外麻醉患者的血流动力学、呼吸功能均较稳定,苏醒时间较短。     

Subarachnoid anesthesia in the repair of urinary stress incontinence using a Burch-type colposuspension by means of extraperitoneal laparoscopy

Extraperitoneal laparoscopy does not lead to increased intra-abdominal pressure, meaning that the mainly respiratory physiological changes that develop derive from CO2 absorption from the extraperitoneal cavity that is created. Therefore, subarachnoid anesthesia might possibly be appropriate for this type of procedure. OBJECTIVE: To assess the efficacy of subarachnoid anesthesia for correcting urinary incontinence by extraperitoneal Burch laparoscopic colposuspension. PATIENTS AND METHODS: Six consecutive patients undergoing extraperitoneal Burch laparoscopic colposuspension under intradural anesthesia. A lateral decubitus puncture was made and 12 mg of 0.5% hyperbaric bupivacaine was infused with 20 micrograms of fentanyl. We monitored hemodynamic variables, end-tidal CO2 and respiratory frequency. Complications occurring during surgery and recovery were recorded. RESULTS: Four patients presented intraperitoneal CO2 leaks upon insufflation of the extraperitoneal cavity, with dyspnea and chest-shoulder pain in addition to anxiety and agitation, such that general anesthesia had to be provided. Subcutaneous emphysema was observed to the cervical zone after surgery but discharge was not delayed. The study was halted in view of the results obtained. CONCLUSION: Subarachnoid anesthesia was not effective for extraperitoneal Burch laparoscopic colposuspension because of the impossibility of alleviating discomfort from intraperitoneal leakage and subcutaneous emphysema that can develop during the procedure.     

喉罩通气全麻在腹腔镜手术中的应用

目的:观察腹腔镜手术中喉罩(laryngeal mask,LAM)置入后患者血流动力学的变化及呕吐、返流、损伤等情况。方法:选择ASAI～II级的腹腔镜手术患者680例,应用表面麻醉和少量镇静镇痛药,以减少LAM置入时的反应。LAM置入后,通气罩内充气压至60cmH2O后,记录1～5min SBP、DBP和HR的变化情况,观察有无漏气、置入前后及麻醉期间呼吸并发症和呼吸道损伤情况。结果:LAM首次插入后血流动力学基本无变化,未发现憋气、喉痉挛、呼吸道梗阻、恶心呕吐、返流误吸损伤等并发症。结论:LAM具有很好的密封性,能很好地进行肺通气,是全身麻醉患者安全有效的呼吸道管理工具之一。     

腹腔镜妇科手术对呼气末CO_2分压和气道压力的影响(附532例报告)

目的 :观察腹腔镜妇科手术中CO2 气腹对呼气末二氧化碳分压 (PETCO2 )和气道压力 (Paw)的影响。方法 :总结 5 32例腹腔镜妇科手术的麻醉经验。结果 :CO2 气腹后 5、10minPETCO2 、Paw明显升高 ,气腹后15min达最高值 ,30min后逐渐开始下降 ,消气腹后接近气腹前水平。结论 :采用控制性定容呼吸 ,及时调整通气参数 ,增加呼吸频率 ,适当过度通气 ,可减少气腹对呼吸功能的影响     

两种麻醉方法在腹腔镜直肠癌根治术中的对比分析

目的探讨全身麻醉复合硬膜外麻醉对腹腔镜直肠癌手术患者的临床效果。方法将52例ASAI~II级的直肠癌患者随机分为全身麻醉复合硬膜外麻醉(实验组)和全身麻醉(对照组)各26例,在实施相应的麻醉后行腹腔镜下直肠癌切除术。观察患者术中血流动力学、呼吸功能、苏醒时间及苏醒质量评价。结果两组患者气道压(Paw),呼气末CO2分压(PETCO2)均升高;实验组术中血流动力学较对照组平稳;实验组苏醒时间及苏醒质量优于对照组。结论在腹腔镜直肠癌切除术中使用全身麻醉复合硬膜外麻醉,患者多项生命体征平稳,苏醒时间短,苏醒质量好。     

腰-硬联合阻滞复合浅全麻在妇科腹腔镜手术的临床应用研究

目的:探讨腰-硬联合阻滞(combined spinal epidural anesthesia,CSEA)技术辅以静脉浅全麻在妇科腹腔镜手术中的临床麻醉效果及安全性。方法:在腰-硬联合阻滞后分别予以力月西、杜氟合剂、异丙酚辅助麻醉施行腹腔镜妇科手术;回顾分析269例妇科腹腔镜手术的临床麻醉数据,进行统计分析,分析其麻醉效果、副作用。结果:术中麻醉效果良好,镇静充分,DBP、SBP、HR指标在CSEA后10min内有变化但平稳(P>0.05),均在正常范围;CO2气腹后10min与气腹前比较,HR增快,有统计学意义(P<0.05),RR加快、PETCO2升高,有统计学意义(P<0.01),两者变化最为显著,但仍可维持在正常范围,而SpO2变化幅度不显著(P>0.05),在气腹30min后,各项指标均有所改善,排气后10min各项指标与气腹前比较无统计学意义(P>0.05),269例患者均顺利完成妇科腹腔镜手术,无一例发生麻醉并发症及意外。结论:在妇科腹腔镜手术中,应用腰-硬联合阻滞辅以静脉浅全麻,在强化麻醉管理、充分吸氧的前提下能很好的控制血流动力学和呼吸功能的变化而维持正常的生命体征,麻醉效果良好,可在选择适应证的前提下推广应用。     

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??Main problems about patients with pulmonary dysfunction during laparoscopic surgery DAI Meng-hua. Department of General Surgery, Peking Union Medical College Hospital ,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730,China
Abstract Because expertise and equipment have improved, laparoscopy has become one of the most common surgical procedures performed on an outpatient basis and to sicker patients, rendering managements of patients for laparoscopy technically difficult and challenging. Some factors impact the outcomes of patients after laparoscopic procedure, including carbon dioxide pneumoperitoneum??abdominal pressure??extremes of patient positioning, morbidly obese and type of anesthesia, even leading to pathophysiological changes of patients. A thorough understanding of the pathophysiological changes is fundamental for optimal anesthetic care and perioperative management of patient with dysfunction of respiratory. It considers the pathophysiological changes of respiratory system during laparoscopy using carbon dioxide for intraabdominal insufflation, discusses various techniques to reduce postoperative pulmonary complications, such as preoperative assessment and treatment of pulmonary disease, intraoperative monitoring the changes of respiratory function, usefulness of fast track anesthesia and postoperative treatments of pain.     

Anesthetic management for laparoscopic surgery in a patient with Charcot-Marie-Tooth disease

A 50-year-old woman was scheduled for laparoscopic cholecystectomy under general anesthesia. She was suffering from Charcot-Marie-Tooth (CMT) disease for 21 years, and implanted with a permanent pacemaker for IIIrd degree AV block. Anesthesia was induced with fentanyl and propofol, and maintained with oxygen-air-sevoflurane. Neuromuscular blockade was not used because of the presence of peripheral neuropathy and respiratory muscle weakness. We suggest that sevoflurane anesthesia might be useful for anesthetic management of CMT patient with a risk of postoperative respiratory failure.     

Combined use of high-frequency jet ventilation and abdominal lift for laparoscopic cholecystectomy in a patient with glottic impairment

Effective airway management during laparoscopic anesthesia is important to minimize the adverse consequences of the carbon dioxide (CO2) pneumoperitoneum (PP). During PP, reduced respiratory excursion and tidal volumes with increased CO2 absorption may lead to hypoxia, hypercapnia, and respiratory acidosis. Although these problems can usually be avoided by use of positive pressure ventilation and an endotracheal tube, patients with a restricted airway who cannot be intubated pose a unique challenge. High-frequency jet ventilation (HFJV) has been described as an alternative to endotracheal intubation in other settings. The use of the small-diameter jet tube allows relatively unobstructed access to the larynx during laryngeal surgery. In patients with glottic impairment related to vocal fold immobility, jet ventilation allows positive pressure ventilation without the use of an endotracheal tube or tracheostomy in cases where lung and diaphragmatic compliance permit adequate excursion for ventilation and glottal diameter permits an adequate outflow of air. In this report, we describe the successful use of HFJV combined with an abdominal lifting technique and low-pressure PP for laparoscopic surgery in a patient with glottic compromise related to vocal fold immobility. Using these techniques, a laparoscopic cholecystectomy was performed successfully without endotracheal intubation or the need for a tracheostomy.     

Anesthesia for laparoscopy with emphasis on outpatient laparoscopy

Laparoscopy has developed extremely rapidly and is currently applicable to virtually every surgical subspecialty. Most of the experience is with gynecologic laparoscopy, which has been performed for many years. Some of these procedures are simple and brief, with minimal gas insufflation. In these cases, respiratory compromise is limited, and spontaneous ventilation appears acceptable. Such procedures therefore can be performed with the patient under local or regional anesthesia, or using the LMA with general anesthesia, because the risk of aspiration is small. As laparoscopy has developed, more prolonged operations have become possible, but these normally require general anesthesia, controlled ventilation, and tracheal intubation. More sophisticated laparoscopic surgery has reduced postoperative morbidity, shortened hospital stays, and moved many procedures into the outpatient arena. These newer laparoscopic operations present many challenges, especially in the provision of adequate analgesia and the minimization of PONV. Analgesia should be multimodal, using local anesthesia and NSAIDs as first-line therapy. This combination may be sufficient for more minor procedures, and the elimination of opioids helps to reduce PONV. For more extensive operations, opioids also are required, but should not be the mainstay of analgesia. PONV should be treated effectively whenever it occurs, with consideration given to the use of prophylactic antiemetics in especially high-risk groups. Laparoscopic surgery clearly offers significant advantages in many cases. Although this technology can make some procedures technically possible on an outpatient basis, the morbidity following operations such as laparoscopic cholecystectomy is considerable. The ever-greater cost savings from the expansion of outpatient surgery is being achieved at the expense of patient discomfort and dissatisfaction. Extended care (23 h) could be a better option in some circumstances. The future will see further developments in laparoscopic surgery. Microlaparoscopy permits simple procedures to be performed with minimal analgesia and sedation in an office setting. At present, this technology allows only diagnostic and minor operative procedures, the stage at which conventional laparoscopy was in the early 1980s. Further developments in optical fibers could reduce the requirements for general anesthesia for other operations and substantially reduce postoperative morbidity. Until then, laparoscopy continues to present many challenges.     

地氟醚复合吗啡快通道麻醉在腹腔镜胆囊切除术的应用

目的 研究地氟醚复合吗啡快通道麻醉在腹腔镜胆囊切除术（LC） 的应用.方法 选择ASAⅠ-Ⅱ级LC 患者90 例,随机分为3 组：P 组（丙泊酚＋ 瑞芬太尼）、S 组（七氟醚＋瑞芬太尼）和D 组（地氟醚＋ 吗啡）,术前和诱导用药相同,麻醉维持：P 组静脉输注丙泊酚、瑞芬太尼和顺式阿曲库铵;S 组吸入七氟醚及静脉输注瑞芬太尼,不追加顺式阿曲库铵;D 组吸入地氟醚及静脉注射吗啡,不追加顺式阿曲库铵.术中观察血流动力学波动情况和呼吸恢复、拔管、离室时间、术中知晓发生率以及苏醒期躁动评分.结果 与P 组比较,D 组和S 组的血压和心率波动例数减少（P 〈 0.05）;与P 组和S 组比较,D 组呼吸恢复、拔管、离室的时间缩短（P 〈 0.05）,苏醒期躁动的评分较高（P 〈 0.05）.3 组患者均未出现术中知晓.结论 地氟醚复合吗啡快通道麻醉应用于腹腔镜胆囊切除术对血流动力学波动影响小,术后苏醒速度快、质量高.     

腹腔镜胆囊切除术的麻醉管理

目的:研究腹腔镜胆囊切除术(LC)的麻醉管理。方法:总结LC 16 153例的麻醉经验。结果:95％的患者停药后5～10min清醒,呼吸功能和肌张力恢复,5％的患者10～20min清醒,恢复呼吸功能和肌张力。除2例因CO2蓄积和1例术后脑溢血延迟清醒外,无其它麻醉意外及并发症发生。结论:由于LC对患者的创伤及刺激均较小,手术时间也较短,所以不需过深的麻醉即可完成手术。     

静脉异丙酚复合硬膜外麻醉用于腹腔镜胆囊切除术的临床观察

目的观察异丙酚复合硬膜外麻醉用于腹腔镜胆囊切除术时呼吸和循环的变化,评价其实用性和安全性。方法选择60例ASAⅠ～Ⅱ级择期腹腔镜胆囊切除术病人,随机分为异丙酚复合硬膜外麻醉组(P组)和单纯硬膜外麻醉组(E组)。结果E组硬膜外给药后SBP、MAP、DBP、HR明显降低,P组收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)、心率(HR)在异丙酚后3分钟下降(P<0.01),其中28例(93.33%)仍属正常范围。E组术中血压明显低于P组,两组相比有显著意义(P<0.05)。P组VT、SPO2在泵入异丙酚后有所下降,PETCO2增加,但仍在正常范围,与E组相比有显著意义(P<0.05)。结论异丙酚复合硬膜外麻醉用于LC手术,术中能达到良好的镇痛和镇静,是一种理想安全的麻醉方法。但应注意两者复合对呼吸和循环的抑制作用。     

Changes in cardio-pulmonary function during laparoscopic colectomy and postoperative quality of life--comparison with laparotomy

BACKGROUND: We investigated whether laparoscopic colectomy would affect the degree of respiratory and circulatory changes during surgery and could improve postoperative quality of life (QOL) as compared with laparotomy. METHODS: Fifty-one patients (ASA 1-3) scheduled for elective colectomy under general anesthesia with epidural anesthesia were enrolled in the study. All patients were divided into two groups (laparoscopic group: n = 33 and laparotomy group: n = 18) by surgical indication. Respiratory functions and hemodynamic changes were measured during surgery. Postoperative complications, pain scores, the time to start of walking and the period of hospital stay were examined. The serum concentrations of inflammatory cytokines (IL-6, IL-1 ra) and KL-6 were measured perioperatively. RESULTS: It was demonstrated that pneumoperitoneum and postural tilt had a bad influence on respiratory functions especially on pulmonary compliance and a-ET(D)co2 in laparoscopic group. The serum concentrations of inflammatory cytokines were significantly lower and the number of rescue for postoperative pain were less in laparoscopic group. The patients in laparoscopic group could begin to walk and leave hospital earlier after surgery. CONCLUSIONS: Severe complication did not occurr in both groups during the perioperative period. Laparoscopic surgery could improve postoperative QOL.     

Laparoscopic bilateral inguinal hernia repair under local anesthesia

A case report of the laparoscopic repair of bilateral inguinal hernias performed under local anesthesia with intravenous sedation is presented. The combination of nitrous oxide for peritoneal insufflation and an ultrasonically activated scalpel for dissection made the procedure feasible. It is hoped that this technique can extend laparoscopic surgery to patients who are poor candidates for general anesthesia.     

不同麻醉方法在小儿腹腔镜手术中的应用体会

目的:对比分析不同麻醉方法对小儿腹腔镜手术患者插管及拔管前后心率、并发症情况的影响。方法:随机将56例腹腔镜手术患儿分为骶管复合气管插管全麻组(A组)、骶管复合喉罩全麻组(B组)、单纯喉罩全麻组(C组)、单纯气管插管全麻组(D组),每组14例。患儿10个月~5岁,体重9.5~21 kg。分别于麻醉插管后即刻、拔管前1 min、拔管后即刻记录心率变化,观察拔管时有无喉痉挛、呼吸道分泌物情况,术中记录心率、血氧饱和度、呼气末二氧化碳分压及BIS值。术后2 h内观察有无咽喉部疼痛不适、声音嘶哑、哭闹、咳嗽、呼吸异常及意识恢复情况。结果:B组插管后即刻、拔管后即刻对心率的影响较其他三组小,患儿术后清醒时咽喉部疼痛、咳嗽、喉痉挛、呼吸道分泌物明显减少,耐受的BIS指数更高。拔除喉罩患儿呼吸更平稳、清醒更彻底。结论:小儿腹腔镜手术行骶管复合喉罩全麻患儿麻醉前后心率的变化波动较小,术后患儿清醒更彻底,并发症更少。     

Regional anesthesia for laparoscopic surgery: a narrative review

Laparoscopic surgery has advanced remarkably in recent years, resulting in reduced morbidity and shorter hospital stay compared with open surgery. Despite challenges from the expanding array of laparoscopic procedures performed with the use of pneumoperitoneum on increasingly sick patients, anesthesia has remained largely unchanged. At present, most laparoscopic operations are usually performed under general anesthesia, except for patients deemed “too sick” for general anesthesia. Recently, however, several large, retrospective studies questioned the widely held belief that general anesthesia is the best anesthetic method for laparoscopic surgery and suggested that regional anesthesia could also be a reasonable choice in certain settings. This narrative review is an attempt to critically summarize current evidence on regional anesthesia for laparoscopic surgery. Because most available data come from large, retrospective studies, large, rigorous, prospective clinical trials comparing regional vs. general anesthesia are needed to evaluate the true value of regional anesthesia in laparoscopic surgery.     

腹腔镜胆囊切除术与腹腔镜妇科手术中麻醉、体位、CO2气腹对血流动力学及呼吸动力学影响的比较研究

目的:观察腹腔镜胆囊切除术(LC)与腹腔镜妇科手术中麻醉、体位、CO2气腹对血压、心率、SpO2、PetCO2、气道压的影响。方法:选择ASAⅠ~Ⅱ级择期行腹腔镜胆囊切除术,腹腔镜妇科手术病人各38例,予以异丙酚、异氟醚维持麻醉,分别于诱导前、插管后即刻、插管后5min、气腹后3min、8min及气腹放气后平卧位记录血流动力学及呼吸动力学参数。结果:两组插管后5min血压、心率明显低于诱导前;气腹后3min、8min血压、PetCO2、气道压明显高于插管后5min(P<0.01)。两组之间相比,妇科手术气道压、PetCO2显著高于LC组(P<0.01)。结论:腹腔镜妇科手术呼吸动力学的改变明显大于LC组,血流动力学改变两组间无显著差异。     

Effect of PEEP on regional ventilation during laparoscopic surgery monitored by electrical impedance tomography

Background: Anesthesia per se and pneumoperitoneum during laparoscopic surgery lead to atelectasis and impairment of oxygenation. We hypothesized that a ventilation with positive end‐expiratory pressure (PEEP) during general anesthesia and laparoscopic surgery leads to a more homogeneous ventilation distribution as determined by electrical impedance tomography (EIT). Furthermore, we supposed that PEEP ventilation in lung‐healthy patients would improve the parameters of oxygenation and respiratory compliance. Methods: Thirty‐two patients scheduled to undergo laparoscopic cholecystectomy were randomly assigned to be ventilated with ZEEP (0 cmH₂O) or with PEEP (10 cmH₂O) and a subsequent recruitment maneuver. Differences in regional ventilation were analyzed by the EIT‐based center‐of‐ventilation index (COV), which quantifies the distribution of ventilation and indicates ventilation shifts. Results: Higher amount of ventilation was examined in the dorsal parts of the lungs in the PEEP group. Throughout the application of PEEP, a lower shift of ventilation was found, whereas after the induction of anesthesia, a remarkable ventral shift of ventilation in ZEEP‐ventilated patients (COV: ZEEP, 40.6 ± 2.4%; PEEP, 46.5 ± 3.5%; P<0.001) was observed. Compared with the PEEP group, ZEEP caused a ventral misalignment of ventilation during pneumoperitoneum (COV: ZEEP, 41.6 ± 2.4%; PEEP, 44 ± 2.7%; P=0.013). Throughout the study, there were significant differences in the parameters of oxygenation and respiratory compliance with improved values in PEEP‐ventilated patients. Conclusion: The effect of anesthesia, pneumoperitoneum, and different PEEP levels can be evaluated by EIT‐based COV monitoring. An initial recruitment maneuver and a PEEP of 10 cmH₂O preserved homogeneous regional ventilation during laparoscopic surgery in most, but not all, patients and improved oxygenation and respiratory compliance.