腹腔镜手术中对大脑中动脉血流的影响

目的：观察腹腔镜胆囊切除术对病人大脑中动脉血流的影响。方法：采用TCD检测19例全麻病人在气腹前、气腹时和气腹后的平均血流速度（ Vm）、脉动指数（PI）和无创伤动脉血压。结果：各时期Vm无明显变化；PI在气腹时期明显增高，气腹后恢复正常；动脉收缩压和舒张压在气腹时增高，舒张压在气腹后仍高于气腹前水平。结论：腹腔镜胆囊切除术中CO2气腹可通过CO2吸收入血而使脑血管阻力有一定程度的改变，但只要PaCO2维持在正常范围，CO2对脑血流的影响不大。     

FloTrac/Vigileo监测下不同体位腹腔镜手术患者血流动力学的变化

目的探讨FloTrac/Vigileo监测下不同体位对腹腔镜阑尾切除术患者血流动力学的影响。方法拟行腹腔镜阑尾切除术患者60例,随机分为三组,每组20例,手术时分别为头低脚高位10°(A组)、20°(B组)和30°(C组)。麻醉前行左桡动脉穿刺连接FloTrac/Vigileo系统。记录气腹前(T0)、气腹后1min(T1)、5min稳定后改变体位时(T2)、气腹后20min(T3)、气腹结束后1 min(T4)及5min稳定后恢复体位时(T5)的HR、MAP、心输出量(CO)、心脏指数(CI)和每搏量(SV),并记录气腹时间和手术时间。结果与T0时比较,T1~T3时三组HR明显增快,MAP明显升高(P0.05);与T1时比较,T2、T3时C组CO及SV明显升高(P0.05)。与C组比较,T2、T3时A、B组CO及SV明显降低(P0.05)。与C组比较,A、B组气腹时间及手术时间明显延长(P0.05)。结论头低脚高位30°下行腹腔镜阑尾切除手术,患者血流动力学的变化在临床安全范围内,且手术时间及气腹时间较10°和20°短。     

超声引导下右侧星状神经节阻滞对腹腔镜胃癌根治术患者双侧脑血流的影响

目的观察超声引导下右侧星状神经节阻滞(stellate ganglion block, SGB)对腹腔镜下胃癌根治术患者双侧脑血流的影响。方法选择2017年8月至2019年2月择期行腹腔镜下胃癌根治术患者60例,男31例,女29例,年龄60~80岁,ASAⅡ或Ⅲ级,采用随机数字表法将患者随机分为两组,每组30例:SGB组(S组)和对照组(C组)。S组于麻醉诱导前在超声引导下行右侧SGB,注入0.375%罗哌卡因8 ml,C组注射等容量生理盐水。通过经颅多普勒超声(TCD)记录SGB前(T0)、SGB后5 min(T1)、30 min(T2)、60 min(T3)、手术结束(T4)时双侧大脑中动脉(MCA)平均血流速度(Vm),计算搏动指数(PI)和阻抗指数(RI),同时记录T0-T4时的MAP、HR和CVP。结果与T0时比较,T2-T4时C组双侧Vm、MAP明显降低,双侧PI和RI明显升高(P<0.05);T2-T4时S组双侧Vm明显明显降低(P<0.05),非阻滞侧PI和RI明显升高(P<0.05);T2时S组MAP明显降低(P<0.05)。T3、T4时C组MAP明显低于S组(P<0.05)。结论超声引导右侧星状神经节阻滞可以明显降低阻滞侧颅内动脉血管阻力,增加腹腔镜下胃癌根治术中颅内血流动力学的稳定性。     

不同气腹压力对腹腔镜妇科手术患者颅内压的影响

目的应用超声测量视神经鞘直径(ONSD)评价不同气腹压力下腹腔镜妇科手术患者颅内压(ICP)的变化。方法择期行腹腔镜妇科手术患者40例,年龄18～65岁,BMI 18～25 kg/m~2,ASAⅠ或Ⅱ级,采用随机数字表法分为两组(n=20):低气腹压力组(A组)和高气腹压力组(B组)。常规麻醉诱导和机械通气。手术开始时行CO_2气腹,A组气腹压力为10 mmHg,B组为14 mmHg。气腹后调整体位为30°头低脚高位,手术结束时恢复为仰卧位。超声测量患者右眼ONSD,根据ONSD计算ICP_(ONSD)。记录麻醉诱导后气腹前(T_0)、气腹后1min(T_1)、头低脚高位即刻(T_2)、气腹后30 min后(T_3)、气腹后60 min后(T_4)、手术结束后5 min(T_5)、15 min(T_6)时的P_(ET)CO_2、PaCO_2、MAP、HR、ONSD和ICP_(ONSD)。结果与T_0时比较,T_4、T_5时两组P_(ET)CO_2、PaCO_2明显升高,T_4—T_6时MAP明显升高(P0.05);T_4—T_6时A组,T_3—T_6时B组HR明显增快(P0.05)。与A组比较,T_3、T_4时B组MAP明显升高,HR明显增快(P0.05)。与T_0时比较,T_4、T_5时A组ONSD、ICP_(ONSD)明显升高,T_3—T_5时B组ONSD、ICP_(ONSD)明显升高(P0.05)。与A组比较,T_3时B组ONSD、ICP_(ONSD)明显升高(P0.05)。结论 10 mmHg和14 mmHg气腹压力均可引起腹腔镜妇科手术患者ONSD和ICP升高,其中14 mmHg气腹压力对ONSD和ICP的影响更大。     

腹腔镜妇科手术的麻醉分析

<正>腹腔镜下妇科手术具有创伤小、术后恢复快等优点,但术中需行人工CO2气腹、妇科手术的头低脚高位,影响患者的呼吸和循环。故其麻醉处理具有一定的特殊性。现将作者参与治疗的腹腔镜下妇科手术153例的麻醉处理体会汇报如下。     

经颅超声多普勒监测氯胺酮对小儿脑血流流速的影响

经颅超声多普勒监测氯胺酮对小儿脑血流流速的影响顾利华殷正红作者单位：２２１００９徐州市第四人民医院为了探讨氯胺酮对脑血流的作用和影响，我们采用经颅超声多普勒诊断仪（ＴＣＤ）监测氯胺酮对小儿脑血流流速的影响，现报告如下。临床资料本组ＡＳＡⅠ级１０例为观...     

目标导向液体治疗对妇科腹腔镜手术术中血流动力学及脑氧饱和度的影响

目的观察目标导向液体治疗(GDFT)对妇科腹腔镜手术术中患者血流动力学及脑氧饱和度(rSO2)的影响。方法选择择期全麻下行腹腔镜妇科肿瘤根治手术患者42例,年龄45~65岁,ASAⅠ或Ⅱ级,采用随机数字表法分为两组:传统液体治疗组(C组)和GDFT组(G组),每组21例。通过LiDCOrapid监测系统监测MAP、心输出量(CO)、心脏指数(CI)、每搏量变异度(SVV)。C组采用传统液体疗法;G组采用SVV指导下的GDFT,维持CI≥2.5 L·min^-1·m^-2。记录麻醉诱导前(T0)、麻醉诱导后(T1)、Trendelenburg体位后30 min(T2)、Trendelenburg体位后1 h(T3)及术毕(T4)时的HR、MAP、CO、CI、SVV、rSO2;记录术中总输液量、晶体液用量、胶体液用量、尿量、血管活性药物使用情况;检测患者术后2 h凝血功能及术后3个月肝肾功能。结果与C组比较,T3时G组HR明显加快(P<0.05),CI明显升高(P<0.05),T2、T3时G组CO明显升高(P<0.05),T1-T3时G组SVV明显降低(P<0.05);G组术中晶体用量[(1 519±472)ml vs(2 112±433)ml]和总输液量[(2 526±587)ml vs (2 745±582)ml]明显减少(P<0.05),胶体用量[(1 007±196)ml vs (633±189)ml]明显增加(P<0.05)。两组患者围术期rSO2、术中尿量、血管活性药物使用、术后2 h凝血功能、术后3个月肝肾功能差异无统计学意义。结论在SVV指导下的GDFT可减少术中总输液量,同时可稳定Trendelenburg体位下行腹腔镜妇科手术患者的血流动力学,且不影响rSO2。     

气管插管对颅内占位病人脑血流速率的影响

本研究应用经颅多普勒超声 (ｔｒａｎｓｃｒａｎｉａｌＤｏｐｐｌｅｒｕｌｔｒａ ｓｏｎｏｇｒａｐｈｙ ,ＴＣＤ)监测颅内占位病人气管插管时大脑中动脉(ＭＣＡ)的血流速率 ,以考察伤害性刺激对脑血流的影响。资料与方法一般资料　选择ＡＳＡⅠ～Ⅱ级病人 2 4例 ,其中幕上占位病人 (观察组 )和下腹部手术病人 (对照组 )各 12例 ,年龄2 2～ 5 0岁 ,体重 5 5～ 80ｋｇ ,心肝肺肾功能正常 ,无脑血管疾病 ,无高血压、血液及内分泌系统疾病 ,术前血容量正常 ,无低蛋白血症。观察组病人无明显颅内高压症状 ,对照组病人无颅脑及中枢神经系统疾病。…     

脑震荡患者脑干听觉诱发电位变化与伤后脑血流动力学改变的相关性分析

目的 探讨脑震荡病人脑干听觉诱发电位(BAEP)变化与伤后脑血流动力学改变的关系. 方法 对60例脑震荡病人伤后24～48小时内检测双侧BAEP,根据BAEP分级标准:Ⅰ级正常为9例,Ⅱ～Ⅳ级为异常51例,异常率为85％,7天后60例病人均经颅多普勒血流超声(TCD)检测. 结果 60例病人中,BAEP异常病人TCD检测血流动力学改变者占94.12％,BAEP正常病人TCD检测血流动力学改变者占11.11％,比较BAEP正常与异常两组病人TCD变化情况,并统计学处理. 结论 BAEP能够检测出大部分脑震荡病人脑干电生理变化,提示脑组织的超微结构损伤,并可能引起脑血流动力学改变,而TCD检测结果证明脑震荡病人伤后1周仍存在脑血流动力学变化,为临床诊治提供有效依据.     

腹腔镜下妇科肿瘤切除术中二氧化碳气腹对患者脑血流的影响

目的 观察妇科肿瘤患者腹腔镜手术期间二氧化碳(CO2)气腹对患者脑血流的影响.方法 选择妇科肿瘤行腹腔镜手术的患者40例,美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级,无心、脑系统疾病,于气腹前、气腹后头低臀高位20 min分别采取桡动脉和颈内静脉血,测定动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、动脉血氧饱和度(SaO2)、颈内静脉血氧分压(PjvO2)和颈内静脉血氧饱和度(SjvO2)等值.结果 气腹前SjvO2为(66±7)％,气腹后20min的SjvO2为(84±6)％,颈内静脉血氧含量(CjvO2)气腹前为(9.4±1.6)％,气腹后20 min为(11.6±1.8)％,PaCO2气腹前为(4.2±0.4) kPa,气腹后20 min为(5.3±0.4) kPa,均显著增加(P＜0.01),脑动静脉血氧含量差(Ca-jvDO2)气腹前为(5.1±1.2)％,气腹后为(2.4±0.9)％,显著减少(P＜0.01).结论 妇科肿瘤患者腹腔镜手术期间,CO2气腹对脑循环产生显著影响,脑血流(CBF)显著增加,Ca-jvDO2明显减少.这种变化提示可能存在脑细胞缺氧.     

不同通气模式对腹腔镜下Trendelenburg体位患者肺通气的影响

目的 采用电阻抗断层成像(EIT)技术观察容量控制通气(VCV)和压力控制容量保证通气(PCV-VG)模式对腹腔镜下Trendelenburg体位患者全麻术中肺通气的影响。方法 择期全麻下行腹腔镜下Trendelenburg体位妇科手术患者60例,年龄40～65岁,BMI 18～30 kg/m²,ASA Ⅰ或Ⅱ级,采用随机数字表法将患者分为两组：VCV模式组（V组）和PCV-VG模式组（P组）,每组30例。V组术中采用VCV模式,P组采用PCV-VG模式。记录入室后(T0)、插管后5 min(T1)、更改体位（由平卧位更改为Trendelenburg体位）后即刻(T2)、更改体位后30 min(T3)、更改体位后60 min(T4)、更改体位后120 min(T5)、改平卧位(T6)时的MAP、HR、通气中心(CoV)、依赖静止区(DSS)、非依赖静止区(NSS)的面积百分比。记录T1、T3—T5时气道峰压（Ppeak）、pH、PaO₂、PaCO₂、氧合指数（OI）。记录术后7 d内肺部感染、呼吸衰竭等肺部并发症发生情况。结果 T0—T6时两组MAP、HR差异无统计学意义。与V组比较,T3—T6时CoV面积百分比明显升高,DSS面积百分比明显降低（P<0.05）,T3—T5时Ppeak明显降低（P<0.05）,T4、T5时PaO₂、OI明显升高（P<0.05）。两组术后7 d内均无肺部并发症。结论 PCV-VG通气模式可明显改善腹腔镜下Trendelenburg体位患者术中肺通气及肺氧合功能。     

Usefulness of epidural anesthesia in gynecologic laparoscopic surgery for infertility in comparison to general anesthesia

Background Although the advantages of epidural anesthesia in open surgery have been established, its usefulness in the setting of laparoscopic surgery remains to be studied.Methods Patients undergoing laparoscopic surgery for infertility were randomly administered epidural anesthesia (group A, n = 11) or general anesthesia (group B, n = 9). The operation was performed under 4 mmHg pneumoperitoneum and in the 20° Trendelenburg position. Respiratory function tests using a spirometer and blood gas analysis were performed during the intra- or perioperative period. Pain status was evaluated with visual analog scale scoring. The number of postoperative recovery days needed to resume daily activities was obtained by a questionnaire.Results Respiratory rate, minute volume, P_aCO₂, % vital capacity (VC), and forced expiratory volume in 1 s (FEV1) % were virtually constant throughout the study period in group A, whereas %VC was decreased immediately after operation in group B (p < 0.05). Minute volume immediately after operation was significantly increased in group B compared with group A (p < 0.01), suggesting shallow respiration in women undergoing general anesthesia. Observed pain scores on abdominal pain, shoulder pain, and dyspnea were very low during operation in group A. Pain scores immediately and 3 h after operation were also minimal in group A, whereas abdominal pain scores at these points were significantly higher in group B than those in group A (both p < 0.01). The number of days required for a half reduction in wound pain, trotting, and full recuperation for group A were less than those for group B (p < 0.05).Conclusions Epidural anesthesia, when used in laparoscppic surgery for infertility treatment, has advantages over general anesthesia in terms of analgesic effects, postoperative respiratory function, and a return to preoperative daily activities.     

术中超声的妇科临床应用

二十世纪80年代起,术中超声以其高分辨率、高频率、实时传感器、多重频率传感器以及灵活可变的探头应用于各学科手术中。术中超声能确定术中病变部位及其与周围组织的关系,与术后病理符合率更高,逐渐成为了外科手术辅助应用设备。本文针对该项术技术的实用性及有效性在妇科腹腔镜手术中的应用予以综述。     

Transcranial doppler waveform differences in hyperemic and nonhyperemic patients after severe head injury

Although increased cerebral blood flow velocity is readily measured by transcranial doppler ultrasonography (TCD), the causes of the velocity elevation may differ. After severe head injury, increased blood flow velocity can develop both in patients with global hyperemia (suggestive of vasodilation) and in those without hyperemia (suggestive of vasospasm). The present study attempts to determine whether TCD can differentiate these two mechanisms of velocity increase.

Fourteen severely brain-injured patients who developed increased middle cerebral artery blood flow velocity (time-averaged mean velocity > 100 cm/s) were studied. Eight cases were nonhyperemic and six were hyperemic as defined by arterial-jugular venous oxygen content differences of more than 4 mL/dL and less than 4 mL/dL, respectively. The TCD waveform of all eight nonhyperemic cases showed a diastolic notch, which was absent in all six hyperemic patients (p = 0.00066). TCD waveform profile appears to provide a noninvasive means of differentiating at the bedside the two causes of increased flow velocity. If associated with raised intracranial pressure, these require different treatment.     

Comparison of volume-controlled and pressure-controlled ventilation in steep Trendelenburg position for robot-assisted laparoscopic radical prostatectomy

Study Objective

To compare the effects of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) on respiratory mechanics and hemodynamics in steep Trendelenburg position.

Design

Prospective, randomized clinical trial.

Setting

University hospital.

Patients

34 ASA physical status 1 and 2 patients undergoing RLRP.

Interventions

Patients were randomly allocated to either the VCV (n = 17) or the PCV group (n = 17). After induction of anesthesia, each patient's lungs were ventilated in constant-flow VCV mode with 50% O₂ and tidal volume of 8 mL/kg; a pulmonary artery catheter was then inserted. After establishment of 30° Trendelenburg position and pneumoperitoneum, VCV mode was switched to PCV mode in the PCV group.

Measurements

Respiratory and hemodynamic variables were measured at baseline supine position (T1), post-Trendelenburg and pneumoperitoneum 60 minutes (T2) and 120 minutes (T3), and return to baseline after skin closure (T4).

Main Results

The PCV group had lower peak airway pressure (AP_peak) and greater dynamic compliance (C_dyn) than the VCV group at T2 and T3 (P < 0.05). However, no other variables differed between the groups. Pulmonary arterial pressure and central venous pressure increased at T2 and T3 (P < 0.05). Cardiac output and right ventricular ejection fraction were unchanged in both groups.

Conclusions

PCV offered greater C_dyn and lower AP_peak than VCV, but no advantages over VCV in respiratory mechanics or hemodynamics.     

颈动脉校正血流时间评估腹腔镜结直肠手术患者容量反应性的有效性

目的 探讨颈动脉校正血流时间（FTc）在评估腹腔镜结直肠手术患者容量反应性的有效性。
方法 选择2021年2—5月择期行腹腔镜结直肠手术患者60例,男32例,女28例,年龄45～70岁,BMI 20～24 kg/m²,ASA Ⅰ或Ⅱ级。分别于气管插管后5 min和肠道吻合完成恢复平卧位后进行补液试验,均在15 min内输注6%羟乙基淀粉6 ml/kg。以每搏量指数（SVI）增加≥15%判定为容量反应阳性,第1次补液与第2次补液后容量反应阳性的患者分别为R1组和R2组,容量反应阴性的患者分别为NR1组和NR2组。记录第1次补液前即刻、第1次补液后5 min、CO₂气腹前即刻、CO₂气腹后5 min、第2次补液前即刻、第2次补液后5 min的SVI、FTc。采用受试者工作特征（ROC）曲线分析FTc评估容量反应性的效能。
结果 与补液前即刻比较,第1次补液与第2次补液后5 min R1组和R2组FTc均明显延长（P<0.05）。非CO₂气腹状态时,FTc曲线下面积为0.755（95%CI 0.522～0.909,P<0.05）,FTc的诊断界值为325 ms,敏感性66.67%,特异性77.78%。CO₂气腹状态时,FTc曲线下面积为0.773（95%CI 0.605～0.940,P<0.05）,FTc的诊断界值为361 ms,敏感性100%,特异性87.69%。
结论 FTc可作为评估腹腔镜结直肠手术患者容量反应性的指标,且CO₂气腹状态时FTc评估容量反应性具有更高的敏感性与特异性。