恩纳配合浅全麻加持续硬膜外麻醉胆道腹腔镜手术的体会

胆道腹腔镜 (ＬＣ)手术需要ＣＯ2 作腹腔充气造成气腹 ,硬膜外麻醉虽然能完成手术 ,但因气腹造成的腹压增高 ,使病人有难以忍受的不适感 ,镇静镇痛药用量过大又可能抑制呼吸 ,使ＳｐＯ2 下降 ,单独用全麻则需要肌松药才能满足手术要求。我们采用恩纳 (ｅｕｔｅｃｔｉｃｍｉｘｔｕｒｅｏｆｌｏｃａｌａｎａｅｓｔｈｅｔｉｃｓ,ＥＭＬＡ)配合浅全麻加持续硬膜外麻醉进行ＬＣ手术 ,取得较好的效果 ,现报道如下。资料与方法一般资料　 10 0例ＬＣ手术病人 ,随机分为两组 ,持续硬膜外麻醉加全麻组 (观察组 ) 5 0例 ,男 2 2例 ,女 2 8例 ,年龄2 2…     

颈部硬膜外麻醉对咳嗽反射时腹腔内压变动的影响

咳嗽反射有发生腹腔内压显著上升严重合并症的危险,抑制咳嗽反射的方法给深麻醉、肌肉松弛药、利多卡因等有用,但有关腹腔内压上升的抑制效果报告的少。作者研讨气管插管病人伴咳嗽反射的腹腔内压变动用膀胱内压测定,颈部硬膜外麻醉有抑制腹腔内压上升作用。对象与方法:女性20名,ASAⅠ～Ⅱ,心循环系与神经系异常者除外。对照组与硬膜外组各10名,对照组全麻,硬膜外组全麻与颈部硬膜外并用,做乳房切除术。     

腹腔镜子宫切除术中不同麻醉方法对应激反应的影响

目的观察在硬膜外麻醉和全麻下腹腔镜子宫切除术中血浆肾上腺素（E）、去甲肾上腺素（NE）的变化。方法将40例拟行腹腔镜子宫切除术患者随机分成全麻（GA）组和硬膜外（EA）组,每组20例,监测麻醉前、气腹前10min、气腹后及放气后5min各时点血浆NE、E浓度。结果EA组术中各时点NE浓度无明显变化,气腹前及气腹后E明显增高（P〈0．05）,术毕基本恢复（P〉0．05）;GA组气腹后NE和E均明显增高（P〈0．05）,术毕E仍未恢复（P〈0．05）。结论两种麻醉方法术中均存在明显应激反应,硬膜外麻醉下施行腹腔镜子宫切除术中应激反应较全麻轻。     

全麻与全麻联合硬膜外阻滞用于腹腔镜辅助阴式全子宫切除术的效果

目的评价全麻与全麻联合硬膜外阻滞用于腹腔镜辅助阴式全子宫切除术的效果。方法采用随机数字表法将行腹腔镜辅助下阴式全子宫切除术的50例患者分为2组,各25例。对照组予以全麻,观察组予以全麻联合硬膜外阻滞。比较2组麻醉前(T_0)、气腹前(T_1)、气腹15 min(T_2)、气腹30 min(T_3)、术后10 min(T_4)的心率(HR)、平均动脉压(MAP),以及清醒时间、自主呼吸恢复时间和拔管时间。结果 T_1～T_3时观察组患者的HR、MAP波动幅度,以及清醒时间、拔管时间、自主呼吸恢复时间等指标均明显优于对照组,差异均有统计学意义(P0.05)。结论全麻联合硬膜外阻滞用于腹腔镜辅助阴式全子宫切除术,有利于血流动力学的稳定和患者术后恢复。     

2种不同工作原理气腹机形成CO2气腹对大鼠腹膜浅方肌组织超微结构的影响

目的探讨不同充气方式形成CO2气腹对大鼠腹膜浅方肌组织超微结构的影响。方法选择脉冲式和恒压变流式2种不同工作原理的气腹机分别对2组各40只大鼠腹腔进行CO2充气,设定气腹压力15mmHg,在充气后60、90、120和180min时分别取10只大鼠腹膜浅方横纹肌组织,用透射电镜方法观察气腹作用后大鼠腹膜浅方肌组织超微结构的变化。对照组10只大鼠,仅行麻醉。结果2组大鼠在气腹后60min即在腹膜浅方肌细胞中出现空泡变性,随气腹作用时间延长而越发显著。上述变化在脉冲式气腹机充气组更为明显。180min后脉冲式气腹机组肌细胞出现明显增宽的间隙,肌细胞之间也出现气泡,而恒压气腹机组不明显。结论CO2气腹可以导致大鼠腹膜浅方肌组织损伤,应用恒压气腹机充气可能有助于减少这种损伤。     

不同麻醉方法腹腔镜胆囊切除术对应激反应的影响

目的 观察在硬膜外麻醉和全身麻醉下,腹腔镜胆囊切术中血浆肾上腺素（Ｅ）和 腺素（ＮＥ）Ｒ 变化。方法将３０例拟行腹腔镜胆切除（ＬＣ）２,随机分为全麻组（ＧＡ组,１５例）和硬膜外麻醉组（ＥＡ组,１５例）监测麻醉前、气腹前、气腹时及术毕各时相点血浆ＮＥ及Ｅ浓度。结果ＥＡ组术中香相点ＮＥ水平均无明显变化,气腹前及气腹时Ｅ明显增高,术毕基本恢复;ＧＡ组气腹前ＮＥ及Ｅ无明显变化,气腹时ＮＥ和Ｅ均明显增高,术     

全麻复合硬膜外阻滞与单纯全麻用于腹腔镜胆囊切除术的比较研究

目的：比较异丙酚全麻复合硬膜外和单纯异丙酚全麻用于腹腔镜胆囊切除术（LC）对BP、HR、血儿茶酚胺、皮质醇和血气等的影响。方法：44例行LC患者随机分成异丙酚全麻组（A组,22例）和异丙酚全麻复合硬膜外组（B组,22例）。术中连续监测HR、BP和和SpO2,分别分时段测定血气及血肾上腺素（E）、去甲肾上腺素（NE）及皮质醇（COS）浓度。结果：（1）气腹时A组HR和BP均明显增加（P＜0.05）;B组各指标无明显变化（P＞0.05）。（2）气腹时两组PaO2、HCO3均明显增高（P＜0.05）,但两组间各指标无明显差异（P＞0.05）。（3）E、NE及COS浓度,气腹时A组有明显差异（P＜0.05）;B组无明显变化（P＞0.05）。结论：异丙酚全麻复合硬膜外用于LC时机体应激反应轻,是较理想的麻醉方法。     

不同麻醉方式用于老年患者腹腔镜乙状结肠原位新膀胱术的临床效果

目的 比较单纯全麻和全麻联合硬膜外阻滞用于老年患者腹腔镜下乙状结肠原位新膀胱术的临床效果.方法 择期行腹腔镜下全膀胱切除并乙状结肠原位新膀胱术老年患者42例,随机均分为单纯全麻组(G组)和全麻联合硬膜外阻滞组(GE组).记录气腹前5min (T1)、气腹后10 min(T2)、30 min(T3)、90min(T4)、180min(T5)、解除气腹后30 min(T6)及术毕(T7)各时点HR、MAP、CVP、气道压(Paw)、PaCO2、pH和血糖(Glu),以及手术时间、气腹时间、出血量、丙泊酚与瑞芬太尼用量、拔管时间、苏醒时间及术后躁动发生率.结果 与G组比较,GE组瑞芬太尼用量较少,术后拔管时间较短,躁动发生率较低(P＜0.05).两组T2～T7时HR、MAP、CVP、Paw、PaCO2及Glu值均增高,pH值下降(P＜0.05).T2、T3、T6、T7时G组HR、MAP较GE组增快升高明显(P＜0.05);T2～T7时G组Glu较GE组升高明显(P＜0.05).结论 老年患者腹腔镜乙状结肠原位新膀胱术中采用全麻联合硬膜外阻滞与单纯全麻相比,血流动力学更稳定,阿片类药物用量更少,术后苏醒质量更高.     

静脉全麻复合硬膜外麻醉用于腹腔镜胆囊切除术的临床观察

目的:探讨静脉全麻复合硬膜外麻醉用于腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)的麻醉效果,并与单纯静脉全麻比较。方法:随机将LC60例患者分为对照组(静脉全麻)与观察组(静脉全麻复合硬膜外麻醉),每组30例。记录麻醉前、麻醉后(气管插管后或硬膜外平面固定后期气腹前)、气腹后5min及术毕时的SBP、DBP、HR、呼之睁眼时间、拔管时间、术后恶心呕吐(PONV)发生例数及8h内的平均VAS评分、两组异丙酚的用量。结果:两组患者术中血流动力学变化无显著性差异;观察组患者苏醒质量、PONV、8h平均VAS评分及异丙酚量与对照组有显著性差异。结论:LC全麻复合硬膜外麻醉对循环和呼吸的干扰小,清醒质量高且经济安全。     

不同麻醉下有或无气腹腹腔镜手术对呼吸和循环的影响

传统的CO2气腹腹腔镜手术对心脏和呼吸系统有潜在的损害作用,甚至可引起有生命威胁的并发症,近年兴起的无气腹悬吊式腹腔镜技术无须向腹腔内注入CO2气体,避免了CO2气体对人体的不良影响,增加了手术的安全性.我们试比较全身麻醉下CO2气腹腹腔镜手术和悬吊式腹腔镜手术在全麻和硬膜外麻醉下呼吸和循环参数的变化,以供临床参考.     

Continuous monitoring of hemoglobin oxygen saturation of the hepatic vein in patients undergoing laparoscopic cholecystectomy

We monitored of hemoglobin oxygen saturation of the hepatic vein (ShvO2) continuously in 6 patients undergoing laparoscopic cholecystectomy under inhalation anesthesia only, and in 6 patients under combined epidural and inhalation anesthesia. In inhalation anesthesia only group, arterial blood pressure increased and ShvO2 values decreased immediately after intraperitoneal insufflation with CO2, demonstrating the mean lowest ShvO2 value of 25 percent. In combined anesthesia group, arterial blood pressure and ShvO2 values were unchanged after the intraperitoneal insufflation compared with values obtained before the insufflation. The results indicate that hepatic blood flow may be better preserved with combined epidural and inhalation anesthesia than with inhalation anesthesia only, suggesting that sympathetic block by epidural anesthesia may contribute to this favorable effect on ShvO2.     

Effects of different anesthetic techniques on antidiuretic hormone secretion during laparoscopic cholecystectomy

BACKGROUND: With the advent of minimally invasive surgery, laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder disease. This study aimed to evaluate the effects of using high- versus low-pressure pneumoperitoneum with different anesthetic techniques on hemodynamics and antidiuretic hormone (ADH) secretion. METHODS: For this prospective study, 60 patients scheduled for elective laparoscopic cholecystectomy were randomly recruited. They were classified into four equal groups: group 1 received general anesthesia with low insufflation pressure (7-9 mmHg); group 2 received general anesthesia with high insufflation pressure (13-15 mmHg); group 3 received general anesthesia in addition to epidural analgesia with low insufflation pressure; and group 4 received general anesthesia in addition to epidural analgesia with high insufflation pressure. Routine intraoperative monitoring was done. The study parameters included heart rate per minute, mean blood pressure (mmHg), and ADH levels (via blood samples) before anesthesia, after induction, 30 and 45 min after abdominal insufflation, and finally, 2 h postoperatively. RESULTS: The heart rate showed significant increases after pneumoperitoneum in group 2, as compared with the other three groups. Significant differences in mean blood pressure were observed between the study groups. In groups 1 and 4, mean arterial pressure (MAP) significantly decreased after 15 min, and this decrease persisted until the end of the study. In group 2, MAP significantly increased after 15, 30, 45, and 60 min and after 60 min postoperatively. In group 3, MAP significantly decreased after 30 min, and this decrease persisted 1 h after surgery. There were no significant differences in ADH levels before and after induction of anesthesia among any of the study groups. In groups 1 and 4, no statistically significant changes in ADH levels were observed throughout the study period except a mild increase in ADH levels 30 and 45 min after abdominal insufflation. In group 2, after pneumoperitoneum, there was statistically significant increase in ADH levels from the baseline value of 6.422 +/- 0.551 pmol/l to 7.749 +/- 0.635 pmol/l at 30 min and to 6.457 +/- 0.450 pmol/l at 45 min. In group 3, there was a statistically significant decrease in ADH levels from the baseline value of 6.551 +/- 0.356 pmol/l to 6.125 +/- 0.618 pmol/l at 30 min, to 6.118 +/- 0.491 pmol/l at 45 min, and to 6.169 +/- 0.676 pmol/l at 2 h after abdominal insufflation. CONCLUSION: Pneumoperitoneum can affect several homeostatic systems, leading to hemodynamic and hormonal stress responses. The use of general anesthesia plus epidural analgesia with low insufflation pressure, general anesthesia with low insufflation pressure, or general anesthesia plus epidural analgesia with high insufflation pressure is safe and effective in attenuating these responses.     

Arterial to end-tidal carbon dioxide tension difference during laparoscopic colorectal surgery

BACKGROUND: Determination of end-tidal carbon dioxide pressure (PET(CO2)) is effective to confirm adequate ventilation, because arterial to end-tidal carbon dioxide tension difference (deltaa-ET(CO2)) does not change normally during operation. But deltaa-ET(CO2) may change during laparoscopic surgery, because peritoneal insufflation of CO2 will increase CO2 production and reduce functional residual volume. Changes in deltaa-ET(CO2) were reported in laparoscopic cholecystectomy with cardiovascular complication, but there is controversy about how deltaaET(CO2) will change in more complicated and long laparoscopic surgery. In this prospective study, we examined changes in deltaa- ET(CO2) during laparoscopic colorectal surgery. METHODS: Fifty patients received combined general and epidural anesthesia. CO2 pneumoperitoneum was initiated after obtaining arterial blood for gas analysis. Mechanical ventilation was used to maintain PET(CO2) at a stable value between 30 and 40 mmHg during the procedure. Arterial blood gas analysis was performed 10, 60, 120 minutes after CO2 insufflation, and 10 minutes after the termination of insufflation. RESULTS: The mean +/- SD for deltaa-ET(CO2) was 5.8 +/- 4.1 before pneumoperitoneum, 7.1 +/- 4.8, 8.1 +/- 5.4, 6. 4 +/- 4.9 in 10, 60, 120 minutes after pneumoperitoneum, and 6.4 +/- 4.9 in 10 minutes after the termination of pneumoperitoneum. deltaa-ET(CO2) increased significantly during pneumoperitoneum, but did not increase further even if CO2 insufflation was longer than 60 minutes. CONCLUSIONS: In laparoscopic colorectal surgery, Pa(CO2) should be checked for at least the first 60 minutes to confirm adequate ventilation.     

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。     

Heated, humidified CO2 gas is unsatisfactory for awake laparoscopy.

BACKGROUND: The necessity for general anesthesia represents an impediment to using a laparoscopic approach for some procedures that are otherwise performed with the patient under local anesthesia using a conventional open technique. Heating and humidifying the insufflation gas reportedly reduces perioperative pain associated with a CO2 pneumoperitoneum, thus enabling awake laparoscopy. METHODS: Two cases are reported herein of laparoscopy performed with the patient under local anesthesia using heated, humidified CO2 gas for the pneumoperitoneum. RESULTS: Both patients experienced pain with insufflation of heated, humidified CO2 gas of sufficient magnitude that the procedure could not be performed. The CO2 gas was washed out and replaced with helium gas insufflation with complete resolution of pain. The laparoscopic procedures were accomplished without further discomfort with local anesthesia and using a helium gas pneumoperitoneum. CONCLUSIONS: Heated, humidified CO2 gas insufflation does not reduce pain sufficiently to permit satisfactory performance of laparoscopy with local anesthesia, especially when full volume insufflation is required. Cold, dry helium gas produces no pain. The theory that cold, dry insufflation gas is a source of peritoneal pain during laparoscopy needs to be reassessed.     

Effects of epidural-and-general anesthesia combined versus general anesthesia during laparoscopic adrenalectomy

Laparoscopic approach is increasingly performed for functional adrenal tumor resections. The aim of this study was to compare general anesthesia and general anesthesia combined with epidural anesthesia for laparoscopic adrenalectomy. In our study, we planned to examine hemodynamic changes (heart rate, systolic, diastolic, and mean pressures) and quantity of adrenocorticotropic hormone, adrenaline, noradrenaline, cortisol, and aldosterone in laparoscopic adrenalectomies under general anesthesia with or without epidural anesthesia. All patients were operated by the same surgical team. With increased experience of the surgical team, the duration of surgery decreased. In parallel with decreased duration of surgery, pneumoperitoneum and undesirable effects also decreased. Nine patients with Conn syndrome, 21 patients with Cushing syndrome, and 2 patients with pheochromocytoma were included in both groups. Thirty-two laparoscopic adrenalectomies for functional adrenal tumors were performed. Sixteen patients who received general anesthesia without epidural anesthesia were compared with 16 patients who received general anesthesia combined with epidural anesthesia. Hemodynamic data, arterial blood gases, and adrenal gland hormones were recorded. Heart rate, systolic blood pressure, and diastolic blood pressure were recorded before anesthesia induction, after insufflation, before adrenalectomy, and after adrenalectomy. Arterial blood gases, adrenocorticotropic hormone (ACTH), cortisol, adrenaline, noradrenaline and aldosterone were recorded before anesthesia induction, after adrenalectomy, and after surgery. Heart rate varied between 68.5 and 84 bpm in general anesthesia group and between 63.5 and 87 bpm in general+epidural anesthesia group. Blood pressure measurements were 154 to 122.5/88.5 to 75 mm Hg in general anesthesia and 149 to 100/86 to 70 mm Hg in general+epidural anesthesia. ACTH was 10.3 to 106.25 in general anesthesia and 17.6 to 104.5 in general+epidural anesthesia. Cortisol was 16.1 to 23.2 μg/dL in general anesthesia and 16.4 to 24.3 μg/dL in general+epidural anesthesia. Aldosterone was 163.3 to 285.2 ng/dL in general anesthesia and 215 to 440 ng/dL in general+epidural anesthesia. There was no significant difference in hemodynamic parameters, ACTH, cortisol, adrenaline, and noradrenaline levels between the 2 groups. Aldosterone levels were higher in general+epidural anesthesia group. The results of our study suggest that epidural anesthesia in addition to general anesthesia in patients with functional adrenal tumors undergoing laparoscopic adrenalectomy might be an effective and safe method to prevent the fluctuations in hormone levels.     

Coronary artery spasm during cholecystectomy with pneumoperitoneum--a case report

A 59-year-old man without a history of ischemic heart disease underwent elective laparoscopic cholecystectomy under general anesthesia with epidural anesthesia. About 15 min after pneumoperitoneum had been achieved, the patient developed ST elevation and hypotension. Vagal stimulation resulting from stretching peritoneum, the procedure and epidural anesthesia are thought to have induced vasospasm. The ST segment became normal after interruption of CO2 insufflation. A postoperative coronary artery angiogram showed normal coronary arteries, but diffuse coronary artery spasm was seen after intracoronary injection of acetylcholine. The patient was discharged on nitrates. Patients with gall bladder stones sometimes have coronary risk factors of obesity, hyperlipidemia and hyperglycemia. Careful attention should also be given to patients who do not have a history of coronary disease.     

Laparoscopic pneumoperitoneum in acute peritonitis does not increase bacteremia or aggravate metabolic or hemodynamic disturbances

The use of laparoscopy in generalized peritonitis has become increasingly frequent in recent years. However, CO2 pneumoperitoneum in association with increased intraperitoneal pressure may have deleterious effects in patients with hemodynamic or metabolic disturbances caused by bacterial peritonitis. The purpose of this study was to investigate the effect of CO2 pneumoperitoneum on bacteremia, mean arterial pressure, and blood gas disturbances in an animal model of bacterial peritonitis. Dogs were anesthetized, orally intubated, and subjected to experimental peritonitis by intraperitoneal inoculation of a suspension containing Escherichia coli and sterile dog feces. The animals were randomly assigned to two groups: control animals were maintained under anesthesia, and the insufflated animals were subjected to intraperitoneal CO2 insufflation. Bacterial peritonitis provoked the appearance of bacteremia and a significant decrease in mean arterial pressure, pH, bicarbonate, and base deficit. The induction of bacterial peritonitis did not significantly influence pH in the control group and partial pressure of arterial CO2 in either group. Thirty minutes of CO2 pneumoperitoneum did not influence the effect of bacterial peritonitis on the analyzed variables. These results suggest that laparoscopic CO2 pneumoperitoneum does not aggravate bacteremia or metabolic and hemodynamic disturbances induced by bacterial peritonitis.     

The effects of combined epidural and general anesthesia on the autonomic nervous system and bioavailability of nitric oxide in patients undergoing laparoscopic pelvic surgery

Background

Pneumoperitoneum during laparoscopic surgery is known to affect visceral blood flow and result in oxidative stress. Whether epidural anesthesia will effectively reduce visceral ischemia and oxidative stress by blocking the sympathetic nervous system (SNS) during laparoscopic surgery has not been proven.

Methods

Forty-five patients who were to undergo robot-assisted laparoscopic prostatectomy were randomly assigned to the combined general–epidural anesthesia group (group GE, n = 22) or to the general anesthesia group (group G, n = 23). Blood pressure, heart rate, and the balance between sympathetic and parasympathetic nervous system activity as measured by heart rate variability were recorded at 10 min after induction of anesthesia (T1), 60 (T2) and 120 (T3) min after intra-abdominal CO₂ insufflation, and 10 min after returning the patient to the supine position following CO₂ exsufflation (T4). Arterial blood gas analysis and blood sampling for measurements of nitrite (NO^2?) and malondialdehyde (MDA) were performed at all time points.

Results

Intraoperative mean blood pressure was significantly lower in group GE compared with group G. The low-frequency to high-frequency ratio was significantly increased after induction of pneumoperitoneum in group G but was unchanged in group GE. Plasma levels of nitrite decreased after pneumoperitoneum induction in group G while there was no change in group GE. A significant increase in MDA levels was seen in group G after pneumoperitoneum induction and were higher than group GE at T3 and T4. The 24-h urine output was higher in group GE than in group G on POD 1. The 24-h CrCl was higher in group GE on POD 1 but was not different between groups on POD 2.

Conclusions

Combined epidural and general anesthesia effectively blocks SNS stimulation during laparoscopic surgery and reduces NO inactivation and oxidative stress.     

Intraocular pressure changes during laparoscopy in patients anesthetized with propofol total intravenous anesthesia versus isoflurane inhaled anesthesia

We examined intraocular pressure (IOP) changes during gynecologic laparoscopy performed under either thiopental-isoflurane anesthesia or total IV propofol anesthesia. Forty adult women with no preexisting eye disease scheduled for gynecologic CO(2) insufflation laparoscopy were included in the study. Heart rate, mean arterial blood pressure, peak and plateau airway pressure, ETCO(2), and IOP (using a Schioetz tonometer) were measured at defined intervals during the procedure. IOP decreased significantly after the induction of anesthesia in both groups, and remained so throughout the procedure in the propofol group. In the isoflurane group, however, IOP was increased significantly above the preinduction level after pneumoperitoneum with head-down position. There was no correlation between IOP and blood pressure or airway pressure. In conclusion, propofol total IV anesthesia may be a better choice for laparoscopic surgery should control of IOP be a concern. IMPLICATIONS: In this study, we examined the effect of two anesthetic techniques on the intraocular pressure changes during laparoscopic surgery in healthy subjects. Propofol IV anesthesia protected against increases in intraocular pressure with pneumoperitoneum and head-down position.