二氧化碳气腹对小儿呼吸和循环的影响

目的:探讨小儿腹腔镜手术时二氧化碳气腹对其呼吸和循环的影响.方法:选择小儿腹腔镜手术的患儿分成婴儿组(A组)和幼儿组(B组),选择开腹手术患儿作为对照组(C组),连续监测记录围手术期心率(HR)、血氧饱和度(SpO2)、血压(SBP/DBP)、血气分析结果(pH、PaCO2、PaO2、SpO2).结果:A组、B组气腹后20min SBP/DBP、PaCO2 明显高于气腹前,(P＜0.05),气腹后60min pH值明显高于气腹前(P＜0.05).A组气腹后20min与C组插管后45min相比SBP/DBP、PaCO2、pH值差异均有统计学意义(P＜0.05).结论:二氧化碳气腹对婴幼儿的呼吸和循环系统均有不同程度的影响.     

心脏起搏器植入患者腹腔镜手术超声刀临床应用的研究

目的 :研究安装心脏起搏器患者腹腔镜手术及应用超声刀前后血液动力学变化 ,并探讨应用腹腔镜手术及超声刀的可行性及安全性。方法 :选择心脏起搏器植入患者 12例 ,腹腔镜手术过程中使用超声刀进行组织分离、切割、止血和管道闭合。分别于手术前 30min、麻醉后 10min(气腹前 )、气腹后 15min、超声刀应用后 5min及手术后 30min监测血液动力学指标 (心率、动脉收缩压、平均动脉压、脉搏血氧饱和度 )并进行比较。结果 :腹腔镜手术中安装心脏起搏器患者麻醉后 10min、气腹后 15min、超声刀应用后 5min及手术后30min指标与手术前 30min相比 (1)心率、平均动脉压均增快及升高 ;(2 )动脉收缩压、脉搏血氧饱和度相比均有下降 ;(3)患者心率、动脉收缩压、平均动脉压、脉搏血氧饱和度于气腹后 15min与手术前 30min比较差异有显著性 (P <0 0 5 ) ;(4 )患者心率、动脉收缩压、平均动脉压、脉搏血氧饱和度于麻醉后 10min、超声刀应用后 5min及手术后 30min指标与手术前 30min比较差异无显著性 (P >0 0 5 )。结论 :安装心脏起搏器患者腹腔镜手术及超声刀使用过程中可出现血液动力学变化 ,与无心脏疾病患者腹腔镜手术一致 ,表明腹腔镜手术中应用心脏起搏器及超声刀未引起血液动力学的特殊改变 ,其变化与麻醉、二氧化     

全麻腹腔镜下行妇科手术对呼吸循环功能的影响

目的妇科腹腔镜手术只要注重呼吸和循环的监测,及时发现并发症,手术是安全的。方法口插全麻下,CO2气腹(12±2 mm Hg),头低脚高25°~30°10 min、30 min和放气后10 min,监测气道压力(Paw),呼气末CO2张力(PetCO2)、血氧饱和度(SpO2)、收缩期血压(SBP)、舒张期血压(DBP)、心率(HR)和心电图(ECG)的值。结果气腹后10 min与气腹前相比;Paw、PetCO2、SBP、DBP、HR都增高(P<0.05)、SpO2在气腹前、气腹中和气腹后都在95%以上。结论CO2气腹、头低脚高位、口插全麻下,可使气管内压增高、呼气末二氧化碳张力增高、血压上升和脉搏加快。若在操作中CO2缓慢注入腹腔,在满足手术条件的前提下,腹压尽量小(12±2)mm Hg,头低脚高位在25°~30°,注意麻醉深度,用增加呼吸频率和减少潮气量的方法,增加每分钟通气量,以纠正吸气末二氧化碳分压的升高,此方法能维持血氧饱和度在95%以上,能安全完成妇科手术。     

CO2气腹对中老年直肠癌行腹腔镜手术患者呼吸和循环系统的影响

摘要为保证中老年直肠癌腹腔镜手术的安全,观测CO2气腹对呼吸和循环系统的影响,选择50例中老年择期行直肠癌腹腔镜手术患者,术中采用气管插管静脉复合结合连续硬膜外麻醉。行腹腔镜手术时,监测心率（HR）、平均动脉血压（MAP）、心电图（ECG）、呼吸频率（RR）、潮气量（VT）、气道压力（PAw）、血氧饱和度（SPO2）、呼气末二氧化碳分压（PetCO2）、动脉血氧分压（PaO2）、动脉二氧化碳分压（PaCO2）。结果显示,患者行CO2气腹前各项指标均在正常范围,CO2气腹后5min、15min的HR增快,MAP、PAw、PETCO2、PaCO2均升高。结果表明,CO2气腹对中老年直肠癌腹腔镜手术者呼吸、循环系统影响很大,因此,术中必须严密监测,备好抢救药品,对中老年合并心肺疾病者更应注意。     

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。     

腹腔镜胆囊切除术CO2气腹对脉搏血氧饱和度的影响

目的:观察腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)CO2气腹对脉搏血氧饱和度的影响。方法:按照美国麻醉医师协会体格情况分级(ASA)标准,选择ASAⅠ~Ⅱ级600例患者全麻下行LC,在围手术期对脉搏血氧饱和度(SpO2)进行连续监测。结果:CO2充气后3m in SpO2明显下降(P<0.01),放气后恢复到术前水平。结论:CO2气腹对脉搏血氧饱和度存在一定程度的影响,因此CO2气腹压力不宜过大,应限制在10~12mm Hg为宜,对老年患者伴有心、肺功能不全及肥胖者更要加强麻醉管理,加强SpO2、呼气末二氧化碳分压(PETCO2)监测。     

腹腔镜治疗食管裂孔疝的麻醉

目的探讨腹腔镜行食管裂孔疝修补术对全身麻醉患者血流动力学、呼吸及动脉血气的影响。方法选择了62例（ASAI—II）食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术,监测气腹前,气腹后30min血压（BP）、心率（HR）、心电图（ECG）、脉搏、氧饱和度（SPO2）及动脉血气、气道压力的变化。结果62例腹腔镜食管裂孔疝修补术全部获得成功。气腹前、后患者的血流动力学变化不明显（P〉0．05）,气道压力,动脉血气发生显著改变,出现高碳酸血症（P〈0．05）。结论腹腔镜行食管裂孔疝修补术CO2气腹对全身麻醉患者呼吸及血气产生一定的影响,术中应加强麻醉的管理及监测。     

免气腹腹腔镜手术治疗特殊人群妇科疾病12例临床分析

目的:探讨免气腹腹腔镜手术治疗合并心肺疾病、老年或妊娠期妇科疾病患者的安全性、可行性及治疗效果。方法:回顾分析2011年3月至2012年9月收治的异位妊娠合并心肺疾病、子宫肌瘤合并心肺疾病、老年卵巢囊肿、孕妇卵巢囊肿蒂扭转12例患者的临床资料。观察手术时间、住院时间、术中出血量、血氧饱和度、气道压力,围手术期pH值、血压、心率,术中、术后并发症等。结果:12例手术均获成功,手术时间平均(45.2±7.6)min,术中出血量平均(105.6±38.9)ml,术后平均住院(5.6±2.5)d。患者术前、术中及术后动脉血pH值、二氧化碳分压、氧分压、碳酸氢根、血氧饱和度、心率、血压(平均动脉压、无创收缩压、无创舒张压)差异均无统计学意义(P>0.05)。结论:免气腹腹腔镜手术治疗合并心肺疾病、老年或妊娠期妇科疾病是安全、可行的,手术操作简单。     

全麻复合硬膜外麻醉用于腹腔镜经阴道式全子宫切除术

目的：观察全麻复合硬膜外麻醉用于腹腔镜经阴道式全子宫切除术时的循环、呼吸及麻醉药用量的变化。方法：择期30例腹腔镜经阴道式全子宫切除术病人，ASA Ⅰ-Ⅱ级，在规定的各个时点记录病人的心率、血压、血氧饱和度，气腹后的气道压峰值、平台压、肺顺应性，以及吸入异氟醚浓度、呼末异氟醚浓度、呼末二氧化碳浓度。结果：诱导后心率和血压有明显下降，气腹后血压较气腹前有轻微上升。气腹后肺动态顺应性明显下降，气道压峰值和平台压有所上升，呼末二氧化碳浓度在气腹后增加。结论：全麻复合硬膜外麻醉用于腹腔镜经阴道式全子宫切除术的麻醉效果可称满意。     

腹腔镜手术中突然无CO_2的应急处理

目的:探讨腹腔镜术中突然无CO2时使用自行设计的应急腹腔充气装置向腹腔充气继续施行手术的可行性。方法:使用本装置建立空气气腹与常规CO2气腹行腹腔镜动物实验,观察建立的手术空间及使用钩状电极时的火花情况,监测动物在麻醉、充气、手术过程中脉搏(pulse,P)、动脉血氧饱和度(SpO2)的变化及术后生存情况,取得一定经验后应用于临床。结果:动物在麻醉、术中、术后半小时P、SpO2的变化曲线一致,能建立足够的手术空间,使用钩状电极切割时无爆炸,火花不明显,术后动物生存良好。使用本装置完成1例腹腔镜异位妊娠取胚术,手术顺利,术中血压(blood pressure,BP)、P、SpO2平稳,术后6h患者BP、P、SpO2正常。结论:腹腔镜术中突然无CO2时用自行设计的应急腹腔充气装置是安全的,具有一定的实用性与可操作性。     

"Low-pressure" laparoscopic cholecystectomy in high risk patients (ASA III and IV): our experience

The insufflation pressure used for laparoscopic cholecystectomy is usually 12-15 mm Hg, and a pneumoperitoneum with carbon dioxide has a significant effect on both cardiovascular and respiratory function. These effects are transient in young, healthy patients, but may be dangerous in ASA III and IV patients with a poor cardiac reserve. This study was designed to assess the feasibility of performing laparoscopic cholecystectomy at 6.5-8 mm Hg insufflation pressure in "high-risk" patients. Thirteen patients, 10 ASA III and 3 ASA IV, with cholelithiasis, were included in this study The insufflation pressure was 6.5-8 mm Hg, with a 10 degrees anti-Trendelenburg position. The cardiovascular and blood gas variables studied were: mean arterial blood pressure, heart rate, respiratory rate, and end-tidal CO2 pressure. The authors reported no conversions and no intra- or postoperative complications. During insufflation heart rate and mean arterial blood pressure increased minimally if compared with laparoscopic cholecystectomy at 12-15 mm Hg. Pa CO2 increased after insufflation (+5 mm Hg), and the end-tidal CO2 pressure gradient was moderate (3.5 mm Hg) and unchanged during surgery. A low-pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse haemodynamic effects of peritoneal insufflation.     

The risk of cardiac injury during laparoscopic fundoplication: cardiac troponin I and ECG study

BACKGROUND: Myocardial trauma has been described during gastroesophageal reflux laparoscopic surgery, in association with the proximity of cardiac structures. In addition, specific haemodynamic changes induced by CO2 pneumoperitoneum could exacerbate perioperative cardiac complication even in patients without cardiac risk factors. The aim of this study was to evaluate the influence of gastroesophageal reflux laparoscopic surgery on the perioperative ECG, cardiac troponin I and myocardial enzyme changes. METHODS: Forty-two ASA I-II patients without ischaemic heart disease or combined double-risk factors were studied. Automated ST segment analysis was used intraoperatively. ECG, plasma myocardial enzyme and cardiac troponin I concentrations were reported on arrival in the recovery room (HO), 4 h (H4) and 24 h (H24) postoperatively. RESULTS: Intraoperative ST segment changes occurred in two patients: the first during a hypotensive episode (MAP<55 mmHg; 3/42 patients) and the second during a hypertensive episode (MAP >110 mmHg; 3/42 patients). One case of intraoperative subcutaneous emphysema occurred without ST disturbance. One case of pneumothorax was observed at H0-H4 in another patient without clinical symptoms. Cardiac troponin I and CK-MB were not increased postoperatively. Transaminase concentrations increased (2-fold normal values) in 26/42 patients. In these 26 patients, 7 experienced 5-fold isolated transaminase increase, associated with left hepatic artery section. CONCLUSION: According to perioperative ECG changes and/or specific cardiac troponin I measurements, we did not identify specific myocardial damage following gastroesophageal reflux laparoscopic surgery. Unexpectedly, the incidence of hepatic cytolysis was frequent (62%) and has not previously been reported in the literature.     

Physiologic effects of pneumoperitoneum in adults with sickle cell disease undergoing laparoscopic cholecystectomy (A case control study)

BACKGROUND: Many studies have demonstrated the adverse consequences of pneumoperitoneum. However, few studies have examined the physiologic effects of pneumoperitoneum in adults with sickle cell disease (SCD) during laparoscopic cholecystectomy (LC). METHODS: 60 ASA 1-capital PE, Cyrillic capital PE, Cyrillic patients, with cholelithiasis, scheduled for elective LC were allocated into two equal groups: group 1, normal patients without SCD (control group), and group 2, patients with SCD. The perioperative parameters of 30 SCD patients matched by age and sex to the 30 members of the non-sickler control group who underwent cholecystectomy were assessed. Study parameters (in the two groups) included heart rate (HR) per minute, mean blood pressure (MAP, mmHg), PETCO(2), and O(2) saturation (SpO(2)) at the following intervals: before induction of anesthesia in the supine position (all except PETCO(2)), after anesthesia and before CO(2) insufflations in the supine position, 15, 30, 45, 60 min after CO(2) insufflations in the anti-Trendelenburg position, at the end of CO(2) exsufflation in the supine position and 5 min after the end of CO(2) exsufflation in the supine position. Arterial blood gases, to measure pH, PaCO(2), and PaO(2), were determined after induction of anesthesia and before CO(2) insufflation in the supine position, then 30 min after CO(2) insufflations in the anti-Trendelenburg position, and 5 min after the end of CO(2) exsufflation in the supine position. Statistical significance was established at the p < 0.05 level. RESULTS: Induction of anesthesia produced a significant increase in HR in both groups. CO(2) insufflations led to an additional increase in HR and persisted till abdominal deflation. After CO(2) insufflations, MAP significantly increased from the baseline at 15, 30, 45, and 60 min, and just before deflation in the anti-Trendelenburg position. CO(2) insufflations led to a significant increase in end-tidal CO(2) (ETCO(2)) in the study groups, reaching a maximum level just before abdominal deflation in the anti-Trendelenburg position. Regarding SpO(2) and PaO(2), there were insignificant changes in the two study groups throughout the procedure. In group 2, none of the patients experienced vaso-occlusive crises or other SCD- related complications. CONCLUSION: This study proved the safety of LC in patients with SCD and cholelithiasis, and that they can tolerate the physiological effects of pneumoperitoneum as non-SCD adults.     

小儿腹腔镜腹股沟疝手术对血气指标及体内循环参数的影响

目的分析小儿腹腔镜腹股沟疝手术中不同气腹压对血气指标、体内循环状况的影响。 方法回顾性分析2015年3月至2016年4月,张家口市妇幼保健院收治的74例腹股沟疝患儿的临床资料,所有患儿均行小儿腹腔镜腹股沟疝手术治疗,依据术中采用的气腹压的不同将患儿分为低气腹压组及高气腹压组,每组患者37例。低气腹压组术中气腹压维持8 mmHg（1 mmHg=0.133 kPa）,而高气腹压组维持12 mmHg。检测并比较术前、气腹后10 min、30 min及放气后10 min患儿血气分析指标及循环指标的变化。 结果与术前比较,气腹后10 min及30 min 2组气道压力（Paw）、呼气末二氧化碳分压（PetCO₂）、动脉二氧化碳分压（PaCO₂）及中心静脉压（CVP）、收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）、心率（HR）、心输出量（CO）及每搏输出量（SV）显著高于术前,且高气腹组显著高于低气腹组（P<0.01）;放气后10 min 2组PetCO₂及PaCO₂仍显著高于术前,且高气腹组显著高于低气腹组（P<0.01）,同时高气腹组SBP、DBP、MAP、CO及SVR显著高于术前,且SBP、DBP及CO仍显著高于低气腹组（P<0.05）;与术前比较,气腹后10 min及30 min 2组胸廓顺应性（Cmpl）显著降低,且高气腹组显著低于低气腹组（P<0.05）;与术前比较,低气腹组全血碱剩余（ABE）及标准碱剩余（SBE）均无显著变化（P>0.05）,而气腹后30 min高气腹组ABE及SBE显著升高（P<0.05）。 结论小儿腹腔镜腹股沟疝手术中高气腹压较低气腹压对患儿的血气及循环的影响大,因此临床应据实际情况尽量避免术中选择12 mmHg以上的气腹压。     

小型猪腹腔镜手术中不同气腹压力对循环功能的影响

目的研究小型猪普通外科腹腔镜手术中不同气腹压力对循环功能的影响,以选择适宜的气腹压完成腹腔镜手术。 方法选择24只25~30 kg巴马小型猪,随机分为A、B、C、D共4组,分别以10、13、15、17 mmHg（1.330、1.729、1.995、2.261 kPa）的气腹压进行腹腔镜实验手术,于不同时间点对心率（HR）、平均动脉压（MAP）、动脉血液气体及酸碱分析指标进行监测。 结果A组的MAP无显著变化,B组在气腹建立30 min和180 min时显著升高,C、D组则在气腹建立30 min后呈显著降低趋势,各时间点的组间差异有统计学意义（P<0.01）;4组HR在气腹后均呈逐渐升高趋势,且气腹压力越大,影响越明显;气腹开始至60 min内,4组的氧分压（PaO₂）几乎无明显变化,120 min时A、C、D组降低（P<0.05）;二氧化碳分压（PaCO₂）在气腹后均有升高,血液酸碱度也随之降低,组间差异有统计学意义（P<0.01）。 结论在25~30 kg的小型猪普通外科腹腔镜手术模型中,既要保证手术视野,又要降低气腹对机体循环功能的影响,气腹压力的选择以10~13 mmHg为宜,不应超过15 mmHg。     

电针内关对妇科腹腔镜手术患者的影响

目的:研究于内关穴位进行电神经刺激疗法对妇科腹腔镜手术患者循环、心肌酶谱的影响。方法:随机将60例妇科腹腔镜手术患者分为穴位组、非穴位组及对照组,每组20例,监测术前及术后24 h三组患者心肌酶谱的变化。术中监测诱导前(T0)、气腹前(T1)、气腹后5 min(T2)、气腹后10 min(T3)3组患者心率(HR)、平均动脉压(MAP)、血氧饱和度(SpO2)的变化,并进行对比分析。结果:T2、T3时,穴位组患者MAP、HR无明显变化;与T1相比,差异无统计学意义(P>0.05);与对照组、非穴位组相比,差异有统计学意义(P<0.05)。术后24 h,穴位组患者心肌酶谱无明显变化,与术前相比,差异无统计学意义(P>0.05);明显优于非穴位组、对照组(P<0.05);非穴位组、对照组患者CK、AST明显增高,与术前相比,差异有统计学意义(P<0.05)。结论:妇科腹腔镜手术后患者循环及心肌酶谱均可发生改变,容易诱发心肌损伤,老年及心脏病患者尤应注意。电针内关可抑制妇科腹腔镜手术患者心肌酶的增加,保证循环稳定,保护心脏。     

Hemodynamic and respiratory effects of pediatric urological retroperitoneal laparoscopic surgery: a prospective study

PURPOSE: Our understanding of the effects of retroperitoneal CO(2) insufflation on cardiopulmonary variables in children remains limited. This study was designed to investigate prospectively the effect of CO(2) insufflation in a pediatric population undergoing retroperitoneal laparoscopic surgery. MATERIALS AND METHODS: We prospectively evaluated a consecutive series of patients enrolled between July 2003 and August 2004. Anesthesia was administered following a standardized protocol. Data collection included respiratory rate, PAP, O(2) saturation, ETCO(2), HR, MAP, electrocardiogram and insufflation pressure. All variables were recorded before, during and after CO(2) insufflation at regular intervals of 1 to 2 minutes, with up to 23 measurements recorded for each period. RESULTS: A total of 18 participants were recruited. Mean +/- SD for age and weight were 79.4 +/- 53.2 months and 26.7 +/- 15.5 kg, respectively. Mean retroperitoneal CO(2) insufflation pressure was kept at 12 mm Hg. Significant differences (p <0.05) in average ETCO(2), PAP and MAP were noted after CO(2) insufflation compared to baseline (pre-pneumoretroperitoneum) values. HR and temperature did not change. At completion of the laparoscopic intervention physiological variables exhibited a trend to return to baseline values. CONCLUSIONS: This prospective study documents significant changes in systemic hemodynamic variables that seem to be directly associated with the insufflation of CO(2) during pediatric retroperitoneal laparoscopic surgery. This ongoing evaluation confirms the effect of laparoscopic urological surgery and CO(2) insufflation on cardiopulmonary function in children.     

Transesophageal echocardiographic detection of gas embolism and cardiac valvular dysfunction during laparoscopic nephrectomy

We used transesophageal echocardiography (TEE) to monitor venous gas embolism, cardiac performance, and the hemodynamic effects of positioning and pneumoperitoneum in 16 healthy kidney donors undergoing laparoscopic nephrectomy. A four-chamber view was used continuously, except at predetermined intervals, when a complete TEE examination for cardiac function was performed. Other clinical variables recorded include systolic, diastolic, and mean arterial blood pressure; heart rate (HR), pulse oximetric saturations; and end-tidal CO2. Baseline valvular incompetence was seen in 13 of the 16 patients when supine and asleep. After positioning for surgery and induction of pneumoperitoneum, TEE revealed valvular incompetence with regurgitation more pronounced from baseline in 15 of the 16 patients. In one patient, during renal vein dissection, gas entered the right atrium from the inferior vena cava, worsening tricuspid regurgitation. Hemodynamic variables and ejection fraction were tested by using repeated-measures analysis of variance for significance (P < 0.05). Pneumoperitoneum increased (P < 0.05) systolic blood pressure (from 102.8 +/- 3.89 to 120.8 +/- 3.88 mm Hg) and HR (from 68.9 +/- 3.19 to 75.6 +/- 2.62). Ejection fraction was unchanged. The high incidence of valvular incompetence indicates that further studies are needed to assess these effects during laparoscopic nephrectomy with cardiac disease. IMPLICATIONS: Laparoscopic surgery has gained popularity as a procedure for the removal of donated kidneys. Although the insufflation of gas necessary for this relatively simple approach poses a low risk of venous air embolism, it may increase the risk of changes in valvular competency.