腹腔鏡手術麻醉課件

第三十二章1腹腔鏡手術的麻醉Chapter32Anesthesia

forlaparoscopic

SurgeryThe

field

of

abdominal

surgeryhas

been

radically

changedwith

the

introduction

oflaparoscopy.2Recent

advance

in

robotic

and

video

technologyhave

made

the

use

of

laparoscopic

proceduresmore

widely

applicable.With

the

evolution

of

laparoscopy，a

substantialnumber

of

abdominal

procedures

are

beingperformed

using

this

approach,

includingcholecystectomy,

myomectomy,

and

soon.345Part

IPhysiological

changesduring

laparoscopic

surgeryThe

first

step

in

laparoscopy

isestablishment

of

pneumoperitoneum.The

ideal

insufflating gas

would

becolorless,

nonexplosive,Physiologically

inertand

readily

solubleinplasma.6Part

I7Physiological

changesduring

laparoscopic

surgeryCO2

is

used

extensively

in

clinic.Thespeed

and

pressure

of

thepneumoperitioneum

effect

theabsorption

of

CO2.Positioning

changes

will

effect

thephysiological

function.I. Cardiovascular

systemThe

pressure

of

pneumopertioneumeffect

three

aspects

.systemic vascular

resistance(SVR.

Afterloail).venous

return

(preload

).cardiac

function.8I. Cardiovascular

systemDuring

laparoscopic

cholecystectomyIf

intraabdominal

pressure

(IAP)

>10mmHg CVP

↑PAWP↑

SVR↑

CO

and

MAP↑If

intraabdominal

pressure

(IAP)

>20mmHgCVP

↓

SVR↑↑

CI CO↓

MAP↑↓or

normal9I. Cardiovascular

systemThe

cause

:Intraabdominal

positive

pressureintrathoracic

pressure

cardiacblood

flow

COIPPV

or

PEEP

intrathoracicpressure

CO10I. Cardiovascular

system11The

arrhythmias

during

laparoscopy

isapproximately

14%,Bradyarrhythemias

includingbradycardia,

nodal

rhythm

areattributed

to

a

vagal

response

due

torapid

insufflations.2.The

patients

were

placed

indifferent

body

position

(Table1)During

cholecystectomy

,

the

patientis

placed

on

head-up

about

10-20°.122.The

patients

were

placed

indifferent

body

position

(Table1)During

gynecological

surgery,

thepatient

is

placed

onhead-downposition.13Table-1

Hemodynamic

measurements

before

and

duringpneumoperitoneum（PP）during

laparoscopiccholecystectomy

in

healthy

patients14SupineHead-downHead-upSupinewithppHead-downwithppHead-upWith

ppHeartrate(beats/min)61±753

±466

±966

±1653

±370

±8MAP(mmHg)69

±776

±664

±

991

±1187

±884

±13CVP(mmHg)6.2

±2.910.2±3.50.8

±3.510.9±2.715.9±4.63.1

±2.6MPAP(mmHg)14.1±1.517.4±1.28.5

±3.518.4±3.720.0±6.110.8±2.5SVR(dynes/sec/cm5)1310±3021381±3131419±3421795±4441577±3442047±4303.

Carbon

dioxide

absorption15The

absorption

of

CO2

isinfluenced

significantly

byduration

of

interoperationinsufflationsIAP and

the

solubility

ofCO2

.3.

Carbon

dioxide

absorption16Hypercarbia

resulting

fromCO2

insufflations

has

direct

andindirect

homodynamic

effects.3.

Carbon

dioxide

absorptionThe

direct

effectsinclude

peripheralvasodilatation

and

depression

ofmyocardial

contractility.The

indirect

effects

include

activationof

the

central

nervous

system

andsympathizes

system,

which

increasemyocardial

contractility and

causestachycardia

and

hypertension17II.

Pulmonary

functionChanges

in

pulmonary

function

withpneumoperitoneum

:positioninganesthesiaElevation

of

diaphragm

maybeassociated

with

reduction

in

lungvolumes.18II.

Pulmonary

function

In

patients

undergoing

laparoscopic

procedure

with

15

degree

head-downtilt,

the

total

pulmonary

compliancedecreased

by

40%.with

20

degree

head-up

tilt,

thetotalpulmonary

compliance

decreased

by20%.19II.

Pulmonary

function20Increased

IAP

and

upwarddisplacement

of

the

diaphragmcan cause

alveolar collapse

andventilation/perfusionmismatching,resulting

in

hypoxemia

andhypercarbia.III. The

otherphysiological

changesIncreased

IAP

can

result

in

reductionin

splanchenic

and

renal

perfusion.Hepatic

blood

flow

is

decreased

.21III. The

other

physiologicalchangesReduction

in

urine

output.the

compression

of

renal

vesselincreased

plasma

renin

activity

.Increased IAP

can

result

inaspiration

and

regurgitation.22Part

IIAnesthesia

forlaparoscopic

surgery23Ⅰ. Preoperative

evaluation

andpreparation

for

anesthesia.1.

EvaluationElderly,

obesity,

hypertension,coronary

artery

disease.Serious

hypertension

,

cardiacdysfunction

, COPD

.The

open

surgery

(opencholecystectomy)

duo

to

medicalproblem

(serious

hypercarbia).24Ⅰ.

Preoperative

evaluation

andpreparation

for

anesthesia.2.

Preparation

and

premedicationSame

as

general

surgery.Meperidine

and

opioid

is

thought

tocausesphincter

of

oddi

spasm.Atropine

may

help

decease

spasm.H2

antagonist

(ranitidine)

may

be

given(the

patient

being

at

risk for

gastricaspiration).To

open

upper

extremity

vein.25Ⅱ.The

choice

of

anesthesia1.The

principle

of

choiceThe

principle

is

rapidly,

shorter,safety

comfortable

and

return

to

anormal

activity

early.General

anesthesia

is

may

bemoresuitable

than other

anesthesia.26Ⅱ.The

choice

of

anesthesia2.Method

of

anenthesiaA. General

anesthesiaAdvantage:①Proper

depths

of

anesthesia.②

Effective

ventilation.③

To

control

the

relax

of

muscle.④

Adjusting

MVV.27Ⅱ.The

choice

of

anesthesiaAnesthetic

ManagementThe

endotracheal

intubation

issuggested.An

oral

gastric

tube

should

beinserted

to

ensure

that

gastricdistension

does

not

exist.28Ⅱ.The

choice

of

anesthesiaAnesthetic

agents.Propofol,

Etomidate,

Midazolam.Fentanyl,

Remifentanyl,Succinyicholine

Vecuronium

Atracurium.Isoflurane,

desflurane.The

use

of

N2O

is

controversial.It

increases

bowel

distention,

and

produceconflicting

results

on

the

rate

of

N2O

onpostoperative

nausea.29Ⅱ.The

choice

of

anesthesiaB.Epidural

anesthesia。A

high

level

is

required

for

completemuscle

relaxation。70prevent

diaphragmatic

irritationcaused

by

gas

insufflationandsurgical

manipulations.30Ⅱ.The

choice

of

anesthesiaB.Epidural

anesthesia。Serious

respiratorg

depression

ispossiblea

high

regional

blockthe

use

ofopioidthe

diaphragm

is

rised

duringinsufflation.The

occasional

occurrence

of

referredshoulder

pain31Ⅱ.The

choice

of

anesthesia32C.

General

Aesthesia

and

Epiduralanesthesia.D.

Regional

anesthesia.Ⅲ.Perioprative

monitoring33Cardiovascular

functionRespiratory

functionUrinary

volumeNeuromuscular

transmissionⅣ.Special

considerations

inthe

anesthesia34Control

ofintra-abdominalpressurelaparoscopic

cholecystetomy,

IAP10-15mmHgPrevention

of

aspiration

of

gastriccontents.Gynecologic

laparoscopy，IAP20-40mmHg*

obesity，abdominal

wall

lift

isusedⅣ.Special

considerations

inthe

anesthesia35PositionLaparoscopic

cholecystetomy

，supine

is

placed，reverse

trendelenburgwith

right

side

elevates.Gynecologic

laparoscopy,

head-down

andfeet-up.Ⅳ.Special

considerations

inthe

anesthesia36Enhance

respiratory

managementduring

operationThe

use

of

neuromuscularblockers

and

complete

musclerelaxation are

requiredⅣ.Special

considerations

inthe

anesthesia37If

it

is

not

possible

to

complete

thelaparoscopic

procedure,

for

example:

a

majorabdominal vessel

lacerated,peritonitis

and

hemorrhage,

a

opensurgery

will

be

performed.Ⅳ.Special

considerations

inthe

anesthesia38Epidural

anesthesia

representalternative

for

laparoscopic

surgery.But

a

high

level

is

required.

Adisadvantage

is

the

occurrence

ofreferred

shoulder

pain.Ⅳ.Special

considerations

inthe

anesthesiaAfter

operation,

the

residualpheumoperitoneum

should