三种麻醉方法对腹腔镜手术二氧化碳气腹期间自主神经活动趋势的影响

Effects of Three Kinds of Anesthesia Procedures on Tendency of Autonomic Nervous Activity during CO_2 Pneumoperitoneum Pressure in Laparoscopic Cholecystectomy

目的以心率变异性（heart rate variability，HRV）为观察指标，观察分析不同的麻醉方法对腹腔镜胆囊切除手术（Laparoscopic cholecystectomy，LC）二氧化碳（CO2）气腹期间自主神经活动趋势的影响。方法选择ASAⅠ～Ⅱ级的择期L患者45例，按手术日期分为全身麻醉组（Ⅰ组，对照组）、全身麻醉＋艾司洛尔组（Ⅱ组）和全麻复合硬膜外阻滞组（Ⅲ组），分别在麻醉前，气腹前，气腹后5、10、20及30min观察HRV及血流动力学的变化。结果与气腹前相比，Ⅰ组低频（LF）、低频／高频（LF／HF）在气腹后不同时点均显著升高（P〈0．05）；Ⅱ组LF／HF在气腹后5、10min显著升高（P〈0．05）；Ⅲ组气腹后各时点LF、HF、LF／HF均无显著变化（P〉0．05）。组间比较，Ⅰ组LF、LF／HF在气腹后各时点均显著高于Ⅱ、Ⅲ组（P〈0．05），Ⅱ组LF在气腹后10min显著高于Ⅲ组（P〈0．05），LF／HF在气腹后5、10min显著高于Ⅲ组（P〈0．05）。HF各组间差异无显著性（P〉0．05）。结论艾司洛尔可减轻气腹引起的应激反应，但不能完全阻止其交感活性的增强；全麻复合硬膜外阻滞用于腹腔镜胆囊切除手术，可以抑制气腹引起的交感神经兴奋，维持自主神经的稳定性。

Objective To analyze effects of different anesthesia procedures on heart rate variability （HRV） as an index of autonomic nervous activity and hemodynamics during CO2 pneumoperitoneum pressure in laparoscopic cholecystectomy （LC）. Methods 45 patients of ASA Ⅰ or Ⅱ phage scheduled for LC were divided into general anesthesia group（ Group Ⅰ, Control Group） , general anesthesia combined with esmolol group （ Group Ⅱ） and general anesthesia combined with epidural block group （ Group Ⅲ） according to operation date. HRV, HR and MAP were measured before anesthesia（ T1 ）, before pneumoperitoneum（T2） and at 5 min （T3） , 10 min （T4）, 20 min （T5） , 30 min（T6） after pneumoperitoneum. Results As compared with pre-pneumoperitoneum （T2） , low frequency （LF） , low frequency/high frequency （LF/HF） in the Group Ⅰ increased significantly （P 〈0.01 ） at 33, T4, T5, T6; LF/HF in the Group Ⅱ increased significantly （ P 〈 0. 05 ） at 5,10 min after pneumoperitoneum; LF, HF, LF/HF in the Group Ⅲ at all time points after pneumoperitoneum had no obvious changes （ P 〉 0. 05）. Comparisons among the three groups, LF, LF/HF in the Group Ⅰ at all time points after pneumoperitoneum were significantly higher than those in the Ⅱ and Ⅲ Group （ P 〈 0. 05 ） ; LF in the Group Ⅱ at 10 min after pneumoperitoneum was significantly higher than that in the Group Ⅲ（ P 〈 0. 05 ） ; LF/HF in the Group Ⅱ at 5,10 min after pneumoperitoneum were significantly higher than that in the Group Ⅲ （ P 〈0.05）. There was no obvious difference in HF among the three groups （P 〉 0. 05 ）. Conclusions Esmolol can relieve stress reaction induced by pneumoperitoneum, but it can＇t completely block increasing of sympathetic nerve activity; using general anesthesia combined with epidural block in LC can inhibit sympathetic nerve excitation, sustain automatic never stability.