妇科腹腔镜手术头低脚高位和CO_2气腹对循环的影响

Influence of the trendelenburg position and CO_2 pneumoperitoneum on the circulation in gynecological laparoscopic surgery

目的探讨妇科腹腔镜手术头低脚高位和CO2气腹对循环的影响。方法选择于北京妇产医院行妇科腹腔镜手术的10例ASAⅠ级的健康女性为研究对象,以瑞芬太尼和依托咪酯静脉诱导气管插管和维持。监测创建气腹前平躺时(T1)、头低10°时(T2)、头低20°时(T3)、手术开始时、创建气腹后气腹压10 mm Hg及15 mm Hg平躺时、头低10°时及头低20°时(T4-1、T4-2、T4-3和T5-1、T5-2、T5-3)的心率、收缩压(SBP)、舒张压(DBP)、平均动脉压、心排量、心指数、每搏量、每搏指数、每搏量变异和脑电双频指数(BIS)。结果腹腔充气前,仰卧位、头低脚10°和20°三个时点,各项血流动力学参数无明显变化;充气前SBP为(105.8±4.0)mm Hg、DBP为(64.1±2.2)mm Hg,充气后SBP为(121.4±4.1)mm Hg、DBP为(81.3±3.6)mm Hg,充气后血压明显高于充气前,差异有高度统计学意义(P<0.01),但是充气后体位对各项血流动力学参数并无明显影响。气腹压12 mm Hg和15 mm Hg相比,血流动力学无明显改变。结论无合并症的患者可以较好地耐受常规的头低脚高位对机体的影响,腹腔镜下CO2气腹对患者的循环影响较大,如果高气腹压持续时间较长,会对患者造成不良影响,特别是老年人、高血压及心脏病患者。

Objective To investigate the influence of trendelenburg position and CO2 pneumoperitoneum on the circu- lation. Methods 10 ASA I healthy women with gynecological laparoscopy in Beijing Obstetrics and Gynecology Hos- pital were selected as study objects. Anesthesia was induced and maintained with Remifentanil combined with Etomi- date by intravenous induction endotraeheal intubation. Heart rate, systolic blood pressure （SBP）, diastolic blood pres- sure （DBP）, mean arterial pressure, cardiac output, cardiac index, stroke volume, stroke volume index, stroke volume variation and BIS were monitored in supine position （Tl）, 10 degrees trendelenburg position （T2） and 20 degrees tren- delenburg position （T3） before establishment of pneumoperit0neum; supine position, 10 degrees trendelenburg position and 20 degrees trendelenburg position with presence of 12 mm Hg pressure of CO2 pneumoperitoneum （T4-1, T4-2 and T4-3） and 15 mm Hg pressure of CO2 pneumoperitoneum （T5-1, Ts-2 and Ts-3） after establishment of pneumoperitoneum at the beginning of surgery. Results There was no statistical change in hemodynamic parameters at the supine position, 10 degrees trendelenburg position or 20 degrees trendelenburg position before establishment of pneumoperitoneum; the SBP and DBP before establishment of pneumoperitoneum [（105.8±4.0） mm Hg, （64.1±2.2） mm Hg] were lower than those after establishment of pneumoperitoneum [（121.4±4.1） mm Hg, （81.3±3.6） mm Hg], the differences were highly statistically significant （P 〈 0.01）, but the body position had no significant effect on hemodynamic parameters. There was no statistical hemodynamic difference CO2 pressure of pneumoperitoneum between 12 mm Hg and 15 mm Hg. Conclusion Patients without complications can easily tolerate the effects of routine supine position on the body, CO2 pneumoperitoneum has huge impact on circulation under laparoscopy, and if high pressure of pneumoperitoneum main- tains for a long time, it will exert negative effects on patients, especially those with hypertension, heart diseases and old people.