经食管超声心动图观察腹腔镜全子宫切除术静脉气栓的研究

The study of transesophageal echocardiography monitoring for detection of venous air embolism in total laparoscopic hysterectomy

目的通过经食管超声心动图探讨腹腔镜下全子宫切除术（total laparoscopic hysterectomy,TLH）和经腹全子宫切除术（total abdominal hysterectomy,TAH）患者静脉气栓（venous air embolism,VAE）的发生情况和等级。方法选择美国麻醉医师协会麻醉风险分级（ASA）Ⅰ级的接受TLH和TAH的患者各43例。全身麻醉后,经食管插入多平面经食管超声心动图（TEE）探头。在食管中段持续监测心脏四腔和上、下腔静脉,麻醉医生根据TEE结果对VAE分级。结果 TLH组100%发生VAE,其中17例（39.5%）为Ⅲ-Ⅳ级。TAH组7例（16.3%）发生VAE,均为Ⅰ级。2组VAE的等级构成比较,差异有统计学意义（Z=-7.955,P〈0.001）。2组VAE患者均未出现血流动力学不稳定或心电图异常,37例TLH患者VAE发生在子宫圆韧带横断和子宫阔韧带剪切时。结论 TLH组VAE的发生率为100%。TLH组VAE等级高于TAH组,子宫圆韧带横断和子宫阔韧带剪切时发生VAE尤为显著。

Objective To observe the occurrence and grade of venous air embolism（VAE） in total laparoscopic hysterectomy（TLH） and those in total abdominal hysterectomy（TAH） using transesophageal echocardiography（TEE）. Methods Forty-three patients（ASAⅠ） scheduled for TLH and forty-three（ASAⅠ） for TAH were enrolled. After induction of general anesthesia, a multiplane TEE probe was inserted. The midesophageal four-chamber or bicaval view was continuously monitored. VAE was graded by TEE. Results All the patients in TLH group showed VAE, and III-IV grade VAE occurred in 17（ 39.5%） patients; Seven（16.3%） patients in TAH group showed VAE, and all of the VAE were grade I（P 0.001）. Hemodynamic instability or electrocardiogram changes at the time of VAE occurrence were not observed in the two groups. Thirty-seven VAE in TLH group occurred during transaction of the round ligament and dissection of the broad ligament. Conclusion The incidence of VAE in the patients of TLH group is 100%. VAE grade in TLH is higher than that in TAH, especially during transection of the round ligament and dissection of the broad ligament.