不同气腹压力对腹腔镜妇科手术患者颅内压的影响

Effects of different pneumoperitoneum pressure on intracranial pressure in patients undergoing laparoscopic gynecological surgery

目的应用超声测量视神经鞘直径(ONSD)评价不同气腹压力下腹腔镜妇科手术患者颅内压(ICP)的变化。方法择期行腹腔镜妇科手术患者40例,年龄18~65岁,BMI 18~25 kg/m2,ASA Ⅰ或Ⅱ级,采用随机数字表法分为两组(n=20):低气腹压力组(A组)和高气腹压力组(B组)。常规麻醉诱导和机械通气。手术开始时行CO2气腹,A组气腹压力为10 mmHg,B组为14 mmHg。气腹后调整体位为30°头低脚高位,手术结束时恢复为仰卧位。超声测量患者右眼ONSD,根据ONSD计算ICPONSD。记录麻醉诱导后气腹前(T0)、气腹后1min(T1)、头低脚高位即刻(T2)、气腹后30 min后(T3)、气腹后60 min后(T4)、手术结束后5 min(T5)、15 min(T6)时的PETCO2、PaCO2、MAP、HR、ONSD和ICPONSD。结果与T0时比较,T4、T5时两组PETCO2、PaCO2明显升高,T4—T6时MAP明显升高(P<0.05);T4—T6时A组,T3—T6时B组HR明显增快(P<0.05)。与A组比较,T3、T4时B组MAP明显升高,HR明显增快(P<0.05)。与T0时比较,T4、T5时A组ONSD、ICPONSD明显升高,T3—T5时B组ONSD、ICPONSD明显升高(P<0.05)。与A组比较,T3时B组ONSD、ICPONSD明显升高(P<0.05)。结论10 mmHg和14 mmHg气腹压力均可引起腹腔镜妇科手术患者ONSD和ICP升高,其中14 mmHg气腹压力对ONSD和ICP的影响更大。

Objective To investigate the effects of different pneumoperitoneum pressure on intracranial pressure(ICP) in patients undergoing laparoscopic gynecological surgery by monitoring optic nerve sheath diameter(ONSD) under ultrasonic. Methods Forty patients, aged 18-65 years, with a BMI 18-25 kg/m2, falling into ASA physical status Ⅰ or Ⅱ,were recruited and scheduled to undergo elective gynecologic laparoscopic surgery. All patients were randomly divided into 2 groups(n = 20): low pneumoperitoneum pressure group(group A) and high pneumoperitoneum pressure group(group B). Conventional anesthesia induction and mechanical ventilation were performed. CO2 pneumoperitoneum was performed at the beginning of the operation. The patients of groups A and B underwent CO2 pneumoperitoneum with intra-abdominal pressure 10 mmHg and 14 mmHg, respectively. Then the position of operation of the patients were at an angle of 30° Trendelenburg position, and returned to the supine position at the end of the operation. ONSD of the right eye in the patient was monitored by ultrasound and ICPONSD was calculated based on ONSD. PETCO2, PaCO2, MAP, HR, ONSD and ICPONSD were recorded before pneumoperitoneum(T0), 1 minute after pneumoperitoneum(T1), immediately at the time point of Trendelenburg position(T2), 30 minutes after pneumoperitoneum(T3), 60 minutes after pneumoperitoneum(T4), 5 minutes(T5) and 15 minutes after the end of surgery(T6). Results Compared with T0, PETCO2 and PaCO2 increased at T4 and T5 and MAP increased significantly at T4-T6 in patients of the two groups(P < 0.05);HR of patients in group A at T4-T6, and in group B at T3-T6 increased significantly(P < 0.05). Compared with group A, MAP and HR increased significantly at T3 and T4 in patients of group B(P < 0.05). Compared with T0, ONSD and ICPONSD of group A at T4 and T5, and of group B at T3-T5 increased significantly(P < 0.05). Compared with group A, ONSD and ICPONSD increased significantly at T3 in patients of group B(P < 0.05). Conclusion Both 10 mmHg and 14 mmHg pneumoperitoneum pressure can increase ONSD and ICP in patients undergoing laparoscopic gynecological surgery. The effect of 14 mmHg pneumoperitoneum on ONSD and ICP is greater than of 10 mmHg.