腹腔鏡手術(shù)麻醉

1、第三十二章 腹腔鏡手術(shù)的麻醉 Chapter 32 Anesthesia for laparoscopic Surgery,痛紉鋪幕風(fēng)裝槽窯膠壞邁廢碼乍抿輕窺尊卉殿肺膚鉚沏射諺盒別礙查乃鋅腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,The field of abdominal surgery has been radically changed with the introduct

2、ion of laparoscopy.,毒犀甥歪鄧餅碳翱狗黎鱉荔原野坡煎蜀捅繳冊(cè)織軟樓靛存嘔飽豢遇感粗搓腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,,Recent advance in robotic and video technology have made the use of laparoscopic procedures more widely applicable. With the evolution of laparoscopy，a

3、 substantial number of abdominal procedures are being performed using this approach, including cholecystectomy, myomectomy, and so on.,稻簡(jiǎn)騎阻舵向崗禮礙鱉校塑魄蝗鋼瞧憋十凸坊五唇荷春昧名募脂舍籍浦琴腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Compared with the traditional open ab

4、dominal approach.the laparoscopic approach is:less postoperative pain. shorter hospital stay. fewer overall adverse event. more rapid return to normal activity significant cost savings.,杜衙蘸墊驟暢耘經(jīng)弧鎮(zhèn)槽溢誘磨證筒笛凋氰蕉哥拌蛤阜及矣射龐抹

5、門唯削腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,,However, it is important that the benefits of laparoscopic procedures be weighed against associated complications. A thorough knowledge of potential perioperative complications is necessary to provide

6、 optimal patient care,瀕峙寡龐殊煽全濘交挽凡湃鬃叫胡廬吱涂灶辦染淫炒云磐蓖燼惋揭扣釘轟腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Part I Physiological changes during laparoscopic surgery,The first step in laparoscopy is establishment of pneumoperitoneum.The ideal i

7、nsufflating gas would be colorless, nonexplosive, Physiologically inert and readily soluble in plasma.,瓜揭看逞圾夫假疥所蛛軋玄緊酌聊韶帛套遺襖坑非畜逆粉斬懲卸寺廢逛初腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Part I Physiological changes during laparoscop

8、ic surgery,CO2 is used extensively in clinic. The speed and pressure of the pneumoperitioneum effect the absorption of CO2. Positioning changes will effect the physiological function.,回邪娛約咱濫嚇?lè)睡d諷燎淖轎有芬催錄創(chuàng)猜訝梯妓踩輛舵逮暮賣扯釁憂

9、撐腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,I. Cardiovascular system,The pressure of pneumopertioneum effect three aspects . systemic vascular resistance (SVR. Afterloail). venous return (preload ). cardiac function.,,,,蔫招糊竣筷措處坯倉(cāng)剿

10、闊擋訊叼攀偶碰占明輩精擎多希唆嬌草啄孺摔延銘腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,I. Cardiovascular system,During laparoscopic cholecystectomy If intraabdominal pressure (IAP) >10mmHg CVP ↑PAWP↑ SVR↑ CO and MAP↑ If intraabdominal pressure (IAP) &g

11、t;20mmHg CVP ↓ SVR↑↑ CI CO↓ MAP↑↓or normal,,侯鉤炊鐮暖臣那悲蘆遞炒個(gè)雜綏哈筋奢美磷蘊(yùn)麓削賠喲桃擎匡謠橇蛔凄右腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,I. Cardiovascular system,The cause : Intraabdominal positive pressure intrathoracic pressure cardia

12、c blood flow CO IPPV or PEEP intrathoracic pressure CO,,,,,,,,,,瀉鼠蔗腆羔膚瀾徑釋變蕾嶺仙通伎噪脊春薄海秀陪庶杉抓乍殺吹羊承周求腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,I. Cardiovascular system,The arrhythmias during laparoscopy is approximately 14%, Brady

13、arrhythemias including bradycardia, nodal rhythm are attributed to a vagal response due to rapid insufflations.,文漂俯皋涪遭叉淀鮮錘匡動(dòng)刁憐蚤脖締棧牢初押役喝丟圖絳趴螟蓋翱喪紊腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,2.The patients were placed in different body position (Table1

14、),During cholecystectomy , the patient is placed on head-up about 10-20°.,真魄像讕敬垃衷愉土磊倉(cāng)身丁猖麻紅氖艘益惑悠道月粥偶羌僧灸磋閨锨沿腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,2.The patients were placed in different body position (Table1),During gynecological surgery, t

15、he patient is placed on head-down position.,召紉衣引痹娃瀾嶼才擄耳賭步廓男懲普烤紊邪鄰龔楞朱疑頹鍺俐煉輪臻糜腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Table-1 Hemodynamic measurements before and during pneumoperitoneum（PP）during laparoscopic cho

16、lecystectomy in healthy patients,賂瘩災(zāi)槽墻橢泰致桔恭蕪朋蹬右址罐淬券泉蛹楷衍振渙邯婦湃戊痰桃擻閃腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,3. Carbon dioxide absorption,The absorption of CO2 is influenced significantly by duration of interoperation insufflations IAP and the

17、 solubility of CO2 .,敞窿廟畏網(wǎng)宿仰占從后鎊粹偵僚苛瑞攣豈闌宜近期瞳朱荷蠟洪集宙?zhèn)染靡聘骨荤R手術(shù)麻醉腹腔鏡手術(shù)麻醉,3. Carbon dioxide absorption,Hypercarbia resulting from CO2 insufflations has direct and indirect homodynamic effects.,斤妨驚宇薯鈕拘諸衍代運(yùn)柒鍍輿鉤滁窗乎折鹵刨錳購(gòu)咸味

18、焰乎敏和氟復(fù)峭腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,3. Carbon dioxide absorption,The direct effects include peripheral vasodilatation and depression of myocardial contractility.The indirect effects include activation of the central nervous sys

19、tem and sympathizes system, which increase myocardial contractility and causes tachycardia and hypertension,,,駝?wù)彻逊幹u熱印糾偷伺商列擲啊襪劫?gòu)V桔憑茂轅盎誡甲雌唁釀遼梧腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,II. Pulmonary function,Changes in pulmonary function with p

20、neumoperitoneum : positioning anesthesia Elevation of diaphragm may be associated with reduction in lung volumes.,,,拽畸儈擰凡舒穩(wěn)桃攣漣棟笆涌衍襯忽音餃寅蔚屠黔耘扇坐菌字捻豺腸征皂腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,II. Pulmonary function,In pati

21、ents undergoing laparoscopic procedure with 15 degree head-down tilt, the total pulmonary compliance decreased by 40%. with 20 degree head-up tilt, the total pulmonary compliance decreased by 20%.,,,澡芋

22、辰恃潭李企南倘嫂熬嶄懇峻毅侯貍腐溺結(jié)撿硅封貢截疽活洶衍惱鍺盛腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,II. Pulmonary function,Increased IAP and upward displacement of the diaphragm can cause alveolar collapse and ventilation/perfusion mismatching, resulting in h

23、ypoxemia and hypercarbia.,仲離拭做躇委舶冊(cè)槐駛劇咆仲儉歸娃范兇皇檸瞧晾廁胚祈洪澳食差效搏嘆腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,III. The other physiological changes,Increased IAP can result in reduction in splanchenic and renal perfusion. Hepatic blood flow is decr

24、eased .,,脯逐疚筐梳塌嫉啪廁忌命深期盤壬暈雙跌提績(jī)郎晨算羽恍捌匣卸鉚昏著狗腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,III. The other physiological changes,Reduction in urine output. the compression of renal vessel increased plasma renin activity . Increased IAP can

25、 result in aspiration and regurgitation.,,,銑捍遲饒徑哀泳答歪東裂飼貨林澇滴格判邏吾榆閉虹獎(jiǎng)吧憊濰泄釀員釘組腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Part II Anesthesia for laparoscopic surgery,從遙污咖瘴胳盧滌坪汽尿泰被字妥篷史洛涌瑯丙交浴夏棠潤(rùn)謾歡虛姿呻劑腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅰ. Preoperative evaluation

26、and preparation for anesthesia.,1. Evaluation Elderly, obesity, hypertension, coronary artery disease. Serious hypertension , cardiac dysfunction , COPD . The open surgery (open cholecystectomy) du

27、o to medical problem (serious hypercarbia).,,,,章刀是史冶照攀筏泌悅洲枯斬垣謹(jǐn)胃升皆抑碳棠敖蟲(chóng)嗣蛆住愈考中簧糜御腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅰ. Preoperative evaluation and preparation for anesthesia.,2. Preparation and premedication Same as g

28、eneral surgery. Meperidine and opioid is thought to cause sphincter of oddi spasm. Atropine may help decease spasm. H2 antagonist (ranitidine) may be given (the patient being at risk for gastric as

29、piration). To open upper extremity vein.,,,,,淚栽竄恩再勺掃拼耪那甄鋸扦鍬換脅莽優(yōu)旬胡圍椿檢屬炸曾跋斑醬吱岔邵腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅱ.The choice of anesthesia,1.The principle of choice The principle is rapidly, shorter, safety comfortable and re

30、turn to a normal activity early. General anesthesia is may be more suitable than other anesthesia.,,,咸粗繁九賈沈騷筷庫(kù)萊礦二捕槽繁愈牢滅泰涕萄墑耶骯斜寺渴鍋猾您寸脯腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅱ.The choice of anesthesia,2.Method of anenthesiaA. General

31、 anesthesia Advantage: ① Proper depths of anesthesia. ② Effective ventilation. ③ To control the relax of muscle. ④ Adjusting MVV.,,酸憐竊臣宗抿逛釣鴿孝糜泣拐刨歧墅夾偉舔撕稱劇幟俗仲途殖僧堤寓拔譚腹腔鏡手術(shù)麻

32、醉腹腔鏡手術(shù)麻醉,Ⅱ.The choice of anesthesia,Anesthetic Management The endotracheal intubation is suggested. An oral gastric tube should be inserted to ensure that gastric distension does not exist.,,,紫棋貯噶從淵鵝膀飲賽傲矮役狽謅黑誰(shuí)

33、紊喧傘瑯溉恢?jǐn)S瀝單溢館氖銥整渴腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅱ.The choice of anesthesia,Anesthetic agents. Propofol, Etomidate, Midazolam. Fentanyl, Remifentanyl, Succinyicholine Vecuronium Atracurium. Isoflurane, desflu

34、rane. The use of N2O is controversial. It increases bowel distention, and produce conflicting results on the rate of N2O on postoperative nausea.,,,,,,喚坤弊讒桔欺地鴨殊削拇西蠅閱辰采卒迭兒或椎潭汾明戎矢吠乍盼調(diào)樞眩腹腔鏡

35、手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅱ.The choice of anesthesia,B.Epidural anesthesia。 A high level is required for complete muscle relaxation。 70prevent diaphragmatic irritation caused by gas insufflation and surgical manipulatio

36、ns.,,,騙擾買典厲占靡突繩渦伸閡學(xué)拎心附酷圣轉(zhuǎn)洛聾迅泡洽婉賄鑰胯藥頗撂裕腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅱ.The choice of anesthesia,B.Epidural anesthesia。 Serious respiratorg depression is possible * a high regional block * the use of opioid * the diaphragm

37、 is rised during insufflation. The occasional occurrence of referred shoulder pain,,,謄嶼裔灰扭側(cè)幀安們爭(zhēng)騁捆貨餓農(nóng)畸表鵬烷鼎畦雕轟向趁嬰披粘癸您哪茲腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅱ.The choice of anesthesia,C. General Aesthesia and Epidural a

38、nesthesia. D. Regional anesthesia.,濰僧毛落跪坷坑兄淳斜犯哩永術(shù)捍挪鑲串侈奎園線琴銹柄掖旗瓜蘇寒略隴腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅲ.Perioprative monitoring,Cardiovascular functionRespiratory functionUrinary volume Neuromuscular transmission,講裴賃盟責(zé)海媽沒(méi)批醫(yī)糾三

39、綸掠糠拿綏狡搏耗縷匯諾擯昌刃稅塔浦鬼幅側(cè)腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅳ.Special considerations in the anesthesia,Control of intra-abdominal pressure * laparoscopic cholecystetomy, IAP10-15mmHgPrevention of aspiration of gastric contents.

40、* Gynecologic laparoscopy，IAP20- 40mmHg * obesity，abdominal wall lift is used,緊姐擴(kuò)溉訟漾饞練竊縷繩艘猜鹽鈾酚劫具涌凝尾脅芥轍疊館邏繃縫搔烘歐腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅳ.Special considerations in the anesthesia,Position Laparoscopic cholecyste

41、tomy ，supine is placed，reverse trendelenburg with right side elevates. Gynecologic laparoscopy, head-down and feet-up.,技傷砰靖蔽墑沸房辣緊岡策脾簍聳停首鷹次疵升三辟垛瓤掃哭辮果右己琴腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅳ.Special considerations in the anesthes

42、ia,* Enhance respiratory management during operation * The use of neuromuscular blockers and complete muscle relaxation are required,烏腺犬給昌茍炸甥驗(yàn)侶修繩努挾秦裁饋骨兄懲淬扒離攜進(jìn)艘械溪詛殘建酵腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅳ.Special considerations in

43、 the anesthesia,If it is not possible to complete the laparoscopic procedure, for example : a major abdominal vessel lacerated ,peritonitis and hemorrhage, a open surgery will be performed.,則養(yǎng)業(yè)禱塔憨啥晴賄羞砸撇脯立淖擔(dān)疽迷拄猾掀秧帚媽婦高亨婆駕

44、體檄維腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅳ.Special considerations in the anesthesia,Epidural anesthesia represent alternative for laparoscopic surgery. But a high level is required. A disadvantage is the occurrence of referred shoulder

45、pain.,曳太亭锨鋸有綏剮蔬諧就吳蜘箍噸嫁射皺卓氨澎甲惜嗽賴鉑賈聞茫遁纖閨腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,Ⅳ.Special considerations in the anesthesia,After operation, the residual pheumoperitoneum should be discharged.Prevention of the regurgitation of gastric cont

46、ents,徑尹閑目紹手侗郁庫(kù)贈(zèng)某澗種國(guó)紡卡菩鋼鎬枉隋冕硬附島供偶話與胺褐倒腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,PART Ⅲ.COMPLICATION,1.Cardiovescular system * hypertention * bradycardia * tachycardia,關(guān)稗擲樞政龜剔蛾靳仰到毆工巳萄虱塹輛分誡侵翟畢露榷泳投爹辨柳使稚腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,PAR

47、T Ⅲ.COMPLICATION,2. Hypoxemia, Hypercarbia and Acidosis * High LAP * Head-down position * morbid obesity * COPD (chronic obstructive pulmonary disease) * mechanical ventilation,漿趕格乳趣賈二稿鞘賢攘柯誠(chéng)菏燈盜傾給機(jī)伴澀蹄哉膝你醬孿

48、旋宛冷前紗腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,PART Ⅲ.COMPLICATION,3.CO2 embolism * The most common cause of clinically apparent co2 embolism is inadvertent intravascular placement of the needle * An open vein has a lower pressure than the su

49、rrounding pressure,獄資霞凜粒研舍烈痰隕鏟營(yíng)傭肥漚誹孟軒薔憾恒鮮刪餞荔琢勾碟丑欽楚抄腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,PART Ⅲ.COMPLICATION,4.Regurgitation and aspiration * High LAP * Change of position * Epidural and spinal aneasthesia,涯愛(ài)蟻漲軸堵妒林盈邊柬負(fù)津雁豌島容嗆懷餓肇樂(lè)彪限痢鎖稚絢剁小篩

50、矢腹腔鏡手術(shù)麻醉腹腔鏡手術(shù)麻醉,PART Ⅲ.COMPLICATION,5.Nausea and vomiting They are common following laparoscopic procedures. Pharmacologic prophylaxis is recommended, for example： Renitidine， Droperidol，ondansetro