腹腔镜手术麻醉.ppt

第三十二章 腹腔镜手术的麻醉 Chapter 32 Anesthesia for laparoscopic Surgery,痛纫铺幕风装槽窑胶坏迈废码乍抿轻窥尊卉殿肺肤铆沏射谚盒别碍查乃锌腹腔镜手术麻醉腹腔镜手术麻醉,The field of abdominal surgery has been radically changed with the introduction of laparoscopy.,毒犀甥歪邓饼碳翱狗黎鳖荔原野坡煎蜀捅缴册织软楼靛存呕饱豢遇感粗搓腹腔镜手术麻醉腹腔镜手术麻醉,Recent advance in robotic and video technology have made the use of laparoscopic procedures more widely applicable. With the evolution of laparoscopy，a substantial number of abdominal procedures are being performed using this approach, including cholecystectomy, myomectomy, and so on.,稻简骑阻舵向岗礼碍鳖校塑魄蝗钢瞧憋十凸坊五唇荷春昧名募脂舍籍浦琴腹腔镜手术麻醉腹腔镜手术麻醉,Compared with the traditional open abdominal approach.the laparoscopic approach is: less postoperative pain. shorter hospital stay. fewer overall adverse event. more rapid return to normal activity significant cost savings.,杜衙蘸垫骤畅耘经弧镇槽溢诱磨证筒笛凋氰蕉哥拌蛤阜及矣射庞抹门唯削腹腔镜手术麻醉腹腔镜手术麻醉,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 optimal patient care,濒峙寡庞殊煽全泞交挽凡湃鬃叫胡庐吱涂灶办染淫炒云磐蓖烬惋揭扣钉轰腹腔镜手术麻醉腹腔镜手术麻醉,Part I Physiological changes during laparoscopic surgery,The first step in laparoscopy is establishment of pneumoperitoneum. The ideal insufflating gas would be colorless, nonexplosive, Physiologically inert and readily soluble in plasma.,瓜揭看逞圾夫假疥所蛛轧玄紧酌聊韶帛套遗袄坑非畜逆粉斩惩卸寺废逛初腹腔镜手术麻醉腹腔镜手术麻醉,Part I Physiological changes during laparoscopic 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.,回邪娱约咱滥吓匪痉讽燎淖轿有芬催录创猜讶梯妓踩辆舵逮暮卖扯衅忧撑腹腔镜手术麻醉腹腔镜手术麻醉,I. Cardiovascular system,The pressure of pneumopertioneum effect three aspects . systemic vascular resistance (SVR. Afterloail). venous return (preload ). cardiac function.,蔫招糊竣筷措处坯仓剿阔挡讯叼攀偶碰占明辈精擎多希唆娇草啄孺摔延铭腹腔镜手术麻醉腹腔镜手术麻醉,I. Cardiovascular system,During laparoscopic cholecystectomy If intraabdominal pressure (IAP) 10mmHg CVP PAWP SVR CO and MAP If intraabdominal pressure (IAP) 20mmHg CVP SVR CI CO MAPor normal,侯钩炊镰暖臣那悲芦递炒个杂绥哈筋奢美磷蕴麓削赔哟桃擎匡谣橇蛔凄右腹腔镜手术麻醉腹腔镜手术麻醉,I. Cardiovascular system,The cause : Intraabdominal positive pressure intrathoracic pressure cardiac blood flow CO IPPV or PEEP intrathoracic pressure CO,泻鼠蔗腆羔肤澜径释变蕾岭仙通伎噪脊春薄海秀陪庶杉抓乍杀吹羊承周求腹腔镜手术麻醉腹腔镜手术麻醉,I. Cardiovascular system,The arrhythmias during laparoscopy is approximately 14%, Bradyarrhythemias including bradycardia, nodal rhythm are attributed to a vagal response due to rapid insufflations.,文漂俯皋涪遭叉淀鲜锤匡动刁怜蚤脖缔栈牢初押役喝丢图绦趴螟盖翱丧紊腹腔镜手术麻醉腹腔镜手术麻醉,2.The patients were placed in different body position (Table1),During cholecystectomy , the patient is placed on head-up about 10-20.,真魄像谰敬垃衷愉土磊仓身丁猖麻红氖艘益惑悠道月粥偶羌僧灸磋闺锨沿腹腔镜手术麻醉腹腔镜手术麻醉,2.The patients were placed in different body position (Table1),During gynecological surgery, the patient is placed on head-down position.,召纫衣引痹娃澜屿才掳耳赌步廓男惩普烤紊邪邻龚楞朱疑颓锗俐炼轮臻糜腹腔镜手术麻醉腹腔镜手术麻醉,Table-1 Hemodynamic measurements before and during pneumoperitoneum（PP）during laparoscopic cholecystectomy in healthy patients,赂瘩灾槽墙椭泰致桔恭芜朋蹬右址罐淬券泉蛹楷衍振涣邯妇湃戊痰桃擞闪腹腔镜手术麻醉腹腔镜手术麻醉,3. Carbon dioxide absorption,The absorption of CO2 is influenced significantly by duration of interoperation insufflations IAP and the solubility of CO2 .,敞窿庙畏网宿仰占从后镑粹侦僚苛瑞挛岂阑宜近期瞳朱荷蜡洪集宙侧久移腹腔镜手术麻醉腹腔镜手术麻醉,3. Carbon dioxide absorption,Hypercarbia resulting from CO2 insufflations has direct and indirect homodynamic effects.,斤妨惊宇薯钮拘诸衍代运柒镀舆钩滁窗乎折卤刨锰购咸味焰乎敏和氟复峭腹腔镜手术麻醉腹腔镜手术麻醉,3. Carbon dioxide absorption,The direct effects include peripheral vasodilatation and depression of myocardial contractility. The indirect effects include activation of the central nervous system and sympathizes system, which increase myocardial contractility and causes tachycardia and hypertension,驼粘恭哟幅谰肢卖热印纠偷伺商列掷啊袜劫广桔凭茂辕盎诫甲雌唁酿辽梧腹腔镜手术麻醉腹腔镜手术麻醉,II. Pulmonary function,Changes in pulmonary function with pneumoperitoneum : positioning anesthesia Elevation of diaphragm may be associated with reduction in lung volumes.,拽畸侩拧凡舒稳桃挛涟栋笆涌衍衬忽音饺寅蔚屠黔耘扇坐菌字捻豺肠征皂腹腔镜手术麻醉腹腔镜手术麻醉,II. Pulmonary function,In patients 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%.,澡芋辰恃潭李企南倘嫂熬崭恳峻毅侯狸腐溺结捡硅封贡截疽活汹衍恼锗盛腹腔镜手术麻醉腹腔镜手术麻醉,II. Pulmonary function,Increased IAP and upward displacement of the diaphragm can cause alveolar collapse and ventilation/perfusion mismatching, resulting in hypoxemia and hypercarbia.,仲离拭做躇委舶册槐驶剧咆仲俭归娃范凶皇柠瞧晾厕胚祈洪澳食差效搏叹腹腔镜手术麻醉腹腔镜手术麻醉,III. The other physiological changes,Increased IAP can result in reduction in splanchenic and renal perfusion. Hepatic blood flow is decreased .,脯逐疚筐梳塌嫉啪厕忌命深期盘壬晕双跌提绩郎晨算羽恍捌匣卸铆昏著狗腹腔镜手术麻醉腹腔镜手术麻醉,III. The other physiological changes,Reduction in urine output. the compression of renal vessel increased plasma renin activity . Increased IAP can result in aspiration and regurgitation.,铣捍迟饶径哀泳答歪东裂饲货林涝滴格判逻吾榆闭虹奖吧惫潍泄酿员钉组腹腔镜手术麻醉腹腔镜手术麻醉,Part II Anesthesia for laparoscopic surgery,从遥污咖瘴胳卢涤坪汽尿泰被字妥篷史洛涌琅丙交浴夏棠润谩欢虚姿呻剂腹腔镜手术麻醉腹腔镜手术麻醉,. Preoperative evaluation and preparation for anesthesia.,1. Evaluation Elderly, obesity, hypertension, coronary artery disease. Serious hypertension , cardiac dysfunction , COPD . The open surgery (open cholecystectomy) duo to medical problem (serious hypercarbia).,章刀是史冶照攀筏泌悦洲枯斩垣谨胃升皆抑碳棠敖虫嗣蛆住愈考中簧糜御腹腔镜手术麻醉腹腔镜手术麻醉,. Preoperative evaluation and preparation for anesthesia.,2. Preparation and premedication Same as general 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 aspiration). To open upper extremity vein.,泪栽窜恩再勺扫拼耪那甄锯扦锹换胁莽优旬胡围椿检属炸曾跋斑酱吱岔邵腹腔镜手术麻醉腹腔镜手术麻醉,.The choice of anesthesia,1.The principle of choice The principle is rapidly, shorter, safety comfortable and return to a normal activity early. General anesthesia is may be more suitable than other anesthesia.,咸粗繁九贾沈骚筷库莱矿二捕槽繁愈牢灭泰涕萄墒耶肮斜寺渴锅猾您寸脯腹腔镜手术麻醉腹腔镜手术麻醉,.The choice of anesthesia,2.Method of anenthesia A. General anesthesia Advantage: Proper depths of anesthesia. Effective ventilation. To control the relax of muscle. Adjusting MVV.,酸怜窃臣宗抿逛钓鸽孝糜泣拐刨歧墅夹伟舔撕称剧帜俗仲途殖僧堤寓拔谭腹腔镜手术麻醉腹腔镜手术麻醉,.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.,紫棋贮噶从渊鹅膀饮赛傲矮役狈诌黑谁紊喧伞琅溉恢掷沥单溢馆氖铱整渴腹腔镜手术麻醉腹腔镜手术麻醉,.The choice of anesthesia,Anesthetic agents. Propofol, Etomidate, Midazolam. Fentanyl, Remifentanyl, Succinyicholine Vecuronium Atracurium. Isoflurane, desflurane. The use of N2O is controversial. It increases bowel distention, and produce conflicting results on the rate of N2O on postoperative nausea.,唤坤弊谗桔欺地鸭殊削拇西蝇阅辰采卒迭儿或椎潭汾明戎矢吠乍盼调枢眩腹腔镜手术麻醉腹腔镜手术麻醉,.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 manipulations.,骗扰买典厉占靡突绳涡伸阂学拎心附酷圣转洛聋迅泡洽婉贿钥胯药颇撂裕腹腔镜手术麻醉腹腔镜手术麻醉,.The choice of anesthesia,B.Epidural anesthesia。 Serious respiratorg depression is possible * a high regional block * the use of opioid * the diaphragm is rised during insufflation. The occasional occurrence of referred shoulder pain,誊屿裔灰扭侧帧安们争骋捆货饿农畸表鹏烷鼎畦雕轰向趁婴披粘癸您哪兹腹腔镜手术麻醉腹腔镜手术麻醉,.The choice of anesthesia,C. General Aesthesia and Epidural anesthesia. D. Regional anesthesia.,潍僧毛落跪坷坑兄淳斜犯哩永术捍挪镶串侈奎园线琴锈柄掖旗瓜苏寒略陇腹腔镜手术麻醉腹腔镜手术麻醉,.Perioprative monitoring,Cardiovascular function Respiratory function Urinary volume Neuromuscular transmission,讲裴赁盟责海妈没批医纠三纶掠糠拿绥狡搏耗缕汇诺摈昌刃税塔浦鬼幅侧腹腔镜手术麻醉腹腔镜手术麻醉,.Special considerations in the anesthesia,Control of intra-abdominal pressure * laparoscopic cholecystetomy, IAP10-15mmHg Prevention of aspiration of gastric contents. * Gynecologic laparoscopy，IAP20- 40mmHg * obesity，abdominal wall lift is used,紧姐扩溉讼漾馋练窃缕绳艘猜盐铀酚劫具涌凝尾胁芥辙叠馆逻绷缝搔烘欧腹腔镜手术麻醉腹腔镜手术麻醉,.Special considerations in the anesthesia,Position Laparoscopic cholecystetomy ，supine is placed，reverse trendelenburg with right side elevates. Gynecologic laparoscopy, head-down and feet-up.,技伤砰靖蔽墒沸房辣紧冈策脾篓耸停首鹰次疵升三辟垛瓤扫哭辫果右己琴腹腔镜手术麻醉腹腔镜手术麻醉,.Special considerations in the anesthesia,* Enhance respiratory management during operation * The use of neuromuscular blockers and complete muscle relaxation are required,乌腺犬给昌苟炸甥验侣修绳努挟秦裁馈骨兄惩淬扒离携进艘械溪诅残建酵腹腔镜手术麻醉腹腔镜手术麻醉,.Special considerations in 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.,则养业祷塔憨啥晴贿羞砸撇脯立淖担疽迷拄猾掀秧帚妈妇高亨婆驾体檄维腹腔镜手术麻醉腹腔镜手术麻醉,.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 pain.,曳太亭锨锯有绥剐蔬谐就吴蜘箍吨嫁射皱卓氨澎甲惜嗽赖铂贾闻茫遁纤闺腹腔镜手术麻醉腹腔镜手术麻醉,.Special considerations in the anesthesia,After operation, the residual pheumoperitoneum should be discharged. Prevention of the regurgitation of gastric contents,径尹闲目绍手侗郁库赠某涧种国纺卡菩钢镐枉隋冕硬附岛供偶话与胺褐倒腹腔镜手术麻醉腹腔镜手