腹腔镜手术麻醉教学材料

腹腔镜手术麻醉教学材料腹腔镜手术麻醉教学材料 第三十二章腹腔镜手术的麻醉Chapter32Anesthesia for laparoscopic Surgery The fieldof abdominalsurgery hasbeen radicallychanged withthe introductionof laparoscopy Recent advancein roboticand videotechnology havemade the use oflaparoscopic proceduresmore widelyapplicable With theevolution oflaparoscopy a substantialnumber ofabdominal proceduresare beingperformed usingthis approach including cholecystectomy myomectomy and soon Compared withthe traditionalopen abdominalapproach the laparoscopicapproach is less postoperativepain shorter hospitalstay fewer overalladverse event more rapidreturn tonormal activity significant costsavings Part IPhysiological changesduring laparoscopic surgery The firststep inlaparoscopy isestablishment ofpneumoperitoneum The idealinsufflating gaswould becolorless nonexplosive Physiologically inertand readilysoluble inplasma Part IPhysiological changesduring laparoscopicsurgery CO2is usedextensively inclinic The speedand pressureof thepneumoperitioneum effectthe absorption of CO2 Positioning changeswill effectthe physiologicalfunction I Cardiovascular systemThe pressureof pneumopertioneumeffect threeaspects systemic vascularresistance SVR Afterloail venous return preload cardiac function I Cardiovascular systemDuring laparoscopiholecystectomy If intraabdominal pressure IAP 10mmHg CVP PAWP SVR CO andMAP If intraabdominalpressure IAP 20mmHg CVP SVR CI CO MAP or normalI Cardiovascular system The cause Intraabdominal positivepressure intrathoracic pressure cardiacblood flowCO IPPVor PEEPintrathoracicpressureCO I Cardiovascular system The arrhythmiasduring laparoscopyis approximately14 Bradyarrhythemias includingbradycardia nodal rhythmare attributedto avagal responsedue torapid insufflations 2 The patientswere placedin differentbody position Table1 During cholecystectomy the patientis placedon head up about10 20 2 The patientswere placedin differentbody position Table1 During gynecologicalsurgery the patientis placedon head down position Table 1Hemodynamic measurementsbefore andduring pneumoperitoneum PP during laparoscopiholecystectomy inhealthy patientsSupine Head down Head up Supinewith pp Head down withppHead up Withpp Heartrate beats min 61 753 466 966 1653 370 8MAP mmHg 69 776 664 991 1187 884 13CVP mmHg 6 2 2 910 2 3 5 0 8 3 510 9 2 715 9 4 63 1 2 6MPAP mmHg 14 1 1 517 4 1 28 5 3 518 4 3 720 0 6 110 8 2 5SVR dynes sec cm5 131 0 3021381 3131419 3421795 4441577 3442047 4303 Carbon dioxideabsorption Theabsorptionof CO2is influencedsignificantly by duration ofinteroperation insufflations IAP andthe solubilityofCO2 3 Carbon dioxideabsorption Hypercarbiaresulting fromCO2insufflations hasdirect andindirect homodynamiceffects 3 Carbon dioxideabsorption Thedirect effects include peripheralvasodilatation anddepression ofmyocardial contractility The indirecteffectsincludeactivation ofthe centralnervous systemand sympathizessystem which increasemyocardial contractilityand causestachycardia andhypertension II Pulmonary functionChanges inpulmonary functionwith pneumoperitoneum positioning anesthesiaElevation ofdiaphragm may be associatedwith reductionin lungvolumes II Pulmonary functionIn patientsundergoing laparoscopic procedure with15degree head down tilt the totalpulmonary pliancedecreased by40 with20degree head up tilt the totalpulmonary pliancedecreased by20 II Pulmonary function Increased IAPand upwarddisplacement ofthe diaphragmcan causealveolar collapseand ventilation perfusion mismatching resulting inhypoxemia andhypercarbia III The otherphysiological changes Increased IAPcan resultin reductionin splanchenicand renalperfusion Hepatic bloodflow isdecreased III The otherphysiological changesReduction inurine output the pressionof renalvessel increasedplasma reninactivity Increased IAPcan resultin aspirationand regurgitation Part IIAnesthesia forlaparoscopicsurgery Preoperative evaluationand preparationfor anesthesia 1 Evaluation Elderly obesity hypertension coronary arterydisease Serious hypertension cardiac dysfunction COPD The opensurgery open cholecystectomy duo tomedical problem serious hypercarbia Preoperative evaluationand preparationfor anesthesia 2 Preparation andpremedication Sameas generalsurgery Meperidine andopioid isthought tocause sphincterof oddispasm Atropine mayhelp deceasespasm H2antagonist ranitidine maybegiven the patientbeing atrisk forgastric aspiration To openupper extremityvein The choiceof anesthesia1 The principleof choiceThe principleis rapidly shorter safety fortableand returnto anormal activityearly General anesthesiais maybe moresuitable thanother anesthesia The choiceof anesthesia2 Method ofanenthesia A General anesthesiaAdvantage Proper depthsof anesthesia Effective ventilation To controlthe relaxof muscle Adjusting MVV The choiceof anesthesiaAnesthetic ManagementThe endotrachealintubation issuggested An oralgastric tubeshould beinserted toensure thatgastric distensiondoes notexist The choiceof anesthesiaAnesthetic agents Propofol Etomidate Midazolam Fentanyl Remifentanyl S uinyicholine VecuroniumAtracurium Isoflurane desflurane The useof N2O iscontroversial It increasesbowel distention and produceconflicting resultson therate ofN2O onpostoperative nausea The choiceof anesthesiaB Epidural anesthesia A high level is required forplete musclerelaxation 70prevent diaphragmaticirritation causedby gasinsufflation andsurgical manipulations The choiceof anesthesiaB Epidural anesthesia Serious respiratorgdepression ispossible a highregional block theuseof opioid the diaphragmis risedduring insufflation The oasionalourrence ofreferred shoulderpain The choiceof anesthesiaC General Aesthesiaand Epidural anesthesia D Regional anesthesia Perioprative monitoring Cardiovascular function Respiratory function Urinary volume Neuromuscular transmission Special considerationsin theanesthesia Control ofintra abdominalpressure laparoscopic cholecystetomy IAP10 15mmHg Prevention ofaspiration of gastric contents Gynecologic laparoscopy IAP20 40mmHg obesity abdominal walllift isused Special considerationsin theanesthesia Position Laparoscopiholecystetomy supine isplaced reverse trendelenburgwith rightside elevates Gynecologic laparoscopy head down andfeet up Special considerationsin theanesthesia Enhance respiratorymanagement duringoperation The useof neuromuscularblockers andplete musclerelaxation arerequired Special considerationsin theanesthesia If itis notpossible toplete thelaparoscopicprocedure for example a majorabdominal vessellacerated peritonitis andhemorrhage a opensurgery willbe performed Special considerationsin theanesthesia Epiduralanesthesiarepresent alternativeforlaparoscopicsurgery But ahighlevelisrequired A disadvantageis theourrence ofreferred shoulderpain Special considerationsin theanesthesia After operation the residualpheumoperitone