腹腔镜手术麻醉.ppt

第三十二章腹腔镜手术的麻醉Chapter32AnesthesiaforlaparoscopicSurgery,Thefieldofabdominalsurgeryhasbeenradicallychangedwiththeintroductionoflaparoscopy.,Recentadvanceinroboticandvideotechnologyhavemadetheuseoflaparoscopicproceduresmorewidelyapplicable.Withtheevolutionoflaparoscopy，asubstantialnumberofabdominalproceduresarebeingperformedusingthisapproach,includingcholecystectomy,myomectomy,andsoon.,Comparedwiththetraditionalopenabdominalapproach.thelaparoscopicapproachis:lesspostoperativepain.shorterhospitalstay.feweroveralladverseevent.morerapidreturntonormalactivitysignificantcostsavings.,However,itisimportantthatthebenefitsoflaparoscopicproceduresbeweighedagainstassociatedcomplications.Athoroughknowledgeofpotentialperioperativecomplicationsisnecessarytoprovideoptimalpatientcare,PartIPhysiologicalchangesduringlaparoscopicsurgery,Thefirststepinlaparoscopyisestablishmentofpneumoperitoneum.Theidealinsufflatinggaswouldbecolorless,nonexplosive,Physiologicallyinertandreadilysolubleinplasma.,PartIPhysiologicalchangesduringlaparoscopicsurgery,CO2isusedextensivelyinclinic.ThespeedandpressureofthepneumoperitioneumeffecttheabsorptionofCO2.Positioningchangeswilleffectthephysiologicalfunction.,I.Cardiovascularsystem,Thepressureofpneumopertioneumeffectthreeaspects.systemicvascularresistance(SVR.Afterloail).venousreturn(preload).cardiacfunction.,I.Cardiovascularsystem,DuringlaparoscopiccholecystectomyIfintraabdominalpressure(IAP)10mmHgCVPPAWPSVRCOandMAPIfintraabdominalpressure(IAP)20mmHgCVPSVRCICOMAPornormal,I.Cardiovascularsystem,Thecause:IntraabdominalpositivepressureintrathoracicpressurecardiacbloodflowCOIPPVorPEEPintrathoracicpressureCO,I.Cardiovascularsystem,Thearrhythmiasduringlaparoscopyisapproximately14%,Bradyarrhythemiasincludingbradycardia,nodalrhythmareattributedtoavagalresponseduetorapidinsufflations.,2.Thepatientswereplacedindifferentbodyposition(Table1),Duringcholecystectomy,thepatientisplacedonhead-upabout10-20.,2.Thepatientswereplacedindifferentbodyposition(Table1),Duringgynecologicalsurgery,thepatientisplacedonhead-downposition.,Table-1Hemodynamicmeasurementsbeforeandduringpneumoperitoneum（PP）duringlaparoscopiccholecystectomyinhealthypatients,3.Carbondioxideabsorption,TheabsorptionofCO2isinfluencedsignificantlybydurationofinteroperationinsufflationsIAPandthesolubilityofCO2.,3.Carbondioxideabsorption,HypercarbiaresultingfromCO2insufflationshasdirectandindirecthomodynamiceffects.,3.Carbondioxideabsorption,Thedirecteffectsincludeperipheralvasodilatationanddepressionofmyocardialcontractility.Theindirecteffectsincludeactivationofthecentralnervoussystemandsympathizessystem,whichincreasemyocardialcontractilityandcausestachycardiaandhypertension,II.Pulmonaryfunction,Changesinpulmonaryfunctionwithpneumoperitoneum:positioninganesthesiaElevationofdiaphragmmaybeassociatedwithreductioninlungvolumes.,II.Pulmonaryfunction,Inpatientsundergoinglaparoscopicprocedurewith15degreehead-downtilt,thetotalpulmonarycompliancedecreasedby40%.with20degreehead-uptilt,thetotalpulmonarycompliancedecreasedby20%.,II.Pulmonaryfunction,IncreasedIAPandupwarddisplacementofthediaphragmcancausealveolarcollapseandventilation/perfusionmismatching,resultinginhypoxemiaandhypercarbia.,III.Theotherphysiologicalchanges,IncreasedIAPcanresultinreductioninsplanchenicandrenalperfusion.Hepaticbloodflowisdecreased.,III.Theotherphysiologicalchanges,Reductioninurineoutput.thecompressionofrenalvesselincreasedplasmareninactivity.IncreasedIAPcanresultinaspirationandregurgitation.,PartIIAnesthesiaforlaparoscopicsurgery,.Preoperativeevaluationandpreparationforanesthesia.,1.EvaluationElderly,obesity,hypertension,coronaryarterydisease.Serioushypertension,cardiacdysfunction,COPD.Theopensurgery(opencholecystectomy)duotomedicalproblem(serioushypercarbia).,.Preoperativeevaluationandpreparationforanesthesia.,2.PreparationandpremedicationSameasgeneralsurgery.Meperidineandopioidisthoughttocausesphincterofoddispasm.Atropinemayhelpdeceasespasm.H2antagonist(ranitidine)maybegiven(thepatientbeingatriskforgastricaspiration).Toopenupperextremityvein.,.Thechoiceofanesthesia,1.TheprincipleofchoiceTheprincipleisrapidly,shorter,safetycomfortableandreturntoanormalactivityearly.Generalanesthesiaismaybemoresuitablethanotheranesthesia.,.Thechoiceofanesthesia,2.MethodofanenthesiaA.GeneralanesthesiaAdvantage:Properdepthsofanesthesia.Effectiveventilation.Tocontroltherelaxofmuscle.AdjustingMVV.,.Thechoiceofanesthesia,AnestheticManagementTheendotrachealintubationissuggested.Anoralgastrictubeshouldbeinsertedtoensurethatgastricdistensiondoesnotexist.,.Thechoiceofanesthesia,Anestheticagents.Propofol,Etomidate,Midazolam.Fentanyl,Remifentanyl,SuccinyicholineVecuroniumAtracurium.Isoflurane,desflurane.TheuseofN2Oiscontroversial.Itincreasesboweldistention,andproduceconflictingresultsontherateofN2Oonpostoperativenausea.,.Thechoiceofanesthesia,B.Epiduralanesthesia。Ahighlevelisrequiredforcompletemusclerelaxation。70preventdiaphragmaticirritationcausedbygasinsufflationandsurgicalmanipulations.,.Thechoiceofanesthesia,B.Epiduralanesthesia。Seriousrespiratorgdepressionispossible*ahighregionalblock*theuseofopioid*thediaphragmisrisedduringinsufflation.Theoccasionaloccurrenceofreferredshoulderpain,.Thechoiceofanesthesia,C.GeneralAesthesiaandEpiduralanesthesia.D.Regionalanesthesia.,.Perioprativemonitoring,CardiovascularfunctionRespiratoryfunctionUrinaryvolumeNeuromusculartransmission,.Specialconsiderationsintheanesthesia,Controlofintra-abdominalpressure*laparoscopiccholecystetomy,IAP10-15mmHgPreventionofaspirationofgastriccontents.*Gynecologiclaparoscopy，IAP20-40mmHg*obesity，abdominalwallliftisused,.Specialconsiderationsintheanesthesia,PositionLaparoscopiccholecystetomy，supineisplaced，reversetrendelenburgwithrightsideelevates.Gynecologiclaparoscopy,head-downandfeet-up.,.Specialconsiderationsintheanesthesia,*Enhancerespiratorymanagementduringoperation*Theuseofneuromuscularblockersandcompletemusclerelaxationarerequired,.Specialconsiderationsintheanesthesia,Ifitisnotpossibletocompletethelaparoscopicprocedure,forexample:amajorabdominalvessellacerated,peritonitisandhemorrhage,aopensurgerywillbeperformed.,.Specialconsiderationsintheanesthesia,Epiduralanesthesiarepresentalternativeforlaparoscopicsurgery.Butahighlevelisrequired.Adisadvantageistheoccurrenceofreferredshoulderpain.,.Specialconsiderationsintheanesthesia,Afteroperation,theresidualpheumoperitoneumshouldbedischarged.Preventionoftheregur