腹腔鏡手術(shù)麻醉課件

第三十二章

腹腔鏡手術(shù)的麻醉

Chapter32

AnesthesiaforlaparoscopicSurgery第三十二章

腹腔鏡手術(shù)的麻醉

1Thefieldofabdominalsurgeryhasbeenradicallychangedwiththeintroductionoflaparoscopy.Thefieldofabdominalsurgery2Recentadvanceinroboticandvideotechnologyhavemadetheuseoflaparoscopicproceduresmorewidelyapplicable.Withtheevolutionoflaparoscopy，asubstantialnumberofabdominalproceduresarebeingperformedusingthisapproach,includingcholecystectomy,myomectomy,andsoon.Recentadvanceinroboticand3Comparedwiththetraditionalopenabdominalapproach.thelaparoscopicapproachis:lesspostoperativepain.shorterhospitalstay.feweroveralladverseevent.morerapidreturntonormalactivitysignificantcostsavings.Comparedwiththetraditional4腹腔鏡手術(shù)麻醉課件5腹腔鏡手術(shù)麻醉課件6PartIPhysiologicalchanges

duringlaparoscopicsurgeryCO2isusedextensivelyinclinic.ThespeedandpressureofthepneumoperitioneumeffecttheabsorptionofCO2.

Positioningchangeswilleffectthephysiologicalfunction.PartIPhysiologicalchanges7I.CardiovascularsystemThepressureofpneumopertioneumeffectthreeaspects.

systemicvascularresistance(SVR.Afterloail).venousreturn(preload).cardiacfunction.I.Cardiovascularsystem8I.CardiovascularsystemDuringlaparoscopiccholecystectomy

Ifintraabdominalpressure(IAP)>10mmHgCVP↑PAWP↑SVR↑COandMAP↑Ifintraabdominalpressure(IAP)>20mmHgCVP↓SVR↑↑CICO↓MAP↑↓ornormalI.Cardiovascularsystem9I.CardiovascularsystemThecause:IntraabdominalpositivepressureintrathoracicpressurecardiacbloodflowCOIPPVorPEEPintrathoracicpressureCOI.CardiovascularsystemThec10I.CardiovascularsystemThearrhythmiasduringlaparoscopyisapproximately14%,Bradyarrhythemiasincludingbradycardia,nodalrhythmareattributedtoavagalresponseduetorapidinsufflations.I.CardiovascularsystemThea112.Thepatientswereplacedindifferentbodyposition(Table1)Duringcholecystectomy,thepatientisplacedonhead-upabout10-20°.2.Thepatientswereplacedin122.Thepatientswereplacedindifferentbodyposition(Table1)Duringgynecologicalsurgery,thepatientisplacedonhead-downposition.2.Thepatientswereplacedin13Table-1Hemodynamicmeasurementsbeforeandduring

pneumoperitoneum（PP）duringlaparoscopic

cholecystectomyinhealthypatientsSupineHead-downHead-upSupinewithppHead-downwithppHead-upWithppHeartrate(beats/min)61±753±466±966±1653±370±8MAP(mmHg)69±776±664±991±1187±884±13CVP(mmHg)6.2±2.910.2±3.50.8±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)1310±3021381±3131419±3421795±4441577±3442047±430Table-1Hemodynamicmeasure143.CarbondioxideabsorptionTheabsorptionofCO2isinfluencedsignificantlybydurationofinteroperationinsufflationsIAPandthesolubilityofCO2.3.Carbondioxideabsorption153.Carbondioxideabsorption

HypercarbiaresultingfromCO2insufflationshasdirectand

indirecthomodynamiceffects.3.Carbondioxideabsorption163.Carbondioxideabsorption

Thedirecteffectsincludeperipheralvasodilatationanddepressionofmyocardialcontractility.Theindirecteffectsincludeactivationofthecentralnervoussystemandsympathizessystem,whichincreasemyocardialcontractilityandcausestachycardiaandhypertension3.CarbondioxideabsorptionT17II.Pulmonaryfunction

Changesinpulmonaryfunctionwithpneumoperitoneum:

positioninganesthesia

Elevationofdiaphragmmaybeassociatedwithreductioninlungvolumes.II.PulmonaryfunctionCh18II.PulmonaryfunctionInpatientsundergoinglaparoscopicprocedurewith15degreehead-downtilt,thetotalpulmonarycompliancedecreasedby40%.

with20degreehead-uptilt,thetotalpulmonarycompliancedecreasedby20%.II.Pulmonaryfunction19II.Pulmonaryfunction

IncreasedIAPandupwarddisplacementofthediaphragmcancausealveolarcollapseandventilation/perfusionmismatching,resultinginhypoxemiaandhypercarbia.II.PulmonaryfunctionInc20III.TheotherphysiologicalchangesIncreasedIAPcanresultinreductioninsplanchenicandrenalperfusion.Hepaticbloodflowisdecreased.III.Theotherphysiological21III.TheotherphysiologicalchangesReductioninurineoutput.

thecompressionofrenalvesselincreasedplasmareninactivity.

IncreasedIAPcanresultinaspirationandregurgitation.III.Theotherphysiological22PartII

AnesthesiaforlaparoscopicsurgeryPartII

Anesthesia23Ⅰ.Preoperativeevaluationandpreparationforanesthesia.

1.EvaluationElderly,obesity,hypertension,coronaryarterydisease.Serioushypertension,cardiacdysfunction,COPD.Theopensurgery(opencholecystectomy)duotomedicalproblem(serioushypercarbia).Ⅰ.Preoperativeevaluationand24Ⅰ.Preoperativeevaluationandpreparationforanesthesia.

2.PreparationandpremedicationSameasgeneralsurgery.Meperidineandopioidisthoughttocausesphincterofoddispasm.Atropinemayhelpdeceasespasm.H2antagonist(ranitidine)maybegiven(thepatientbeingatriskforgastricaspiration).Toopenupperextremityvein.Ⅰ.Preoperativeevaluationand25Ⅱ.Thechoiceofanesthesia

1.TheprincipleofchoiceTheprincipleisrapidly,shorter,safetycomfortableandreturntoanormalactivityearly.Generalanesthesiaismaybemoresuitablethanotheranesthesia.

Ⅱ.Thechoiceofanesthesia26Ⅱ.Thechoiceofanesthesia2.MethodofanenthesiaA.Generalanesthesia

Advantage:

①

Properdepthsofanesthesia.②Effectiveventilation.③Tocontroltherelaxofmuscle.④AdjustingMVV.Ⅱ.Thechoiceofanesthesia2.Me27Ⅱ.ThechoiceofanesthesiaAnestheticManagementTheendotrachealintubationissuggested.Anoralgastrictubeshouldbeinsertedtoensurethatgastricdistensiondoesnotexist.

Ⅱ.ThechoiceofanesthesiaAnes28Ⅱ.ThechoiceofanesthesiaAnestheticagents.Propofol,Etomidate,Midazolam.Fentanyl,Remifentanyl,SuccinyicholineVecuroniumAtracurium.Isoflurane,desflurane.

TheuseofN2Oiscontroversial.

Itincreasesboweldistention,andproduceconflictingresultsontherateofN2Oonpostoperativenausea.Ⅱ.ThechoiceofanesthesiaAnes29Ⅱ.ThechoiceofanesthesiaB.Epiduralanesthesia。Ahighlevelisrequiredforcompletemusclerelaxation。70preventdiaphragmaticirritationcausedbygasinsufflationandsurgicalmanipulations.Ⅱ.ThechoiceofanesthesiaB.Ep30Ⅱ.ThechoiceofanesthesiaB.Epiduralanesthesia。Seriousrespiratorgdepressionispossible

*ahighregionalblock*theuseofopioid*thediaphragmisrisedduringinsufflation.TheoccasionaloccurrenceofreferredshoulderpainⅡ.ThechoiceofanesthesiaB.Ep31Ⅱ.Thechoiceofanesthesia

C.GeneralAesthesiaandEpiduralanesthesia.

D.Regionalanesthesia.Ⅱ.ThechoiceofanesthesiaC32Ⅲ.PerioprativemonitoringCardiovascularfunctionRespiratoryfunctionUrinaryvolumeNeuromusculartransmissionⅢ.PerioprativemonitoringCardi33Ⅳ.Specialconsiderationsin

theanesthesiaControlofintra-abdominalpressure

*

laparoscopiccholecystetomy,IAP10-15mmHgPreventionofaspirationofgastriccontents.

*Gynecologiclaparoscopy，IAP20-40mmHg*obesity，abdominalwallliftisusedⅣ.Specialconsiderationsin

34Ⅳ.Specialconsiderationsin

theanesthesia

PositionLaparoscopiccholecystetomy，supineisplaced，reversetrendelenburgwithrightsideelevates.

Gynecologiclaparoscopy,head-downandfeet-up.Ⅳ.Specialconsiderationsin

35Ⅳ.Specialconsiderationsin

theanesthesia

*Enhancerespiratorymanagementduringoperation*TheuseofneuromuscularblockersandcompletemusclerelaxationarerequiredⅣ.Specialconsiderationsin

36Ⅳ.Specialconsiderationsin

theanesthesiaIfitisnotpossibletocompletethelaparoscopicprocedure,forexample:amajorabdominalvessellacerated,peritonitisandhemorrhage,aopensurgerywillbeperformed.Ⅳ.Specialconsiderationsin

37Ⅳ.Specialconsiderationsin

theanesthesiaEpiduralanesthesiarepresentalternativeforlaparoscopicsurgery.Butahighlevelisrequired.Adisadvantageistheoccurrenceofreferredshoulderpain.Ⅳ.Specialconsiderationsin

38Ⅳ.Specialconsiderationsin

theanesthesiaAfteroperation,theresidualpheumoperitoneumshouldbedischarged.PreventionoftheregurgitationofgastriccontentsⅣ.Specialconsiderationsin

39PARTⅢ.COMPLICATION1.Cardiovescularsystem

*hypertention*bradycardia*tachycardiaPARTⅢ.COMPLICATION1.Cardioves40PARTⅢ.COMPLICATION2.Hypoxemia,HypercarbiaandAcidosis

*HighLAP*Head-downposition*morbidobesity*COPD(chronicobstructivepulmonarydisease)*mechanicalventilationPARTⅢ.COMPLICATION2.Hypoxemi41PARTⅢ.COMPLICATION3.CO2embolism

*Themostcommoncauseofclinicallyapparentco2embolismisinadvertentintravascularplacementoftheneedle*AnopenveinhasalowerpressurethanthesurroundingpressurePARTⅢ.COMPLICATION3.CO2embol42PARTⅢ.COMPLICATION4.Regurgitationandaspiration

*HighLAP*Changeofposition*EpiduralandspinalaneasthesiaPARTⅢ.COMPLICATION4.Regurgita43PARTⅢ.COMPLICATION5.Nauseaandvomiting

Theyarecommonfollowinglaparoscopicprocedures.

Pharmacologicprophylaxisisrecommended,forexample：Renitidine，Droperidol，ondansetron.PARTⅢ.COMPLICATION5.Nauseaan44第三十二章

腹腔鏡手術(shù)的麻醉

Chapter32

AnesthesiaforlaparoscopicSurgery第三十二章

腹腔鏡手術(shù)的麻醉

45Thefieldofabdominalsurgeryhasbeenradicallychangedwiththeintroductionoflaparoscopy.Thefieldofabdominalsurgery46Recentadvanceinroboticandvideotechnologyhavemadetheuseoflaparoscopicproceduresmorewidelyapplicable.Withtheevolutionoflaparoscopy，asubstantialnumberofabdominalproceduresarebeingperformedusingthisapproach,includingcholecystectomy,myomectomy,andsoon.Recentadvanceinroboticand47Comparedwiththetraditionalopenabdominalapproach.thelaparoscopicapproachis:lesspostoperativepain.shorterhospitalstay.feweroveralladverseevent.morerapidreturntonormalactivitysignificantcostsavings.Comparedwiththetraditional48腹腔鏡手術(shù)麻醉課件49腹腔鏡手術(shù)麻醉課件50PartIPhysiologicalchanges

duringlaparoscopicsurgeryCO2isusedextensivelyinclinic.ThespeedandpressureofthepneumoperitioneumeffecttheabsorptionofCO2.

Positioningchangeswilleffectthephysiologicalfunction.PartIPhysiologicalchanges51I.CardiovascularsystemThepressureofpneumopertioneumeffectthreeaspects.

systemicvascularresistance(SVR.Afterloail).venousreturn(preload).cardiacfunction.I.Cardiovascularsystem52I.CardiovascularsystemDuringlaparoscopiccholecystectomy

Ifintraabdominalpressure(IAP)>10mmHgCVP↑PAWP↑SVR↑COandMAP↑Ifintraabdominalpressure(IAP)>20mmHgCVP↓SVR↑↑CICO↓MAP↑↓ornormalI.Cardiovascularsystem53I.CardiovascularsystemThecause:IntraabdominalpositivepressureintrathoracicpressurecardiacbloodflowCOIPPVorPEEPintrathoracicpressureCOI.CardiovascularsystemThec54I.CardiovascularsystemThearrhythmiasduringlaparoscopyisapproximately14%,Bradyarrhythemiasincludingbradycardia,nodalrhythmareattributedtoavagalresponseduetorapidinsufflations.I.CardiovascularsystemThea552.Thepatientswereplacedindifferentbodyposition(Table1)Duringcholecystectomy,thepatientisplacedonhead-upabout10-20°.2.Thepatientswereplacedin562.Thepatientswereplacedindifferentbodyposition(Table1)Duringgynecologicalsurgery,thepatientisplacedonhead-downposition.2.Thepatientswereplacedin57Table-1Hemodynamicmeasurementsbeforeandduring

pneumoperitoneum（PP）duringlaparoscopic

cholecystectomyinhealthypatientsSupineHead-downHead-upSupinewithppHead-downwithppHead-upWithppHeartrate(beats/min)61±753±466±966±1653±370±8MAP(mmHg)69±776±664±991±1187±884±13CVP(mmHg)6.2±2.910.2±3.50.8±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)1310±3021381±3131419±3421795±4441577±3442047±430Table-1Hemodynamicmeasure583.CarbondioxideabsorptionTheabsorptionofCO2isinfluencedsignificantlybydurationofinteroperationinsufflationsIAPandthesolubilityofCO2.3.Carbondioxideabsorption593.Carbondioxideabsorption

HypercarbiaresultingfromCO2insufflationshasdirectand

indirecthomodynamiceffects.3.Carbondioxideabsorption603.Carbondioxideabsorption

Thedirecteffectsincludeperipheralvasodilatationanddepressionofmyocardialcontractility.Theindirecteffectsincludeactivationofthecentralnervoussystemandsympathizessystem,whichincreasemyocardialcontractilityandcausestachycardiaandhypertension3.CarbondioxideabsorptionT61II.Pulmonaryfunction

Changesinpulmonaryfunctionwithpneumoperitoneum:

positioninganesthesia

Elevationofdiaphragmmaybeassociatedwithreductioninlungvolumes.II.PulmonaryfunctionCh62II.PulmonaryfunctionInpatientsundergoinglaparoscopicprocedurewith15degreehead-downtilt,thetotalpulmonarycompliancedecreasedby40%.

with20degreehead-uptilt,thetotalpulmonarycompliancedecreasedby20%.II.Pulmonaryfunction63II.Pulmonaryfunction

IncreasedIAPandupwarddisplacementofthediaphragmcancausealveolarcollapseandventilation/perfusionmismatching,resultinginhypoxemiaandhypercarbia.II.PulmonaryfunctionInc64III.TheotherphysiologicalchangesIncreasedIAPcanresultinreductioninsplanchenicandrenalperfusion.Hepaticbloodflowisdecreased.III.Theotherphysiological65III.TheotherphysiologicalchangesReductioninurineoutput.

thecompressionofrenalvesselincreasedplasmareninactivity.

IncreasedIAPcanresultinaspirationandregurgitation.III.Theotherphysiological66PartII

AnesthesiaforlaparoscopicsurgeryPartII

Anesthesia67Ⅰ.Preoperativeevaluationandpreparationforanesthesia.

1.EvaluationElderly,obesity,hypertension,coronaryarterydisease.Serioushypertension,cardiacdysfunction,COPD.Theopensurgery(opencholecystectomy)duotomedicalproblem(serioushypercarbia).Ⅰ.Preoperativeevaluationand68Ⅰ.Preoperativeevaluationandpreparationforanesthesia.

2.PreparationandpremedicationSameasgeneralsurgery.Meperidineandopioidisthoughttocausesphincterofoddispasm.Atropinemayhelpdeceasespasm.H2antagonist(ranitidine)maybegiven(thepatientbeingatriskforgastricaspiration).Toopenupperextremityvein.Ⅰ.Preoperativeevaluationand69Ⅱ.Thechoiceofanesthesia

1.TheprincipleofchoiceTheprincipleisrapidly,shorter,safetycomfortableandreturntoanormalactivityearly.Generalanesthesiaismaybemoresuitablethanotheranesthesia.

Ⅱ.Thechoiceofanesthesia70Ⅱ.Thechoiceofanesthesia2.MethodofanenthesiaA.Generalanesthesia

Advantage:

①

Properdepthsofanesthesia.②Effectiveventilation.③Tocontroltherelaxofmuscle.④AdjustingMVV.Ⅱ.Thechoiceofanesthesia2.Me71Ⅱ.ThechoiceofanesthesiaAnestheticManagementTheendotrachealintubationissuggested.Anoralgastrictubeshouldbeinsertedtoensurethatgastricdistensiondoesnotexist.

Ⅱ.ThechoiceofanesthesiaAnes72Ⅱ.ThechoiceofanesthesiaAnestheticagents.Propofol,Etomidate,Midazolam.Fentanyl,Remifentanyl,SuccinyicholineVecuroniumAtracurium.Isoflurane,desflurane.

TheuseofN2Oiscontroversial.

Itincreasesboweldistention,andproduceconflictingresultsontherateofN2Oonpostoperativenausea.Ⅱ.ThechoiceofanesthesiaAnes73Ⅱ.ThechoiceofanesthesiaB.Epiduralanesthesia。Ahighlevelisrequiredforcompletemusclerelaxation。70preventdiaphragmaticirritationcausedbygasinsufflationandsurgicalmanipulations.Ⅱ.ThechoiceofanesthesiaB.Ep74Ⅱ.ThechoiceofanesthesiaB.Epiduralanesthesia。Seriousrespiratorgdepressionispossible

*ahighregionalblock*theuseofopioid*thediaphragmisrisedduringinsufflation.TheoccasionaloccurrenceofreferredshoulderpainⅡ.ThechoiceofanesthesiaB.Ep75Ⅱ.Thechoiceofanesthesia

C.GeneralAesthesiaandEpiduralanesthesia.

D.Regionalanesthesia.Ⅱ.ThechoiceofanesthesiaC76Ⅲ.PerioprativemonitoringCardiovascularfunctionRespiratoryfunctionUrinaryvolumeNeuromusculartransmissionⅢ.PerioprativemonitoringCardi77Ⅳ.Specialconsiderationsin

theanesthesiaControlofintra-abdominalpressure

*

laparoscopiccholecystetomy,IAP10-15mmHgPreventionofaspirationofgastriccontents.

*Gynecologiclaparoscopy，IAP20-40mmHg*obesity，abdominalwallliftisusedⅣ.Specialconsiderationsin

78Ⅳ.Specialconsiderationsin

theanesthesia

PositionLaparoscopiccholecystetomy，supineisplaced，reversetrendelenbu