不同CO_2气腹压对婴儿腹腔镜手术呼吸和循环功能的影响
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摘要
目的：研究不同的CO_2气腹压下婴儿腹腔镜手术呼吸力学和循环功能的影响。
方法：30例ASAⅠ-Ⅱ级小于1岁婴儿拟行腹腔镜手术，随机分为2组，每组15例。A组：CO_2气腹压为8mmHg，B组：CO_2气腹压为12mmHg．所有患儿均在标准麻醉下进行。患儿入手术室后予基础麻醉MKA0．1ml／kg(每毫升MKA含氯胺酮20mg，咪唑安定2mg，阿托品0．1mg)肌注。入睡后开放静脉。麻醉诱导用：MKA0．05ml／kg、芬太尼10ug／kg、万可松0．1mg／kg静推，术中予0．75MAC的七氟醚吸入维持。病人在仰卧位下行手术，所有病人均予机械控制呼吸定容模式(潮气量10-12ml／kg，呼吸频率为24-28次／min)以保持正常的呼末二氧化碳分压。整个研究过程呼吸机参数不再调整。麻醉中予50／50的氧气和空气的混和气吸入。术中予15-20ml／kg／hr的复方林格氏液输注以补充生理需要量和术中丢失。气腹前5min、气腹后10min、放气后5min监测心率(HR)、收缩压(SBP)、舒张压(DBP)、平均动脉压(MBP)、肺顺应性(Cdyn)、气道阻力(Raw)、潮气量(VT)、呼吸频率(RR)、气道峰压(Ppeak)、气道平台压(Pplac)、呼吸末二氧化碳(P_(ET)CO2)、脉博氧饱和度(SpO2)及血气分析。
结果：结果己总结在表1、2、3、4。
(1)A组和B组呼末二氧化碳(P_(ET)CO_2)水平T1比T0有统计学意义(P<0．05)，T2比T0有统计学意义(P<0．05)。A组和B组血气分析PH值及PaCO_2水平T1比T0有统计学意义(P<0．05)。A组和B组平均动脉压(MBP)及脉搏(HR)T1比T0无统计学意义(P>0．05)，T2比T0无统计学意义(P>0．05)。A组和B组血气分析HCO3~-水平及PaO_2T1比T0均无统计学意义(P>0．05)。
(2)A组肺顺应性(Cdyn)、气道阻力(Raw)、气道峰压(Ppeak)T1比T0无统计学意义(P>0．05)，T2比T0无统计学意义(P>0．05)。
(3)B组肺顺应性(Cdyn)、气道阻力(Raw)、气道峰压(Ppeak)T1比T0有统计学意义(P<0．05)，T2比T0无统计学意义(P>0．05)。
(4)A组和B组T0期P_(ET)CO2、Cdyn、Raw、Ppeak、MAP、HR及血气分析PH、PaCO2、HCO3~-、PaO2相比较无统计学意义(P>0．05)。A组和B组T1期Cdyn、Raw、Ppeak相比较有统计学意义(P<0．05)，P_(ET)O2、MAP、HR及血气分析PH、PaCO2、HCO3~-、PaO2相比较无统计学意义(P>0．05)。
结论：1 8mmHg和12mmHg CO_2气腹压均可引起肺顺应性下降，气道阻力、气道峰压和呼吸末二氧化碳分压升高。
2 8mmHg比12mmHg气腹压对患儿呼吸和循环的影响小，在满足手术需要的前提下，我们应选择低气腹压。
Objective: To observe and investigate the effects of infant respiration and circulation in laparoscopic surgery under different CO2 pneumoperitoneum pressure.
Methods: Thirty ASAⅠ-Ⅱpatients less than 1 year of age underwent LCwere randomly divided into two groups with 15 patients in each group. The CO2 pneumoperitoneum pressure was set at 8 mmHg in the Group A.12mmHg in the Group B. All patients received a standardized anaesthetic. When they came into the operation room, the patients were anesthetized with intramuscular injection of MKA 0.1ml/kg (Ketamine 20mg/ml, Midazolam 2mg/ml, Atropine 0.1mg/ml). Anaesthesia induction used MKA 0.05ml/kg, fentant 0.01mg/kg, norcuron 0.1mg/kg, and maintained with sevoflurane 0.75MAC. Surgery was performed in the supine position. All patients underwent mechanical ventilation using volume-controlled mode (initial tidal volume 10-12ml/kg; respiratory rate 24-28/min) to maintain normocapnia .General aneasthesia was maintained with an oxygen/air mixture of 50/50 .A basalⅣinfusion (15-20ml/kg/hr) of lactated Ringer's solution was given to compensate for the fasting state and intraoperativ losses. BP、HR、SpO2、P_(ET)CO2、 PIP、VT、Cdyn、Raw、MV、Ppeak、Pplat were determined at the three time points: 5min before peritoneal insufflation (T_0),10min after peritoneal insufflation (T_1),5min after exsufflation(T_2).
Results : Results are summarized in Table 1、2、3、4.
(1) The P_(ET)CO_2 leve in group A and group B at T_1 were no significantly different compared with those at T_0, At T_2 the P_(ET)CO_2 level in both groups were significantly different compared with those at T0.The PH and PaCO_2 levels in both groups at T_1 were significantly different compared with those at T_0.There were no significant changes in MAP and HR in both groups at T_1 and T_2.
(2) The Cdyn、Raw、Ppeak levels in group A at T_1 were no significantly different compared with those at T_0. At T_2 those were no significant changes compared with those at T_0.
(3) The Cdyn、Raw、Ppeak levels in group B at T_1 were significantly different compared with those at T_0. At T_2 those were no significant changes compared with those at T_0.
(4) The P_(ET) CO2、Cdyn、Raw、Ppeak、MAP、HR、PH、PaCO2、PaO2、HCO_3~- levels in group A and group B at T_0 were no significantly different.The Cdyn、Raw、Ppeak levels in group B at T_1 have significantly different from group A.
Conclusion:
1 8mmHg and 12mmHg CO_2 pneumoperitoneum pressure both causedCdyn decrease , PetCO_2、Raw and Ppeak increase.
2 8mmHg CO_2 pneumoperitoneum pressure is less likely to effect infant respiratory and hemodynamic than 12mmHg CO_2 pneumoperitoneum pressure. Lower CO_2 pneumoperitoneum pressure is more preferable can be satisfied performed.
方法：30例ASAⅠ-Ⅱ级小于1岁婴儿拟行腹腔镜手术，随机分为2组，每组15例。A组：CO_2气腹压为8mmHg，B组：CO_2气腹压为12mmHg．所有患儿均在标准麻醉下进行。患儿入手术室后予基础麻醉MKA0．1ml／kg(每毫升MKA含氯胺酮20mg，咪唑安定2mg，阿托品0．1mg)肌注。入睡后开放静脉。麻醉诱导用：MKA0．05ml／kg、芬太尼10ug／kg、万可松0．1mg／kg静推，术中予0．75MAC的七氟醚吸入维持。病人在仰卧位下行手术，所有病人均予机械控制呼吸定容模式(潮气量10-12ml／kg，呼吸频率为24-28次／min)以保持正常的呼末二氧化碳分压。整个研究过程呼吸机参数不再调整。麻醉中予50／50的氧气和空气的混和气吸入。术中予15-20ml／kg／hr的复方林格氏液输注以补充生理需要量和术中丢失。气腹前5min、气腹后10min、放气后5min监测心率(HR)、收缩压(SBP)、舒张压(DBP)、平均动脉压(MBP)、肺顺应性(Cdyn)、气道阻力(Raw)、潮气量(VT)、呼吸频率(RR)、气道峰压(Ppeak)、气道平台压(Pplac)、呼吸末二氧化碳(P_(ET)CO2)、脉博氧饱和度(SpO2)及血气分析。
结果：结果己总结在表1、2、3、4。
(1)A组和B组呼末二氧化碳(P_(ET)CO_2)水平T1比T0有统计学意义(P<0．05)，T2比T0有统计学意义(P<0．05)。A组和B组血气分析PH值及PaCO_2水平T1比T0有统计学意义(P<0．05)。A组和B组平均动脉压(MBP)及脉搏(HR)T1比T0无统计学意义(P>0．05)，T2比T0无统计学意义(P>0．05)。A组和B组血气分析HCO3~-水平及PaO_2T1比T0均无统计学意义(P>0．05)。
(2)A组肺顺应性(Cdyn)、气道阻力(Raw)、气道峰压(Ppeak)T1比T0无统计学意义(P>0．05)，T2比T0无统计学意义(P>0．05)。
(3)B组肺顺应性(Cdyn)、气道阻力(Raw)、气道峰压(Ppeak)T1比T0有统计学意义(P<0．05)，T2比T0无统计学意义(P>0．05)。
(4)A组和B组T0期P_(ET)CO2、Cdyn、Raw、Ppeak、MAP、HR及血气分析PH、PaCO2、HCO3~-、PaO2相比较无统计学意义(P>0．05)。A组和B组T1期Cdyn、Raw、Ppeak相比较有统计学意义(P<0．05)，P_(ET)O2、MAP、HR及血气分析PH、PaCO2、HCO3~-、PaO2相比较无统计学意义(P>0．05)。
结论：1 8mmHg和12mmHg CO_2气腹压均可引起肺顺应性下降，气道阻力、气道峰压和呼吸末二氧化碳分压升高。
2 8mmHg比12mmHg气腹压对患儿呼吸和循环的影响小，在满足手术需要的前提下，我们应选择低气腹压。
Objective: To observe and investigate the effects of infant respiration and circulation in laparoscopic surgery under different CO2 pneumoperitoneum pressure.
Methods: Thirty ASAⅠ-Ⅱpatients less than 1 year of age underwent LCwere randomly divided into two groups with 15 patients in each group. The CO2 pneumoperitoneum pressure was set at 8 mmHg in the Group A.12mmHg in the Group B. All patients received a standardized anaesthetic. When they came into the operation room, the patients were anesthetized with intramuscular injection of MKA 0.1ml/kg (Ketamine 20mg/ml, Midazolam 2mg/ml, Atropine 0.1mg/ml). Anaesthesia induction used MKA 0.05ml/kg, fentant 0.01mg/kg, norcuron 0.1mg/kg, and maintained with sevoflurane 0.75MAC. Surgery was performed in the supine position. All patients underwent mechanical ventilation using volume-controlled mode (initial tidal volume 10-12ml/kg; respiratory rate 24-28/min) to maintain normocapnia .General aneasthesia was maintained with an oxygen/air mixture of 50/50 .A basalⅣinfusion (15-20ml/kg/hr) of lactated Ringer's solution was given to compensate for the fasting state and intraoperativ losses. BP、HR、SpO2、P_(ET)CO2、 PIP、VT、Cdyn、Raw、MV、Ppeak、Pplat were determined at the three time points: 5min before peritoneal insufflation (T_0),10min after peritoneal insufflation (T_1),5min after exsufflation(T_2).
Results : Results are summarized in Table 1、2、3、4.
(1) The P_(ET)CO_2 leve in group A and group B at T_1 were no significantly different compared with those at T_0, At T_2 the P_(ET)CO_2 level in both groups were significantly different compared with those at T0.The PH and PaCO_2 levels in both groups at T_1 were significantly different compared with those at T_0.There were no significant changes in MAP and HR in both groups at T_1 and T_2.
(2) The Cdyn、Raw、Ppeak levels in group A at T_1 were no significantly different compared with those at T_0. At T_2 those were no significant changes compared with those at T_0.
(3) The Cdyn、Raw、Ppeak levels in group B at T_1 were significantly different compared with those at T_0. At T_2 those were no significant changes compared with those at T_0.
(4) The P_(ET) CO2、Cdyn、Raw、Ppeak、MAP、HR、PH、PaCO2、PaO2、HCO_3~- levels in group A and group B at T_0 were no significantly different.The Cdyn、Raw、Ppeak levels in group B at T_1 have significantly different from group A.
Conclusion:
1 8mmHg and 12mmHg CO_2 pneumoperitoneum pressure both causedCdyn decrease , PetCO_2、Raw and Ppeak increase.
2 8mmHg CO_2 pneumoperitoneum pressure is less likely to effect infant respiratory and hemodynamic than 12mmHg CO_2 pneumoperitoneum pressure. Lower CO_2 pneumoperitoneum pressure is more preferable can be satisfied performed.
引文
1. Georgeson K. Minimally invasive surgery in neonates. Semin Neonnatol. 2003,8:243-248.
2. Turienzo-Santos EO, Rodriguez-Garcia JI, Trelles-Martin A, et al. Integral management of the process of laparoscopic cholecystectomy. Cir Esp, 2006, 80(6):385-394.
3. Zitsman JL. Current concepts in minimal access surgery for children. Pediatrics, 2003,111 :1239-1252.
4. Allal H, Captier G, Lopez M, et al. Evaluation of 142 consecutive laparosco pic fundoplications in children: effects of the learning curve and technical choice. J Pediatr Surg, 2001,36 :921 -926.
5. Rothenberg SS. Laparoscopic Nissen procedure in children. Semin Laparoscopic Surg, 2002,9 :146-152.
6. Rubin SZ, Davis MG.. Pneumoperitoneum in the pediatric age. In : Rosenthal RJ, Friedman RL, Phillips EH,eds. The Pathophysiology of pneumoperitoneum . Berlin: Springer-Verlag, 1998,159-167.
7．文建国，腹腔镜在小儿外科的应用．中华小儿外科学杂志，2001，22：183．
8. S.G. Sakka, E. Huettemann, GPetral, et al. Transoesophageal echocardiographic assessment of haemodynamic changes during laparoscopic herniorrhappy in small children. British Tournal of Anaesthesia , 2000,84:330- 334.
9. Mchoney M, Corzia L,Eaton S,et al. Carbon dioxide elimination during laparoscopy in children is age dependent. J Pediatr Surg ,2003,38:105-110.
10．王庆宝．腹腔镜CO_2气腹对呼吸和循环的影响．中国厂矿医学．2004，17： 463-464．
11. Sumit Dave, Walid A. Farhat WA. Physiological effects of pediatric urological laparoscopic surgery. Indian Journal of Urology,2006,22:304-309.
12. Bergesio R, Habre W, Lanteri P. Changes in respiratory mechanics during abdominal laparoscopic surgery in Children. Anaesth Intensive Care, 1999, 27:245-250.
13. Bozkurt P, Kaya G, Yeker Y. Arterial carbon dioxide markedly increases duri ng diagnostic laparoscopy in portal hypertensive children..2002,95(5):1236-1240.
14. Halachmi S, El-Ghoneimi A, Bissonnette B,et al.Hemodynamic and respiratory effect of pediatric urological lapaloscopic surgery :a retrospective study. J Urol,2003 ,170:1651-1654.
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2. Turienzo-Santos EO, Rodriguez-Garcia JI, Trelles-Martin A, et al. Integral management of the process of laparoscopic cholecystectomy. Cir Esp, 2006, 80(6):385-394.
3. Zitsman JL. Current concepts in minimal access surgery for children. Pediatrics, 2003,111 :1239-1252.
4. Allal H, Captier G, Lopez M, et al. Evaluation of 142 consecutive laparosco pic fundoplications in children: effects of the learning curve and technical choice. J Pediatr Surg, 2001,36 :921 -926.
5. Rothenberg SS. Laparoscopic Nissen procedure in children. Semin Laparoscopic Surg, 2002,9 :146-152.
6. Rubin SZ, Davis MG.. Pneumoperitoneum in the pediatric age. In : Rosenthal RJ, Friedman RL, Phillips EH,eds. The Pathophysiology of pneumoperitoneum . Berlin: Springer-Verlag, 1998,159-167.
7．文建国，腹腔镜在小儿外科的应用．中华小儿外科学杂志，2001，22：183．
8. S.G. Sakka, E. Huettemann, GPetral, et al. Transoesophageal echocardiographic assessment of haemodynamic changes during laparoscopic herniorrhappy in small children. British Tournal of Anaesthesia , 2000,84:330- 334.
9. Mchoney M, Corzia L,Eaton S,et al. Carbon dioxide elimination during laparoscopy in children is age dependent. J Pediatr Surg ,2003,38:105-110.
10．王庆宝．腹腔镜CO_2气腹对呼吸和循环的影响．中国厂矿医学．2004，17： 463-464．
11. Sumit Dave, Walid A. Farhat WA. Physiological effects of pediatric urological laparoscopic surgery. Indian Journal of Urology,2006,22:304-309.
12. Bergesio R, Habre W, Lanteri P. Changes in respiratory mechanics during abdominal laparoscopic surgery in Children. Anaesth Intensive Care, 1999, 27:245-250.
13. Bozkurt P, Kaya G, Yeker Y. Arterial carbon dioxide markedly increases duri ng diagnostic laparoscopy in portal hypertensive children..2002,95(5):1236-1240.
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