腹腔镜手术麻醉课件

,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,第三十二章,腹腔镜手术的麻醉,Chapter 32,Anesthesia for laparoscopic Surgery,The field of abdominal surgery has been radically changed with the introduction of laparoscopy,.,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.,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.,Part I Physiological changes during laparoscopic surgery,CO,2,is used extensively in clinic.The speed and pressure of the pneumoperitioneum effect the absorption of CO,2.,Positioning changes will effect the physiological function.,I.Cardiovascular system,The pressure of pneumopertioneum effect three aspects.,systemic vascular resistance(SVR.Afterloail).,venous return(preload).,cardiac function.,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,I.Cardiovascular system,The cause:,Intraabdominal positive pressure intrathoracic pressure cardiac blood flow CO,IPPV or PEEP intrathoracic pressure CO,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.,2.The patients were placed in different body position(Table1),During cholecystectomy,the patient is placed on head-up about 10-20,.,2.The patients were placed in different body position(Table1),During gynecological surgery,the patient is placed on head-down position.,Table-1,Hemodynamic measurements before and during pneumoperitoneum（PP）during laparoscopic cholecystectomy in healthy patients,Supine,Head-down,Head-up,Supine with pp,Head-down with pp,Head-up,With pp,Heart rate(beats/min),617,53 4,66 9,66 16,53 3,70 8,MAP(mmHg),69 7,76 6,64 9,91 11,87 8,84 13,CVP(mmHg),6.2 2.9,10.2 3.5,0.8 3.5,10.9 2.7,15.9 4.6,3.1 2.6,MPAP(mmHg),14.1 1.5,17.4 1.2,8.5 3.5,18.4 3.7,20.0 6.1,10.8 2.5,SVR(dynes/sec/cm,5,),1310 302,1381 313,1419 342,1795 444,1577 344,2047 430,3.Carbon dioxide absorption,The absorption of CO,2,is influenced significantly by,duration of interoperation insufflations,IAP and the solubility of CO,2,.,3.Carbon dioxide absorption,Hypercarbia resulting from,CO,2,insufflations has,direct,and,indirect,homodynamic effects.,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,II.,Pulmonary function,Changes in pulmonary function with,pneumoperitoneum:,positioning,anesthesia,Elevation of diaphragm may be associated with reduction in lung,volumes.,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%.,II.,Pulmonary function,Increased IAP and upward,displacement of the diaphragm can cause alveolar collapse and,ventilation/perfusion mismatching,resulting in hypoxemia and,hypercarbia.,III.The other physiological changes,Increased IAP can result in reduction in splanchenic and renal perfusion.,Hepatic blood flow is decreased.,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.,Part II Anesthesia for laparoscopic surgery,.,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).,.,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.,.,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.,.,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.,.,The choice of anesthesia,Anesthetic Management,The endotracheal intubation is s