硬膜外麻醉联合无创正压通气下腹腔镜胆囊切除术的可行性

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　　【摘要】目的:评价硬膜外麻醉下腹腔镜胆囊切除的安全性和可行性。方法:腹腔镜胆囊切除患者40例,ASAⅠ级或Ⅱ级,随机分为2组(n=20):插管全麻组(Ⅰ组)、硬膜外联合钮氏面罩(复旦大学附属中山医院科技发展公司)无创正压通气(NIPPV)组(Ⅱ组)。分别于气腹前即刻、气腹后10 min、无创通气后10 min记录潮气量(VT),动脉血二氧化碳分压(PaCO2)、呼气末二氧化碳分压(PETCO2)、脉搏血氧饱和度(SPO2)、并记录机械通气时间、住苏醒室(EICU)时间、术中、术后恶心呕吐(PONV)发生率。结果:与Ⅰ组比较,Ⅱ组在气腹后10 min(机械通气前) PETCO2、PaCO2升高、SpO2降低(P<0.05)。组内比较,Ⅱ组气腹后20 min(机械通气后10min)PETCO2、PaCO2,SpO2均恢复正常,与Ⅱ组气腹后10分钟比较(P<0.05);Ⅱ组在总机械通气时间、住苏醒室时间、术后恶心呕吐(PONV)率等指标均优于Ⅰ组(P<0.05)。结论:硬膜外麻醉联合钮氏面罩无创机械通气可保证足够的通气量、可防止术中呕吐误吸、术后苏醒快、用于腹腔镜胆囊切除是安全可行的。
　　【关键词】硬膜外麻醉;无创正压通气;腹腔镜胆囊切除术;钮氏面罩
　　The feasibility of epidural anesthesia combined with non invasive positive pressure ventilation in laparoscopic cholecystectomy
　　Niu Juhui Zhao Hua
　　【Abstract】Objectives:To evaluate the security and the feasible of epidural anesthesia combined with non invasive positive pressure ventilation in laparoscopic cholecystectomy (LC). Methods: We selected forty 40 patients, for age from 36 to 60, weight from 55 to 76 kg, and ASA physicalⅠor Ⅱ. Undergoing LC, we divided the patients into two groups (n=20)randomly, in which GroupⅠ=genera l anesthesia; groupⅡ= epidural block + non invasive positive pressure ventilation (NIPPV). VT, PaCO2, PETCO2, and SPO2 were recorded at 10 minutes after pneumoperitoneum and they all recorded at 10 minutes after NIPPV. The time of mechanical ventilation and stayed in EICU and the rate of PONV are also recorded. Results:Compared with group Ⅰ, in group Ⅱ, SPO2、VT were significantly decreased at 10 minutes after pneumoperitoneum, and they were significantly increased at 10 minutes after using mechanical ventilation. While PaCO2、PETCO2 were significantly increased at 10 minutes after pneumoperitoneum, and decreased to normal lever at 10min after using mechanical ventilation. In group Ⅱ, the period of mechanical ventilation, in EICU , and the cases of PONV were all significantly shorter than that in groupⅠ. Conclusions:Non invasive positive pressure ventilation combined with epidural block can keep adequate ventilator capacity, and prevent from the response of vomit and aspiration during surgery, so the method in LC is feasible.
　　【Key words】Epidural anesthesia; Non invasive positive pressure ventilation; Laparoscopic;Cholecystectomy;Niushi master
　　【中图分类号】R971+2【文献标识码】A【文章编号】1002-574X(2010)09-0107-02
　　腹腔镜技术广泛用于胆囊切除,人工气腹对呼吸循环功能的影响已引起人们的关注。目前,这类手术通常采用全身麻醉,近几年喉罩(LAM)在国外已得到广泛应用,使用者已超过1亿例[1],国内使用LAM尚不普遍,且多用于困难气道管理。全麻联合硬膜外阻滞,可减轻术后创口疼痛,使病人心理趋于平静,提高通气效率,有利于改善肺功能,减少术后呼吸系统并发症,提高康复质量。硬膜外麻醉患者行腹腔镜手术时人工气腹限制了呼吸运动,长时间手术可引起CO2潴留,本项研究拟评价硬膜外麻醉联合无创正压通气下腹腔镜胆囊切除的安全性和可行性。
　　1资料与方法
　　1.1临床资料:择期腹腔镜胆囊切除患者40例,ASAⅠ级或Ⅱ级,年龄30-60岁,体重55-76 kg。随机分为两组(n =20):全麻组(Ⅰ组)、硬膜外麻醉联合无创通气组(Ⅱ组)。
　　所有患者入室后开放上肢静脉,并行左侧桡动脉穿刺置管,监测有创动脉压,Ⅰ组静脉注射咪唑安定2 mg,芬太尼3~5 μg/kg,异丙酚1.5~2 mg/kg,维库溴胺0.1 mg/kg诱导,经口明视气管内插管,接Julian麻醉机(Drager公司,德国)行机械通气,氧流量2L/min,潮气量8~10 ml/kg,呼吸频率12次/min,吸呼比1∶2 。术中追加维库溴铵维持肌松,瑞芬太尼微泵输注镇痛,吸入七氟醚镇静,术毕关闭气腹按全麻拔管要求拔管。Ⅱ组患者选取T8～9棘间隙穿刺,头侧置管4cm,首量注入2%利多卡因4ml,5min后,根据测试阻滞平面再注2%利多卡因7～10ml,感觉阻滞平面达T4～T12(随后每隔35分钟追加2%利多卡因5~6)。然后将钮氏面罩(复旦大学附属中山医院科技发展公司制造)系好头带,下胃管并将其穿过钮氏面罩的胃管开口,系好系带,机械通气前先适当放松头带。气腹后(控制气腹压力11～12mmHg)10分钟开始无创正压通气(NIPPV),用面罩以双水平正压模式(BiPAP)行NIPPV ,使用德国伟康公司生产的BiPAP S/T 呼吸机,设置参数如下: 吸入氧浓度((Fio2)25%～30%,通气模式为压力支持/压力控制((S/T):吸气压力为12～16cmH2o,呼气压力为4cmH2o,备用呼吸频率12～16次,调节氧流量以维持脉搏血氧饱和度((SPO2)90%～100%。术毕关闭气腹观察10min ,待MAP、 HR 、PETCO2 和SPO2正常后送至麻醉苏醒室观察 ,两组患者术中均采用HXD-1 型多功能监测系统486PC(黑龙江华翔科技有限公司)监测 MAP、HR 和SPO2。

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