不同气腹压力对腹腔镜妇科手术患者颅内压的影响
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摘要
目的应用超声测量视神经鞘直径(ONSD)评价不同气腹压力下腹腔镜妇科手术患者颅内压(ICP)的变化。方法择期行腹腔镜妇科手术患者40例,年龄18～65岁,BMI 18～25 kg/m~2,ASAⅠ或Ⅱ级,采用随机数字表法分为两组(n=20):低气腹压力组(A组)和高气腹压力组(B组)。常规麻醉诱导和机械通气。手术开始时行CO_2气腹,A组气腹压力为10 mmHg,B组为14 mmHg。气腹后调整体位为30°头低脚高位,手术结束时恢复为仰卧位。超声测量患者右眼ONSD,根据ONSD计算ICP_(ONSD)。记录麻醉诱导后气腹前(T_0)、气腹后1min(T_1)、头低脚高位即刻(T_2)、气腹后30 min后(T_3)、气腹后60 min后(T_4)、手术结束后5 min(T_5)、15 min(T_6)时的P_(ET)CO_2、PaCO_2、MAP、HR、ONSD和ICP_(ONSD)。结果与T_0时比较,T_4、T_5时两组P_(ET)CO_2、PaCO_2明显升高,T_4—T_6时MAP明显升高(P<0.05);T_4—T_6时A组,T_3—T_6时B组HR明显增快(P<0.05)。与A组比较,T_3、T_4时B组MAP明显升高,HR明显增快(P<0.05)。与T_0时比较,T_4、T_5时A组ONSD、ICP_(ONSD)明显升高,T_3—T_5时B组ONSD、ICP_(ONSD)明显升高(P<0.05)。与A组比较,T_3时B组ONSD、ICP_(ONSD)明显升高(P<0.05)。结论 10 mmHg和14 mmHg气腹压力均可引起腹腔镜妇科手术患者ONSD和ICP升高,其中14 mmHg气腹压力对ONSD和ICP的影响更大。
Objective To investigate the effects of different pneumoperitoneum pressure on intracranial pressure(ICP) in patients undergoing laparoscopic gynecological surgery by monitoring optic nerve sheath diameter(ONSD) under ultrasonic. Methods Forty patients, aged 18-65 years, with a BMI 18-25 kg/m~2, falling into ASA physical status Ⅰ or Ⅱ,were recruited and scheduled to undergo elective gynecologic laparoscopic surgery. All patients were randomly divided into 2 groups(n = 20): low pneumoperitoneum pressure group(group A) and high pneumoperitoneum pressure group(group B). Conventional anesthesia induction and mechanical ventilation were performed. CO_2 pneumoperitoneum was performed at the beginning of the operation. The patients of groups A and B underwent CO_2 pneumoperitoneum with intra-abdominal pressure 10 mmHg and 14 mmHg, respectively. Then the position of operation of the patients were at an angle of 30° Trendelenburg position, and returned to the supine position at the end of the operation. ONSD of the right eye in the patient was monitored by ultrasound and ICP_(ONSD) was calculated based on ONSD. P_(ET)CO_2, PaCO_2, MAP, HR, ONSD and ICP_(ONSD) were recorded before pneumoperitoneum(T_0), 1 minute after pneumoperitoneum(T_1), immediately at the time point of Trendelenburg position(T_2), 30 minutes after pneumoperitoneum(T_3), 60 minutes after pneumoperitoneum(T_4), 5 minutes(T_5) and 15 minutes after the end of surgery(T_6). Results Compared with T_0, P_(ET)CO_2 and PaCO_2 increased at T_4 and T_5 and MAP increased significantly at T_4-T_(6 ) in patients of the two groups(P < 0.05); HR of patients in group A at T_4-T_6, and in group B at T_3-T_6 increased significantly(P < 0.05). Compared with group A, MAP and HR increased significantly at T_3 and T_4 in patients of group B(P < 0.05). Compared with T_0, ONSD and ICP_(ONSD) of group A at T_4 and T_5, and of group B at T_3-T_5 increased significantly(P < 0.05). Compared with group A, ONSD and ICP_(ONSD) increased significantly at T_3 in patients of group B(P < 0.05). Conclusion Both 10 mmHg and 14 mmHg pneumoperitoneum pressure can increase ONSD and ICP in patients undergoing laparoscopic gynecological surgery. The effect of 14 mmHg pneumoperitoneum on ONSD and ICP is greater than of 10 mmHg.
Objective To investigate the effects of different pneumoperitoneum pressure on intracranial pressure(ICP) in patients undergoing laparoscopic gynecological surgery by monitoring optic nerve sheath diameter(ONSD) under ultrasonic. Methods Forty patients, aged 18-65 years, with a BMI 18-25 kg/m~2, falling into ASA physical status Ⅰ or Ⅱ,were recruited and scheduled to undergo elective gynecologic laparoscopic surgery. All patients were randomly divided into 2 groups(n = 20): low pneumoperitoneum pressure group(group A) and high pneumoperitoneum pressure group(group B). Conventional anesthesia induction and mechanical ventilation were performed. CO_2 pneumoperitoneum was performed at the beginning of the operation. The patients of groups A and B underwent CO_2 pneumoperitoneum with intra-abdominal pressure 10 mmHg and 14 mmHg, respectively. Then the position of operation of the patients were at an angle of 30° Trendelenburg position, and returned to the supine position at the end of the operation. ONSD of the right eye in the patient was monitored by ultrasound and ICP_(ONSD) was calculated based on ONSD. P_(ET)CO_2, PaCO_2, MAP, HR, ONSD and ICP_(ONSD) were recorded before pneumoperitoneum(T_0), 1 minute after pneumoperitoneum(T_1), immediately at the time point of Trendelenburg position(T_2), 30 minutes after pneumoperitoneum(T_3), 60 minutes after pneumoperitoneum(T_4), 5 minutes(T_5) and 15 minutes after the end of surgery(T_6). Results Compared with T_0, P_(ET)CO_2 and PaCO_2 increased at T_4 and T_5 and MAP increased significantly at T_4-T_(6 ) in patients of the two groups(P < 0.05); HR of patients in group A at T_4-T_6, and in group B at T_3-T_6 increased significantly(P < 0.05). Compared with group A, MAP and HR increased significantly at T_3 and T_4 in patients of group B(P < 0.05). Compared with T_0, ONSD and ICP_(ONSD) of group A at T_4 and T_5, and of group B at T_3-T_5 increased significantly(P < 0.05). Compared with group A, ONSD and ICP_(ONSD) increased significantly at T_3 in patients of group B(P < 0.05). Conclusion Both 10 mmHg and 14 mmHg pneumoperitoneum pressure can increase ONSD and ICP in patients undergoing laparoscopic gynecological surgery. The effect of 14 mmHg pneumoperitoneum on ONSD and ICP is greater than of 10 mmHg.
引文
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[11] 张俊锋,熊炜.床旁超声联合脑室内颅内压监测在颅脑外伤所致.浙江创伤外科,2019,24(1):160-161.
[12] Kimberly H H,Shah S,Marill K,et al.Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure.Acad Emerg Med,2008,15(2):201-204.
[13] 王婧,谷亮,张献礼,等.儿童重型颅脑损伤后颅内压与视神经鞘直径的相关性.南京医科大学学报,2018,38(12):1778-1780.
[14] 凌峻,刘鹏,曾晓英,等.超声检查视神经鞘直径监测重症颅脑外伤病人颅内压的相关性研究.赣南医学院学报,2015,35(6):920-923.
[2] Barr C,Madhuri TK,Prabhu P,et al.Cerebral oedema following robotic surgery:a rare complication.Arch Gynecol Obstet,2014,290(5):1041-1044.
[3] 吴环立,马现启,赵海洋.重度颅脑损伤病人开颅术后视神经鞘直径与颅内压及预后关系.青岛大学学报(医学版),2018,54 (4):423-426.
[4] Dubourg J,Geeraerts T,Messerer M,et al.Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure:a systematic review and meta-analysis.Intensive Care Med,2011,37(7):1059-1068.
[5] Robba C,Cardim D,Donnelly J,et al.Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure assessed using different non-invasive methods.Br J Anaesth,2016,117(6):783-791.
[6] Kim MS,Bai SJ,Lee JR,et al.Increase in intracranial pressure during carbon dioxide pneumoperitoneum with steep trendelenburg positioning proven by ultrasonographic measurement of optic nerve sheath diameter.J Endourol,2014,28(7):801-806.
[7] Hoefnagel D,Dammers R,Ter Laak-Poort MP,et al.Risk factors for infections related to external ventricular drainage.Acta Neurochir(Wien),2008,150(3):209-214.
[8] Chin JH,Seo H,Lee EH,et al.Sonographic optic nerve sheath diameter as a surrogate measure for intracranial pressure in anesthetized patients in the Trendelenburg position.BMC Anesthesiol,2015,15(1):43.
[9] Whiteley J R,Taylor J,Henry M,et al.Detection of elevated intracranial pressure in robot-assisted laparoscopic radical prostatectomy using ultrasonography of optic nerve sheath diameter.J Neurosurg Anesthesiol,2015,27(2):155-159.
[10] Min JY,Lee JR,Oh JT,et al.Ultrasonographic assessment of optic Nerve sheath diameter during pediatric laparoscopy.Ultrasound in Medicine & Biology,2015,41(5):1241-1246.
[11] 张俊锋,熊炜.床旁超声联合脑室内颅内压监测在颅脑外伤所致.浙江创伤外科,2019,24(1):160-161.
[12] Kimberly H H,Shah S,Marill K,et al.Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure.Acad Emerg Med,2008,15(2):201-204.
[13] 王婧,谷亮,张献礼,等.儿童重型颅脑损伤后颅内压与视神经鞘直径的相关性.南京医科大学学报,2018,38(12):1778-1780.
[14] 凌峻,刘鹏,曾晓英,等.超声检查视神经鞘直径监测重症颅脑外伤病人颅内压的相关性研究.赣南医学院学报,2015,35(6):920-923.