连续硬脊膜外阻滞麻醉对二氧化碳气腹患者 内脏灌注和代谢的影响

The effect of thoracic epidural anesthesia on gastric submucosal perfusion and metabolism during pneumoperitoneum

摘要:

目的 观察胸段硬膜外阻滞对二氧化碳气腹患者内脏灌注和代谢的影响。方法 26例ASAⅠ－Ⅱ级行腹腔镜胆囊切除术（laparoscopic cholecystomy, LC手术患者随机分为全身麻醉组（G）和连续硬脊膜外阻滞麻醉复合全身麻醉组（E），监测麻醉后、气腹前即刻，气腹后30 min，气腹后60 min，放气后30 min时MAP、HR、呼气末二氧化碳分区PETCO2和胃黏膜二氧化碳分压PgCO2值，同步采动脉血行PHa、PaCO2、BE、HCO3-及乳酸值测定。计算胃黏膜pHi和胃黏膜与动脉血二氧化碳分压梯度（PCO2gap）。结果 ①G组气腹时HR、MAP均明显增高（P﹤0.05），E组无明显变化。②与气腹前相比，两组PCO2gap、PgCO2气腹后均明显升高、pHi明显降低，G组与E组比，气腹后60 min时点存在明显差异。③两组动脉血乳酸值、PHa值、动脉血HCO3-、BE值在正常范围之内，差异无显著性。结论 气腹压在13～15 mmHg时，CO2气腹可以减少胃黏膜下灌注和代谢，胸段硬膜外阻滞有减轻气腹中胃黏膜下低灌注的作用，有利于维持血流动力学平稳。

Abstract:

【Objective】 To investigate the effects of thoracic epidural anesthesia on the gastric submucosal perfusion and metabolism during pneumoperitoneum in laparoscopic cholecystectomy surgery. 【Methods】 Twenty-six patients were randomly allocated to general anesthesia (group G, n =13) or general anesthesia combined with thoracic epidural anesthesia (group E, n =13). MAP, HR, PETCO2, and automated air tonometric variables were monitored before pneumoperitoneum, 30 min, 60 min during the pneumoperitoneum and 30 min after the end of the pneumoperitoneum. Gastric intramucosal pH and gastric inramucosal-arterial PCO2 gradient (PCO2gap) were calculated according to Henderson-Hasselbach equation. 【Results】 Compared with the baseline, the PgCO2 and PCO2gap increased significantly after abdominal pneumatic inflation and remained increased after surgery; and pHi decreased after pneumoperitoneum; There are significant difference between E group and G group in pHi and PCO2gap 60 min after pneumoperitoneum. HR, MAP were increased significantly in group G, but not in group E, and significant difference was found between two groups after pneumoperitoneum. There were no significant difference in PHa, PaCO2, PETCO2, BE, HCO3- and lactic acid after pneumoperitoneum between the two groups. 【Conclusion】 Pneumoperitoneum induces gastric submucosal hypoperfusion and that TEA can attenuate this effect. General anesthesia combined with thoracic epidural anesthesia is an ideal technique for laparoscopic cholecystectomy.