腹腔镜手术中央周围血流动力学变化及应用IPC后的相应变化.docx

腹腔镜手术中央周围血流动力学变化及应用IPC后的相应变化.docx

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腹腔镜手术中央周围血流动力学变化及应用IPC后的相应变化

腹腔镜手术中央，周围血流动力学变化及应用IPC后的相应变化

CentralandPeripheralAdverseHemodynamicChangesDuringLaparoscopicSurgeryandTheirReversalwithaNovelIntermittentSequentialPneumaticCompressionDevice

SiamackAlishahi,FRCS,*NadirFrancis,FRCS,*SallyCrofts,FRCA,+LesleyDuncan,FRCA,+AmitatiBickel,MD,*andAlfredCuschieri,MD,FRSE*

FromtheDepartmentsof*Surgery&MolecularOncologyand+Anaesthesia,NinewellsHospitalandMedicalSchool,UniversityofDundee,Dundee,Scotland

Objective

Tostudytheinfluenceofanovelintermittentsequentialpneumaticcompressiondevice（Lympha-press）ontheadversecardiacandperipheralhemodynamicchangesinducedbypositive-pressurepneumoperitoneum（PPPn）inlaparoscopicsurgery.

SummaryBackgroundData

CreationofPPPnisknowntocauseadversecentralandperipheralhemodynamicchanges.AnintrasubjectobservationalstudywasundertakentoquantitatetheseadversechangesandtoassesstheinfluenceofanintermittentsequentialpneumaticcompressionsystemontheseadversehemodynamicchangesduringlaparoscopicsurgerywithPPPn.

Methods

Thestudyinvolved16consecutivepatientsundergoinglaparoscopicsurgerywithPPPnof12mmHgand30ºhead-uptiltposition.ThefollowingperipheralhemodynamicrecordingsweremadeusingDopplerultrasound:

peaksystolicvelocity（PSV）,enddiastolicvelocity（EDV）,andcross-sectionalareaofthefemoralvein.CentralmonitoringincludedcardiacoutputandstrokevolumebytransesophagealDoppler,bloodpres-sure,andpulse.ThehemodynamicstatebasedontheseparameterswasassessedbeforeinductionofPPPnwiththeanesthetizedpatientinthesupineposition,afterinductionofPPPnandhead-uptiltpositionwithLympha-pressoff,andduringPPPnandhead-uptiltpositionwithLympha-presson,andafter.desufflationwiththepatientinthesupinepositionundergeneralanesthesia.

Results

Positive-pressurepneumoperitoneumandthehead-uptiltpositionresultedina33%reductioninPSV,a21%reductioninEDV,anda29%increaseincross-sectionalareaofthefemoralvein.Thiswasassociatedwitha20%reductionincardiacoutputandan18%reductioninstrokevolume.ActivationofLympha-pressduringPPPnandthehead-uptiltpositionresultedina129%increaseinPSVanda55%increaseinEDVby55%.Italsoincreasedthecardiacoutputby27%andstrokevolumeby16%,withnoeffectoncross-sectionalarea.Comparedwiththepre-PPPnstage,therewasnodifferenceincardiacoutputorstrokevolume,butthePSVwashigherby78%andtheEDVby32%.Afterabdominaldesuffiationinthesupineposition,thecardiacoutputandstrokevolumewererestoredtothepre-PPPnlevel,butpersistentandsignificantelevationswereobservedduringtheperiodofstudyinPSV,EDV,andcross-sectionalarea.

Conclusions

SignificantandindividuallyvariablecentralandperipheralhemodynamicchangesareencounteredduringlaparoscopicsurgerywithPPPnandthehead-uptiltposition.ThesearereversedbyintermittentsequentialpneumaticcompressionusingLympha-press.

Comparedwithopensurgery;laparoscopicsurgicalproceduresareassociatedwithreducedtraumaticinsultandmetabolicstresstothepatientandhenceasmootherpost-operativeperiodandacceleratedrecovery,k2Onthesegrounds,thelaparoscopicapproachhasbeenproposedforsurgeryonhigh-riskpatientswithcomorbidcardiopulmonarydisease.3However,therearedocumentedadversecardiovascular,hormonal,andneuroendocrinechanges1,4,5causedbypositive-pressurepneumoperitoneum（PPPn）,andtherehavebeenreportsofsuddenintraoperativecardiovascularcollapseorseverepulmonaryedemarequiringwentilationafteruneventfullaparoscopiccholecystectomy.6,7

Correspondence:

Prof.SirAlfredCuschieri，DepartmentofSurgeryand

MolecularOncology,NinewellsHospitalandMedicalSchool,UniversityofDundee,DundeeDD19SY,UK.

E-mail:

a.cuschieri@dundee.ac.uk

AcceptedforpublicationMay12,2000.

TheadverseeffectsoncardiacperformanceproducedbyPPPnmayincreasetheriskofcardiaccomplicationsinsusceptiblepatientgroups.8-10Inadditiontothecentralchanges,PPPnresultsinreducedperipheralvenousflow11-16anddiminishedperfusionofintraabdominatorgans.17-19

Inaddressingthisproblem,severalremedieshavebeenproposedascontendersforclinicalevaluation.20Oneoftheseisamechanicalsolutionthatinvolvestheapplicationofintermittentsequentialpneumaticcompression（ISPC）ofthelowerlimbsduringlaparoscopicsurgery.ThebeneficialeffectsofISPCdevicesontheperipheralvenousflowinducedbyPPPnhavebeendocumented.1s.16.21ThepresentstudywasdesignedtoevaluatetheeffectofanovelISPCsystem（Lympha-press,MegoAfekKibbutzafek30042,Israel）onboththecentralandperipheralhemodynamicchangesinducedbyPPPnduringlaparoscopicsurgery.

METHODS

Informedconsentwassecuredfrom16patientsinAmericanSurgicalAssociation（ASA）categoriesIandII（5menages26-65years,11womenages38-78years）whowereundergoinglaparoscopicsurgery（cholecystectomy,fundoplication,liverthermalablation）atNinewellsHospital,Dundee,Scotland.Theprospectivestudywasdesignedasapairedinvestigation,witheachpatientactingashisorherowncontrol.EthicalapprovalwasobtainedfromtheTaysideCommitteeonMedicalResearchEthics.Theexclusioncriteriawerepreviouspulmonaryembolismanddeepveinthrombosis,abnormalcoagulopathy,chronicvenousinsufficiency,andASAcategoriesIIIandIV.OnlythreepatientswereinASAcategoryII,oneofwhomhadmoderatestableanginaandahistoryofmyocardialinfarction.

PeripheralVenousFlowStudies

Femoralvenouscross-sectionalareaandvelocitieswereobtainedusinganultrasoundDopplermachine（AlokaDiagnosticSystem,SSD-2200,Mitaka-Shi,Tokyo,Japan）.Thetechniqueinvolvedidentifyingthebifurcationoftheprofundafemorisarteryfromthecommonfemoralarteryandthenselectingasegmentoffemoralveinjustproximaltothisarea.Thewindowofthelineararrayultrasoundmicroconvexprobe（7.5MHz）（Aloka,UST-995）wasse-curedinacustomizedtemplatefixedat45ºtoflowaxisthroughouttheprocedure（Fig.1）.

CardiacFunction

CardiacoutputandstrokevolumeweremeasuredusingatransesophagealDopplermachine（ODMII,S/N2060,Abbott,Maidenhead,Kent,UK）withsingle-use4-MHzsterileprobes（AbbottSinglePatientProbeG975）.Bloodpressureandpulseratewererecordedfromananestheticmonitoringsystem（M1205A,Omnicare,Model24/24C,Hewlett-Packard,PaloAlto,CA）.

Figure1.CombinedfemoralvenousvelocityprofileatcenteroffemoralveinandcrosssectionalareaareshowninDuplex（BandD）mode.Peaksystolicvelocity（PSV）offemoralveinismeasuredatt2.3cm/sec.

StudyEndpoints

Endpointswerepeaksystolicvelocity（PSV）andenddiastolicvelocity（EDV）offemoralvenousflow（cm/s）,cross-sectionalareaofthefemoralvein（mm2）,cardiacoutput（L/min）,strokevolume（mL）,systolicanddiastolicbloodpressure（mmHg）,andpulserate.Allthesewereobtainedatfollowingstages:

·Pre-PPPninsupinepositionundergeneralanesthesiawiththeLympha-pressoff（stage1）

·PPPnandhead-uptiltpositionwiththeLympha-pressoff（stage2）

Figure2.Lympha-presssystem,showingcompressor,distributor,andmulticelltrousers.Thepressureisdistributedintooverlappingaircompartmentsfromdistaltoproximal.Each30-secondcycleconsistsof18secondscompressionand12secondsdecompression.

Figure3.（A）Peaksystolicvelocity（PSV）,（B）enddiastolicvelocity（EDV）and（C）Cross-sectionalarea（CSA）offemoralveinduringstages1through4.Stage1=Pre.PPPn+supine;stage2=PPPn+Tilt+Lympha-press,off;stage3=PPPn+Tilt+Lympha-press,on;stage4=postPPPn+supine.*P<.01,stage1vs.2;1-P<.01,stage2vs.3;+P<.01,stage3vs.1;P<.01,stage4vs.1.*P<.05,stage1vs.4.

·PPPnandhead-uptiltpositionwiththeLympha-presson（stage3）

·Post-PPPninsupinepositionundergeneralanesthesiawiththeLympha-pressoff（stage4）

Femoralvenousrecordingsweretakenevery5minutesandcardiacrecordingsevery2to3minutes.Eachrecordingwasanaverageofthreereadings.A5-minutestabilizationtimewasallowedbetweenrecordingsofanevent（definedasachangebetweenanytwosuccessivestages）.

IntermittentSequentialPneumaticCompressionDevice

TheLympha-presssystemconsistsofacompressor,adistributor,andamulticellsleeve（Fig.2）.Eachsleeveisacarpetlikewrappingofninecellsthatisadaptedtoeachlowerlimbfromankletogroin.Theadjustablepressuregeneratedbythepneumaticcompressorissetatamaximumof55mmHgandisdistributedintooverlappingaircompartmentssequentiallyfromdistaltoproximaltobothlegssimultaneously.Thiseffecttranslatestoamilkingmechanismonthelowerlimbveins.The30-secondcycleconsistsof18secondsofcompression（eachcellisinflatedforapproximately2seconds）and12secondsofdecompression,startingwithafewsecondsofintermissionperiodwhenallcellsareinasimultaneouscompressionstate,followedby.simultaneousdecompressionofallcells.

AnesthesiaandPneumoperitoneum

Astandardizedgeneralanestheticprotocoladministeredbytwoanesthetistswasfollowedinallpatients.Allprocedureswerecarriedoutunder12mmHgPPPnanda30head-uptiltposition.Patientswereallowedtoeatordrinkuptomidnightbeforesurgeryandthenwerefullyfasted.Thisregimenwasadjustedifpatientswerescheduledforalatertimeonthesurgerylist.Intraoperativefluidmaintenancewasprovidedbycrystalloidinfusion（7mL/kgperhour）,andextralosseswerereplacedasclinicallyindicated.EndtidalCO2