泌尿外科腹腔镜手术CO2 气腹对血气的影响及处理

Effect of using CO2 pneumoperitonum in laparoscopic urinary surgery on arterial blood gas and its treatment

关键词:  腹腔镜手术  高碳酸血症  血气分析  碳酸氢钠

Key words:  laparoscopic surgery  carbonemia  arterial blood gas analysis  sodium bicarbonate

摘要:

［目的］探讨泌尿外科腹腔镜手术CO₂ 气腹对血气分析的影响和处理。［方法］ 腹腔镜手术77例，其中后腹腔镜组35例，腹腔镜组20例和术前应用NaHCO₃ 腹腔镜组22例三组。采用全麻，术中CO₂ 气腹压力维持在13~14 mmHg。设立3个监测时点，术前5 min（Ⅰ）、术中30 min（Ⅱ）、术后30 min（Ⅲ），进行血气分析监测，观察并记录pH、PCO₂、PO₂、BE。［结果］ 本组12例皮下气肿，5例手术时间>2 h，3例体重>90 kg，5例年龄>70岁，均发生高碳酸血症。后腹腔镜组Ⅱ、Ⅲ中pH、PCO₂ 与Ⅰ相比明显下降。腹腔镜组Ⅱ、ⅢpH与Ⅰ相比明显下降，PCO₂明显上升。腹腔镜与后腹腔镜组相比术中pH降低更明显，PCO₂ 上升更明显，差异有显著性意义（P<0.01），表明腹腔镜组比后腹腔镜组更易引起高碳酸血症。两组术后均有轻度高碳酸血症。同法，术前应用NaHCO₃ 腹腔镜组与前两组相比术中pH明显升高，PCO₂ 明显下降，BE明显升高，差异有显著性意义（P<0.01）。［结论］ 术前控制慢性病，缩短手术时间，术后即刻排空气体，减少皮下气肿发生，术前应用NaHCO₃ 有利于控制术中CO₂ 对血气的影响。经腹腔途径比后腹腔途径更易发生高碳酸血症，因此，对于泌尿外科腹腔镜手术，应注意选择手术入路。

Abstract:

［Objective］ To study the influence of CO₂ pneumoperitonum to arterial blood gas in laparoscopic urinary surgery and its clinical treatment. ［Methods］ Seventy-seven patients with laparoscopic surgery were divided into 3 groups. Thirty-five cases were in group of the retroperitoneal approach, 20 cases were in the transperitioneal approach and 22 cases (12 of them with retroperitoneal approach and 10 with transperitioneal approach) were given with 5% sodium bicarbonate 30 minutes before the laparoscopic surgery. General anesthesia was applied. The CO2 inflation rate was 2 L/min and the pressure was kept between 13 and 14 mmHg during the operation. Arterial blood samples were collected for arterial blood gas analysis in 5 minutes before the operation (Ⅰ), 30 minutes after the operation started (Ⅱ) and 30 minutes after the operation (Ⅲ). Parameters including blood pH, arterial partial pressure of carbon dioxide (PCO₂), arterial partial pressure of oxygen (PO₂) and base excess (BE) were examined. ［Results］ Carbonemia occurred in 12 cases with subcutaneous emphysema, 5 cases with operation time longer than 2 hours, 3 cases with body weight over 90 kg and 5 cases with age older than 70 years. In both retroperitoneal and transperitioneal groups, the average blood pH measured atⅡand Ⅲ was lower than that measured atⅠ(P<0.01), while the average PCO₂ increased. In addition, patients in both groups were in the condition of carbonemia after the operation. In those 22 laparoscopic cases who received 250 mL 5% sodium bicarbonate intravenously 30 minutes before the operation, blood sample collected atⅠ, Ⅱ and Ⅲ showed that pH and BE increased, and PCO₂ decreased obviously. ［Conclusions］ In order to prevent carbonemia, we need to deal with chronic diseases before operation, shorten operation time, immediately discharge CO₂ after operation to reduce the probability of subcutaneous emphysema. The intravenous application of 250 mL 5% sodium bicarbonate before operation can correct the influence of CO₂ to arterial blood gas. The incidence of carbonemia in the transperitioneal approach is higher than that in the retroperitoneal approach. It is important to choose the proper approach to practice urological laparoscopic surgery.