正反Trendelenburg 体位对气腹 相关血流动力学变化的影响

Hemodynamic effect of Trendelenburg position and reverse Trendelenburg position on patients with laparoscopic abdominal surgery

摘要:

目的 探讨气腹及正反Trendelenburg 体位对腹腔镜腹部手术患者血流动力学的影响。方法 44 例行腹腔镜手术患者被纳入研究。根据手术体位分为A 组：反Trendelenberg 位（头高30°）。B 组： Trendelenberg 位（头低30°）。术中所有患者的气腹压力均设为13 ～ 15 mmHg，使用Frotrac 传感器在各时间 点对心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）、心排血量（CO）、体循环阻力（SVR）等数据 进行收集。结果 气腹即刻可以引起MAP、CVP、SVR 升高，HR 增快，CO 下降；在体位改变后，A 组中 CVP 降低，随后SVR 和MAP 呈下降趋势，CO 和CVP 呈上升趋势；B 组中MAP，CVP 及CO 升高，SVR 降低，随后SVR、MAP 及CVP 呈下降趋势，CO 呈上升趋势。结论 气腹可以引起血流动力学的剧烈波动。 Trendelenberg 体位可以改善患者在气腹条件下的血流动力学波动，但是对于患有心功能不全的患者，可能增加心 血管风险。反Trendelenberg 体位对气腹后血流动力学的影响较小。腹腔镜手术可以减轻手术操作时对患者 胃肠道的刺激。

Abstract:

Objective To prospectively examine the hemodynamics of pneumoperitoneum and Trendelenburg and reverse Trendelenburg position in the patients undergoing laparoscopic abdominal surgery. Methods Fortyfour patients undergoing laparoscopic surgery were included in the study. According to surgical requirements they were divided into a group A (reverse Trendelenburg position, head up 30°) and a group B (Trendelenburg position, head down 30°). All patients received an abdominal pressure of 13-15 mmHg during operation. The data including heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), cardiac output (CO) and systemic circulation resistance (SVR) were collected at various time points using the Frotrac sensor. Results Insufflation caused significant increases in MAP, CVP, SVR and reduction of CO, and slight increase of HR. In the group A, CVP dropped, followed by decreasing trends of SVR and MAP and increasing trends of CO and CVP. In the group B, MAP, CVP and CO of the patients were increased, SVR was decreased, but HR remained unchanged; then CO showed an upward trend, while SVR, MAP and CVP showed downward trends. Conclusions Pneumoperitoneum can cause significant fluctuation of hemodynamic indexes. Trendelenburg position can improve hemodynamic fluctuations in the patients under pneumoperitoneum and reduce adverse effects on the body, however, for the patients with heart failure, the increase in pre-cardiac load may be more detrimental to the patients. Reverse Trendelenburg position nearly does not change the patients’ hemodynamics. Laparoscopic surgery can reduce gastrointestinal irritation in the patients during operation.