培训课件-麻醉中的呼吸管理.pptVIP

* * * * * * * Pneumoperitoneum decreases thoracopulmonary compliance. Compliance is reduced by 30% to 50% in healthy,[5][6][7][8][9][10] obese,[11][12][13] and American Society of Anesthesiologists (ASA) class III or IV patients, but the shape of the pressure-volume loop does not change (Fig. 57-1). After the pneumoperitoneum is created and kept constant, compliance is not affected by subsequent patient tilting[14] or by increasing the minute ventilation required to avoid intraoperative hypercapnia. Reduction in functional residual capacity due to elevation of the diaphragm[15] and changes in the distribution of pulmonary ventilation and perfusion from increased airway pressure can be expected. However, increasing IAP to 14 mm Hg with the patient in a 10- to 20-degree head-up or head-down position does not significantly modify physiologic dead space or shunt in patients without cardiovascular problems.[16][17][18] * During uneventful CO2 pneumoperitoneum, the increase in partial pressure of arterial carbon dioxide (Paco2) progressively increases to reach a plateau 15 to 30 minutes after the beginning of CO2 insufflation in patients under controlled mechanical ventilation during gynecologic laparoscopy in the Trendelenburg position[19] or laparoscopic cholecystectomy in head-up position[20][21] (Fig. 57-2). Any significant increase in Paco2 after this period requires a search for a cause independent of or related to CO2 insufflation, such as CO2 subcutaneous emphysema. The increase in Paco2 depends on the IAP.[22] During laparoscopy with local anesthesia, Paco2 remains unchanged, but minute ventilation significantly increases.[23] However, during general anesthesia with spontaneous breathing, the compensatory hyperventilation is insufficient to avoid hypercapnia because of anesthetic-induced ventilatory depression and increased work of breathing from the decreased thoracopulmonary compliance. Because it takes 15 to 30 minutes for Paco2 to plateau, anesthetic techniq