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作 者:丁玲玲[1] 张宏[1] 米卫东[1] 刘靖[1] 金朝海[1] 袁维秀[1] 刘毅[2] 倪丽亚[2] 薄禄龙[2] 邓小明[2]
机构地区:[1]解放军总医院麻醉手术中心,北京100853 [2]上海长海医院麻醉科,上海200433
出 处:《北京大学学报(医学版)》2013年第5期819-822,共4页Journal of Peking University:Health Sciences
摘 要:目的:总结机器人辅助根治性膀胱切除+原位新膀胱手术的麻醉方法和术中管理.方法:2012年3月美国南加州大学的Gill医生来华演示机器人辅助根治性膀胱切除+原位新膀胱手术,其中3例在上海长海医院完成,7例在北京解放军总医院完成.10例患者男8例,女2例,年龄38~71岁,体重57~82 kg,ASA分级Ⅰ~Ⅲ级.术前均诊断为膀胱癌,拟施机器人辅助根治性膀胱切除+扩大淋巴清扫+原位新膀胱手术.所有患者未见明显心、肺、肝、肾功能异常.麻醉诱导:除1例术前评估为困难气道外,其余9例采用快诱导气管插管.芬太尼3 μg/kg静脉小壶注入,静脉推注咪达唑仑0.04 mg/kg、丙泊酚1~2 mg /kg,患者入睡后给予罗库溴胺0.6 mg/kg.困难气道患者给与咪达唑仑1 mg、芬太尼0.1 mg、丁卡因50 mg气道表面麻醉后气管插管,之后给予异丙酚及罗库溴铵.连接Ohmeda麻醉机机械通气,吸入空气与氧气体积比1:2混合气体,流量2 L/min,潮气量为6~12 mL/kg,呼吸频率为10~20 次/min,力图维持气道峰压<35 mmHg(1 mmHg=0.133 kPa),PETCO2 (呼气末CO2分压)<45 mmHg.麻醉维持:持续吸入0.6 MAC(最低肺泡有效浓度minimum alveolar concentration)七氟醚、静脉泵注丙泊酚2~4 mg/(kg·h)和瑞芬太尼0.1~0.3 μg/(kg·min),维持BIS值在40~60,术中间断按需静脉注射罗库溴铵0.2 mg/kg.手术体位为60°Trendelenburg(特伦德伦伯格卧位,头低、脚高+截石位)体位,双腿外展支起呈截石位.机器人系统位于两腿之间,支臂置于患者腹部上方.监测记录呼吸参数、血流动力学指标,并记录动脉血气分析数据、苏醒时间、出入量及术中并发情况.结果:所有患者均顺利完成手术.术中失血量(342.9±303.4) mL;与气管插管后比较头低足高位及气腹后气道峰压升高;呼气末CO2增高;平均动脉压升高、中心静脉压升高;pH降低;2例患者气腹后15 min,呼气末CO2分�Objective:To summarize anesthesia management of laparoscopic radical cystectomy and or- thotopic bladder surgery with a robotic surgical system. Methods: In the study of 10 cases of bladder cancer, the robot-assisted radical cystectomy + expand lymphadenectomy + orthotopic bladder surgery with 60 degrees of Trendelenburg surgical position, was inserted into the manipulator under the video system monitor positioning, to complete the removal of the diseased tissue dissection and orthotopic ileal neoblad- der intra-abdominal. The respiratory parameters, hemodynamic parameters, arterial blood gas analysis were monitored and the waking time, intake and output, and intraoperative concurrent recorded.Results: All the patients were operated successfully. The intraoperative blood loss was ( 342.9 ± 303.4) feet, associated with hypercapnia and temperature drop; the wake time (withdrawal to the extubation time) was (94.2 ± 35.6) min. Conclusion: Robot-assisted radical cystectomy + orthotopic bladder surgery is a newly-performed clinical surgery. Because of the huge machines, long time pneumoperitone- um and over-head-down, it is prone to acid-base balance and ion imbalance, thus increasing the difficul- ty and complexity to anesthesia management. It' s necessary to further summarize the impact on the resoiratorv, hemodvnamic, and nervous system.
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