[The resorption of carbon dioxide from the pneumoperitoneum in laparoscopic cholecystectomy].
[The resorption of carbon dioxide from the pneumoperitoneum in laparoscopic cholecystectomy].
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腹腔镜胆囊切除术中气腹二氧化碳的吸收[J].
DOI：
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发表时间：
1993
期刊：
影响因子：
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通讯作者：
S. Jelen
中科院分区：
文献类型：
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作者：
M. Blobner;A. Felber;S. Goegler;H. Feußner;E. Weigl;G. Jelen;S. Jelen
腹腔镜胆囊切除术据称是一种微创手术，但从气腹 (CO2-PP) 中吸收二氧化碳 (CO2) 可引起临床相关的高碳酸血症。在这项前瞻性研究中，研究了腹腔镜胆囊切除术期间的二氧化碳吸收。方法。 30 名患者（ASA I 和 II）使用丙泊酚和芬太尼进行全静脉麻醉。使用 Engström Erica 呼吸机开始控制通气，潮气量为 10 ml/kg min，呼吸频率为 10/min，FiO2 = 0.4。当呼气末 CO2 (PeCO2) 升至 42 mmHg 时，呼吸频率增加。除了标准监测外，还测量腹内压（IAP）。通过 Erica 代谢监测仪的间接量热法记录每分钟通气量 (VI)、二氧化碳消除量 (VCO2)、摄氧量 (VO2) 和呼吸商 (RQ)。 CO2 再吸收 (delta VCO2) 通过以下公式计算：delta VCO2(Mi) = VCO2(Mi) RQ(M1)VO2(Mi)。 (i = 1; 2; ...;5) 所有值均为中位数（四分位距）或范围。所有参数均在腹腔镜胆囊切除术特有的五个测量点进行比较：M1 基线，麻醉诱导后 30 分钟，M2 开始 CO2 吹入后 10 分钟，从肝床动员胆囊时的 M3，从腹腔中取出胆囊时的 M4，以及排出 CO2-PP（自主呼吸）后 10 分钟的 M5。结果。观察到 VCO2 的典型模式（图 1）。基线 VCO2 为 165 (145-180) ml/min，PeCO2 为 33 (31-35) mmHg，VI 为 6.0 (6.0-7.0) l/min。注入 CO2 至 IAP 为 14 至 20 mmHg 后，VCO2 增加至 201 (179-222) ml/min (P < 0.05)。在胆囊动员期间，IAP 在 12 至 18 mmHg 之间，并且未观察到 VCO2 (200 (179-229) ml/min) 进一步增加。在从腹腔中取出胆囊的过程中，CO2-PP 放气，IAP 下降至 1-5 mmHg。在此阶段，最大 VCO2 和增量 VCO2 分别测量为 232 (206-245) ml/min 和 43 (30-57) ml/min (P < 0.05)。尽管 VI 增加至 7.0 (6.0-8.4) l/min (P < 0.05)，但 PeCO2 升至 40 (37-42) mmHg (P < 0.05)。 VO2 的完整模式如图 2 所示，RQ 图 3 所示，Delta VCO2 图 4 所示。PeCO2、IAP 和 VI 的值列于表 2 中。 讨论。 CO2-PP 期间 VCO2 增加和 VO2 稳定的组合必须解释为表明 CO2 从腹腔吸收。在吹入 CO2-PP 期间以及 IAP 下降后立即必须假定有必要的 CO2 再吸收。在胆囊解剖过程中，没有观察到CO2吸收增加，因此实验结果[19]可以在临床上证实，高于毛细血管压力的IAP通过压缩腹膜毛细血管来防止CO2进一步吸收。 CO2 吸收具有临床相关性，因为必须增加 VI 才能维持正常碳酸血症。因此，二氧化碳图在腹腔镜胆囊切除术中是绝对必要的。
Laparoscopic cholecystectomy is claimed to be a minimally invasive procedure, but uptake of carbon dioxide (CO2) from the pneumoperitoneum (CO2-PP) can cause clinically relevant hypercapnia. In this prospective study, CO2 resorption during laparoscopic cholecystectomy was investigated. METHODS. In 30 patients (ASA I and II) total intravenous anesthesia was performed with propofol and fentanyl. Controlled ventilation was started with a tidal volume of 10 ml/kg min, a respiratory rate of 10/min, and FiO2 = 0.4 using an Engström Erica ventilator. When end-tidal CO2 (PeCO2) rose to 42 mmHg the respiratory rate was increased. In addition to standard monitoring, intra-abdominal pressure (IAP) was measured. Minute volume (VI), CO2 elimination (VCO2), oxygen uptake (VO2), and the respiratory quotient (RQ) were registered by indirect calorimetry from the Erica Metabolic Monitor. The CO2 resorption (delta VCO2) was calculated from the equation: delta VCO2(Mi) = VCO2(Mi) RQ(M1)VO2(Mi). (i = 1; 2; ...;5) All values are medians (interquartile range) or ranges. All parameters were compared at five measuring points that are characteristic for laparoscopic cholecystectomy: M1 baseline, 30 min after induction of anaesthesia, M2 10 min after starting CO2 insufflation, M3 while mobilising the gallbladder from the liver bed, M4 while extracting the gallbladder from the abdominal cavity, and M5 10 min after desufflating the CO2-PP (spontaneous breathing). RESULTS. A typical pattern of VCO2 was observed (Fig. 1). Baseline VCO2 was 165 (145-180) ml/min, PeCO2 was 33 (31-35) mmHg, and VI was 6.0 (6.0-7.0) l/min. After insufflation of CO2 to an IAP of between 14 and 20 mmHg, an increase in VCO2 to 201 (179-222) ml/min was registered (P < 0.05). During mobilisation of the gallbladder, the IAP was between 12 and 18 mmHg and no further increase in VCO2 (200 (179-229) ml/min) was observed. During extraction of the gallbladder from the abdominal cavity, the CO2-PP deflated and IAP dropped to 1-5 mmHg. In this phase, maximal VCO2 and delta VCO2 were measured at 232 (206-245) ml/min and 43 (30-57) ml/min (P < 0.05), respectively. PeCO2 rose to 40 (37-42) mmHg (P < 0.05) although VI was increased to 7.0 (6.0-8.4) l/min (P < 0.05). The complete pattern of VO2 is shown in Fig. 2, the RQ in Fig. 3, and delta VCO2 in Fig. 4. The values of PeCO2, IAP, and VI are listed in Table 2. DISCUSSION. The combination of increased VCO2 and stable VO2 during CO2-PP must be interpreted as indicating resorption of CO2 from the abdominal cavity. Essential CO2 resorption must be assumed during insufflation of the CO2-PP and immediately after a decrease in IAP. During dissection of the gallbladder no increase in CO2 resorption was observed, so the experimental finding [19] can be confirmed clinically that an IAP higher than the venous capillary pressure protects from further CO2 resorption by compressing the venous capillaries of the peritoneum. CO2 resorption is clinically relevant because VI must be increased to maintain normocapnia. Therefore, capnography is absolutely necessary during laparoscopic cholecystectomy.