Laparoscopic surgery is used most of pneumoperitoneum, abdominal swelling most commonly used medium is the C02, for those determined to pulmonary insufficiency, but also the use of helium (He) did abdominal swelling medium. Pneumoperitoneum low complication rate and serious level, in addition to the patient's own state, but also with the level of abdominal pressure gas, gas type, duration of pneumoperitoneum vary asked.
compartment syndrome refers to a limited dissection chamber volume, pressure, increased so that the chamber after the occurrence of tissues and organs of blood circulation disorder, and thus of functional and organic damage to a group of syndromes. is the most common clinical limb bone fascia compartment syndrome. peritoneal cavity as a separate room, under pressure in the pneumoperitoneum can occur that change the same.
normal intra-abdominal pressure and atmospheric pressure similar to the contents of any form of abdominal volume increase, can cause increased intra-abdominal pressure, the formation of abdominal compartment syndrome ( abdominal compartment syndrome, ACS), the most vulnerable organ system affected the cardiovascular system, respiratory system and kidneys, mainly as increased peripheral vascular resistance, reduced cardiac output, increased airway resistance, lung compliance, or even anoxia . peritoneal pathological changes than after decompression can often be reversed quickly, but are not limited to sexual ACS can cause fatal organ failure.
gas abdominal laparoscopic surgery in the automatic regulation of pneumoperitoneum and under strict monitoring of patients is rarely formed in the ACS, but the adaptive ability to regulate the body reduction for elderly patients or liver and kidney dysfunction associated with cardiopulmonary patients, laparoscopy in abdominal pressure to take the gas as low as possible is highly benefits.
a subcutaneous emphysema and gas embolism
(a) of the subcutaneous emphysema subcutaneous emphysema
the exact incidence and cause of the unknown. Kunming General Hospital, where the author of more than 8,000 cases of LC CCP appeared in 23 cases, were associated with significant hypercapnia, but all patients are closely monitored in the completion of surgery. retrospective analysis of these 23 patients during surgery and found that the following factors and subcutaneous emphysema occurrence of obvious relevance: ① the location of improper Veress needle to establish pneumoperitoneum gas was injected into the extraperitoneal space; ② casing surrounding the abdominal cavity into the subcutaneous tissue through C02; ③ repeated puncture needle or tube taper off the original puncture site, created in the abdominal wall to form multiple channel, C02 enter the skin through Chong Road; ④ with expander expansion of puncture or other methods (such as check except when the gallbladder), the abdominal wall and the casing of the reduction between the closed, gas from the the gap between the abdominal wall and the casing to the subcutaneous tissue diffusion; ⑤ intra-abdominal pressure is increased when the potential closure of the inguinal canal does not pass, the gas can leak into the subcutaneous tissue from the abdomen.
severe and widespread oppression of thoracic subcutaneous emphysema may be and upper respiratory tract, the lung compliance, increased airway resistance, severe hypoxemia or produce C02 accumulation. on the cardiovascular system can be expressed as emphysema local vascular compression, the late decline in emissions can be developed Zhixin , central venous pressure, mean arterial pressure and heart rate changes are also frequent.
mild subcutaneous emphysema little effect on the body, do not need special treatment. a serious and extensive subcutaneous emphysema because of the negative of cardiopulmonary effects must be closely monitored to do surgery, especially when patients are determined to pulmonary insufficiency. appropriate to reduce the intra-abdominal pressure, the anesthesiologist uses hyperventilation to poke holes at Extruded emphysema, all help to reduce the adverse emphysema effect and slow the spread of emphysema. difficult to correct because of subcutaneous emphysema caused by heart and lung function changes or hypercapnia, should be converted to open surgery, but this is rare.
an interesting phenomenon: the author subcutaneous emphysema, 23 cases occurred in the early cases, nearly 4,000 cases of post-LC has not been to see subcutaneous emphysema. As mentioned above caused by subcutaneous emphysema in a number of related factors can not be in nearly 4,000 cases of LC does not appear This can not help but gives rise to the following questions: whether the production of subcutaneous emphysema and some unknown other factors.
(b)
gas embolism gas embolism (hereinafter referred to as air embolism) is a rare complication of pneumoperitoneum , but its consequences are very serious, usually fatal. embolism may be the site of the right atrium, pulmonary artery, to a rare coronary and cerebral arteries. The exact incidence of air embolism can not be estimated, Cottin reported that a group of 1994 cases of laparoscopic surgery, air embolism occurred in 2 cases and lead to patient death, which is the highest known incidence of a group. inflatable gas species and the formation of air embolism should have between the exact probability of relevance. C02 As a high solubility of gases, as long as not a lot in a short time into the blood vessels, the possibility of the formation of air embolism is small. such as the use of helium inflated, because of its low solubility, only very small amount into the blood vessels, which the formation of air embolism can be fatal, it has been confirmed by experiments.
to the current lack of actual laparoscopic surgery carried out against the background of the formation mechanism of air embolism experimental study, suggesting the formation of the following ways: ① pneumoperitoneum strayed into the abdominal vein needle, large amounts of gas directly into the blood within a short time; ② tissue wound separation fracture or broken veins on a high-pressure gas into the portal circulation; ③ the gas dissolved in the blood as could be, like decompression sickness the formation of bubbles, is not yet certain.
the literature of many prevention of air embolism and intraoperative monitoring methods to do a lot of discussion, but the incidence of air embolism is very low, making it difficult to apply these measures in routine clinical patients, but the incidence of air embolism is unpredictable and almost impossible to determine so-called air embolism monitoring, preventive measures, in the present not much practical significance.
meaningful, perhaps, is how the existing emergency air embolism. The existing methods include: ① the immediate lifting of pneumoperitoneum, stop source of air embolism; ② left lateral position so that gas is not easy to enter the right ventricle; ③ rapid central venous catheter sucked out of the right atrium and right ventricle and pulmonary artery bubbles; ④ possible emergency air bubbles out of direct puncture of right atrium; ⑤ inhalation of pure Oxygen; ⑥ breathing underwent cardiac arrest cardiopulmonary resuscitation; ⑦ hyperbaric oxygen therapy.
Second, hypercapnia and respiratory acidosis
C02 pneumoperitoneum laparoscopic surgery can cause hypercapnia and respiratory acidosis, and this phenomenon has long been recognized by the industry, but mainly limited to the previous diagnostic laparoscopy and gynecological minor such do not seem to highlight the issue. With the significance.
study shows that: the intra-abdominal pressure associated with pneumoperitoneum may limit diaphragmatic movement, leading to reduced lung and possible tidal CO2 retention, and the resulting increase in P C02 can be caused by positive cardiac inotropic effect and the surrounding enhanced vasoconstriction. by supporting muscle relaxant drugs and positive pressure breathing intervention, a way to overcome the pneumoperitoneum on the impact of lung ventilation, the ventilation will not be any significant decline and the increase of P C02.
C02 pneumoperitoneum state whether there hypercapnia, respiratory acidosis often associated with the following factors:
1. pneumoperitoneum Ishizaki experiments showed that the pneumoperitoneum pressure 16mmHg or more, for 1 hour after pneumoperitoneum cardiac output that is significantly decreased peripheral vascular resistance increased significantly; intra-abdominal pressure in the 8 mmHg ~ 12 mmHg, the above changes is not obvious. intra-abdominal pressure is increased to the C02 has increased the dispersion of blood, if the additional decrease in cardiac output, and increased peripheral vascular resistance, the retention of blood in the C02 will be more obvious.
2. pneumoperitoneum Leighton found that the gas of choice: C02 pneumoperitoneum can produce respiratory acidosis animals, He does not have this pneumoperitoneum phenomenon. In addition, C02 absorption and tissue perfusion related to the time of hemorrhagic shock is often more severe hypercapnia.
3. pneumoperitoneum asked the length of the longer duration of pneumoperitoneum, peritoneal absorption of the C02 is also more.
4. subcutaneous emphysema and pneumothorax occurred in laparoscopic surgery such as subcutaneous emphysema or pneumothorax, often accompanied by more pronounced hypercapnia and acidosis.
5. anesthetic effects such as the former above, when the pneumoperitoneum laparoscopic surgery to muscle relaxants and positive pressure breathing supplementary intervention, it would be a way to correct or block the pneumoperitoneum on the impact of lung ventilation.
6. the body of the cardiopulmonary Wittgen compensatory ability of functional results have been widely cited. The study found that: LC preoperative patients with normal cardiopulmonary function can be well tolerated without the occurrence of C02 pneumoperitoneum and hypercapnia and acidosis; and cardiopulmonary dysfunction LC patients are prone to difficult surgery to correct the respiratory acidosis. of the result that: arterial blood gas analysis is pneumoperitoneum laparoscopic surgery better means of monitoring, and preoperative blood gas analysis and cardiopulmonary function assessment should be made to adapt LC Choose one of the screening criteria permit.
for the prevention of laparoscopic intraoperative hypercapnia and respiratory acidosis, in addition to preoperative surgical indication to grasp, but also during the operation proper monitoring, understanding pulse rate , oxygen saturation, pulmonary ventilation, airway pressure, blood gas analysis, PET C02 and other indicators of real change. in the event of hypercapnia, hyperventilation viable product from the body retention of C02, but the speed can not be too quickly, Otherwise, hypercapnia has been adapted to the respiratory, circulatory central hypercapnia due to sudden loss of stimulation, there will be the so-called and the sharp drop in blood pressure caused by coronary artery contraction and respiratory depression. a heavier degree of retention of C02 should be the end of surgery as soon as possible, completely eliminate the residual intra-abdominal C02, appropriate application of basic drugs. that can not correct the hypercapnia and respiratory acidosis, and must be converted to laparotomy.
three
shoulder pain shoulder pain after laparoscopic surgery is a very common symptom, its incidence can be as high as 35% to 60%. on the LC patients, even After becoming the most common but one of the major complaints. This symptom may be the incentive for intra-abdominal residual C02 caused by phrenic nerve stimulation, was noted when the patient semi-recumbent position to take the pain when the shoulder is often increased. If the above suggested the establishment of the net emission of surgery should be able to reduce the intra-abdominal postoperative C02 of shoulder pain, but unfortunately the practice is not entirely the case. on postoperative severe symptoms, can be symptomatic with salicylic acid drugs. Narchi Randomized comparative study: intraoperative use in the liver of local anesthetic diaphragm can significantly reduce postoperative shoulder pain patients.
four, arrhythmia
pneumoperitoneum state arrhythmia is not uncommon, but its exact The reason remains unclear, in addition to the surgeon's own state outside the pneumoperitoneum should also be an important incentive. have found that arrhythmia-prone of the pneumoperitoneum established in the initial period, and concluded that the establishment of the initial arrhythmia and pneumoperitoneum When the amount of traffic on C02. Whether or not this view is correct, considering the body's ability to adapt to the various organ systems, the timing of mobilization, then the establishment of pneumoperitoneum to low flow began, and then gradually increase to high traffic and high traffic maintain intraoperative pneumoperitoneum should be a principle must be followed. In addition, that the temperature of the C02 pneumoperitoneum also contributed to the possible causes of arrhythmia.
five, deep venous congestion and thrombosis
DVT is common complications after surgery. literature, more than 40 years of age are not common prophylactic anticoagulant treatment in patients after surgery, about 25% of the occurrence of DVT. vein angiography in patients after open cholecystectomy about 7% l0%, there may be DVT, pulmonary embolism rate of 0.4% to 0.7%. With 70% of DVT patients had no clinical manifestations, so the true incidence of DVT after surgery is difficult to estimate. laparoscopic surgery due to pneumoperitoneum intra-abdominal pressure on the lower extremity venous blood flow obstruction, combined with low pupil is sometimes used in the first position, suggesting that there should be higher than traditional surgical incidence of DVT, but there is still lack of convincing a large series of comparative results. small sample results obtained in different rooms of a completely different conclusions. Patel's research shows a high incidence of DVT after LC in open cholecystectomy, Kopanski the result was the opposite. causes of this phenomenon may be due to: ① hidden most of the clinical DVT; ② While there is venous congestion and laparoscopic hypercoagulable state, but a shorter operation time and more small to offset part of the impact of the trauma; ③ preventive measures taken to calculate the true incidence of rate greatly. Nevertheless, laparoscopic surgery of lower extremity venous stasis of blood flow is an indisputable fact remains, it is necessary to take appropriate disposal.
(b) the mechanism of thrombosis and prevention
1. thrombus formation mechanism
(1) venous stasis venous blood flow stasis, vascular wall endothelial damage and blood hypercoagulability is the three elements of venous thrombosis. gas abdominal pressure exceeds venous blood pressure, will lead to changes in hemodynamics, manifested as lower extremity vein dilation, blood flow slows, blood pressure increased.
Christen balloon pressure in vitro method of simulated abdominal laparoscopic pneumoperitoneum when the state of the multi-pulse Determination of volunteers Doppler femoral vein diameter and blood flow velocity changes. The results showed: air bag pressure can cause abdominal pressure associated with a significant increase of femoral vein diameter and blood flow slowed down. LC surgery in 11 mmHg ~ 13 mmHg abdominal pressure, the femoral vein diameter significantly increased pressure by 7.5mmHg increase to 15.5 mmHg, femoral vein flow velocity by 12.5cm / s down to 8.5cm/s.Beebe a study has reached the same conclusion. position state of pneumoperitoneum have significant effects on venous return. Ido measured by color Doppler in patients undergoing LC the right femoral vein blood flow changes, the results showed that with the increase of intra-abdominal pressure, blood flow velocity has slowed down, head high more obvious when low enough. When low pupil from scratch into a supine position, blood flow improved significantly, suggesting that LC surgery without first pupil will help alleviate the low status of venous stasis.
venous stasis due to blood viscosity higher degree and become risk factors for venous thrombosis. Intravenous increased pressure can lead to occurrence of micro-vascular endothelial tear (microtears), collagen fibers exposed, and induce coagulation.
(2) changes in blood coagulation research Caprini that, despite the use of elastic stockings, and intraoperative preventive measures such as lower limb compression device, but compared with the control group, LC postoperative day thrombelastography preoperative total index was still significantly elevated partial thromboplastin time (PTT) was significantly shorter in patients after LC shows that hypercoagulability. clotting mechanism to rely more on activation of coagulation factors, rather than the quantity and quality of platelets. Zhujiang Fan LC compared with OC and other patients with perioperative coagulation fibrinolytic system changes in some indicators. Based on the results of that: in terms of the stability of the blood alone, LC does not increase the risk of thrombotic complications.
2. the prevention of thrombosis in the majority of authors believe that laparoscopic surgery is currently , due to venous flow stasis, hypercoagulability and other factors, prone to thromboembolic complications, and should take preventive measures. A survey showed that .60% of North American surgeons to take the patients to accept preventive LC measures after DVT. specific ways, including: for the use of lower extremity venous stasis, intermittent compression devices and elastic stockings and other physical and hypercoagulable states for use of heparin and other anticoagulant drugs law.
(1) physical method in abdominal surgery Application of leg compression devices for prevention of postoperative DVT and pulmonary embolism has been shown to be effective measures. This device can periodically oppressed the lower leg and thigh of patients, and promote venous (sinus, especially in the calf muscles) and evacuation, to prevent vein dilation, while fibrinolytic plasminogen activation system. Although such measures can not be sure of venous pressure and blood flow have much impact, but to prevent vein dilation, activation of fibrinolytic system, major surgery on laparoscopic patients is beneficial. Christen found: in vitro balloon pressure to 50 mmHg abdominal pressure, the use of intermittent lower extremity compression devices can be effective in restoring pressure venous blood flow velocity, but can not change the shares vein diameter and pressure. Ido found: When the intra-abdominal pressure of 5 mmHg or less, the application of compression bandages to prevent venous stasis; and abdominal pressure was 10 mmHg or lower during the first pupil, pressure bandages can not play this types of preventive effect, suggesting that this method applies only without the establishment of pneumoperitoneum and changes in position of the open surgery, laparoscopic surgery but may be ineffective. pneumoperitoneum removed, the femoral vein blood velocity and cross-sectional area can quickly return to base value, so that venous stasis condition rapidly improved. Thus, repeated in laparoscopic surgery may be inflated and deflated in a way to prevent DVT.
(2) Drugs Act, the use of heparin in the conventional surgery can reduce the incidence of venous thrombosis. However, Kadm dar et al reported that even with heparin, the incidence of pulmonary embolism after surgery remains high (0.7%). The incidence of pulmonary embolism after laparoscopic surgery may be higher than the above figures. Beebe and other reports of heparin can be successfully combined with ergotamine in preventing postoperative venous thrombosis. heparin to prevent blood clot formation, ergotamine may cause venous contraction, reducing the vein diameter, thereby reducing the stimulation of connective tissue on the vein wall and vascular endothelial damage. Caprini taken comprehensive measures to prevent the occurrence of DVT after laparoscopic surgery: 2 hours before surgery until discharge system using a long elastic stockings (TED); intraoperative and early postoperative use in the legs stockings continuous pressure device (SCD); on the high-risk patients low-dose subcutaneous heparin 10000U / d, and adjust the dose to TEG index maintained at + / -2 between, until after 7 days to 30 days; after l week, 3 weeks, blood tests, respectively, to adjust the heparin dose. Following the above treatment, l00 l cases LC cases occurred only in patients with asymptomatic DVT. I believe that the use of elastic stockings, and intraoperative leg compression device, high-risk patients (old age, obesity, hypertension, etc.) subcutaneous heparin, Salvia oral tablets, intravenous infusion of dipyridamole and so can effectively prevent the occurrence of DVT after laparoscopic surgery.
six, abdominal internal organs ischemia
because of increased intra-abdominal pressure, abdominal organs (liver, kidney, stomach intestine, etc.) may be due to mechanical compression of blood flow and reduce the impact of neuroendocrine. pneumoperitoneum laparoscopy in intra-abdominal organs caused by decreased blood flow and function of the damage mechanisms include: ① splanchnic vascular mechanical compression; ② vessels plus pressure release material; ③ surgical position and vena cava blood pressure reduction caused by Huixin; ④ visceral blood flow after the lifting of pneumoperitoneum reperfusion; ⑤ oxygen free radicals and intestinal bacterial translocation; ⑥ C02 pneumoperitoneum to peritoneal The temperature dropped, the small blood vessels; ⑦ halothane and other anesthetics on visceral vascular contraction.
(a) and other liver function
Halevy observed spectrum of liver enzymes after LC change. of the 67 cases preoperative alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP) levels were normal in patients with LC after 3 days of enzymatic observations, the results: AST increased in 53 patients (79% ), more than normal levels of l.8 times; ALT increased in 55 cases (82%) is 2.2 times the average preoperative; ALP increased in 36 cases (53%), but is normal; otherwise lO (14%) postoperative bilirubin. the enzyme index change and patient's age, narcotic drugs and surgery independent of time. All patients recovered uneventfully after surgery. authors speculate that these enzymes as indicators of possible mechanisms of change: ① abdominal increased pressure, liver blood flow; ② When isolated gallbladder squeeze liver enzyme release into the blood; ③ heat damage to the liver; ④ traction gallbladder dysfunction caused by extrahepatic bile duct, bile duct pressure increased; ⑤ hepatic vagus cystic artery was clipped; ⑥ small stones within the biliary excretion; ⑦ the comprehensive reasons.
the author of the 40 cases of LC in patients with liver function before and after surgery were observed, one of the following circumstances do not enter the list of observations: ① preoperative abnormal liver function; ② patients with chronic liver disease; ③ transfer surgery; ④ line before surgery ERCP; ⑤ intraoperative cholangiography was OK. Infarct: LC l before and after the first day, 3 days of serum total protein ( TP), albumin (A), globulin (G), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), glutamyl (base) transferase (GGT), total bile acid (TBA), the results can be seen: LC on postoperative day 1, patients with TP, G, TBA decreased significantly, ALT, AST, LHD, GGT and other indicators of liver enzymes increased significantly 3 days after surgery, liver enzyme indicators have declined, but still significant difference between preoperative and TP, A, G, TBA no recovery trend. more reason for the change of pressure with the change of pneumoperitoneum has important links. LC C02 used in the operation gas abdominal pressure is generally maintained at 1.5kPa ~ 2.0kPa (11.2mmHg ~ 15mmHg), such as intra-abdominal pressure in the short time to ask the rise in liver blood flow is more significant. pneumoperitoneum lifted, will result in the liver in rats. The deep meaning of changes in liver function is: With the broadening of the indications of laparoscopic surgery, laparoscopic surgery than some more complex or time-consuming LC longer for the liver function has been damage to such complex patients in laparoscopic surgery, the need to more fully consider the surgery in patients with liver function may be negative effects.
(b) changes in renal function related to pneumoperitoneum
renal function under There are many studies. Harman observed in intra-abdominal pressure of 20.25 mmHg, the renal blood flow and glomerular filtration rate values were based on only 21% and 23%, 55% increase in renal vascular resistance, renal venous pressure higher than the intra-abdominal pressure 0.75 mmHg ~ 2.25 mmHg. Although gas abdominal laparoscopic surgery is usually not more than l5 mmHg, intra-abdominal pressure on renal function but there is still some impact. Iwase et al renal function in patients after LC observation indicates high intra-abdominal pressure group (12mmHg) to show decline in renal function, and low gas abdominal group (3.97mmHg) is not present significant changes in renal function. of the view that LC temporary postoperative renal dysfunction is due to long abdominal pressure due to higher gas.
the exclusion of the original factors of renal dysfunction, the author of 40 patients with LC preoperative and postoperative renal function to do the survey, the results show on postoperative day 1 was significantly BUN down, cr was significantly increased, BUN / Cr decreased significantly after 3 days BUN / Cr compared with a further decrease on day 1, indicating that LC does pneumoperitoneum on renal function have an impact.
renal blood flow during pneumoperitoneum reduction is an important factor of renal function, the mechanism is multifaceted, including the impact of pneumoperitoneum pressure, neuroendocrine changes and so on. on chronic renal impairment, old age, hypertension, glucose mirage than patients in need purple complex laparoscopic renal function required special attention to the protection, if necessary, can be used without pneumoperitoneum laparoscopic surgery.
(c) intestinal ischemia, necrosis
pneumoperitoneum pressure to reduce visceral blood flow is a common However, intestinal ischemia, necrosis is very rare. According to the literature, it is mainly seen in the upper abdominal laparoscopic surgery. Elefsheriadis LC compared with OC patients of gastric pH value of the police. LC group was found to be significantly gastric pH, below 0C group, suggesting that when the gastric organization LC ischemia and hypoxia: Mirror posthumous shame generally love life and bowel necrosis within 1 week after surgery, mainly seen in elderly patients and Guangdong, the heart thing to Lei: diabetes mellitus and operation time longer patients to arterial thrombosis is more common, but venous thrombosis may also occur.
main clinical manifestations: sudden recovery process after abdominal pain, often accompanied by nausea, vomiting, some patients have diarrhea, systemic poisoning symptoms can be very quickly into a state of shock. then very difficult to diagnosis before surgery, the mortality can be as high as 70% to 90%. When the patients after sudden unexplained severe abdominal pain, consider this complication, if necessary can be used for angiography. Treatment measures include: Application vasodilators and anticoagulants, effective fluid resuscitation and timely laparotomy.
typical case: Female, 62 years old, due to cholecystitis and reflux esophagitis admission. has its own analogy hemolytic anemia with thrombocytopenic purpura, was treated with prednisone and other drugs. elective LC, the operation lasted 40min. l days after surgery the patient body in good condition and continue to give cortisone drugs. surgery 2 days after sudden severe abdominal pain, rapid pulse, abdominal plain film was normal. 3 days after surgery patients had abdominal distension, abnormal liver enzyme indices, the day of death. autopsies no biliary leakage, bleeding and infection, superior mesenteric artery thrombosis, Cooke's ligament necrosis of the small intestine and right colon.
laparoscopic surgery can also cause venous thrombosis. Valeri 12 cases of laparoscopic splenectomy patients, l cases of spontaneous thrombocytopenic purpura patients by color Doppler ultrasound and angiography had confirmed partial right portal vein and the left branch of complete thrombosis. 48h followed by a heparin anticoagulation (dicumaro1) 5 days of cold treatment, symptoms, liver enzyme levels back to normal. continue anticoagulant therapy l months, Doppler ultrasound showed patency of the portal vein has been completely restored. Klugewitz other reports l IC patients undergoing blood 24 hours after it occurred in patients 41 years old male: similar to acute inflammatory bowel disease, the high-dose heparin treatment 44 days after discharge, 6 months after the laparotomy found fully restore the integrity of intestinal mucosa.
view of this, the high-risk patients, such as older age, diabetes mellitus (blood coagulation at high state), hypertension, etc., preoperative administration of vasodilator drugs and the prophylactic use of anticoagulant drugs is necessary.
(d) adrenal hemorrhage and acute adrenal crisis
adrenal hemorrhage after surgery is a rare The risk of complications, due to non-specific clinical manifestations, diagnosis is often difficult, but as long as an understanding of this complication, Determination of blood glucocorticoid levels and abdominal CT, MRl seized apricot can confirm the diagnosis. Belmore has been reported a typical case:
male patients, aged 53, undergoing elective LC l days after surgery, was discharged in good condition because of the body. postoperative day 5 because of abdominal pain, systemic failure hospitalization. examination: body temperature 38.600C blood pressure 68.2 mmHg / 40.5 mmHg, moderate degree of dehydration, abdominal tenderness in the right upper quadrant as the weight, no muscle health and rebound tenderness, no back tenderness, decreased bowel sounds. hyponatremia 125mmoL / L, potassium 5.2mmoL / L, amylase l971U / L, diagnosed as acute pancreatitis. subsequent abdominal CT scan prompted both sides of the adrenal hemorrhage associated with renal infarction, serum cortisol l4mg / L. The final diagnosis: primary adrenal insufficiency. hormone replacement therapy given after 48h of symptoms improved, was discharged in good condition after .2 weeks after emergency re-admission in critical condition, and ultimately death, the cause of acute adrenal crisis may be lines.
Shuhou causes adrenal hemorrhage and adrenal stress response and vascular Special anatomy related. hypotension or other conditions (such as venous congestion, increased demand for stress hormones, etc.) adrenal venous pressure will rise, causing bleeding. when 90% of the adrenal cortex is destroyed, adrenal insufficiency can occur . Postoperative acute adrenal insufficiency nonspecific clinical manifestations make the diagnosis of this complication is often the experience-dependent, serum cortisol, CT, MRI scans both sides. adrenalectomy has confirmed significance. hormone replacement therapy is the treatment of adrenal cortex The only effective measure dysfunction.
seven, N20 anesthesia and the abdominal cavity caused by blasting the possibility of coagulation
early laparoscopic Zengyi N20 (nitrous oxide) the establishment of pneumoperitoneum due to coagulation may cause intra-abdominal CO2 blasting the use of foreign lines have been widely used inhaled anesthetic N20/02, N20 has a highly organized inter-diffuse, fast into the abdominal cavity. George found: inhalation of 66% N20/33% 02, 30min after the intraperitoneal anesthesia N20 concentration of up to 47%. bowel contains hydrogen (H2) and methane (CH4), the highest concentration reached 69% and 56%. In vitro studies have shown that 47% of the N20 can be 56% combustion CH4; 29% of the N20 68% can be combustion H2. surgery if bowel injury, bowel within the H2 and CH4 that spilled into the abdominal cavity, abdominal N20 in the combustion can be achieved under the blasting of the critical point, and finally by coagulation start burning H2 and CH4 explosion. The authors suggest that laparoscopic surgery, anesthesia should be reduced or completely avoid the use of N20 concentration of N20. currently although N20 anesthesia caused the relevant report blasting the abdominal cavity, but should arouse our vigilance. author of laparoscopic surgery hospital to CO2 pneumoperitoneum established, and a smoke free static N20 anesthesia, completely avoid the occurrence of these risks.
eight, intra-abdominal high concentration of carbon monoxide (C0) of the operating room pollution
C02 pneumoperitoneum the hypoxic environment caused intra-abdominal, the use of transurethral electrocoagulation organization, the organization is not completely oxidized to produce high concentrations of C0. electrocoagulation after 5mm, the average concentration of intra-abdominal C0 up to l2.32 (0.89 ~ 57.14) mmoL / L, has exceeded the allowable limit C0 concentration 1.25mmol / L 54 times. Beebe's research has not yet found that C0 levels in the blood of patients, but intraoperative conversion equipment gas leakage caused by abdominal surgery can cause indoor pollution C0, that is or inhalation of a small amount of C0 is also sufficient to endanger the health of operating room staff. Therefore, the operating room should have good ventilation, not in a poorly ventilated environment to work long hours.
nine, with no added temperature drops
temperature of C02 (C02 cylinders are common low-temperature C02) inflatable, or intraperitoneal C02 replacement can lead to excessive patient temperature drops, more common in infants and young children. Holland and other 26 cases /}, JL and 42 cases of laparoscopic surgery / I, JL laparotomy carried out a comparative study of temperature changes and found that the average body temperature of children dropped peritoneoscopy 0.69 ℃, and laparotomy only decreased 0.47 ℃, although not statistically significant, but the heat prompted laparoscopy loss may be more. So in pediatric laparoscopic surgery should be closely observed in the temperature changes, keep warm, not too low operating room temperature.
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